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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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Chapter 5 – Supraclavicular Block

PERSPECTIVE

Supraclavicular block provides anesthesia of the entire upper extremity in the most consistent, time-efficient manner of any brachial plexus technique. It is the most effective block for all portions of the upper extremity and is carried out at the “division” level of the brachial plexus. Perhaps this is why there is often little or no sparing of peripheral nerves if an “adequate” paresthesia is obtained. If this block is to be utilized for shoulder surgery, it should be supplemented with a superficial cervical plexus block to anesthetize the skin overlying the shoulder.

Patient Selection.

Almost all patients are candidates for this block, with the exception of those who are uncooperative. In addition, in less experienced hands it may be inappropriate for outpatients. Although pneumothorax is an infrequent complication of the block, such an event often becomes apparent only after a delay of several hours, when an outpatient may already be at home. Also, because the supraclavicular block relies principally on bony and muscular landmarks, extremely obese patients are not good candidates because they often have supraclavicular fat pads that interfere with easy application of this technique.

Pharmacologic Choice.

As with other brachial plexus blocks, the prime consideration for drug selection should be the length of the procedure and the degree of motor blockade desired. Mepivacaine (1%–1.5%), lidocaine (1%–1.5%), bupivacaine (0.5%), and ropivacaine (0.5%–0.75%) are all applicable to brachial plexus block. Lidocaine and mepivacaine produce 2 to 3 hours of surgical anesthesia without epinephrine and 3 to 5 hours when epinephrine is added. These drugs can be useful for less involved or outpatient surgical procedures. For extensive surgical procedures requiring hospital admission, a longer-acting agent such as bupivacaine can be chosen. Plain bupivacaine produces surgical anesthesia lasting 4 to 6 hours, and the addition of epinephrine may prolong this time to 8 to 12 hours; ropivacaine is slightly shorter acting.

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