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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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PEARLS

The predictability and rapid onset of the supraclavicular block allow one to “keep up” with even a fast orthopedic surgeon. This is an advantage, as regional anesthesia can be used for hand surgery, even in a busy practice. As previously outlined, this block seems to require a longer time in which to attain proficiency than most other regional blocks, and for that reason the anesthesiologist should develop a system for its use. “Wishful” probing at the root of the neck without a system is not the way to approach this block. Likewise, one should choose either the classic or the vertical approach and give each a fair trial before abandoning one or the other.

If a pneumothorax does occur after supraclavicular block, it most often can be observed and the patient reassured. If the pneumothorax is large enough to cause dyspnea or patient discomfort, aspiration of the pneumothorax through a small-gauge catheter is often all that is necessary for treatment. The patient should be admitted for observation; however, it is the exceptional patient who requires formal, large-bore chest tube placement for reexpansion of the lung. Obviously difficult patients should not be chosen as subjects until one has developed expertise with this block.

For completeness, it should be mentioned that some anesthesiologists combine the axillary and interscalene blocks (in the so-called AXIS block) to approximate the results achieved from a more typical supraclavicular block. To perform a combined AXIS block, the total doses of local anesthetic must be increased; to be effective, one must be willing to use almost 60 mL of whichever drug is injected. Time will tell whether this combined approach offers any advantages over the supraclavicular block. With the AXIS block, the axillary portion should be blocked first, with the interscalene block performed second to minimize the risk of injecting an anesthetic into an area already blocked by local anesthesia.

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