ULTRASOUND-GUIDED INTERSCALENE BRACHIAL PLEXUS BLOCK
Analgesia to the shoulder and upper arm
INDICATIONS
Indicated for anesthesia to the shoulder, arm & elbow.
Blocks the brachial plexus at the level of the roots/trunks.
The ulnar nerve is often spared: unreliable for hand or wrist procedures.
Commonly performed for surgery of the humerus/shoulder and for insertion of an AV graft. ​
CONTRAINDICATIONS
Absolute contraindications:
Patient refusal
Infection at injection site
Significant coagulation abnormalities
Presence of pneumonectomy or contralateral hemidiaphragmatic paralysis: 100% incidence of ipsilateral hemidiaphragmatic paralysis due to phrenic nerve blockade.
Relative contraindications:
Inability to cooperate during block placement or surgery
Preexisting neurologic disease
​COPD
POTENTIAL COMPLICATIONS
Hoarse voice due to blockade of the RLN
Horner's syndrome: mild ipsilateral ptosis, miosis, and anhydrosis. Reassure patients that symptoms are temporary.
SUPPLIES
Patient monitoring devices
Ultrasound equipment & a high-frequency linear transducer
Appropriately-sized sterile gloves
Local anesthetic for local infiltration with a small-gauge needle
Local anesthetic of choice and syringes
Echogenic needle
Lubricating jelly
Probe cover
Sterile skin cleansing solution
​
*Always have emergency equipment/drugs available*
LANDMARKS
Clavicle
Carotid artery
Anterior scalene muscle and middle scalene muscle
TECHNIQUE
Apply patient monitoring devices.
Position the patient supine with head turned away.
Don sterile gloves and cleanse the site with a sterile skin cleansing solution.
Place a sterile probe cover and lubricating jelly over the ultrasound probe.
Identify landmarks: clavicle & external jugular vein.
Position the transducer transverse approximately 3-4 cm superior to the clavicle.
Identify the pulsating carotid artery.
Move the transducer laterally across the neck until the brachial plexus is visualized as a group of hypoechoic circular structures lying between the anterior and middle scalene muscles.
Localize the skin.
Insert the needle posterior to the plexus in-plane until it is in close proximity to the roots of the brachial plexus.
Aspirate and incrementally inject 15-20 mL while visualizing the spread of the local anesthetic.