Patient Position: The patient lies supine, the head slightly to contralateral side, the arm extended comfortably along the body; a roll sheet is placed under both shoulders.

Indications: Anesthesia and postoperative analgesia for surgery of the shoulder and of the proximal upper arm, above the elbow.

Needle Size: A 23- to 24-gauge, 25- to 35-mm, insulated beveled needle.

Volume: Ropivacaine 0.2% for children up to 7 years, levobupivacaine 0.5% for older children, 0.5 mL/kg.

Anatomic Landmarks: The clavicle, the lateral border of the sternocleidomastoid muscle, and the transverse process of C6 (Chassaignac tubercle). The puncture is made at the junction of the upper two-thirds with the lower third of the line joining the C6 transverse process to the midpoint of the clavicle (Fig. 47-1).

Approach and Technique: Find the superficial projection of the Chassaignac tubercle (insertion of the transverse line at the level of the cricoid cartilage and the lateral border of the sternocleidomastoid muscle). The site of introduction of the needle is the junction of the upper two-third and the lower one-third of the line joining the midpoint of the clavicle and the Chassaignac tubercle. Set the nerve stimulator at a frequency of 2 Hz and a current of 2.5 mA. Connect this to the pen dedicated for the transcutaneous technique (instead of the pen it is possible to use the negative electrode of the ENS) and point it perpendicularly to the skin in an anteroposterior direction until a motor response (contraction of biceps and/or brachial muscle) is elicited. Then insert the needle connected to the nerve stimulator set at 1 mA and 2 Hz, exactly at the point evidenced via transcutaneous in an anteroposterior direction until a motor response is again elicited. Adjust the position of the needle to maintain the appropriate muscle response with a current of 0.4 to 0.5 mA. Then, after negative aspiration, slowly inject the local anesthetic solution.

Patient Position: The patient lies supine, the arm on the side to be injected abducted at the shoulder and flexed at a right angle at the elbow so that the wrist is at the same level as the patient’s head.

Indications: Anesthesia and postoperative analgesia of the forearm and hand.

Needle Size: A 23- to 25-gauge, 25- to 35-mm, insulated beveled needle.

Volume: Ropivacaine 0.2% for children up to 7 years, levobupivacaine 0.5% for older children, 0.5 mL/kg.

Anatomic Landmarks: The axillary artery, the coracobrachialis muscle, the pectoralis major muscle (Fig. 47-2).

Approach and Technique: The axillary artery should be palpated and followed as high as possible up into the axilla. The site of introduction of the needle is just above the axillary artery which is firmly held by finger compression at the crossing of the medial border of the coracobrachialis with the lower border of the pectoralis major muscle. Set the nerve stimulator at a frequency of 2 Hz and a current of 1.5 mA, then point the needle in an anteroposterior direction until the motor response is elicited (e.g., contraction of the hand—it is usually easier to stimulate the median nerve with a flexion of the thumb and the first three fingers). Adjust the position of the needle to maintain the appropriate muscle response with a current of 0.4 to 0.5 mA. Then, after negative aspiration, slowly inject the local anesthetic solution.