Landmarks include lateral and posterior borders of sternal and clavicular heads of sternocleidomastoid (SCM) muscle, C₆ tubercle, interscalene groove (formed by the anterior and middle scalene muscles), upper border of cricoid cartilage, and the clavicle (Fig. 22.3).

The patient is positioned supine with the head turned away from side to be blocked and arms relaxed at the side. A line is drawn laterally from the top portion of cricoid cartilage in a direction toward and past the posterior border of (SCM) muscle (coincides with C₆ transverse process). This line will serve as the path along which to take when searching for appropriate muscle twitch. The bony tubercle of the C₆ transverse process can often be palpated along this line. The posterior border of the SCM muscle is marked which bisects the previously drawn line. The posterior border of the SCM muscle can easily be palpated by instructing the patient to raise their head off the table and/or flex the neck. The interscalene groove is marked by palpating for the groove immediately behind and deep to the posterior border of the SCM muscle (point along the C₆ transverse process line).

A 22G 2 in. b-bevel needle connected to a nerve stimulator set at 1.0 mA (activate nerve stimulator subsequent to subcutaneous needle placement) is inserted at the mark of the interscalene groove and directed perpendicular to the skin. The block needle is inserted until an appropriate motor twitch of the deltoid or biceps muscle is obtained at a stimulation between 0.2 and 0.5 mA or paresthesia to the arm or thumb is elicited. Muscle twitch typically occurs superficially at a depth of 1–2 cm (up to 3 cm in obese patients). About 20–40 ml of local anesthetic is injected following frequent negative aspiration of blood/CSF. A single orifice catheter may be inserted (provides continuous infusion of local anesthetic) although securing and maintaining such a catheter in the interscalene groove may be difficult.

Landmarks include the sternocleidomastoid muscle, anterior and middle scalene muscles, clavicle, 1st rib, and the subclavian artery. The patient is positioned supine or semi-sitting with the head turned away from side to be blocked and arms remaining relaxed at the side. The brachial plexus is targeted at the midpoint of the clavicle (Fig. 22.4a). A 22G 2 in. b-bevel needle is connected to a nerve stimulator set at 1.0 mA (activate nerve stimulator subsequent to subcutaneous needle placement), and inserted 1 finger width cephalad to the mid-clavicular point and directed caudally (2.5 cm lateral to the SCM muscle attachment of the clavicle, Fig. 22.4b).

The first rib is contacted with the needle at a depth of 2–4 cm and then “walked off” the first rib until a corresponding muscle twitch is obtained at a threshold of 0.2–0.5 mA or a paresthesia to the arm or thumb is elicited. NOTE: Use caution and avoid directing the block needle medially toward the cupola of the lung. Following desired nerve stimulation (flexion or extension of wrist or digits), 20–40 ml of local anesthetic is injected in incremental doses with frequent negative aspiration. A single orifice catheter may be inserted and used for continuous infusion of local anesthetic solution.

Landmarks include the spine of the scapula which is palpated laterally to identify the acromion (Fig. 22.5). With the patient seated, the spine of the scapula is identified and a perpendicular line is drawn from the angle of the scapula upward to bisect the spine of the scapula.

A 25 G 2 in. needle is inserted about 2 cm lateral to the intersecting point, in the upper outer quadrant of the scapula (at the junction of spine of the scapula and acromion). The needle is directed inferiorly toward the scapula, and upon encountering the body of the scapula it is walked off superiorly and laterally until the needle enters the suprascapular notch. Once a paresthesia is elicited, the block needle should not be advanced any further. However, if paresthesia is not elicited, the needle is advanced half an inch further until it crosses the coracoclavicular ligament, after which 10 ml of local anesthetic is slowly injected after negative aspiration.

Landmarks include the pectoralis major and minor muscles, subscapularis and teres major muscles, serratus anterior muscle, humerus, scapula, clavicle, and the coracoid process (Fig. 22.6). The patient is positioned supine, with the head turned toward the contralateral side and the arm to be blocked at the side or flexed at the elbow and resting on the abdomen. Following local skin infiltration and sterile preparation, a 2 in. 22G b-bevel needle is connected to a nerve stimulator set at 1.0 mA and inserted perpendicularly to the skin 2 cm caudad and 2 cm medial to the coracoid process.

The block needle is directed in a vertical and parasagittal plane aimed toward the axilla while searching for a paresthesia to the distal upper extremity or an appropriate muscle twitch (stimulation between 0.2 and 0.5 mA). NOTE: Muscle twitch/stimulation at wrist or hand, and NOT the musculocutaneous nerve, is considered appropriate. After negative aspiration of blood, 30–40 ml of local anesthetic is injected (with frequent negative aspiration). The brachial plexus depth during infraclavicular block can vary from 2 to 8 cm depending on body habitus (average 4 cm). Continuous infusion of local anesthetic can be provided with a single orifice catheter.

Landmarks include the axilla, axillary artery, and the humerus (Fig. 22.7). Figure 22.8 shows the axillary nerve map. Distal to the axillary hair pad, imagine the upper arm in a cross-sectional view with the musculocutaneous nerve found outside the neural vascular bundle in the 9–12 O’clock position and embedded in the coracobrachialis muscle, the median nerve typically located in the 12–3 O’clock position above the pulse of the axillary artery and within the neural vascular bundle, the ulnar nerve usually located in the 3–6 O’clock position, and the radial nerve located in the 6–9 O’clock position (variable) below the pulse of the axillary artery (both branches within the neural vascular bundle).

The patient is positioned supine with the head neutral or away from the side to be blocked, while the arm to be blocked is abducted 90° at the shoulder and flexed 90° at the elbow. The axillary artery is then palpated and marked. Following skin preparation and local infiltration, a 22G 2 in. b-bevel needle is connected to a nerve stimulator set at 1.0 mA (activate nerve stimulator subsequent to subcutaneous needle placement). While palpating the axillary artery, the block needle is inserted at 30–45° to the skin and directed toward the axilla overlying the palpable artery in the distal axilla. The block needle is inserted searching for paresthesia or appropriate motor response at the wrist, hand, or thumb (at 0.2–0.5 mA). Consistent muscle twitch of the wrist and hand indicates ulnar, radial, and/or median nerve stimulation. About 30–40 ml of local anesthetic is injected following frequent negative aspiration.

Cognizant of the clockwise arrangement of nerves within the neural vascular bundle (ulnar, median, and radial), each quadrant should have local anesthetic injected to insure blockade of each terminal nerve. For the transarterial method, the local anesthetic should be injected in at least two locations around the artery (superficial and deep) within the neural vascular bundle (increases block success). A single orifice catheter can be inserted to provide continuous local anesthetic infusion. The musculocutaneous nerve branches higher in the axilla and passes into the coracobrachialis muscle; therefore, the musculocutaneous nerve is typically blocked outside the neurovascular bundle within the belly of this muscle. Inserting the needle into and through the coracobrachialis muscle until contacting the humerus and then pulling back a few mm off the periosteum prior to injection will cause musculocutaneous nerve blockade.