Patient Position: Supine, head turned as far as is comfortable to the contralateral side, ipsilateral arm adducted.

Indications: Arm, elbow, forearm, or hand surgery.

Needle Size: 22-gauge, 50-mm insulated block needle.

Volume of Local Anesthetic: 20 to 30 mL.

Ultrasonographic Landmarks: The subclavian artery is situated on top of the first rib. The plexus lies posterosuperior to the subclavian artery. The anterior scalene muscle is found anterior to the brachial plexus and subclavian artery. The subclavian vein lies anterior to the anterior scalene muscle. The pleura is immediately deep to the first rib (Fig. 34-1). The plexus at this level appears to be a “cluster of grapes,” made up of small fascicles. The superior, middle, and inferior trunks may be contained in separate fascial compartments or lie within a single epineurial compartment.