Patient Position: Supine, with head and neck slightly rotated to the opposite side. The arm and shoulder are placed caudad (toward the feet) to widen the space between the neck and shoulder.

Indications: Anesthesia and postoperative analgesia of the shoulder, biceps, and humerus surgery.

Needle Size and Catheter: 18-gauge, 38-mm insulated Tuohy needle and 20- or 21-gauge catheter.

Volume and Infusion rate: 30 to 40 mL initially 0.5% ropivacaine, followed by either a continuous infusion of 8 to 10 mL/hour or a patient-controlled infusion of 0.2% ropivacaine (5 mL/hour basal, 3 to 4 mL bolus, with a lockout period of 20 minutes).

Anatomic Landmarks: The sternocleidomastoid (SCM) muscle, the clavicle, and the anterior and middle scalene muscles as well as the cricothyroid membrane (C6).

Approach and Technique: With the head and neck rotated to the opposite side, the patient is asked to lift the head slightly off the bed (contracting and accentuating the SCM muscle). The lateral border of the SCM muscle is identified and marked. Next, two fingers are placed on the posterior edge of the muscle, and the patient is asked to relax the neck.
The fingers are gently slid posteriorly and the first bandlike muscle is the anterior scalene muscle. The next muscle is the middle scalene muscle. The interscalene groove is marked. The site of needle introduction is the intersection between the horizontal line drawn at the level of the cricothyroid membrane and the interscalene groove. The insulated Tuohy needle connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) with the bevel oriented to the axilla is introduced through the skin and directed medially, slightly caudad, and posterior (Fig. 26-1A) at approximately 30° to the skin. As the needle punctures the fascia, there is a subtle “click” and sudden motor movement, which helps confirm proper placement. The position of the needle is adjusted to produce a motor response distal to the shoulder, which is maintained with a current less than 0.5 mA. After negative aspiration for blood, the local anesthetic is slowly injected with repeated aspiration for blood. Maintaining the introducer-insulated needle in the same position, the catheter is threaded 3 to 5 cm beyond the needle tip. The introducer needle is removed, and the catheter is secured in place with Steri-Strip (3M, St. Paul, MN) and covered with a transparent dressing (Fig. 26-1B).

Patient Position: Supine, with the head slightly turned away, and with the hand placed on the abdomen.

Operator Position: Stand next to the patient's head, opposite the side to be blocked.

Indications: Anesthesia, postoperative analgesia for shoulder surgery, and active physical therapy.

Needle Size and Catheter: 18-gauge, 50- to 100-mm (depending on the size of the neck) insulated introducer catheter needle and 20- or 21-gauge catheter.

Volume and Infusion Rate: 30 to 40 mL initially 0.5% ropivacaine, followed by either a continuous infusion of 8 to 10 mL/hour or a patient-controlled infusion of 0.2% ropivacaine (5 mL/hour basal, 3 to 4 mL bolus, with a lockout period of 20 minutes).

Anatomic Landmarks: The sternal and clavicular heads of the SCM, the midclavicle, and the superior border of the chest wall.

Approach and Technique: The sternal and clavicular heads of the SCM as well as the midclavicle are located and marked. The puncture site is situated one fingerbreadth above the clavicle, between the heads of the SCM, medial to the clavicular head. Next, the puncture site is pre-incised with an 18-gauge needle to facilitate the penetration of the introducer needle or catheter (Fig. 26-2A). The introducer needle connected to a nerve stimulator (2 mA, 2 Hz, 0.1 ms) is introduced, initially at a 45° angle from the table plane and 15° from (almost parallel to) the posterior border of the clavicular head of the SCM and advanced laterally, posteriorly, and caudally aiming at a point 1 cm posterior to the
midclavicle. This initial orientation leads to stimulation of the lateral border of the superior trunk (Fig. 26-2B) which is lateral to the rest of the brachial plexus and produces glenohumeral coaptation and contraction of the supraspinatus muscle. From this initial position lateral to the brachial plexus, the needle can be slightly walked medially and inferiorly to seek for stimulation of the middle trunk. The following motor responses help identify which part of the brachial plexus is being stimulated:

After appropriate positioning of the needle allowing the same motor response to be maintained with a current less than 0.5 to 0.6 mA, and after negative aspiration for blood, the local anesthetic solution is injected slowly, 5 mL at a time, with aspiration in between.

The catheter is introduced 2 to 3 cm beyond the tip of the introducer needle. The introducing cannula is removed, and the catheter is secured in place with Steri-Strip and covered with a transparent dressing.

Patient Position: Supine, with head slightly turned to opposite side.

Indications: Shoulder surgery, including arthroscopic procedures. Continuous interscalene infusions are typically used to allow aggressive postoperative physical therapy and to maintain joint range of motion.

Needle Size and Catheter: 18-gauge, 44.5-mm catheter over 20-gauge short-bevel introducer needle, and a 20- or 21-gauge catheter.

Volume and Infusion Rate: 20 mL 0.5% ropivacaine followed by continuous infusion at the rate of 8 to 14 mL/hour 0.2% ropivacaine starting within 1 hour of loading. A patient-controlled analgesic technique for continuous interscalene block has also been described.

Anatomic Landmarks: SCM muscle and interscalene groove. The patient is positioned supine with the head turned to the contralateral side. The interscalene groove is located by rolling the index finger laterally across the belly of the anterior scalene muscle to determine the groove between the anterior and middle scalene muscles. The needle insertion site is high in the interscalene groove, at the level of C6.

Approach and Technique: The modified perivascular technique allows easy catheter advancement because the needle approach is parallel to the brachial plexus sheath. However, the clinician must be able to visualize the nerves of the brachial plexus as they travel from the cervical foramen, through the interscalene groove, and posteriorly to the midpoint of the clavicle, where they form terminal nerves at the level of the axilla. The needle is inserted high in the interscalene groove and advanced parallel to the long axis of the body. A paresthesia or nerve stimulator response usually occurs at a depth of approximately 2.5 cm (Fig. 26-3). The catheter is advanced 5 cm into the sheath. The introducer needle is removed, and the catheter is secured in place with Steri-Strip and covered with a transparent dressing.

If the brachial plexus is not identified, the needle should be redirected laterally in small steps.

Patient Position: Sitting, with the head slightly flexed forward.

Indications: Anesthesia and postoperative analgesia following shoulder surgery.

Needle Size and Catheter: A 17-gauge Tuohy needle, a 19-gauge catheter with a steel spring conducting electrical impulses to its distal uncovered end (a “stimulating catheter”), and a loss-of-resistance syringe.

Volume and Infusion Rate: 30 to 40 mL 0.5% ropivacaine, followed by either a continuous infusion of 8 to 10 mL/hour or a patient-controlled infusion of 0.2% ropivacaine (5 mL/hour basal, 3 to 4 mL bolus, with a lockout period of 20 minutes).

Anatomic Landmarks: The brachial plexus (BP), the anterior (AS) and middle (MS) scalene muscles, the vertebral artery (VA) guarded by the bony structures of the vertebrae, the trapezius muscle (TM) and levator scapulae muscles (SM), the phrenic nerve (PN), the internal jugular vein (IJV), the carotid artery (CA), and the trachea (T) (Fig. 26-4).

Approach and Technique: The lateral border of the trapezius muscle and the medial border of the levator scapula muscles are located and marked. The site of Tuohy needle introduction is located immediately superior to the apex of the “V” formed by the intersection between the lateral border of the trapezius muscle and the medial border of the levator scapula muscle (Fig. 26-5). The insulated introducer Tuohy needle, with the bevel oriented laterally and connected to a nerve stimulator (1.5 mA, 2 Hz, 0.2 ms) and to a loss-of-resistance syringe, is introduced through the skin in an anterior, slightly caudal, and medial direction toward the suprasternal notch until contact is made with the transverse process of C6. Next, the needle stylet is removed and replaced with a syringe (loss-of-resistance device) containing 2 to 3 mL air. The needle is then walked laterally off the transverse process and slowly advanced anteroinferiorly (Fig. 26-6A). When the needle enters the cervical paravertebral space, there will be a sudden loss of resistance to air followed immediately by a stimulation of the brachial plexus resulting in related muscle responses. Next, the nerve stimulator is disconnected from the introducing Tuohy insulated needle and connected to the stimulating catheter. The stimulating catheter is introduced into the Tuohy needle, which results in a motor response similar to the one initially obtained with the introducer needle (Fig. 26-6B). The catheter is then gradually advanced beyond the needle tip by 3 to 5 cm. After negative blood aspiration, the local

anesthetic solution is injected slowly with repeat negative blood aspiration every 5 mL (Fig. 26-7A).

After the injection, the catheter is tunneled posteriorly (Fig. 26-7B). The catheter is secured in place with Steri-Strip and covered with a transparent dressing.

Anatomic Landmarks: The main anatomic landmark is the coracoid process of the scapula. From the center of the coracoid process mark a point that is exactly 2 cm caudal and 1 cm medial as per Whiffler or 2 cm medial as per Wilson. This point represents the site of introduction of the needle.

Approach and Technique: The direction of the puncture is oriented toward the patient's axilla and the long axis of the needle perpendicular to the gurney in all planes. Directing the needle tip out of the paramedian sagittal plane must be avoided because it increases the risk of pneumothorax.

Anatomic Landmarks: A point bisecting a line joining the ventral acromial process of the scapula (lateral landmark) and the incisura jugularis sternii (medial landmark) is marked. To identify these landmarks, the patient lies supine with the arm in a neutral position along the body. The point of emergence of the axillary artery at the fossa axillary is next identified.

Patient Position: To perform the block, the patient's head is slightly turned away from the arm to be anesthetized, the arm being abducted to 90° and elevated by approximately 30°.

Approach and Technique: The whole length of the clavicle is marked after palpation. A skin wheal is raised 1 cm caudal below the inferior border of the clavicle at its central point. The needle is directed laterally between 45° and 60° to the skin toward the emergence of the axillary artery in the fossa axillary as close as possible to the lateral border of the pectoralis major muscle.

All infraclavicular blocks are performed with a standardized procedure by using a nerve stimulator, connected to a cannula over the needle. Start with a modus of stimulation from 1.4 mA current and an impulse duration of 0.1 ms. The placement of the needle is successful when a muscle distal to the deltoid is stimulated with a threshold intensity of the current ≤0.3 mA and an impulse duration of 0.1 ms. The aim is to elicit a distal response of the hand to predict a successful infraclavicular block (flexion or extension of the fingers or the wrist, for example flexor carpi radialis or ulnaris). The best response is finger or wrist extension (posterior cord stimulation).

In the case of the Whiffler approach the needle is introduced perpendicular to the cord, while with the modified approach of the Raj the direction of the needle is tangential to the cords, leading to an easier catheter placement. For the catheter placement, the cannula over needle technique is used with a plastic cannula and a catheter with a stylet. The catheter is threaded no more than 2 to 3 cm distal to the end of the cannula. After subcutaneous tunneling, the catheter is fixed with adhesive tape.

If general anesthesia is not part of the anesthetic procedure a complete block of the brachial plexus with good muscular relaxation is necessary. To achieve this aim, an initial bolus of 40 mL ropivacaine 0.5% over the catheter is recommended. The onset time with ropivacaine 0.5% is on average 15 to 30 minutes.

Postoperative analgesia:

If general anesthesia is part of the anesthetic procedure (combined regional and general anesthesia), an initial bolus of 20 to 30 mL ropivacaine 0.5% is sufficient.

The surgeon may wish to check the neurological status of the arm after some surgeries. In this context the infraclavicular catheter is placed before surgery but activated only after neurological control has been performed by the surgeon.