Anaes · Regional anaesthesia
Upper limb regional anaesthesia: brachial plexus approaches
Also known as upper limb regional blocks
Exam-exhaustive upper-limb brachial plexus anaesthesia: interscalene, supraclavicular, infraclavicular, axillary; ultrasound landmarks, phrenic and pneumothorax risk, LAST rescue with lipid 1.5 mL/kg, incomplete-block rescue, and ANZCA Final viva stems.
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Red flags
- Interscalene block routinely phrenic-pareses the ipsilateral hemidiaphragm — avoid or modify in severe respiratory disease.
- LAST after large-volume plexus blocks: lipid emulsion 20 percent 1.5 mL/kg lean body weight bolus then infusion — know the kit location.
- Supraclavicular block risks pneumothorax; ultrasound reduces but does not eliminate the risk.
- Never inject against high resistance; aspirate, fractionate, and stay below maximum LA dose.
Meet the patient
A 55-year-old smoker with severe COPD (FEV1 forty percent predicted) needs an open reduction of a distal radius fracture. The surgeon wants a block for postoperative analgesia. The registrar reaches for an interscalene — the wrong block for the wrong territory, and one that would paralyse a hemidiaphragm this man cannot spare.[5][6]
Two questions settle every upper-limb block decision, and they settle this one: what territory does the surgery and tourniquet cover? and can the patient's breathing tolerate a phrenic block? A distal radius fracture in a respiratory cripple points to axillary or infraclavicular — never interscalene — because infraclavicular carries a fraction of the diaphragmatic risk (complete paresis 3 versus 34 percent) and a higher success rate than supraclavicular.[4][5]
References7ShowHide
- [1]Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med, 2018.PMID 29356773
- [2]Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med, 2018.PMID 29561531
- [3]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth, 2015.PMID 26556848
- [4]Muir D, Cara J, Morris R, et al. Supraclavicular versus infraclavicular brachial plexus block in upper limb orthopaedic surgery: a systematic review and meta-analysis of randomised controlled trials. Eur J Orthop Surg Traumatol, 2024.PMID 39287814
- [5]Petrar SD, Seltenrich ME, Head SJ, Schwarz SK Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med, 2015.PMID 25650633
- [6]Renes SH, Rettig HC, Gielen MJ, et al. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med, 2009.PMID 19920426
- [7]Mangal V, Meena C, Meena K, et al. Comparison of USG-Guided Supraclavicular Brachial Plexus Block by Single-Point Versus Multiple-Point Injection Technique: A Prospective Randomized Trial. Cureus, 2023.PMID 38111430