Appendix A

The following is a guide to the performance of some common techniques used in a pain management practice. For other blocks, the reader is referred to any standard textbook of regional anesthesia. Although not specifically mentioned, the anesthesiologist should use their own discretion regarding such details as whether intravenous placement before the block is necessary, whether the patient should be maintained with an empty stomach for several hours before the injection, and whether resuscitative equipment is needed at the bedside.

The complications and side effects mentioned are those specific to the particular nerve block discussed. Other potential complications inherent in any injection technique include intravascular injection, hematoma formation, and infection, the seriousness of which will be determined by the particular site of injection. The anesthesiologist is advised to keep these potential complications in mind when attempting to perform any block.

### Technique

###### Figure A-1

Stellate ganglion block, paratracheal approach. Transverse section at the level of C6, showing the needle medial to the finger retracting the carotid vessel laterally. (Reproduced with permission from Raj PP, ed. Handbook of Regional Anesthesia. New York: Churchill Livingstone; 1985.)

The patient lies supine with the neck hyperextended and a thin pillow under the shoulders. The carotid artery is palpated, the trachea identified, and using two fingers, the transverse body of C6 (Chassaignac tubercle) is palpated (block at C7 is associated with a higher incidence of pheumothorax). This is the most prominent of the cervical transverse processes and lies at the level of the cricoid cartilage. A skin wheal is raised and a 22-gauge 1½-inch needle is advanced between the carotid and cricoid perpendicular to the skin until it contacts the transverse process. The needle then is pulled approximately 2 mm back, the syringe is aspirated, and a 1-ml test dose is given. Assuming there is no untoward reaction, the remaining solution is injected. This volume will spread along the fascial plane, typically from the middle cervical ganglion to T4 or T5 ganglion, thus affecting the sympathetic supply to structures of the head and neck, upper extremity, and chest.

### Drugs

Use 8 to 20 ml of lidocaine 0.5% to 1%, or bupivacaine 0.25% to 0.5%, or procaine 1%.

### Tips

• 1. Patient should be informed to expect a Horner syndrome, hoarseness, and warmth.
• 2. Success of block is confirmed by a Horner syndrome (miosis, ptosis, and anhidrosis) and more importantly, a skin temperature of the arm of at least 2°F greater than the contralateral arm.
• 3. The patient should be cautioned not to swallow or talk during the procedure but should be instructed to communicate paresthesias by raising a hand.
• 4. Avoid bilateral blocks.
• 5. Meticulous aspiration for blood or cerebrospinal fluid should be done before and ...

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