Chapter 26

The supraclavicular block is one of several techniques used to anesthetize the plexus. The block is performed at the level of the brachial plexus trunks where almost the entire sensory, motor, and sympathetic innervation of the upper extremity is carried in just three nerve structures confined to a very small surface area. Consequently, typical features of this block include rapid onset, predictability, and dense anesthesia.1–3 In 1911 Kulenkampff in Germany performed the first percutaneous supraclavicular approach, reportedly on himself, a few months after Hirschel described a surgical approach to the brachial plexus in the axilla. The technique was later published in the United States in 1928 by Kulenkampff and Persky.4 As they described it, the technique was performed with the patient in the sitting position (“a regular chair will suffice”) or in the supine position with a pillow between the shoulders if the patient could not adopt the sitting position. The operator sat on a stool at the side of the patient. The needle was inserted above the midpoint of the clavicle where the pulse of the subclavian artery could be felt and it was directed medially toward the spinous process of T2 or T3. Kulenkampff's familiarity with brachial plexus anatomy allowed him to recognize that “the best way to reach the trunks was in the neighborhood of the subclavian artery over the first rib.” His technique was also simple; “all the branches of the plexus could be anesthetized through one injection.” These two assertions are still valid today. Unfortunately his advice on needle direction carried an inherently high risk of pneumothorax. The popularity of the supraclavicular block remained high during the entire first half of the twentieth century until well after World War II. During this time the technique underwent several modifications, most of them intended to deal with the risk of pneumothorax.1,5–8

The introduction of axillary techniques by Accardo and Adriani9 in 1949 and especially by Burnham10 in 1958 marked the beginning of the decline in interest for supraclavicular block. The axillary block was particularly popularized after a publication in the journal Anesthesiology by De Jong in 1961.11 The paper was based on cadaver dissections and included the now well-known calculation of 42 mL as the volume needed to fill a cylinder 6 cm long (axillary sheath). According to De Jong this dose “should be sufficient to completely bathe all branches of the brachial plexus.” The article was also critical of the supraclavicular approach. Coincidentally the same journal published a paper by Brand and Papper12 who compared axillary and supraclavicular techniques and managed to produce a 6.1% rate of pneumothorax. This uniquely high rate is frequently cited in the literature in reference to supraclavicular block.

More modern modifications of supraclavicular block include Winnie and Collins's subclavian perivascular technique13 and the “plumb-bob” technique of Brown and collaborators.14 The former is more a concept than a radically different technique, ...

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