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