The Upper Extremity Blocks

Understanding how to block the arm and hand for surgery is a crucial skill for an anesthesiologist. It can allow the avoidance of general anesthesia and its attendant risks, which can be critical for the extremely ill patient and be helpful to improve the perioperative experience of the healthy patient. Whereas a lower extremity surgery can be replaced by a spinal or epidural technique, there is no equivalent for the shoulder, arm, or hand.

Each upper extremity block has its challenges. For example, blocking the nerve roots between the interscalene muscles has steep learning curve because the ultrasound tends to slide down the neck due to gravity. When I first started this block, I always lost my ultrasound image as I concentrated on my needle. I would then attempt to fix the ultrasound in place and develop hand cramping from bad ergonomics. Placing a catheter next to the nerves in the neck also fails commonly because the targets are so shallow; movement of a centimeter can result in a failed block. Understanding this block is important as well; it often misses the ulnar or pinky side of the hand so it's not appropriate for those surgeries. Patients can develop hoarseness, a droopy eyelid, or changes in breathing from a successful block. Much of the rotation was understanding these types of details about each nerve block. By the end of the month, I became very comfortable with the suprascapular block, which is a standard one for lower arm or hand surgery as well as the infraclavicular block, a more challenging block for the hand, but better for catheter placement. With ultrasound, the risks with these procedures are minimized, so I did fewer old-school pre-ultrasound blocks like the axillary approach to the brachial plexus.