Br.J. Anaesth. (1978), 50, 965

APPLICATION OF THE DOPPLER ULTRASOUND BLOODFLOWDETECTOR IN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK

P. DU P. LA GRANGE, P. A. FOSTER AND L. K. PRETORIUS

SUMMARY

A Doppler ultrasound bloodflow detector was used to localize the third division of the subclavianartery, rendering the supraclavicular approach to the brachial plexus safer and highly successful.

The supraclavicular approach for a brachial plexusblock is a technique favoured by many as it producesa more extensive area of blockade than the axillaryapproach for the same dose of local anaesthetic.However, the risk of pneumothorax and, to a lesserextent, of arterial puncture and haematoma formationis less with the axillary approach, although punctureis made through skin with a high population of micro-organisms. Any method which may decrease theproblems of the supraclavicular approach warrantsattention. The method described here has reducedthe risks and made it possible to carry out supra-clavicular brachial plexus blocks successfully in theobese patient or where the normal anatomy is dis-torted. No complications have been encountered.

METHOD

The major nerve trunks lie close to the major vessels.We have used a standard 9.5-mHz ultrasonic Dopplerbloodflow detector for the localization of the sub-clavian artery. On the basis of a constant relationshipbetween the third division of this artery and the sixdivisions of the three trunks of the brachial plexus,accurate placement of local anaesthetic drug shouldbe possible. Sixty-one adult patients undergoingorthopaedic procedures were anaesthetized. Thepatient was positioned supine with the arm to beblocked at the side and the chin fully rotated in theopposite direction. The shoulder was depressed asfar as possible. Palpation of the subclavian artery

P. DU P. LA GRANGE,* ARTS DRS.(MED.), M.MED.(ANAES.),Department of Anaesthesia; P. A. FOSTER, M.B. CH.B.(U.C.T.), D.A.(ENGLAND), D.A.R.C.P. & S.I., F.F.A.R.C.P. & S.I.,Department of Anaesthesia; L. K. PRETORIUS, M.B. B.CH.,B.A.O., F.R.C.S.(I), Department of Orthopaedics; TygerbergHospital, Tygerberg, C.P., Republic of South Africa.

* Present address: Launceston General Hospital,Launceston, Tasmania.

Correspondence to L. K. P., P.O. Box 63, Tygerberg7505, Republic of South Africa.

0007-0912/78/0050-0965 $01.00

above the midclavicular point was attempted. Ifthere was any doubt about its location, the Dopplerprobe head containing transmitting and receivingelements was applied over the area using a sterilecoupling jelly. The artery and its accompanying veinwere then located precisely and marks made with awater-soluble dye on the skin outside the area to besterilized (figs 1, 2). The puncture area was cleansedand sterilized. A skin weal was raised with local

FIG. 1. Position of Doppler probe head and skin marks.

© Macmillan Journals Ltd 1978

966 BRITISH JOURNAL OF ANAESTHESIA

TABLE I. Comparison of various approaches to the brachial plexus, showing success rate and complications

Series

Balas (1971)

Brand and Papper(1961)

De Jongh (1961)La Grange, Foster

and Pretorius(present study)

Ward (1974)

Winnie (1970)Winnie and Collins

(1964)

Route

Subclavian andparavertebral

AxillarySupraclavicularAxillarySupraclavicular

Interscalene

InterscaleneSubclavian

No. ofpatients

300

246230

9461

34

200100

0/

/oSuccess

95.33

91.584.491.598.00

91

9498

Pneumo-thorax

2.67

06.100

3

0

% Complications

Phrenicnerve palsy

0

10

—

6

00

Other

0.67 Totalspinal

2 Haematoma3 Haematoma

00

3 Recurrentlaryngeal

01 Convulsion

FIG. 2. The anatomical relations of the subclavian arteryand brachial plexus.

analgesic and a 22-gauge needle (3 cm length)attached to a 20-ml syringe containing 2% mepi-vacaine with adrenaline 1 : 200 000 was inserteddownwards and backwards, in a direction towards the3rd and 4th thoracic vertebrae (Atkinson et al., 1977).If paraesthesiae were felt, 10 ml of the solution wasinjected. The needle was withdrawn slightly and5 ml deposited medial and 5 ml lateral to the area atwhich paraesthesiae were found, taking care alwaysto aspirate for blood before injection. If paraesthesiaecould not be elicited after one or two needle thrusts,the upper surface of the rib was contacted andmepivacaine 10 ml was injected between this spot andthe skin during slow withdrawal of the needle. A

further 5 ml was deposited between the anteriorborder of the rib and skin and the posterior border ofthe rib and skin (a total volume of 20 ml).

In a few instances the Doppler detected the posi-tion of the artery, but it was not possible to contactthe surface of the first rib or elicit paraesthesiae afterone or two needle thrusts; further careful probingwas undertaken for paraesthesiae. Care was takennever to penetrate more than 2 cm and the patientwas instructed to report immediately any discomfortin the chest. As soon as paraesthesiae were elicitedin this way, mepivacaine 10 ml was injected in theposition for paraesthesiae and 5 ml just lateral and5 ml just medial to this.

RESULTS

The success rate with this technique is shown intable I.

DISCUSSION

Our blocks were performed for various procedures:surgery for carpal tunnel syndrome, tendon transplant,nerve suturing, tendon suturing, repair of Dupuy-tren's contracture and excision of a ganglion. Forthis type of work many orthopaedic surgeons preferthe patient to receive brachial plexus block rather thangeneral anaesthesia because of the lesser frequency ofvasospasm and oedema after operation. Our colleaguesalso found that the accompanying sympatheticblockade reduced infection after operation byinhibiting sweating in the arm (Rank, Wakefield andHueston, 1973; Flynn, 1975). All patients wereassessed 24-48 h after operation by the anaesthetist

APPLICATION OF THE DOPPLER ULTRASOUND BLOODFLOW DETECTOR 967

or surgeon. No neurological sequelae were found. Inaddition there were no symptoms or clinical evidenceof pneumothorax. During the 6-month period of thisseries, the authors were not always able to attendevery operative session, in which case the orthopaedicsurgeons performed the nerve blocks. Supraclavicularbrachial plexus blocks performed without Dopplercontrol have been associated with pneumothorax inapproximately 5% of the patients.

It would seem that by utilizing the ultrasonicDoppler bloodflow detector it is possible to block thebrachial plexus as successfully by the supraclavicularapproach as by any other technique, and virtuallywithout complications. The standard ultrasonicDoppler bloodflow detector used is a small, simpleand relatively inexpensive apparatus.

REFERENCES

Atkinson, R. S., Rushman, G. B., and Lee, J. A. (1977). ASynopsis of Anaesthesia, 8th edn, p. 381. Bristol: JohnWright & Sons.

BalaSj G. I. (1971). Regional anaesthesia for surgery on theshoulder. Anesth. Analg. (Cleve.), 50, 1036.

Brand, L., and Papper, E. M. (1961). A comparison ofsupraclavicular and axillary techniques for brachialplexus blocks. Anesthesiology, 22, 226.

De Jong, R. H. (1961). Axillary block of the brachialplexus. Anesthesiology, 22, 215.

Flynn, J. E. (1975). Hand Surgery, 2nd edn, p. 55. Balti-more: Williams & Wilkins Co.

Rank, B. K., Wakefield, A. R., and Hueston, J. T. (1973).Surgery of the Hand, 4th edn, p. 84. Edinburgh andLondon: Churchill Livingstone.

Ward, M. E. (1974). Interscalene brachial plexus block.Anaesthesia, 29, 147.

Winnie, A. P. (1970). Interscalene brachial plexus block.Anesth. Analg. {Cleve.), 49, 455.

Collins, V. J. (1964). The subclavian perivasculartechnique of brachial plexus anesthesia. Anesthesiology,25, 353.

APPLICATION DU DETECTEUR DE DEBITSANGUIN A ULTRASONS A EFFET DOPPLERDANS LE BLOCAGE DU PLEXUS BRACHIAL

SUPRACLAVICULAIRE

RESUME

On a utilise un detecteur de debit sanguin a ultrasons et aeffet Doppler pour localiser la troisieme division de l'arteresous-claviere, afin de faciliter l'approche supraclaviculairedu plexus brachial et de la rendre plus sure.

ANWENDUNG VON DOPPLERULTRASCHALL BLUTSTROMDETEKTOR IM

SUPRACLAVICULAREN, BRACHIALENPLEXUSBLOCK

ZUSAMMENFASSUNG

Ein Doppler Ultraschall Blutstromdetektor wurde benutzt,um die dritte Teilung der subclavischen Arterie zulokalisieren. Damit wurde die subraclavicularische Annaher-ung zum brachialen Plexus sicher und erfolgreich erreicht.

APLICACION DEL DETECTOR DE LACIRCULACION DE SANGRE POR

ULTRASONIDO DOPPLER EN EL BLOQUEODEL PLEXO BRAQUIAL

SUPRACLAVICULAR

SUMARIO

Se utilizo un detector de la circulation de sangre porultrasonido Doppler para localizar la tercera division de laarteria subclavia, haciendo que la aproximacion supra-clavicular al plexo braquial fuera mas segura y diera muybuenos resultados.