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Congratulations on stepping outside your comfort zone to learn this useful technique. Without a picture, I cannot be sure I'm answering your question accurately. Nevertheless, (a) we often see the cephalic vein taking off from the subclavian just distal to the clavicle. (you see it just off to the right of the screen from 2:52-3:05) (b) if imaging more distally, there is often a bundle of vessels between pec major and pec minor (see 2:40 in the infraclavicular video czcams.com/video/_WqJpAIcCgs/video.html). Regardless, my approach to avoiding vessels in the trajectory is the same: approach them at a tangent to their surface, advance slowly and gently, and they will usually slide aside as the needle tip nudges past. As you may know from peripheral IVs, veins that aren't fixed in place are suprisingly hard to pierce!

Depends where you are. more medial - you will see thoracic cage and pleura. however it is at least 2-3cm deeper to the plexus in adults. PTX is not a risk if you can see and control your needle.

(1) Perform a proximal-distal survey scan back and forth, and look to see a structure sliding towards and away from the artery. (2) occasionally it is impossible to find it, though this is rare in my experience. Inject 10ml or so around the median nerve region, and that should spread to the MCN, as they are often in same compartment. Test the area of interest, e.g. the LACN territory to see if it has been blocked. If not, you can rescue using a LACN block at the antecubital region (see my other video)

Thank you so much for your reply! Much appreciated.

See the detailed video at czcams.com/video/SQLd-_C_qCY/video.html. That will explain it.

My suggestions: (1) start with just a little gel, and add to it only if needed (2) have a towel ready, and wipe area clean (3) make marks some distance away from the probe (as far as you can be without being inaccurate) (4) really clean off the area after you finish marking, and if you notice that marks are being wiped off, "reinforce" them with a clean marker before applying skin prep. Saline is possible, but unlike vascular work, you may find yourself sliding the probe over a large area, and the friction now may become a hindrance rather than an advantage. You may find yourself applying lots of saline and soaking the surroundings.

@@KiJinnChin thanks that’s very helpful

Good question .. I think the landmark technique would probably land you closer to the clavicle and vein, so a shorter passage through less soft tissue, and thus potentially somewhat easier. And, as you say possibly more horizontal trajectory - IF you use the technique described in my other video, vs a "walk-down" approach that can result in a steeper dive to get under the clavicle. Nevertheless, I think it's still useful to appreciate that care must be taken to ensure that dilator/wire is not bending, and how to handle any challenges that may arise from trying to drive the catheter through the tissues. I have found it to be something that happens fairly often.

​@@KiJinnChin Thank you so much for the answer. Great advice!

Sorry to hear about your condition. I cannot offer specific medical advice - however the physician doing the block for you will likely be looking to see if it provides relief. If it does, they should be able to advise on a next step to produce a more permanent result.

@@KiJinnChin thank you. I just meant in general, are there other procedures available. Not specific to me. I did search online and found ablation or surgery as options. If the block helps I will definitely be discussing those options with my doctor. Thanks for your response.

Apologies, but those are not procedures I do.

Hi Stefan, thanks for the very clear and pertinent question. Apologies for any confusion, and I appreciate the opportunity to clarify. For carpal tunnel release surgery specifically, I would do a median nerve + ulnar nerve + LACN block. See here - czcams.com/video/C728WYn7dGU/video.html Based on my accumulated experience, I can say that the LACN lies superficial and close to the radial artery - so in this respect, a "blind" SC infiltration to target the LACN should extend into the region just lateral to the radial artery to be sure of blocking it. So just slightly onto the volar aspect - but you do not have to go further out onto the volar surface than that. Since the publication of the video aboce, I have discovered that the LACN and the SRN are now very easily identified by looking for the brachioradialis muscle - they have a very consistent relationship superficial and deep to it. This is now what I teach all my trainees and colleagues. See here - czcams.com/video/QhaI84RUDNA/video.html and here - czcams.com/video/i6CUFSaU_vI/video.html

Yes this should work. Some of my trainees have told me that they often do this in crash c-sections to get enough height. The only caution is that I think in general many people may find being head down uncomfortable - so I would be mindful of that, and flatten them again if they complain. In this respect hypobaric and head-up positions have an advantage.

My pleasure. This is a go-to block for me, and I hope it helps you and your patients too.

I agree that this can be an issue, especially if the needle tip is resting against the surface of the TP - the bone is an obstruction to catheter advancement. I try to skim the "far" corner of the TP I'm aiming for, and I still try initially to open a space with bolus injection well under the deep fascia. If I cannot thread the catheter, then I will pull back slightly, and try again to open up a more obvious pocket while remaining under the muscle fascia. To prevent dislodgement and malpositon of the catheter, I consider it important to thread 4-5cm into the plane under the muscle, so I would make that a priority - over trying to keep the needle tip in the hybrid ESP-ITP zone.

Yes I hope to - and will move it up the priority list! Thanks for the suggestion.

May not be dense enough for surgical anesthesia. However should be good for postoperative analgesia - can perform it after turning them lateral for the spinal anesthetic.

@@KiJinnChin apart from SA , do you perform combined regional nerve block for # hip in frail pts ? Thx

Thanks for the suggestion. It's on my to-do list! There have been some recent articles on it, including the recommendation (which I agree with) that it should more properly be called the sacral multifidus plane block.

Have you recovered from it because i am having suferfecial nerve damage

I consider the DCIA more of a structure to be avoided rather than a surrogate endpoint target. It also usually sits superficial to transversus abdominis, so it's separated from fascia iliaca by this muscle. As such, I don't expect to see lifting of the artery, nor am I looking for it. I just want to avoid it as I insert the needle, and then I want to see spread under fascia iliaca pushing the muscle down. Hope that helps!

I think this comment is for the SIFI block video? If so - I think that the bow tie approach is another good and safe alternative, but that utilizes an infrainguinal insertion point, which may not always be accessible. The suprainguinal puncture point is physically closer to the target nerves, so possibly spread will be greater, and may increase probability of a good block in more patients. It's always good to have multiple "tricks" up one's sleeve

@@KiJinnChin yes, I was refering to the SIFI block, sorry for the confusion (misclicking on the smartphone probably). your answer makes a lot of sense to me, even if I prefer an in-plane view, and the respective orientation for cathether insertion seems intuitive. thank you for the video and tips, keep up the great content :)