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Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 256-257

Ultrasound guided subclavian perivascular block: The modified parasagittal approach

Department of Anaesthesiology, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India

Correspondence Address:
Dr. Tuhin Mistry
First Floor, No. 51, Periyasubbanan 3rd Street, Opp. Shri Hari Hospital, Coimbatore - 641 011, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_753_18

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Date of Web Publication26-Jun-2019

How to cite this article:
Sekar C, Mistry T, Senthilkumar B, Elayavendhan K. Ultrasound guided subclavian perivascular block: The modified parasagittal approach. Saudi J Anaesth 2019;13:256-7

How to cite this URL:
Sekar C, Mistry T, Senthilkumar B, Elayavendhan K. Ultrasound guided subclavian perivascular block: The modified parasagittal approach. Saudi J Anaesth [serial online] 2019 [cited 2019 Dec 7];13:256-7. Available from:


Ultrasound guided subclavian perivascular brachial plexus block (SPBPB) not only ensures a higher success rate but also decreases the incidence of complications such as vascular puncture and pneumothorax. Various approaches have been proposed to accomplish SPBPB. Chan et al. described the placement of the probe in coronal oblique plane in the supraclavicular fossa (parallel and immediately posterior to the clavicle) to visualize the subclavian artery and brachial plexus in the transverse sectional view.[1] It provides a stable location but only short segment of the rib is visualized (as the first rib is not straight anatomically) with the pleura close to the plexus or subclavian artery. If the tip of the needle is not accurately seen or not advanced in a controlled manner, it might accidentally cause pneumothorax. With limited visualisation of the rib, beginners are more prone to puncture the pleura. Searle et al. described a parasagittal approach with in-plane needling technique.[2] However, practically needle maneuvering is difficult in in-plane in a supine patient, and the angle of insonation might change during needle advancement, which may result in pleural injury.

In modified parasagittal approach, the probe is positioned posterior to the clavicle and perpendicular to the first rib. The angle of insonation is similar to viewing the ipsilateral great toe with 30-degree lateral tilt [Figure 1]. The out-of-plane needling technique in modified parasagittal approach offers easy manipulation of the needle, short travel distance and less discomfort to the awake patient. If the proper insonation angle is maintained, it will be possible to visually align the needle pathway. The needle never crosses the first rib, which is seen as a continuous hyperechoic white line [Figure 2]. Thus removing the chances of puncturing the pleura, which lies just beneath the first rib. The work agronomics is better as the space parallel to the probe is much broader and easy to access. Although our technique seems to be safe and easy to perform, a randomized controlled trial with larger sample size is needed to validate its superior efficacy and reliability compared to other described techniques.
Figure 1: Position of probe and needling technique in modified parasagittal approach; C = Clavicle, S = Shoulder, N = Neck

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Figure 2: Sonoanatomy of Brachial Plexus in Modified Parasagittal approach; A = Anterior, P = Posterior, SV = Subclavian vein, SA = Subclavian artery, BP = Brachial plexus

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  References Top

Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003;97:1514-7.  Back to cited text no. 1
Searle A, Niraj G. Ultrasound-guided brachial plexus block at thesupraclavicular level: A new parasagittal approach. Int J Ultrasound Appl Technol Perioper Care 2010;1:19-22.  Back to cited text no. 2


  [Figure 1], [Figure 2]


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