Regional Anesthesia for Upper Limb Surgery: A Narrative Review

  • Zahid Hussain Khan Professor of Anesthesiology and Critical Care, Deputy for Research, Department of Anesthesiology and Critical Care, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
  • Hamid Reza Amiri Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
  • Amjed Qasim Mohammed Tehran university of medical science
Keywords: Regional anesthesia, Upper limb, Local anesthetics.


Regional anesthesia is an expanding subspecialty and is gaining increasing popularity due to its significant benefits over general anesthesia if appropriately accomplished, which includes superior intraoperative pain control, attenuation of the surgical stress response, minimal systemic impairment, lower incidence of postoperative nausea and vomiting, excellent localized postoperative analgesia, and decreased hospital cost and stay. Needle conduction guide toward the targets always has a great importance. The most commonly used local anesthetics include lidocaine, ropivacaine, bupivacaine, and mepivacaine. The type of local anesthetic, the concentration, the volume administered, and the location of the block will affect the onset, duration and depth /type of block. Due to ineffectivity of neuraxial block in upper limbs, upper extremity blocks may be considered as the sole substitute or supersede method of anesthesia for upper limb surgeries.

Author Biography

Amjed Qasim Mohammed, Tehran university of medical science

MSc of anesthesia tecniques


1. Amiri et al. Methods to determine the nerve location/Upper limb blocks. In: Clinical Applications of Peripheral Nerve Block In Regional Anesthesia. 1: 2000. p. 31-125.
2. Miller RD et al. Peripheral Nerve Blocks. In: Miller’s Anesthesia. 1: Elsevier; 2015. p. 2011-22.
3. Neal JM, Gerancher J, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD, et al. Upper extremity regional anesthesia essentials of our current understanding, 2008. Reg Anesth Pain Med. 2009; 34(2):134.
4. Butterworth JF et al. Peripheral Nerve Blocks. In: Morgan Clinical anesthesia. 12012. p. 975-92.
5. Brattwall M, Jildenstål P, Stomberg MW, Jakobsson JG. Upper extremity nerve block: how can benefit, duration, and safety be improved? An update. F1000Res. 2016;5.
6. Grauman S, Boethius J, Johansson J. Regional Anaesthesia Is Associated with Shorter Postanaesthetic Care and Less Pain Than General Anaesthesia after Upper Extremity Surgery. Anesthesiol Res Pract. 2016; 2016;432-7.
7. Ahn JC. Ultrasound-guided Regional Anesthesia A Practical Approach to Peripheral Nerve Blocks and Perineural Catheters. Anesthesiology. 2011; 115(5):1142-3.
8. McGinley J. Method for treating and confirming diagnosis of exertional compartment syndrome. Google Patents; 2016.
9. Steinfeldt T, Volk T, Kessler P, Vicent O, Wulf H, Gottschalk A, et al. Peripheral nerve blocks on the upper extremity. Der Anaesthesist. 2015;64(11):846-54.
10. Buckenmaier C. Military advanced regional anesthesia and analgesia handbook: Government Printing Office; 2009; p. 32-44
11. Carlo D. Franco M. Upper Extremity Blocks. In: Manual Of Regional Anesthesia. 1. Third ed. Chicago, IL; 2008. p. 71-90.
12. Brown DL. Atlas of regional anesthesia: Elsevier Health Sciences; 2010.
13. Chatterjee S, Konar S, Dey A, Ghosh AK, Ghosh T, Biswas S. Comparison between interscalene and supraclavicular brachial plexus block: a cadaveric study. Journal of Evolution of Medical and Dental Sciences. 2014;3(27):7630-5.
14. Chuan A, Scott DM. Regional Anaesthesia: a pocket guide: Oxford University Press, USA; 2014.
15. Schroeder LE, Horlocker TT, Schroeder DR. The efficacy of axillary block for surgical procedures about the elbow. Anesth Analg. 1996;83(4):747-51.
16. Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology. 1983;59(2):117-22.
17. Bernucci F, Gonzalez AP, Finlayson RJ, Tran DQ. A prospective, randomized comparison between perivascular and perineural ultrasound-guided axillary brachial plexus block. Reg Anesth Pain Med. 2012; 37(5):473-7.
18. Ambi U, Bhanupriya P, Hulkund SY, Prakashappa D. Comparison between perivascular and perineural ultrasound-guided axillary brachial plexus block using levobupivacaine: A prospective, randomised clinical study. Ind J Anaesth. 2015;59(10):658.
19. Schoenmakers KP, Wegener JT, Stienstra R. Effect of local anesthetic volume (15 vs 40 mL) on the duration of ultrasound-guided single shot axillary brachial plexus block: a prospective randomized, observer-blinded trial. Reg Anesth Pain Med. 2012;37(3):242-7.
20. Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol. 2015;31(3):296.
21. Liu SS, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009; 109(1):265-71.
22. Gonano C, Kettner S, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103(3):428-33.
23. Verelst P, van Zundert A. Respiratory impact of analgesic strategies for shoulder surgery. Regional Anesthesia and Pain Medicine. 2013;38(1):50-3.
24. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg. 2015;120(5):1114-29.
25. Palhais N, Brull R, Kern C, Jacot-Guillarmod A, Charmoy A, Farron A, et al. Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial. Br J Anaesth. 2016;116(4):531-7.
26. Büttner B, Mansur A, Hinz J, Erlenwein J, Bauer M, Bergmann I. Combination of general anesthesia and peripheral nerve block with low-dose ropivacaine reduces postoperative pain for several days after outpatient arthroscopy: A randomized controlled clinical trial. Medicine. 2017;96(6).
27. Sakae TM, Marchioro P, Schuelter-Trevisol F, Trevisol DJ. Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: A randomized, double-blinded clinical trial. J Clinic Anesth. 2017; 38:133-6.
28. Doost ER, Heiran MM, Movahedi M, Mirafzal A. Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations. Am J Emerg Med. 2017; 35(10): 1435-9.
29. Sadowski M, Tułaza B, Łysenko L. Renaissance of supraclavicular brachial plexus block. Anaesthesiol Intensive Ther. 2014; 46(1):37-41.
30. Gamo K, Kuriyama K, Higuchi H, Uesugi A, Nakase T, Hamada M, et al. Ultrasound-guided supraclavicular brachial plexus block in upper limb surgery. Bone Joint J. 2014;96(6):795-9.
31. Vaghadia H, Chan V, Ganapathy S, Lui A, McKenna J, Zimmer K. A multicentre trial of ropivacaine 7.5 mg· ml− 1vs bupivacaine 5 mg· ml− 1 for supra clavicular brachial plexus anesthesia. Can J Anaesth. 1999;46(10):946-51.
32. Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Anesth Analg. 2010; 111(4):1072.
33. Park S-K, Lee S-Y, Kim WH, Park H-S, Lim Y-J, Bahk J-H. Comparison of Supraclavicular and Infraclavicular Brachial Plexus Block: A Systemic Review of Randomized Controlled Trials. Anesth Analg. 2017; 124(2):636-644.
34. Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anesth. 2009; 56(11):812-8.
35. Taboada M, Rodríguez J, Amor M, Sabaté S, Alvarez J, Cortés J, et al. Is ultrasound guidance superior to conventional nerve stimulation for coracoid infraclavicular brachial plexus block? Reg Anesth Pain Med. 2009; 34(4):357-60.
36. Eren G, Altun E, Pektas Y, Polat Y, Cetingok H, Demir G, et al. To what extent can local anesthetics be reduced for infraclavicular block with ultrasound guidance? Anaesthesist. 2014; 63(10):760-5.
37. Ponde V, Shah D, Johari A. Confirmation of local anesthetic distribution by radio‐opaque contrast spread after ultrasound guided infraclavicular catheters placed along the posterior cord in children: a prospective analysis. Pediatr Anesth. 2015; 25(3):253-7.
38. Ince I, Aksoy M, Dostbil A, Tuncer K. Can we use lower volume of local anesthetic for infraclavicular brachial plexus nerve block under ultrasound guidance in children? J Clin Anesth. 2017; 41:132-136.
39. Mosaffa F, Gharaei B, Qoreishi M, Razavi S, Safari F, Fathi M, et al. Do the Concentration and Volume of Local Anesthetics Affect the Onset and Success of Infraclavicular Anesthesia? Anesth Pain Med. 2015; 5(4): e23963.
40. Leurcharusmee P, Elgueta MF, Tiyaprasertkul W, Sotthisopha T, Samerchua A, Gordon A, et al. A randomized comparison between costoclavicular and paracoracoid ultrasound-guided infraclavicular block for upper limb surgery. Can. J Anesth. 2017; 64(6):617-25.
41. Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M. Brachial plexus anesthesia: a review of the relevant anatomy, complications, and anatomical variations. Clin Anat. 2014; 27(2):210-21.
42. Russon K, Pickworth T, Harrop‐Griffiths W. Upper limb blocks. Anaesthesia. 2010;65(s1):48-56.
43. Chin KJ, Alakkad H, Cubillos JE. Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm. Cochrane Database Syst Rev. 2013;8.
44. Badiger SV, Desai SN. Comparison of nerve stimulation-guided axillary brachial plexus block, single injection versus four injections: a prospective randomized double-blind study. Anesthesia, Essays and Researches. 2017;11(1):140.
45. Ranganath A, Srinivasan KK, Iohom G. Ultrasound guided axillary brachial plexus block. Med Ultrason. 2014; 16(3):246.
46. Barrington MJ, Gledhill SR, Kluger R, Clarke AL, Wong DM, Davidson H, et al. A Randomized Controlled Trial of Ultrasound Versus Nerve Stimulator Guidance for Axillary Brachial Plexus Block. Reg Anesth Pain Med. 2016;41(6):671-7.
How to Cite
Khan Z, Amiri HR, Mohammed A. Regional Anesthesia for Upper Limb Surgery: A Narrative Review. Arch Anesth & Crit Care. 5(1):22-9.
Review Article(s)