People avoiding interscalene block in pt with OSA?

[neuroride]

Trying to get a feel. I was taught to avoid ISB in patients with the obvious respiratory issues like COPD but it was always a little gray when sleep apnea was involved. I have noticed many more people with OSA diagnosis recently and in patients with mild obesity if at all.

Yesterday I had a guy that was 6'2" and 225, BMI was 28. OSA with compliant CPAP use, only other med problem was controlled HTN going for rotator cuff repair. I ended up basically doing a supraclavicular block hoping to reduce my side effects; he did well postop with no pain.

Thoughts?

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[stonemd]

ISB means you can avoid / reduce opioids for up to the first 36 hours postop. This should reduce apnea/hypopnea during that period. Thus I prefer to use ISB in these patients.

 

[psychbender]

What is your rationale for avoiding ISB in a pt with OSA? Are you concerned about phrenic nerve block? Why would that be an issue in the absence of severe COPD?

In a pt with OSA without bad COPD, I am aggressive with non-opioid analgesia, to include blockade of the brachial plexus, to avoid respiratory depression. An ISB works best for this, but if you are really concerned, you can probably just get away with a supraclav (done that plenty of times), and supplement with a suprascapular block if you feel the need.

 

[pgg]

I don't see a reason to be concerned about phrenic nerve blockade in your garden variety OSA'er. These patients ought to be a the top of the list for non-opiate pain control, including PNBs.

 

[neuroride]

Thanks; using the block was a part of my rationale of reducing opoids like you guys have said. My partner was giving me some flack for doing it mainly for the possibility of phrenic nerve involvement. The patient had also gone to another hospital in town for his other shoulder and they did not do a block at that time for whatever reason also.

 

[B-Bone]

Also, if I recall, there is a nontrivial incidence of phrenic nerve blockade with supraclavicular block (like 30-70% in some studies) so if that's your real concern, I would not do supraclavicular block either. I, personally, routinely do ISBs for OSA pts.

 

[psychbender]

For the patients in whom you have a serious concern for phrenic nerve block undergoing any shoulder procedure, has anyone just done a suprascapular nerve block? I've only done it once, and figured that at least covering the posterior third of the joint should provide better analgesia than opioids alone. My n of 1 did quite well post-op, with no phrenic nerve paralysis and minimal opioid use at 24 hours.

 

[Planktonmd]

Avoiding intrascalene blocks in OSA does not make any sense.
As for supraclavicular blocks they are just as good as ISB for shoulder surgery and you can actually do only SCBs for all your shoulders and get excellent results all the time.

 

[Arch Guillotti]

Avoiding intrascalene blocks in OSA does not make any sense.
As for supraclavicular blocks they are just as good as ISB for shoulder surgery and you can actually do only SCBs for all your shoulders and get excellent results all the time.

Agree.

 

[bcat85]

I agree. If anything, regional anesthesia should be encouraged in patients with OSA to help avoid postoperative narcs. Intrathoracic respiratory mechanics aren't really an issue.

 

[DreamLover]

Trying to get a feel. I was taught to avoid ISB in patients with the obvious respiratory issues like COPD but it was always a little gray when sleep apnea was involved.

So what areas of respiratory physiology and ISBs are gray for you concerning sleep apnea? Who was teaching you not to block pt's with sleep apnea? That makes no sense. If anything, you want to block as many as you can to avoid post op opioids like mentioned above.

 

[stonemd]

Supraclavicular block has a significant incidence of phrenic block. If a patient has contraindication to ISB / SCB like contra lateral pneumnoectomy, I would do suprascapular and axillary nerve nerve block. Of course that is ax nerve as it lies on humerus NOT axillary approach to the brachial plexus.

 

[RxBoy]

Had a pt going for bilateral shoulder replacement. Both previous prosthetics became infected and had to replace them both.

Shoulder 1: IS cath
0 pain

Shoulder 2: infraclavicular block
Moderate pain but not excruciating.

Infraclavicular for shoulder helps a little too but def not a SCB or ISB.

 

[Arch Guillotti]

Had a pt going for bilateral shoulder replacement. Both previous prosthetics became infected and had to replace them both.

Shoulder 1: IS cath
0 pain

Shoulder 2: infraclavicular block
Moderate pain but not excruciating.

Infraclavicular for shoulder helps a little too but def not a SCB or ISB.

Why was an infra done in the first place?

 

[OB1🤙]

Presumably not to bag both phrenics?

 

[OB1🤙]

Of course that is ax nerve as it lies on humerus NOT axillary approach to the brachial plexus.

Huh. I gotta learn that one.

 

[Arch Guillotti]

Presumably not to bag both phrenics?

I guess so. Seems like kind of a strange approach though.

 

[Mman]

I guess so. Seems like kind of a strange approach though.

about as strange as doing both shoulders at once. Did they have a femoral line for IV access? Femoral arterial line as well?

 

[BuzzPhreed]

I know BladeMDA has posted a case report about bagging the phrenic nerve during a SCB, but I have never had that complication and I think this is a better approach in general for shoulders. I don't think you should avoid regional in these patients as the tendency is to give more narcs post-op and, for many of them, this is a worse conundrum.

 

[deleted126335]

I know BladeMDA has posted a case report about bagging the phrenic nerve during a SCB, but I have never had that complication and I think this is a better approach in general for shoulders. I don't think you should avoid regional in these patients as the tendency is to give more narcs post-op and, for many of them, this is a worse conundrum.

Are you sure? In many patients bagging the phrenic with a block is very well tolerated. Do you auscultate every patient or get CXRs routinely post block? I suspect that if you listen to breath sounds in your patients in PACU, you will find that a lot of them have decreased breath sounds on the side of the block. A lot of complication rates are considered low because they are temporary, not terribly bothersome in many cases and because we don't look that hard.

 

[BuzzPhreed]

Are you sure? In many patients bagging the phrenic with a block is very well tolerated. Do you auscultate every patient or get CXRs routinely post block? I suspect that if you listen to breath sounds in your patients in PACU, you will find that a lot of them have decreased breath sounds on the side of the block. A lot of complication rates are considered low because they are temporary, not terribly bothersome in many cases and because we don't look that hard.

Of course I'm not 100% "sure". But I have not had one patient complain of SOB since we stopped doing IS blocks for shoulders. We uniformly changed this in our practice and my colleagues would share a similar experience. If you block the brachial plexus lower your chances of hitting the phrenic go down substantially. Not zero (as at least one case report offered by BladeMDA shows). But we just don't get the routine "I can't catch my breath" that we used to when we did IS blocks.

Use ultrasound for all of these blocks too. Especially in COPD patients who's lung domes may be dangerously close to where you're sticking the needle.

 

[Mman]

Of course I'm not 100% "sure". But I have not had one patient complain of SOB since we stopped doing IS blocks for shoulders. We uniformly changed this in our practice and my colleagues would share a similar experience. If you block the brachial plexus lower your chances of hitting the phrenic go down substantially. Not zero (as at least one case report offered by BladeMDA shows). But we just don't get the routine "I can't catch my breath" that we used to when we did IS blocks.

Use ultrasound for all of these blocks too. Especially in COPD patients who's lung domes may be dangerously close to where you're sticking the needle.

My incidence of a new postop oxygen requirement after interscalene block vs supraclavicular block (both under u/s) guidance is identical. Both are extremely rare because unilateral phrenic nerve paralysis is tolerated extremely well by most patients. Why is the incidence so similar? Because they are almost the same block. The tip of the needle for an U/S guided supraclavicular block is about 1 cm away from the tip of a needle for an U/S Guided Interscalene nerve block and you are putting in 20-40 mls of local.

U/S guided interscalene blocks are more distal than landmark interscalene blocks. Conversely, U/S guided supraclavicular blocks are more proximal than landmark based supraclavicular blocks. The old adage about supraclavicular blocks being far less likely to cause phrenic nerve paralysis just doesn't work when you use ultrasound because an U/S guided supraclavicular is more likely to get the phrenic nerve than a landmark based technique (but similar in incidence to U/S guided interscalene).


In short, if you use an ultrasound then a supraclavicular block and an interscalene block are almost the exact same thing. Supraclav slightly better at getting the ulnar nerve and Interscalene slightly better at getting nerves that branch off earlier like Suprascapular.

 

[Planktonmd]

My incidence of a new postop oxygen requirement after interscalene block vs supraclavicular block (both under u/s) guidance is identical. Both are extremely rare because unilateral phrenic nerve paralysis is tolerated extremely well by most patients. Why is the incidence so similar? Because they are almost the same block. The tip of the needle for an U/S guided supraclavicular block is about 1 cm away from the tip of a needle for an U/S Guided Interscalene nerve block and you are putting in 20-40 mls of local.

U/S guided interscalene blocks are more distal than landmark interscalene blocks. Conversely, U/S guided supraclavicular blocks are more proximal than landmark based supraclavicular blocks. The old adage about supraclavicular blocks being far less likely to cause phrenic nerve paralysis just doesn't work when you use ultrasound because an U/S guided supraclavicular is more likely to get the phrenic nerve than a landmark based technique (but similar in incidence to U/S guided interscalene).


In short, if you use an ultrasound then a supraclavicular block and an interscalene block are almost the exact same thing. Supraclav slightly better at getting the ulnar nerve and Interscalene slightly better at getting nerves that branch off earlier like Suprascapular.

Agree!

 

[pgg]

As an aside, don't forget that IS/SC blocks will often get the recurrent laryngeal nerve. I'm just going to repost one of my learning experiences as a resident, that has a couple points related to this thread:

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You could consider a continuous interscalene block where the catheter is threaded out distally. You're further away from the phrenic nerve and can use smaller volumes ... supposedly less risk of bagging that hemidiaphragm.

I had an M&M as a newbie CA-1 that started out a lot like your case. COPDer scheduled for a total shoulder arthroplasty. She had preexisting contralateral vocal cord paralysis from an old thyroidectomy gone bad. After a previous surgery, she'd had a respiratory arrest because even the small amount of narcotic they gave her sent her into a hypercarbic tailspin. Attending wanted to avoid using narcotics postop so (despite my fear of blocking her remaining good RLN) we put in an interscalene catheter, threaded it out about 4-5 cm distally and ran an infusion. She did great postop until the next day, when the catheter migrated, and (as feared) her RLN got blocked ... CXR showed an elevated hemidiaphragm on that side so we probably got the phrenic too. She got stridorous, now both vocal cords are paramedian, and she was intubated until the block wore off. She wakes up, gets extubated, and plan B takes effect (PCA), and sure enough she has another hypercarbic respiratory arrest and gets tubed again.

There were plenty of errors in this fiasco, but overall this experience did not make me a big believer in "phrenic sparing" interscalene blocks.

 

[BLADEMDA]

Had a pt going for bilateral shoulder replacement. Both previous prosthetics became infected and had to replace them both.

Shoulder 1: IS cath
0 pain

Shoulder 2: infraclavicular block
Moderate pain but not excruciating.

Infraclavicular for shoulder helps a little too but def not a SCB or ISB.

For those patients who can't tolerate an ISB/SCB the ICB plus Suprascapular block is the ticket if you have the time. Stone's Axillary block on the humerus plus Suprascapular block is another well described postop analgesic technique.