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Supraclavicular block for shoulder surgery

Discussion in 'Anesthesiology' started by zonker1, Dec 27, 2008.

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  1. zonker1

    zonker1

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    I have a new locums who says that he can cover the pain from shoulder arthoscopy with a supraclavicular block, I have read it will not but books do not tell everything anyone else doing this?
  2. turnupthevapor

    turnupthevapor

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    You may miss dorsal scapular nerve, which may or may not matter....interscalene is easier and safer anyway:hungover:
  3. IceDoc

    IceDoc Junior Member

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    Ditto on why one would choose supraclavicular over interscalene. Enough propofol during the procedure will ensure the supra scapular nerve is blocked! A superficial cervical plexus block would also be needed; and the surgeon should still give some local at the sites.

    Anyway, I won't do a suprascapular without ultrasound; that pesky lung is just too close.
  4. coprolalia

    coprolalia Bored Certified

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    :eyebrow:

    -copro
  5. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    I think the original question was asked by someone who did not know the difference between supraclavicular block and suprascapular block.
    I think he heard that a suprascapular block would be good for post op pain after shoulder arthroscopy which is true and actually safer than interscalene in patients with marginal respiratory function.
  6. coprolalia

    coprolalia Bored Certified

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    More importantly, why did zonker1 get banned?

    -copro
  7. Gator05

    Gator05 Resident

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    Suprascap only gets the posterior 50% of the AC joint, and not that much of the more lateral RC. To get complete (or near complete) AC and prox RC, you need to also get the lateral articular branch of the pectoral nerve. We're actually working on this block with some phenomenal results in the SAD's.
  8. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

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    He is over on the CRNA debate area and continues to be a pain in the
  9. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    True,
    A suprascapular block is not perfect but it's better than nothing if you can't do an interscalene or if your interscalene is not working.
    Where do you block the pectoral nerve?
  10. alex1

    alex1

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    supraclavicular
    not suprascapular
  11. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    Oh, thanks for clarifying.
    So you are the OP who now has a different name?
  12. sbmed100

    sbmed100 New Member

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    Ultrasound guided supraclavicular block is all you need for any type of upper extremity surgery including shoulder surgery. I routinely do even shoulder replacements with just this block and moderate sedation -yes, that means no GA and no supplemental blocks like superficial cervical. You have to be comfortable with an ultrasound though, and moving the needle to at least two positions. To my knowledge, to date, there have been no reports of pneumothorax with this block under ultrasound guidance.

    Why SCB over interscalene?? Cause you don't have to discuss hoarseness, Horner's syndrome or unilateral phrenic nerve palsy with patients. This is a TREMENDOUS advantage, and allows much greater acceptance if you are starting a regional program at your local hospital like I did. Furthermore, you are not exposing your patients to both regional and GA.
  13. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    Makes sense.
  14. USAnesthesiaDoc

    USAnesthesiaDoc

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    I definitely agree that u/s guided supraclavicular block is great. It is truly the spinal of the shoulder/arm. Whenever I have a case operated on from the shoulder to the wrist, it is frequently my 1st choice. If I have a shoulder case and the patient is thin without asthma, sleep apnea, or smoking hx and the brachial plexus is easily identified on ultrasound in the interscalene groove, I'll block it there. Otherwise, supraclavicular works just as well and you don't get the phrenic nerve and superior laryngeal nerve blocks that come with an interscalene. For shoulder surgery, the supraclavicular blocks the entire shoulder joint; there is some occasional sparing of skin of the posterior shoulder, but the surgeon can always supplement with local there. For more distal surgery, you have to make sure you get adequate distribution of local in the supraclavicular brachial plexus area and watch out to avoid missing the ulnar nerve. Ultrasound guidance is key and making sure you can define your entire needle including the tip to avoid PTX.

    Have done this block in many morbidly obese patients and it is almost always quite easy to id the plexus in the supraclavicular location and they usually don't get a phrenic nerve block. I had one obese patient who was a repeat shoulder surgery that I did an interscalene on with nerve stimulator about a year ago (before we had u/); he said he was extremely relieved when the block wore off so he felt like he could breathe again. For his 2nd surgery about 2 months ago, I discussed doing the supraclavicular and using ultrasound and it worked perfectly with no respiratory compromise and he was MUCH happier. It also took me much less time.
  15. Pooh & Annie

    Pooh & Annie Member

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    If this is true, (I don't doubt you), you should collect some data for publication.
  16. Gator05

    Gator05 Resident

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    We get better results, including posterior shoulder coverage, with cervical paravertebral. Also easier and more reliable catheter placement. Same minimization of side effects. Less risk of hitting the pleura and can be done with stim or ultrasound.
  17. Hawaiian Bruin

    Hawaiian Bruin Breaking Good

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    As I said in a recent thread, I love the supraclavicular. We've been doing it for shoulders also, but even with the U/S and obvious bathing of the plexus with LA, we've had to supplement with a superficial cervical plexus on occasion. We've had great results most of the time, but it's not 100% IMO.
  18. CambieMD

    CambieMD cambiemd

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    I use a nerve stimulator along with an u/s. Some may think that this is overkill. For my pop blocks for bunionectomies I like to make sure that I get the post. tibialis. I look for plantar flexion. I also dial down the stim to see where I loose movement. This helps prevent intraneural injection of LA.

    I use an u/s for most of my blocks. I don't use an u/s for ankle blocks.
    By the way,ankle block is a fovorite board topic.

    Someone asked about a good regional book. I recommend the book by Peter Marhofer. It is small and cost less than $ 50. The book can fit in your lab coat pocket. I have a rule of purchasing soft cover books over expensive hard cover books.

    I apologize for going off of the original topic.

    Cambie
  19. Noyac

    Noyac SDN Advisor SDN Advisor

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    SO you believe that everyone that gets or would get a PTX after a block would report it?
  20. sbmed100

    sbmed100 New Member

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    I don't believe everyone who gets a pneumothorax with a block will write it up, however, this is a block which some large academic centers have been doing for a while now. At such places people jump at the chance to write up cases.

    Pooh & Annie, data was/is being collected for publication.
  21. SleepIsGood

    SleepIsGood Support the ASA !

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    SBMED...Noy brings up a point.

    U/S being a reason to avoid PTX and a way of increasing returns, would people truly report it.

    I dont know the answer. I'd hope people werent unethical, but....
  22. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    Do you guys know which block is the best block for the patient?
    It is the block that the anesthesiologist is most comfortable doing and does all the time.
    It is good to know how to do different techniques but at the end of the day each anesthesiologist should develop a personal style and preferences.
    Like everything else in this field, there is no absolute right or wrong there is always many good ways to achieve the same result.

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