Case Question: Patient with COPD on chronic narcotics: Interscalene block?

[jd1572]

Clinical case: 65 yr old for shoulder arthroplasty. Has COPD, sat 94% on RA but patient uses 4L NC at home with activity. Patient is on high dose narcotics because of pain due to prior lumbar disc surgery and a cervical fusion, in addition to the shoulder pain that is prompting the surgery. Patient's pain is currently not very well controlled, 9/10 as you speak to patient preop.

Questions:
1) Would you do an interscalene block (knowing that the phrenic nerve will be paralyzed)?
2) If so, what concentration and medication would you use?
3) If COPD or "poor baseline respiratory function" is a reason to not do this block, how bad does the COPD have to be?

Just wondering what people think about this. Thanks!

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[2ndyear]

If this were my patient tommorrow, at this stage in my career, no block. I don't know what his lung function is but when you knock out the phrenic it will be even less than it is now. If PFT's were in the chart anywhere I'd look at them. If they were recent and FEV1 was 80% of pred., then maybe. But I doubt it's that good. That being said, this is going to hurt. Bad. He's already on the junk and pain control will difficult. If you presented it to the patient that the block might make his breathing more difficult, and he may even have to be intubated overnight then you could make a case for it.

If you haven't checked out the neuraxiom site I highly recommend it. There is an ongoing database about phrenic sparing interscalene blocks. Anything with stim (stim alone or US and stim) so far has a 100% phrenic block. US only 45%. 25% with a local volume of 1-10 cc's. Very small number of patients, but I guess if I were to do it, US guided, and as little volume as possible.

 

[zippy2u]

Dude, I haven't looked at a PFT in 6 years, do they still do that crap? Blow off the ISB and tell surgeon to inject about 30 mls of 0.5% marcaine with epi in the shoulder joint once he's done. Some Toradol and demerol in the PACU and he's out the ASC in 1 hour. Next! Regards, ----Zippy

 

[Planktonmd]

Clinical case: 65 yr old for shoulder arthroplasty. Has COPD, sat 94% on RA but patient uses 4L NC at home with activity. Patient is on high dose narcotics because of pain due to prior lumbar disc surgery and a cervical fusion, in addition to the shoulder pain that is prompting the surgery. Patient's pain is currently not very well controlled, 9/10 as you speak to patient preop.

Questions:
1) Would you do an interscalene block (knowing that the phrenic nerve will be paralyzed)?
2) If so, what concentration and medication would you use?
3) If COPD or "poor baseline respiratory function" is a reason to not do this block, how bad does the COPD have to be?

Just wondering what people think about this. Thanks!

If a patient is taking high dose narcotics pre-op and is telling you that he has 9/10 pain, this means that most likely you are dealing with a drug addict, and your regional anesthetic will not work no matter what you do because he will never tell you that he feels better unless you give him more drugs.
So, do you want to do a procedure that will not work but could have serious side effects?

 

[Tenesma]

on the other hand if his COPD is severe enough then his diaphragms may be flat and his phrenic nerve may be useless at this point in time, since he is probably relying 99% on accessory muscles (intercostals, etc...)...

i agree w/ zippy - and have him on ketamine post-operatively

 

[jd1572]

Thanks for the thoughts. Some other questions I had with regard to everyone's excellent replies:

1) It seems most surgeons don't like their patients to get ketorolac, so that part is usually thrown out of the analgesic regimen. I can't remember exactly, but some of them also quote studies about reduced bone healing with NSAIDS (osteoclast activity, blah, blah).

2) Zip - you mentioned demerol? What would be the benefit of that, as compared to something like fentanyl or hydromorphone?

3) As for ketamine - Would you give this intraop, or just postop? And what doses? For someone "elderly", how much do you worry about delirium/hallucinations from the ketamine?

4) What do you guys think about doing the interscalene block with a lower concentration of local, something like ropivacaine 0.2% or 0.15%? I don't know the literature, but would this decrease the chance of phrenic nerve/diaphragm weakness?

Thanks!

 

[pgg]

Just wondering what people think about this. Thanks!

Intraarticular local with or without morphine, with or without one of those take-home spring pumps to infuse more local.

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.

 

[zippy2u]

The pt' is an addict with 9/10 pain. Give him something he'll enjoy like demerol or dilaudid that will last until ya get him out the door. Fentanyl doesn't last very long. The guy's a squirrel, ketamine will make him moreso. Everybody got paid, it's time to unleash him to the outside world after an hour so the rest of the world may benefit from his presence-- Zip don't do babysittin'. Regards, ----Zippy

 

[pmichaelmd]

I would generally shy away from single-shot interscalenes in folks with severe COPD. However, in this case, I would consider inserting a stimulating catheter and drive it distally as described above. If you get good stimulation 4-6cm distally and THEN inject, you have a greater chance of sparing the phrenic. I don't have exact numbers, and this advice is based on personal anecdotes from training under a regional guru at Mayo, but it worked pretty well while I was in training. We could inject 0.5% ropivacaine, 25-30 cc, through the catheter and still spare the phrenic. Of course, if you want to be conservative, I'd use 0.2% ropivacaine instead and get it running on a pump at 8 cc/hr with an 8 cc bolus q1h early in the case. Also agree with the above, that this pt. is likely a drug seeker and you'll have a difficult time making him happy without indulging his narcotic needs. Dilaudid PCA + interscalene stim cath and pure local. Yep, I'd consider that 🙂

Regards,
PMMD

 

[9french]

Do a suprascapular block. Not quite as good as an interscalene, but much safer in a COPDer.

 

[Noyac]

I wouldn't have any problem doing a block in this guy. I do it all the time in COPD'ers and they don't seem to any problems and this is at altitude. I would see phrenic n involvement more when I was a resident and new attending. I don't see it so much any more and I'm not sure why.

I typically do blocks in these pain pts and give them their regular meds. They can complain all they want about pain but it gonna work. They go home in the same condition they walked in.

Zip, I like your demerol plan. I do it all the time. If fent or MS are not getting them comfy I go directly to demerol and it works every time. Pts love the feeling.

 

[Planktonmd]

I wouldn't have any problem doing a block in this guy. I do it all the time in COPD'ers and they don't seem to any problems and this is at altitude. I would see phrenic n involvement more when I was a resident and new attending. I don't see it so much any more and I'm not sure why.

I typically do blocks in these pain pts and give them their regular meds. They can complain all they want about pain but it gonna work. They go home in the same condition they walked in.

Zip, I like your demerol plan. I do it all the time. If fent or MS are not getting them comfy I go directly to demerol and it works every time. Pts love the feeling.

I like Demerol as well, I think it triggers a great euphoric experience and makes patients happy at least for a short period of time that would allow you to discharge them from the PACU so someone else gets to deal with them which is precisely Zippy's philosophy 😀
As for interscalene blocks in severe COPD patients I tend to do supra-scapular blocks and call it a day. Remember that the suprascapular nerve is the main nerve for the shoulder joint itself.

 

[Planktonmd]

Do a suprascapular block. Not quite as good as an interscalene, but much safer in a COPDer.

👍

 

[Noyac]

never done one

Will need to add it to the repertoire

 

[USAnesthesiaDoc]

I haven't done one either. Does anyone have any good description of the technique, with or without using ultrasound?

 

[militarymd]

I haven't done one either. Does anyone have any good description of the technique, with or without using ultrasound?

this nerve is probably too small to be seen by ultrasound

 

[Planktonmd]

I haven't done one either. Does anyone have any good description of the technique, with or without using ultrasound?

You don't need ultrasound or even a nerve stimulator.
Mark the scapular spine and draw a line between the accromion and the medial end of the scapular spine.
Mark the middle of this line, now draw a line 2 cm up perpendicular to the scapular spine then 2 cm medial.
Insert the needle at 45 degree lateral toward the scapula, when you encounter bone withdraw 1 mm aspirate and inject.
If you use a stimulator you can look for abduction twitches of the shoulder.
You will not get skin anesthesia with this block but you will get anesthesia of the joint.

 

[jetproppilot]

I think it comes down to risk-benefit.

Whats the risk of doing a straight general, being light with adjunctive medicines (benzos, opiods), waking the guy up, then titrating in opiods after extubation has been accomplished?

Whats the risk of making a dude with zero pulmonary reserve breathe with halffa diaphragm because of the block?

Severe preoperative pulmonary dysfunction would make me shy away from bagging a phrenic via interscalene block.....and I'm a regional advocate.

Yeah, pain sucks after an operation.

Potentially breathing thru a snorkel postoperatively sucks worse.

 

[dhb]

Do a suprascapular block. Not quite as good as an interscalene, but much safer in a COPDer.