Interscalene Block

[stanleykristian]

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I do about 2 to 3 interscalene blocks a week. I usually use about 15-20 cc of .5% ropivicaine and have had great success, but I have read that some clonidine will extend the block considerably. Has anyone tried this and if so what is your favorite mix? I will try it at some point I am sure.

 

[Noyac]

Tell me your technique. Because how you do it matters. Please go into detail. Then I can tell you if clonidine will help.

 

[VentdependenT]

I do about 2 to 3 interscalene blocks a week. I usually use about 15-20 cc of .5% ropivicaine and have had great success, but I have read that some clonidine will extend the block considerably. Has anyone tried this and if so what is your favorite mix? I will try it at some point I am sure.

I would also like to know.

Volume seems a bit low though eh?

 

[stanleykristian]

Identify the interscalene groove advance cath perpendicular to the skin with stimulator at 1.0 Ma. When I get appropriate response i.e. forearm twitch , pec twitch reduce voltage until response is maintained at .5Ma or less. Inject 20 cc.5% ropivicaine. On the way out run cath subcue to get the superficial cervical plexus.

 

[mille125]

just add more volume...your volume is low

 

[Noyac]

Identify the interscalene groove advance cath perpendicular to the skin with stimulator at 1.0 Ma. When I get appropriate response i.e. forearm twitch , pec twitch reduce voltage until response is maintained at .5Ma or less. Inject 20 cc.5% ropivicaine. On the way out run cath subcue to get the superficial cervical plexus.

So what do you do with the Pec twitch? Besides turn down the stimulator. What size catheter are you using? What is the dose in the cervical plexus? What are you trying to accomplish with the cervical plexus block?

 

[stanleykristian]

anesthesia and analgesia for shoulder scope, 22g cath, pectoral twitch indicates you are stimulating the plexus, as you turn stimulator down advance cath to maintain response.

 

[stanleykristian]

No problems with results just wanting to know if anyone is using clonidine and if it effective. I know what I am doing works. Just want to see if there is a significant difference using clonadine.

 

[mille125]

if your results are so good why change your technique, clonidine is not without side effects...hypotension can and does happen and brings in another variable...is hypotension from GA, spinal block, or clonidine....I dont see why you want to change if what you are doing works.........

 

[stanleykristian]

To see if they can be better, and since I have not used clonadine in these blocks, to see if anyone has. And to find out if benifits can outwigh the possible complications. Always look for improvment

 

[Noyac]

Are you doing these as continuos blocks?

What part of the plexus stimulates the pectoralis?

 

[stanleykristian]

No single shot, pec is stimulated by the upper trunk

 

[Noyac]

No single shot, pec is stimulated by the upper trunk

So if its a single sot, why are you using a catheter?

I never get a pec stimulation.

 

[stanleykristian]

I am not using an indwelling cath, when I say cath I am refering to the insulated needle, sorry for the confusion. I do not always get pec stimulation actually only once or twice but NYORSA web site lists it and I get results, so go figure.

 

[Noyac]

It sounds like you are reading the NYSORA website and not really doing these blocks to me.

How long are your blocks lasting?

 

[stanleykristian]

I perform these blocks using NYSORA as a guide,anesthesia at least 4 hours analgesia about 12. Do you have an answer or not, I do not know if you perform these blocks either this is the internet. If you do not have an answer just say so.

 

[Planktonmd]

I think he is getting a phrenic nerve stimulation and when he sees the hemithorax jumping he thinks it's the pectoralis.
But even if he injects at the phrenic nerve he might still get some degree of block to the brachial plexus, although he said that when he sees the "pectoralis twitch" he advances the needle which I think meant he goes more posterior and that would do it.
That's my analysis 🙂

I have used Clonidine in the past with interscalenes but wasn't very impressed.

 

[mille125]

I think he is getting a phrenic nerve stimulation and when he sees the hemithorax jumping he thinks it's the pectoralis.
But even if he injects at the phrenic nerve he might still get some degree of block to the brachial plexus, although he said that when he sees the "pectoralis twitch" he advances the needle which I think meant he goes more posterior and that would do it.
That's my analysis 🙂

I have used Clonidine in the past with interscalenes but wasn't very impressed.

your analysis is right on....clonidine for interscalenes does not offer much benefit (i have tried it to)...my question to him was why add it if you already have a good block........he really needs to give more volume (20cc's, good grief)

 

[urgewrx]

What part of the plexus stimulates the pectoralis?

Don't know which part per se, but it is innervated by brachial plexus.

Pec twitches work very well for interscalene. Probably cover the hole arm.

 

[Noyac]

Don't know which part per se, but it is innervated by brachial plexus.

Pec twitches work very well for interscalene. Probably cover the hole arm.

No ****.

This guy doesn't do IS blocks. And that is what I am getting at. He stated that he advances after getting a pec twitch. I asked "what part of the plexus stimulate the pec's?" He is lost and trying to cover some earlier posts.

 

[Noyac]

By the way the pec stimulus comes from C 5&6 with a minor contribution from C 4. It provides a small contribution to the lateral pectoralis.

 

[epidural man]

just add more volume...your volume is low

15 to 20 cc is adequate if placed in the right spot. Try it under ultrasound and you will see that the nerves can be completely engulfed with local if needle placement is good. Since we started using ultrasound, our volumes have decreased quite a bit without loosing anything in efficacy.

As far as clonidine, the literature is somewhat confusing. Adjuncts like clonidine do prolong a block but mostly if the local is short acting. For example, if you are using mepivicaine, clonidine will prolong analgesia. However, with bupivicaine, it is less likely to be helpful. Same thing with buprenophine (Buprenex), which will greatly prolong a short acting block but will do much less with longer acting.

My take on ropivicaine is that it is shorter acting than bupivicaine and certainly not as dense. My guess is that clonidine might do something but I think you are better off with Buprenex. This drug can work well with little side effects. Add 300mcg to your mixture. I usually will add all 300 to the first syringe so I know it makes it to the area. Some will split it and add 150 to each 20cc syringe. If you go with clonidine, 100mcg works well. I really like the idea of clonidine if you are using a general on top of your regional block because of all the perioperative benefits clonidine adds to your anesthestic. Clonidine has so many great perioperative benefits that have been shown in our literature, yet few use it.

 

[epidural man]

One more thing I wanted to add...

After our blocks, we do 24 hr follow up calls, and I know what the literature says on these things, but it seems to me from this small cohort of our patients that buprenex really can give a long lasting analgesia on some. It has amazed me that sometimes people will report 24+ hrs of good pain relief - and they knew EXACTLY when the block wore off. It can be impressive.

On the flip side of that, I often think that perhaps it is not good for a nerve to get bathed in poison to stop it from working correctly, and then add a drug that prolongs this dysfunction for even longer. Maybe it is harmful for the nerve to get "numbed" for so long.

 

[VolatileAgent]

i dont' remember ever looking for pec twitches for interscalene, but them i'm not usually looking at the pecs. doing a infracoracoid approach, yes. but that just means you need to go deeper.

 

[militarymd]

i dont' remember ever looking for pec twitches for interscalene, but them i'm not usually looking at the pecs. doing a infracoracoid approach, yes. but that just means you need to go deeper.

I'll get pec twitches once or twice a month...not very common, but I have always gotten excellent blocks when I inject on them...NYSORA recommends injecting on pec twitches.

 

[burgundylover]

i dont' remember ever looking for pec twitches for interscalene, but them i'm not usually looking at the pecs. doing a infracoracoid approach, yes. but that just means you need to go deeper.

Ok, just happened to come across this forum & thought I would chip in my 2 cents. Let me preface this by saying that I've been in private practice for 10 years & split my time between a large hospital & a busy orthopedic surgery center where I will do 10-15 interscalene nerve blocks / week on average.

1. The use of the ultrasound is a great tool and allows you to use 20 cc of local anesthetic or less on your blocks. I typically use 15-20 but some people are using around 10 cc.

2. If you want to use a nerve stimulator, I don't think anyone in our group or during training accepted a pec twitch as acceptable. Now with the ultrasound, we notice that you can get a great block & not even elicit a twitch response.

3. As to adjuvants, I think the data is mixed on clonidine if you are using ropivicaine, probably doesn't show a great benefit with bupivicaine.

4. The use of epi appears to hasten the onset of the block, but probably doesn't do much for duration.

5. I would recommend the use of the lightest concentration of local anesthetic if you are performing a general anesthesia for the surgery.

 

[OffPiste]

U/S definitely preferred here, and can direct your local right around the plexus. Volume and local conc. depends on if one will used this as a surgical block w/ some deep sedation/LMA or if it will be for post op pain.

For surgical block I often use Ropi 0.75 up to 20 cc +/- clonidine. If using adjuvants, not uncommon to see blocks last 20+ hrs.

If gramps is going to sleep for sure, 0.5% ropi will do for post op analgesia, ~20cc.

With good visualization on U/S you can get by with 15cc or less of 0.75% ropi.

Dont care so much about twitches with U/S, but if you still arent sold and going straight twitch, I want the biceps/triceps.

 

[imfrankie]

Dexamethasone adjunct is nice when not contraindicated.

 

[dhb]

Dexamethasone adjunct is nice when not contraindicated.

4 or 8mg?

 

[imfrankie]

4 or 8mg?

8

 

[PinchandBurn]

Dexamethasone adjunct is nice when not contraindicated.

Dexmethasone for a post op analgesia (for perio op management, not for chronic pain patients)?

You arent talking about dexmedetomidine right?

 

[sevoflurane]

Dexamethasone extends block duration.