Need some Jedi Advice

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99 replies to my question.....BRAVO SDN! I really appreciate what each of you had to add. Although I thought the suprascap/Infra Post Cord was sexy I was worried about the infra cath being in the field and the suprascap not offering prolonged analgesia.

So when meeting her in HA she had some conversational dyspnea and a room air PAO2 of 60. 1 mg of versed and headed to the room. I put her on her side and placed a Pajunck Echo Curl Catheter in a low interscalene position (under the superior trunk in a grapeish vs traffic light spot). I placed 7 ml of 1.5 mepi @ which point all her pain went away. I did this to evaluate how she would tolerate the catheter overnight. If she failed I would have induced GA and the Mepi would be gone when she woke up, if she tolerated it I would use the catheter on the floor for the next few days.

During the awake A-line I kept an eye on her and noted she developed no increased work of breathing making me think I didn’t wack the phrenic (or if I did she tolerated it). Moved her to the SPIDER and induced with 40 mg of the white stuff and intubated. She was 99% on 31 % FIO2 with PSV and a touch of PEEP. During the case I added 5 ml of .2 Ropi on 2 separate occasions and at the end of the case extubated her. In PACU pain score 0 and I ran 5 ml/hr .2 ropi with 5 ml q 1 hr demand bolus. Just called the MICU and the RN informed me pain score 0 and happy as a clam!!!

Just to note she clinically was not as severe as her spirometry painted her out to be. If she had been more decompensated the supra/infra would be potentially the winner!
 
Timeoutofmind said:
Serious bro...what's your prob?
This is just mean spirited.
Blade never has taken it to a personal level, posts clinical stuff all the time for the betterment of the forum, and cares about his work more than most in anes.
U need to introspect...
Click to expand...
He does not get to call people names just because he is crazy!
But maybe you like to be called "Slim"?
 
BLADEMDA said:
As you can see from the diagram a SSN plus ICB blocks all 5 nerves responsible for post-surgical shoulder pain.
Click to expand...
So now you are talking about a full infraclavicular block! What happened to selectively blocking the posterior cord? or the axillary nerve?
Yes, a good infraclavicular block with or without SSB would most likely provide some post-op analgesia for a proximal humerus fracture, but everyone knows that or did you just discover it?
 
Last edited:
turnupthevapor said:
99 replies to my question.....BRAVO SDN! I really appreciate what each of you had to add. Although I thought the suprascap/Infra Post Cord was sexy I was worried about the infra cath being in the field and the suprascap not offering prolonged analgesia.

So when meeting her in HA she had some conversational dyspnea and a room air PAO2 of 60. 1 mg of versed and headed to the room. I put her on her side and placed a Pajunck Echo Curl Catheter in a low interscalene position (under the superior trunk in a grapeish vs traffic light spot). I placed 7 ml of 1.5 mepi @ which point all her pain went away. I did this to evaluate how she would tolerate the catheter overnight. If she failed I would have induced GA and the Mepi would be gone when she woke up, if she tolerated it I would use the catheter on the floor for the next few days.

During the awake A-line I kept an eye on her and noted she developed no increased work of breathing making me think I didn’t wack the phrenic (or if I did she tolerated it). Moved her to the SPIDER and induced with 40 mg of the white stuff and intubated. She was 99% on 31 % FIO2 with PSV and a touch of PEEP. During the case I added 5 ml of .2 Ropi on 2 separate occasions and at the end of the case extubated her. In PACU pain score 0 and I ran 5 ml/hr .2 ropi with 5 ml q 1 hr demand bolus. Just called the MICU and the RN informed me pain score 0 and happy as a clam!!!

Just to note she clinically was not as severe as her spirometry painted her out to be. If she had been more decompensated the supra/infra would be potentially the winner!
Click to expand...

Nice job. FYI, I have found that single shot blocks like the SSN plus ICB can last over 24 hours (even 30 hours) in 90 year old patients. The combination of 0.5% Bupivacaine with dexamethasone really prolongs the analgesia.

The other point is that the vast majority of patients with lung disease will tolerate a low ISB or SCB if the volume injected is fairly low (around 10 mls). Most of my colleagues do this sort of thing for patients with severe COPD and the results have been excellent with no patients needing overnight postop ventilation secondary to the block.

I do think the SSN plus ICB (posterior cord is all you need to block really as the spread to the lateral cord is guaranteed with 10 mls) is the academic answer to the question you originally asked in this thread. The last time I did a SSN plus ICB (posterior cord) was for an 89 year old with severe COPD having a total shoulder replacement. The case was a request for me and the patient did well with no pain for 26 hours postoperatively.
 
An injection to block the posterior cord almost always spreads to the lateral cord. From the picture below the posterior cord and lateral cord combined with a SSN should provide very good postop analgesia for a total shoulder replacement.

brachial-plexus-injuries-by-krr-6-638.jpg
 
algosdoc said:
Just for stats purposes, the interscalene approach results in a 43% incidence of hemidiaphragmatic paralysis whereas a supraclavicular approach it is 24%. https://www.ncbi.nlm.nih.gov/pubmed/27098548
Click to expand...
I think these numbers are more realistic than the usually echoed 100%, but one could argue that these were continuous blocks, which might imply that the initial bolus was not a large volume, which could explain why the phrenic nerve was more frequently spared.
 
Last edited:
turnupthevapor said:
99 replies to my question.....BRAVO SDN! I really appreciate what each of you had to add. Although I thought the suprascap/Infra Post Cord was sexy I was worried about the infra cath being in the field and the suprascap not offering prolonged analgesia.

So when meeting her in HA she had some conversational dyspnea and a room air PAO2 of 60. 1 mg of versed and headed to the room. I put her on her side and placed a Pajunck Echo Curl Catheter in a low interscalene position (under the superior trunk in a grapeish vs traffic light spot). I placed 7 ml of 1.5 mepi @ which point all her pain went away. I did this to evaluate how she would tolerate the catheter overnight. If she failed I would have induced GA and the Mepi would be gone when she woke up, if she tolerated it I would use the catheter on the floor for the next few days.

During the awake A-line I kept an eye on her and noted she developed no increased work of breathing making me think I didn’t wack the phrenic (or if I did she tolerated it). Moved her to the SPIDER and induced with 40 mg of the white stuff and intubated. She was 99% on 31 % FIO2 with PSV and a touch of PEEP. During the case I added 5 ml of .2 Ropi on 2 separate occasions and at the end of the case extubated her. In PACU pain score 0 and I ran 5 ml/hr .2 ropi with 5 ml q 1 hr demand bolus. Just called the MICU and the RN informed me pain score 0 and happy as a clam!!!

Just to note she clinically was not as severe as her spirometry painted her out to be. If she had been more decompensated the supra/infra would be potentially the winner!
Click to expand...

I think there is a still a risk of Phrenic nerve palsy with any ISB or SCB; yes, the incidence is reduced to 5-10% but not entirely eliminated. IMHO, the majority of private practice providers would choose this technique (low ISB or SCB) for the case mentioned in this thread. I would still go the SSN plus ICB route if you are really concerned about phrenic nerve palsy. In addition, a catheter can be placed near the SSN for a postop infusion of local anesthetic.

Regional Anesthesia & Pain Medicine:
September/October 2009 - Volume 34 - Issue 5 - pp 498-502
doi: 10.1097/AAP.0b013e3181b49256
Ultrasound Articles
Ultrasound-Guided Low-Dose Interscalene Brachial Plexus Block Reduces the Incidence of Hemidiaphragmatic Paresis
Renes, Steven H. MD*; Rettig, Harald C. MD, PhD†; Gielen, Mathieu J. MD, PhD*; Wilder-Smith, Oliver H. MD, PhD*; van Geffen, Geert J. MD, PhD*



icon-minus.gif

Abstract

Background and Objectives: Interscalene brachial plexus block is associated with 100% incidence of hemidiaphragmatic paresis as a result of phrenic nerve block. We examined whether an ultrasound (US)-guided interscalene brachial plexus block performed at the level of root C7 versus a nerve stimulation interscalene brachial plexus block, both using 10 mL of ropivacaine 0.75%, resulted in a lower incidence of hemidiaphragmatic paresis.

Methods: In a prospective randomized controlled trial, 30 patients scheduled for elective shoulder surgery under combined general anesthesia and interscalene brachial plexus block were included. Interscalene brachial plexus block using the same dose was performed using either US or nerve stimulation guidance of ropivacaine for both groups. General anesthesia was standardized. Ventilatory function was assessed using spirometry, and movement of the hemidiaphragm was assessed by US.

Results: Two patients in the US group showed complete paresis of the hemidiaphragm, but in the nerve stimulation group, 12 patients showed complete and 2 patients had partial paresis of the hemidiaphragm (13% versus 93%, respectively; P < 0.0001). Ventilatory function (forced expiratory volume at 1 second, forced vital capacity, and peak expiratory flow) was significantly reduced in the nerve stimulation group compared with the US-guided group (P < 0.05). One block failure occurred in the nerve stimulation group compared with none in the US group. No adverse effects occurred in either group.

Conclusions: Ultrasound-guided interscalene brachial plexus block performed at the level of root C7 using 10 mL of ropivacaine 0.75% reduces the incidence of hemidiaphragmatic paresis.
 
turnupthevapor said:
99 replies to my question.....BRAVO SDN! I really appreciate what each of you had to add. Although I thought the suprascap/Infra Post Cord was sexy I was worried about the infra cath being in the field and the suprascap not offering prolonged analgesia.

So when meeting her in HA she had some conversational dyspnea and a room air PAO2 of 60. 1 mg of versed and headed to the room. I put her on her side and placed a Pajunck Echo Curl Catheter in a low interscalene position (under the superior trunk in a grapeish vs traffic light spot). I placed 7 ml of 1.5 mepi @ which point all her pain went away. I did this to evaluate how she would tolerate the catheter overnight. If she failed I would have induced GA and the Mepi would be gone when she woke up, if she tolerated it I would use the catheter on the floor for the next few days.

During the awake A-line I kept an eye on her and noted she developed no increased work of breathing making me think I didn’t wack the phrenic (or if I did she tolerated it). Moved her to the SPIDER and induced with 40 mg of the white stuff and intubated. She was 99% on 31 % FIO2 with PSV and a touch of PEEP. During the case I added 5 ml of .2 Ropi on 2 separate occasions and at the end of the case extubated her. In PACU pain score 0 and I ran 5 ml/hr .2 ropi with 5 ml q 1 hr demand bolus. Just called the MICU and the RN informed me pain score 0 and happy as a clam!!!

Just to note she clinically was not as severe as her spirometry painted her out to be. If she had been more decompensated the supra/infra would be potentially the winner!
Click to expand...

Your technique was almost identical to the one used in this study where they deposited 6 mls near C7.


Regional Anesthesia & Pain Medicine:
November 2010 - Volume 35 - Issue 6 - pp 529-534
doi: 10.1097/AAP.0b013e3181fa1190
Original Articles
Minimum Effective Volume of Local Anesthetic for Shoulder Analgesia by Ultrasound-Guided Block at Root C7 With Assessment of Pulmonary Function
Renes, Steven H. MD*; van Geffen, Geert J. MD, PhD*; Rettig, Harald C. MD, PhD†; Gielen, Mathieu J. MD, PhD*; Scheffer, Gert J. MD, PhD*



icon-minus.gif

Abstract

Background and Objectives: This study was performed to determine the minimum effective volume of ropivacaine 0.75% required to produce effective shoulder analgesia for an ultrasound (US)-guided block at the C7 root level with assessment of pulmonary function.

Methods: Using the Dixon and Massey up-and-down method study design, 20 patients scheduled for elective open shoulder surgery under combined general anesthesia and continuous interscalene brachial plexus block were included. Initial volume of ropivacaine 0.75% was 6 mL; block success or failure determined a 1-mL decrease or increase for the subsequent patient, respectively. General anesthesia was standardized. A continuous infusion of ropivacaine 0.2% was started at a rate of 6 mL/hr at 2 hrs after completion of surgery. Ventilatory function was assessed using spirometry, and movement of the hemidiaphragm was assessed by US.

Results: The minimum effective volume of local anesthetic in 50% and 95% of the patients was 2.9 mL (95% confidence interval, 2.4-3.5 mL) and 3.6 mL (95% confidence interval, 3.3-6.2 mL), respectively. Ventilatory function and hemidiaphragmatic movement was not reduced up to and including 2 hrs after completion of surgery, but 22 hrs after start of the continuous infusion of ropivacaine 0.2%, ventilatory function and hemidiaphragmatic movement were significantly reduced (P < 0.001).

Conclusions: The minimum effective volume of local anesthetic for shoulder analgesia for a US-guided block at the C7 root level in 50% and 95% of the patients was 2.9 and 3.6 mL, respectively. Pulmonary function was unchanged until 2 hrs after completion surgery, but reduced 22 hrs after start of a continuous infusion of ropivacaine 0.2%.
 
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