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Rescue block after Exparel ISB
Started by okayplayer
No way I’m doing another block immediately post-op if they had Exparel, I’m not sure that defendable. You get a ton of spread with supraclav to the ISB anyway, I am not sure the anatomy would be standard so soon as a block anyway.
I’m hesitant and basically never do it even when a traditional block fails.
Maybe POD 1, but with Exparel I’d probably follow the package insert as, again, it would be difficult to defend if anything untoward happens as a block is elective.
No experience with this but I wonder if maybe a suprascapular block might be ok.
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Absolutely. Won’t be like a ISB, but it def. will help.
Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial
This study suggests that anterior suprascapular block provides noninferior analgesia compared to interscalene block, and better preserves vital capacity. While supraclavicular block was associated with some vital capacity preservation compared to interscalene block, the analgesia provided by...
David is a good guy and does a lot of regional/catheters in his practice. He is a big supporter of suprascapular NB... especially in the pulmonary cripples.
Although ISB is (far) superior to suprascapular block IMHO....
Great alternative to brachial plexus block due to pulmonary issues, failed exparel block, etc.
Great alternative to brachial plexus block due to pulmonary issues, failed exparel block, etc.
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I would do a rescue anterior suprascapular nerve block with 8-10 mls of local anesthetic.
If you mix 10 mls of 0.5% Bup with 10 mls of Exparel (133 mg) I am not sure how the block could fail? If you visualize C5 or C6 nerve roots and place this mixture right next to the sheath or in the sheath the block never fails. But, if you Can not visualize the nerve roots (this is very, very rare for me) then I could see how blasting in the exparel in the vicinity of the trunks/ somewhere near them could result in a patchy block.
Was there any other local in the original block other than the exparel?
I wouldn't do another block at the same site because they are technically now insensate there and wouldn't be able to tell you about any parasthesias. Could go elsewhere, but ISB and supraclav are too close.
Less worried about the local anesthetic volumes but it's something to consider certainly.
I wouldn't do another block at the same site because they are technically now insensate there and wouldn't be able to tell you about any parasthesias. Could go elsewhere, but ISB and supraclav are too close.
Less worried about the local anesthetic volumes but it's something to consider certainly.
How did it fail? What was in the initial block? Just exparel?
i would do another ISB because the first one obviously missed, limiting my local to a total (failed and rescue block) of 30ml of 0.5% plus the exparel.
a pure exparel block is going to yield this result very often, must mix in lots marcaine
I posted this in the other thread but didn’t get any response, so I’ll try again here:
Beyond anecdotal evidence, does anyone have any non-industry funded study that shows Exparel is better than plain bupivacaine? I still haven't read a convincing study that it is, and last time I checked pretty much all non-industry funded studies showed no clinically significant difference between the two.
Thanks
Beyond anecdotal evidence, does anyone have any non-industry funded study that shows Exparel is better than plain bupivacaine? I still haven't read a convincing study that it is, and last time I checked pretty much all non-industry funded studies showed no clinically significant difference between the two.
Thanks
Used 15ml 0.5% bupi, 10ml/133mg Exparel.
I presume it failed because it wasn’t injected close enough to the nerve roots to have the desired effect? Have some of you guys never had a failed ISB (or other block)? It does happen occasionally....
Large patient, challenging anatomy, failure on my end obviously. The original question was what to do in this scenario, because had it been straight LA I would have just done a rescue block and hopefully fixed the problem. More complicated after Exparel has been used.
Blocks do fail of course, though usually it's just a partial miss in one spot or something like that. I was wondering if you had used some bupi in the exparel as well.
Did the patient have a partial block or no block?
No block, I'd be tempted to just put 5-10 straight into the sheath and call it a day. Partial block I wouldn't reblock in the same area from a medicolegal perspective.
A complete failure of the block means no analgesia, no motor block and no signs such as tingling, paresthesia, weakness, etc. If that is the scenario then just re-block the patient with pure, standard local anesthetic like 0.5% Bupivacaine.
More likely, there was a partial block with some signs of interference with nerve conduction. In that case, I would perform a rescue Anterior suprascapular nerve block with 8-10 mls of 0.5% Bupivacaine. After you do about 10 of these blocks the C5 branch becomes easy to visualize under the Omohyoid muscle. This C5 branch is consistently lateral to the Subclavian artery and underneath the small omohyoid muscle.
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The C5 branch you want to block is just lateral to the main plexus of nerves. This C5 branch is located underneath the Omohyoid muscle.
I'm posting an image of a Supraclavicular nerve block. I have never examined this patient nor followed the C5 branch of interest down the interscalene groove. Still, I'm pretty sure I can locate the C5 branch of interest in this picture. I'm hoping you can too. Look for the nerve of interest (C5 branch) underneath the belly of the omohyoid muscle; typically, that branch lies in the middle or lateral portion in relation to the omohyoid muscle (just underneath the lateral 1/3 of the belly)
Reg Anesth Pain Med. 2017 May/Jun;42(3):310-318. doi: 10.1097/AAP.0000000000000573.
Anterior Suprascapular Nerve Block Versus Interscalene Brachial Plexus Block for Shoulder Surgery in the Outpatient Setting: A Randomized Controlled Patient- and Assessor-Blinded Trial.
Wiegel M1, Moriggl B, Schwarzkopf P, Petroff D, Reske AW.
Author information
Abstract
BACKGROUND AND OBJECTIVES:
The interscalene brachial plexus block (ISB), a potent option to control pain after shoulder surgery, has notable adverse effects. The anterior suprascapular nerve block (SSNB) might provide comparable analgesia and cause less grip-strength impairment. These characteristics were studied in this randomized controlled patient- and assessor-blinded trial.
METHODS:
Outpatients were randomized to single-shot ultrasound-guided SSNB (10 mL ropivacaine 1%) or ISB (20 mL ropivacaine 0.75%) before general anesthesia for arthroscopic shoulder surgery. Pain (Numerical Rating Scale, 0-10), grip strength, degree of satisfaction, and strength of recommendation were assessed.
RESULTS:
We randomized 168 patients to each group and analyzed 164 in the SSNB group and 165 in the ISB group. Nerve blocks were successful in 98% of the patients from each group. Both procedures provided good postoperative analgesia, and the mean pain level for SSNB was slightly but significantly lower by 0.32 units (95% confidence interval, 0.18-0.46; P < 0.001) and noninferior given a margin of 1.1 units; P < 0.001. Within the first 24 hours, 162 (99%) of SSNB patients had unimpaired grip strength compared to 81 (49%) of ISB patients (P < 0.001). The multiple primary outcome, superior unimpaired grip strength, and noninferior pain control was significant; P < 0.001. Compared to ISB patients (n = 130 [79%]), significantly more SSNB patients (n = 150 [91%]) were satisfied/highly satisfied. Patients in the SSNB group were more likely to recommend the procedure highly.
CONCLUSIONS:
For outpatients undergoing arthroscopic shoulder surgery under general anesthesia, the SSNB seems preferable to ISB. It provides excellent postoperative analgesia without exposing patients to impaired mobility and to risks of the more potent but also more invasive ISB.
Anterior Suprascapular Nerve Block Versus Interscalene Brachial Plexus Block for Shoulder Surgery in the Outpatient Setting: A Randomized Controlled Patient- and Assessor-Blinded Trial.
Wiegel M1, Moriggl B, Schwarzkopf P, Petroff D, Reske AW.
Author information
Abstract
BACKGROUND AND OBJECTIVES:
The interscalene brachial plexus block (ISB), a potent option to control pain after shoulder surgery, has notable adverse effects. The anterior suprascapular nerve block (SSNB) might provide comparable analgesia and cause less grip-strength impairment. These characteristics were studied in this randomized controlled patient- and assessor-blinded trial.
METHODS:
Outpatients were randomized to single-shot ultrasound-guided SSNB (10 mL ropivacaine 1%) or ISB (20 mL ropivacaine 0.75%) before general anesthesia for arthroscopic shoulder surgery. Pain (Numerical Rating Scale, 0-10), grip strength, degree of satisfaction, and strength of recommendation were assessed.
RESULTS:
We randomized 168 patients to each group and analyzed 164 in the SSNB group and 165 in the ISB group. Nerve blocks were successful in 98% of the patients from each group. Both procedures provided good postoperative analgesia, and the mean pain level for SSNB was slightly but significantly lower by 0.32 units (95% confidence interval, 0.18-0.46; P < 0.001) and noninferior given a margin of 1.1 units; P < 0.001. Within the first 24 hours, 162 (99%) of SSNB patients had unimpaired grip strength compared to 81 (49%) of ISB patients (P < 0.001). The multiple primary outcome, superior unimpaired grip strength, and noninferior pain control was significant; P < 0.001. Compared to ISB patients (n = 130 [79%]), significantly more SSNB patients (n = 150 [91%]) were satisfied/highly satisfied. Patients in the SSNB group were more likely to recommend the procedure highly.
CONCLUSIONS:
For outpatients undergoing arthroscopic shoulder surgery under general anesthesia, the SSNB seems preferable to ISB. It provides excellent postoperative analgesia without exposing patients to impaired mobility and to risks of the more potent but also more invasive ISB.
Orthop J Sports Med. 2018 Dec 28;6(12):2325967118815859. doi: 10.1177/2325967118815859. eCollection 2018 Dec.
Suprascapular Nerve Blockade for Postoperative Pain Control After Arthroscopic Shoulder Surgery: A Systematic Review and Meta-analysis.
Kay J1, Memon M1, Hu T2, Simunovic N3, Duong A3, Paul J4, Athwal G5, Ayeni OR1.
Author information
Abstract
BACKGROUND:
Regional nerve blocks are commonly used to manage postoperative pain after arthroscopic shoulder procedures. The interscalene brachial plexus block (ISB) is commonly used; however, because of the reported side effects of ISB, the use of a suprascapular nerve block (SSNB) has been described as an alternative strategy with fewer reported side effects.
PURPOSE:
To examine the efficacy of SSNB for pain control after shoulder arthroscopy compared with ISB as well as anesthesia without a nerve block.
STUDY DESIGN:
Systematic review; Level of evidence, 1.
METHODS:
Three databases (PubMed, MEDLINE, and EMBASE) were searched on April 20, 2018, to systematically identify and screen the literature for randomized controlled trials (RCTs). A meta-analysis of standard mean differences (SMDs) was performed to pool the estimated effects of the nerve blocks.
RESULTS:
The search identified 14 RCTs that included 1382 patients, with a mean age of 54 years (SD, 13 years). The mean follow-up time was 3 days (range, 24 hours to 6 weeks). Postoperative pain control was significantly more effective in the SSNB groups compared with the control groups within 1 hour (SMD, -0.76; 95% CI, -1.45 to -0.07; P = .03) and 4 to 6 hours (SMD, -0.81; 95% CI, -1.53 to -0.09; P = .03) postoperatively. However, pain control was significantly less effective in the SSNB groups compared with ISB within 1 hour (SMD, 0.87; 95% CI, 0.28 to 1.46; P = .004). No major complications were noted in the SSNB groups, and minor complications such as hoarseness and prolonged motor block were significantly less common for SSNB compared with ISB.
CONCLUSION:
Although not more efficacious than ISB in terms of pain control for patients undergoing shoulder arthroscopy, SSNB provides significantly improved pain control in comparison with analgesia without a nerve block. Moreover, few major and minor complications are associated with SSNB reported across the literature
Suprascapular Nerve Blockade for Postoperative Pain Control After Arthroscopic Shoulder Surgery: A Systematic Review and Meta-analysis.
Kay J1, Memon M1, Hu T2, Simunovic N3, Duong A3, Paul J4, Athwal G5, Ayeni OR1.
Author information
Abstract
BACKGROUND:
Regional nerve blocks are commonly used to manage postoperative pain after arthroscopic shoulder procedures. The interscalene brachial plexus block (ISB) is commonly used; however, because of the reported side effects of ISB, the use of a suprascapular nerve block (SSNB) has been described as an alternative strategy with fewer reported side effects.
PURPOSE:
To examine the efficacy of SSNB for pain control after shoulder arthroscopy compared with ISB as well as anesthesia without a nerve block.
STUDY DESIGN:
Systematic review; Level of evidence, 1.
METHODS:
Three databases (PubMed, MEDLINE, and EMBASE) were searched on April 20, 2018, to systematically identify and screen the literature for randomized controlled trials (RCTs). A meta-analysis of standard mean differences (SMDs) was performed to pool the estimated effects of the nerve blocks.
RESULTS:
The search identified 14 RCTs that included 1382 patients, with a mean age of 54 years (SD, 13 years). The mean follow-up time was 3 days (range, 24 hours to 6 weeks). Postoperative pain control was significantly more effective in the SSNB groups compared with the control groups within 1 hour (SMD, -0.76; 95% CI, -1.45 to -0.07; P = .03) and 4 to 6 hours (SMD, -0.81; 95% CI, -1.53 to -0.09; P = .03) postoperatively. However, pain control was significantly less effective in the SSNB groups compared with ISB within 1 hour (SMD, 0.87; 95% CI, 0.28 to 1.46; P = .004). No major complications were noted in the SSNB groups, and minor complications such as hoarseness and prolonged motor block were significantly less common for SSNB compared with ISB.
CONCLUSION:
Although not more efficacious than ISB in terms of pain control for patients undergoing shoulder arthroscopy, SSNB provides significantly improved pain control in comparison with analgesia without a nerve block. Moreover, few major and minor complications are associated with SSNB reported across the literature
I believe I was an early poster to discuss doing a Suprascapular nerve block combined with an Infraclavicular block for a total shoulder replacement in a pulmonary cripple. Others have duplicated my approach with excellent results.
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Need some Jedi Advice
So Monday have a 90 yo severe COPD pt (FEV1 40%) for Total shoulder. Pulmonary recommends the case done under regional! My experience is she probably will not tolerate wacking the phrenic. May be worth a shot as if she doesn't tolerate the ISB I will just intubate (as I would have for GA...
forums.studentdoctor.net
Please read post number 7. The year was 2016.
There is ZERO (Unbiased) evidence that it does anything better than good old Bupivacaine.
But there are countless anecdotal experiences here on SDN! 😉
