Shoulder blocks

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dhb said:
A collegue talked to me about non truncular blocks for shoulders.
Anybody doing the suprascapular nerve block (SSNB) and axillary nerve block (ANB)?

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Just curious why do these over a simple interscalene? If you are worried about phrenic paralysis then that is a concern but most people tolerate it fairly well and a low interscalene with the local delivered right at the plexus doesn’t necessarily get the phrenic every time.
 
The other only reason for that approach is if the patient is truly a pulmonary cripple. Otherwise ISB every time.

This is a cool trick to have in your back pocket for that once a year sick-as-poop end-stage COPD’er proximal humerus Fx.
 
Did a bunch of SSNBs in residency. We would do them for total shoulders.

We HAD been doing ISBs, and then the orthopods were noticing a lot of plexus injuries post-op, which they promptly blamed on our blocks. It was clearly BS...because they tried to blame a plexus injury on our block WHEN WE HADN'T EVEN BLOCKED THAT PATIENT AT ALL. So our regional head nixed all ISBs/SC blocks for total shoulders and we just went with suprascaps. They worked okay...not great...like adding something else to multi-modal analgesia. But then the orthos couldn't blame their injuries on us. Sucked, because it was the patients that ultimately suffered.
 
dhb said:
To avoid motor block?
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If you are also doing an axillary block also you are going to get motor block for the arm and hand. It will spare the rotator cuff but you are still getting motor block.
 
@dhb My mentor in residency has actually written a paper on this very recently.

In order to obey hilton's law for the shoulder joint, a total of 6 nerves that innvervate across the joint must be blocked. However, successful surgical anesthesia has been described blocking the suprascapular nerve, axilllary nerve, and the lateral pectoral nerve. you can do this with ease under ultrasound. I was actually going to try to execute this once on a pt who's Pulm doc told her that she would die if she ever got intubated, so she adamantly refused general anes, and her COPD was pretty bad. But the case got cancelled 🙁

People in the chronic pain world also block articular (which are only sensory) branches of those nerves, it would be theretically be the best anaglesic option without any motor blockade. But the fidelity of these blocks that i've observed/done have been very low.

I will try to link the article if i can find it later.
 
dchz said:
@dhb My mentor in residency has actually written a paper on this very recently.

In order to obey hilton's law for the shoulder joint, a total of 6 nerves that innvervate across the joint must be blocked. However, successful surgical anesthesia has been described blocking the suprascapular nerve, axilllary nerve, and the lateral pectoral nerve. you can do this with ease under ultrasound. I was actually going to try to execute this once on a pt who's Pulm doc told her that she would die if she ever got intubated, so she adamantly refused general anes, and her COPD was pretty bad. But the case got cancelled 🙁

People in the chronic pain world also block articular (which are only sensory) branches of those nerves, it would be theretically be the best anaglesic option without any motor blockade. But the fidelity of these blocks that i've observed/done have been very low.

I will try to link the article if i can find it later.
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I've done the Suprascapular block plus ICB for a total shoulder replacement (N=2). Both times postop pain scores were less than 1. Zero chance you block the phrenic nerve with a low volume ICB.
 
BLADEMDA said:
I've done the Suprascapular block plus ICB for a total shoulder replacement (N=2). Both times postop pain scores were less than 1. Zero chance you block the phrenic nerve with a low volume ICB.
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If your ICB = Infrac Clav brachial plexus and not Intercostal brachial. why would an ICB be better than a supraclav? also doesn't both have the chance to miss the lateral pectoral nerve?
 
Airlife91 said:
Did a bunch of SSNBs in residency. We would do them for total shoulders.

We HAD been doing ISBs, and then the orthopods were noticing a lot of plexus injuries post-op, which they promptly blamed on our blocks. It was clearly BS...because they tried to blame a plexus injury on our block WHEN WE HADN'T EVEN BLOCKED THAT PATIENT AT ALL. So our regional head nixed all ISBs/SC blocks for total shoulders and we just went with suprascaps. They worked okay...not great...like adding something else to multi-modal analgesia. But then the orthos couldn't blame their injuries on us. Sucked, because it was the patients that ultimately suffered.
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Kinda like doing an ACB instead of a FNB for knees.
 
dchz said:
If your ICB = Infrac Clav brachial plexus and not Intercostal brachial. why would an ICB be better than a supraclav? also doesn't both have the chance to miss the lateral pectoral nerve?
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The Infraclavicular block will get the lateral cord because the spread from the posterior cord to the lateral cord is very reliable. If you have concern then a 3 point injection technique will block all 3 cords (posterior 10 ml, lateral 5 ml and medial cord 5 ml)
dchz said:
If your ICB = Infrac Clav brachial plexus and not Intercostal brachial. why would an ICB be better than a supraclav? also doesn't both have the chance to miss the lateral pectoral nerve?
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A posterior cord injection of 10 mls typically spreads to the lateral cord. If you are concerned then place an additional 5 mls around the lateral cord:

lateral pectoral nerve (C5-C6; originates from lateral cord of brachial plexus), and musculocutaneous nerve (C5–C7; originates from lateral cord of brachial plexus)
 
Noyac said:
I know that’s been well documented but I just haven’t seen it.
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I agree with you. In fact, I’ve never seen it be an issue after an ISB either. I don’t really wanna test it on the horrible pulmonary cripple though.

On a side note, I couldn’t tell you the last time I saw a Horner’s or hoarseness from an ISB either. I think these “collateral damage” issues are minimized now that we are using U/S routinely. I don’t think it’s because of the imaging itself though, but rather due to the approach you take with U/S vs a classic nerve stim approach. Coming in deeper from from posterior means less local spills out and affects the other nerves than coming straight down from the top.
 
SaltyDog said:
I agree with you. In fact, I’ve never seen it be an issue after an ISB either. I don’t really wanna test it on the horrible pulmonary cripple though.

On a side note, I couldn’t tell you the last time I saw a Horner’s or hoarseness from an ISB either. I think these “collateral damage” issues are minimized now that we are using U/S routinely. I don’t think it’s because of the imaging itself though, but rather due to the approach you take with U/S vs a classic nerve stim approach. Coming in deeper from from posterior means less local spills out and affects the other nerves than coming straight down from the top.
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Never get hoarseness, but I get a Horner's a good 20-30%. Then again, I still use high volume to achieve longer duration (30 ml 0.5%). All done with u/s.
 
Such high volume is going to push you towards the phrenic, regardless of how low your approach. I typically use 15cc to a max of 20 of 0.25%. Easily get through a shoulder with no opioid.
 
SaltyDog said:
I agree with you. In fact, I’ve never seen it be an issue after an ISB either. I don’t really wanna test it on the horrible pulmonary cripple though.

On a side note, I couldn’t tell you the last time I saw a Horner’s or hoarseness from an ISB either. I think these “collateral damage” issues are minimized now that we are using U/S routinely. I don’t think it’s because of the imaging itself though, but rather due to the approach you take with U/S vs a classic nerve stim approach. Coming in deeper from from posterior means less local spills out and affects the other nerves than coming straight down from the top.
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Interesting fact here, I rarely noticed any phrenic compromise when I did the block without US. Started to use the US and started to get some phrenic compromise. I speculated that I was seeing this because I made an effort to surround all the trunks with local. Pretty much stopped doing US for ISB since my results are better without it. I only use 20cc 0.5% ropiv. Maybe I’ll start up with US again and focus the local on the C6/7 trunks.
 
Interesting how we all have different experiences doing pretty much the same thing. I’ve noticed that with U/S you tend to go a bit more caudal than with a traditional stim approach which may have something to do with it. My U/S ISB’s are only maybe 2cm up from where I would do an SCB - just seems to be where the roots image best.
 
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DrZzZz said:
Such high volume is going to push you towards the phrenic, regardless of how low your approach. I typically use 15cc to a max of 20 of 0.25%. Easily get through a shoulder with no opioid.
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Duration of block is directly tied to dose of drug your giving (both conc and volume). Personally like to make the block last as long as possible. Of course you can do a fine block with 0.25% and low volumes. But for what gain?

How many people complain if a Horner's? How many are symptomatic from a phrenic nerve?

If a patient is a pulmonary cripple, I def do things to minimize or avoid all together phrenic nerve risk (ie: no block), otherwise I don't see the point.
 
facted said:
Duration of block is directly tied to dose of drug your giving (both conc and volume). Personally like to make the block last as long as possible. Of course you can do a fine block with 0.25% and low volumes. But for what gain?

How many people complain if a Horner's? How many are symptomatic from a phrenic nerve?

If a patient is a pulmonary cripple, I def do things to minimize or avoid all together phrenic nerve risk (ie: no block), otherwise I don't see the point.
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10cc of bupi 0.5% + dexa gives you 24h.
I don't see how 30cc is going to give you more durqtion than 15cc. I usually don't know what to do with the 2nd 5cc.
 
dhb said:
10cc of bupi 0.5% + dexa gives you 24h.
I don't see how 30cc is going to give you more durqtion than 15cc. I usually don't know what to do with the 2nd 5cc.
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More local, longer block. Have had blocks 30, 36 hrs.

30ml 0.5% with 6mg pf dex. Less for the smaller patients. Agree, I could easily do a ISB with 5-10ml, but just want the block to last longer, which it does.

Randomized study of the effect of local anesthetic volume and concentration on the duration of peripheral nerve blockade. - PubMed - NCBI
 
facted said:
More local, longer block. Have had blocks 30, 36 hrs.

30ml 0.5% with 6mg pf dex. Less for the smaller patients. Agree, I could easily do a ISB with 5-10ml, but just want the block to last longer, which it does.

Randomized study of the effect of local anesthetic volume and concentration on the duration of peripheral nerve blockade. - PubMed - NCBI
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Group 5 mL was excluded post hoc because of an unacceptably high block failure rate.
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This study tells me that volume compensates for bad technique: 5cc is plenty for an ISB
 
dhb said:
This study tells me that volume compensates for bad technique: 5cc is plenty for an ISB
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All their groups show a tiered increase in block time with increased volume and increased conc. This makes perfect sense and why people consistently overlook this seemingly obvious point is beyond me.

You don't believe the premise that higher volume and higher conc. give you longer block time?
 
facted said:
All their groups show a tiered increase in block time with increased volume and increased conc. This makes perfect sense and why people consistently overlook this seemingly obvious point is beyond me.

You don't believe the premise that higher volume and higher conc. give you longer block time?
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Agree that higher volumes will give you a longer block, to whatever the ceiling volume would be. I just don't think it's necessary to give more than 15-20cc. Like I said, it drastically lowers the risk of phrenic involvement. If you want extended length, add decadron or precedex, not more volume. We do that for totals on a Friday since we won't.be around to reblock them on Saturday. SAD/DCE's never come back for a reblock.
 
DrZzZz said:
Agree that higher volumes will give you a longer block, to whatever the ceiling volume would be. I just don't think it's necessary to give more than 15-20cc. Like I said, it drastically lowers the risk of phrenic involvement. If you want extended length, add decadron or precedex, not more volume. We do that for totals on a Friday since we won't.be around to reblock them on Saturday. SAD/DCE's never come back for a reblock.
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Agree that more volume increases phrenic nerve involvement. I just posit that for my patient population, it's not noticeable and of the last maybe 200 I've done, I've had one guy tell me he had trouble taking a deep breath, which is likely attributed to the block. My practice is luckily mostly devoid of pulmonary cripples and big fatties. I would alter my practice in those people.

As it were, I actually inject well lateral to the sheath (and never in it)which has also been shown to markedly reduce phrenic nerve paralysis.

I do already use decadron, i just want my blocks to last a few hours longer still.
 
facted said:
Agree that more volume increases phrenic nerve involvement. I just posit that for my patient population, it's not noticeable and of the last maybe 200 I've done, I've had one guy tell me he had trouble taking a deep breath, which is likely attributed to the block. My practice is luckily mostly devoid of pulmonary cripples and big fatties. I would alter my practice in those people.

As it were, I actually inject well lateral to the sheath (and never in it)which has also been shown to markedly reduce phrenic nerve paralysis.

I do already use decadron, i just want my blocks to last a few hours longer still.
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Agree about the more volume = longer block, fact.

Also agree that noticeable or bothersome phrenic nerve involvement IMO is rare like 1:50??

If you are concerned about the phrenic, but want to give analgesia, do a supraclavicular...

I have done many SSNBs mainly in the setting of chronic shoulder pain both before and after surgery, with good results, but would not rely on it for OR.

Id rather the surgeon just give the local intra and periarticularly if i cant do a brachial plexus block
 
I’m curious as to why people want the block to last as long as possible? I want pt to get through the night and wake up with a numb limb but at that point, I want the block to wear off. Blocks that last more than 24hrs are just not necessary. These pts need to get a handle on the recovery process and pain control. Having had multiple surgeries I can tell you that having a numb limb is worse than the actual pain. Now if we can manage the density better then I’m all ears. Motor function without pain is probably the gold standard. But I haven’t seen anyone reliably accomplish this. Just remember, we are putting toxic **** on these nerves. Why would we increase the amount just to add 6hrs of pain relief?
 
SaltyDog said:
Interesting how we all have different experiences doing pretty much the same thing. I’ve noticed that with U/S you tend to go a bit more causal than with a traditional stim approach which may have something to do with it. My U/S ISB’s are only maybe 2cm up from where I would do an SCB - just seems to be where the roots image best.
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I think there must be a difference in our block location. I am basically at the level of the cricoid for both US and nonUS Blocks.
 
Noyac said:
I’m curious as to why people want the block to last as long as possible? I want pt to get through the night and wake up with a numb limb but at that point, I want the block to wear off. Blocks that last more than 24hrs are just not necessary. These pts need to get a handle on the recovery process and pain control. Having had multiple surgeries I can tell you that having a numb limb is worse than the actual pain. Now if we can manage the density better then I’m all ears. Motor function without pain is probably the gold standard. But I haven’t seen anyone reliably accomplish this. Just remember, we are putting toxic **** on these nerves. Why would we increase the amount just to add 6hrs of pain relief?
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There is absolutely no correlation between the amount of local anesthetic and clinical nerve injury risk. Would love to see any data you have that says the opposite.

I call all my patients post-op and I've had maybe a handful tell me that the numbness was worse than the pain.

If I could keep someone comfortable for 36hrs vs 24 hrs with the same risk profile, why on Earth would I choose 24hrs?!?
 
facted said:
There is absolutely no correlation between the amount of local anesthetic and clinical nerve injury risk. Would love to see any data you have that says the opposite.

I call all my patients post-op and I've had maybe a handful tell me that the numbness was worse than the pain.

If I could keep someone comfortable for 36hrs vs 24 hrs with the same risk profile, why on Earth would I choose 24hrs?!?
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Because exparel costs a ton of money
 
Psai said:
Because exparel costs a ton of money
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No one is talking about Exparel.

30ml 0.5% bupi and decadron (using 6mg personally). No need for exparel. Lasts a few hours longer than lower volumes or concentrations.
 
facted said:
There is absolutely no correlation between the amount of local anesthetic and clinical nerve injury risk. Would love to see any data you have that says the opposite.

I call all my patients post-op and I've had maybe a handful tell me that the numbness was worse than the pain.

If I could keep someone comfortable for 36hrs vs 24 hrs with the same risk profile, why on Earth would I choose 24hrs?!?
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Ok, ok. Touchy subject for you I see.

I’ll leave it at this, you and I see things differently and therefore we choose to practice in a different manner.
 
Noyac said:
I think there must be a difference in our block location. I am basically at the level of the cricoid for both US and nonUS Blocks.
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Ya. I notice that most guys that learned to block using landmark/stim still block up higher like that with U/S. Being the young whippersnapper that I am - I learned on ultrasound. I don't pay much attention to surface landmarks. I put the probe on and briefly scan up and down until I find the best image. This is almost always a few centimeters caudad to the classic landmark based location. It's really not much more cephalad than where you get your supraclav view - but the angle of the probe is much more transverse than looking down into the corner like you do for a supraclav. Try blocking a little further south than you're used to and see if you still get as much collateral damage even if you still try to surround all the trunks.
 
Noyac said:
I’m curious as to why people want the block to last as long as possible? I want pt to get through the night and wake up with a numb limb but at that point, I want the block to wear off. Blocks that last more than 24hrs are just not necessary. These pts need to get a handle on the recovery process and pain control. Having had multiple surgeries I can tell you that having a numb limb is worse than the actual pain. Now if we can manage the density better then I’m all ears. Motor function without pain is probably the gold standard. But I haven’t seen anyone reliably accomplish this. Just remember, we are putting toxic **** on these nerves. Why would we increase the amount just to add 6hrs of pain relief?
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I suspect it depends on how painful it is.

If it is very painful surgery - I bet a patient wouldn't mind being numb a little longer. This is certainly true for ankle ORIF's.

I think for single shot, 24 hrs is the sweet spot - but honestly, it is hard to reliably get 24hrs. Adjuncts help, but because of patient variability, blocks can last 12 - 36 hours. The worst block is the 12-18 hours where patients wake up at 3 in the morning in pain.
 
Noyac said:
I only use 20cc 0.5% ropiv.
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I think i finally figured out why I don't see phrenic nerve blocks.... My interscalene are usually on the magnitude of 5-8ccs... 20cc for an interscalene is HUGE dose in my mind, specially since if you can get in between the muscles you can see all 3 trunks surrounded by local with less than 5 ccs a majority of the time.
 
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dchz said:
I think i finally figured out why I don't see phrenic nerve blocks.... My interscalene are usually on the magnitude of 5-8ccs... 20cc for an interscalene is HUGE dose in my mind, specially since if you can get in between the muscles you can see all 3 trunks surrounded by local with less than 5 ccs a majority of the time.
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What is your duration with 5 mL?
 
dchz said:
I do'nt know how you are all so precise within 2 hours... but i'd say first pain pill POD1 would be most of the range.
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Nobody routinely follows up on every single block they do so all of this is just speculation. I rarely follow up the next day. However, the feedback I get from the nursing staff that call the pt the following day and surgeons confirms my practice. We are all very good at regional in my practice and my pts do as well or better than most. This includes PACU and the following day. So I’m not really looking to change anything.
 
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