POSTERIOR INTERSCALENE BLOCKPOSTERIOR INTERSCALENE BLOCKErcan KURT

GÜLHANE MILITARY MEDICAL FACULTYDEPARTMENT OF ANESTHESIOLOGY AND REANIMATION

ANKARA

INTERSCALENE BRACHIAL PLEXUS INTERSCALENE BRACHIAL PLEXUS BLOCKBLOCK

ANTERIOR APPROACH•SINGLE – DOSE TECHNIQUE•CATHETER TECHNIQUE

POSTERIOR APPROACH•SINGLE – DOSE TECHNIQUE•CATHETER TECHNIQUE

₡ INDICATIONSShoulder and upper arm surgery

Immobility of shoulder joint

Shoulder manipulations

Chronic pain therapy

Arthroscopic shoulder surgery

₡ ADVANTAGES Easily performed in any position of the arm

₡ DISADVANTAGES Ulnar nerve may not be blocked Serious complications may occur

INTERSCALENE BRACHIAL PLEXUS INTERSCALENE BRACHIAL PLEXUS BLOCKBLOCK

ISB CONTRAINDICATIONSISB CONTRAINDICATIONS

¥ Skin infection

¥ Refusal of the procedure by the patient

¥ Haemorrhagic diathesis

¥ Contralateral phrenic nerve or recurrent nerve paralysis

¥ Known neuropathy involving the arm undergoing

surgery

¥ Severe bronchopulmonary disease

¥ Known allergy to the trial drugs

¥ Previous neurologic damage to the brachial plexus

INTERSCALENE BLOCKINTERSCALENE BLOCK

ANATOMY OF ANATOMY OF BRACHIAL PLEXUSBRACHIAL PLEXUS

Subclavian v.

Subclavian a.

Phrenic nerve

V.J.Interna

A. C.Communis

Subclavian a-v

Anterior and middle scalene

Cupola of lung

Vertebral a.

Phrenic nerve

SCM muscleAnterior scalene

m.

Middle scalene m.

Subclavian a.

ANATOMICAL LANDMARKS ANATOMICAL LANDMARKS OF BRACHIAL PLEXUSOF BRACHIAL PLEXUS

Arteria carotis communis Apex of lung Phrenic nerve

LOCAL ANESTHETICS MAY SPREAD LOCAL ANESTHETICS MAY SPREAD INTO SUBARACHNOIDAL SPACE INTO SUBARACHNOIDAL SPACE

THROUGH THREE WAYSTHROUGH THREE WAYS

1- INTERVERTEBRAL FORAMEN2- DURAL SHEATH 3- INTRANEURALLY

SINGLE - DOSE ISB USING SINGLE - DOSE ISB USING POSTERIOR APPROACHPOSTERIOR APPROACH

1- Skin-subcutaneous tissue

2- M. trapezius

3- M. splenius capitis

4- M. semispinalis capitis

5- M. semispinalis cervitis

6- M. scaleneus posterior

7- M. scaleneus medius

ISB USING POSTERIOR APPROACHISB USING POSTERIOR APPROACH ANATOMICAL LAYERS IN ANATOMICAL LAYERS IN

TRANSVERSE SECTIONTRANSVERSE SECTION

C-7 SPINOUS PROCESS BRACHIAL PLEXUS

ISB USING POSTERIOR ISB USING POSTERIOR APPROACHAPPROACH

POSTERIOR ISBPOSTERIOR ISB

SITTING POSITIONSITTING POSITION LATERAL DECUBITIS POSITIONLATERAL DECUBITIS POSITION

SINGLE - DOSE ISB USING SINGLE - DOSE ISB USING POSTERIOR APPROACH POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH SINGLE - DOSE ISB USING POSTERIOR APPROACH

LOCAL ANESTHETICS FOR ISBLOCAL ANESTHETICS FOR ISB

A TOTAL VOLUME OF 40 – 50 MLA TOTAL VOLUME OF 40 – 50 ML

20 -25 ml 0,5 % 20 -25 ml 0,5 % bupivacaine + 20 - 25 ml 1 % prilocainebupivacaine + 20 - 25 ml 1 % prilocaine 20 - 25ml 0,5 % 20 - 25ml 0,5 % bupivacaine + 20 - 25 ml 1 % lignocainebupivacaine + 20 - 25 ml 1 % lignocaine 20 - 25ml 0,2 %20 - 25ml 0,2 %ropivacaine + 20 - 25 ml 1 % lignocaineropivacaine + 20 - 25 ml 1 % lignocaine

INDICATIONS FOR CATHETER INDICATIONS FOR CATHETER

Acute pain therapy (postoperative) Management of chronic pain (CRPS) Supportive adjunct to physiotherapy/exercise

therapy Sympatholysis (for improving wound healing) Preventive analgesia (phantom pain prophylaxis)

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH CONTINUOUS ISB USING POSTERIOR APPROACH

STIMULATING CATHETERSSTIMULATING CATHETERS

• Does Interscalene Catheter Placement with Does Interscalene Catheter Placement with Stimulating Catheters Improve Postoperative Stimulating Catheters Improve Postoperative Pain or Functional Outcome After Shoulder Pain or Functional Outcome After Shoulder Surgery? Surgery? Regional Anest Vol 104(2) 2007Regional Anest Vol 104(2) 2007

Stevens M.F.Stevens M.F.

Precisely control catheter placementPrecisely control catheter placementImproved onset of motor nerve blockImproved onset of motor nerve block

Brachial Plexus Block With Catheter Brachial Plexus Block With Catheter Using The Posterior Interscalene Using The Posterior Interscalene

ApproachApproach

• In The Management Of Neuropathic Cancer Pain (2 Case Report)TÜRKER G. TÜRKER G.

Uludağ Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, BURSAUludağ Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, BURSA

Decreased likelihood of catheter Decreased likelihood of catheter dislodgement due to neck movementdislodgement due to neck movement

ISB COMPLICATIONSISB COMPLICATIONS Horner syndrome N. recurrens paralysis Phrenic nerve paralysis Bronchospasm Total spinal anesthesia Acute respiratory insufficiency Contralateral anesthesia Loss of consciousness and apnea Hematoma Nerve injury

ACCIDENTAL EPIDURAL ACCIDENTAL EPIDURAL CATHETERIZATIONCATHETERIZATION

• During continuous interscalene block via the posterior approach

Gurbet A.

2005 Journal The Pain Clinic

5 ml of contrast medium were injected and a C-arm fluoroscopic

imaging showed contrast medium in the epidural space with catheter opacification

•the patient should be awake and conscious during catheter placement

•radiographic confirmation of catheter position should be

obtained before the first injection

•after each local anesthetic injection the patient should be monitored.

INTRACORD INJECTION

• Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene

Block Performed Under General Anesthesia

• Benumof Jonathan L• Volume 93(6), December 2000, 1541- 4

How to Prevent Catastrophic How to Prevent Catastrophic Complications When Performing ISBComplications When Performing ISB

In our institution, we only perform interscalene blocks before or after surgery in awake patients

PRECAUTIONS IN ISB

ISB should not be performed in patients with a history including contralateral hemidiaphragmatic paralysis, pneumothorax and pneumonectomy

The patients who can not tolerate a 25 % reduction of FVC are not appropriate for ISB

Pulse oxymetry should be used

Supplemental nazal oxygen should be given

IN CASE OF DISPNEA AFTER ISBIN CASE OF DISPNEA AFTER ISB

The patient should be closely observed

Patient is positioned in reverse Trendelenburg or sitting

position

Breath sounds should be oscultated to evaluate

diaphragmatic hemiparesis

A chest radiogram is required to check pneumothorax

Ventilatory support or endotracheal intubation is indicated, if

necessary

AS A RESULTAS A RESULT

₪Prevention of these complications includes the proper selection of patients

₪The performance of blocks either before or after anesthesia in patients who are awake or mildly sedated