Slayt Basligi Yok

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POSTERIOR INTERSCALENE BLOCK Ercan KURT GÜLHANE
MILITARY MEDICAL FACULTY DEPARTMENT OF
ANESTHESIOLOGY AND REANIMATION ANKARA
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INTERSCALENE BRACHIAL PLEXUS BLOCK

• ANTERIOR APPROACH
• SINGLE DOSE TECHNIQUE
• CATHETER TECHNIQUE
• POSTERIOR APPROACH
• SINGLE DOSE TECHNIQUE
• CATHETER TECHNIQUE

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INTERSCALENE BRACHIAL PLEXUS BLOCK

• INDICATIONS
• Shoulder 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

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ISB 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

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INTERSCALENE BLOCK

• ANATOMY OF BRACHIAL PLEXUS

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V.J.Interna
A. C.Communis
Phrenic nerve
Subclavian a.
Subclavian v.
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Anterior and middle scalene
Subclavian a-v
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Vertebral a.
Phrenic nerve
Middle scalene m.
SCM muscle
Anterior scalene m.
Subclavian a.
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ANATOMICAL LANDMARKS OF BRACHIAL PLEXUS

• Arteria carotis communis
• Apex of lung
• Phrenic nerve

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LOCAL ANESTHETICS MAY SPREAD INTO SUBARACHNOIDAL
SPACE THROUGH THREE WAYS

• 1- INTERVERTEBRAL FORAMEN
• 2- DURAL SHEATH
• 3- INTRANEURALLY

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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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ISB USING POSTERIOR APPROACH ANATOMICAL LAYERS
IN TRANSVERSE SECTION

• 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

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ISB USING POSTERIOR APPROACH
BRACHIAL PLEXUS
C-7 SPINOUS PROCESS
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POSTERIOR ISB
SITTING POSITION
LATERAL DECUBITIS POSITION
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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SINGLE - DOSE ISB USING POSTERIOR APPROACH
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LOCAL ANESTHETICS FOR ISB

• A TOTAL VOLUME OF 40 50 ML
• 20 -25 ml 0,5 bupivacaine 20 - 25 ml 1
  prilocaine
• 20 - 25ml 0,5 bupivacaine 20 - 25 ml 1
  lignocaine
• 20 - 25ml 0,2 ropivacaine 20 - 25 ml 1
  lignocaine

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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)

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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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CONTINUOUS ISB USING POSTERIOR APPROACH
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STIMULATING CATHETERS

• Precisely control catheter placement
• Improved onset of motor nerve block

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

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Brachial Plexus Block With Catheter Using The
Posterior Interscalene Approach
Decreased likelihood of catheter dislodgement
due to neck movement

• In The Management Of Neuropathic Cancer Pain (2
  Case Report)TÜRKER G.
• Uludag Üniversitesi Tip Fakültesi,
  Anesteziyoloji ve Reanimasyon AD, BURSA

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ISB 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

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ACCIDENTAL EPIDURAL CATHETERIZATION

• During continuous interscalene block via the
  posterior approach
• Gurbet A.
• 2005 Journal The Pain Clinic

• 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.

5 ml of contrast medium were injected and a C-arm
fluoroscopic imaging showed contrast medium in
the epidural space with catheter opacification
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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

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How to Prevent Catastrophic Complications When
Performing ISB

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

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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

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IN 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

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AS 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