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POSTERIOR INTERSCALENE BLOCK Ercan KURT GÜLHANE MILITARY MEDICAL FACULTY

POSTERIOR INTERSCALENE BLOCK Ercan KURT GÜLHANE MILITARY MEDICAL FACULTY DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION ANKARA. INTERSCALENE BRACHIAL PLEXUS BLOCK. ANTERIOR APPROACH SINGLE – DOSE TECHNIQUE CATHETER TECHNIQUE POSTERIOR APPROACH SINGLE – DOSE TECHNIQUE CATHETER TECHNIQUE.

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POSTERIOR INTERSCALENE BLOCK Ercan KURT GÜLHANE MILITARY MEDICAL FACULTY

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  1. POSTERIOR INTERSCALENE BLOCK Ercan KURT GÜLHANE MILITARY MEDICAL FACULTY DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION ANKARA

  2. INTERSCALENE BRACHIAL PLEXUS BLOCK ANTERIOR APPROACH SINGLE – DOSE TECHNIQUE CATHETER TECHNIQUE POSTERIOR APPROACH SINGLE – DOSE TECHNIQUE CATHETER TECHNIQUE

  3. 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

  4. ISB CONTRAINDICATIONS • Skin infection • Refusal of the procedure by the patient • Haemorrhagic diathesis • Contralateral phrenicnerve or recurrentnerve paralysis • Known neuropathy involving the arm undergoing surgery • Severe bronchopulmonary disease • Known allergy to the trial drugs • Previous neurologic damage to the brachial plexus

  5. INTERSCALENE BLOCK ANATOMY OF BRACHIAL PLEXUS

  6. V.J.Interna A. C.Communis Phrenic nerve Subclaviana. Subclavian v.

  7. Cupola of lung Anterior and middle scalene Subclavian a-v

  8. Vertebral a. Phrenic nerve Middlescalenem. SCM muscle Anterior scalene m. Subclaviana.

  9. ANATOMICAL LANDMARKS OF BRACHIAL PLEXUS • Arteria carotis communis • Apex of lung • Phrenic nerve

  10. LOCAL ANESTHETICS MAY SPREAD INTO SUBARACHNOIDAL SPACE THROUGH THREE WAYS 1- INTERVERTEBRAL FORAMEN 2- DURAL SHEATH 3- INTRANEURALLY

  11. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  12. 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

  13. ISB USING POSTERIOR APPROACH BRACHIAL PLEXUS C-7 SPINOUS PROCESS

  14. POSTERIOR ISB SITTING POSITION LATERAL DECUBITIS POSITION

  15. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  16. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  17. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  18. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  19. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  20. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  21. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  22. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  23. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  24. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  25. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  26. SINGLE - DOSE ISB USING POSTERIOR APPROACH

  27. 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

  28. 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)

  29. CONTINUOUS ISB USING POSTERIOR APPROACH

  30. CONTINUOUS ISB USING POSTERIOR APPROACH

  31. CONTINUOUS ISB USING POSTERIOR APPROACH

  32. CONTINUOUS ISB USING POSTERIOR APPROACH

  33. CONTINUOUS ISB USING POSTERIOR APPROACH

  34. CONTINUOUS ISB USING POSTERIOR APPROACH

  35. CONTINUOUS ISB USING POSTERIOR APPROACH

  36. CONTINUOUS ISB USING POSTERIOR APPROACH

  37. CONTINUOUS ISB USING POSTERIOR APPROACH

  38. CONTINUOUS ISB USING POSTERIOR APPROACH

  39. CONTINUOUS ISB USING POSTERIOR APPROACH

  40. CONTINUOUS ISB USING POSTERIOR APPROACH

  41. Precisely control catheter placement • Improved onset of motor nerve block STIMULATING CATHETERS • 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.

  42. 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. Uludağ Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, BURSA

  43. 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

  44. 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. 5ml of contrast medium were injected and a C-arm fluoroscopic imaging showed contrast medium in the epidural space with catheter opacification

  45. 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 INTRACORD INJECTION

  46. How to Prevent Catastrophic Complications When Performing ISB • In our institution, we only perform interscalene blocks before or after surgery in awake patients

  47. 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

  48. 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

  49. 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

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