Interscalene & supraclavicular nerve blocks

nerve blocks

1. INTERSCALENE & SUPRACLAVICULAR NERVE BLOCKS DR. DAVIS KURIAN

2. INTERSCALENE BLOCK INDICATIONS : surgery or manipulation on clavicle, shoulder or upper arm (except the medial aspect. therapeutic-frozen shoulder, post herpetic neuralgia, tumour related pain etc

3. INTERSCALENE BLOCK Donot reliably block the inferior trunk, hence requires supplementation at ulnar nerve for surgeries of hand and forearm.

4. INTERSCALENE BLOCK CONTRAINDICATIONS : SPECIFIC : Infection or malignant disease in the neck. Infection of the skin in the puncture area. Contralateral paresis of the phrenic or recurrent laryngeal nerves. Anticoagulation treatment. Distorted anatomy - e.g. due to prior surgical interventions or trauma to the neck.

5. INTERSCALENE BLOCK RELATIVE : Hemorrhagic diathesis. Local nerve injury (as there may be doubt whether the cause is surgery or anesthesia ). Severe chronic obstructive pulmonary disease

6. INTERSCALENE BLOCK Before any regional block Check that the emergency equipment is present and in working order. Sterile precautions. Intravenous access, ECG monitoring, pulse oximetry, intubation kit, emergency medication, ventilation facilities.

7. INTERSCALENE BLOCK ANTERIOR APPROACH (WINNIE’S) POSTERIOR APPROACH (PIPPA’S TECH ) Blocks can be given using – landmarks alone, nerve stimulator guided, USG guided or with both USG and nerve stimulator guided.

8. INTERSCALENE BLOCK WINNIE’S ANTERIOR ROUTE : SINGLE SHOT: POSITION – supine, head turned to opposite side LANDMARKS Sternocleidomastoid muscle, interscalene groove between the scalenus anterior and scalenus medius muscles transverse process (C6), external jugular vein.

9. INTERSCALENE BLOCK Turn head to opposite side + slight lift (20 ). Roll finger posterolaterally from the posterior border of sternocliedomastoid over the anterior scalene muscle to reach the interscalene groove. The injection site in the interscalene groove lies at thelevel of the cricoid , opposite the transverse process of C6 ( Chassaignac's tubercle).

10. INTERSCALENE BLOCK Line extended laterally from the cricoid cartilage to intersect the interscalene groove indicates the level of the transverse process of C6. Although the external jugular vein often overlies this point of intersection, it is not a constant or reliable landmark. When there are anatomical difficulties, it is helpful for the patient to inhale deeply or to try and blow out the cheeks. The scalene muscles then tense up and the interscalene groove becomes more easily palpable.

11. INTERSCALENE BLOCK

12. INTERSCALENE BLOCK INJECTION TECHNIQUE: The traditional technique first described by Winnie is a classic paresthesia technique. Prepare the area, infiltrate the skin, isolate the area with middle and index fingers. 22- to 25-gauge, 4-cm needle is inserted perpendicular to the skin at 45-degree caudally, medially and slightly posterior.

13. INTERSCALENE BLOCK When the needle is positioned superficially, paresthesias usually occur in the area of the elbow, index finger and thumb. Paresthesias in the shoulder region also frequently occur. These result from stimulation of the suprascapular nerve, which is often located in the connective tissue sheath

14. INTERSCALENE BLOCK Electrical nerve stimulator can also be used – where motor response of the arm or shoulder is also equally efficacious when compared with classical parasthesia technique. If a blunt needle bevel is used, a “click” may be detected as the needle passes through the prevertebral fascia. If bone is encountered within 2 cm of the skin, it is likely to be a transverse process, and the needle may be “walked” across this structure to locate the nerve.

15. INTERSCALENE BLOCK Normal anatomy – no parasthesia in 2-2.5cm, position of needle must be corrected. Contraction of the diaphragm indicates phrenic nerve stimulation and anterior needle placement; the needle should be redirected posteriorly to locate the brachial plexus.

16. INTERSCALENE BLOCK After negative aspiration, 10 to 40  mL of solution is injected incrementally, depending on the desired extent of blockade. After each 4-5ml, aspiration is done. After successful injection, the entire area is massaged in order to ensure even distribution of the local anesthetic . This also provides hematoma prophylaxis

17. INTERSCALENE BLOCK With a nerve stimuator the goal is stimulation of the brachial plexus with a current intensity of 0.2-0.5 mA (0.1 ms). The following motor responses  result in a similar success rate: Pectoralis muscle Deltoid muscle Triceps muscle Biceps muscle Any twitch of the hand or forearm

18. INTERSCALENE BLOCK CONTINUOUS INTERSCALENE BLOCK : identification of the posterior edge of the sternocleidomastoid muscle at the level of the superior thyroid notch. block needle is introduced at an angle of 30" caudally and slightly laterally, in the direction of the transition from the middle to the lateral third of the clavicle. Position of needle confirmed with ms twitch and local anaesthetic injected.

19. INTERSCALENE BLOCK POSTERIOR TECHNIQUE : first described by Kappis in 191 2, and was republished by Pippa in 1990 as a ”loss of resistance” technique. Sitting, with the neck flexed (to relax the cervical muscles) and supported by an assistant (the lateral recumbent position can be used as an alternative)

20. INTERSCALENE BLOCK LANDMARKS Spinous processes of the sixth (C6) and seventh (C7 - vertebra prominens) cervical vertebrae . The mid-point between the spinous processes of C6 and C7 is marked. The puncture site is located approximately 3 cm lateral to this point. Level of the cricoid cartilage (target direction).

21. INTERSCALENE BLOCK The needle is introduced at the sagittal level and perpendicular to the skin, aiming approximately for the level of the ipsilateral cricoid cartilage. At a depth of about 3.5-6 cm, contact is made with the transverse process of C7. The needle is withdrawn slightly, the injection direction is corrected slightly cranially, and one advances past the transverse process a further 1.5-2 cm deeper. Then the normal process follows.

22. INTERSCALENE BLOCK

23. INTERSCALENE BLOCK COMPLICATIONS: Risk of dural puncture if performed too medially. Risk of pneumothorax

24. INTERSCALENE BLOCK SIDE EFFECTS & COMPLICATIONS : Ipsilateral phrenic nerve block diaphragmatic paresis altered pulmonary function.

25. INTERSCALENE BLOCK Severe hypotension and bradycardia (i.e., the Bezold-Jarisch reflex) have been reported in awake, sitting patients undergoing shoulder surgery under an interscalene block d/t stimulation of intracardiac mechanoreceptors by decreased venous return, which produces an abrupt withdrawal of sympathetic tone and enhanced parasympathetic output.

26. INTERSCALENE BLOCK Nerve damage and neuritis – rarely seen. Local anaesthetic toxicity. Associated horner’s syndrome can develop due to stellate ganglion block. Rarely pneumothorax

27. INTERSCALENE BLOCK Usual areas of blockade after interscalene block

28. SUPRACLAVICULAR BLOCK Injection of a local anesthetic into the area of the brachial plexus trunks in the caudal part of the interscalene groove, in its most compact part above the clavicle. The first percutaneous supraclavicular block was performed in 1911 by German surgeon Diedrich Kulenkampff on himself.

29. SUPRACLAVICULAR BLOCK Blockade occurs at the distal trunk–proximal division level. At this point, the brachial plexus is compact and a small volume of solution produces rapid onset of reliable blockade of the brachial plexus. Additional advantage is that the block can also be performed with the patient's arm in any position.

30. SUPRACLAVICULAR BLOCK The supraclavicular block is often called the "spinal anesthesia of the upper extremity" because of its ubiquitous application for upper extremity surgery.

31. SUPRACLAVICULAR BLOCK INDICATIONS Surgery on the upper arm, forearm and hand. As such no therapeutic indications. CONTRAINDICATIONS Infections or malignant diseases in the area of the throat and neck or at the site of injection. Bleeding disorders & anticoagulant therapy. Contralateral pneumothorax Severe COPD

32. SUPRACLAVICULAR BLOCK LANDMARKS : The clavicular head of sternocleidomastoid . Interscalene groove

33. SUPRACLAVICULAR BLOCK The interscalene groove - caudal part in the supraclavicular fossa – difficult to identify – covered by omohyoid muscle. The midpoint of the clavicle. The injection point is located about 1.5-2 cm lateral to the clavicular head of the sternocleidomastoid muscle and 2 cm above the clavicle. Subclavian artery – close proximity to trunks – pulse is an important landmark for injection.

34. SUPRACLAVICULAR BLOCK TECHNIQUE Patient in supine position with the head turned away from the side to be blocked. Arm adducted – preferably pulled down to ipsilateral knee as far as possible. Interscalene groove identified and mark should be made approximately 1.5 to 2.0 cm posterior to the midpoint of the clavicle. Palpation of the subclavian artery at this site confirms the landmark.

35. SUPRACLAVICULAR BLOCK Needle is directed in a caudally, slightly lateral , and posterior direction until a paresthesia or motor response is elicited or the first rib is encountered. If the first rib is encountered without elicitation of a paresthesia , the needle can be systematically walked anteriorly and posteriorly along the rib until the plexus or the subclavian artery is located.

36. SUPRACLAVICULAR BLOCK If artery – slight posteromedial shift – brachial plexus. Avoid too much posteromedial orientation as the dome of pleura is in close proximity to first rib – chance of pneumothorax .

37. SUPRACLAVICULAR BLOCK Modified plumb-bob approach uses similar patient positioning, although the needle entry site is at the point where the lateral border of the sternocleidomastoid muscle inserts into the clavicle. Aspirate and inject – massage after injection – to avoid hematoma and spread of the drug.

38. SUPRACLAVICULAR BLOCK SIDE EFFECTS Concomitant block of the following nerves and ganglia: Vagus nerve Recurrent laryngeal nerve Phrenic nerve. Stellate ganglion

39. SUPRACLAVICULAR BLOCK COMPLICATIONS Pneumothorax Neural injury lntravascular injection Stellate ganglion block CNS intoxication

40. SUPRACLAVICULAR BLOCK Areas blocked after supraclavicular block

41. REFERENCES MILLER’S ANAESTHESIA 7 TH EDN. ANESTHESIOLOGY – BY DAVID.E.LONGNECKER DANILO JANKOVIC REGIONAL NERVE BLOCK AND INFILTRATION THERAPY TEXTBOOK 3 RD EDN. NYSORA WEBSITE – www.nysora.com

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