A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series

Background - Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis. Methods - Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15 mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound. Results - Median NRS (0-10) at 1, 3, 6, 8 and 24 hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5 mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%). Conclusions - The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty

A randomised placebo-controlled trial examining the effect on hand supination after the addition of a suprascapular nerve block to infraclavicular brachial plexus blockade

This is the peer reviewed version of the following article: Flohr-Madsen, S., Ytrebø, L.M., Valen, K., Wilsgaard, T. & Klaastad, Ø. (2016). A randomised placebo-controlled trial examining the effect on hand supination after the addition of a suprascapular nerve block to infraclavicular brachial plexus blockade. Anaesthesia, 71, 938–947, which has been published in final form at https://doi.org/10.1111/anae.13504. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.Some surgeons believe that infraclavicular brachial plexus blocks tends to result in supination of the hand/forearm, which may make surgical access to the dorsum of the hand more difficult. We hypothesised that this supination may be reduced by the addition of a suprascapular nerve block. In a double‐blind, randomised, placebo‐controlled study, our primary outcome measure was the amount of supination (as assessed by wrist angulation) 30 min after infraclavicular brachial plexus block, with (suprascapular group) or without (control group) a supplementary suprascapular block. All blocks were ultrasound‐guided. The secondary outcome measure was an assessment by the surgeon of the intra‐operative position of the hand. Considering only patients with successful nerve blocks, mean (SD) wrist angulation was lower (33 (27) vs. 61 (44) degrees; p = 0.018) and assessment of the hand position was better (11/11 vs. 6/11 rated as ‘good’; p = 0.04) in the suprascapular group. The addition of a suprascapular nerve block to an infraclavicular brachial plexus block can provide a better hand/forearm position for dorsal hand surgery

A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery

Background - Interscalene brachial plexus block is currently the gold standard for intra‐ and post‐operative pain management for patients undergoing arthroscopic shoulder surgery. However, it is associated with block related complications, of which effect on the phrenic nerve have been of most interest. Side effects caused by general anesthesia, when this is required, are also a concern. We hypothesized that the combination of superficial cervical plexus block, suprascapular nerve block, and infraclavicular brachial plexus block would provide a good alternative to interscalene block and general anesthesia. Methods - Twenty adult patients scheduled for arthroscopic shoulder surgery received a combination of superficial cervical plexus block (5 ml ropivacaine 0.5%), suprascapular nerve block (4 ml ropivacaine 0.5%), and lateral sagittal infraclavicular block (31 ml ropivacaine 0.75%). The primary aim was to find the proportion of patients who could be operated under light propofol sedation, without the need for opioids or artificial airway. Secondary aims were patients' satisfaction and surgeons' judgment of the operating conditions. Results - Nineteen of twenty patients (95% CI: 85–100) underwent arthroscopic shoulder surgery with light propofol sedation, but without opioids or artificial airway. The excluded patient was not comfortable in the beach chair position and therefore received general anesthesia. All patients were satisfied with the treatment on follow‐up interviews. The surgeons rated the operating conditions as good for all patients. Conclusion - The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery

Minimum effective volume of ropivacaine 7.5mg/ml for an ultrasound-guided infraclavicular brachial plexus block

Background - Ultrasound guidance has been shown to reduce the minimum effective volume (MEV) of local anaesthetics for several peripheral nerve blocks. Although the lateral sagittal infraclavicular block (LSIB) is a well‐established anaesthesia method, MEV for this technique has not been established. Our aim with this study was to determine the MEV using ropivacaine 7.5 mg/ml for the LSIB method. Methods - Twenty‐five adult American Society of Anesthesiologists physical status I‐II patients scheduled for hand surgery received an ultrasound‐guided LSIB with ropivacaine 7.5 mg/ml. A successful block was defined as anaesthesia or analgesia for all five sensory nerves distal to the elbow, 30 min after local anaesthetic injection. The MEV for a successful block in 50% of the patients was determined by using the staircase up‐and‐down method introduced by Dixon and Massey. Logistic regression and probit transformation were applied to estimate the MEV for a successful block in 95% of the patients. Results - The patients received ropivacaine 7.5 mg/ml volumes in the range of 12.5–30 ml. The MEVs in 50% and 95% of the patients were 19 ml [95% confidence interval (CI), 14–27] and 31 ml (95% CI, 18–45), respectively. Conclusions - For surgery distal to the elbow, the MEV in 95% of patients for an ultrasound‐guided LSIB with ropivacaine 7.5 mg/ml was estimated to be 31 ml (95% CI, 18–45 ml). Further studies should determine the factors that influence the volume of local anaesthetic required for a successful infraclavicular block

MRI of axillary brachial plexus blocks: A randomised controlled study

BACKGROUND: Axillary plexus blocks are usually guided by ultrasound, but alternative methods may be used when ultrasound equipment is lacking. For a nonultrasound-guided axillary block, the need for three injections has been questioned. OBJECTIVES: Could differences in block success between single, double and triple deposits methods be explained by differences in local anaesthetic distribution as observed by MRI? DESIGN: A blinded and randomised controlled study. SETTING: Conducted at Oslo University Hospital, Rikshospitalet, Norway from 2009 to 2011. PATIENTS: Forty-five ASA 1 to 2 patients scheduled for surgery were randomised to three equally sized groups. All patients completed the study. INTERVENTIONS: Patients in the single-deposit group had an injection through a catheter parallel to the median nerve. In the double-deposit group the patients received a transarterial block. In the triple-deposit group the injections of the two other groups were combined. Upon completion of local anaesthetic injection the patients were scanned by MRI, before clinical block assessment. The distribution of local anaesthetic was scored by its closeness to terminal nerves and cords of the brachial plexus, as seen by MRI. The clinical effect was scored by the degree of sensory block in terminal nerve innervation areas. MAIN OUTCOME MEASURES: Sensory block effect and MRI distribution pattern. RESULTS: The triple-deposit method had a higher success rate (100%) than the single-deposit method (67%) and the double-deposit method (67%) in blocking all cutaneous nerves distal to the elbow (P = 0.04). The patients in the triple-deposit group most often had the best MRI scores. For any nerve or cord, at least one of the single-deposit or double-deposit groups had a similarly high MRI score as the triple-deposit group. CONCLUSION: Distal to the elbow, the triple-deposit method had the highest sensory block success rate. This could be explained to some extent by analysis of the magnetic resonance images. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01033006

Microcirculation and haemodynamics after infraclavicular brachial plexus block using adrenaline as an adjuvant to lidocaine: a randomised, double-blind, crossover study in healthy volunteers

We evaluated the effect of adrenaline on human skin microcirculation (nutritive and sub‐papillary) and systemic cardiovascular variables after it was added to lidocaine in infraclavicular brachial plexus blocks. Twelve healthy, non‐smoking male volunteers were included, each attending two study sessions 2 weeks apart, and they were studied using a crossover design. In both sessions, they received an ultrasound‐guided infraclavicular brachial plexus block in the non‐dominant arm with 0.4 ml.kg−1 lidocaine, 15 mg.ml−1 with or without adrenaline 5 μg.ml−1. Microcirculation was assessed by laser Doppler fluxmetry (sub‐papillary blood flow), capillary video microscopy (nutritive blood flow) and continuous temperature measurements. Heart rate and arterial pressure were recorded continuously and non‐invasively. Median (IQR [range]) sub‐papillary blood flow increased substantially 30 min after the brachial plexus block, from 8.5 (4.4–13.5 [2.9–28.2]) to 162.7 (111.0–197.8 [9.5–206.7]) arbitrary units with adrenaline (p = 0.017), and from 6.9 (5.3–28.5 [1.8–42.1] to 133.7 (16.5–216.7 [1.0–445.0] arbitrary units without adrenaline (p = 0.036). Nutritive blood flow (functional capillary density, capillaries.mm−2, measured at the dorsal side of the hand) decreased in the blocked extremity when adrenaline was used as adjuvant, from median (IQR [range]) 45 (36–52 [26–59]) to 38 (29–41 [26–42]), p = 0.028, whereas no significant change occurred without adrenaline. Median finger skin temperature (°C) increased by 44% (data pooled) with no significant differences between the groups. No significant changes were found in the systemic cardiovascular variables with or without adrenaline. We conclude that lidocaine infraclavicular brachial plexus blocks caused an increase in skin sub‐papillary blood flow. The addition of adrenaline produced stronger and longer lasting blocks, but decreased the nutritive blood flow