Interscalene Nerve Block

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Anesthesia for surgery of the shoulder and arm
  • Analgesia for the shoulder and arm
    • Post-surgical
    • Post-traumatic
    • Frozen shoulder
    • Complex regional pain syndrome
    • Post-amputation pain
    • Vascular disease (ischemic limb pain)
    • Tumor-related pain
  • Vasodilation for some upper extremity procedures
    • Vascular flaps
    • Reimplantation of forearm, hand, digits
  • Post-thoracotomy shoulder pain
CONTRAINDICATIONS
  • Absolute contraindications
    • Patient refusal
    • Allergy to local anesthetics
    • Local infection at or near the needle insertion site
  • Relative contraindications
    • Non-cooperative patient
    • Severe respiratory compromise
    • The need for bilateral upper extremity anesthesia (and risk for bilateral phrenic nerve blockade or pneumothoraces)
    • Coagulopathy or medical anticoagulation
    • Traumatic nerve injury in the upper extremity or neck
    • Preexisting neurodeficits in the distribution of the block
    • Previous surgery in the neck that may distort brachial plexus anatomy
EQUIPMENT
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, typically:
    • 1% to 1.5% lidocaine
    • 1% to 1.5% mepivacaine
    • 0.25% to 0.5% bupivacaine
    • 2% chloroprocaine
  • Sterile gloves and mask
  • Sterile fenestrated drape or sterile towels for draping
  • Sterile prep solution
  • Two 20-mL syringes
  • A 5-mL sterile syringe and small gauge (25- or 30-gauge) needle for local anesthetic infiltration of the skin
  • IV extension tubing
  • 3-way stopcock
  • Peripheral nerve stimulator and ECG electrode
  • 1- to 1.5-inch, 25-gauge, short-bevel, insulated nerve stimulating needle
ANATOMY
  • The plexus is formed from the anterior rami of C5-8 and most of T1. Contributions to the plexus also come from C4 and T2, and occasionally the plexus is mainly derived from C4-8 (“pre-fixed” plexus), or from C6-T2 (“post-fixed” plexus).
  • The five roots of the plexus emerge from the intervertebral foramina, and all five roots are then sandwiched between the anterior and middle scalene muscles. The roots mingle and unite to form three trunks: the upper trunk (C5 and C6), the middle trunk (C7), and the lower trunk (C8 and T1).
  • The three trunks emerge from between the scalene muscles and pass downward and laterally across the first rib. Behind the clavicle, each trunk then divides into an anterior and posterior division. These six divisions stream into the axilla, where they unite into three cords—the lateral, medial, and posterior cords—named for their relationship to the axillary artery. The lateral cord gives rise to the lateral pectoral nerve, the musculocutaneous nerve, and the lateral head of the median nerve. The medial cord gives rise to the medial pectoral nerve, the medial cutaneous nerve of the arm, the medial cutaneous nerve of the forearm, the medial head of the median nerve, and the ulnar nerve. The posterior cord gives rise to the upper and lower subscapular nerves, the thoracodorsal nerve, the axillary nerve, and the radial nerve. These nerves exit into the axilla in close relation to the axillary artery, with the median nerve lying anteriorly, the ulnar nerve posteriorly, and the radial nerve posterolaterally.
  • In the neck the nerves of the brachial plexus pass laterally in a deep groove or “gutter” in the superior surface of the transverse process of the cervical vertebrae. The gutter runs laterally and slightly forward and at about a 45-degree angle downward.
  • The interscalene groove can be identified by palpating the posterior border of the sternocleidomastoid muscle at the level of the transverse process of C6 (the level of the cricoid cartilage). The fingers are then rolled back from the sternocleidomastoid muscle to palpate the belly of the anterior scalene muscle. The interscalene groove lies directly posterior to the anterior scalene muscle. In thin patients, deep palpation in this area can often elicit an uncomfortable paresthesia due to pressure on the brachial plexus. Often the external jugular vein lies close to the point of needle insertion.

PROCEDURE
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  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Immediately after placing the block:
    • Instruct the patient to avoid moving the arm; poor motor control of the arm can lead to injury.
    • Assess the distribution of nerve block.
    • Areas not covered by the block can be done by supplemental local anesthetic at surgical site (field block).
    • Full development of the block can take 30 minutes.
    • Patient should be monitored closely for at least 30 minutes after injection of the block; epidural or spinal anesthesia can occur due to migration of local anesthetic proximally along the nerve roots to the epidural space or subarachnoid space.
  • After surgery
    • In PACU reassess the pain level and score.
    • Look for any evidence of neck hematoma.
    • Assess respiratory function: unilateral phrenic nerve paralysis (temporary) is common with interscalene block and may cause respiratory distress in patients with significant pulmonary compromise.
    • Shortness of breath, chest pain, cough, or hypoxemia can indicate the presence of pneumothorax or can also be symptoms of phrenic paralysis.
    • Hoarseness is common after interscalene block due to recurrent laryngeal nerve blockade.
    • Small pupil, unilateral fascial anhydrosis, and ptosis can all result from cervical sympathetic nerve blockade. These effects are temporary, and the patient should be reassured.
    • Assess the motor and sensory function; let the patient know that an interscalene block may not recede for 4 to 6 hours.
    • Provide the patient with an arm sling to use until the block recedes.
    • Follow up with patient after complete resolution of the block by assessing the motor and sensory function.
COMPLICATIONS
  • Complications of vascular puncture
    • Neck tenderness
    • Ecchymosis
    • Hematoma
    • Intravascular injection
  • Local anesthetic toxicity
    • Absorption of local anesthetic from the perivascular compartment
    • Intravascular injection
  • Nerve injury
    • Intraneural injection
    • Direct needle injury
    • Neuritis—possibly due to concentrated local anesthetic solutions or vasoconstrictors in the local anesthetic solution
    • Injury resulting from malpositioning of the anesthetized limb
  • Complications of needle puncture of soft tissue
    • Infection
    • Swelling
    • Bruising
  • Total spinal or epidural block
    • Due to migration of local anesthetic up the neural sheath and into the epidural or subarachnoid space
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