Regional Anesthesia for Clavicle and Shoulder Surgery
Case Presentation: Multitrauma Patient for Clavicle and Ankle Surgery
What was the clinical scenario presented?
The case involved a poly-trauma patient with multiple refractures,
specifically scheduled for a clavicle repair and an ankle surgery.
The goal was to perform the procedures with minimal general anesthesia,
using regional blocks while keeping the patient awake and comfortable.
What was the overall anesthetic strategy for this patient?
The plan was to perform both the clavicle repair and ankle surgery solely under regional anesthesia,
avoiding intubation, an LMA, or general anesthesia.
The patient received a combination of blocks:
- For the clavicle: Interscalene block, Supraclavicular nerve block, and Clavipectoral fascia block.
- For rib fractures: An Erector Spinae block.
- For the ankle: Adductor canal (saphenous) and Popliteal sciatic blocks.
This allowed two surgical teams to operate simultaneously on an awake, cooperative patient.
What sedation technique was used alongside the blocks?
A "TIVA starter" was prepared and administered. This mixture included Dexmedetomidine, Fentanyl, and Midazolam.
The patient was also given an "MDX" combination (Midazolam and Dexmedetomidine).
When the patient experienced a brief moment of pain, 20 mg of Ketamine was used as a rescue analgesic.
Interscalene Brachial Plexus Block
What was the first block performed for the clavicle surgery and why?
The first block performed was an interscalene block. It was chosen to anesthetize the brachial plexus roots
to provide primary anesthesia for the clavicle repair.
Can you describe the needling approach used for the interscalene block?
The approach used was from medial to lateral, which is an alternative to the more common lateral-to-medial approach.
The choice of direction depends on the practitioner's comfort level and expertise, as well as the patient's anatomy.
Why is it important to use an extension tube when injecting the local anesthetic?
Using an extension tube allows the operator to focus solely on hand-eye coordination—maintaining the ultrasound probe in the correct position
while managing the needle. If you try to inject the drug yourself without an extension, the ultrasound probe is likely to slip,
causing you to lose sight of the needle and potentially leading to nerve or vessel injury.
How was the injection site confirmed on ultrasound?
The practitioner visualized the "traffic light" sign—the hypoechoic roots of the brachial plexus in the interscalene groove.
The needle was guided in-plane until its tip was positioned among these roots. The local anesthetic was then deposited,
and its spread could be seen surrounding the nerves. A supplementary dose was given specifically around the C5 root to ensure complete coverage.
summary>What volume and type of local anesthetic was used for the interscalene block?
For this block, performed as the sole anesthetic, approximately 10 mL of 0.25% Ropivacaine was used.
The presenter notes that 5-7 mL is often sufficient. The Ropivacaine was diluted from a 0.75% solution.
This lower concentration helps increase the volume available for multiple blocks while reducing the risk of local anesthetic toxicity.
Supplemental Blocks for Complete Clavicle Coverage
What is the difference between a Superficial Cervical Plexus Block and a Supraclavicular Nerve Block?
- Superficial Cervical Plexus Block: Performed at the C5 root level, it blocks the greater auricular and other nerves,
anesthetizing the entire side of the neck (C2, C3, C4). This is essential for procedures like an awake central line insertion.
- Supraclavicular Nerve Block: A more specific block that targets the three divisions of the supraclavicular nerve.
It can be performed at the C6 or C7 level and primarily anesthetizes the skin over the shoulder and clavicle.
Why was a second block performed after the interscalene block?
The initial attempt at a superficial supraclavicular nerve block was suboptimal,
requiring needle repositioning to ensure adequate drug delivery around the targeted nerves.
What is a Clavipectoral Fascia Block and why was it added?
The Clavipectoral Fascia Block is a very superficial block performed along the shaft of the clavicle.
It was added to provide "double insurance" for pain relief. The local anesthetic is injected just at the tip of the clavicle,
lifting the fascia and spreading along the bone. For a fracture, it is performed on both sides of the fracture site to ensure complete coverage.
What important communication occurred with the surgeon regarding the blocks?
The surgeon initially attempted to place a suture through the towel clip below the clavicle.
The anesthesiologist had to intervene, explaining that this area was not blocked and asking the surgeon to use a towel clip instead,
highlighting the importance of teamwork and communication in regional anesthesia.
Technical Considerations and Clinical Pearls
What are the modern concepts regarding local anesthetic volume for blocks?
The presenter challenges the old misconception of needing large volumes of high-concentration drugs for blind blocks.
With ultrasound guidance, lower volumes (5-10 mL per block) of diluted, long-acting anesthetics like 0.25% Ropivacaine are often sufficient.
This approach allows for performing multiple blocks safely without reaching toxic doses,
with the caveat that the practitioner must be experienced in recognizing and managing local anesthetic toxicity.
Why might an interscalene catheter be placed, and what is a key tip for doing so?
An interscalene catheter is placed for postoperative pain relief, especially after shoulder arthroscopy,
to facilitate early physiotherapy and mobilization. A key tip for placement is to inflate the space with saline
to confirm the catheter tip is correctly positioned among the nerve roots before threading it further.
A Perifix catheter, made of a specific polymer, can potentially be left in place for up to 21 days,
but is certainly useful for the 7-10 days of initial, intense physiotherapy.
What are the limitations of performing a shoulder arthroscopy solely under a block?
While a short (e.g., 30-minute) shoulder arthroscopy in a cooperative patient can be done under a block,
longer procedures lasting 2-3 hours can be challenging. Patient agitation and the prolonged duration
often make a general anesthetic or a block with sedation a more practical choice.
Why is a Superficial Cervical Plexus Block considered a "must-do" for an awake central line insertion?
This block anesthetizes the skin and deeper structures of the entire anterolateral neck.
Performing it under ultrasound guidance before preparing for a central line dramatically improves patient comfort,
making the procedure much more tolerable for an awake patient.