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. ₡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 INTERSCALENE BRACHIAL PLEXUS BLOCK

4. ISB CONTRAINDICATIONS ¥ Skin infection ¥ Refusal of the procedure by the patient ¥ Haemorrhagic diathesis ¥ Contralateral phrenic nerve or recurrent nerve 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. Subclavian v. Subclavian a. Phrenic nerve V.J.Interna A. C.Communis

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

8. Vertebral a. Phrenic nerve SCM muscle Anterior scalene m. Middle scalene m. Subclavian a.

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. 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 ISB USING POSTERIOR APPROACH ANATOMICAL LAYERS IN TRANSVERSE SECTION

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

14. POSTERIOR ISB SITTING POSITION LATERAL DECUBITIS POSITION

15. 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

41. STIMULATING CATHETERS Does Interscalene Catheter Placement with Stimulating Catheters Improve Postoperative Pain or Functional Outcome After Shoulder Surgery?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. Precisely control catheter placement Precisely control catheter placement Improved onset of motor nerve block Improved onset of motor nerve block

42. Brachial Plexus Block With Catheter Using The Posterior Interscalene Approach TÜRKER G.In The Management Of Neuropathic Cancer Pain (2 Case Report) TÜRKER G. Uludağ Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, BURSA Decreased likelihood of catheter dislodgement due to neck movement

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

45. INTRACORD INJECTION 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

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