Blocks for Shoulders

80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.

Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. International Journal of Surgery, Volume 45, September 2017, Pages 85-91.

  • Supraclavicular block could provide similar analgesic efficacy compared with interscalene block.
  • Ultrasound-guided supraclavicular block was associated with a low incidence of hoarseness and Horner syndrome.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. European Journal of Anaesthesiology 36(6):p 427-435, June 2019

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology July 2018, Vol. 129, 47–57.

From Anesthesiology July 2018, Vol. 129, 47–57.

A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery. Regional Anesthesia & Pain Medicine 2018;43:590-595.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand. 2021; 65: 674– 680.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research volume 16, Article number: 376 (2021).

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review. Osteology 20222(1), 52-61.

YouTube: Anterior suprascapular nerve block and literature 11:43 for procedure

YouTube: Suprascapular and axillary nerve block

Anesthesia for Latissimus Dorsi Flap for Breast Reconstruction

What is a latissimus dorsi flap?

From MDAnderson.org

Latissimus Dorsi Flap in Breast Reconstruction. Cancer Control. 2018 Jan-Dec; 25(1): 1073274817744638.

A Retrospective Study of Latissimus Dorsi Flap in Immediate Breast Reconstruction. Front. Oncol., 04 November 2021. https://doi.org/10.3389/fonc.2021.598604

Anesthetic Techniques

Regional Anesthesia For Breast Reconstruction. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Anaesthesia for breast surgery. BJA Education, 18(11): 342e348 (2018).

Anaesthesia for free flap breast reconstruction. BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166.

Paravertebral Analgesia with Levobupivacaine Increases Postoperative Flap Tissue Oxygen Tension after Immediate Latissimus Dorsi Breast Reconstruction Compared with Intravenous Opioid Analgesia. Anesthesiology February 2004, Vol. 100, 375–380.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review. Anesth Pain Med. 2016 Oct; 6(5): e39476.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res. 2018;11:1567-1581.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth. 2021 Sep;72:110274.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth. 2022 Apr;69(4):527-549.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia. 2021 Mar;76(3):404-413.

Erector Spinae Plane Block Similar to Paravertebral Block for Perioperative Pain Control in Breast Surgery: A Meta-Analysis Study. Pain Physician. 2021 May;24(3):203-213.

Erector Spinae Plane Block for Mastectomy and Breast Flap Reconstructive Surgery: A Three Case Series. Open Journal of Anesthesiology
Vol.10 No.01(2020), Article ID:97889,8 pages.

Regional Anesthesia for AV fistula revision

Case info

Types of regional anesthesia for AV fistula

Regional anaesthesia practice for arteriovenous fistula formation surgery. Anaesthesia 2020, 75, 626–633.

Observational study of the efficacy of supraclavicular brachial plexus block for arteriovenous fistula creation. Indian J Anaesth. 2018 Aug; 62(8): 616–620.

NYSORA Ultrasound-guided Supraclavicular Block video

Ultrasound-guided supraclavicular versus infraclavicular brachial plexus nerve block in chronic renal failure patients undergoing arteriovenous fistula creation. Egyptian Journal of Anaesthesia. Volume 30, Issue 2, April 2014, Pages 161-167.

SonoSite Ultrasound-guided Supraclavicular Block video

Practical Anesthesia Techniques ultrasound-guided infraclavicular block video

From Doctorlib.info

A brachial plexus block technique for upper arm AV Fistula. BJA: British Journal of Anaesthesia, Volume 113, Issue eLetters Supplement, 29 December 2014.

Axillary Nerve Block for Upper Extremity Arteriovenous Fistula Creation. Proceedings of UCLA Healthcare. VOLUME 21 (2017).

Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure. Saudi J Anaesth. 2017 Jan-Mar; 11(1): 77–82.

Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial. JASN August 2020, 31 (8) 1871-1882.

Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis. BMC Anesthesiology volume 20, Article number: 219 (2020).

From Doctorlib.info

Is it ok to do regional blocks in sepsis patients?

Neuraxial Regional Anaesthesia in Patients with Active Infection and Sepsis: A Clinical Narrative Review. Turk J Anaesthesiol Reanim. 2018 Feb; 46(1): 8–14.

Exparel

Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.

Exparel FDA drug sheet

  • Max Dose: 266 mg or 4mg/kg (6yo-17yo). Interscalene NB max dose (adults) =133mg
Exparel website: Field blocks
Exparel website: Interscalene NB

Exparel dosing company info: Pocket Dosing Guide , Billing Guide

Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5: 257–264.

Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017 Apr-Jun; 33(2): 151–156.

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016 Aug 25;2016(8):CD011476.

Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb; 2017(2): CD011419.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med. 2022 Feb; 12(1): e123112.

Cardiac/Thoracic

The role of liposomal bupivacaine in thoracic surgery. J Thorac Dis. 2019 May; 11(Suppl 9): S1163–S1168.

Intercostal nerve blockade for thoracic surgery with liposomal bupivacaine: the devil is in the details. J Thorac Dis. 2019 May; 11(Suppl 9): S1202–S1205.

  • VATs: Dilute liposomal bupivacaine (266 mg, 20 cc) mixed with 20 cc injectable saline. We use two syringes to save time (refill syringe between injections).
  • For planned thoracotomy, we add 60 cc injectable saline for wider injection.
  • The efficacy of this strategy requires attention to specific details, such as timing and technique of injection, dilution with saline, and injection of multiple interspaces (typically interspaces 3–10 when technically possible).
  • Inject EXPAREL slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
  • Infiltrate above and below the fascia and into the subcutaneous tissue
  • Aspirate frequently to minimize the risk of intravascular injection
  • Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
  • Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage

Liposomal Bupivacaine Versus Bupivacaine for Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. Pain Physician. 2020 Jun;23(3):E251-E258.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 May;35(5):1404-1409.

Is liposomal bupivacaine superior to standard bupivacaine for pain control following minimally invasive thoracic surgery? Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 2, August 2020, Pages 199–203, https://doi.org/10.1093/icvts/ivaa083

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res. 2020 Feb;246:19-25.

Rib fractures case report: ESP block


Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy. Am Surg. 2021 Dec;87(10):1561-1564.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain. Anesth Essays Res. 2020 Apr-Jun; 14(2): 300–304.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg. 2020 Jul;35(7):1525-1530.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol. 2021; 21: 98.

Pain Relief Following Sternotomy in Conventional Cardiac Surgery: A Review of Non Neuraxial Regional Nerve Blocks. Ann Card Anaesth. 2020 Apr-Jun; 23(2): 200–208.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery. Case Rep Anesthesiol. 2021; 2021: 5521136.

Breast/Gen Surg

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Jan 19;10(1):e4010.

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med. 2020 Oct; 10(5): e105686.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol. 2019; 19: 31.


Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019 Sep;15(9):1554-1562.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol. 2020 Jan-Mar; 36(1): 110–114.

Ortho

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res. 2017 Jan;475(1):110-117.

OB

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg. 2020 Dec; 131(6): 1830–1839.

Fascia Iliaca blocks for TAVR under conscious sedation

Editorial: The use of Fascia iliaca Block with Minimal Conscious Sedation in Transcatheter Aortic Valve Replacement: Advances in TAVR Anesthesia. Cardiovasc Revasc Med. 2020 May;21(5):602-603. doi: 10.1016/j.carrev.2020.03.017.

Local Anesthesia-Conscious Sedation: The Contemporary Gold Standard for Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv. 2018 Mar 26;11(6):579-580. doi: 10.1016/j.jcin.2018.01.238.

Transfemoral Transcatheter Aortic Valve Replacement Using Fascia Iliaca Block as an Alternative Approach to Conscious Sedation as Compared to General Anesthesia. Cardiovasc Revasc Med. 2020 May;21(5):594-601. doi: 10.1016/j.carrev.2019.08.080. Epub 2019 Sep 7.

**NYSORA U/S guided Fascia Iliaca nerve block**

From EMbeds.co.uk – FOAMed @ CHT-ED

TCT-808 Transfemoral Transcatheter Aortic Valve Replacement Using Fascia Iliaca Block as an Alternative Approach to Conscious Sedation as Compare to General Anesthesia: Findings From a Single Center. J Am Coll Cardiol. 2019 Oct, 74 (13_Supplement) B792

Fascia Iliaca block for hip surgery

Why place regional blocks for surgery?

JNYSORA Volume 10 March 2009: Nerve Blocks For Postoperative Analgesia: Choices After Common Lower Extremity Procedures.

What is it?

NYSORA description

From Starship Child Health

NYSORA video describing the block

Academic Life in EM. Aug 21, 2019. Fascia iliaca nerve block: A hip fracture best-practice

EM St. John. Fascia Iliaca Nerve Block. .

From Starship Child Health

How to do it?

Suprainguinal Fascia Iliaca Plane block

MySigRA Suprainguinal Fascia Iliaca Plane block

From Highland EM Ultrasound

Literature says:

Journal of Orthopaedic Trauma: January 2020 – Volume 34 – Issue 1 – p 49-54. Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial.

Eur J Emerg Med. 2016 Feb;23(1):12-8. Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.

BJA VOLUME 120, ISSUE 6, P1368-1380, JUNE 01, 2018. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial. BMC Geriatr 19, 180 (2019).

Anesthesiology September 2018, Vol. 129, 536–543. Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

J Surg, Volume 16:2, 2020. Peripheral Nerve Blocks in Hip Arthroscopy.

Am J Orthop (Belle Mead NJ).  2018 Jun;47(6). Outcomes After Peripheral Nerve Block in Hip Arthroscopy.

Transversus Abdominis Plane (TAP) block

Indications and Technique

Figure 1. Biomed Res Int. 2017; 2017: 8284363.
Figure 1. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 5. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 6. Biomed Res Int. 2017; 2017: 8284363.

Pros & Cons

The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial. Diseases of the Colon & Rectum: November 2014 – Volume 57 – Issue 11 – p 1290-1297


How to perform a TAP block?

YouTube: U/S guided TAP block

YouTube: RAUKvideos U/S guided TAP block Fast forward to 0:39

YouTube: 3D How-To U/S Guided TAP block Fast forward to 1:00

YouTube: 2012 ISURA TAP block lecture Fast forward to 16:55 for summary.

YouTube: ASRA Society Fast forward to 0:55. Sound off.

YouTube: Pajunk TAP block


Current mix:

  • July 2020
    • 0.25% bupi + epi + 1 mcg/kg dexmedetomidine (roughly 30 ml per side)

Paravertebral Block and Catheters

Review: Thoracic Paravertebral Block. Anesthesiology. Sept 2001.

Ultrasound-Guided Paravertebral Block Anaesthesia Tutorial of the Week. April 2018. Tutorial #376.

YouTube: PVB catheter technique

YouTube: LSORA U/S-guided PVB

YouTube: U/S-guided PVB by Block Jocks

YouTube: nerveblocks U/S-guided PVB

YouTube: thoracic PVB and anatomy

YouTube: Ottawa Hospital PVB

From SPPM Newsletter

Update:

Nov 2021:

https://www.sciencedirect.com/science/article/pii/S1053077020300987?via%3Dihub


Insertion of paravertebral block catheters intraoperatively to reduce incidence of block failure. Interact Cardiovasc Thorac Surg. 2012 May; 14(5): 648–649.

Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study. Journal of Cardiothoracic Surgery volume 12, Article number: 5 (2017)

From The mid‐point transverse process to pleura (MTP) block: a new end‐point for thoracic paravertebral block. https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14004
Table 3. Drug and Dosage for Thoracic Paravertebral Block

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia. Anesthesia & Analgesia:September 2008 – Volume 107 – Issue 3 – p 1026-1040

Thoracic surgery: PVB, SAPB, TEpi, ESP block, Precedex

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study.  JCVA February 2017. Volume 31, Issue 1, Pages 142–146.

To place the PV catheter at the T4-5 level, the authors used an in-plane transverse technique under ultrasound guidance, with the probe in a transverse orientation. After identifying the anatomic landmarks on ultrasound, a 17-gauge Tuohy needle was advanced in a lateral to medial direction, until the tip was beneath the transverse process. For all recipients in the study, the authors further confirmed correct PV catheter placement with real-time infusion of a local anesthetic (1-3 mL of 1.5% lidocaine with epinephrine 1:200,000); they were able to visualize on ultrasound the spread from the tip of the catheter.

Once it was confirmed that the tip remained in position, the PV catheter was secured with skin glue (Dermabond®, Ethicon, Inc.; Somerville, NJ). Next, at the PV catheter insertion site, the authors placed an occlusive dressing on a chlorhexidine-impregnated sponge (BioPatch®, Johnson & Johnson Wound Management, a division of Ethicon, Inc.; Somerville, NJ). The PV catheter was connected to an elastomeric pump (ON-Q®, Halyard Health, Alpharetta, GA), an infusion of 0.2% ropivacaine was started at a rate of 0.2 to 0.25 mL/kg/h; the maximum dose was 7 mL/h per side in bilateral lung transplant recipients and 14 mL/h in unilateral single-lung transplant recipients.

pic3
From NYSORA


Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. JCVA February 2017. Volume 31, Issue 1, Pages 152–158.

Under sterile conditions and while patients still were in the lateral position with the diseased side up, a linear ultrasound transducer (10-12 MHz) was placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the ribs were counted down until the fifth rib was identified in the midaxillary line (Fig 1).18 The following muscles were identified overlying the fifth rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscles (deep and inferior). The needle (a 22-gauge, 50-mm Touhy needle) was introduced in plane with respect to the ultrasound probe, targeting the plane superficial to the serratus anterior muscle (Fig 2). Under continuous ultrasound guidance, 30 mL of 0.25% levobupivacaine was injected, and then a catheter was threaded. A continuous infusion of 5 mL/hour of 0.125% levobupivacaine then was started through the catheter.

Figure-17-Nagdev-2017-ACEP-Now-Ultrasound-Guided-Serratus-Anterior-Plane-Block-Can-Help-Avoid-Opioid-Use-for-Patients-with-Rib-Fractures-
From http://painandpsa.org/rnb/


Erector Spinae Plane Block


Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-Thoracotomy Pain Syndrome After Thoracotomy: A Randomized Controlled Trial. JCVA February 2017. Volume 31, Issue 1, Pages 159–165.

Adjuvants to prolong regional anesthesia

Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

**Updated May 2022**

Indications:

The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun; 72(3): 209–220.

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

  • Braun Periflex catheter through 17g epidural needle
  • Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
  • 20ml 0.25% bupi + epi prior to catheter
  • Catheter 5cm in space
  • 5 ml 0.25% bupi + epi after catheter placed
  • Mix: 0.125% bupi + fentanyl @ 10 ml/hr
  • If PCEA available, bolus 15ml every 3 hours; continuous as mix above.