Continous Interscalene Block For Anesthesia And Pain Control Of UpperExtremity SurgeryKaryadi1, Doso Sutiyono11 Department of Anaesthesia And Intensive care Diponegoro University, Kariadi GeneralHospital , Semarang, Central JavaAbstractSingle injection interscalene brachial plexus block is an effective anesthetic; however, it islimited by the duration of action of the local anesthetic.1 Continuous peripheral nerve blockade isan alternative technique that can provide prolonged postoperative analgesia. It has beenparticularly effective in treating pain after shoulder, and other upper extremity surgery bydecreasing postoperative opioid requirements and reducing anesthetic side effects.2 . We reportits successful use in open reduction and internal fixation of left Supra Condilar Humerusfracture. The interscalene brachial plexus were localized by a nerve stimulator with sustainedbiceps motor response at less than 0.5 mA and 40 ml of local anesthetic, comprising 24 ml0.5% bupivacaine and 16 ml 2.0% of lidocaine was administered to establish the block.Surgical anesthesia was achieved 15 minutes after instituting the block and surgery lasted 120minutes without complications. 10 ml of Bupivacaine 0.125% was administered every 12 hoursintermitenly for post operative analgesia. This technique may obviate the use of generalanesthesia with its risks.Keyword: Interscalene block, Anaesthesia, upper extremity surgeryIntroductionRoad traffic accident (RTA) is the most frequent cause of musculoskeletal injuries in manycountries. Regional anesthesia offers in this setting appropriate analgesia sufficient for pain reliefand surgical intervention in extremity injuries.3 These techniques may obviate the use of generalanesthesia with their side effects. Furthermore, opioid requirements are reduced in these patientsand opioid-related side effects such as nausea, vomiting, pruritus, and respiratory depression are
avoided.4 The continous interscalene block is not commonly used as a primary anesthetictechnique for open reduction and internal fixation of a fractured head of humerus in Semarang.We report its use in this 16-year-old female with left Supra Condilar Humerus fracturefollowing RTA.Case ReportA 16-year-old female patient, 48 kg, American Society of Anesthesiologists′ physical status 1,presented with a closed fracture of the left head of humerus following RTA. The initialassessment, resuscitation, and stabilization were done in another hospital before her referral tothe Emergency Department of the RSDK, Semarang. She was scheduled for open reduction andinternal fixation of the fractured left Supra Condilar Humerus under anesthesia. His packed cellvolume was 34.6% and Urea and Electrolytes were normal. The anesthetic option, continousinterscalene brachial plexus block was discussed with the patient and verbal consent wasobtained for the procedure.In the operating room, patients were sedated with 3 mg of IV midazolam and 50 µg of fentanyl,titrated to moderate sedation (arousable on command). Monitoring consisted of noninvasiveblood pressure (BP), electrocardiography, pulse oximetry, and heart rate (HR) using the SiemenSC 7000 Modular Multiparameter monitor. The preblock vital signs include BP, 100/70 mmHg;HR, 80 beats/min; and oxygen saturation (SaO 2 ), 98% breathing room air. The patient was insupine position, his head turned away from the side to be blocked. The interscalene groove waspalpated from rolling the fingers laterally from the posterior border of the sternomastoid muscleover the belly of the anterior scalene muscle. This groove between the anterior and middlescalene muscles was identified at the level of the cricoid cartilage corresponding to the sixthcervical vertebra. After skin preparation with antiseptic and drapes, a 5-cm 18 G continuousblock needle system (the Contiplex Tuohy needle system) was inserted perpendicular to the skinand directed caudally using nerve stimulator. Muscle twitch of the biceps which was obtained atthis current threshold was sustained at 0.3 mA, confirming correct needle placement. A total of40 ml of local anesthetic comprising 24 ml 0.5% bupivacaine and 16 ml 2.0% of lidocaine withwas injected slowly in divided doses with repeated negative aspiration tests. The Tuohy needlewas Stabilized with one hand (it may be helpful to hold the needle with part of the hand braced
against the patient), the catheter was held at the distal tip and advance it through the center of thediaphragm. Continue to thread the catheter until it reaches the end of the needle. the catheter wasadvanced in small increments until it reaches the desired distance . USG was used to ensure thecorrect placement of the catheter, the catheters expected to remain in place for more than 3 daysso its should be tunneled. Tunneling makes the catheter less likely to fall out and may decreasethe risk of infection. Sensorimotor block was complete in 15 minutes with loss of pinpricksensation, inability to lift or abduct arm, and numbness over the affected shoulder. He wassedated with intravenous diazepam 3 mg and fentanyl 50 mcg, and remained hemodynamicallystable throughout the procedure which lasted 120 minutes. SaO 2 was 97 to 99% on oxygenthrough facemask at 3 l/min; HR was stable at 82 to 98 beats/min, systolic BP range was 100 to125 mmHg, and diastolic BP was 74 to 88 mmHg. He had 800 ml of Ringers′ lactate withestimated blood loss of about 150 ml. The block lasted 5 hours, and the patient described thesurgical anesthesia as good and would choose a brachial plexus block, if he was to have a repeatsurgery.DiscussionThis case report illustrates the effectiveness of interscalene block as a primary anesthetic forshoulder and upper extremity surgery. Brachial plexus anesthesia using local anesthetic agentsprovide sensorimotor block to the entire upper limb, suitable for orthopedic and plasticoperations.3,5,6 Joshy et al.7 in a study of 104 patients undergoing shoulder surgery reported thatinterscalene block provided safe and sustained adequate pain relief. Only a small percentage(6%) showed signs of Horner′s syndrome which resolved by 12 hours.The interscalene approach to the brachial plexus is ideal for proximal upper limb procedures.Winnie′s approach uses the sixth cervical transverse process as landmark for needleinsertion.8 Borgeat et al. described a modified lateral approach in which the block needlepuncture point is 0.5 cm below the level of the cricoid (Winnie′s point) to avoid piercing thescalene muscles.9 We were able to achieve complete surgical anesthesia within 15 minutes ofinstituting the block, and surgery lasted 120 minutes. This case demonstrated it was possible toextend the duration of anesthesia and analgesia by using a continuous peripheral nerve blockeffectively.
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