Interscalene Brachial Plexus Block Combined with Superficial Cervical Plexus Block and Light Sedation for Shoulder Arthroscopy

3 weeks ago a 56 kg and 56 year old female patiënt, nurse on an internistic ward in our hospital, was referred to me to discuss the anesthesiological plan for her planned right shoulder arthroscopy (biceps-tenotomy and AC resection) for a slap-lesion and diseased biceps tendon.

Her major concern was NOT to get a general anesthesia. Every former general anaesthesia gave her at least one week of exhausting nausea and vomiting, and merely the idea made her panicking.

Our hospital is a 500-beds regional hospital in Ypres (Ieper) Belgium where the anesthesiology department exists of 16 anesthesiologists for 14.000 surgical interventions a year. We do have a fair amount of orthopaedic surgery, where peripheral nerve blocks are increasingly used.

Our standard anesthesiological protocol for shoulder arthroscopy exists in an US guided interscalene block, followed by a general anaesthesia for patient comfort during the intervention (AND for the peace of mind of the anaesthesiologist ;-).
For surgeon 1 the patient is positioned in lateral decubitus, the position for surgeon 2 (the surgeon in this case) is beach chair position.

2 weeks ago me and 2 of my colleagues were invited at CREER (Centre for Research, Education and Enhanced Recovery after Orthopaedic Anaesthesia) at the ZOL hospital in Genk (Belgium). We had a great and extremely interesting day. As we were using regional blocks for quit some time now, our interest went not only at the technical aspects of the different blocks, but also in the proven practical approach and organisation of an acute pain service at CREER. Every of our questions was answered. I specifically questioned dr. Hadzic about some tips and tricks for awake shoulder arthroscopy, knowing I had a case waiting for me.

Today I proceeded as planned with this perfect patient for my first awake shoulder arthroscopy. Because the operation before this was finished way before schedule, there was no possibility to perform the block in the pre-anaesthetic block room.

After light sedation with midazolam 2 mg and a small dose of ketamine (10 mg) and 5L oxygen/min by face mask, the ultrasound image of the plexus in this non-obese woman was textbook material. Starting with some local anaesthesia, the interscalene (15 ml) and superficial cervical plexus (5 ml) were bathed in a mixture of ropivacaïne 1% 10 ml plus lidocaïn 2% 10 ml. All of this happened in the operating theatre itself.

The nurses continued preparing the patient, positioning her in a beach chair position, disinfecting and draping. We kept a visual contact with the patient.

After this rather short installation-time, the block was deep enough to proceed.

Even in the presence of  additional light sedation with propofol (target 0.5 mcg/ml), the patient was able to follow the procedure on a dedicated screen, and was very happy doing that.

As extra precautions against PONV, she received a bolus of ondansetron 4 mg and dexamethasone 5 mg.

The intervention proceeded uneventful, with good operating conditions for the surgeon (it was his first awake arthroscopy as well) and a comfortable, slightly sedated patient.

At the end of the intervention the patient thanked me extensively. She agreed on taking this selfie, as a memory for her and for me, as soon as she arrived in the recovery room.

When I visited her later that day, she just finished her meal, and was preparing to leave for home.

Stefan Van Hooreweghe

Jan Yperman Ziekenhuis - Ieper

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