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Case Reports  |   March 2003
Combined Infraclavicular Plexus Block with Suprascapular Nerve Block for Humeral Head Surgery in a Patient with Respiratory Failure: An Alternative Approach
Author Affiliations & Notes
  • Julia Martínez, M.D.
    *
  • Xavier Sala-Blanch, M.D.
    *
  • Isabel Ramos, M.D.
  • Carmen Gomar, M.D.
Article Information
Case Reports
Case Reports   |   March 2003
Combined Infraclavicular Plexus Block with Suprascapular Nerve Block for Humeral Head Surgery in a Patient with Respiratory Failure: An Alternative Approach
Anesthesiology 3 2003, Vol.98, 784-785. doi:
Anesthesiology 3 2003, Vol.98, 784-785. doi:
ALTHOUGH shoulder surgery is usually performed during general anesthesia, the use of interscalene block alone or in combination with other anesthetic procedures is increasing. Interscalene block is associated with diaphragmatic paralysis, which may cause severe impairment of respiratory function. For this reason, most authors dissuade its use in patients with respiratory failure. 1,2 We report a case of a patient presenting with an acute asthma exacerbation who underwent emergent surgery for traumatic humeral head fracture. Anesthesia was provided by a combination of an infraclavicular brachial plexus block and a suprascapular nerve block.
Case Report
A 43-yr-old man with chronic bronchial asthma suffering from frequent episodes of acute bronchospasm was admitted in the emergency department of our hospital with a traumatic fracture of the left humeral head. The patient brought the results of his lung function test performed during stable periods of the disease, which showed a pattern of severe airway obstruction, a forced vital capacity of 2.93 l (65% of predicted), a forced expiratory volume in 1 s of 1.13 l (32% of predicted), and a lung residual volume of 4.29 l (222% of predicted). The patient was in long-term therapy with inhaled long-term β2agonists, inhaled steroids, and oral prednisone, 15 mg per day.
Preanesthetic examination showed a patient with dyspnea at rest, tachypnea (32 breaths/min), and wheezing. While 35% oxygen was administered by Venturi mask, arterial blood gas analysis showed a pH of 7.40, a Pao2of 62 mmHg, and a Paco2of 36.7 mmHg. Inhaled albuterol, 5 mg, in saline solution and 100 mg intravenous prednisolone were administered, and the patient's clinical status improved after 60 min. Due to the high risk of axillary nerve compression, immediate reduction and surgical stabilization of the humeral fracture was indicated. The patient was premedicated with 2 mg intravenous midazolam (Midazolam ROVI®; ROVI Pharmaceutical Laboratories, Madrid, Spain) and 25 mg intravenous ketamine (Ketolar®; Parke-Davis, Madrid, Spain) before anesthetic block. The suprascapular nerve block was performed at the suprascapular notch with the patient sitting up and leaning forward using the posterior approach, as described by Moore. 3 The suprascapular nerve was identified by using a nerve stimulator (Stimuplex-NHS II; B. Braun, Melsungen, Germany) connected to a needle (Stimuplex A 50, B. Braun, Melsungen, Germany). When infraspinatus muscle contraction was observed at 0.5 mA current, 10 ml mepivacaine, 1% (Scandinibsa 1%, Inibsa Laboratories, Barcelona, Spain), was injected. Brachial plexus block was performed using the coracoid and infraclavicular technique. The coracoid process was identified, and the needle (Stimuplex A 50) was introduced perpendicular to coronal and parasagittally at a point located 2 cm medial and caudal to it, as described by Wilson et al.  4 When muscular contraction in the hand was observed at 0.5 mA current, 40 ml mepivacaine, 1%, was injected. Complete anesthetic block was obtained in the left upper limb, and the patient was able to undergo surgery comfortably and without incident. The duration of surgery was 95 min. Peripheral oxygen saturation was maintained at more than 96% during the operation and in the immediate postoperative period. Postoperative outcome was uneventful, and the patient was discharged from the hospital 3 days after surgery.
Discussion
A general anesthetic was not considered in this patient because of the presence of severe bronchospasm with acute respiratory insufficiency. Because of the risk of ipsilateral diaphragmatic paralysis associated with interscalene block, 1,2 this technique was also contraindicated. Likewise, the incidence of phrenic nerve block and diaphragmatic paralysis is approximately 67–80% after supraclavicular techniques for brachial plexus block, 5,6 which are also associated with the risk of pneumothorax. Infraclavicular approaches to brachial plexus block have similar anesthetic efficacy as supraclavicular techniques, 6 are more effective than the axillary approach, and minimize the complications associated with supraclavicular approaches. 7,8 The infraclavicular brachial plexus technique produces an anesthetic effect over the brachial plexus and the infraclavicular collateral nerves—the subscapular nerve (C5–C6), axillary nerve (C5–C6), and lateral pectoral nerve (C5–C6), 9 which provide sensation to the anterior joint of the shoulder. However, the suprascapular nerve, a collateral branch of the upper trunk of the brachial plexus providing sensation to the posterior shoulder joint capsule, is not blocked by infraclavicular techniques. For this reason, in the present case we decided to combine vertical infraclavicular access with selective suprascapular nerve block, as described by Moore, 3 to achieve complete shoulder blockade. We obtained a good anesthetic block without any side effects on pulmonary function. Clinical effects of different blocks are shown in figure 1.
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A  ) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B  ) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A 
	) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B 
	) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A  ) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B  ) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
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Nevertheless, both of the techniques used in this patient produce discomfort during performance, and light sedation is recommended. A combination of low doses of ketamine and midazolam was chosen because of its bronchodilator effects and relative absence of respiratory depressant effects.
Conclusions
The combination of infraclavicular plexus block with suprascapular nerve block has not been described for shoulder surgery, and, after our experience in the case presented, we think that it could be an alternative in patients with severe pulmonary disease requiring regional anesthesia for shoulder surgery.
References
Urmey WF, Talts KH, Sharrock NE: One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991; 72: 498–503Urmey, WF Talts, KH Sharrock, NE
Sala-Blanch X, Lázaro JR, Correa J, Gómez-Fernández M: Phrenic nerve block caused by interscalene brachial plexus block: Effects of digital pressure and a low volume of local anesthetic. Reg Anesth Pain Med 1999; 24: 231–5Sala-Blanch, X Lázaro, JR Correa, J Gómez-Fernández, M
Moore DC: Block of the suprascapular nerve, Regional nerve block, 4th edition. Springfield, IL, Charles C. Thomas, 1979, pp 300–3
Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR: Infraclavicular brachial plexus block: Parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3Wilson, JL Brown, DL Wong, GY Ehman, RL Cahill, DR
Knoblanche GE: The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesth Intensive Care 1979; 7: 346–9Knoblanche, GE
Neal JM, Moore JM, Kopacz DJ, Liu SS, Kramer DJ, Plorde JJ: Quantitative analysis of respiratory, motor and sensory function after supraclavicular block. Anesth Analg 1998; 86: 1239–4Neal, JM Moore, JM Kopacz, DJ Liu, SS Kramer, DJ Plorde, JJ
Salazar CH, Espinosa W: Infraclavicular brachial plexus block: Variation in approach and results in 360 cases. Reg Anesth Pain Med 1999; 24: 411–6Salazar, CH Espinosa, W
Rodríguez J, Barcena M, Rodríguez V, Aneiros F, Álvarez J: Infraclavicular brachial plexus block effects on respiratory function and extent of the block. Reg Anesth Pain Med 1998; 23: 564–8Rodríguez, J Barcena, M Rodríguez, V Aneiros, F Álvarez, J
Aszmann OC, Dellon AL, Birely BT, McFarland EG: Innervation of the human shoulder joint and its implications for surgery. Clin Orthop 1996; 330: 202–7Aszmann, OC Dellon, AL Birely, BT McFarland, EG
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A  ) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B  ) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A 
	) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B 
	) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
Fig. 1. Anterior and posterior views of the upper extremity showing the cutaneous (A) and bone sensitivity (B and C) and the clinical effects of different shoulder blocks. (A  ) Metameric innervation of the upper extremity showing the clinical effects of interscalene brachial plexus block. (B  ) Nervous innervation of the upper extremity showing the clinical effects of infraclavicular vertical brachial plexus block with (C) and without (B) suprascapular nerve block. 1 =median nerve; 2 =ulnar nerve; 3 =radial nerve; 4 =musculocutaneous nerve; 5 =axillary nerve; 6 =medial cutaneous nerve of the forearm; 7 =medial cutaneous nerve of the arm; 8 =intercostobrachial nerve; 9 =supraclavicular nerves; 10 =subscapular nerve; 11 =subclavian nerve; 12 =suprascapular nerve.
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