Regional anaesthesia is presented as an alternative to general anaesthesia offering better control of postoperative pain and a shorter anaesthetic recovery time, although not without complications. These benefits are of great importance in patients with high comorbidity where general anaesthesia may pose a high risk.
The brachial plexus block at interscalene level is one of the most commonly used techniques for upper limb surgery. The incorporation of ultrasound during the performance of the blocking has reduced the volume of local anaesthesia necessary to obtain adequate analgesia and / or anaesthesia minimising side effects.
We report the case of a hypertensive 76-year old man with revascularised chronic ischemic heart disease with a triple bypass, chronic alcoholic liver disease and ardenocarcinoma of the prostate undergoing radiotherapy, who was admitted to the ICU after being diagnosed with necrotising fasciitis in the proximal third of MSD.
It involved cleaning, healing and wound closure on a scheduled basis. The patient exhibited a significant overall clinical deterioration classified as ASA IV. He had previously undergone several surgeries for debridement and wound healing under general anaesthesia.
Facing the situation described, it was decided to perform an anaesthetic Interscalene Block to perform the surgical procedure. The patient was monitored according to SEDAR criteria, oxygen therapy was applied with 2 lpm nasal prongs, and after premedication with Midazolam 2mg, the technique guided by ultrasound and nerve stimulation (1mA) was performed with a ultrasounds Hybrid needle for Temena Group (EH055-22 22G) using a total dose of 14ml of 1% mepivacaine without incident. It was also decided to place a perineural catheter for adequate control of postoperative pain through continuous infusion of levobupivacaine to 0.0625% at a rate of 5 ml/h through elastomeric pump.
The surgery was performed in 30 minutes and was well tolerated by the patient who remained stable at all times with adequate pain control without requiring other pharmaceuticals to control the pain. After the procedure, a control chest X-ray was taken which showed no evidence of hemidiaphragm elevation of the side involved.
The choice of anaesthetic technique in a high-risk patient is crucial to good perioperative development. In our case, the interscalene block becomes the most suitable option given the clinical situation of the patient. It has been reported that the Interscalene Block involves the blocking of the phrenic nerve in its output at C4 level in almost 100% of cases which can lead to significant deterioration of the respiratory function.
Using ultrasound, the use of low volumes of local anaesthesia with a short half life allowed us to perform a more selective blocking, minimising the effects on the phrenic nerve and its consequent ipsilateral diaphragmatic paralysis, obtaining a safe and effective outcome.
Regional anaesthesia provides excellent anaesthetic quality in high-risk patients. The argument that it may cause diaphragmic paralysis derived from interscalene blocking is offset by the benefit that the technique gives us. The support of ultrasound alongside the correct selection of pharmaceuticals and doses allows us to largely avoid the side effects of the blocking, making it the best option in certain situations.
- Quinn H. Hogan. Phrenic Nerve Function after Interscalene Block Revisited Now, the Long View .Anesthesiology 2013; 119:250-2
- Steven H, Renes, Geert J. van Geffen. Minimum Effective Volume of Local Anesthetic for Shoulder Analgesia by Ultrasound-Guided Block at Root C7 With Assesment of Pulmonary Function. Regional Anesthesia and Pain Medicine. 2010. 35 (6)
Martín N, Carrió M, Cerrada T, Hernando J, Tejada S, Agulló J. Anaesthesia Service.
Anaesthesia Service. University Hospital San Juan de Alicante