Saturday, February 18, 2012

Brachial Plexus Blocks for Upper Extremity Surgery - JAAOS

The January issue of JAAOS publishes an article on brachial plexus blocks by Andrew Green and co-authors. This is a comprehensive review of the relevant anatomy, possible applications, technical considerations.  The authors quote the article by UW shoulder fellow Lenters et al. pointing to a substantial complication rate which, although lower in the hands of anesthesiologists experienced in the technique, was still significant for those who had performed many of them.

As we have discussed in a previous post, we avoid plexus blocks in most cases because of the potential for serious and possibly long term complications that are not seen with general anesthesia. As the authors state, "permanent <nerve> injury can result in substantial disability."  Even though the rate of these injuries is low, we are aware of a number of cases where career-ending neuropathies have occurred in surgeons and engineers and where previously independent individuals became dependent because of irreversible loss of function.

The authors also mention phrenic nerve palsy 'in almost all patients with interscalene block'. Our observations are similar and note that for many individuals with sleep apnea, COPD, or other respiratory conditions, even the transient loss of half of their pulmonary function can be critical.

The authors also describe other systemic complications, pneumothorax, vascular puncture, and the risks of indwelling catheters.

The proponents of blocks point to the value of postoperative analgesia. Our experience is that with shoulder arthritis surgery the use of blocks only delays the onset of pain until the block wears off in the evening or the wee hours of the morning when the nurse/patient ratio is lower.

So, again, after a rather prolonged use of blocks, we no longer find that the advantages outweigh the disadvantages and have discontinued their routine use.


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