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Apnea in Beach-Chair Position Status Post Interscalene Block: A Simulation Case for Anesthesia Residents.

ABSTRACT: Introduction:Regional anesthesia is commonly performed for orthopedic operations, especially in situations when general anesthesia is preferably avoided. Anesthesia residents should understand the complications of regional procedures and should know how to treat them if treatment is warranted. This simulation involves a 60-year-old man who became apneic in the beach-chair position following an interscalene block for rotator cuff repair. It presents trainees with the opportunity to further their learning with regard to perioperative management and associated complications of patients receiving brachial plexus blocks. Methods:This simulation is designed to be delivered in a single, 1-hour session. Materials contained within this simulation include a case template, a checklist of critical actions, a brief summary for key takeaways, and an evaluation form. At the conclusion of this simulation and debriefing session, the learner has had the opportunity to demonstrate progress in several of the anesthesiology milestones outlined by the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology in the Anesthesiology Milestone Project as they relate to this particular clinical topic. Results:At the time of this submission, a total of 15 junior residents had completed this simulation. Commonly missed critical actions included difficulty of management of analgesia in a block that is not complete and correlation between noninvasive blood pressure on the arm and cerebral perfusion pressure. Learners' comments were generally positive, indicating the residents felt this simulation was a worthwhile learning experience. Discussion:The majority of anesthesia residents who have participated in this simulation were able to properly address apnea in the beach-chair position following a brachial plexus block. It is expected that this simulation will be performed approximately 15-20 times annually.

SUBMITTER: Voigt T

PROVIDER: S-EPMC6440401 | biostudies-literature | 2016 Oct

REPOSITORIES: biostudies-literature

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Apnea in Beach-Chair Position Status Post Interscalene Block: A Simulation Case for Anesthesia Residents.

Voigt Tyler T Wagner Allison A Obr Clark C Swaran Singh Tejinder T

MedEdPORTAL : the journal of teaching and learning resources 20161031

<h4>Introduction</h4>Regional anesthesia is commonly performed for orthopedic operations, especially in situations when general anesthesia is preferably avoided. Anesthesia residents should understand the complications of regional procedures and should know how to treat them if treatment is warranted. This simulation involves a 60-year-old man who became apneic in the beach-chair position following an interscalene block for rotator cuff repair. It presents trainees with the opportunity to furthe ...[more]

PMID: 30984831

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Project description:BACKGROUND:Historically, the anterolateral interscalene block--deposition of local anesthetic adjacent to the brachial plexus roots/trunks--has been used for surgical procedures involving the shoulder. The resulting block frequently failed to provide surgical anesthesia of the hand and forearm, even though the brachial plexus at this level included all of the axons of the upper-extremity terminal nerves. However, it remains unknown whether deposition of local anesthetic adjacent to the seventh cervical root or inferior trunk results in anesthesia of the hand and forearm. METHODS:Using ultrasound guidance and a needle-in-plane posterior approach, a Tuohy needle was positioned with the tip located between the deepest and next-deepest visualized brachial plexus root/trunk, followed by injection of mepivacaine (1.5%). Grip strength and the tolerance to cutaneous electrical current in 5 terminal nerve distributions were measured at baseline and then every 5 minutes following injection for a total of 30 minutes. The primary end point was the proportion of cases in which the interscalene nerve block resulted in a decrease in grip strength of at least 90% and hand and forearm anesthesia (tolerance to >50 mA of current in all 5 terminal nerve distributions) within 30 minutes. The primary hypothesis was that a single-injection interscalene brachial plexus block produces a similar rate of anesthesia of the hand and forearm to the published success rate of 95% for other brachial plexus block approaches. RESULTS:Of 55 subjects with blocks placed per protocol, all had a successful block of the shoulder as defined by inability to abduct at the shoulder joint. Thirty-three subjects had measurements at 30 minutes following local anesthetic deposition, and only 5 (15%) of these subjects had a surgical block of the hand and forearm (P < 0.0001; 95% confidence interval, 6%-33%). We therefore reject the hypothesis that the interscalene block as performed in this study provides equivalent anesthesia to the hand and forearm compared with other brachial plexus block techniques. Block failures of the hand and forearm were due to inadequate cutaneous anesthesia of the ulnar (n = 27; 82%), median (n = 26; 78%), or radial (n = 22; 67%) distributions; the medial forearm (n = 25; 76%); and/or the lateral forearm (n = 14; 42%). Failure to achieve at least a 90% reduction in grip strength occurred in 16 subjects (48%). CONCLUSIONS:This study did not find evidence to support the hypothesis that local anesthetic injected adjacent to the deepest brachial plexus roots/trunks reliably results in surgical anesthesia of the hand and forearm.

Dataset Information

Apnea in Beach-Chair Position Status Post Interscalene Block: A Simulation Case for Anesthesia Residents.

Publications

Apnea in Beach-Chair Position Status Post Interscalene Block: A Simulation Case for Anesthesia Residents.

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