American Society of Regional Anesthesia and Pain Medicine November 2017 - 18

Dr Maniker: Yes, I would recommend long-acting, single-shot,
combined infraclavicular and suprascapular nerve blocks. I would
avoid interscalene or supraclavicular block because the patient
has a low pulmonary reserve (given her continuous oxygen
requirement) and would likely not tolerate ipsilateral phrenic block.
Infraclavicular block would cover the axillary nerve, as well as
lateral pectoral and upper and lower subscapular nerves. When
combined with a suprascapular nerve block, this should provide
good postoperative analgesia and only spares the supraclavicular
nerves from the superficial cervical plexus. I would consider
catheters but would need to further discuss issues, including
coagulation status, plan for timing of hospital discharge, and
interference with the surgical field.
Dr Harrington: I am concerned about respiratory reserve as well as
platelet function (in the face of clopidogrel plus aspirin). A regional
technique of single-shot suprascapular block plus surgical wound
infiltration would be encouraged.
Dr Pawa: There are clearly several options for anesthesia and
analgesia here with a number of potential risks and complications.
My concerns with a classic interscalene block as the sole mode
of anesthesia here relate to the impact of phrenic nerve palsy on
her COPD and her being able to tolerate this perioperatively. One
option is to perform a single-shot interscalene or superior trunk
block and use a continuous positive airway pressure (CPAP) mask
perioperatively to support respiration. I would also be aware that
performing a plexus block with clopidogrel use within 7 days also
makes the risk of hematoma a concern and would dissuade me
from using a catheter.
I could do the interscalene and combine it with GA, or my backup
plan would be to perform ultrasound-guided suprascapular
and axillary nerve blocks supported by sedation or a GA. These
techniques may be challenging in someone of her size, but a clear
risk-versus-benefit discussion with the patient would help me
reach a decision.
How does the presence of clopidogrel, elevated BMI, and
history of chronic pain influence your decision?
Dr Auyong: Whenever confronted with a difficult decision, I try to
look at this from the patient's perspective. First, in regard to the
clopidogrel, there is always a balancing act between anticoagulation,
risk of recurrent clots (DVT or pulmonary embolism), risk of stent
thrombosis, and risk of procedural bleeding. For a compressible
nerve block that has significant analgesic or outcome benefit for
the patient, I would proceed with the nerve block despite not having
been off clopidogrel for 5 to 7 days.
Second, this patient has several comorbidities (obesity and
chronic pain) that, if combined with poor postoperative analgesia,

18

could place her at significantly higher risk for postoperative
complications. The alternative primary analgesic is using opioids,
which comes with obvious unwanted side effects. Obesity is the
most common cause of restrictive lung disease, and patients
with restrictive lung disease are most reliant on diaphragmatic
movement for ventilation. Therefore, obese patients are most
affected by hemidiaphragmatic paralysis seen in brachial plexus
regional anesthesia.
To better assess the effect of possible hemidiaphragmatic paralysis
on this patient, I would place a suprascapular catheter using a
short-acting local anesthetic (lidocaine or chloroprocaine). I would
then monitor the patient and evaluate the effect of the nerve block
for 20 minutes. If the patient has clinical dyspnea, it indicates that
she is unable to tolerate any decrease in diaphragm function. In
this scenario, I would not initiate the continuous infusion through
the catheter because of the poor clinical outcome of phrenic nerve
paralysis in this patient. If the patient does well and does not have
side effects from the bolus of local anesthetic, I would start the
continuous infusion via the suprascapular nerve catheter.
Finally, in regard to her chronic pain, I know her preoperative
reliance on opioids also increases her postoperative risk for
complications, especially in the setting of obesity. Her history of
chronic pain makes me all the more apt to offer regional anesthesia
via a continuous catheter.
Dr Maniker: Because clopidogrel has not been held for 7 days, an
increased, albeit low, risk of bleeding remains because of platelet
inhibition. Additionally, nerve blocks in this case are at relatively
peripheral and compressible locations. Furthermore, these
decisions require the weighing of overall risk and benefit. Avoiding
peripheral nerve blocks would result in administration of more
opioids in the intraoperative and immediate postoperative periods
and risk significant respiratory depression in this patient with
morbid and extreme obesity (class III). Given these considerations, I
would still proceed with peripheral nerve blocks.
Dr Harrington: I would be reluctant to perform any brachial plexus
block if clopidogrel was discontinued fewer than 5 days prior
without first documenting a normal platelet function assay.
Because of her elevated BMI, decreased functional residual
capacity and respiratory reserve make any brachial plexus block
above the clavicle (interscalene or supraclavicular block) hazardous.
This patient has chronic pain with significant opioid tolerance,
making regional techniques attractive. I would definitely administer
ketamine intraoperatively.
Dr Pawa: The chronic pain history emphasizes the importance of
maintaining her usual drug therapy in the perioperative period and

American Society of Regional Anesthesia and Pain Medicine
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