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Abstract
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Background and Aims Interscalene block is the most efficient regional anaesthesia technique for proximal humerus surgeries with an incidence of almost 100% hemidiaphragmatic paresis. It is relatively contraindicated in patients having contralateral lung/diaphragmatic pathology as it could lead to total respiratory failure needing mechanical ventilation. We present a case of proximal humerus fracture in whom we gave ultrasound guided low interscalene block for surgical fixation with history of contralateral pneumonectomy, after weighing risk-benefit ratio and explaining to patient and relatives.
Methods 60 year old female presented with history of fall leading to right proximal humerus fracture and was posted for open reduction and internal fixation. She had history of left lung adenocarcinoma diagnosed 21 months back, and had recieved multiple cycles of radiotherapy, chemotherapy followed by left pneumonectomy done 15 months back. Her effort tolerance was 1 flight of stairs with recuurent cough, requiring oxygen by nasal prongs at 2litres/minute and maintaining oxygen saturation of 97-98%. PFTs showed FVC -53%, FEV1 - 58%, FEV1/FVC -100% corresponding with restrictive pathology. Ultrasound guided right low interscalene block was given with 50mm Stimuplex needle using 12ml of 0.5% Levobupivacaine under all aseptic precautions.
Results Onset of sensory block was within 10 minutes, patient had complete motor block of proximal arm by 20 minutes. Surgery was done without the need of postoperative ventilation and patient was shifted to ICU for observation with Oxygen at 4litres/minute via hudson mask.
Conclusions Ultrasound guided low volume interscalene block can be given in certain high risk group of patients posted for proximal arm surgeries.
Pre-operative Chest X-ray showing Left Pneumonectomy
Awake patient with oxygen via hudson mask during surgery
Surgical incision & metallic plate insertion in proximal humerus