Background and Aims Severe respiratory disease presents a challenge for anaesthesia in shoulder surgery. Awake surgery under interscalene block may be considered. However, the reduction in FEV1 and FVC due to phrenic nerve palsy may be prohibitive. Numerous techniques have been described as phrenic nerve sparing for shoulder analgesia. However, there is limited published data regarding effectiveness in anaesthesia for awake shoulder and clavicular surgery.

Methods We describe a case of a 64-year-old male undergoing brachial plexus exploration with open reduction and internal fixation for clavicle non-union. Following an injury 10 months previously, he presented with medial cord symptoms; sensory deficit predominately in the ulnar nerve distribution and hand weakness. Significant comorbidities included severe COPD with a FEV1 <27%.

A low volume phrenic nerve sparing interscalene block with superficial cervical plexus block (5 ml of 0.5% Bupivaicaine with Adrenaline for each) was performed under ultrasound guidance. The skin and subcutaneous layers were infiltrated with 10 ml of 1% Xylocaine with Adrenaline as a field block.

Results Using a direct approach to the clavicle, the non-union was excised and fracture ends debrided. The inferior periosteum was carefully elevated off the clavicle to protect the brachial plexus. There was an intraoperative improvement in ulnar nerve symptoms observed when the lateral clavicle was reduced. There was no evidence of clinically significant phrenic nerve involvement; oxygen saturations were stable and the patient remained comfortable with no respiratory symptoms.

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Abstract 192 Figure 1

Conclusions Low volume regional anaesthetic techniques can facilitate awake shoulder and clavicular surgery without clinically significant phrenic nerve involvement in selected patients.