Correctly identifying the fascia iliacus plane that is superior to the femoral nerve is critical step in achieving femoral block success. The needle must penetrate the fascia iliacus layer and local anesthetic must be deposited beneath this layer to ensure block success.
Blocks options for posterior analgesic coverage include: iPACK, selective tibial, popliteal plexus, and local infiltrative block techniques.
The placement of a interscalene block for shoulder surgery in a patient with significant respiratory disease should be avoided in order to prevent respiratory failure from the loss of diaphragm function due to phrenic nerve blockade. Loss of diaphragmatic function from the blockade of the phrenic nerve is an expectant complication of an interscalene block and can be reduced, but not eliminated, by lowering the local anesthetic concentration and volume used in the block. The phrenic nerve is located anterior to the anterior scalene muscle and medial to the brachial plexus and is contained within the same compartment as the brachial plexus at the interscalene block level, which results in the phrenic nerve being anesthetized when performing an interscalene block. As the brachial plexus travels under the clavicle, the phrenic nerve remains medial and is located at a further distance away from the brachial plexus. Blocks placed at the trunk (selective superior with low volumes of local anesthestic) or division levels of the brachial plexus could lower the incidence of a phrenic nerve block, but this risk is not completely eliminated with blocks (supraclavicular/interscalene) placed above the clavicle for shoulder surgery.
Alternative blocks that can performed for shoulder surgery that eliminate the risk of phrenic nerve blockade in the respiratory compromised patient includes:
Isolated Suprascapular nerve block using an anterior or posterior approach.
Posterior cord block place at the infraclavicular level to target the axillary and the lower/upper subscapular nerves that innervate the shoulder joint.