Clavicle fracture analgesia with liposomal bupivacaine

Abstract: 4017

Scientific Abstracts & gt; Regional Anesthesia

Clavicle fracture analgesia with liposomal bupivacaine Mike Guzman

Community Surgery Center East

Introduction

Clavicle fractures account for 2.6% of all fractures and are commonly seen in operating rooms. Cutaneous innervation of the skin above the clavicle is supplied by the supraclavicular nerve of the superficial cervical plexus. The sensory of the clavicle itself is supplied by branches of sensory nerves including suprascapular, subclavian, lateral pectoral, and long thoracic as they pass in a plane between the clavipectoral fascia and the clavicle. Regional anesthesia pain techniques for clavicle ORIF were extensively reviewed for 3161 patients (1). Many of these studies suggest a superficial cervical plexus block combined with a brachial plexus block (interscalene or supraclavicular) is a common reliable choice for clavicular postoperative analgesia. Clavicular fascial plane block (CPB) has been described as a motor sparing alternative (2). Hematoma blocks are commonly practiced by emergency room staff and orthopedic surgeons for peripheral fractures. A recent description in Emergency Medicine (3) documents clavicular hematoma block for immediate pain relief for clavicle fracture. The primary limitation for an emergency room clavicle hematoma block is analgesia duration before surgical correction. In 2011, the FDA approved liposomal bupivacaine via infiltration to provide post-surgical analgesia. The FDA in 2018 also approved liposomal bupivacaine for brachial plexus regional analgesia. lt was hypothesized that a combination using a selective supraclavicular block, CVP, and a clavicle fracture hematoma block with liposomal bupivacaine would provide extended analgesia without significant motor loss after clavicular ORIF.

Materials and Methods

Community Hospital Network policy does not require IRB review if case reports are devoid of patient identifiable information. Informed consent was obtained for all patients.

Results/Case Report

23 patients with mid shaft clavicle fracture were scheduled for ORIF.

Patients age was 16-65, ASA 1-3, and pre-op pain scores were 5-6/10. Patients received clavicular pain blocks before surgery. Local anesthesia mixture was bupivacaine 0.25% 15 ml, liposomal bupivacaine (266 mg) 20 ml, and normal saline 15 ml, total local anesthetic volume was 50 ml. Patients were placed in a sitting position and received midazolam 2-5 mg IV for sedation. Patients received superior trunk supraclvicular block (15 ml), infiltration (20 ml) of the superficial clavicle fascia (image 1), and infiltration (15 ml) of the clavicle fracture hematoma site (image 2). Pain scores were 0/10 after the combination clavicle blocks. Patients received endotracheal general anesthesia including

propofol, rocuronium, and sevoflurane, PACU surgical pain was 0-1/10 and additional postoperative medicines included ketorolac 30 mg, intravenous acetaminophen 1000 mg, and oxycodone 5 mg prn. Followup by PACU nursing revealed no respiratory complaints and continued pain relief for the first 48 hours.

Discussion

Extensive review by others (1,2,3) has shown brachial plexus regional anesthesia significantly reduces postoperative clavicle ORIF pain scores. Pain reduction with a brachial plexus block has known respiratory consequences as well as motor weakness that can persist. Selective low volume local anesthetic supraclavicular block allows minimal patient discomfort while infiltrating the clavicle fascial plane. CPB is an effective regional anesthesia technique as clavicle sensory nerves pass in this plane. Clavicle hematoma block placement in an awake patient is remarkably painless after the above mentioned are performed. Prolonged postoperative analgesia was noted combining supraclavicular block, CPB, and hematoma block with liposomal bupivacaine.

References:

1.(Basel)

. 2022 Aug 7;10(8):1487. doi: 10.3390/healthcare10081487.Regional anesthetic and analgesia techniques for clavicle fractures-Chang Chun Melvin Lee

2. reus

. 2020 Jul 8;12(7):e9072. doi: 10.7759/cureus.9072.Ultrasound guided Clavipectoral fascial plane block for surgery involving the clavicle-Kukreja,P

3. March 2021 Journal of Emergency Medicine 60(5) DOI:10.1016/j.jemermed.2021.01.034 Ultrasound guided hematoma block for clavicle fracture.