Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL

Diaphragm-sparing efficacy of subparaneural upper trunk block for arthroscopic shoulder surgery: A randomised controlled trial

BACKGROUND

Inter-scalene block (ISB) is associated with an inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risk of HDP, an upper trunk block (UTB) has been proposed at the brachial plexus division level.

OBJECTIVE

We hypothesised that UTB would be associated with a lower incidence of HDP than ISB while providing sufficient analgesia following arthroscopic shoulder surgery.

DESIGN

Randomised controlled trial.

SETTING

A tertiary teaching hospital.

PATIENTS

Seventy patients aged 20 to 80 years undergoing arthroscopic rotator cuff repair.

INTERVENTION

Ultrasound-guided ISB or UTB was performed with 5 ml 0.75% ropivacaine.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of complete HDP, assessed by diaphragm excursion using ultrasound, defined as a decrease to 25% or less of baseline or occurrence of paradoxical movement. Postoperative pulmonary function change, pain scores, opioid consumption and pain-related outcomes were the secondary outcomes.

RESULTS

The UTB group had a significantly lower incidence of complete HDP than the ISB group [5.9% (2/34) vs. 41.7% (15/36); absolute difference, 35.8%; 95% confidence interval (CI), 17.8 to 53.7%; P < 0.001]. The postblockade decline in pulmonary function was more pronounced in the ISB group than that in the UTB group. The pain score at 1 h postoperatively was not significantly different between the groups (ISB vs. UTB group: median 0 vs. 1; median difference, -1; 95% CI, -2 to 0.5). No significant difference was observed in any other secondary outcomes.

CONCLUSION

UTB was associated with a lower incidence of HDP compared with ISB while providing excellent analgesia in arthroscopic shoulder surgery.

TRIAL REGISTRATION

Clinical Trial Registry of Korea (https://cris.nih.go.kr) identifier: KCT0007002.

IRB NUMBER

Chungnam National University Hospital Institutional Review Board No. 2021-12-069.

A Case of Hospitalization After Pre-operative Interscalene Nerve Block in an Ambulatory Surgery Center

Interscalene nerve block (ISB) is an effective and low-risk local anesthetic (LA) procedure that is commonly employed for shoulder surgery. While phrenic nerve involvement occurs to some degree in every ISB procedure, the incidence of hypoxemia and other clinical signs of diaphragmatic disruption is much lower. This is a case of a 36-year-old female with no underlying respiratory disease who developed hypoxemia requiring a night of observation following an ISB for a rotator cuff repair procedure in an ambulatory surgical center. Her hypoxemia was easily treated with supplemental oxygen and she made a full recovery by the next day. The use of ultrasound guidance, reduced LA volume, less potent medication, sterile fluid for optimal visualization, and extrafascial administration should be considered for all patients receiving an ISB to prevent respiratory complications.

The efficacy of ultrasound-guided upper thoracic erector spinae plane block for postoperative analgesia in proximal shoulder surgery and its effect on phrenic nerve function: A prospective exploratory study

Background and Aims

The upper thoracic (T2) erector spinae plane block (UT-ESPB) has been proposed as an alternative to interscalene brachial plexus block for postoperative analgesia in shoulder surgery. The current study was conducted to evaluate the same.

Material and Methods

Patients scheduled for shoulder surgery under general anesthesia (GA) received ultrasound-guided UT-ESPB. The outcomes measured were diaphragmatic movements, block characteristics, and quality of recovery at 24 h.

Results

A total of 43 patients were recruited. The incidence of phrenic nerve palsy was 0%. The sensory level achieved by the maximum number of patients at the end of 30 min was C7-T5 level, and none had a motor block. Forty-two percent of patients did not require rescue analgesia till 24 h postoperative. In the rest of the patients, the mean (SD) duration of analgesia was 724.2 ± 486.80 min, and the mean postoperative requirement of fentanyl was 98.80 ± 47.02 μg. The median pain score (NRS) during rest and movement is 2 to 3 and 3 to 4, respectively. The median quality of recovery score at the end of 24 h after the block was 14 (15-14).

Conclusion

The upper thoracic ESPB resulted in a sensory loss from C7-T5 dermatomes without any weakness of the diaphragm and upper limb. However, the block was moderately effective in terms of the total duration of analgesia, postoperative pain scores, analgesic requirement, and quality of recovery in patients undergoing proximal shoulder surgeries under GA. Further studies are required to establish its role due to its poor correlation with sensory spread.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

A Randomized Comparison Between Interscalene and Combined Interscalene-Suprascapular Blocks for Arthroscopic Shoulder Surgery: A Prospective Clinical Study

Background

To compare the analgesic effect of ISB with a combination of ISB-SSNB and patients who were given opioids with PCA without block in adult patients undergoing shoulder surgery, as measured by opioid consumption and pain intensity in the first 24 hours postoperatively.

Methods

Ninety patients who underwent shoulder surgery were randomly divided into three groups. Group I in which ISB was performed and patient-controlled analgesia (PCA) was inserted, Group II with; ISB and SSNB combined, and PCA was inserted, and Group III where; only PCA was used. Visual analog scale (VAS) pain scores at the second, fourth, sixth, 12th, and 24th hours, morphine consumption, additional analgesic requirement, and patient satisfaction were evaluated.

Results

Compared with Group III, the VAS pain score was significantly lower in Group I and Group II at 2, 4, 6, 12, and 24 hours postoperatively. In Group I, the VAS score at rest at the 6th hour was found to be higher than in Group II. The 24-hour total morphine consumption was higher in the control group than in Group I and Group II. The satisfaction score of the control group was lower than Group I and Group II.

Conclusion

The combined application of ISB and SSNB block is beneficial in shoulder surgery to provide both intraoperative and postoperative analgesia and opioid consumption.

Level of Evidence

Level I; Randomized Controlled Trial; Treatment Study.

Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy: A Systematic Review and Meta-Analysis

The interscalene block (ISB) is the standard regional anesthesia for shoulder arthroscopy. However, the superior trunk block (STB) is an alternative with a potentially safer profile. This meta-analysis aimed to compare the incidence and degree of hemidiaphragmatic paralysis and block efficacy of these techniques. We searched MEDLINE, EMBASE, Scopus, and Cochrane databases to identify randomized controlled trials (RCTs). The main outcome was total hemidiaphragmatic paralysis. We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence. Four RCTs and 359 patients were included. The STB group showed lower total hemidiaphragmatic paralysis (RR 0.07; 95% CI 0.04 to 0.14; p<0.0001). The incidence of subjective dyspnea (p = 0.002) and Horner's syndrome (p<0.001) was significantly lower with STB relative to ISB. There was no significant difference between groups in block duration (p = 0.67). There was a high certainty of evidence in the main outcome as per the GRADE framework. Our findings suggest that STB has a better safety profile than ISB, resulting in lower rates of hemidiaphragmatic paralysis and dyspnea while providing a similar block. Therefore, STB could be preferred to ISB, especially in patients susceptible to phrenic nerve paralysis complications.

Comparison between low-volume local anesthetic with intravenous dexamethasone and conventional volume without dexamethasone for superior trunk block after arthroscopic shoulder surgery: a randomized controlled non-inferiority trial

INTRODUCTION

This study aimed to investigate whether low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while maintaining the analgesic duration compared with conventional volume of local anesthetic without intravenous dexamethasone when performing ultrasound-guided superior trunk block in patients undergoing arthroscopic shoulder surgery.

METHODS

Eighty-four adult patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to receive ultrasound-guided superior trunk block using 7 mL of 0.5% ropivacaine with 0.15 mg/kg of intravenous dexamethasone (treatment group), or 15 mL of 0.5% ropivacaine with intravenous normal saline (control group). The co-primary outcomes were (1) the duration of analgesia (time between block completion and onset of surgical pain with a Numeric Rating Scale pain score of 4 or higher), which was compared against a non-inferiority margin of 3 hours, and (2) the incidence of diaphragmatic paresis evaluated using M-mode ultrasonography in the post-anesthesia care unit.

RESULTS

The mean duration of analgesia was 12.4 (6.8) and 11.2 (4.6) hours in the treatment and control groups, respectively (mean difference: -1.2 hours; 95% CI -3.8 to 1.3]; p for non-inferiority<0.001), meeting the non-inferiority criteria. The incidence of diaphragmatic paresis was 45.2% and 85.4% in the treatment and control groups, respectively (relative risk: 0.53; 97.5% CI 0.35 to 0.80; p<0.001).

CONCLUSIONS

Superior trunk block using low-volume local anesthetic with intravenous dexamethasone can reduce the incidence of diaphragmatic paresis while providing non-inferior analgesic duration compared with the conventional volume of local anesthetic in patients undergoing arthroscopic shoulder surgery.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service of Republic of Korea Registry (KCT0005998).

Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery

Peripheral nerve blocks are an increasingly common method of providing postoperative analgesia for shoulder surgeries. However, the standard technique, the interscalene block (ISB), inevitably causes hemidiaphragmatic paresis (HDP), secondary to phrenic nerve palsy. This can cause morbidity in patients with preexisting respiratory compromise, prompting investigation into alternative "phrenic-sparing" nerve blocks. The aim of this review was to give an overview of these blocks and critically evaluate the current literature to determine if any are suitable replacements for ISB. The incidence of HDP and analgesic efficacy were considered. We queried four electronic databases and one register. Twenty-eight original articles were selected for review. The use of ultrasound guidance, lower volumes of local anaesthetic (LA), and injection 4 mm outside the brachial plexus fascia reduced HDP incidence for the ISB; however, no single modification did so sufficiently. While the anterior suprascapular nerve block (SSNB) showed comparable analgesic effects to the ISB, HDP prevalence was also high. The posterior SSNB produced consistently low HDP incidences but also inferior analgesia to ISB, except when combined with an infraclavicular brachial plexus block. The superior trunk block (STB) provided equivalent analgesia to the ISB while reducing HDP incidence, but not significantly. Lower LA volumes consistently led to lower HDP incidence across all blocks, likely due to a reduced ability to spread to the phrenic nerve. Further investigation into the minimum effective volumes of the extrafascial ISB, anterior SSNB, STB, and combined posterior SSNB with infraclavicular block is warranted to determine if any of these blocks can successfully balance HDP prevention with analgesic efficacy.

Low-Volume Targeted Interscalene Brachial Plexus Block in the Emergency Department as a Safer Alternative for Pain Control for Glenohumeral Reduction: A Case Series

BACKGROUND

Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation.

CASE SERIES

We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5-10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

Effect of interscalene brachial plexus block with dexmedetomidine and ropivacaine on postoperative analgesia in patients undergoing arthroscopic shoulder surgery: a randomized controlled clinical trial

BACKGROUND

Dexmedetomidine, a potent and highly selective α2-adrenoreceptor agonist has become a popular adjuvant to local anesthetics. The study was designed to explore the effect of dexmedetomidine added to ropivacaine for interscalene brachial plexus block (IBPB) on postoperative analgesia in patients undergoing arthroscopic shoulder surgery.

METHODS

Forty-four adult patients undergoing arthroscopic shoulder surgery were randomly divided into 2 groups. Group R received 0.25% ropivacaine alone, whereas group RD received 0.25% ropivacaine and 0.5 μg/kg dexmedetomidine. A total volume of 15 ml was administered for ultrasound-guided IBPB in both groups. Duration of analgesia, visual analog scale (VAS) pain score, frequency of PCA pressed, first time of PCA pressed, sufentanil consumption, and patient satisfaction with analgesia quality were recorded.

RESULTS

Compared with group R, the duration of analgesia was prolonged (8.25±1.76 vs. 11.55±2.41 h; P<0.05), the VAS pain scores were decreased at 8 and 10 h postoperatively (3 (2-3) vs. 0 (0-0) and 2 (2-3) vs. 0 (0-2.25), respectively; P<0.05), the frequencies of PCA pressed were decreased at 4-8 and 8-12 h time intervals (0 (0-0.25) vs. 0 (0-0) and 5 (1.75-6) vs. 0 (0-2), respectively; P<0.05), the time of first PCA pressed was prolonged (9.27±1.85 vs. 12.98±2.35 h; P<0.05), the total 24h sufentanil consumption was reduced (108.72±15.92 vs. 94.65±12.47 μg; P<0.05 ) and patient satisfaction score was also improved (3 (3-4) vs. 4 (4-5); P<0.05) in group RD.

CONCLUSION

We concluded that adding 0.5 μg/kg dexmedetomidine to 0.25% ropivacaine for IBPB provided better postoperative analgesia, decreased the sufentanil consumption and improved the patient's satisfaction in patients undergoing arthroscopic shoulder surgery.

What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials.

QUESTIONS/PURPOSES

In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery?

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate).

RESULTS

At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved.

CONCLUSION

When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods.

LEVEL OF EVIDENCE

Level I, therapeutic study.

A randomised controlled trial in patients undergoing arthroscopic shoulder surgery comparing interscalene block with either 10 ml or 20 ml levobupivacaine 0.25

The interscalene brachial plexus block is recommended for analgesia after shoulder surgery but it may cause hemidiaphragmatic dysfunction. We tested whether ipsilateral hemidiaphragmatic contraction was better after a smaller dose of local anaesthetic without impairing analgesic effect. We randomly allocated 48 adults to 10 ml or 20 ml levobupivacaine 0.25% before arthroscopic shoulder surgery. The primary outcome was hemidiaphragmatic paralysis, defined as inspiratory thickness < 1.2 times expiratory thickness, measured by ultrasound 4 h after block. Hemidiaphragmatic paralysis was recorded for 6/24 vs. 23/24 supine participants after 10 ml vs. 20 ml levobupivacaine 0.25%, respectively, and for 4/24 vs. 23/24 sitting participants, respectively, p < 0.001 for both. Pain scores after 10 ml injectate were not worse than after 20 ml injectate. Median (IQR [range]) morphine doses in the first 24 postoperative hours after 10 ml and 20 ml levobupivacaine 0.25% were 2 (0-6 [0-23]) mg vs. 1 (0-2 [0-11]) mg, respectively, p = 0.12. No participant had a complication after 10 ml interscalene levobupivacaine, whereas seven had complications after 20 ml levobupivacaine, p = 0.009. Hemidiaphragmatic function was better after 10 ml vs. 20 ml interscalene levobupivacaine 0.25% without impairing analgesia for 24 postoperative hours.

Understanding fascial anatomy and interfascial communication: implications in regional anesthesia

With the extensive application of ultrasound in regional anesthesia, there has been rapid development of interfascial plane block techniques recently. Compared with neuraxial anesthesia or nerve plexus blocks, the interfascial plane blocks have many advantages, such as technical simplicity, fewer complications and comparable or better analgesia. The concept of fascial interconnectivity is fundamental in understanding the effects and complications of interfascial plane blocks. Many fascial planes are continuous and communicate with each other without a clear anatomical boundary. The prevertebral fascia of the neck, endothoracic fascia of the chest, transversalis fascia of the abdomen, and the fascia iliaca of the pelvic cavity form a natural fascial continuation. This anatomical feature suggests that the space beneath the cervical prevertebral fascia, the thoracic paravertebral space, the space between transversalis fascia and psoas muscles (psoas major and quadratus lumborum), and the fascia iliaca compartment are a confluent potential cavity. Additionally, the permeability of the fascia at different anatomical locations to local anesthetics is different, which can also influence the block effect and the incidence of complications. This article summarizes the anatomical characteristics and communication relationships of the major fascia which are related to regional anesthesia, and their relationships with block effects and complications.

Comparison Between Subparaneural Upper Trunk and Conventional Interscalene Blocks for Arthroscopic Shoulder Surgery: A Randomized Noninferiority Trial

BACKGROUND

Although interscalene nerve block is the standard for shoulder analgesia, the risk of hemidiaphragmatic paralysis restricts its use in patients with compromised pulmonary function. We hypothesized that a novel subparaneural upper trunk block would provide noninferior postoperative analgesia but superior diaphragmatic sparing effect compared to interscalene block.

METHODS

This randomized controlled trial comprised 96 patients who underwent arthroscopic shoulder surgery under either subparaneural upper trunk block (5 mL of 0.5% ropivacaine) or interscalene block (15 mL of 0.5% ropivacaine), followed by supraclavicular nerve block (5 mL of 0.5% ropivacaine). General anesthesia was standardized. The coprimary outcomes were (1) recovery room resting pain score at 30 minutes, measured on an 11-point numerical rating scale, with a prespecified noninferiority margin of 1 point and (2) the incidence of hemidiaphragmatic paralysis, diagnosed using ultrasound. Among secondary outcomes, resting pain scores were assessed with numerical rating scale at 4, 8, and 24 hours postoperatively.

RESULTS

Recovery room resting pain scores at 30 minutes were 0 (0-1) in the subparaneural upper trunk group versus 0 (0-0) in the interscalene group, with a median difference of 0 (95% CI, 0-0); the upper 95% CI limit was lower than the prespecified noninferiority margin (noninferiority P < .001). Hemidiaphragmatic paralysis was observed in 16.7% of patients in the subparaneural upper trunk group versus 100% of those in the interscalene group (RR, 0.17; 95% CI, 0.09-0.31; P < .001), with complete paralysis occurring in 6.3% and 93.7% of patients, respectively. In this study, any reported differences in pain scores at 4, 8, and 24 hours postoperatively were not clinically important.

CONCLUSIONS

The subparaneural upper trunk block compared to interscalene block provided noninferior analgesia at 30 minutes in the recovery room after arthroscopic shoulder surgery but resulted in less hemidiaphragmatic paralysis.

Evaluation of lung function and clinical features of interlaminar cervical epidural steroid injections: a randomized controlled trial

OBJECTIVE

Interlaminar cervical epidural steroid injections (ICESIs) are commonly used to treat axial neck pain and cervical radicular pain. However, local anesthetics can spread to and block the phrenic nerve and upper segments of the thoracic spinal cord where the sympathetic innervation of the lungs emerges. Therefore, changes in lung function may occur following ICESIs.

METHODS

The primary outcome measure was the pulmonary function test (PFT) result 30 minutes before and after ICESI with ropivacaine (0.1875% or 0.25%). The secondary outcome measure was the comparison of the pain scores and functional disability between the two concentrations of ropivacaine 4 weeks after the ICESIs.

RESULTS

Fifty patients were randomly assigned to either the R1 (0.1875% ropivacaine) or R2 (0.25% ropivacaine) group. No significant difference was observed between the pre-ICESI and 30-minute post-ICESI PFT results within each group, and no difference was observed between the two groups. After 4 weeks of treatment, both groups showed a significant decrease in pain scores and functional disability; however, no significant differences were observed between the two groups.

CONCLUSIONS

This study showed no significant change in lung function after ICESIs in either group and no local anesthetic concentration-based difference in the clinical efficacy of the ICESIs.

Phrenic Nerve Block and Respiratory Effort in Pigs and Critically Ill Patients with Acute Lung Injury

BACKGROUND

Strong spontaneous inspiratory efforts can be difficult to control and prohibit protective mechanical ventilation. Instead of using deep sedation and neuromuscular blockade, the authors hypothesized that perineural administration of lidocaine around the phrenic nerve would reduce tidal volume (VT) and peak transpulmonary pressure in spontaneously breathing patients with acute respiratory distress syndrome.

METHODS

An established animal model of acute respiratory distress syndrome with six female pigs was used in a proof-of-concept study. The authors then evaluated this technique in nine mechanically ventilated patients under pressure support exhibiting driving pressure greater than 15 cm H2O or VT greater than 10 ml/kg of predicted body weight. Esophageal and transpulmonary pressures, electrical activity of the diaphragm, and electrical impedance tomography were measured in pigs and patients. Ultrasound imaging and a nerve stimulator were used to identify the phrenic nerve, and perineural lidocaine was administered sequentially around the left and right phrenic nerves.

RESULTS

Results are presented as median [interquartile range, 25th to 75th percentiles]. In pigs, VT decreased from 7.4 ml/kg [7.2 to 8.4] to 5.9 ml/kg [5.5 to 6.6] (P < 0.001), as did peak transpulmonary pressure (25.8 cm H2O [20.2 to 27.2] to 17.7 cm H2O [13.8 to 18.8]; P < 0.001) and driving pressure (28.7 cm H2O [20.4 to 30.8] to 19.4 cm H2O [15.2 to 22.9]; P < 0.001). Ventilation in the most dependent part decreased from 29.3% [26.4 to 29.5] to 20.1% [15.3 to 20.8] (P < 0.001). In patients, VT decreased (8.2 ml/ kg [7.9 to 11.1] to 6.0 ml/ kg [5.7 to 6.7]; P < 0.001), as did driving pressure (24.7 cm H2O [20.4 to 34.5] to 18.4 cm H2O [16.8 to 20.7]; P < 0.001). Esophageal pressure, peak transpulmonary pressure, and electrical activity of the diaphragm also decreased. Dependent ventilation only slightly decreased from 11.5% [8.5 to 12.6] to 7.9% [5.3 to 8.6] (P = 0.005). Respiratory rate did not vary. Variables recovered 1 to 12.7 h [6.7 to 13.7] after phrenic nerve block.

CONCLUSIONS

Phrenic nerve block is feasible, lasts around 12 h, and reduces VT and driving pressure without changing respiratory rate in patients under assisted ventilation.

EDITOR’S PERSPECTIVE

Analgesic comparison between perineural and intravenous dexamethasone for shoulder arthroscopy: a meta-analysis of randomized controlled trials

Introduction

The analgesic comparison between perineural and intravenous dexamethasone on interscalene block for pain management after shoulder arthroscopy remains controversial. We conduct this meta-analysis to explore the influence of perineural versus intravenous dexamethasone on interscalene block for pain control after shoulder arthroscopy.

Methods

We have searched PubMed, Embase, Web of science, EBSCO and Cochrane library databases through April 2021 and included randomized controlled trials (RCTs) assessing the effect of perineural and intravenous dexamethasone on interscalene block in patients with shoulder arthroscopy.

Results

Five RCTs were included in the meta-analysis. Overall, compared with intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone led to similar block duration (SMD = 0.12; 95% CI − 0.12 to 0.35; P = 0.33), pain scores at 12 h (SMD = − 0.67; 95% CI − 1.48 to 0.15; P = 0.11), pain scores at 24 h (SMD = − 0.33; 95% CI − 0.79 to 0.14; P = 0.17), opioid consumption (SMD = 0.01; 95% CI − 0.18 to 0.19; P = 0.95) and incidence of nausea/vomiting (OR = 0.74; 95% CI 0.38–1.44; P = 0.38).

Conclusions

Perineural and intravenous dexamethasone demonstrated comparable pain relief after shoulder arthroscopy.

Dyspnea induced by hemidiaphragmatic paralysis after ultrasound-guided supraclavicular brachial plexus block in a morbidly obese patient

RATIONALE

Hemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function.

PATIENT CONCERNS

A 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia.

DIAGNOSES

After ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia.

INTERVENTIONS

It led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation.

OUTCOMES

The unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital.

LESSONS

This case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.

Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: Arthroscopy-Guided Continuous Suprascapular Nerve Block Versus Ultrasound-Guided Continuous Interscalene Block

PURPOSE

To compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block and ultrasound-guided continuous interscalene block in postoperative analgesia in patients undergoing arthroscopic rotator cuff repair.

METHODS

A prospective study was performed between March and November 2020. In total, 76 patients were enrolled and divided into 2 groups: in the 38 patients of group 1 (arthroscopy-guided continuous suprascapular nerve block), an indwelling catheter was introduced via the Neviaser portal under arthroscopic view before closing the portal at the end of the surgery; and in the 38 patients of group 2 (ultrasound-guided continuous interscalene block), an indwelling catheter was inserted and directed toward the interscalene brachial plexus prior to the surgery under ultrasound guidance. The primary outcome was the pain score measured by the visual analog scale at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of these events: neurologic complications, such as sensory/motor change in the upper extremities; hemidiaphragmatic paresis; dyspnea; dysphonia; and Horner's syndrome. Opioid usage until postoperative 3 weeks was compared between the groups.

RESULTS

The visual analog scale scores in groups 1 and 2 were comparable at each postoperative time point (analysis of variance, P = .919; trends, P = .132). Neurologic deficits were more common in group 2 than in group 1 (8 vs 32 patients, P < .001). Decreased excursion of the diaphragm was more common in group 2 (partial or complete paresis of the hemidiaphragm: 1 vs 29 patients, P < .001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, P = .195).

CONCLUSIONS

Our findings show that arthroscopy-guided continuous suprascapular nerve block is not inferior to ultrasound-guided continuous interscalene block for postoperative pain control after arthroscopic rotator cuff repair while showing fewer temporary neurologic complications.

LEVEL OF EVIDENCE

Level II, prospective cohort study, interventional study.

Effects of Local Anesthetic Volume (Standard Versus Low) on Incidence of Hemidiaphragmatic Paralysis and Analgesic Quality for Ultrasound-Guided Superior Trunk Block After Arthroscopic Shoulder Surgery

BACKGROUND

Relative to interscalene block, superior trunk block (STB) provides comparable analgesia and a reduced risk of hemidiaphragmatic paralysis. However, the incidence of hemidiaphragmatic paralysis remains high when a standard volume (15 mL) of local anesthetic is used. This study aimed to evaluate the effects of local anesthetic volume of STB on the incidence of phrenic nerve palsy, as well as its analgesic efficacy following arthroscopic shoulder surgery.

METHODS

Patients scheduled for elective arthroscopic shoulder surgery were randomized to receive ultrasound-guided STB using either 5- or 15-mL 0.5% ropivacaine before general anesthesia. The primary outcome was the incidence of hemidiaphragmatic paralysis at 30 minutes after block. The secondary outcomes were pulmonary function, grade of sensory and motor blockade, pain score, opioid consumption, adverse effects, and satisfaction.

RESULTS

Relative to standard-volume STB, low-volume STB was associated with a lower incidence of hemidiaphragmatic paralysis after block (14.3 [4.8%-30.3%] vs 65.7 [46.8%-80.9%]; difference 51.4% [95% confidence intervals {CIs}, 29.0%-67.1%]; P < .0001) and at the postanesthesia care unit (9.4% vs 50.0%; difference 40.6 [95% CI, 18.9%-57.7%]; P = .0004). Pulmonary function was also better preserved in the low-volume group than in the standard-volume group. The extent of the sensory and motor blocks was significantly different between the groups. Pain-related outcomes, satisfaction, and any adverse events were not significantly different between the groups.

CONCLUSIONS

Low-volume STB provided a lower incidence of hemidiaphragmatic paralysis with no significant difference in analgesic efficacy relative to standard-volume STB for arthroscopic shoulder surgery.

Regional Anesthesia in the Field for Trauma Victims

This article addresses the importance of anesthesiologists providing regional anesthesia techniques that are beneficial to the care of trauma patients in the field. It also discusses the advantages and risks associated with regional anesthesia in the field along with how to avoid those risks. In addition, it describes some of the benefits of modern ultrasound techniques compared with landmark techniques with stimulation and other important considerations when performing regional anesthesia in the field. The article gives the unique indications, risks, and key points of the most useful regional techniques for anesthesiologists operating in field environments.

Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study

Background

Arthroscopic shoulder surgery causes severe postoperative pain. An interscalene brachial plexus block provides adequate analgesia, but unintended spread of the local anesthetic administered may result in a phrenic nerve block, usually associated with a nonnegligible incidence of acute hemidiaphragmatic paralysis.

The main purpose of this trial will be to analyze the incidence of hemidiaphragmatic paralysis ensuing after interscalene brachial plexus block in patients undergoing arthroscopic shoulder surgery administered a standard volume (20 ml) vs. a low volume (10 ml) of levobupivacaine 0.25%.

Methods

This will be a prospective double-blind randomized controlled single-center two-arm comparative trial. Forty-eight patients will be included. The primary goal will be to ultrasonographically determine the incidence of hemidiaphragmatic paralysis by calculating the diaphragmatic thickness ratio in each group. The secondary goals will be to compare the two arms in terms of (1) decrease in forced vital capacity and (2) in forced expiratory volume at 1 s by spirometry; (3) decrease in diaphragmatic excursion by ultrasound; (4) 24-h total intravenous morphine consumption; (5) time to first opioid request of a patient-controlled analgesia pump; and (6) postoperative complications.

Discussion

This trial will demonstrate that a low-volume interscalene brachial plexus block decreases hemidiaphragmatic paralysis following arthroscopic shoulder surgery according to spirometry and ultrasound measurements and does not provide inferior postoperative analgesia to the standard volume, as measured by opioid requirements.

Trial registration

EudraCT and Spanish Trial Register (REec) registration number: 2019-003855-12 (registered on 7 January 2020). ClinicalTrials.gov identification number: NCT04385966 (retrospectively registered on 8 May 2020). Ethics Committee approval: EC19/093 (18 December 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05216-6.

Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus 0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Trial

BACKGROUND

Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB.

METHODS

Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site.

RESULTS

The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance.

CONCLUSIONS

In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.

Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study

Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart^®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart^® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings.

Dexmedetomidine combined with suprascapular nerve block and axillary nerve block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair

PURPOSE

Suprascapular nerve block (SSNB) is the most commonly used block for the relief of postoperative pain from arthroscopic rotator cuff repair and can be used in combination with axillary nerve block (ANB). Dexmedetomidine (DEX) is a type of alpha agonist that can elongate the duration of regional block. The aim of this study was to compare the effects of the use of dexmedetomidine combined with SSNB and ANB with those of the use of SSNB and ANB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair.

METHODS

Forty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single-center, double-blinded randomized controlled trial study. Twenty patients were randomly allocated to group 1 and received ultrasound-guided SSNB and ANB using a mixture of 0.5 ml (50 μg) of DEX and 9.5 ml of 0.75% ropivacaine preemptively. The other 20 patients were allocated to group 2 and underwent ultrasound-guided SSNB and ANB alone using a mixture of 0.5 ml of normal saline and 9.5 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were postoperatively checked within 48 h. The plasma interleukin (IL)-6, IL-8, IL-1β, cortisol, and serotonin levels were also postoperatively measured within 48 h.

RESULTS

Group 1 showed a significantly lower mean VAS (visual analog scale of pain) score 1, 3, 6, 12, 18 and 24 h after operation, and a significantly higher mean SAT (patient satisfaction) score 1, 3, 6, 12, 18, 24 and 36 h after the operation than group 2. Group 1 showed a significantly lower mean plasma IL-8 level 1 and 48 h after the operation, and a significantly lower mean IL-1β level 48 h after the operation than group 2. Group 1 showed a significantly lower mean plasma serotonin level 12 h after the operation than group 2. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (36 h > 23 h, p = 0.007). Six patients each in groups 1 and 2 showed rebound pain. The others did not show rebound pain.

CONCLUSIONS

Ultrasound-guided SSNA and ANB with DEX during arthroscopic rotator cuff repair resulted in a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h after the operation than SSNB and ANB alone. Additionally, SSNB and ANB with DEX tended to result in a later mean timing of rebound pain accompanied by significant changes in IL-8, IL-1β, and serotonin levels within 48 h after the operation. The present study could provide the basis for selecting objective parameters of postoperative pain in deciding the optimal use of medication for relieving pain.

LEVEL OF EVIDENCE

Level I.

TRIAL REGISTRATION

2015-20, ClinicalTrials.gov Identifier: NCT04398589.

IRB NUMBER

2015-20, Hallym University Chuncheon Sacred Heart Hospital.

Proximal vs Distal Approach of Ultrasound-guided Suprascapular Nerve Block for Patients With Adhesive Capsulitis of the Shoulder: Prospective Randomized Controlled Trial

OBJECTIVES

To evaluate the early clinical outcomes of ultrasound (US)-guided suprascapular nerve block (SSNB) using a proximal approach compared with a distal approach for outpatient treatment of adhesive capsulitis.

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic PARTICIPANTS: Participants (N=47) with symptomatic adhesive capsulitis.

INTERVENTIONS

Participants were randomly assigned to either US-guided SSNB using a proximal approach (n=23, proximal group) or a distal approach (n=24, distal group).

MAIN OUTCOME MEASURES

The primary outcome measure was the visual analog scale (VAS) for pain at week 12. Secondary outcomes included the American Shoulder Elbow Surgeon's (ASES) score, University California Los Angeles score, Short Form-36 mental and physical component summaries, and range of motion. All patients completed clinical follow-up at 2, 6, and 12 weeks after treatment. On US images, depth and insertion angle of needle during injection were measured.

RESULTS

The VAS significantly improved in both groups at week 12. After treatment, no significant differences were found in early clinical outcomes (weeks 2, 6, and 12) between groups (all P>.05), except that ASES at 2 weeks showed a significantly higher score in the distal group than in the proximal group (87.1±4.8 and 83.0±6.3, respectively; P=.014). The mean depth and insertion angle of needle was significantly lower (depth: 13.4±3.9 and 30.6±4.3 mm, respectively; P<.001; insertion angle: 19.6°±6.4° and 38.7°±5.8°; P<.001) in the proximal group than in the distal group.

CONCLUSIONS

This study demonstrated that proximal approach of US-guided SSNB provided favorable short-term outcomes of pain and functional improvement and that outcomes were comparable to those of the distal approach in adhesive capsulitis. The suprascapular nerve was located more superficially and easily identified in the proximal approach, suggesting that this method might improve the accuracy of injection.

Efficacy of a single injection compared with triple injections using a costoclavicular approach for infraclavicular brachial plexus block during forearm and hand surgery: A randomized controlled trial

OBJECTIVES

It was recently proposed that a costoclavicular (CC) approach can be used in ultrasound (US)-guided infraclavicular brachial plexus block (BPB). In this study, we hypothesized that triple injections in each of the 3 cords in the CC space would result in a greater spread in the 4 major terminal nerves of the brachial plexus than a single injection in the CC space without increasing the local anesthetic (LA) volume.

METHODS

Sixty-eight patients who underwent upper extremity surgery randomly received either a single injection (SI group, n = 34) or a triple injection (TI group, n = 34) using the CC approach. Ten milliliters of 2% lidocaine, 10 mL of 0.75% ropivacaine, and 5 mL of normal saline were used for BPB in each group (total 25 mL). Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at 5 minutes intervals for 30 minutes immediately after LA administration.

RESULTS

Thirty minutes after the block, the blockage rate of all 4 nerves was significantly higher in the TI group than in the SI group (52.9% in the SI group vs 85.3% in the TI group, P = .004). But there was no significant difference in the anesthesia grade between the 2 groups (P = .262). The performance time was similar in the 2 groups (3.0 ± 0.9 minutes in the SI group vs 3.2 ± 1.2 minutes in the TI group, respectively; P = .54).

DISCUSSION

The TI of CC approach increased the consistency of US-guided infraclavicular BPB in terms of the rate of blocking all 4 nerves without increasing the procedure time despite administering the same volume of the LA.

Regional Anesthesia Practices in Turkey During the COVID-19 Pandemic

Introduction

The aim of the survey was to investigate the changes, methods, and preferences in regional anesthesia (RA) applications during the COVID-19 pandemic in Turkey.

Methods

The questionnaire prepared on surveymonkey.com was sent to anesthesiology and reanimation specialists by e-mail.

Results

A total of 126 physicians participated in the study. Forty-two point sixty-two percent (42.62%) of the participants reported an increase in RA practices in their clinical anesthesia applications, whereas 57.38% did not state any change. Neuraxial anesthesia was determined to be the most preferred RA application, with a rate of 74%. The distribution of peripheral nerve blocks (PNBs) showed that upper extremity blocks were used at a rate of 64.9%, lower extremity blocks at 30.38%, and trunk blocks at 15%. Investigation of neurostimulator (NS) and/or ultrasound (US) use with PNB showed that 44% of the participants used only US while 50% used both US and NS.

Conclusion

Neuraxial blocks play an important role in RA applications. PNB comprise one-quarter of RA applications during the pandemic. The importance of ultrasound has gradually increased in RA applications worldwide, as well as in Turkey, during the pandemic.

The Comparison of Two Different Volumes of 0.5% Ropivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block Onset and Duration of Analgesia for Upper Limb Surgery: A Randomized Controlled Study

Background

The study is based on the fact that a lower volume of local anesthetic drugs for ultrasound-guided supraclavicular brachial plexus block is useful for upper limb surgeries lasting for a shorter duration, and result in a lower incidence of complications.

Aim

The aim of this study is to compare the effectiveness of 35 mL of 0.5% ropivacaine with 20 mL of 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block for upper limb surgery.

Setting

Patients undergoing upper limb surgery in an industry-based government hospital in New Delhi, India. Patients were followed in the operation theater and the recovery room.

Design

The study design involves a prospective, double-blind, randomized controlled trial.

Materials and Methods

A total of 40 participants were recruited for this study. Twenty participants in each group (referred to as group 20 and 30) received 20 mL and 35 mL of 0.5% ropivacaine, respectively, in ultrasound-guided supraclavicular brachial plexus block.

Statistical Analysis

The statistical analysis was performed using the software SPSS version 15 and a value of P < 0.05% was considered statistically significant. The statistical tests used included Student's t-test to compare values between the two groups for the mean of parametric data, Mann-Whitney U-test for a median of nonparametric data, and Chi-square test or Fisher's exact test for the categorical data.

Results

The sensory and motor block onset in group 20 was 18.06 ± 3.04 and 23.89 ± 2.14 min, respectively. The sensory and motor block onset in group 30 was 17 ± 2.01 and 23.75 ± 2.22 min, respectively. The duration of analgesia in group 20 and 30 was 575.56 ± 104.39 and 730.75 ± 102.09 min, respectively (P < 0.001).

Conclusion

The onset of sensory and motor block of 20 mL of 0.5% ropivacaine is comparable to 35 mL of 0.5% ropivacaine for supraclavicular brachial plexus block for upper limb surgery. There was a 21% decrease in the duration of analgesia with a decrease in volume of 0.5% ropivacaine from 35 mL to 20 mL.

Comparison between two different concentrations of a fixed dose of ropivacaine in interscalene brachial plexus block for pain management after arthroscopic shoulder surgery: a randomized clinical trial

Background

Only a few studies have evaluated the differences between varying concentrations of a fixed dose of local anesthetics. This study was conducted to compare the effects of two different concentrations of a fixed dose of ropivacaine used in ultrasound-guided interscalene brachial plexus block.

Methods

This prospective, randomized, double-blind study included 62 patients who underwent arthroscopic surgery under general anesthesia. The patients were randomly assigned to receive ultrasound-guided interscalene block with 75 mg of ropivacaine at one of two concentrations: 0.75% (10 ml; Group C) or 0.375% (20 ml; Group V). Time to onset of sensory blockade, degree of blockade, pulmonary function changes, analgesic duration of the interscalene block, postoperative opioid requirement within 24 h, postoperative pain scores, satisfaction, and incidence of complications were recorded.

Results

Although the time to onset of sensory blockade was shorter for Group C (P = 0.015), successful blockade was achieved at 30 min after the interscalene block in both groups. The analgesic duration of the interscalene block was not significantly different between the groups. The amount of opioid used within 24 h after surgery was significantly reduced for Group V compared with Group C (P = 0.016). The rest of the parameters did not show any significant differences between the two groups.

Conclusions

Compared with 10 ml of 0.75% ropivacaine, interscalene block with 20 ml of 0.375% ropivacaine could be effective for the reduction of postoperative opioid requirement within 24 h after surgery despite it might not prolong the analgesic duration.

Subclavian transcatheter aortic valve implantation (TAVI): superficial cervical plexus block combined with low-dose interscalene block

PURPOSE

Transcatheter aortic valve implantation (TAVI) has become a widely used technique for treating aortic stenosis. Subclavian access may be warranted in the presence of poor vasculature that precludes femoral access. Conscious sedation is increasingly being adopted with some evidence suggesting better outcomes compared with those of general anesthesia. We describe the use of two regional anesthetic techniques to facilitate subclavian access for TAVI.

CLINICAL FEATURES

Our case report involves the successful management of a challenging patient with severe peripheral vasculopathy and respiratory compromise undergoing a trans-subclavian TAVI. Surgical anesthesia was provided by low-dose local anesthetic titrated via an interscalene perineural catheter and a single-shot superficial cervical plexus block while preserving respiratory function.

CONCLUSIONS

The interscalene catheter in situ allowed for low-dose local anesthetic titration without further jeopardizing the pulmonary function throughout the procedure. Unlike other interfascial plane blocks, combined low-dose superficial cervical plexus and interscalene brachial plexus blocks offer surgical anesthesia and limb immobility, thus providing optimal condition for subclavian TAVI to be performed with minimal sedation.

Analgesic efficacy of ultrasound-guided interscalene block vs. supraclavicular block for ambulatory arthroscopic rotator cuff repair: A randomised noninferiority study

BACKGROUND

Ultrasound-guided interscalene block (ISB) is the reference technique for pain control after ambulatory upper limb surgery, but supraclavicular block (SCB) is an alternative.

OBJECTIVES

The aim of this study was to compare the efficacy of SCB vs. ISB in patients undergoing ambulatory arthroscopic rotator cuff repair (ARCR), with the hypothesis of noninferiority of SCB analgesia compared with ISB.

DESIGN

A randomised, single-blind, noninferiority study.

SETTING

Hôpital Privé Jean Mermoz, Centre Paul Santy, Lyon, France.

PATIENTS

Ambulatory ARCR patients.

INTERVENTION

Patients were randomly allocated (1 : 1) to receive a single injection SCB or ISB, as well as general anaesthesia. All patients received a postoperative analgesic prescription for home use before leaving hospital (including fast-acting oral morphine sulphate). Patients completed a telephone questionnaire on days 1 and 2 postsurgery.

MAIN OUTCOME MEASURES

Primary endpoint was oral morphine consumption (mg) during the first 2 days postsurgery. If the difference between mean morphine consumption in the SCB vs. ISB group was less than 30 mg, noninferiority of SCB compared with ISB would be demonstrated. Secondary evaluation criteria included pain scores (numerical rating scale), duration of motor and sensory blockade, and satisfaction with treatment.

RESULTS

The per-protocol cohort included 103 patients (SCB = 52, ISB = 51) (57% men, median age 58 years). Mean morphine consumption in the 48 h postsurgery was 9.4 vs. 14.7 mg in the SCB and ISB groups, respectively (difference −5.3, P < 0.001). The upper limit of the 95% CI was less than 30 mg, demonstrating noninferiority of SCB compared with ISB. No difference was observed between the two groups in terms of pain scores or the duration of motor or sensory blockade. Overall, 98% of patients in the SCB group vs. 90% in the ISB group were satisfied with their treatment.

CONCLUSION

SCB is as effective as ISB in terms of postoperative analgesia based on oral morphine consumption in patients undergoing ambulatory ARCR.

TRIAL REGISTRATION

EudraCT number: 2016-A00747-47.

Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair

PURPOSE

Interscalene brachial plexus block (ISB) is one of the most commonly used regional blocks in relieving postoperative pain after arthroscopic rotator cuff repair. Dexmedetomidine (DEX) is an alpha 2 agonist that can enhance the effect of regional blocks. The aim of this study was to compare the effects of DEX combined with ISB with ISB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair.

METHODS

Fifty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single center, double-blinded randomized controlled trial study. Twenty-five patients were randomly allocated to group 1 and received ultrasound-guided ISB using a mixture of 1 ml (100 μg) of DEX and 8 ml of 0.75% ropivacaine preemptively. The other 25 patients were allocated to group 2 and underwent ultrasound-guided ISB alone using a mixture of 1 ml of normal saline and 8 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were checked within 48 h postoperatively. The plasma interleukin (IL)-6, -8, -1β, cortisol, and substance P levels were also measured within 48 h, postoperatively.

RESULTS

Group 1 showed a significantly lower mean VAS score and a significantly higher mean SAT score than group 2 at 1, 3, 6, 12, and 18 h postoperatively. Compared with group 2, group 1 showed a significantly lower mean plasma IL-6 level at 1, 6, 12, and 48 h postoperatively and a significantly lower mean IL-8 level at 1, 6, 12, 24, and 48 h postoperatively. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (12.7 h > 9.4 h, p = 0.006).

CONCLUSIONS

Ultrasound-guided ISB with DEX in arthroscopic rotator cuff repair led to a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h postoperatively than ISB alone. In addition, ISB with DEX showed lower mean plasma IL-6 and IL-8 levels than ISB alone within 48 h postoperatively, with delayed rebound pain.

LEVEL OF EVIDENCE

I.

TRIAL REGISTRATION

2013-112, ClinicalTrials.gov Identifier: NCT02766556.

A Novel Application of Ultrasound-Guided Interscalene Anesthesia for Proximal Humeral Fractures

BACKGROUND

Proximal humeral fractures are commonly encountered in the emergency department (ED). These injuries are often associated with significant pain, with patients often receiving multiple doses of opiate medications while awaiting definitive management. The interscalene nerve block has been efficacious as perioperative analgesia for patients undergoing operative shoulder repair. The utilization of the interscalene nerve block in the ED for proximal humeral fractures is largely unexplored.

DISCUSSION

We report the use of an ultrasound-guided interscalene nerve block in the ED for a patient presenting with significant pain from a proximal humerus fracture. The procedure provided excellent regional anesthesia with no additional need for intravenous or oral opiates during the rest of her ED course. With the significant risks associated with pain medication, particularly opiates, regional anesthesia may be an excellent option for the appropriate patient in the ED.

CONCLUSIONS

As documented in this report, the ultrasound-guided interscalene block, in particular, may be utilized as a means to provide adequate pain control for patients with proximal humerus fractures in the ED.

Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study

Background

Hemidiaphragmatic paralysis, a frequent complication of the brachial plexus block performed above the clavicle, is rarely associated with an infraclavicular approach. The costoclavicular brachial plexus block is emerging as a promising infraclavicular approach. However, it may increase the risk of hemidiaphragmatic paralysis because the proximity to the phrenic nerve is greater than in the classical infraclavicular approach.

Methods

This retrospective analysis compared the incidence of hemidiaphragmatic paralysis in patients undergoing costoclavicular and supraclavicular brachial plexus blocks. Of 315 patients who underwent brachial plexus block performed by a single anesthesiologist, 118 underwent costoclavicular, and 197 underwent supraclavicular brachial plexus block. Propensity score matching selected 118 pairs of patients. The primary outcome was the incidence of hemidiaphragmatic paralysis, defined as a postoperative elevation of the hemidiaphragm > 20 mm. Factors affecting the incidence of hemidiaphragmatic paralysis were also evaluated.

Results

Hemidiaphragmatic paralysis was observed in three patients (2.5%) who underwent costoclavicular and 47 (39.8%) who underwent supraclavicular brachial plexus blocks (P < 0.001; odds ratio, 0.04; 95% confidence interval, 0.01-0.13). Both the brachial plexus block approach and the injected volume of local anesthetic were significantly associated with hemidiaphragmatic paralysis.

Conclusions

The incidence of hemidiaphragmatic paralysis is significantly lower with costoclavicular than with supraclavicular brachial plexus block.

Understanding and Treating Iatrogenic Nerve Injuries in Shoulder Surgery

As surgical techniques and technology continue to advance in shoulder surgery along with the increased use of regional anesthesia, it is important to remember that iatrogenic nerve injuries remain a possible complication. Iatrogenic nerve injuries associated with shoulder surgery lead to patient disability and distress, increased healthcare costs, and possibly additional procedures. To obtain the best possible outcome for the patient after the nerve injury has been discovered, a timely appreciation of the management options is necessary rather than expectant management. Early recognition, appropriate neurodiagnostic testing, and prompt treatment or referral are mandatory for optimal outcomes.

Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Interscalene brachial plexus block of the C5–C6 roots provides highly effective postoperative analgesia after shoulder surgery but usually results in hemidiaphragmatic paresis. Injection around the superior trunk of the brachial plexus is an alternative technique that may reduce this risk. The authors hypothesized that the superior trunk block would provide noninferior postoperative analgesia compared with the interscalene block and reduce hemidiaphragmatic paresis.

Methods

Eighty patients undergoing arthroscopic shoulder surgery were randomized to receive a preoperative injection of 15 ml of 0.5% ropivacaine and 5 μg · ml−1 epinephrine around either (1) the C5–C6 nerve roots (interscalene block group) or (2) the superior trunk (superior trunk block group). The primary outcome was pain intensity 24 h after surgery measured on an 11-point numerical rating score; the prespecified noninferiority limit was 1. Diaphragmatic function was assessed using both ultrasonographic measurement of excursion and incentive spirometry by a blinded investigator before and 30 min after block completion.

Results

Seventy-eight patients completed the study. The pain score 24 h postoperatively (means ± SDs) was 1.4 ± 1.0 versus 1.2 ± 1.0 in the superior trunk block (n = 38) and interscalene block (n = 40) groups, respectively. The mean difference in pain scores was 0.1 (95% CI, −0.3 to 0.6), and the upper limit of the 95% CI was lower than the prespecified noninferiority limit. Analgesic requirements and all other pain measurements were similar between groups. Hemidiaphragmatic paresis was observed in 97.5% of the interscalene block group versus 76.3% of the superior trunk block group (P = 0.006); paresis was complete in 72.5% versus 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the interscalene block group.

Conclusions

The superior trunk block provided noninferior analgesia compared with interscalene brachial plexus block for up to 24 h after arthroscopic shoulder surgery and resulted in significantly less hemidiaphragmatic paresis.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Diaphragm-sparing nerve blocks for shoulder surgery, revisited

Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence <10%.

Superior Trunk Block

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve.

Methods

This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction.

Results

The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P &lt; 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1.

Conclusions

Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

Diaphragm-sparing effect of the infraclavicular subomohyoid block vs low volume interscalene block. A randomized blinded study

BACKGROUND

Both low volume interscalene and infraclavicular-subomohyoid blocks were suggested to provide shoulder analgesia with low risk of phrenic nerve block. The aim of this study was to compare the frequency of the phrenic nerve block between these two techniques.

METHOD

Seventy-two patients scheduled for shoulder arthroscopy were included in this randomized controlled blind study. Before induction of general anesthesia, patients received low volume interscalene block using 5 mL of ropivacaine 0.5% (LVS group) or infraclavicular-subomohyoid block using 25 mL of ropivacaine 0.5% (ISO group). The diaphragmatic excursion was measured (using ultrasound) before the block and after surgery. If the ratio of postoperative to pre-block excursions was <25%, a phrenic nerve block was concluded. Secondary outcomes were: the duration of analgesia, the 24-hour morphine requirement, and patient satisfaction.

RESULTS

The phrenic nerve was blocked in 88.9% of patients in LVS group vs 5.6% in ISO group (P < 0.001). There was no significant difference between the two groups with regard to the duration of analgesia, the morphine consumption, and the patient satisfaction.

CONCLUSION

Compared with the low volume interscalene block, the infraclavicular subomohyoid block resulted in a significantly less frequent phrenic nerve block and with no difference in postoperative analgesia. Therefore, it may be relevant to consider for patients who cannot tolerate a phrenic nerve block.

Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial

Background and Aims:

Hemidiaphragmatic paresis occurs in almost all patients undergoing interscalene block for proximal upper limb surgeries. This study tested hypothesis that ultrasound-guided extrafascial approach of interscalene block under nerve stimulator guidance reduces incidence of hemidiaphragmatic paresis in comparison to intrafascial approach by achieving same degree of anaesthesia and analgesia.

Methods:

Sixty patients undergoing proximal upper limb surgeries were randomised to receive an ultrasound-guided interscalene brachial plexus block (ISB) with the aid of nerve stimulator for surgical anaesthesia and analgesia using 20 mL 0.5% ropivacaine by extrafascial (Group E) or intrafascial (Group I) approach. The incidence of hemidiaphragmatic paresis was measured by M-mode ultrasound before and 30 min after the procedure. Secondary outcomes such as respiratory functions (forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate) were measured, and complications were recorded and compared. The statistics was obtained using SPSS Version 19. Levene's test and paired and unpaired t-test were used. P value <0.05 was considered significant.

Results:

The incidence of hemidiaphragmatic paresis was 17% and 46% in Group E and Group I, respectively (P < 0.0001). All other respiratory outcomes were preserved in Group E compared with Group I.

Conclusion:

Ultrasound-guided ISB with the aid of nerve stimulator through extrafascial approach reduces the incidence of hemidiaphragmatic paresis and also reduces respiratory function impairment when compared with intrafascial approach.

Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons

The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].