The indications and applications of interscalene brachial plexus block for surgery about the shoulder

Shaping the Anesthetic Approach to TricValve Implantation: Insights From a Case Series

OBJECTIVES

Caval valve implantation (CAVI) represents a minimally invasive strategy for managing severe tricuspid regurgitation in high-risk patients unsuitable for surgical or transcatheter tricuspid valve implantation. This case series aimed to assess the anesthesia management challenges and outcomes associated with this procedure, seeking to generate insights that can inform and refine anesthesia protocols.

DESIGN

A case series.

SETTING

At a cardiac catheterization laboratory of a teaching hospital.

PARTICIPANTS

Eight patients undergoing CAVI with the Tricvalve system INTERVENTIONS: The anesthetic protocol included preprocedural planning, fast-track general anesthesia, and postprocedural debriefing. Intraoperative management involved anesthesia depth monitoring, real-time guidance via transesophageal echocardiography, and hemodynamic stability maintenance. Postoperative analgesia involved preemptive intravenous paracetamol and morphine as needed.

MEASUREMENTS AND MAIN RESULTS

No anesthesia-related or implantation-related complications were observed, with a mean procedure duration of 112 ± 44 minutes. The median hospital stay was 4 days, and only 1 patient required brief intensive care unit monitoring. Postoperative right shoulder pain was reported by half of the patients, and was managed with morphine bolus administration (average dose 4.75 ± 3.6 mg). All patients had the device correctly positioned, as confirmed by postoperative transthoracic echocardiograms. None of the patients required outpatient analgesic therapy upon discharge.

CONCLUSIONS

The authors' study demonstrated the potential of TricValve implantation in effectively managing severe tricuspid regurgitation with no procedure-related complications and a 100% survival rate. A collaborative, interdisciplinary approach and targeted anesthesia management proved crucial for this success. Postoperative shoulder pain emerged as a frequent complication, whose pathogenesis is still not clear, and successfully was managed using targeted analgesic therapy.

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial

BACKGROUND

Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB).

METHODS

This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05.

RESULTS

Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different.

CONCLUSION

Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.

The PECS II block as a major analgesic component for clavicle operations: A description of 7 case reports

Clavicle fractures correspond to 35% of traumatic fractures of the shoulder girdle. Regional anaesthesia has shown better analgesic results than systemic treatment for perioperative management. Innervation of the clavicle is complex, at present its knowledge raises controversy. The lateral pectoral nerve through the innervating musculature predominantly participates in the lateral and anterior part of the clavicle. The following report of 7 cases describes the effective postoperative analgesia of modified PEC II block in patients with middle third clavicle fracture or acromioclavicular dislocation who underwent a modified PEC II block for postoperative pain management, in the context of a multimodal analgesia. The potential advantage of this management over other analgesic procedures should be evaluated in specific clinical trials.

Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To compare the effects of a single-dose interscalene block and general anesthesia (SISB/GA) with the effects of GA only in the early postoperative period after arthroscopic rotator cuff repair by evaluating subjective pain visual analog scale scores and objective pain-related stress biomarkers.

METHODS

Patients refractory to conservative treatment of the affected shoulder were enrolled in this prospective, randomized endpoint study. Patients diagnosed with a rotator cuff tear (1-4 cm) based on magnetic resonance imaging were included. Exclusion criteria were small (<1 cm) and massive (>4 cm) rotator cuff tears. Thirty-one patients each were randomized into the SISB/GA and GA treatment groups. Preoperative pain scores were measured at 6:00 AM on the day of surgery, measured again at 1 and 6 hours postoperatively, and then every 6 hours until 3 days postoperatively. Blood sampling was performed to evaluate the stress biomarkers insulin, dehydroepiandrosterone sulfate, and fibrinogen preoperatively at 6:00 AM on the day of surgery and postoperatively at 18, 42, and 66 hours (6:00 AM on postoperative days 1-3).

RESULTS

Pain scores were significantly decreased in the SISB/GA group (2.50 ± 0.94) versus the GA group (3.82 ± 1.31) on the day of surgery (P < .001), and especially at 6 hours postoperatively (SISB/GA: 2.42 ± 1.43; GA: 4.23 ± 2.17; P < .001). Insulin was decreased significantly in the SISB/GA group (10.55 ± 7.92 μU/mL) versus the GA group (20.39 ± 25.60 μU/mL) at 42 hours postoperatively (P = .048). There was no significant change in dehydroepiandrosterone sulfate or fibrinogen over time (P > .05).

CONCLUSIONS

After arthroscopic rotator cuff repair, an SISB effectively relieved pain on the day of surgery without any complications. In addition, insulin levels were significantly reduced at 42 hours postoperatively.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Effect of intravenous ondansetron on reducing the incidence of hypotension and bradycardia events during shoulder arthroscopy in sitting position under interscalene brachial plexus block: A prospective randomized trial

Background and Aims:

Sudden, profound hypotension and bradycardia events (HBEs) have been reported in more than 20% of patients undergoing shoulder arthroscopy in the sitting position. The present study was designed to know whether intravenous (IV) ondansetron (selective 5-hydroxy tryptamine 3-antagonist) can help in reducing the HBEs associated with shoulder arthroscopy performed in sitting position under interscalene brachial plexus block (ISBPB).

Methods:

A total of 100 patients (age 20–50 years) undergoing shoulder arthroscopy performed in the sitting position under ISBPB were assigned randomly to one of the two groups: Group C received 10 ml of normal saline and Group T received 4 mg of ondansetron diluted in 10 ml of normal saline` IV. All patients received ISBPB using levobupivacaine 0.5%. Assessment of motor and sensory blockade, pulse rate, systolic blood pressure, respiration, and side effects were noted every 5 min for first 30 min and every 10 min till the end of surgery. HBEs were recorded in both groups.

Results:

IV injection of ondansetron significantly reduces the incidence of HBEs from 11 (22.44% in Group C) to 3 (6.1% in Group T). The duration of analgesia was significantly longer in Group C (8.1 ± 3.3) in comparison with Group T (6.3 ± 4.2 h).

Conclusion:

We conclude that 4 ml of IV ondansetron can significantly reduce the HBEs during shoulder arthroscopy done in the sitting position under ISBPB.

The effect of norepinephrine versus epinephrine in irrigation fluid on the incidence of hypotensive/bradycardic events during arthroscopic rotator cuff repair with interscalene block in the sitting position

PURPOSE

To compare the occurrence rate of hypotensive and bradycardic events (HBEs) during arthroscopic rotator cuff repair performed with interscalene brachial plexus block anesthesia in the sitting position in 2 groups of patients who underwent the procedure with norepinephrine or epinephrine added to the irrigation fluid. The secondary objective was to evaluate the efficacy of norepinephrine in comparison with epinephrine in controlling intraoperative bleeding and maintaining adequate visualization of the arthroscopic field of view during the procedure. We hypothesized that norepinephrine added to the irrigation fluid during shoulder arthroscopy in the sitting position would reduce the occurrence of HBEs, allowing optimal intraoperative bleeding control.

METHODS

One hundred twenty patients underwent an arthroscopic rotator cuff repair performed under peripheral anesthesia and in the beach-chair position. Patients were randomly divided into 2 groups of 60 cases each: Norepinephrine (0.66 mg/L) and epinephrine (0.33 mg/L) were added to irrigation bags in group N and group E, respectively. The primary outcome was the occurrence rate of HBEs during surgery. The secondary outcomes were timing of onset of HBEs, accompanying symptoms, and intraoperative bleeding that impaired arthroscopic visualization. The clarity of the visual field was rated postoperatively by the surgeon using a visual analog scale. Comparison between groups for all baseline variables and outcome measurements was performed with the χ(2) or Fisher exact test, as appropriate, for categorical variables and the Student t test or Mann-Whitney U test, as appropriate, for continuous variables. Significance was set at P < .05.

RESULTS

One patient was excluded from group E because of block failure; therefore 119 patients were finally included in the study. Comparison between groups showed no significant differences in baseline characteristics. The occurrence rate of HBEs was significantly greater in group E (n = 15) than in group N (n = 5) (P = .02). No differences between groups were found in the average time of onset of HBEs, accompanying symptoms, and clarity of the visual field.

CONCLUSIONS

Continuous administration of norepinephrine, 0.66 mg/L, diluted in irrigation fluid during arthroscopic rotator cuff repair with the patient in the beach-chair position reduces the incidence of HBEs and is as effective as epinephrine in controlling intraoperative bleeding and maintaining the visual clarity of the surgical field.

LEVEL OF EVIDENCE

Level I, randomized clinical study.

Effect of interscalene brachial plexus block on heart rate variability

Background

Interscalene brachial plexus block (ISB) may be followed by cardiovascular instability. Until date, there is no clear picture available about the underlying mechanisms of ISB. In this study, we aimed to determine the changes in heart rate variability (HRV) parameters after ISB and the differences between right- and left-sided ISBs.

Methods

We prospectively studied 24 patients operated for shoulder surgery in sitting position and divided them into two respective groups: R (right-sided block = 14 pts) and L (left-sided block = 10 pts). HRV data were taken before and 30 min after the block. Ropivacaine without ephedrine was used for the ISB through an insulated block needle connected to a nerve stimulator. Statistical analysis implemented chi-square, Student's and t-paired tests. Skewed distributions were analyzed after logarithmic transformation.

Results

All the studied patients had successful blocks. Horner's syndrome signs were observed in 33.3% of the patients (R = 5/14, L = 3/10; [P = 0.769]). There were no significant differences in pre-block HRV between the groups. The application of ISB had differential effect on HRV variables: R-blocks increased QRS and QTc durations and InPNN50, while a statistical decrease was seen in InLF. L-blocks did not show any significant changes. These changes indicate a reduced sympathetic and an increased parasympathetic influence on the heart's autonomic flow after R-block.

Conclusions

Based on the obtained results we conclude that ISB, possibly through extension of block to the ipsilateral stellate ganglion, alters the autonomic outflow to the central circulatory system in a way depending on the block's side.

Hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene brachial plexus blocks

Sudden, profound hypotensive and bradycardic events (HBEs) have been reported in more than 20% of patients undergoing shoulder arthroscopy in the sitting position. Although HBEs may be associated with the adverse effects of interscalene brachial plexus block (ISBPB) in the sitting position, the underlying mechanisms responsible for HBEs during the course of shoulder surgery are not well understood. The basic mechanisms of HBEs may be associated with the underlying mechanisms responsible for vasovagal syncope, carotid sinus hypersensitivity or orthostatic syncope. In this review, we discussed the possible mechanisms of HBEs during shoulder arthroscopic surgery, in the sitting position, under ISBPB. In particular, we focused on the relationship between HBEs and various types of syncopal reactions, the relationship between HBEs and the Bezold-Jarisch reflex, and the new contributing factors for the occurrence of HBEs, such as stellate ganglion block or the intraoperative administration of intravenous fentanyl.

Interscalene block for shoulder surgery in physician-owned community ambulatory surgery centers

PURPOSE

To retrospectively report on a series of patients who had interscalene block regional anesthesia performed for outpatient open and arthroscopic shoulder surgical procedures in a community-based ambulatory surgery center setting.

METHODS

We reviewed the cases of 1,945 patients who had interscalene block regional anesthesia performed during an 8-year period.

RESULTS

The complication rate was 0.63%, with all complications occurring in the immediate postoperative period, none of which were permanent.

CONCLUSIONS

With an expert, experienced anesthesia team, the interscalene block can be a safe method (temporary complication rate, 0.63%) of intraoperative anesthesia and perioperative analgesia for outpatient open and arthroscopic shoulder surgery in physician-owned ambulatory surgery centers.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Continuous infusion of a local anesthetic versus interscalene block for postoperative pain control after arthroscopic shoulder surgery

PURPOSE

The purpose of this investigation was to evaluate the efficacy, complication rate, and cost of a 1-time interscalene block compared with a continuous infusion of a local anesthetic for postoperative pain relief in patients having arthroscopic shoulder surgery.

METHODS

After prospective power analysis and institutional review board approval, 56 consecutive patients having arthroscopic shoulder surgery under general anesthesia performed by a single surgeon were randomly assigned to 1 of 2 groups to evaluate postoperative pain control. Group 1 patients received a preoperative interscalene block, and group 2 patients received a subacromial continuous infusion of a local anesthetic (0.5% bupivacaine) via a pain pump for 48 hours postoperatively. Pain was evaluated at 12, 24, 36, and 48 hours and then daily on postoperative days 3 through 7 by use of a visual analog scale included in a patient diary. Patients were provided with 2 "rescue" medication options: ibuprofen and Percocet (Endo Pharmaceuticals, Chadds Ford, PA). The total number of tablets ingested was also evaluated over these same intervals. Total hospital outpatient surgical costs for each group were calculated by dividing total hospital charges by the ratio of annual hospital cost to charges.

RESULTS

No statistically significant differences were identified between the 2 groups with regard to visual analog scale pain scores, medication intake, or cost. Complications did not occur in either group. One patient inadvertently removed the pain pump catheter.

CONCLUSIONS

Our results support the null hypothesis. We found no difference between interscalene block versus continuous subacromial infusion of a local anesthetic with regard to efficacy, complication rate, or cost.

LEVEL OF EVIDENCE

Level I, prospective, randomized controlled trial.