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Shin HJ, You HS, Lee K, Je LG, Kim SG, Yang KS, Jeong WK. Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study. Arthroscopy 2024; 40:1409-1419. [PMID: 37890542 DOI: 10.1016/j.arthro.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE To assess the effects of intravenous tranexamic acid (TXA) on visual clarity at various surgical stages and the correlation between the severity of synovitis and bursitis and the grade of visual clarity in patients undergoing arthroscopic shoulder surgery under an interscalene brachial plexus block. METHODS This double-blind, randomized controlled study included patients undergoing arthroscopic rotator cuff repair. The TXA group underwent injection of a 100-mL mixture of 1,000 mg of TXA and normal saline solution intravenously whereas the control group was administered the same volume of normal saline solution at 10 minutes preoperatively. Visual clarity was rated according to a 3-grade visual clarity scoring system from grade 1 (clear) to grade 3 (poor) at 4 surgical stages (I, intra-articular soft-tissue procedures including synovectomy; II, acromioplasty; III, bursectomy; and IV, greater tuberoplasty). The primary outcome was arthroscopic visual clarity. The secondary outcomes were medications administered for hemodynamic stability, length of hospital stay, and thromboembolic events. RESULTS Altogether, 63 patients were included in the study; they were divided into the TXA group, comprising 32 patients, and the control group, comprising 31 patients. The TXA group showed significantly better visual clarity than the control group (median [interquartile range], 1 [1-2] vs 2 [1-2]; P = .027) during stage I but not during stages II through IV. Spearman correlation analysis revealed a significant correlation between synovitis and visual clarity grade during synovectomy (correlation coefficient, 0.393; P = .001) but not between bursitis and visual clarity grade during bursectomy. Deep vein thrombosis and pulmonary embolism did not occur in either group. CONCLUSIONS Intravenous TXA can improve visual clarity during intra-articular soft-tissue procedures, including synovectomy. However, it does not have a significant effect during acromioplasty, bursectomy, and greater tuberoplasty. TXA can be used to improve visual clarity in patients with suspected severe synovitis. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Kaehong Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Lee Gyeong Je
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Seul Gi Kim
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Woong Kyo Jeong
- Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Republic of Korea.
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Amaral S, Arsky Lombardi R, Medeiros H, Nogueira A, Gadsden J. Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e48217. [PMID: 38050517 PMCID: PMC10693833 DOI: 10.7759/cureus.48217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
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.
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Affiliation(s)
- Sara Amaral
- Anesthesiology, Hospital Regional Deputado Afonso Guizzo, Ararangua, BRA
| | | | - Heitor Medeiros
- Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Alleh Nogueira
- Anesthesiology, Escola Bahiana de Medicina e Saúde Pública, Salvador, BRA
| | - Jeff Gadsden
- Anesthesiology, Duke University Medical Center, Durham, USA
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Campbell AS, Johnson CD, O'Connor S. Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery. Anesthesiol Res Pract 2023; 2023:9962595. [PMID: 37727810 PMCID: PMC10506885 DOI: 10.1155/2023/9962595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023] Open
Abstract
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.
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Affiliation(s)
- Aaron S. Campbell
- Centre for Biomedical Sciences Education, Queen's University, Belfast BT9 7AA, UK
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Horner's Syndrome and Lymphocele Following Thyroid Surgery. J Clin Med 2023; 12:jcm12020474. [PMID: 36675400 PMCID: PMC9865845 DOI: 10.3390/jcm12020474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/27/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid−related HS represents an unusual entity underling thyroid nodules/goiter/cancer−HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2−6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally—aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.
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Zhao Y, Qin S, Yang X, Gao C, Yuan X, Li T, Chen Z. Comparison of the anesthesia effect of ultrasound-guided middle and low interscalene brachial plexus block: a randomized, controlled, non-inferiority trial. BMC Anesthesiol 2023; 23:1. [PMID: 36597045 PMCID: PMC9808947 DOI: 10.1186/s12871-022-01963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ultrasound-guided low interscalene brachial plexus block (LISB) can provide satisfactory anesthesia for surgery at or below the elbow. However, the anesthesia effect of ultrasound-guided middle interscalene brachial plexus block (MISB) has not been fully investigated. We hypothesized that MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow. METHODS A total of 82 patients with ASA I-III (18-65 years) scheduled for elective surgery at or below the elbow were randomized to the MISB group or the LISB group equally, located 1/2 or 2/3 of the caudal distance from C6 to the clavicle. Both groups were administered 15 mL 0.5% ropivacaine at the lower part of the brachial plexus with the first injection and equivalent volume at the upper part with the second injection. RESULTS For the primary outcome, 92.3% in the MISB group experienced successful anesthesia compared to 94.6% in the LISB group [difference: -2.3%, 95% confidence interval (CI) -13.4% to 8.8%], exceeding the predefined non-inferiority margin -15%. For the secondary outcomes, the incidence of pleura suppression for the first injection (7.7% vs. 45.9%, P < 0.001) and the time to perform the block (9.9 ± 1.3 vs. 10.7 ± 1.3 min, P = 0.006) were significantly less in MISB compared to LISB. No significant differences were observed in the consumption of perioperative rescue analgesics, VAS score, and adverse events within the two groups. CONCLUSIONS MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow. TRIAL REGISTRATION Chinese Clinical Trial Register (identifier: ChiCTR2100054196).
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Affiliation(s)
- Yang Zhao
- grid.413387.a0000 0004 1758 177XDepartment of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 The South of Maoyuan Road, Nanchong, Sichuan 637000 People’s Republic of China ,grid.412594.f0000 0004 1757 2961Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, No. 22 Shuangyong Road, 530021 Guangxi, People’s Republic of China
| | - Shiming Qin
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Xue Yang
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Chongmei Gao
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Xia Yuan
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
| | - Tao Li
- grid.440164.30000 0004 1757 8829Department of Radiology, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan China
| | - Zhaohui Chen
- grid.203458.80000 0000 8653 0555Department of Anesthesiology, Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), No.1 Shuanghu Branch Road, Chongqing, 401120 China
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Uchida R, Hombu A, Ishida Y, Nagasawa M, Chosa E. Investigation of cryotherapy for pain relief after arthroscopic shoulder surgery. J Orthop Surg Res 2022; 17:553. [PMID: 36536379 PMCID: PMC9764510 DOI: 10.1186/s13018-022-03404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Recently, cryotherapy has become a common practice for postoperative pain management. The current accepted practice in Japan is the use of cryotherapy at 5 °C after arthroscopic shoulder surgery. However, this therapy has been reported to be highly intense because the sustained low temperature causes discomfort for patients. The optimum temperature and duration of cooling required for comfortable and effective cryotherapy after arthroscopic shoulder surgery were investigated. METHODS Because pain levels might differ depending on the condition, we selected 52 patients with rotator cuff injuries, which were the most common disorders indicated for arthroscopic shoulder surgery. Patients were treated with cryotherapy at 5 °C or 10 °C for 16 h or 24 h. The pain level was determined using the visual analogue scale, and deep shoulder joint temperatures were recorded at different time points for analysis. RESULTS Pain after arthroscopic shoulder surgery was found to be related to the presence of a brachial plexus block using the interscalene approach during surgical anesthesia. To obtain effective analgesia with cryotherapy, the cooling temperature and duration of cryotherapy had to be changed based on the presence or absence of the brachial plexus block. Patients who received brachial plexus blocks had the lowest recorded pain scores after receiving cryotherapy at 5 °C for 24 h after surgery. Patients who did not receive the block had the lowest recorded pain scores when receiving cryotherapy at either 5 °C for 16 h or 10 °C for 24 h. CONCLUSIONS Using universal cryotherapy intensity and duration settings regardless of the use of other interventions is likely to unintentionally increase postoperative pain levels. This study revealed that cryotherapy at 5 °C for 24 h was optimal for patients who received an anesthesia block and at 5 °C for 16 h or at 10 °C for 24 h for those who did not receive the anesthesia block. These results can be used as a reference for setting the temperature and duration of cryotherapy after arthroscopic shoulder surgery.
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Affiliation(s)
- Rinko Uchida
- grid.410849.00000 0001 0657 3887School of Nursing, Faculty of Medicine, University of Miyazaki, 5200 Kihara Kiyotake-Cho, Miyazaki-City, Miyazaki 889-1692 Japan
| | - Amy Hombu
- grid.410849.00000 0001 0657 3887Center for Language and Cultural Studies, University of Miyazaki, Miyazaki, Japan
| | | | - Makoto Nagasawa
- grid.410849.00000 0001 0657 3887Department of Orthopaedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Etsuo Chosa
- grid.410849.00000 0001 0657 3887Department of Orthopaedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Liu Z, Li YB, Wang JH, Wu GH, Shi PC. Efficacy and adverse effects of peripheral nerve blocks and local infiltration anesthesia after arthroscopic shoulder surgery: A Bayesian network meta-analysis. Front Med (Lausanne) 2022; 9:1032253. [PMID: 36438028 PMCID: PMC9684667 DOI: 10.3389/fmed.2022.1032253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
Study objective To quantitatively assess and compare the efficacy and adverse effects of six different peripheral nerve block techniques after arthroscopic shoulder surgery (ASS). Design Bayesian network meta-analysis. Methods The PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure database, Chinese Scientific Journal database, Wan Fang databases were searched to retrieve randomized clinical trials comparing interscalene brachial plexus block, continuous interscalene brachial plexus block, supraclavicular brachial plexus block, suprascapular nerve block, combined suprascapular and axillary nerve block and local infiltration analgesia on postoperative pain, opioid consumption, and adverse effects (defined as Horner’s syndrome, dyspnea, hoarseness, vomiting, and nausea) after ASS under general anesthesia (GA). Two reviewers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies. Results A total of 1,348 articles were retrieved initially and 36 randomized clinical trials involving 3,124 patients were included in the final analysis. The network meta-analysis showed that interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to the five other interventions. However, adverse effects were reduced using suprascapular nerve block and combined suprascapular and axillary nerve block compared to interscalene brachial plexus block. Conclusion Interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to other peripheral nerve blocks but had a higher frequency of adverse events.
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Affiliation(s)
- Zheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi-bo Li
- Huaiyin District Center for Disease Control and Prevent, Jinan, China
| | - Ji-hua Wang
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Guang-han Wu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Peng-cai Shi
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- *Correspondence: Peng-cai Shi,
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Shao P, Li H, Shi R, Li J, Wang Y. Understanding fascial anatomy and interfascial communication: implications in regional anesthesia. J Anesth 2022; 36:554-563. [PMID: 35697947 DOI: 10.1007/s00540-022-03082-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Peiqi Shao
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Huili Li
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Rong Shi
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Jinlei Li
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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Kapukaya F, Ekinci M, Ciftci B, Atalay YO, Gölboyu BE, Kuyucu E, Demiraran Y. Erector spinae plane block vs interscalene brachial plexus block for postoperative analgesia management in patients who underwent shoulder arthroscopy. BMC Anesthesiol 2022; 22:142. [PMID: 35550031 PMCID: PMC9097375 DOI: 10.1186/s12871-022-01687-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Interscalene brachial plexus block (ISB) is the gold standard method used for postoperative analgesia after arthroscopic shoulder surgery. Ultrasound guided erector spinae plane block (ESPB) is an interfascial plane block. The aim of this study is to compare the analgesic efficacy of ESPB and ISB after shoulder arthroscopy. The primary outcome is the comparison of the perioperative and postoperative opioid consumptions. Methods Sixty patients with ASA score I-II planned for arthroscopic shoulder surgery were included in the study. ESPB was planned in Group ESPB (n = 30), and ISB was planned in Group ISB (n = 30). Intravenous fentanyl patient-controlled analgesia was administered to both groups in the postoperative period. Intraoperative and postoperative opioid and analgesic consumption of both groups, side effects and complications related to opioid use, postoperative pain scores and rescue analgesic use were recorded in the first 48 h postoperatively. Results Pain scores were significantly higher in the ESPB group in the first 4 h postoperatively than in the ISB group (p < 0.05). The total fentanyl consumption and number of patients using rescue analgesics in the postoperative period were significantly higher in the ESPB group (p < 0.05). The incidence of nausea in the postoperative period was significantly higher in the ESPB group (p < 0.05). Conclusions In our study, it was seen that ISB provided more effective analgesia management compared to ESPB in patients underwent shoulder arthroscopy surgery.
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Affiliation(s)
- Furkan Kapukaya
- Department of Anesthesiology and Reanimation, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mursel Ekinci
- Department of Anesthesiology and Reanimation, Bursa City Hospital, Bursa, Turkey
| | - Bahadir Ciftci
- Department of Anesthesiology and Reanimation, School of Medicine, Istanbul Medipol University, Istanbul, Turkey.
| | - Yunus Oktay Atalay
- Department of Anesthesiology and Reanimation, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Birzat Emre Gölboyu
- Department of Anesthesiology and Reanimation, School of Medicine, Katip Çelebi University, Izmir, Turkey
| | - Ersin Kuyucu
- Department of Orthopedics and Traumatology, Medical Park Bahçelievler Hospital, Istanbul, Turkey
| | - Yavuz Demiraran
- Department of Anesthesiology and Reanimation, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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10
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. [The impact of unilateral diaphragmatic paralysis on sleep-disordered breathing: a scoping review]. Can J Anaesth 2021; 68:1064-1076. [PMID: 33725316 DOI: 10.1007/s12630-021-01970-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Unilateral diaphragm paralysis (UDP) may potentially worsen sleep-disordered breathing (SDB). Unilateral diaphragm paralysis has been associated with proximal brachial plexus blockade, such as interscalene and supraclavicular block. The impact of UDP in patients with SDB is not known in this context. The objectives of this scoping review were to explore the associations between UDP and worsening SDB severity, oxygenation, and pulmonary function. METHODS A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to include studies involving adult patients (≥ 18 yr) with SDB, where the effects of UDP on SDB severity, oxygenation, and pulmonary function were examined. RESULTS Six studies (n = 100 patients) with UDP and SDB were included. The sample population was derived exclusively from respirology-sleep clinics, and none were surgical patients. Compared with control (no UDP), UDP was associated with an increased respiratory disturbance index, most pronounced during rapid eye movement (REM) sleep and supine sleep. Supine and REM sleep were associated with obstructive and mixed (both obstructive and central) events, respectively. Compared with control, UDP was associated with a lower mean and minimum oxygen saturation and arterial oxygen tension during all sleep stages and in all body positions. The majority of UDP patients were found to have clinically significant reductions in mean forced expiratory volume in one second and forced vital capacity values, consistent with restrictive ventilatory pattern. CONCLUSION We observed an association between UDP and increasing SDB severity, particularly during REM sleep and while sleeping in the supine position. Although we identified weaknesses in study design and lack of perioperative data, anesthesiologists should be aware of this association when considering proximal brachial plexus blockade in patients with SDB.
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Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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11
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Layera S, Saadawi M, Tran DQ, Salinas FV. Motor-Sparing Peripheral Nerve Blocks for Shoulder, Knee, and Hip Surgery. Adv Anesth 2020; 38:189-207. [PMID: 34106834 DOI: 10.1016/j.aan.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Sebastián Layera
- Department of Anesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, University of Chile, Office B222 Second Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Mohammed Saadawi
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - De Q Tran
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, 600 Broadway, Suite 270, Seattle, WA 98122, USA.
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12
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Analgesic efficacy of ultrasound-guided interscalene block vs. supraclavicular block for ambulatory arthroscopic rotator cuff repair: A randomised noninferiority study. Eur J Anaesthesiol 2020; 36:778-786. [PMID: 31361631 PMCID: PMC6738543 DOI: 10.1097/eja.0000000000001065] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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13
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Hussain N, Costache I, Kumar N, Essandoh M, Weaver T, Wong P, Tierney S, Rose P, McCartney CJL, Abdallah FW. Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis. Anesth Analg 2020; 130:1304-1319. [PMID: 32102013 DOI: 10.1213/ane.0000000000004692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Interscalene block (ISB) is the acute pain management technique of choice for shoulder surgery, but its undesirable respiratory side effects have prompted seeking alternatives. Supraclavicular block (SCB) is proposed as an ISB alternative, but evidence of comparative analgesic and respiratory-sparing effects is inconsistent. We compared the analgesic and respiratory effects of SCB and ISB for shoulder surgery. METHODS Trials comparing ISB to SCB for shoulder surgery were sought. We decided a priori that SCB would be an acceptable alternative if it were noninferior for (1) postoperative 24-hour cumulative oral morphine equivalent consumption (primary outcome, noninferiority margin Δ = -25 mg) and (2) postoperative pain (secondary outcome, noninferiority margin Δ = 4.0 cm·hour); and superior for (3) postblock respiratory dysfunction (primary outcome). Opioid-related side effects and block-related complications were also evaluated. RESULTS Fifteen studies (1065 patients) were analyzed. In single-injection blocks, SCB was noninferior to ISB for 24-hour morphine consumption (mean difference for SCB-ISB, MD [95% confidence interval {CI}] = -3.11 mg [-9.42 to 3.19], Δ = -25 mg); it was also noninferior for 24-hour pain scores (MD = 0.78 cm·hour [0.07-1.49], Δ = 4.0 cm·hour); and decreased the odds of respiratory dysfunction (odds ratio [OR] [95% CI] = 0.08 [0.01-0.68]). Similarly, in continuous blocks, SCB was noninferior to ISB for 24-hour morphine consumption (MD = 0.46 mg [-6.08 to 5.15], Δ = -25 mg), and decreased the odds of respiratory dysfunction (OR = 0.22 [0.08-0.57]). SCB also decreased odds of minor block-related complications (OR = 0.36 [0.20-0.68] and OR = 0.25 [0.15-0.41] for single-injection and continuous blocks, respectively). Consequently, the null joint-hypothesis was rejected, and SCB can be considered an acceptable alternative to ISB. CONCLUSIONS For acute pain control following shoulder surgery, high-quality evidence indicates that SCB can be used as an effective ISB alternative. SCB is noninferior for postoperative opioid consumption and acute pain, and it reduces the odds of postblock respiratory dysfunction.
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Affiliation(s)
- Nasir Hussain
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Ioana Costache
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicolas Kumar
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio.,Faculty of Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Michael Essandoh
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Tristan Weaver
- From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Patrick Wong
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Tierney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Rose
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.,Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Sconfienza LM, Adriaensen M, Albano D, Allen G, Aparisi Gómez MP, Bazzocchi A, Beggs I, Bignotti B, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gielen J, Gitto S, Gupta H, Klauser AS, Lalam R, Martin S, Martinoli C, Mauri G, McCarthy C, McNally E, Melaki K, Messina C, Mirón Mombiela R, Neubauer B, Obradov M, Olchowy C, Orlandi D, Gonzalez RP, Rutkauskas S, Snoj Z, Tagliafico AS, Talaska A, Vasilevska-Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Plagou A. Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb. Eur Radiol 2019; 30:1498-1506. [PMID: 31712960 DOI: 10.1007/s00330-019-06479-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/30/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence. METHODS An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed. RESULTS Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%). CONCLUSIONS This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus. KEY POINTS • An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy.
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy.
| | - Miraude Adriaensen
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, Heerlen, Brunssum, Kerkrade, The Netherlands
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, 90127, Palermo, Italy
| | - Georgina Allen
- St Luke's Radiology Oxford Ltd, Oxford, UK
- University of Oxford, Oxford, UK
| | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, 1023, New Zealand
- Department of Radiology, Hospital Vithas Nueve de Octubre, 46015, Valencia, Spain
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Ian Beggs
- Department of Radiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | | | - Vito Chianca
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
| | - Angelo Corazza
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Danoob Dalili
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Miriam De Dea
- UOC Radiologia, Ospedale di Feltre, AULSS1 Dolomiti, Veneto, Italy
| | - Jose Luis Del Cura
- Department of Radiology, Donostia University Hospital, 20014, Donostia/San Sebastian, Spain
- University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Francesco Di Pietto
- Dipartimento di Diagnostica per Immagini, Pineta Grande Hospital, Castel Volturno, (CE), Italy
| | - Eleni Drakonaki
- Private Institution of Ultrasonography and MSK Radiology, Heraklion, Greece
- Department of Anatomy, Medical School of the European University of Cyprus, Engomi, Cyprus
| | - Fernando Facal de Castro
- IBERORAD 1895 S.L., 08021, Barcelona, Spain
- Department of Radiology, General University Hospital of Valencia, Valencia, Spain
| | - Dimitrios Filippiadis
- 2nd Department of Radiology, University General Hospital "ATTIKON" Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan Gielen
- University of Antwerp, Antwerp, Belgium
- University of Antwerp Hospital (UZA), Edegem, Belgium
| | | | | | - Andrea S Klauser
- Medical University Innsbruck, Innsbruck, Austria
- Department of Radiology, Innsbruck, Austria
| | - Radhesh Lalam
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, UK
| | - Silvia Martin
- Hospital Son Llatzer, Palma de Mallorca, Spain
- Universidad de las Islas Baleares Medicine, Palma, Balearic Islands, Spain
| | - Carlo Martinoli
- Ospedale Policlinico San Martino, 16132, Genoa, Italy
- University of Genoa - DISSAL Department of Health Sciences, Genoa, Italy
| | - Giovanni Mauri
- Division of Interventional Radiology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Catherine McCarthy
- The Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
- Oxford Musculoskeletal Radiology, Oxford, UK
| | | | - Kalliopi Melaki
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy
| | - Rebeca Mirón Mombiela
- Department of Physiology, Universidad de Valencia/INCLIVA, 46010, Valencia, Spain
- Herlev og Gentofte Hospital Radiologisk Afdeling, Herlev Ringvej 75, opgang 51, Herlev, Denmark
| | - Benedikt Neubauer
- Radiology, Medical University of Vienna, Vienna, Austria
- Ordensklinikum Linz, Linz, Austria
| | - Marina Obradov
- Sint Maartenskliniek, 9011, Nijmegen, 6500GM, The Netherlands
| | - Cyprian Olchowy
- Department of Oral Surgery, Wroclaw Medical University, Wrocław, Poland
| | | | | | - Saulius Rutkauskas
- Radiology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ziga Snoj
- Department of Radiology, University Medical Centre Ljubljana, Zaloška 7, Ljubljana, 1000, Slovenia
| | - Alberto Stefano Tagliafico
- Ospedale Policlinico San Martino, 16132, Genoa, Italy
- Department of Health Sciences, University of Genoa, 16132, Genoa, Italy
| | | | - Violeta Vasilevska-Nikodinovska
- Medical Faculty, University "Ss.Cyril and Methodius", Skopje, North Macedonia
- University Surgical Clinic "St.Naum Ohridski", Skopje, North Macedonia
| | - Jelena Vucetic
- Department of Radiology, General University Hospital of Valencia, Valencia, Spain
- Department of Physiology, Universidad de Valencia/INCLIVA, 46010, Valencia, Spain
| | - David Wilson
- St Luke's Radiology Oxford Ltd, Oxford, UK
- University of Oxford, Oxford, UK
| | - Federico Zaottini
- University of Genoa - DISSAL Department of Health Sciences, Genoa, Italy
| | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
- Varelli Institute, Naples, Italy
| | - Athena Plagou
- Department of Radiology, Private Institution of Ultrasonography, Athens, Greece
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15
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Abstract
Abstract
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 < 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.
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16
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Cros Campoy J, Domingo Bosch O, Pomés J, Lee J, Fox B, Sala-Blanch X. Upper trunk block for shoulder analgesia with potential phrenic nerve sparing: a preliminary anatomical report. Reg Anesth Pain Med 2019; 44:rapm-2019-100404. [PMID: 31118281 DOI: 10.1136/rapm-2019-100404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/02/2019] [Accepted: 05/08/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Ipsilateral phrenic nerve palsy (PNP) is an undesirable side of conventional approaches to interscalene brachial plexus blocks. The purpose of this study was to demonstrate whether or not the phrenic nerve can be spared by dye when injected at the division of the upper trunk of the brachial plexus. METHODS Under ultrasound guidance, 5 mL of radiolabeled dye was injected between the anterior and posterior division of the upper trunk in two fresh, cryopreserved cadavers. CT scan analysis, cadaveric dissection, and cryosectioning were performed to examine the spread of the injectate. RESULTS We found staining of the injectate over the entire upper trunk with its anterior and posterior divisions, the suprascapular nerve under the omohyoid muscle and the lateral pectoralis nerve, and the C5 and C6 roots. The middle trunk was partially stained. There was no evidence of dye staining of the lower trunk, anterior aspect of the anterior scalene muscle, or the phrenic nerve. CONCLUSIONS Our study offers an anatomical basis for the possibility of providing shoulder analgesia and avoiding a PNP.
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Affiliation(s)
- José Cros Campoy
- Anesthesia, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Jaume Pomés
- Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jing Lee
- Anesthesia, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Ben Fox
- Anaesthesia, Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Xavier Sala-Blanch
- Anesthesia, Hospital Clinic de Barcelona, Barcelona, Spain
- Human Anatomy and Embriology, Universitat de Barcelona, Barcelona, Spain
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17
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Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ 2019; 19:98-104. [PMID: 33456877 DOI: 10.1016/j.bjae.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- D W Hewson
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK
| | - M Oldman
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - N M Bedforth
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK
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18
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Selvi O, Tulgar S, Ozer Z. Case Report Presentation of Ultrasound-guided Erector Spinae Plane Block in Shoulder Surgery: Three Patients and Two Different Results. Cureus 2018; 10:e3538. [PMID: 30648071 PMCID: PMC6318083 DOI: 10.7759/cureus.3538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Erector spinae block (ESPB) is an effective therapy for chronic shoulder pain. However, ESPB has not been used as a postoperative analgesia method in shoulder surgeries. In this case report, we report three patients undergoing shoulder surgeries that received ESPB preoperatively for postoperative analgesia. All patients had relief of preoperative pain and no associated motor block. Two of the patients manifested with low maximum pain scores (4/10, 3/10) on a numeric rating scale (NRS). The other patient reported a maximum pain score of 8/10 on NRS. While this patient's shoulder mobility immediately improved after ESPB application, the ESPB did not provide adequate analgesia for the postoperative period. The use of the ESPB for acute postoperative analgesia after shoulder surgery is novel and clinically interesting. However, postoperative analgesia was not completely opioid-sparing. Consequently, the efficiency of ESPB at the level of T2 for postoperative analgesia should be considered for surgeries that involve the shoulder cap given the possible inadequate migration of local anesthetic into the cervical plexus. Clinicians should carefully consider an ESPB as a postoperative analgesic option when considering shoulder operations and the possibility for the incomplete spread of local anesthetic in targeted neural structures.
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Affiliation(s)
- Onur Selvi
- Aneasthesiology, Maltepe University Faculty of Medicine, Istanbul, TUR
| | - Serkan Tulgar
- Anaesthesiology, Maltepe University Faculty of Medicine, Istanbul, TUR
| | - Zeliha Ozer
- Anaesthesiology, Maltepe University Faculty of Medicine, Istanbul, TUR
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