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Litz RJ, Feigl GC, Radny D, Weiß T, Schwarzkopf P, Mäcken T. Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:233. [PMID: 38399521 PMCID: PMC10890524 DOI: 10.3390/medicina60020233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/20/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
| | - Georg C. Feigl
- Institute of Anatomy, University of Witten/Herdecke, 58455 Witten, Germany;
| | - Daniel Radny
- Department of Anaesthesiology and Intensive Care Medicine, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany;
| | - Thomas Weiß
- Department of Anesthesia and Intensive Care Medicine, Thurgau Cantonal Hospital, 8596 Münsterlingen, Switzerland;
| | - Peter Schwarzkopf
- Clinic for Anesthesiology, Intensive Care, Palliative and Pain Medicine, Sana Hospital Leipziger Land, 04552 Borna, Germany;
| | - Tim Mäcken
- Department of Anaesthesiology, Intensive Care and Pain Medicine, BG University Hospital Bergmannsheil, 44789 Bochum, Germany
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Bloc du plexus brachial pour la chirurgie de l’épaule. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Muacevic A, Adler JR, Koyuncu Ö, Gurkan Y, Erçelen Ö. The Minimum Effective Analgesic Volume of 0.5% Bupivacaine for Ultrasound-Guided Anterior Suprascapular Nerve Block. Cureus 2022; 14:e31350. [PMID: 36514616 PMCID: PMC9741702 DOI: 10.7759/cureus.31350] [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: 11/10/2022] [Indexed: 11/12/2022] Open
Abstract
Objective The interscalene brachial plexus block (ISBB) constitutes the gold standard for analgesia after shoulder procedures. Ipsilateral phrenic nerve block remains the most common adverse effect after ISBB. Alternative nerve blocks are performed in shoulder surgery in order to prevent hemi-diaphragmatic paralysis (HDP). The purpose of the present study was to investigate the minimum effective local anesthetic volume of 0.5% bupivacaine for postoperative analgesia with an anterior suprascapular nerve block (ASSB). The secondary aim was to investigate diaphragm functions with the local anesthetic doses used while conducting effective volume research. Method This prospective observational study was conducted at the American Hospital of Istanbul, Turkey, from March to July 2022. The initial injected volume of 0.5% bupivacaine was 10 ml. Our clinical experience indicates that this yields a complete sensory block of the anterior suprascapular nerve. In accordance with the up-and-down method, the volume of 0.5% bupivacaine used for a particular patient was determined by the outcome of the preceding block, which represented block success. In case of effective ASSB being achieved, the volume of 0.5% bupivacaine to be administered to the next patient was lowered by 1 ml. In case of block failure, however, the volume of 0.5% bupivacaine to be applied in the subsequent case was increased by 1 ml. Ipsilateral hemi-diaphragmatic movement measurements were taken before (baseline) and 30 minutes after the block. General anesthesia was induced 60 minutes after the completion of the block performance by means of a standardized protocol. Results Sixty-seven patients were included in the study. The ED50 and ED95 calculated for anterior suprascapular nerve block using probit transformation and logistic regression analysis were 2.646 (95% CI, 0.877-2.890) and 3.043 ml (95% CI, 2.771-4.065), respectively. When complete paralysis was defined as 75% or above, partial paralysis as 25-50%, and no paralysis as 25% or less, volumes of 6 ml or lower appeared to cause no paralysis for the anterior suprascapular nerve block. Conclusion We, therefore, recommend using a volume of 6 ml or less in order to achieve diaphragm-sparing features for anterior suprascapular nerve blocks.
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Marhofer P, Harkanyi A, Hopkins PM. Regional anesthesia for shoulder surgery. Minerva Anestesiol 2022; 88:629-634. [PMID: 35164494 DOI: 10.23736/s0375-9393.22.16295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Regional anaesthesia should be the preferred technique for analgesia in shoulder surgery, which is a frequent procedure in the daily practice of anaesthesiologists. The use of ultrasound guidance enables the visualization of the relevant nerve structures and the adjacent anatomical details. Low volumes of local anaesthetics reduce the incidence of inadvertent blockade of the phrenic nerve with subsequent respiratory impairment. The additional administration of dexmedetomidine to local anaesthetics prolonges the duration of analgesia with a minimal increased incidence of haemodynamic side effects. An optimal workflow is associated with economical advantages due to an improved use of operation rooms. Attention have to be paid regarding intraoperative hypotension, cerebral hypoperfusion and complications due to positioning.
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Affiliation(s)
- Peter Marhofer
- Department of Anaesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria - .,Department of Anaesthesiology, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria -
| | - Arpad Harkanyi
- Department of Anaesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
| | - Phil M Hopkins
- Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Minimum effective volume of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block in preschool-age children. Sci Rep 2021; 11:17002. [PMID: 34417524 PMCID: PMC8379224 DOI: 10.1038/s41598-021-96582-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022] Open
Abstract
Ultrasound-guided axillary brachial plexus block is increasingly used in preschool-age patients. However, the minimum effective volume of local anaesthetics has not been determined. With ethical committee approval and written informed consent from the guardians of all paediatric patients, we studied 27 consecutive patients aged 3 to 6 years who were scheduled for hand surgery. After general anaesthesia, eligible patients received a set volume of ultrasound-guided axillary brachial plexus block. We determined the volume of 0.2% ropivacaine for consecutive patients from the preceding patient's outcome. The initial volume was 0.4 ml/kg. The testing interval was set at 0.05 ml/kg, and the lowest volume was 0.1 ml/kg. The following conditions were defined as a successful block: no heart rate changes, body movement, or ventilatory disorders during the operation; no use of fentanyl in the PACU; and a postoperative sensory block score < 3. The sequences of positive and negative blocks in consecutive patients were recorded. Using probit regression analysis, the 50% effective volume was 0.185 ml/kg (95% CI 0.123-0.234), and the 95% effective volume was 0.280 ml/kg (95% CI 0.232-0.593). EV50 and EV95 values of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block were 0.185 ml/kg and 0.280 ml/kg, respectively.
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Oliver-Fornies P, Ortega Lahuerta JP, Gomez Gomez R, Gonzalo Pellicer I, Oliden Gutierrez L, Viñuales Cabeza J, Gallego Ligorit L, Orellana Melgar CE. 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. Trials 2021; 22:287. [PMID: 33874993 PMCID: PMC8053891 DOI: 10.1186/s13063-021-05216-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
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).
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Affiliation(s)
- P Oliver-Fornies
- Morphological Madrid Research Center Investigator, Department of Anesthesiology, Critical Care and Pain Management, Lozano Blesa University Clinical Hospital, Aragon Institute for Health Research, Avda. San Juan Bosco, 15 50009, Zaragoza, Spain.
| | - J P Ortega Lahuerta
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Zaragoza, Spain
| | - R Gomez Gomez
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Zaragoza, Spain
| | - I Gonzalo Pellicer
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Zaragoza, Spain
| | - L Oliden Gutierrez
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Zaragoza, Spain
| | - J Viñuales Cabeza
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Zaragoza, Spain
| | - L Gallego Ligorit
- Department of Anesthesiology, Critical Care and Pain Management, Miguel Servet University Hospital, Aragon Institute for Health Research, Zaragoza, Spain
| | - C E Orellana Melgar
- Department of Pneumology, Miguel Servet University Hospital, Zaragoza, Spain
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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. Anesth Analg 2021; 132:1129-1137. [PMID: 33464760 DOI: 10.1213/ane.0000000000005373] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Vadagandla K, Jahagirdar V, Rama K, Qavi D. Minimum Effective Volume of 0.75% Ropivacaine for Ultrasound-Guided Axillary Brachial Plexus Block. Cureus 2020; 12:e12229. [PMID: 33409105 PMCID: PMC7779144 DOI: 10.7759/cureus.12229] [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] [Indexed: 11/17/2022] Open
Abstract
Background Ultrasound-guided peripheral nerve block provides direct visualization of nerve and reduces the complications associated with classical landmark guided technique, by reducing the dosage of local anesthetic drugs. This study aims to determine the minimum effective volume (MEAV) of 0.75% ropivacaine for ultrasound-guided axillary brachial plexus block. Methodology A total of 23 patients of age group 18-75 years belonging to ASA grade 1, 2, and 3 were selected based on inclusion criteria. The MEAV was determined by using Dixons & Massey Step-up and Step-down method. The initial volume was selected as 15 mL based on previous studies. Depending on block success or failure, 1 mL of the drug was decreased or increased. Block was assessed in terms of motor and sensory components. The study was aborted after attaining five cases of block failure, followed by five cases of a successful block. Results The MEAV to be given for a successful block in 50% of patients (MEAV50) was 8.62 mL (95%CI 3.54-9.89). The MEAV to be given for a successful block in 90% of patients (MEAV 90) was 11.82 mL (95% CI 9.9-75.7). Conclusion Ultrasound guidance reduces the dosage of local anesthetic drugs to be used and provides surgical anesthesia without any complications or adverse effects.
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Affiliation(s)
| | - Vinay Jahagirdar
- Internal Medicine, Gandhi Medical College and Hospital, Secunderabad, IND
| | - Kaanthi Rama
- Internal Medicine, Gandhi Medical College and Hospital, Secunderabad, IND
| | - Danish Qavi
- Internal Medicine, Eras Lucknow Medical College, Lucknow, IND
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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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Chadha M, Si S, Bhatt D, Krishnan S, Kumar R, Bansal A, Sharma AK. 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. Anesth Essays Res 2020; 14:87-91. [PMID: 32843799 PMCID: PMC7428099 DOI: 10.4103/aer.aer_4_20] [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: 01/12/2020] [Revised: 01/19/2020] [Accepted: 02/17/2020] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Mamta Chadha
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Saibal Si
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Devika Bhatt
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Sushil Krishnan
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Rakesh Kumar
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Ashok Bansal
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
| | - Anil Kumar Sharma
- Department of Anesthesia, Northern Railway Central Hospital, New Delhi, India
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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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Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery. Anesthesiology 2020; 132:839-853. [DOI: 10.1097/aln.0000000000003132] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background
Interscalene brachial plexus block, the pain relief standard for shoulder surgery, is an invasive technique associated with important complications. The subomohyoid anterior suprascapular block is a potential alternative, but evidence of its comparative analgesic effect is sparse. The authors tested the hypothesis that anterior suprascapular block is noninferior to interscalene block for improving pain control after shoulder surgery. As a secondary objective, the authors evaluated the success of superior trunk (C5–C6 dermatomes) block with suprascapular block.
Methods
In this multicenter double-blind noninferiority randomized trial, 140 patients undergoing shoulder surgery were randomized to either interscalene or anterior suprascapular block with 15 ml of ropivacaine 0.5% and epinephrine. The primary outcome was area under the curve of postoperative visual analog scale pain scores during the first 24 h postoperatively. The 90% CI for the difference (interscalene-suprascapular) was compared against a –4.4-U noninferiority margin. Secondary outcomes included presence of superior trunk blockade, pain scores at individual time points, opioid consumption, time to first analgesic request, opioid-related side-effects, and quality of recovery.
Results
A total of 136 patients were included in the analysis. The mean difference (90% CI) in area under the curve of pain scores for the (interscalene-suprascapular) comparison was –0.3 U (–0.8 to 0.12), exceeding the noninferiority margin of –4.4 U and demonstrating noninferiority of suprascapular block. The risk ratio (95% CI) of combined superior trunk (C5–C6 dermatomes) blockade was 0.98 (0.92 to 1.01), excluding any meaningful difference in superior trunk block success rates between the two groups. When differences in other analgesic outcomes existed, they were not clinically important.
Conclusions
The suprascapular block was noninferior to interscalene block with respect to improvement of postoperative pain control, and also for blockade of the superior trunk. These findings suggest that the suprascapular block consistently blocks the superior trunk and qualify it as an effective interscalene block alternative.
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Gritsenko K, Polshin V, Agrawal P, Nair S, Shaparin N, Gruson K, Tan-Geller M. Incidence of vocal cord paresis following ultrasound-guided interscalene nerve block: An observational cohort study. Best Pract Res Clin Anaesthesiol 2019; 33:553-558. [PMID: 31791570 DOI: 10.1016/j.bpa.2019.05.006] [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: 05/08/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Interscalene brachial plexus block (IBPB) has become a standard practice for perioperative analgesia for shoulder procedures. However, several side effects may occur owing to its anatomic location. We have chosen to evaluate vocal cord paresis and dysphonia following interscalene blocks. METHODS After IRB approval, eight patients undergoing arthroscopic shoulder procedures were recruited into this prospective cohort study. Following informed consent, vocal cords were assessed by standardized fiberoptic evaluation. Subsequently, IBPB was performed under ultrasound (US) guidance. Patients were re-evaluated for vocal cord changes by a repeat fiberoptic assessment one hour following IBPB. Our primary outcome measure was incidence of vocal cord immobility. RESULTS No patients had diminished vocal cord motion, dysphonia, or dysphagia. CONCLUSIONS Although larger studies are required to determine the true incidence of vocal cord paresis following US-guided IBPB, our results suggest that incidence of unwanted nerve blockade other than brachial plexus is much lower than that previously described.
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Affiliation(s)
- Karina Gritsenko
- Department of Anesthesiology and Pain Management, Montefiore Medical Center, 1250 Waters Pl, Tower II, 8th Floor, Bronx, 10461, NY, USA
| | - Victor Polshin
- Department of Anesthesiology and Perioperative Medicine, UMASS Memorial Medical Center, 119 Belmont St, Worcester, 01605, MA USA.
| | - Priya Agrawal
- Department of Anesthesiology and Pain Management, Montefiore Medical Center, 1250 Waters Pl, Tower II, 8th Floor, Bronx, 10461, NY, USA.
| | - Singh Nair
- Department of Anesthesiology and Pain Management, Montefiore Medical Center, 1250 Waters Pl, Tower II, 8th Floor, Bronx, 10461, NY, USA
| | - Naum Shaparin
- Department of Anesthesiology and Pain Management, Montefiore Medical Center, 1250 Waters Pl, Tower II, 8th Floor, Bronx, 10461, NY, USA
| | - Konrad Gruson
- Department of Orthopedics, Department of Anesthesiology and Pain Management, Montefiore Medical Center, 1250 Waters Pl, 11th Floor, Suite B, Bronx, 10461, NY, USA.
| | - Melin Tan-Geller
- Department of Otolaryngology, Montefiore Medical Center, 222 Bloomingdale Rd, Suite 205, White Plains, 10605, Bronx, NY, USA.
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Tran DQ, Layera S, Bravo D, Cristi-Sanchéz I, Bermudéz L, Aliste J. Diaphragm-sparing nerve blocks for shoulder surgery, revisited. Reg Anesth Pain Med 2019; 45:rapm-2019-100908. [PMID: 31541010 DOI: 10.1136/rapm-2019-100908] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/28/2019] [Accepted: 09/04/2019] [Indexed: 12/21/2022]
Abstract
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%.
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Affiliation(s)
- De Q Tran
- Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Sebastián Layera
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Daniela Bravo
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Iver Cristi-Sanchéz
- Escuela de Kinesiología, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
| | - Loreley Bermudéz
- Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
| | - Julián Aliste
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
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Barrington MJ, Uda Y. Did ultrasound fulfill the promise of safety in regional anesthesia? Curr Opin Anaesthesiol 2018; 31:649-655. [DOI: 10.1097/aco.0000000000000638] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oxlund J, Clausen AH, Venø S, Nielsen MD, Pall M, Strøm T, Toft P. A randomized trial of automated intermittent ropivacaine administration vs. continuous infusion in an interscalene catheter. Acta Anaesthesiol Scand 2018; 62:85-93. [PMID: 29034961 DOI: 10.1111/aas.13011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/23/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ultrasound-guided interscalene nerve block with ropivacaine as local anesthetic agent given as boluses or continuous infusion is the preferred pain management after major shoulder surgery. The use of automated intermittent boluses has been shown to be superior to continuous infusion in sciatic and epidural nerve block. HYPOTHESIS Automated intermittent boluses reduce pain after major shoulder surgery. METHODS Seventy patients aged 18-75 years, scheduled for major shoulder surgery under general anesthesia with interscalene nerve block were included in this randomized controlled trial. Patients were allocated to either automated intermittent boluses with 16 mg ropivacaine every 2 h combined with patient-controlled administration or to a conventional regimen of continuous infusion of 8 mg/h (4 ml/h) of ropivacaine combined with patient controlled administration (2 ml, lockout time 30 min). Pain (Visual Analog Scale, VAS) was assessed every 8 h postoperatively. RESULTS Fifty-seven patients completed the study, 29 in the continuous infusion group and 28 in the automated intermittent bolus group. Shoulder arthroplasty was performed in 49 (86%) of the cases. There were no significant differences in VAS score from 8 to 48 h post-operatively. No significant difference in opioid usage was observed. The automated intermittent bolus group reported significantly less force on coughing and more hoarseness. A significantly lower volume of ropivacaine was used in the automated intermittent bolus group. CONCLUSION Automated intermittent boluses did not reduce pain or rescue opioid consumption compared with continuous infusion of ropivacaine. The automated intermittent bolus group had significantly less force on coughing and more hoarseness.
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Affiliation(s)
- J. Oxlund
- Department of Anesthesiology; South West Jutland Hospital; Esbjerg Denmark
| | - A. H. Clausen
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
| | - S. Venø
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
| | - M. D. Nielsen
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
| | - M. Pall
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
| | - T. Strøm
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
| | - P. Toft
- Department of Anesthesiology; Odense University Hospital; Odense Denmark
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López Escárraga VM, Dubos España K, Castillo Bustos RH, Peidró L, Sastre S, Sala-Blanch X. Diaphragmatic thickness ratio (inspiratory/expiratory) as a diagnostic method of diaphragmatic palsy associated with interescalene block. ACTA ACUST UNITED AC 2017; 65:81-89. [PMID: 29126611 DOI: 10.1016/j.redar.2017.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Diaphragmatic paralysis is a side-effect associated with interscalene block. Thickness index of the diaphragm muscle (inspiratory thickness/expiratory thickness) obtained by ultrasound has recently been introduced in clinical practice for diagnosis of diaphragm muscle atrophy. Our objective was to evaluate this index for the diagnosis of acute phrenic paresis associated with interscalene block. PATIENTS AND METHODS We designed an observational study in 22 patients scheduled for shoulder arthroscopy. Spirometry was performed (criteria of phrenic paresis was a decrease in FVC and FEV1 ≥20%). Ultrasound apposition zone was assessed in anterior axillary line and diaphragmatic displacement was evaluated on inspiration and expiration (number of intercostal spaces; phrenic paresis considered a reduction ≥25%) and thickness of the diaphragm muscle (a phrenic paresis was considered an index <1.2). These determinations were performed before and at 20min after interscalene block at C5-C6 with 20ml of 0.5% ropivacaine. RESULTS Twenty-one patients (95%) presented phrenic nerve block according to one or more of the methods used. One patient did not show any symptoms or signs suggestive of phrenic paralysis and was excluded. All the patients presented phrenic paresis based on the diaphragmatic thickness index, with the pre-block index being 1.8±0.5 and post-block of 1.05±0.06 (P<0.001). Ninety percent of the patients (19) presented phrenic paresis according to spirometry and all the patients had a reduction in diaphragmatic movement after the block (from 1.9±0.5 intercostal spaces to 0.5±0.3; P<0.001). CONCLUSION The index of inspiratory / expiratory diaphragmatic thickness at cut-off <1.2 seems to be useful in the diagnosis of phrenic paresis associated with interscalene block. This index does not require a baseline pre-assessment.
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Affiliation(s)
- V M López Escárraga
- Anestesiología, Fellow de Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | - K Dubos España
- Anestesiología, Fellow de Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | - R H Castillo Bustos
- Anestesiología, Fellow de Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | - L Peidró
- Ortopedia y Traumatología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - S Sastre
- Ortopedia y Traumatología, Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - X Sala-Blanch
- Anestesiología, Hospital Clinic, Barcelona, España; Departamento de Anatomía y Embriología Humana, Facultad de Medicina, Universitat de Barcelona, Barcelona, España.
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Musso D, Flohr-Madsen S, Meknas K, Wilsgaard T, Ytrebø LM, Klaastad Ø. A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery. Acta Anaesthesiol Scand 2017; 61:1192-1202. [PMID: 28776638 DOI: 10.1111/aas.12948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/02/2017] [Accepted: 07/02/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Interscalene brachial plexus block is currently the gold standard for intra- and post-operative pain management for patients undergoing arthroscopic shoulder surgery. However, it is associated with block related complications, of which effect on the phrenic nerve have been of most interest. Side effects caused by general anesthesia, when this is required, are also a concern. We hypothesized that the combination of superficial cervical plexus block, suprascapular nerve block, and infraclavicular brachial plexus block would provide a good alternative to interscalene block and general anesthesia. METHODS Twenty adult patients scheduled for arthroscopic shoulder surgery received a combination of superficial cervical plexus block (5 ml ropivacaine 0.5%), suprascapular nerve block (4 ml ropivacaine 0.5%), and lateral sagittal infraclavicular block (31 ml ropivacaine 0.75%). The primary aim was to find the proportion of patients who could be operated under light propofol sedation, without the need for opioids or artificial airway. Secondary aims were patients' satisfaction and surgeons' judgment of the operating conditions. RESULTS Nineteen of twenty patients (95% CI: 85-100) underwent arthroscopic shoulder surgery with light propofol sedation, but without opioids or artificial airway. The excluded patient was not comfortable in the beach chair position and therefore received general anesthesia. All patients were satisfied with the treatment on follow-up interviews. The surgeons rated the operating conditions as good for all patients. CONCLUSION The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery.
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Affiliation(s)
- D. Musso
- Department of Anesthesiology; University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - S. Flohr-Madsen
- Department of Anesthesiology; Sykehuset Sørlandet; Kristiansand Norway
| | - K. Meknas
- Department of Orthopedic Surgery; University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - T. Wilsgaard
- Department of Community Medicine; UiT-The Arctic University of Norway; Tromsø Norway
| | - L. M. Ytrebø
- Department of Anesthesiology; University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - Ø. Klaastad
- Department of Anesthesiology; University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
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Abstract
Abstract
Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients. The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context. They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The most important of these include limiting local anesthetic dose and injection volume and performing the injection further away from the C5–C6 nerve roots. Targeting peripheral nerves supplying the shoulder, such as the suprascapular and axillary nerves, may be an effective alternative to brachial plexus blockade in selected patients. The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article.
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Silva MPDA, Matsui C, Kim DD, Vieira JE, Malheiros CA, Mathias LAST. Sugammadex ED90 dose to reverse the rocuronium neuromuscular blockade in obese patients. Rev Col Bras Cir 2017; 44:41-45. [PMID: 28489210 DOI: 10.1590/0100-69912017001010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 10/11/2016] [Indexed: 12/18/2022] Open
Abstract
Objective to determine the ED90 (minimum effective dose in 90% of patients) of sugammadex for the reversal of rocuronium-induced moderate neuromuscular blockade (NMB) in patients with grade III obesity undergoing bariatric surgery. Methods we conducted a prospective study with the biased coin up-and-down sequential design. We chosen the following doses: 2.0mg/Kg, 2.2mg/Kg, 2.4mg/Kg, 2.6mg/Kg, 2.8mg/Kg. The complete reversal of rocuronium-induced NMB considered a T4/T1 ratio ≥0.9 as measured by TOF. After induction of general anesthesia and calibration of the peripheral nerve stimulator and accelerometer, we injected rocuronium 0.6mg/kg. We administered propofol and remifentanil by continuous infusion, and intermittent boluses of rocuronium throughout the procedure. Results we evaluated 31 patients, of whom 26 had displayed successful reversal of the NMB with sugammadex, and failure in five. The mean time to complete moderate NMB reversal was 213 seconds (172-300, median 25-75%). The ED90 of sugammadex calculated by regression was 2.39mg/kg, with a 95% confidence interval of 2.27-2.46 mg/kg. Conclusion the ED90 of sugammadex in patients with grade III obesity or higher was 2.39mg/kg.
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Affiliation(s)
- Mauro Prado DA Silva
- - Central Hospital, Brotherhood of the Santa Casa de Misericórdia de São Paulo, Sevice of Anesthesiology, Sao Paulo, São Paulo State, Brazil
| | - Christiano Matsui
- - Central Hospital, Brotherhood of the Santa Casa de Misericórdia de São Paulo, Sevice of Anesthesiology, Sao Paulo, São Paulo State, Brazil
| | - Daniel Dongiou Kim
- - Central Hospital, Brotherhood of the Santa Casa de Misericórdia de São Paulo, Sevice of Anesthesiology, Sao Paulo, São Paulo State, Brazil
| | - Joaquim Edson Vieira
- - Faculty of Medicine, University of São Paulo, Service of Anesthesiology, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
| | - Carlos Alberto Malheiros
- - Central Hospital, Brotherhood of the Santa Casa de Misericórdia de São Paulo, Sevice of Anesthesiology, Sao Paulo, São Paulo State, Brazil
| | - Ligia Andrade Silva Telles Mathias
- - Central Hospital, Brotherhood of the Santa Casa de Misericórdia de São Paulo, Sevice of Anesthesiology, Sao Paulo, São Paulo State, Brazil
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Choi S, Wang JJ, Awad IT, McHardy P, Safa B, McCartney CJ. The minimal effective volume (MEAV 95) for interscalene brachial plexus block for surgical anesthesia under sedation: A prospective observational dose finding study. Can J Pain 2017; 1:8-13. [PMID: 35005337 PMCID: PMC8730609 DOI: 10.1080/24740527.2017.1304805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Interscalene brachial plexus (ISB) block is routinely used to provide anesthesia and analgesia for shoulder surgery. Traditional local anesthetic volumes for ISB result in near universal ipsilateral phrenic nerve paresis potentially including oxygenation and ventilation. Aims: The purpose of this study was to determine the lowest minimal effective anesthetic volume in 95% of patients (MEAV 95) of ropivacaine 0.75% for ISB that provides surgical anesthesia for arthroscopic shoulder surgery. Methods: Prospective observational cohort study in patients undergoing arthroscopic shoulder surgery under ISB (C6 level) with sedation. The dose finding protocol used the Narayana rule for up/down sequential allocation to estimate the MEAV 95 of ropivacaine 0.75%. Successful ISB was defined as complete absence of pinprick sensation in the C5 and C6 dermatomes 30 min postblock. Secondary outcomes assessed included ability to complete surgery with propofol sedation, change in slow vital capacity, room air oxygen saturation postblock, block duration, ISB complications, and numeric rating scale for pain immediately after surgery. Results: The study was stopped early due to futility. Among 225 participants approached, 54 consented to participate. The MEAV 95 for ultrasound-guided ISB of ropivacaine 0.75% for shoulder surgery was unable to be accurately estimated. Local anesthetic volumes between 5 and 20 ml did not influence any of the predefined secondary outcomes. Conclusions: The MEAV 95 (at 30 min) of ropivacaine 0.75% for ultrasound-guided ISB exceeds the local anesthetic volumes that consistently produces hemidiaphragmatic impairment. ISB cannot be guaranteed to provide surgical anesthesia at 30 min without the potential for concomitant phrenic nerve block.
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Affiliation(s)
- Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jane J. Wang
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Imad T. Awad
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul McHardy
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ben Safa
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Colin J. McCartney
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
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Zhai W, Wang X, Rong Y, Li M, Wang H. Effects of a fixed low-dose ropivacaine with different volume and concentrations on interscalene brachial plexus block: a randomized controlled trial. BMC Anesthesiol 2016; 16:80. [PMID: 27716157 PMCID: PMC5045604 DOI: 10.1186/s12871-016-0248-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 09/14/2016] [Indexed: 12/04/2022] Open
Abstract
Background Ultrasound guidance has reduced the amount of local anesthetics to achieve a successful block. Previous studies of the relationship between the volume or concentration of local anesthetics and the effects of the block were based on relatively high doses of local anesthetics. We tested the hypothesis that providing low dose of ropivacaine at three combinations of volumes and concentrations for ultrasound-guided interscalene brachial plexus block would produce different effects in the aspect of onset time, pain control and the incidence of side effects. Methods Ninety-nine patients undergoing elective arthroscopic shoulder surgery were randomized to receive an ultrasound guided combined with nerve stimulator mediated interscalene block with ropivacaine 0.75 % (6.7 ml, Group 0.75), 0.5 % (10 ml, Group 0.5) or 0.25 % (20 ml, Group 0.25). The primary end point was the onset time of the sensory blockade, assessed by using a pinprick in the C5-6 dermatome. The secondary end points included the onset time of the motor blockade, block success rate, postoperative pain rating score, rescue analgesics requirement, sleep quality, strength of the hand on the block side,and the incidence of hemi-diaphragmatic paresis which was evaluated by ultrasonography. Results There was a statistically significant difference of the sensory block median onset times among Group 0.75 (5 min), Group 0.5 (10 min) and Group 0.25 (20 min). One patient in Group 0.5 and 20 patients in Group 0.25 did not achieve a complete motor block within 30 min, which were also significantly different. No significant difference was observed in postoperative analgesia, decrease of handgrip strength and the incidence of hemi-diaphragmatic paresis among the 3 groups. Conclusions This study demonstrates that ropivacaine 50 mg as 0.25, 0.5 or 0.75 % solution for interscalene brachial plexus block before arthroscopic shoulder surgery produces comparable blockade with few side effects, while 0.75 % seems to be more preferable as it is associated with faster onset time. Trial registration ChiCTR-TRC-13004058. Registered 4 December 2013.
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Affiliation(s)
- Wenwen Zhai
- Department of Anesthesiology, Peking University Third Hospital, No. 49, Hua Yuan North Street, Hai Dian District, Beijing, China
| | - Xuedong Wang
- Department of Anesthesiology, Peking University Third Hospital, No. 49, Hua Yuan North Street, Hai Dian District, Beijing, China
| | - Yulan Rong
- Department of Anesthesiology, Peking University Third Hospital, No. 49, Hua Yuan North Street, Hai Dian District, Beijing, China
| | - Min Li
- Department of Anesthesiology, Peking University Third Hospital, No. 49, Hua Yuan North Street, Hai Dian District, Beijing, China.
| | - Hong Wang
- Department of Anesthesiology, West Virginia University, 6245 Inkster Rd., Garden City, MI, 48135, USA.
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Wiesmann T, Feldmann C, Müller HH, Nentwig L, Beermann A, El-Zayat BF, Zoremba M, Wulf H, Steinfeldt T. Phrenic palsy and analgesic quality of continuous supraclavicular vs. interscalene plexus blocks after shoulder surgery. Acta Anaesthesiol Scand 2016; 60:1142-51. [PMID: 27098548 DOI: 10.1111/aas.12732] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 03/22/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hemidiaphragmatic palsy is a common consequence of the interscalene brachial plexus block. It occurs less commonly with the supraclavicular approach. Register data suggest that the analgesic quality of a supraclavicular blockade is sufficient for arthroscopic shoulder surgery, although data on the post-operative analgesic effect are lacking. METHODS After approval by the ethics committee, patients having arthroscopic shoulder surgery under general anaesthesia were randomized to receive a continuous interscalene or supraclavicular blockade. Phrenic nerve function was evaluated through ultrasound examination of the diaphragm in combination with spirometry. Pain scores at rest and activity etc. were determined before catheter insertion, during observation in the post- anaesthesia care unit (PACU) and on post-operative day 1 (POD1). The initial application of 10 ml of ropivacaine 0.2% was followed by continuous application of 4 ml of ropivacaine 0.2%, plus a patient controlled analgesia (PCA) bolus of 4 ml/h. RESULTS One hundred and twenty patients were randomized, of which 114 data sets were analysed. Complete hemidiaphragmatic paresis occurred in 43% of the interscalene group vs. 24% in the supraclavicular group during PACU stay. Rates of dyspnoea and hoarseness were similar. Horner's syndrome occurred in 21% of the interscalene but only 3% of the supraclavicular group on POD1. Pain scores were comparable for pain at rest and during stress at each time point. CONCLUSIONS This trial showed a significantly greater incidence of phrenic nerve palsy of the interscalene group in PACU, but not on POD1. Post-operative analgesic quality was similar in both groups. Continuous supraclavicular blockade is a suitable alternative to the continuous interscalene technique.
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Affiliation(s)
- T. Wiesmann
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - C. Feldmann
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - H. H. Müller
- Institute of Medical Biometry and Epidemiology; Philipps University; Marburg Germany
| | - L. Nentwig
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - A. Beermann
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - B. F. El-Zayat
- Center for Orthopedics and Trauma Surgery; University Hospital Giessen and Marburg; Marburg Germany
| | - M. Zoremba
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - H. Wulf
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
| | - T. Steinfeldt
- Department of Anesthesia and Intensive Care Medicine; University Hospital Giessen and Marburg; Marburg Germany
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Di Filippo A, Falsini S, Adembri C. Volume mínimo de anestésico em anestesia regional guiada por ultrassom. Braz J Anesthesiol 2016. [DOI: 10.1016/j.bjan.2014.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Minimum anesthetic volume in regional anesthesia by using ultrasound-guidance. Braz J Anesthesiol 2016; 66:499-504. [DOI: 10.1016/j.bjane.2014.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 05/06/2014] [Indexed: 11/21/2022] Open
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Careskey M, Naidu R. Continuous Suprascapular Nerve Block With a Perineural Catheter for Reverse Shoulder Arthroplasty Rescue Analgesia in a Patient With Severe Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2016; 7:37-40. [PMID: 27258178 DOI: 10.1213/xaa.0000000000000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Reverse open shoulder arthroplasty requires a comprehensive analgesic plan involving regional anesthesia. The commonly performed interscalene brachial plexus blockade confers a high likelihood of diaphragmatic paralysis via phrenic nerve palsy, making this option riskier in patients with limited pulmonary reserve. Continuous blockade of the suprascapular nerve, a more distal branch of the C5 and C6 nerve roots, may be a viable alternative. We report a successful case of the use of a suprascapular nerve block with continuous programmed intermittent bolus perineural analgesia in a patient with severe chronic obstructive pulmonary disease who underwent reverse open shoulder arthroplasty.
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Affiliation(s)
- Matthew Careskey
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
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Koh WU, Kim HJ, Park HS, Choi WJ, Yang HS, Ro YJ. A randomised controlled trial comparing continuous supraclavicular and interscalene brachial plexus blockade for open rotator cuff surgery. Anaesthesia 2016; 71:692-9. [DOI: 10.1111/anae.13419] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 11/28/2022]
Affiliation(s)
- W. U. Koh
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
| | - H. J. Kim
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
| | - H. S. Park
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
| | - W. J. Choi
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
| | - H. S. Yang
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
| | - Y. J. Ro
- Department of Anesthesiology and Pain Medicine; University of Ulsan; Asan Medical Center; Seoul Korea
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Kim JY, Song KS, Kim WJ, Park YH, Kang H, Woo YC, Shin HY. Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2016; 24:931-9. [PMID: 26063452 DOI: 10.1007/s00167-015-3667-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/29/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE Randomized controlled trials, Therapeutic study, Level I.
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Affiliation(s)
- Jae-Yoon Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Won-Joong Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Young-Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hwa-Yong Shin
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea.
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Hemidiaphragmatic paresis associated with brachial plexus blockade: a common adverse effect masquerading as cardiopulmonary disease. Am J Emerg Med 2016; 34:1733.e5-7. [PMID: 26786519 DOI: 10.1016/j.ajem.2015.12.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/18/2015] [Indexed: 11/22/2022] Open
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Regional anesthesia and lipid resuscitation for local anesthetic systemic toxicity in China: results of a survey by the orthopedic anesthesia group of the Chinese Society Of Anesthesiology. BMC Anesthesiol 2016; 16:1. [PMID: 26728368 PMCID: PMC4700758 DOI: 10.1186/s12871-015-0163-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 12/03/2015] [Indexed: 02/05/2023] Open
Abstract
Background Intravenous lipid emulsions have been introduced for the management of patients with Local Anesthetic Systemic Toxicity (LAST). These emulsions have been stated as a first-line treatment in the guidelines of several international anesthesia organizations. Nevertheless, the adoption of lipid rescue therapy by Chinese practitioners remains unknown. We, therefore, evaluated the current approaches to treat LAST and the use of lipid rescue therapy among anesthesiologists in China. Methods In September 2013, a 23-question survey on regional anesthesia practice and availability of lipid emulsions was sent by e-mail to directors or designated individuals at 41 academic anesthesiology departments listed by the orthopedic anesthesia group of the Chinese Society of Anesthesiology. Results Responses were received from 36 of the 41 (88 %) anesthesiology departments. To simplify the analysis, responses were divided into two groups according to the annual percentage of patients who received regional anesthesia (RA) for orthopedic anesthesia: 14 departments (39 %) with high-utilization (≥50 %) and 22 departments (61 %) low-utilization (<50 %) of RA. Ropivacaine and bupivacaine were the common drugs used for RA, which were independent of RA utilization. Interestingly, ultrasound-guided techniques were much more frequently used in low-utilization institutions than in high-utilization institutions (P = 0.025). Lipid emulsion was readily available in 8 of the 36 (22 %) responding institutions, with 7 of the other 28 (25 %) institutions planning to stock lipid emulsion. No differences in lipid availability and storage plans were observed between high- and low-utilization institutions. Lipid resuscitation was performed in five of the eight departments that had lipid emulsion. Eleven patients were successfully resuscitated and one was not. Conclusion Lipid emulsion is not widely available in China to treat LAST resulted from RA for orthopedic patients. Efforts are required to promote lipid rescue therapy nationwide. Trial registration Chinese Clinical Trail Registry (Registration number # ChiCTR-EOR-15006960; Date of Retrospective Registration on August 23rd, 2015) http://www.chictr.org.cn/showproj.aspx?proj=11703. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0163-0) contains supplementary material, which is available to authorized users.
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The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia. Reg Anesth Pain Med 2016; 41:181-94. [DOI: 10.1097/aap.0000000000000331] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine vs 0.2% ropivacaine on pain relief, diaphragmatic motility, and ventilatory function. J Clin Anesth 2015. [DOI: 10.1016/j.jclinane.2015.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Distal infrared thermography and skin temperature after ultrasound-guided interscalene brachial plexus block. Eur J Anaesthesiol 2014; 31:626-34. [DOI: 10.1097/eja.0000000000000152] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Dose-finding studies enable the successful conduct of peripheral nerve blocks by ensuring the administration of appropriate doses of local anesthetic. However, the optimal dose-finding methodology remains ambiguous. In this research methodology article, we set out to review the basic aspects pertaining to dose-response curves (graded vs quantal), the pharmacodynamic indices required by dose-finding studies, the properties of different dose-finding methods (sigmoidal dose-response curve analysis, Dixon-Mood method, Biased Coin Design, and Bayesian analysis), as well as strategies and recommendations for future research.
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Permanent Diaphragm Paralysis after Shoulder Rotator Cuff Repair: Interscalene Block Is Not the Only Factor. Anesthesiology 2014; 120:1054-6. [DOI: 10.1097/aln.0000000000000128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mariano ER, Marshall ZJ, Urman RD, Kaye AD. Ultrasound and its evolution in perioperative regional anesthesia and analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:29-39. [DOI: 10.1016/j.bpa.2013.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 11/22/2013] [Indexed: 11/30/2022]
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Ferraro LHC, Takeda A, Falcão LFDR, Rezende AH, Sadatsune EJ, Tardelli MA. Determinação do volume mínimo efetivo de bupivacaína 0,5% para bloqueio do plexo braquial por via axilar guiado por ultrassom. Braz J Anesthesiol 2014. [DOI: 10.1016/j.bjan.2013.03.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ferraro LHC, Takeda A, dos Reis Falcão LF, Rezende AH, Sadatsune EJ, Tardelli MA. Determination of the minimum effective volume of 0.5% bupivacaine for ultrasound-guided axillary brachial plexus block. Braz J Anesthesiol 2013; 64:49-53. [PMID: 24565388 DOI: 10.1016/j.bjane.2013.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/20/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The use of ultrasound for needle correct placement and local anesthetic spread monitoring helped to reduce the volume of local anesthetic required for peripheral nerve blocks. There are few studies of the minimum effective volume of local anesthetic for axillary brachial plexus block. The aim of this study was to determine the minimum effective volume (VE90) of 0.5% bupivacaine with epinephrine (1:200,000) for ultrasound guided ABPB. METHOD Massey and Dixon's up-and-down method was used to calculate the minimum effective volume. The initial dose was 5 mL per nerve (radial, median, ulnar, and musculocutaneous). In case of blockade failure, the volume was increased to 0.5 mL per nerve. A successful blockade resulted in decreased volume of 0.5 mL per nerve to the next patient. Successful blockade was defined as a motor block ≤2, according to the modified Bromage scale; lack of thermal sensitivity; and response to pinprick. The achievement of five cases of failure followed by success cases was defined as criterion to complete the study. RESULTS 19 patients were included in the study. The minimum effective volume (VE90) of 0.5% bupivacaine with 1:200,000 epinephrine was 1.56 mL (95% CI, 0.99-3.5) per nerve. CONCLUSION This study is in agreement with some other studies, which show that it is possible to achieve surgical anesthesia with low volumes of local anesthetic for ultrasound-guided peripheral nerve blocks.
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Affiliation(s)
- Leonardo Henrique Cunha Ferraro
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Alexandre Takeda
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luiz Fernando dos Reis Falcão
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - André Hosoi Rezende
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Jun Sadatsune
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Maria Angela Tardelli
- Disciplina de Anestesiologia, Dor e Terapia Intensiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Flohr-Madsen S, Ytrebø LM, Kregnes S, Wilsgaard T, Klaastad Ø. Minimum effective volume of ropivacaine 7.5 mg/ml for an ultrasound-guided infraclavicular brachial plexus block. Acta Anaesthesiol Scand 2013; 57:495-501. [PMID: 23418881 DOI: 10.1111/aas.12078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ultrasound guidance has been shown to reduce the minimum effective volume (MEV) of local anaesthetics for several peripheral nerve blocks. Although the lateral sagittal infraclavicular block (LSIB) is a well-established anaesthesia method, MEV for this technique has not been established. Our aim with this study was to determine the MEV using ropivacaine 7.5 mg/ml for the LSIB method. METHODS Twenty-five adult American Society of Anesthesiologists physical status I-II patients scheduled for hand surgery received an ultrasound-guided LSIB with ropivacaine 7.5 mg/ml. A successful block was defined as anaesthesia or analgesia for all five sensory nerves distal to the elbow, 30 min after local anaesthetic injection. The MEV for a successful block in 50% of the patients was determined by using the staircase up-and-down method introduced by Dixon and Massey. Logistic regression and probit transformation were applied to estimate the MEV for a successful block in 95% of the patients. RESULTS The patients received ropivacaine 7.5 mg/ml volumes in the range of 12.5-30 ml. The MEVs in 50% and 95% of the patients were 19 ml [95% confidence interval (CI), 14-27] and 31 ml (95% CI, 18-45), respectively. CONCLUSIONS For surgery distal to the elbow, the MEV in 95% of patients for an ultrasound-guided LSIB with ropivacaine 7.5 mg/ml was estimated to be 31 ml (95% CI, 18-45 ml). Further studies should determine the factors that influence the volume of local anaesthetic required for a successful infraclavicular block.
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Affiliation(s)
- S Flohr-Madsen
- Department of Anaesthesiology, University Hospital of North Norway, Tromsø, Norway.
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Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth Analg 2013; 116:1141-1161. [PMID: 23408672 DOI: 10.1213/ane.0b013e318277a270] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of local anesthetics to reduce acute postoperative pain has a long history, but recent reports have not been systematically reviewed. In addition, the need to include only those clinical studies that meet minimum standards for randomization and blinding must be adhered to. In this review, we have applied stringent clinical study design standards to identify publications on the use of perioperative local anesthetics. We first examined several types of peripheral nerve blocks, covering a variety of surgical procedures, and second, we examined the effects of intentionally administered IV local anesthetic (lidocaine) for suppression of postoperative pain. Thirdly, we have examined publications in which vascular concentrations of local anesthetics were measured at different times after peripheral nerve block procedures, noting the incidence when those levels reached ones achieved during intentional IV administration. Importantly, the very large number of studies using neuraxial blockade techniques (epidural, spinal) has not been included in this review but will be dealt with separately in a later review. The overall results showed a strongly positive effect of local anesthetics, by either route, for suppressing postoperative pain scores and analgesic (opiate) consumption. In only a few situations were the effects equivocal. Enhanced effectiveness with the addition of adjuvants was not uniformly apparent. The differential benefits between drug delivery before, during, or immediately after a surgical procedure are not obvious, and a general conclusion is that the significant antihyperalgesic effects occur when the local anesthetic is present during the acute postoperative period, and its presence during surgery is not essential for this action.
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A Dose-Ranging Study of 0.5% Bupivacaine or Ropivacaine on the Success and Duration of the Ultrasound-Guided, Nerve-Stimulator–Assisted Sciatic Nerve Block. Reg Anesth Pain Med 2013; 38:492-502. [DOI: 10.1097/aap.0b013e3182a4bddf] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gaertner E, Bouaziz H. [Ultrasound-guided interscalene block]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:e213-e218. [PMID: 22840929 DOI: 10.1016/j.annfar.2012.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- E Gaertner
- Centre de traitement des brûlés, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75745 Paris cedex 10, France.
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