Effects of interscalene brachial plexus block to intra-operative hemodynamics and postoperative pain for arthroscopic shoulder surgery

Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study

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.

Liposomal bupivacaine interscalene blocks demonstrate a greater proportion of total shoulder arthroplasty patients with clinically tolerable pain: a retrospective quality improvement study of 491 patients

OBJECTIVE

To evaluate the effects of liposomal bupivacaine use for interscalene blocks on postoperative analgesia in total shoulder arthroplasty patients.

METHODS

De-identified total or reverse total shoulder arthroplasty patients between 2018 and 2021 were analyzed. Patients were grouped into single shot interscalene block with liposomal bupivacaine (LB) with plain bupivacaine, other block (OB) with other local anesthetics (mepivacaine, ropivacaine, or plain bupivacaine), or no block (NB). The primary outcome was the proportion of patients with clinically tolerable pain scores (mean VAS ≤4) from 0 to 24 ​h in each group. Secondary outcomes included averaged visual analog pain scores (VAS) and opioid consumption measured in morphine milligram equivalents (MMEs) from 0 to 24 ​h. We also analyzed the proportion of patients with clinically tolerable pain, mean VAS, and opioid consumption from 0 to 72 ​h in those patients with at least a 3-day hospital length of stay.

RESULTS

A total of 491 de-identified total shoulder arthroplasty patients, 285 liposomal bupivacaine group (LB), 178 other block group (OB), and 28 no block group (NB), were analyzed. The primary outcome showed a statistically significant different proportion of patients with clinically tolerable pain from 0 to 24 ​h in the LB group (69 ​%) vs. OB group (39 ​%) vs. NB group (11 ​%) (<0.001). Secondary outcomes included statistically significant differences in VAS (LB median ​= ​3.35, OB median ​= ​4.38, NB median ​= ​5.25 (p ​< ​0.001, <0.001)) and total MME opioid consumption (LB median ​= ​40, OB median ​= ​60, NB median ​= ​88 (p ​< ​0.001, 0.001)) between groups from 0 to 24 ​h. For patients who had hospital stays of at least 3 days, a significant association was found with having achieved clinically tolerable pain 0-72 ​h and the LB group (51 ​%) vs. OB group (21 ​%) vs. NB group (11 ​%) (P ​= ​0.006). However, there was no statistical difference in mean VAS or opioid consumption between these groups.

CONCLUSION

A greater proportion of total shoulder arthroplasty patients that received liposomal bupivacaine in interscalene block have clinically tolerable pain scores from 0 to 24 ​h, lower VAS, and lower MME consumption in patients following total shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III - Clinical Study.

Early clinical efficacy analysis of enhanced recovery following surgery combined with interscalene brachial plexus block for arthroscopic rotator cuff repair

To explore the early clinical value of enhanced recovery after surgery (ERAS) with interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR). We enrolled 240 patients who underwent arthroscopic rotator cuff repair, randomly divided into 3 groups (n = 80 each). Groups A, B, and C underwent only surgery, surgery + ERAS, and ISB + surgery + ERAS, respectively. We analyzed the clinical data and postoperative indicators for the 3 patient groups. Group comparisons of clinical data and postoperative indicators revealed no significant differences in clinical characteristics (P > .05). Group C showed superior Visual Analog Scale scores at 0-6 and 6-24 hours postoperatively (P < .05), and the shortest length of hospital stay (LOS) (P < .05). At 6 weeks and 3 months postoperatively, Constant-Murley shoulder score and University of California-Los Angeles scores were better in Groups B and C than in Group A (P < .05). Joint swelling was more common in Group A than in Groups B and C (P < .05) but with no significant difference in the incidence of postoperative stiffness (P > .05). ERAS can relieve postoperative pain, shorten LOS, and help restore shoulder joint mobility, thereby reducing postoperative swelling. ISB + ERAS optimized pain control and allowed a shorter LOS, but had similar effects on early functional recovery and complications.

General anesthesia versus combined interscalene nerve/superficial cervical plexus block in arthroscopic rotator cuff repair: A randomized prospective control trial

BACKGROUND

In this study, interscalene brachial plexus block (ISB) with superficial cervical plexus block added and general anesthesia (GA) application were evaluated in terms of intraoperative hemodynamics, operative time and postoperative analgesia need in patients who underwent rotator cuff tear repair.

METHODS

70 patients aged between 18 and 75 years were included in this prospective study. Arthroscopic rotator cuff tear repair surgery was performed in all patients. The patients were randomized into 2 groups, namely Group ISB who received a combination of superficial cervical plexus block added to the Interscalene Nerve Block, and Group GA, for those who received GA. Duration of operation, waiting times, intraoperative hemodynamic data, postoperative visual analog scale (VAS), analgesic requirement, as well as patient and surgeon satisfaction levels, were compared between the 2 groups.

RESULTS

While VAS values at the post-anesthesia care unit were lower in ISB group at 2 and 24 hours (P < .05), there was no significant difference between VAS values measured at 6th and 12th hours (P ≥ .05). In the GA group, postoperative morphine and diclofenac consumption was higher, and rescue analgesia was needed earlier (P < .05). The hospital stay was shorter (P < .05), and surgeon and patient satisfaction were higher in the ISB group (P < .05).

CONCLUSION SUBSECTIONS

In rotator cuff tear repair anesthesia, ISB with superficial cervical plexus block provides adequate intraoperative anesthesia, low postoperative VAS level, reduced and deferred consumption of opioids and nonsteroidal anti-inflammatory drugs, higher patient and surgeon satisfaction and early discharge.

Risk factors for insufficient ultrasound-guided supraclavicular brachial plexus block

PURPOSE

Ultrasound-guided supraclavicular brachial plexus block (SCBPB) is performed by surgeons for upper limb anesthesia; however, certain patients need additional local anesthesia. This study aimed to identify risk factors for additional local anesthetic injection requirements.

METHODS

In total, 269 patients receiving ultrasound-guided SCBPB were enrolled. Patient age, sex, body mass index, anesthetic drug dose, surgeon expertise (hand surgeon or resident), tourniquet time, comorbidities (diabetes mellitus and mental disorders), and preoperative blood pressure representing anxiety were compared between the additional local anesthesia and no additional local anesthesia groups matched for background using propensity scores. Receiver operating characteristic analysis was performed to determine risk factor cut-off values with the highest predictive potential.

RESULTS

Of 269 patients, 41 (15.2%) required additional intraoperative local anesthesia. Among surgical sites, elbow surgery showed the highest prevalence of the need for additional local anesthesia (17/41, 41%). A high body mass index and high systolic blood pressure before surgery were identified as risk factors for additional intraoperative local anesthesia requirement. Furthermore, systolic blood pressure > 170 mmHg (area under the curve, 0.66) predicted the need for intraoperative local anesthesia with 36% sensitivity, 89% specificity, 37.5% positive predictive value, and 88.6% negative predictive value. The median systolic blood pressure was significantly greater in patients requiring additional local anesthesia than in those not requiring it [151 (139-171) mmHg vs. 145 (127-155) mmHg; P = 0.026].

CONCLUSION

Elbow surgery, obesity, and high systolic blood pressure (> 170 mmHg) before surgery are predictive of additional intraoperative local anesthesia requirement.

LEVEL OF EVIDENCE

Prognostic Level III.

Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study

Purpose

Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB.

Patients and Methods

In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery.

Results

Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward.

Conclusion

Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

BACKGROUND

Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair.

METHODS

A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated.

RESULTS

Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed.

CONCLUSIONS

The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A randomized comparison between interscalene block and dexmedetomidine for arthroscopic shoulder surgery

Introduction: Management of intraoperative hemodynamics and postoperative analgesia during arthroscopic shoulder surgeries remains a challenge. Although interscalene brachial plexus block (ISB) is considered ideal for shoulder anesthesia it requires skill and proficiency unlike intravenous (IV) dexmedetomidine. Objective: This randomized trial was performed to observe the efficacy of dexmedetomidine infusion which is less invasive and demands lesser skills than plexus block. Methodology: All patients scheduled for elective arthroscopic shoulder surgery under general anesthesia were assigned either to group DEX, which received an IV dexmedetomidine bolus of 0.5 mcg/kg over 20 minutes, followed by an infusion of 0.5 mcg/kg/hour that was stopped 30 minutes before surgery the end of surgery or to group BLOCK which received ultrasound guided ISB with 20ml of 0.25% bupivacaine. The primary outcome assessed was intraoperative hemodynamics; the secondary outcomes were immediate postoperative pain, operating condition as assessed by the surgeon, recovery time, and patient satisfaction after 24 hours. Blinded investigator and composite scores were used for the assessment. Results: Both groups displayed equivalent scores for intraoperative hemodynamics whereas ISB resulted in a better post-operative analgesia (p < 0.001). Surgeon’s opinion and recovery time were comparable. Overall, the patients had a satisfactory experience with both techniques, according to the quality assessment. Conclusion: IV dexmedetomidine infusion is an effective alternative to ISB for reconstructive shoulder surgeries under general anesthesia.

Ultrasound-Guided Stellate Ganglion Block With Preserved Motor Function for Upper Extremity Surgery

While stellate ganglion blockade (SGB) is commonly used in the treatment and management of patients who suffer from chronic pain, we are reporting a case where an ultrasound-guided SGB was used for management of acute perioperative pain for a patient undergoing upper extremity surgery. The patient was classified as the American Society of Anesthesiologists (ASA) class 1, without any significant past medical history, including no history of chronic pain, opioid use, or peripheral neuropathy. The patient was scheduled for tendon repair of the hand following trauma with subsequent lacerations. While general anesthesia, a brachial plexus blockade, or combination of the two are generally used in current practice for upper extremity surgery, these typically do not allow for intraoperative evaluation of motor function. In our case, an ultrasound-guided SGB was used to provide analgesia while still allowing for intraoperative assessment of motor function during the critical components of the repair. This case illustrates the potential advantages of an ultrasound-guided SGB for decreasing acute postoperative pain scores, decreasing overall postoperative pain medication use, as well as maintaining intraoperative motor function in cases where such monitoring may be advantageous and allow for optimal surgical repair.

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

BACKGROUND

Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year.

PURPOSE

To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate.

RESULTS

Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions.

CONCLUSION

Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures

Purpose

Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs.

Methods

A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018—these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts.

Results

Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579).

Conclusion

With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01704-1.

Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background

Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB).

Hypothesis

We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3.

Results

The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001).

Conclusion

VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.

Intra-operative effect of interscalene brachial plexus block to arthroscopic rotator cuff repair surgery

INTRODUCTION

To determine whether the placement of an interscalene brachial plexus block (IBPB) with general anaesthesia before shoulder arthroscopy would be effective in establishing a clear visual field and in shortening the surgical procedure.

METHOD

This prospective randomized control trial study included 152 patients who had undergone arthroscopic rotator cuff repair. Group A received IBPB and group B did not receive IBPB. A visual clarity scale (VCS) was determined by arthroscopic visualization. The systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), duration of surgical procedure, VCS, and medication that was administered for haemodynamic stability were recorded.

RESULTS

The VCS was improved in group A at stages 2 and 3 of the surgical procedures (p < 0.05), but there were no significant difference at stages 1 (p = 0.288) and 4 (p = 0.062). SBP, DBP, and HR were higher in group B during surgery (p < 0.05). The administered analgesics were higher in group B (p = 0.003), but there were no differences in hypotensive agents (p = 0.287). No significant difference was observed for the duration of surgery (p = 0.704).

CONCLUSIONS

Pre-operative IBPB with general anaesthesia for arthroscopic rotator cuff repair was beneficial in maintaining haemodynamic stability and improving the VCS during surgery.

Efficacy and safety of interscalene block combined with general anesthesia for arthroscopic shoulder surgery: A meta-analysis

STUDY OBJECTIVE

There is controversy regarding the efficacy and safety of using interscalene block (ISB) combined with general anesthesia (GA) for arthroscopic shoulder surgery. Our meta-analysis was undertaken to evaluate the utility of this approach.

MEASUREMENTS

We searched the PubMed, Cochrane Library, EMBASE, CNKI, VIP and ClinicalTrials.gov databases for randomized controlled trials. The primary endpoint was extubation time. Secondary endpoints included intraoperative heart rate, pain scores on the day of and 1 day after the operation, intraoperative systolic blood pressure and adverse events.

MAIN RESULTS

Ten RCTs involving 746 patients undergoing arthroscopic shoulder surgery met inclusion criteria. Compared with GA alone, ISB + GA was associated with a shorter extubation time(WMD = -6.13; 95% CI = -8.68 to -3.57; P < 0.00001; I² = 94%), a lower pain score on the day of the operation (WMD = -2.46; 95% CI = -4.53 to -0.40; P = 0.02; I² = 97%), a lower pain score 1 day after the operation (WMD = -1.49; 95% CI = -2.46 to -0.52; P = 0.003; I² = 88%), a lower intraoperative systolic blood pressure (WMD = -12.64; 95% CI = -20.90 to -4.39; P = 0.003; I² = 95%), a lower heart rate (WMD = -8.81; 95% CI = -15.34 to -2.28; P = 0.008; I² = 95%) and a lower incidence of adverse events (RR = 0.31; 95% CI = 0.15-0.66; P = 0.002; I² = 32%).

CONCLUSIONS

In patients undergoing arthroscopic shoulder surgery, ISB + GA is associated with a lower heart rate, lower pain scores on the day of and 1 day after the operation, a lower intraoperative systolic blood pressure, a shorter extubation time and a lower incidence of adverse events compared with GA alone.

Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis

BACKGROUND

Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA).

METHODS

A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission.

RESULTS

4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA.

CONCLUSION

After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.

Pre- or postoperative interscalene block and/or general anesthesia for arthroscopic shoulder surgery: a retrospective observational study

PURPOSE

Arthroscopic shoulder surgery can be performed with an interscalene brachial plexus block (ISBPB) alone, ISBPB combined with general anesthesia (GA), or GA alone. Postoperative pain is typically managed with opioids; however, both GA and opioids have adverse effects which can delay discharge. This retrospective study compares the efficacy of four methods of anesthesia management for arthroscopic shoulder surgery.

METHODS

Charts of all patients who underwent shoulder surgery by a single surgeon from 2012-2015 were categorized by analgesic regimen: GA only (n = 177), single-shot ISBPB only (n = 124), or pre- vs postoperative ISBPB combined with GA (ISBPB + GA [n = 72] vs GA + ISBPB [n = 52], respectively). The primary outcome measure was the time to discharge from the postanesthesia care unit (PACU).

RESULTS

Mean (SD) time in the PACU ranged from 70.5 (39.9) min for ISBPB only to 111.2 (56.9) min for GA only. Use of ISBPB in any combination and regardless of timing resulted in significantly reduced PACU time, with a mean drop of 27.2 min (95% confidence interval [CI], 17.3 to 37.2; P < 0.001). The largest mean pairwise difference was between GA only and ISBPB only, with a mean difference of 40.7 min (95% CI, 25.5 to 55.8; P < 0.001). Use of ISBPB also reduced pain upon arrival at the PACU and, in some cases, upon discharge from the PACU (i.e., ISBPB only but not ISBPB + GA compared with GA). An ISBPB (alone or prior to GA) also reduced analgesic requirements.

CONCLUSION

Previously reported benefits of an ISBPB for arthroscopic shoulder surgery are confirmed. Postoperative ISBPBs may also be beneficial for reducing pain and opioid requirements and could be targeted for patients in severe pain upon emergence. A sufficiently powered randomized-controlled trial could determine the relative efficacy, safety, and associated financial implications associated with each method.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Comparison of the Analgesic Properties of Sevoflurane and Desflurane Using Surgical Pleth Index at Equi-Minimum Alveolar Concentration

Background: Traditionally, minimum alveolar concentration (MAC) has been used as the standard measure to compare the potencies of volatile anesthetics. However, it reflects the spinal mechanism of immobility rather than the subcortical mechanism of analgesia. Recently, the surgical pleth index (SPI) derived from photoplethysmographic waveform was shown to reflect the intraoperative analgesic component. This study was designed to compare the SPI values produced by equi-MAC of two commonly used volatile anesthetics, sevoflurane and desflurane. Methods: Seventy-two patients undergoing arthroscopic shoulder surgery were randomly assigned to two groups receiving either sevoflurane (n = 36) or desflurane (n = 36). General anesthesia was maintained with the respective volatile anesthetic only. A vaporizer was adjusted to maintain end-tidal anesthetic concentration at age-corrected 1.0 MAC throughout the study period. The SPI value as an analgesic estimate and the bispectral index (BIS) value as a hypnotic estimate were recorded at predefined time points during the standardized surgical procedure. Results: During the steady state of age-corrected 1.0 MAC, mean SPI values throughout the entire study period were significantly higher in the sevoflurane group than in the desflurane group (38.1 ± 12.8 vs. 30.7 ± 8.8, respectively, P = 0.005), and mean BIS values were significantly higher in the sevoflurane group than in the desflurane group (40.7 ± 5.8 vs. 36.8 ± 6.2, respectively, P = 0.008). Conclusions: Equi-MAC of sevoflurane and desflurane did not produce similar surgical pleth index values. Therefore, sevoflurane and desflurane may have different analgesic properties at equipotent concentrations.

Does Brachial Plexus Blockade Result in Improved Pain Scores After Distal Radius Fracture Fixation? A Randomized Trial

BACKGROUND

Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients' postoperative course and experience.

QUESTIONS/PURPOSES

We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery?

METHODS

A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits.

RESULTS

Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 ± 2.3 vs brachial plexus blockade 1.4 ± 2.3; mean difference, 5.381; 95% CI, 3.850-6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 ± 1.9 vs brachial plexus blockade 6.3 ± 2.4; mean difference, -2.535; 95% CI, -4.028 to -1.040; p = 0.002) and 24 hours (general anesthesia 3.8 ± 2.2 vs brachial plexus blockade 5.3 ± 2.5; mean difference, -1.492; 95% CI, -3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 ± 16 minutes vs brachial plexus blockade 125 ± 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 ± 137 minutes vs 197 ± 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 μg ± 93 μg vs 6.9 μg ± 14 μg; p < 0.001) and morphine (2.9 μg ± 3.6 μg vs 0.0 μg; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value).

CONCLUSIONS

Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging "rebound pain" after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management.

LEVEL OF EVIDENCE

Level 1, therapeutic study.

Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis

BACKGROUND

Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery.

METHODS

We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed.

RESULTS

A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results.

CONCLUSIONS

ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.

A comparison of three methods for postoperative pain control in patients undergoing arthroscopic shoulder surgery

Background

Arthroscopic shoulder operations (ASS) are often associated with severe postoperative pain. Nerve blocks have been studied for pain in shoulder surgeries. Interscalene brachial plexus blocks (ISB) and an intra-articular injection (IA) have been reported in many studies. The aim of the present study is to evaluate the effect of ISB, a continuous cervical epidural block (CCE) and IA as a means of postoperative pain control and to study the influence of these procedures on postoperative analgesic consumption and after ASS.

Methods

Fifty seven patients who underwent ASS under general anesthesia were randomly assigned to one of three groups: the ISB group (n = 19), the CCE group (n = 19), and the IA group (n = 19). Patients in each group were evaluated on a postoperative numerical rating scale (NRS), their rescue opioid dosage (ROD), and side effects.

Results

Postoperative NRSs were found to be higher in the IA group than in the ISB and CCE groups both at rest and on movement. The ROD were 1.6 ± 2.3, 3.0 ± 4.9 and 7.1 ± 7.9 mg morphine equivalent dose in groups CCE, ISB, and IA groups (P = 0.001), respectively, and statistically significant differences were noted between the CCE and IA groups (P = 0.01) but not in between the ISB and CCE groups.

Conclusions

This prospective, randomized study demonstrated that ISB is as effective analgesic technique as a CCE for postoperative pain control in patients undergoing ASS.

Comparison of interscalene brachial plexus block and intra-articular local anesthetic administration on postoperative pain management in arthroscopic shoulder surgery

BACKGROUND AND OBJECTIVES

In this study, the aim was to compare postoperative analgesia effects of the administration of ultrasound-guided interscalene brachial plexus block and intra-articular bupivacaine carried out with bupivacaine.

METHODS

In the first group of patients 20 mL 0.25% bupivacaine and ultrasound-guided interscalene brachial plexus block (ISPB) were applied, while 20 mL 0.25% bupivacaine was given via intra-articular (IA) administration to the second group patients after surgery. Patients in the third group were considered the control group and no block was performed. Patient-controlled analgesia (PCA) with morphine was used in all three groups for postoperative analgesia.

RESULTS

In the ISPB group, morphine consumption in the periods between 0-4, 6-12 and 12-24 postoperative hours and total consumption within 24h was lower than in the other two groups. Morphine consumption in the IA group was lower than in the control group in the period from 0 to 6h and the same was true for total morphine consumption in 24h. Postoperative VASr scores in the ISPB group were lower than both of the other groups in the first 2h and lower than the control group in the 4th and 6th hours (p<0.05). In the IA group, VASr and VASm scores in the 2nd, 4th and 6th hours were lower than in the control group (p<0.05).

CONCLUSION

Interscalene brachial plexus block was found to be more effective than intra-articular local anesthetic injection for postoperative analgesia.