Post-operative analgesia for shoulder arthroscopic surgeries: A comparison between inter-scalene block and shoulder block

Anesthesia for the Patient Undergoing Shoulder Surgery

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Efficacy of Infraclavicular Brachial Plexus Block Alone Versus Combination With Suprascapular Nerve Block in Patients Undergoing Shoulder Surgeries: A Single-Blind, Randomized Trial

Background and aim The regional anesthesia technique is commonly used for upper extremity surgery as an alternative to general anesthesia. The study aimed to compare the efficacy of infraclavicular brachial plexus block (BPB) and a combination of infraclavicular brachial plexus block with suprascapular nerve block for postoperative analgesia in patients undergoing shoulder surgeries. Method A total of 62 patients of both sexes with the American Society of Anaesthesiologists (ASA) physical status I/II/III, aged between 18 and 65 years, and undergoing shoulder surgery, were included in this prospective, single-blinded, randomized controlled trial. Patients were equally allocated into two groups: 31 in group A and 31 in group B. After pre-anesthetic evaluation, the purpose and protocol of the study were explained to patients, and informed consent was obtained. Thirty-one patients in group A were given infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine while 31 patients in group B were given a combination of infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine and suprascapular nerve block using 5 ml 0.375% bupivacaine. Blocks were given using ultrasound guidance and a peripheral nerve stimulator; the suprascapular block was given in the sitting position while the infraclavicular block was provided in the supine position. General anesthesia was administered in the operation theatre in the supine position after the administration of blocks. The pain was assessed using the visual analog scale (VAS) and the satisfaction score was assessed by the numeric rating scale (NRS). The Mann-Whitney U test was applied for comparison of pain between the two groups. The chi-square test was utilized for comparing the categorical variables. Result The postoperative pain was significantly lower (p<0.001) in group B as compared to group A at all the periods of observation, i.e., 0h (2.77±0.72 vs. 5.42±0.77), 6h (3.89±0.70 vs. 5.94±0.73), 12h (5.66±0.93 vs. 6.58±0.88), and 24h (6.16±0.80 vs. 6.74±0.90). These findings illustrate that group B patients who received a combination of infraclavicular brachial plexus block and suprascapular nerve block for shoulder surgeries had better pain relief than group A patients who received only the infraclavicular approach. The mean NRS score of patient satisfaction in group B (7.26±0.58) was significantly higher (p<0.001) in comparison to group A (6.16±0.64). Diaphragmatic palsy was observed in only one case in group A and none in group B. No other complication was observed in any of the patients during the study period. Conclusion The combination of infraclavicular brachial plexus block and suprascapular nerve block displays a positive postoperative analgesic profile with less usage of rescue analgesic doses and better patient satisfaction after shoulder surgery.

Ultrasound-guided anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: A randomised controlled study

Background and Aims

The interscalene brachial plexus block (ISB) affects the phrenic nerve, resulting in hemi-diaphragmatic paresis (HDP) and, possibly, respiratory distress. Suprascapular nerve block via an anterior approach (SSB-A) is performed more distally at the level of the trunk of the brachial plexus and, thus, may spare the phrenic nerve. This study compares the analgesic efficacy and decline of hemi-diaphragmatic excursion (HDE) following ultrasound (US)-guided SSB-A versus ISB for arthroscopic shoulder surgery.

Methods

This study was conducted on 60 adult participants undergoing arthroscopic shoulder surgery under general anaesthesia. Both US-guided SSB-A (n = 30) and ISB (n = 30) were performed with a combination of 10 ml bupivacaine (0.5%) and 4 mg dexamethasone. The primary objective was to compare the duration of analgesia (time to first rescue analgesia), and secondary objectives were to compare 24-h postoperative numerical rating scale (NRS) scores, 24-h morphine consumption and post block change in HDE, and pulmonary function tests (PFTs) between the two groups. For analysing intergroup differences of NRS, HDE and PFT; Pearson's Chi-squared test or Fisher's exact test, unpaired t test, and Mann-Whitney U test were used. For intragroup differences, paired t test was used. A P value <0.05 was considered significant.

Results

The duration of analgesia (mean ± Standard Deviation) was similar in two groups (SSB-A = 1,345 ± 182 min, ISB = 1,375 ± 156 min; P = 0.8). The reduction in HDE was significantly greater in the ISB group (44%) than in the SSB-A group (10%). Pulmonary function was better preserved in the SSB-A group.

Conclusion

Compared to ISB, SSB-A has a similar analgesic efficacy for arthroscopic shoulder surgeries, but it is superior in preserving diaphragmatic function and pulmonary function.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level I, therapeutic study.

Efficacy and adverse effects of peripheral nerve blocks and local infiltration anesthesia after arthroscopic shoulder surgery: A Bayesian network meta-analysis

Study objective

To quantitatively assess and compare the efficacy and adverse effects of six different peripheral nerve block techniques after arthroscopic shoulder surgery (ASS).

Design

Bayesian network meta-analysis.

Methods

The PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure database, Chinese Scientific Journal database, Wan Fang databases were searched to retrieve randomized clinical trials comparing interscalene brachial plexus block, continuous interscalene brachial plexus block, supraclavicular brachial plexus block, suprascapular nerve block, combined suprascapular and axillary nerve block and local infiltration analgesia on postoperative pain, opioid consumption, and adverse effects (defined as Horner’s syndrome, dyspnea, hoarseness, vomiting, and nausea) after ASS under general anesthesia (GA). Two reviewers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies.

Results

A total of 1,348 articles were retrieved initially and 36 randomized clinical trials involving 3,124 patients were included in the final analysis. The network meta-analysis showed that interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to the five other interventions. However, adverse effects were reduced using suprascapular nerve block and combined suprascapular and axillary nerve block compared to interscalene brachial plexus block.

Conclusion

Interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to other peripheral nerve blocks but had a higher frequency of adverse events.

Anesthesia for the Patient Undergoing Shoulder Surgery

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery

BACKGROUND

The minimally invasive approach of arthroscopic shoulder surgery is beneficial; however, for optimal outcomes, perioperative pain management is essential. This cross-sectional study aimed to examine the analgesic effectiveness of intra-articular injection (IA) versus interscalene brachial plexus block (ISPB) among patients treated with arthroscopic shoulder surgeries.

METHODS

We reviewed 100 consecutive patients who underwent shoulder arthroscopic surgery, of whom 50 each underwent IA (February 2019─January 2020; IA group) and ISPB (October 2018─July 2019; ISPB group). The primary outcome was the postoperative pain score measured using a Wong-Baker FACES Pain Rating Scale preoperatively and at 2, 6, 12, 24, and 48 h postoperatively. We performed multiple regression analysis to examine whether IA/ISPB selection is associated with acute-phase postoperative pain and adjusted for intra-articular injection, interscalene brachial plexus block, postoperative pain management, arthroscopic shoulder surgery, IA with 10 mg of morphine previously reported prognostic factors for postoperative pain (e.g., surgical procedures, operative time, older age, and preoperative pain). Furthermore, we examined induction time, total pentazocine dosage, and total postoperative nausea and vomiting (PONV) events.

RESULTS

There were no significant differences between the IA and ISPB groups in perioperative pain control during the acute-phase periods (p = 0.12, repeated analysis of variance). The difference in anesthesia method was not a prognostic factor for acute-phase postoperative pain (p = 0.11). The IA group (15.06 ± 4.00 min) had a significantly shorter mean anesthesia induction time than the ISPB group (29.23 ± 9.22 min) (p = 0.0001). There was no significant between-group difference in the total pentazocine dosage during the first 7 days (p = 0.3934) postoperatively. PONV was observed in eight (17.0%) and two (4.2%) patients in the IA and ISPB groups, respectively. There was no significant between-group difference in the PONV incidence (p = 0.1582).

CONCLUSIONS

There was no significant difference in acute-phase postoperative pain management between the IA and ISPB groups. The induction time was significantly shorter in IA. IRB: Approval number: UOEHCRB20-078, IRB approval date: September 9th, 2020; study duration: October 2018 to January 2020.

Two Cases of Respiratory Insufficiency Secondary to Pre-procedural Nerve Blocks for Upper Extremity Injuries

Interscalene nerve blocks are common procedures performed before upper extremity surgeries in order to provide post-op pain relief and improve recovery time. Here we present two cases of patients who underwent a unilateral supraclavicular and bilateral interscalene nerve block, respectively. The first patient had no risk factors but the second presented with a body mass index of 45.5 and a history of symptoms consistent with obstructive sleep apnea but never diagnosed. Both patients experienced some form of respiratory distress diagnosed via changes in chest x-ray and clinical presentation. The mechanism of injury that occurs in these procedures is typically from inadvertent damage to the phrenic nerve. Mild adverse effects in interscalene nerve block are relatively common. However, there is minimal data in regards to performing bilateral interscalene nerve blocks. The purpose of this study is to highlight that severe complication in both high and low-risk patients can occur but may be reduced with a safer approach and more effective communication among multidisciplinary team members.

Selective blockade of supraclavicular nerves and upper trunk of brachial plexus "The SCUT block" towards a site-specific regional anaesthesia strategy for clavicle surgeries - A descriptive study

Background and Aims:

Commonly, the superficial cervical plexus and interscalene block were combined to provide surgical anaesthesia for procedures on the clavicle, which are neither selective nor site-specific considering the innervation of the clavicle. The aim was to analyse effectiveness and block dynamics of selectively blocking supraclavicular (SC) nerves and upper trunk (UT) of brachial plexus (SCUT BLOCK) as a site-specific regional anaesthesia strategy for clavicle surgery.

Methods:

SC nerves and UT were blocked with 3-ml and 5-ml local anaesthetic, respectively, in 70 American Society of Anesthesiologists I and II patients aged above 18 years, undergoing clavicle surgery. Sensory-motor conduction blockade was assessed in both the plexus territories, following which surgery ensued. Number of patients who exhibited complete conduction blockade of the targeted nerves, number of surgeries completed under the block, intraoperative rescue analgesics, duration of postoperative analgesia and complications were recorded.

Results:

Sensory and motor mapping showed complete conduction blockade of the targeted nerves in all patients, all other branches were spared. The surgery was completed exclusively under block in 67 (Strategy success rate 96%) out of 70 patients. Intraoperatively, two patients required supplementation of block with a local infiltration and general anaesthesia was administered for one patient. The mean duration of postoperative analgesia was 5 (1.2) hours [mean (standard deviation)]. Only one patient developed ptosis; no other complications were noted.

Conclusions:

“The SCUT block” is an effective site-specific regional anaesthesia strategy for clavicle surgery.

Suprascapular nerve block and axillary nerve block versus interscalene nerve block for arthroscopic shoulder surgery: A meta-analysis of randomized controlled trials

BACKGROUND

The interscalene brachial plexus block (ISB) is a commonly used nerve block technique for postoperative analgesia in patients undergoing shoulder arthroscopy surgery; however, it is associated with potentially serious complications. The use of suprascapular nerve block (SSNB) and axillary Nerve Block (ANB) has been reported as an alternative nerve block with fewer reported side effects for shoulder arthroscopy. This review aimed to compare the impact of SSNB and ANB with ISB during shoulder arthroscopy surgery.

METHODS

A meta-analysis was conducted to identify relevant randomized or quasirandomized controlled trials involving SSNB and ISB during shoulder arthroscopy surgery. We searched Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database from 2010 through August 2021.

RESULTS

We identified 641 patients assessed in 10 randomized or quasirandomized controlled trials. Compared with the ISB group, the SSNB+ANB group had higher visual analog scale or numerical rating scale in PACU (P = .03), 4 hour (P = .001),6 hour after the operation (P = .002), and lower incidence of complications such as Numb/Tingling (P = .001), Weakness (P <.00001), Horner syndrome (P = .001) and Subjective dyspnea (P = .002). No significant difference was found for visual analog scale or numerical rating scale 8 hour (P = .71),12 hour (P = .17), 16 hour (P = .38),1day after operation (P = .11), patient satisfaction (P = .38) and incidence of complications such as hoarseness (P = .07) and nausea/vomiting (P = .41) between 2 groups.

CONCLUSION

Our high-level evidence has established SSNB+ ANB as an effective and safe analgesic technique and a clinically attractive alternative to interscalene block during arthroscopic shoulder surgery, especially for severe chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Given our meta-analysis's relevant possible biases, we required more adequately powered and better-designed randomized controlled trial studies with long-term follow-up to reach a firmer conclusion.

Can saline injection protect phrenic nerve? - A randomised controlled study

Background and Aims

Various methods were attempted to reduce the incidence of phrenic nerve palsy during interscalene brachial plexus nerve block. Mechanism of phrenic palsy was presumed to be due to the spread of local anaesthetic anterior to the anterior scalene muscle. We hypothesised that by injecting saline in this anatomical location prior to performing an interscalene block might reduce the incidence of phrenic palsy.

Methods

This was a double-blinded randomised controlled study performed in a single-centre, university-teaching hospital. A total of 36 patients were randomised to either group C (conventional group) or group S (saline group). Ultrasound-guided interscalene block was administered with 20 ml of 0.25% levo-bupivacaine in both groups. Ten ml of normal saline was injected anterior to anterior scalene muscle in group S prior to performing interscalene block. A blinded radiologist performed diaphragmatic ultrasound pre- and post-operatively to document phrenic palsy. Bedside spirometry was used to perform baseline and post-operative pulmonary function test. The primary outcome was to look at the incidence of phrenic palsy as measured by diaphragmatic palsy on ultrasound performed by radiologist. Statistical Package for the Social Sciences (SPSS) version 25 was used for statistical analysis.

Results

Significantly less patients in the saline group developed diaphragmatic paresis when compared to conventional group (44% vs. 94%, Chi-squared = 10.01, P = 0.002). There was no difference in post-operative pain, subjective sensation of dyspnoea or patient satisfaction between the groups.

Conclusion

Injecting saline anterior to anterior scalene muscle reduces the incidence of diaphragmatic palsy when performing interscalene block.

Comparison of analgesic efficacy of shoulder block versus interscalene block for postoperative analgesia in arthroscopic shoulder surgeries: A randomised trial

Background and Aims

Arthroscopic orthopaedic surgery may lead to significant postoperative pain. Interscalene block (ISB) is associated with undesirable effects like phrenic nerve palsy. Shoulder block (ShB) is a relatively recent diaphragm sparing alternative for analgesia in these cases.

Methods

This prospective randomised trial was conducted in 70 adult patients posted for arthroscopic Bankart repair surgery. Patients were randomly assigned into two groups: interscalene block [Group ISB (n = 35): 0.5% bupivacaine 10 ml] or shoulder block [Group ShB (n = 35): 0.5% bupivacaine (suprascapular block 10 ml and axillary block 10 ml)] using ultrasound and nerve stimulator. The primary aim of our study was to compare the ISB with ShB for visual analogue score (VAS) in recovery area (zero hour). Time for block performance, VAS, time to first rescue analgesia, total analgesic requirement, patient satisfaction and complications were recorded.

Results

VAS was significantly higher in ShB group at 2 and 4 h (P = 0.001 and 0.000) while it was significantly higher in ISB group at 12 h (P = 0.013). The time to first analgesic request was significantly prolonged in ISB group as compared to ShB group (8.22 h vs. 4.69 h; P = 0.002) but total analgesic requirement and patient satisfaction at 24 h were similar. Complications like dyspnoea, ptosis and motor weakness were seen only with ISB group.

Conclusion

Both ShB and ISB blocks have similar efficacy in terms of postoperative pain scores, cumulative analgesic requirements and patient satisfaction. However, considering the various undesirable effects associated with ISB, like phrenic nerve blockade, prolonged upper limb weakness and the occurrence of rebound pain, shoulder block may be preferred for arthroscopic shoulder surgeries.

Application of regional cerebral oxygen saturation monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly hypertensive patients undergoing shoulder arthroscopic surgery

OBJECTIVE

To explore the effect of using regional cerebral oxygen saturation (rScO₂) monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly hypertensive patients undergoing shoulder arthroscopic surgery.

METHODS

Sixty elderly patients with hypertension undergoing shoulder arthroscopic surgery under general anesthesia were enrolled as the research objects for this prospective study, and they were randomly divided into an observation group and a control group. The observation group received bispectral index (BIS) + rScO₂, while the control group only adopted BIS. The changes in BIS, mean arterial pressure (MAP), heart rate (HR), and rScO₂ at 5 min after intubation (T1), 10 min after intubation (T2), immediately after changing position (T3), 5 min after changing position (T4), and 10 min after changing position (T5) of the two groups were recorded. The correlation between MAP and rScO₂ was analyzed. Preoperative and postoperative Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA) scores, serum neuron-specific enolase (NSE) and s100β levels were compared between the two groups. The incidence of postoperative cognitive dysfunction (POCD) at 1-3 days was recorded.

RESULTS

There were no significant differences in BIS, MAP, HR, or rScO₂ between the two groups at T1 and T2 (all P>0.05). At T3-T5, the levels of BIS, MAP, HR, and rScO₂ in the two groups decreased, and the control group had lower levels of the above indicators (all P<0.05). Correlation analysis showed that MAP and rScO₂ levels were positively correlated in the two groups (r>0, P<0.05). There were no significant differences in the MMSE or MoCA scores, NSE or s100β levels between the two groups before surgery (all P>0.05). After surgery, the MMSE and MoCA scores of the two groups were decreased (both P<0.05), while the NSE and s100β levels were increased (both P<0.05). The control group showed greater changes in the above four indexes (all P<0.05). The incidence of POCD in the observation group was lower than that of controls at 1, 2, and 3 days after surgery (all P<0.05).

CONCLUSION

rScO₂ monitoring with near-infrared spectroscopy in peri-anesthesia management of elderly patients with hypertension undergoing shoulder arthroscopic surgery can effectively stabilize hemodynamics and reduce the incidence of postoperative POCD.

Comparison of Ultrasound-Guided Supra-scapular Plus Axillary Nerve Block with Interscalene Block for Postoperative Pain Management in Arthroscopic Shoulder Surgery; A Double-Blinded Randomized Open-Label Clinical Trial

Background

Post-arthroscopic shoulder surgery pain is severe enough to interfere with initial recovery and rehabilitation.

Objectives

We aimed to evaluate the analgesic effects of postoperative ultrasound-guided suprascapular plus axillary nerve blocks superficial subepidermal axon bundles (SSAB) with interscalene block (ISB) in arthroscopic shoulder surgery.

Methods

In this single-blind randomized, open-label clinical trial, 80 candidates of elective arthroscopic shoulder surgery were randomly allocated to receive either SSAB or ISB at a postoperative care unit. The severity of resting and changing position pain was measured using visual analogue scale (VAS) score at 4h, 8h, 12h, 16h, and 24h, postoperatively. Timing of first opioid request, 24h dose requirement, patients' satisfaction rate, and side effects were also recorded. All registered data were analyzed using SPSS software version 23 for Windows (SPSS, Chicago, IL).

Results

Resting and changing position pain scores were comparable between SSAB and ISB groups in the most time intervals. At 12h, moving and resting pain was significantly lower in ISB than SSAB group, while moving pain was more severe in ISB group at 24h assessment. Patient satisfaction scores were comparable between the two groups except for 12h assessment. Time to first analgesic requirement and total dose of 24h opioid requirement were not significantly different between the two groups.

Conclusions

Suprascapular plus axillary nerve block could be an effective and safe alternative for interscalene block for pain management after arthroscopic shoulder surgery.

Patient satisfaction with regional anaesthesia and general anaesthesia in upper limb surgeries: An open label, cross-sectional, prospective, observational clinical comparative study

Background and Aims:

An important assessment of the quality of health care is patient satisfaction. However, only few studies are available which look into this aspect. The primary objective of this study was to compare patient satisfaction between regional anaesthesia (RA) and general anaesthesia (GA) in patients undergoing upper limb surgeries. The length of hospital stay and duration of analgesia between the two techniques were the secondary objectives.

Methods:

This cross-sectional study was carried out in a tertiary care teaching hospital. Patients aged between 18 years and 60 years, of physical status American Society of Anesthesiologists (ASA) grade 1–3, undergoing upper limb surgeries were included in the study. Patient satisfaction with anaesthesia was assessed in patients receiving GA and RA, with 100 patients in each group, at least 24 h after the surgery with a 10-item predesigned peri-operative questionnaire. The continuous variables were compared between the groups using Mann–Whitney–Wilcoxon test, and for categorical variables Chi-square test was used.

Results:

The patients in group RA showed significantly higher satisfaction scores than those in GA (P < 0.001) with respect to all the 10 items of the questionnaire and the total score. Duration of analgesia was also significantly longer in RA than GA (P < 0.001). Duration of hospital stay was also significantly longer in GA than in RA (P < 0.001).

Conclusions:

RA for upper limb surgeries provides better patient satisfaction than GA, along with a longer duration of analgesia and lesser duration of hospital stay.

Truncal injection brachial plexus block: A Description of a novel injection technique and dose finding study

Background and Aims

Brachial plexus (BP) blocks continue to be described with reference to anatomical landmarks (Interscalene and Supraclavicular), even after the introduction of ultrasound which enables us to directly identify the roots, trunks and divisions of the BP. The aim of this study was to describe a novel injection technique targeting trunks of BP and to determine the minimum effective local anaesthetic volume (MELAV) required to produce BP block with this approach.

Methods

Twenty-one male patients in the age group 20-40 years, undergoing elective forearm bony procedures received an ultrasound-guided truncal injection BP block. MELAV₅₀ was determined using the Dixon and Mood up-and-down method. Initial volume of local anaesthetic (LA; 50:50 mixture of bupivacaine 0.5% and lignocaine 2% with 5 μg/ml epinephrine) injected was 6 ml in each trunk, which was varied by 1 ml/trunk for each consecutive patient according to the response of the previous patient. The MELAV₅₀, MELAV₉₅ and MELAV₉₉ were calculated using Probit transformation and logistic regression.

Results

Out of the 21 patients, 13 patients had a successful block. The MELAV₅₀, MELAV₉₅ and MELAV₉₉ were 7.41, 10.47 and 12 ml, respectively. Eight patients in whom block failed had sparing in the ulnar and median nerve territories.

Conclusion

Trunks of the brachial plexus can be identified and targeted for the injection of local anaesthetics. The MELAV₅₀ and MELAV₉₅ required for ultrasound-guided truncal injection brachial plexus block were 7.4 and 10.4 ml, respectively.

Diaphragm-sparing nerve blocks for shoulder surgery, revisited

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