Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023

The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.

Peripheral Nerve Block to Treat Pain Caused by Daboia palaestinae Envenomation

Snakebite pain can be challenging to control. We describe our experience managing intolerable pain after conventional treatment failed. A 35-year-old man, presented after a viper snakebite, suffering from intolerable pain in the affected extremity. He had no significant past medical history. All attempts to control the pain conventionally were unsuccessful. Treatment with a supraclavicular nerve block resulted in immediate relief. After the block receded, only a dull pain remained, which later disappeared without recurrence. This experience illustrates the need for personalized pain treatment to avoid subsequent complications.

Equal mixture of 2% lidocaine with adrenaline and 0.5% bupivacaine 20 mL provided faster onset of complete conduction blockade during ultrasound-guided supraclavicular brachial plexus block than 20 mL of 0.5% bupivacaine alone: a randomized double-blinded clinical trial

INTRODUCTION

Recent evidence has questioned the advantage of local anesthetic (LA) combinations. This study tested the hypothesis that mixing rapid-onset (lidocaine) and long-duration (bupivacaine) LA would provide faster onset of complete conduction blockade (CCB) compared with bupivacaine alone and longer duration of analgesia compared with lidocaine alone during low-volume (20 mL) ultrasound-guided (USG) supraclavicular brachial plexus block (SCBPB).

METHODS

Sixty-three patients receiving USG-SCBPB were randomly allocated into: group L: 20 mL 2% lidocaine with epinephrine 1:200 000; group B: 20 mL 0.5% bupivacaine; group LB: 20 mL of equi-volume mixture of both drugs. Sensory and motor blockade was recorded on a three point sensory and motor assessment scale at 10 min intervals for up to 40 min and the total composite score (TCS) at each time point was determined. The duration of analgesia was also noted.

RESULTS

The mean time to CCB of group LB (16±7 min) was comparable (p>0.05) with group L (14±6 min) and group B (21±8 min) in patients who were attained CCB. However, the proportion of patients attaining complete conduction block (TCS=16/16) was significantly lower (p=0.0001) in group B (48%) when compared with group L (95%) and group LB (95%) at the end of 40 min. The median (IQR) duration of postoperative analgesia was longest in group B; 12.2 (12-14.5) hours, followed by group LB 8.3 (7-11) hours and 4 (2.7-4.5) hours in group L.

CONCLUSION

At 20 mL LA volume, equal mixture of lidocaine and bupivacaine provided significantly faster onset of CCB compared with bupivacaine alone and longer duration of postoperative analgesia compared with lidocaine alone but shorter than bupivacaine alone during low-volume USG-SCBPB.

TRIAL REGISTRATION NUMBER

CTRI/2020/11/029359.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block

BACKGROUND

Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC.

MATERIALS AND METHODS

A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved.

RESULTS

Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness.

CONCLUSIONS

In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Convolutional neural network for brachial plexus segmentation at the interscalene level

BACKGROUND

Regional anesthesia with ultrasound-guided brachial plexus block is widely used for patients undergoing shoulder and upper limb surgery, but needle misplacement can result in complications. The purpose of this study was to develop and validate a convolutional neural network (CNN) model for segmentation of the brachial plexus at the interscalene level.

METHODS

This prospective study included patients who underwent ultrasound-guided brachial plexus block in the Anesthesiology Department of Beijing Jishuitan Hospital between October 2019 and June 2022. A Unet semantic segmentation model was developed to train the CNN to identify the brachial plexus features in the ultrasound images. The degree of overlap between the predicted segmentation and ground truth segmentation (manually drawn by experienced clinicians) was evaluated by calculation of the Dice index and Jaccard index.

RESULTS

The final analysis included 502 images from 127 patients aged 41 ± 14 years-old (72 men, 56.7%). The mean Dice index was 0.748 ± 0.190, which was extremely close to the threshold level of 0.75 for good overlap between the predicted and ground truth segregations. The Jaccard index was 0.630 ± 0.213, which exceeded the threshold value of 0.5 for a good overlap.

CONCLUSION

The CNN performed well at segregating the brachial plexus at the interscalene level. Further development could allow the CNN to be used to facilitate real-time identification of the brachial plexus during interscalene block administration.

CLINICAL TRIAL REGISTRATION

The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055591), the site url is https://www.chictr.org.cn/ . The date of trial registration and patient enrollment is 14/01/2022.

Anaesthetic Effects of Ropivacaine and Bupivacaine on Onset, Duration of Block and Changes in Hemodynamic Parameters in Patients Undergoing Below Elbow Surgeries Under Ultrasound Guided Supraclavicular Brachial Plexus Block

BACKGROUND

Supraclavicular brachial plexus block is commonly used regional anesthetic technique for below elbow upper limb surgeries. Ultrasound and nerve stimulator are used for higher success rates and fewer complications. Ropivacaine has been used as an alternative to Bupivacaine for rapid onset and longer duration along with lesser or no cardiac and neurotoxicity.The study was conducted with objective of assessing sensory and motor block characteristics of Bupivacaine and Ropivacaine in terms of onset, duration and adverse effects.

METHODS

A prospective observational study lasting three month duration from 15th February, 2022 to 14th May, 2022 was conducted among 60 patients divided by convenient sampling method into 30 in Group R (0.2% Ropivacaine 30 ml) and 30 in Group B (0.2% Bupivacaine 30 ml) undergoing below elbow orthopedic surgery under ultrasound and peripheral nerve stimulator guided supraclavicular brachial plexus block.

RESULTS

Block using Ropivacaine as compared to Bupivacaine had faster sensory onset in minutes (7±3.37 vs. 10.17±3.34; P value 0.0005), faster motor onset in minutes (10.17±5 vs. 22.33±5.04), shorter duration of sensory block in minutes (437.16±55.54 vs. 633.38±58.33), shorter duration of motor block in minutes (411±57.15 vs. 698.16±47.89), shorter time required for rescue analgesia in minutes (78.66±25.56 vs. 73.83±21.11) and no complications.

CONCLUSIONS

0.2% Ropivacaine can be used as an alternative to 0.2% Bupivacaine in below elbow upper limb orthopaedic surgeries under ultrasound and nerve stimulator guided supraclavicular brachial plexus block for rapid onset of sensory block and early regression of motor block.

Patient-Reported Quality of Recovery after Local Anesthesia versus Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study

BACKGROUND

Both local anesthesia (LA) and brachial plexus (BP) anesthesia are commonly used in hand surgery. LA has increased efficiency and reduced costs, but BP is often favored for more complex hand surgery, despite requiring greater time and resources. The primary objective of this study was to assess the quality of recovery of patients who received LA or BP block for hand surgery. Secondary objectives were to compare postoperative pain and opioid use.

METHODS

This randomized, controlled, noninferiority study enrolled patients undergoing surgery distal to the carpal bones. Patients were randomized to either LA (wrist or digital block) or BP block (infraclavicular block) before surgery. Patients completed the Quality of Recovery-15 questionnaire on postoperative day (POD) 1. Pain level was assessed with a numeric pain rating scale, and narcotic consumption was recorded on POD1 and POD3.

RESULTS

A total of 76 patients completed the study (LA, n = 46, BP, n = 30). No statistically significant difference was found for median Quality of Recovery-15 score between LA [127.5 (interquartile range, 28)] and BP block [123.5 (interquartile range, 31)]. The inferiority margin of LA to BP block at the 95% confidence interval was less than the minimal clinically important difference of 8, demonstrating noninferiority of LA compared with BP block. There was no statistically significant difference between LA and BP block for numeric pain rating scale scores or narcotic consumption on POD1 and POD3 ( P > 0.05).

CONCLUSION

LA is noninferior to BP block for hand surgery with regard to patient-reported quality of recovery, postoperative pain, and narcotic use.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial

The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248-577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186-474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.

Periarticular injection in addition to interscalene nerve block can decrease opioid consumption and pain following total shoulder arthroplasty: a comparison cohort study

BACKGROUND

Interscalene nerve block (INB) is an effective technique to provide postoperative analgesia for total shoulder arthroplasty (TSA). However, the analgesic effects of the block typically resolve between 8 and 24 hours postadministration, which results in rebound pain and subsequent increased opioid use. The objective of this study was to address this issue by determining how adding an intraoperative periarticular injection (PAI) in combination with INB affects acute postoperative opioid consumption and pain scores in patients undergoing TSA. We hypothesized that compared with INB alone, INB + PAI will significantly reduce opioid consumption and pain scores for the first 24 hours postsurgery.

METHODS

We reviewed 130 consecutive patients who underwent elective primary TSA at a single tertiary institution. The first 65 patients were treated with INB alone, followed by 65 patients treated with INB + PAI. The INB used was 15-20 mL of 0.5% ropivacaine. The PAI used was 50 mL of a combination of ropivacaine (123 mg), epinephrine (0.25 mg), clonidine (40 μg), and ketorolac (15 mg). The PAI was injected using a standardized protocol: 10 mL into the subcutaneous tissues prior to incision, 15 mL into the supraspinatus fossa, 15 mL at the base of the coracoid process, and 10 mL into the deltoid and pectoralis muscles-a protocol analogous with a previously described technique. For all patients, a standardized postoperative oral pain medication protocol was used. The primary outcome was acute postoperative opioid consumption represented by morphine equivalent units (MEUs), whereas the secondary outcome was visual analog scale (VAS) pain scores over the first 24 hours postsurgery, operative time, length of stay, and acute perioperative complications.

RESULTS

No significant differences in demographics existed between patients who received INB alone vs. INB + PAI. Patients who received INB + PAI had a significantly lower 24-hour postoperative opioid consumption compared to the INB alone group (38.6 ± 30.5 MEU vs. 60.5 ± 37.3 MEU, P < .001). Additionally, VAS pain scores for the first 24 hours postsurgery in the INB + PAI group were significantly lower compared to those for the INB alone group (2.9 ± 1.5 vs. 4.3 ± 1.6, P ≤ .001). No differences existed between groups regarding operative time, length of inpatient stay, and acute perioperative complications.

CONCLUSION

Patients undergoing TSA with INB + PAI demonstrated significantly decreased 24-hour postoperative total opioid consumption and 24-hour postoperative pain scores compared to the group treated with INB alone. No increase in acute perioperative complications related to PAI was observed. Thus, compared to an INB, the addition of an intraoperative periarticular cocktail injection appears to be a safe and effective method to reduce acute postoperative pain following TSA.

Perineural low dexamethasone dose as adjuvant in supraclavicular brachial plexus block for arteriovenous fistula creation in end stage renal disease: a randomized controlled trial

BACKGROUND AND AIMS

Dexamethasone as adjunct to local anesthetic solution improves the quality of brachial plexus block (BPB). However, evidence for its efficacy at low doses (< 4 mg) is lacking. This study was designed to evaluate the duration of analgesia attained with low dose dexamethasone as adjuvant to local anesthetic for creation of arteriovenous fistula (AVF) under BPB.

METHODS

Sixty-six patients scheduled for AVF creation were randomly allocated to receive either saline (control) or 2 mg dexamethasone, together with 0.5% ropivacaine and 0.2% lignocaine. The primary outcome was duration of analgesia, defined as time from performing the block to the first analgesic request. The secondary outcomes were time from injection to complete sensory block, time from injection to complete motor block, duration of motor block, postoperative analgesic consumption, and fistula patency at three months.

RESULTS

All the blocks were effective. In the group that received dexamethasone, the time to first analgesic request was significantly delayed (432 ± 43.8 minutes vs. 386.4 ± 40.2 minutes; p < 0.01). The onset of sensory and motor blockade occurred faster in dexamethasone group and overall analgesic consumption was also reduced. However, dexamethasone addition did not prolong the duration of motor block. There was no statistically significant difference in the patency of fistulas between the two groups at three months. (p = 0.34).

CONCLUSION

Addition of low-dose perineural dexamethasone to local anesthetic solution significantly prolonged the duration of analgesia. Further trials are warranted to compare the adverse effects between dexamethasone doses of 4 mg and lower.

Comparison of the Analgesic Efficacy between Arthroscopically Placed Continuous Suprascapular Nerve Block and Ultrasound-guided Continuous Superior Trunk Block: A Double-blinded Randomized Controlled Trial

BACKGROUND

Single-shot suprascapular nerve block and superior trunk block have been reported to provide a noninferior analgesic effect after shoulder surgery with a lesser incidence of hemidiaphragmatic paresis compared with interscalene brachial plexus block. This study hypothesized that continuous suprascapular nerve block provides noninferior analgesia with minimal effects on diaphragmatic movement compared with continuous superior trunk block in patients undergoing arthroscopic shoulder surgery.

METHODS

100 patients were randomized undergoing arthroscopic shoulder surgery between December 2020 and October 2021 into continuous suprascapular nerve block and continuous superior trunk block groups. Before the surgery, patients received either a single-shot superior trunk block or subomohyoid suprascapular nerve block. Thereafter, a superior trunk catheter was inserted by anesthesiologists in patients in the continuous superior trunk block group, and a posterior suprascapular nerve catheter was inserted with arthroscopic assistance during the surgery by surgeon in the continuous suprascapular nerve block group. The primary outcome was the postoperative pain score at postoperative 24 h, and the incidence of hemidiaphragmatic paresis was also compared.

RESULTS

Overall, 98 patients were included in the final analysis. The worst and resting pain scores at postoperative 24 h in the continuous suprascapular nerve block group were inferior compared with those in the continuous superior trunk block group in the test with a noninferiority margin of 1 (worst pain score: mean difference, 0.9; 95% CI, 0.1 to 1.7; resting pain score: mean difference, 0.5; 95% CI, 0.0 to 1.0). However, the continuous suprascapular nerve block group had a significantly lower incidence of hemidiaphragmatic paresis at postoperative 24 h than the continuous superior trunk block group.

CONCLUSIONS

Continuous suprascapular nerve block provides statistically inferior analgesia compared to the continuous superior trunk block; however, the continuous suprascapular nerve block had a minimal effect on the phrenic nerve function.

EDITOR’S PERSPECTIVE

Dexmedetomidine versus sufentanil as adjuvants to bupivacaine for brachial plexus block during upper extremity surgery: a randomized clinical trial

BACKGROUND

Brachial plexus block (BPB) has been accepted as a reliable alternative for general anesthesia in upper limb surgeries. Adding adjuvant drugs like dexmedetomidine and sufentanil has been shown to have clinical and pharmacologic advantages. In this randomized parallel clinical trial, we aim to compare the effects of these two adjuvants for bupivacaine in BPB.

METHODS

In this double-blinded study, by using computer-assisted block randomization, 40 patients ranged from 20 to 65 years old and scheduled for elective upper limb surgeries were assigned to two equal study groups (n = 20), receiving 1 mL of 5 ..g.mL-1 sufentanil (group S) or 1 mL of 100 ..g.mL-1 dexmedetomidine (group D) in adjunction to 30 mL of 0.5% bupivacaine for supraclavicular BPB under the guidance of ultrasonography. Characteristics of local anesthesia and postoperative analgesia were evaluated (n = 40).

RESULTS

The duration of blocks significantly improved in group S (sensory: estimated median difference (EMD) [95%CI] = 100.0 [70.0...130.0], p < 0.001; motor: EMD [95%CI] = 120.0 [100.0...130.0], p < 0.001). Group S also had significantly longer postoperative analgesia and lower opioid consumption within 24 hours after the surgery (EMD [95%CI] = 4.0 [3.0...7.0], p < 0.001; EMD [95%CI] = -5.0 [-5.0...-5.0], p < 0.001; respectively). None of the patients showed adverse effects concerning vital signs, nausea, or vomiting.

CONCLUSION

Our study showed that during ultrasound-guided supraclavicular BPB, sufentanil is a fairly better choice than dexmedetomidine as an adjuvant for bupivacaine and can provide preferable sensory and motor blocks. No significant side effects were seen in either of the study groups.

The Median Effective Volume of 0.375% Ropivacaine for Ultrasound-guided Anterior Suprascapular Nerve Block in Arthroscopic Shoulder Surgery

BACKGROUND

The suprascapular nerve (SSN) is an important nerve that contributes to shoulder joint sensation and movement. The anterior suprascapular nerve block (aSSNB) has the potential for noninferior analgesic effect compared with the interscalene block while preserving respiratory function. This study investigated the median effective volume (MEV) of 0.375% ropivacaine in aSSNB for analgesic effect among patients undergoing arthroscopic shoulder surgery.

OBJECTIVES

Our primary objective was the MEV. The secondary objectives included the 24 hour sufentanil consumption, 24 hour patient-controlled analgesia (PCA) presses, and incidences of diaphragm impairment.

STUDY DESIGN

Prospective registered (ChiCTR2300070129), single-armed, volume-finding study.

SETTING

This study was conducted in a tertiary, single center.

METHODS

There were 23 patients who completed the study. Using an up-and-down process, patients enrolled in the study received different volumes of 0.375% ropivacaine for an aSSNB adjusted based on the success or failure of the previous patient in the study's block by increasing or decreasing the volume by 3 mL. The first patient received 15 mL of 0.375% ropivacaine. The nerve blocks were evaluated by the sensory score of the C5 and C6 dermatomes.

RESULTS

MEV50 (50% of the patients) was 6 mL (95% CI, 5.78 - 6.78 mL), and MEV95 (95% of the patients) was 13.88 mL (95% CI, 13.37 - 14.87 mL). There was no significant difference in the PCA presses, 24 hour sufentanil consumption, and incidences of diaphragm impairments between successful and unsuccessful blocks.

LIMITATIONS

Our study focused on the analgesic effect rather than hemi-diaphragmatic paralysis with 0.375% ropivacaine for an aSSNB. The study also did not test varying ropivacaine concentrations while keeping the volume constant. Further investigation with varying concentrations and a larger sample size is indicated to address the optimal volume and concentration to balance analgesia and diaphragm function.

CONCLUSIONS

To produce effective analgesic effect, the MEV50 is 6 mL, and the MEV95 is 13.88 mL in patients undergoing arthroscopic shoulder surgery who receive an aSSNB using 0.375% ropivacaine for analgesia.

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.

How Does the Addition of Dexamethasone to a Brachial Plexus Block Change Pain Patterns After Surgery for Distal Radius Fractures? A Randomized, Double-blind Study

BACKGROUND

Although brachial plexus block in volar plating surgery for distal radius fractures is reportedly associated with lower postoperative pain scores, rebound pain has been reported to occur after the initial block wears off. Dexamethasone can be used in multimodal strategies for antiemesis and to control pain postoperatively. Although prior studies have suggested that anesthesia can be prolonged by adding dexamethasone to regional blocks, no randomized trials we are aware of have ascertained whether doing so will make a clinically important difference in pain after surgery for distal radius fractures.

QUESTIONS/PURPOSES

Do patients who receive supplemental dexamethasone in a brachial plexus block for volar plating of unstable distal radius fractures have (1) better pain scores at 4, 8, 24, and 48 hours postoperatively than patients who have not received dexamethasone, and (2) lower fentanyl consumption and administration of antiemetic drugs without change in serum blood glucose, as well as a longer analgesic duration from the block after surgery than patients who have not received dexamethasone?

METHODS

This randomized, double-blind trial included 69 patients undergoing surgery for distal radius fractures under ultrasound-guided supraclavicular brachial plexus blocks who were randomly allocated into two groups: a nondexamethasone group receiving a brachial plexus block with 0.5% ropivacaine and a dexamethasone group receiving 0.5% ropivacaine and 5 mg of dexamethasone. Thirty-four patients were allocated to the dexamethasone group and 35 were allocated to the nondexamethasone group. Nine patients (four in the dexamethasone group and five in the nondexamethasone group) were excluded after randomization because local anesthetics were used during their surgical procedures owing to an incomplete block or they requested patient-controlled analgesia after surgery. The treatment groups did not differ in any important ways, including age, gender, BMI, hand dominance, and AO/Orthopaedic Trauma Association classification. All patients received the same surgical procedure and perioperative care protocol, except for the injected agents during their brachial plexus block. The primary outcome was postoperative pain, evaluated using a 10-mm VAS at 4, 8, 12, 24, and 48 hours after surgery. The minimum clinically important difference for the VAS score was 2 of 10 points. Secondary outcome variables included fentanyl administration as a rescue analgesic, the number of patients receiving antiemetic medications because of fentanyl administration, and the duration of brachial plexus block. Serum blood glucose was measured 1 day before, immediately after, and 24 hours after surgery. Patients, surgeons, and outcome assessors were blinded to treatment allocation.

RESULTS

The only clinically important between-group difference in VAS pain scores was at 8 hours, favoring the group that received dexamethasone over the group that did not (1.9 ± 1.6 versus 4.7 ± 2.7; mean difference -2.8 [95% CI -3.9 to -1.6]; p < 0.001). After brachial plexus block, the most severe pain score in both groups was reported at 12 hours postoperatively and gradually diminished over time. There was no between-group difference in fentanyl use between those who received dexamethasone and those who did not (21 ± 38 mcg versus 31 ± 29 mcg; mean difference -10 [95% CI -27.4 to 7.4]; p = 0.26). Furthermore, the use of antiemetics did not differ between the groups (27% [eight of 30] versus 37% [11 of 30]; odds ratio 1.6 [95% CI 0.5 to 4.8]; p = 0.41). Baseline and 24-hour postoperative serum blood glucose level did not differ between the groups. However, the immediately postoperative serum blood glucose level was higher in the dexamethasone group than in the nondexamethasone group (121 ± 29 versus 104 ± 20; mean difference 16 [95% CI 3.3 to 28.8]; p = 0.02). The brachial plexus block duration was 3 hours longer (95% CI 0.8 to 5.2 hours) in the dexamethasone group than that in the nondexamethasone group (11 ± 5 hours versus 8 ± 3 hours; p = 0.01).

CONCLUSION

The postoperative pain level in patients who received supplemental dexamethasone in a regional block was not clinically different from that of patients who received conventional brachial plexus block anesthesia when undergoing volar plating for distal radius fractures. However, patients who received a brachial plexus block with dexamethasone experienced slight prolongation of their block and decrease in pain 8 hours after surgery.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Ultrasound guided interscalene brachial plexus block

Peripheral nerve blocks have long been established as a crucial part of the enhanced recovery pathways after surgery. Interscalene brachial plexus block (ISB) is mainly indicated for anaesthesia and analgesia during shoulder and proximal arm surgery. Ultrasound technology has remarkably improved the efficacy and success rates of the ISB while limiting its potential complications.

Ultrasound-guided brachial plexus block at the clavicle level: A review

The supraclavicular block (SCB) and the infraclavicular block (ICB) are introduced to meet upper extremity surgery, where the transducer or the insertion point is placed superiorly and inferiorly at the approximate midpoint of the clavicle, respectively. These two approaches are highly appealing since they clearly exhibited each cord and its associated anatomy. In addition, it directed the needle accurately with real-time imaging by ultrasound guidance. Therefore, it brought higher success rates and fewer complications. Numerous trials have recently been conducted to examine the SCB and ICB regarding the new approach, injection techniques, block dynamics, and complication of hemidiaphragmatic paresis. It was found that both approaches could improve block effectiveness and postoperative analgesia for upper extremity surgery, according to recent studies at the level of the clavicular brachial plexus block. However, there is still a lack of work comparing the clinical performance and effectiveness of both approaches with ultrasonography. This review aims to outline the current available data from clinical trials along with case reports about these two approaches and to describe the findings published in the literature during the previous 5 years. Based on these findings, we attempt to determine whether there exists a one-size-fits-all approach that has the potential to meet upper extremity surgery.

Long-duration upper extremity surgery under brachial plexus block combined with intravenous dexmedetomidine sedation without an anesthesiologist

BACKGROUND

Dexmedetomidine (DEX) provides a unique conscious sedation without respiratory depression. We examined the usefulness of intravenous (IV) DEX sedation combined with brachial plexus block for long-duration upper extremity surgery without an anesthesiologist.

METHODS

We retrospectively reviewed 90 limbs of 86 patients and measured the actual operative time course in detail. The adverse events and the patient-reported outcomes regarding intraoperative pain and depth of sedation were evaluated.

RESULTS

The mean total time of the operation, tourniquet use, and the IV DEX sedation were 150 min, 132 min, and 117 min, respectively. The mean time between discontinuation of IV DEX sedation and completion of the operation was 51 min. The intraoperative adverse events involved bradycardia (21%), hypotension (18%), and oxygen desaturation (3%). The mean visual analog scale scores of pain during brachial plexus block, surgical site pain, tourniquet pain, and depth of the sedation were 23.4 mm, 0.14 mm, 4.2 mm, and 6.6 mm, respectively. Furthermore, 96% patients expressed a preference for receiving anesthesia as brachial plexus block with IV DEX sedation.

CONCLUSIONS

Long-duration upper extremity surgery, even longer than 2 h, was feasible under brachial plexus block combined with IV DEX sedation without an anesthesiologist. For patients with low blood pressure and/or low heart rate, it is recommended to adjust the continuous infusion of IV DEX to less than 0.4 µg/kg/h. To ensure that the patients are able to promptly leave the operating room fully awake, IV DEX infusion should be stopped at least 30 min before finishing the operation.

Low-Volume Targeted Interscalene Brachial Plexus Block in the Emergency Department as a Safer Alternative for Pain Control for Glenohumeral Reduction: A Case Series

BACKGROUND

Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation.

CASE SERIES

We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5-10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

A Comparison of Distal Nerve Blocks and Brachial Plexus Blocks in Terms of Block Success, Block-related Characteristics, Time to Discharge and Patient Satisfaction

Background: Ultrasound-guided brachial plexus blocks (BPB) are used as an anaesthetic method in hand and wrist surgeries. The radial, median and ulnar nerves can also be selectively blocked. The objective of this retrospective cohort study was to compare distal nerve blocks (DNB) and BPB in terms of block success, block-related characteristics, time to discharge and patient satisfaction. Methods: The data of patients who underwent elective hand and wrist surgery under regional anaesthetic procedures between 01.01.2022 and 01.09.2022 were analysed. Standard multimodal analgesia was performed in all groups, in addition to either ultrasound-guided BPB or DNB. Demographic characteristics, American Society of Anaesthesiology (ASA) classes, presence of additional diseases, block and volume applied, block-related data such as block performance time, onset time, initial analgesia times, perioperative additional anaesthetic or analgesic requirement, surgery times, types of surgery, discharge times and the presence of additional complaints were recorded. In addition, the anaesthesia quality score were determined using a 5-point Likert scale. Results: There was no difference between demographic data. Average surgical time was similar between the DNB and BPB groups (46.0 ± 8.92 vs. 59.95 ± 22.04 min, p < 0.05). Block onset time was significantly lower in the DNB group (26.4 ± 2.73 vs. 32.17 ± 2.94 min, p < 0.001). When patients discharged before and after 12 hours were compared, 11/22 of the patients in the DNB group and 4/23 of the patients in the BPB group were discharged in the first 12 hours (p < 0.05). Patient satisfaction scores were similar between groups (14.22 ± 0.86 vs. 13.65 ± 1.11, p > 0.05). Conclusions: In surgeries of the hand and wrist, the radial, median and ulnar nerves can be used individually or in combination as an alternative to proximal BPB. Level of Evidence: Level III (Therapeutic).

A Comparative Cost Analysis of Local Anesthesia versus Brachial Plexus Block for Complex Hand Surgery

BACKGROUND

Local anesthesia has shown to be safe and cost-effective for elective hand surgery procedures performed outside of the operating room. The economic benefits of local anesthesia compared to regional anesthesia for hand surgeries performed in the operating room involving repair of tendons, nerves, arteries, or bones are unclear. This study aimed to compare costs pertinent to hand surgeries performed in the main operating room under local anesthesia (LA) or brachial plexus (BP) block.

METHODS

We performed a cross-sectional study on the first 70 randomized patients from a prospective controlled trial of anesthesia modalities for hand surgery. The primary objective was to determine the mean anesthesia-related cost, and the secondary objectives were to analyze block performance time, block onset time, duration of anesthesia, duration of surgery, and time in the recovery room.

RESULTS

The mean anesthesia-related cost of performing hand surgery under LA as a wrist and/or digital block was $236 ± 30, compared to $435 ± 43 for BP, a difference of $199 per case. The mean block performance time was shorter for LA (1.3 minutes) versus BP (7.0 minutes). The mean anesthesia-related time was longer in BP (30.7 ± 16 minutes) compared to LA (17.7 ± 6.7 minutes), and consequently the total anesthesia time was longer in BP.

CONCLUSIONS

We demonstrated that local anesthesia compared to brachial plexus block achieved substantial cost savings in complex hand surgeries by decreasing major expenses. In an era of cost-consciousness, the use of LA represents an important modality for health systems to optimize patient flow and increase cost-effectiveness.

The Effects of Vasodilation Induced by Brachial Plexus Block on the Development of Postoperative Thrombosis of the Arteriovenous Access in Patients with End-Stage Renal Disease: A Retrospective Study

Although brachial plexus block (BPB)-induced vasodilation reduces the incidence of arteriovenous access (AC) thrombosis, BPB cannot completely prevent its development. Therefore, we retrospectively investigated the factors affecting BPB-induced vasodilation and their effects on AC thrombosis development. Ninety-five patients undergoing AC surgery under BPB were analyzed. Vessel diameters were measured before and 20 min after BPB. The surgery abandoned before the BPB placement was performed when the BPB-induced increases in vessel diameters met its indications. Complete occlusive access thrombosis (COAT) was defined as loss of pulse, thrill, or bruit. Fourteen patients (14.7%) developed COAT. The outflow vein was more dilated by BPB than the inflow artery (0.6 versus 0.1 mm in median, p < 0.001). The original surgery plan was changed for seven patients (7.4%). Diabetes mellitus (DM) and ischemic heart disease (IHD) decreased the extent of increases in the inflow artery by -0.183 mm (95% confidence interval [CI] [-0.301, -0.065], p = 0.003) and outflow vein diameters by -0.402 mm (95% CI [-0.781, -0.024], p = 0.038), respectively. However, DM, IHD, and changes in the vessel diameters had insignificant effects on the development of COAT. In conclusion, although DM and IHD attenuate the vasodilating effects of BPB, they do not contribute to the development of COAT.

A Comparison of Anesthetic Quality between Single and Septum-based Double Injection for Ultrasound-Guided Costoclavicular Block: A Randomized Controlled Trial

BACKGROUND

In a costoclavicular (CC) approach of an ultrasound (US)-guided infraclavicular brachial plexus block (BPB), a septum between the lateral and the medial/posterior cords can result in an incomplete block. We hypothesized that double injections in each compartment between the septum would result in a higher success rate of BPB than a single injection in the center of the CC space.

OBJECTIVES

This study was conducted to confirm the superiority of block quality achieved by septum-based double injections (experimental group; group E) over single injection in the center of the CC space (control group; group C).

STUDY DESIGN

A randomized, controlled trialSETTING: Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital.

METHODS

Sixty-eight patients who underwent upper extremity surgery randomly received a single (SI group, n = 34) or a septum-based double injection (DI group, n = 34) using the CC approach. Ten milliliters of 2% lidocaine, 10 mL of 0.75% ropivacaine, and 5 mL of normal saline were used for BPB in each group (total 25 mL). Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at 5-minute intervals for 30 minutes immediately after local anesthesia administration. The assessed variables were the success rate, the rate of all 4 nerves blockade, and onset time.

RESULTS

Thirty minutes after the block, the success rate was significantly higher in the DI group than in the SI group (64.7% in the SI group vs 91.2% in the DI group, P = 0.009), and the rate of all 4 nerves blockade also significantly increased in the DI group compared to the SI group (44.1% in the SI group vs 91.2% in the DI group, P = 0). The onset time was significantly shortened in the DI group compared with the SI group (26.3 ± 5.6 min in the SI group vs 21.3 ± 6.2 min in the DI group, P = 0.010).

LIMITATIONS

We considered that the location of the septum was always between the lateral cord superficially and the medial/posterior cords below it. In some patients in whom the septum was not visible, a superficial lateral cord was injected first, and then deep medial and posterior cords were injected, assuming that the 2 compartments were divided by the septum.

CONCLUSIONS

Compared with the SI, the septum-based DI of CC approach increased the success rate and the rate of all 4 nerves blockade and shortened the onset time.

Safety and Duration of Low-Dose Adjuvant Dexamethasone in Regional Anesthesia for Upper Extremity Surgery: A Prospective, Randomized, Controlled Blinded Study

BACKGROUND

Orthopedic procedures concerning the upper extremity commonly use a brachial plexus nerve block to achieve postoperative analgesia. The addition of dexamethasone to peripheral nerve blocks has been shown to significantly prolong its effect. We hypothesize that 1 mg doses of dexamethasone will prolong brachial plexus nerve block with similar efficacy to 4 mg and better than ropivacaine alone.

METHODS

Seventy-nine patients who received a brachial plexus nerve block prior to undergoing upper extremity surgery were randomized to 1 of 4 treatment groups: group 1 received only 30 mL of 0.5% ropivacaine without dexamethasone (control); groups 2, 3, and 4 received 4, 2, and 1 mg of dexamethasone, respectively, added to 30 mL of 0.5% ropivacaine.

RESULTS

Comparison of block duration, specifically "first signs of the block wearing off" to the 0-mg group, referencing the 1-, 2-, and 4-mg groups (P = .02, .04, and .01, respectively) that received steroid adjuvant therapy demonstrated a significant increase in time until the block began to wear off. All study groups receiving steroids also demonstrated a significant increase in duration of the block prior to its effects being completely gone when compared with the control group (P < .01 for all groups).

CONCLUSIONS

Our findings demonstrate that adjuvant dexamethasone can prolong brachial plexus nerve blocks effectively at low doses compared with high doses, in addition to prolonging analgesia compared with local anesthetic alone.

Comparison of Erector Spinae Plane Block at the Level of the Second Thoracic Vertebra With Suprascapular Nerve Block for Postoperative Analgesia in Arthroscopic Shoulder Surgery

BACKGROUND

Appropriate postoperative pain management in shoulder surgeries is the mainstay of rehabilitation therapy and subsequent improved functional outcomes. However, adequate pain control either with opioids or interscalene brachial plexus block is often challenged by their side effects. In this context, this study compared the suprascapular nerve block (SSNB) to the newly emerging erector spinae plane block at the second thoracic vertebral level (high thoracic-ESPB) as an alternative pain therapy.

OBJECTIVES

This study aimed to compare the efficacy of high thoracic-ESPB with SSNB as analgesic options for arthroscopic shoulder surgery.

STUDY DESIGN

Prospective randomized, double-blinded, controlled, clinical trial.

SETTING

This clinical trial was performed at Zagazig University.

METHODS

This prospective, randomized controlled clinical trial was registered at ClinicalTrials.gov (NCT04669639, December 15, 2020). Patient enrollment was initiated after the registration date (December 20, 2020), and the study was conducted from December 2020 to November 2021. Ninety-six adult patients who prepared for arthroscopic surgeries were assigned to the high thoracic-ESPB group, SSNB group, and control group; all with 32 patients each.

RESULTS

A significant difference was found between the control group and block groups concerning the Numeric Rating Scale (NRS-11) at recovery, 2, 4, 6, 8, and 12 hours postoperatively at rest and with shoulder movement. However, the NRS-11 was significantly higher in the SSNB group than in the high thoracic-ESPB group only with movement both at recovery and 2 hours postoperatively. Otherwise, no significant difference between the 2 block groups was found throughout different time points of the study. The doses of fentanyl given intraoperatively were significantly higher in the control group than in the high thoracic-ESPB and SSNB groups (mean ± standard deviation [SD], 326.6 ± 45.8, 224.7 ± 17.1, and 232.8 ± 17.8; P value < 0.001, respectively). A significant difference also was observed concerning postoperative morphine use, where the mean ± SD was 18.8 ± 2.9 in the control group vs 5.7 ± 1.02 and 6 ± 0.81 (P value < 0.001) in the high thoracic-ESPB and SSNB groups, respectively.

LIMITATIONS

A continuous local anesthetic (LA) infusion catheter can be used either in the high thoracic-ESPB or SSNB to provide extended periods of analgesia. However, our investigation was confined to a single LA injection.

CONCLUSIONS

SSNB is not inferior to high thoracic-ESPB in the context of phrenic nerve sparing pain control for arthroscopic surgeries. Moreover, SSNB is a more established technique with more predicted sensory distributions and a lower risk of LA toxicity.

Are the perfusion İndex and pleth variability index title an early İndicator of brachial plexus block?

BACKGROUND

Studies on the evaluation of the Perfusion Index (PI) and the Pleth Variability Index (PVI) and the success of PI and PVI block in patients undergoing brachial plexus are limited and quite inadequate.

AIM

In our study, we aimed to compare PI and PVI between the interscalen block and infraclavicular block and evaluate its use as an early marker in block success.

PATIENTS AND METHODS

Single-center prospective randomized controlled trials. Preoperative unit, operating room. Patients over 18 years of age who have had upper extremity surgery. Brachial plexus block (interscalene, infraclavicular). Demographic data, Hemodynamic parameters, Perfusion index and Pleth Variability Index. 40 patients, including ASA1-2, 20 patients over the age of 18, who were planned for upper extremity surgery, in the interscalen group, and 20 in the supraclavicular group, were included in the study. Demographic data of the patients were recorded by measuring PI and PVI values at baseline before the block and at the 1^st, 5^th, 10^th, 15^th, and 20^th minutes after the block, both simultaneously.

RESULTS

62.5% (n = 25) of the patients included in the study were female. The mean age of the patients was detected as 52.63 ± 16.472, the mean BMI as 26.57 ± 4.423, and the mean entry hemoglobin level as 13.71 ± 1.87 g/dL. The hemodynamic data of the groups were similar across the time periods. The increase in PI increased significantly after 1 minute in both groups. The PVI was similar between the groups at all measurement times.

CONCLUSION

In our study, we observed an increase in PI from the 1^st minute compared to the non-blocked arm in successful block applications. We consider the early indicator of PI in the evaluation of block success. In our study, we did not observe a significant change in the arm that was blocked and the arm that was not treated with PVI.

Evaluation of the Effect of Interscalene Brachial Plexus Block on Intracranial Pressure Using Optic Nerve Sheath Diameter and Internal Jugular vein Collapsibility Index

OBJECTIVE

To determine the effect of single-shot interscalene brachial plexus (ISBP) block on intracranial pressure (ICP) by evaluating the extravascular volume effect of the medicine on the internal jugular vein (IJV).

STUDY DESIGN

Interventional study.

PLACE AND DURATION OF STUDY

Department of Anaesthesiology and Reanimation, Sivas Cumhuriyet University, Sivas, Turkey, from January to June 2022.

METHODOLOGY

Thirty-four patients were included in this prospective clinical study. All patients had single-shot ISBP block with 25 ml of local anaesthetic. Optic nerve sheath diameter (ONSD), maximum (Dmax) and minimum (Dmin) diameters of IJV and IJV collapsibility index (IJV-CI) were recorded before the block (basal), 20 minutes, and 60 minutes after the block.

RESULTS

Twenty-nine patients had higher ONSD values at 60th minute compared to their basal values. There were negative correlations between the changes of ONSD and IJVCI (r=0.616, p<0.001) and ONSD and Dmax (r=0.581, p<0.001) in time period between basal and 20th minute. There were negative correlations between the changes of ONSD and IJVCI (r=0.518, p=0.002), ONSD and Dmax (r=0.664, p<0.001) in time period between basal and 60th minute.

CONCLUSION

Single-shot ISBP block with 25 ml of local anaesthetic may be a factor that increases ICP. Repeated intraoperative ONSD measurements are recommended in patients operated with ISBP block.

KEY WORDS

Interscalene Brachial Plexus Block, Intracranial pressure, Optic nerve sheath diameter, Internal jugular vein collapsibility index.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction

BACKGROUND

Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction.

CASE REPORT

We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

Effect of remifentanil on post-operative analgesic consumption in patients undergoing shoulder arthroplasty after interscalene brachial plexus block: a randomized controlled trial

PURPOSE

Remifentanil is useful in balanced anesthesia; however, there is concern regarding opioid-induced hyperalgesia. The effect of remifentanil on rebound pain, characterized by hyperalgesia after peripheral nerve block has rarely been studied. This study evaluated whether intraoperative remifentanil infusion may increase postoperative analgesic requirement in patients receiving preoperative interscalene brachial plexus block (IBP).

METHODS

Sixty-eight patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly allocated to remifentanil (R) or control (C) group. Preoperative IBP with 0.5% ropivacaine 15 mL was performed in all patients. Intraoperative remifentanil was administered only in the R group. Postoperative pain was controlled using intravenous patient-controlled analgesia (IV-PCA) and rescue analgesics. The primary outcome was the dosage of fentanyl-nefopam IV-PCA infused over 24 h postoperatively. The secondary outcomes included the numeric rating scale (NRS) score recorded at 4-h intervals over 24 h, amount of rescue analgesics and total postoperative analgesics used over 24 h, occurrence of intraoperative hypotension, postoperative nausea and vomiting (PONV) and delirium.

RESULTS

The dosage of fentanyl-nefopam IV-PCA was significantly less in C group than R group for postoperative 24 h. Fentanyl 101 [63-158] (median [interquartile range]) µg was used in the C group, while fentanyl 161 [103-285] µg was used in the R group (median difference 64 µg, 95% CI 10-121 µg, P = 0.02). Nefopam 8.1 [5.0-12.6] mg was used in the C group, while nefopam 12.9 [8.2-22.8] mg was used in the R group (median difference 5.1 mg, 95% CI 0.8-9.7 mg, P = 0.02). The total analgesic consumption: the sum of PCA consumption and administered rescue analgesic dose, converted to morphine milligram equivalents, was higher in the R group than C group (median difference 10.9 mg, 95% CI 3.0-19.0 mg, P = 0.01). The average NRS score, the incidence of PONV and delirium, were similar in both groups. The incidence of intraoperative hypotension was higher in R group than C group (47.1% vs. 20.6%, P = 0.005).

CONCLUSIONS

Remifentanil administration during arthroscopic shoulder surgery in patients undergoing preoperative IBP increased postoperative analgesic consumption.

Comparison of infraclavicular brachial plexus block versus wide-awake local anesthesia no-tourniquet technique in the management of radial shortening osteotomy

OBJECTIVES

The aim of this study was to evaluate the feasibility of the wide-awake local anesthesia no-tourniquet (WALANT) technique in radial shortening osteotomy and to compare it with the infraclavicular brachial plexus block (IBPB).

PATIENTS AND METHODS

Between January 2020 and January 2021, a total of 26 patients (16 males, 10 females, mean age: 40±4.9 years; range, 29 to 45 years) with Kienbock's disease who underwent radial shortening osteotomy were retrospectively analyzed. The patients were divided into two groups according to the type of anesthesia as WALANT (Group 1, n=11) and IBPB (Group 2, n=15) anesthesia. Visual Analog Scale (VAS) during surgery, time from anesthesia to surgical incision, surgical time, overall patient satisfaction regarding the anesthesia was assessed. The Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) and handgrip strengths were compared at the final follow-up and short-term outcomes were analyzed.

RESULTS

Age (p=0.896), sex (p=1.000), and dominant side involvement (p=1.000) were similar between the groups. Waiting time to start surgery in both groups was similar (27 vs. 25 min; p=0.053). Intraoperative VAS-pain scores and the satisfaction from the anesthesia type of both groups were also similar (p=0.546 and p=0.500).

CONCLUSION

The WALANT may be another anesthesia technique for radial shortening osteotomy with favorable outcomes. This technique adequately allows the surgeon to perform osteotomy and obtain a stable reduction without undue risk of tourniquet pain and palsy.

Determination of the minimum effective volume of bupivacaine for ultrasound-guided infraclavicular brachial plexus block: a prospective, observer-blind, controlled study

Background

We aimed to determine the minimum effective volume (MEV) of 0.5% bupivacaine for infraclavicular brachial plexus block.

Methods

We assigned patients to volume groups consisting of five consecutive patients. Local anesthetic was sequentially reduced from a starting dose of 30 mL by 2 mL to form the volume groups. Five patients were included in each volume group, and at least 3 of 5 injections had to be successful to consider the volume of the anesthetic as sufficient. The study ended when the anesthetic volume of a group was determined to be unsuccessful (two or fewer successful blocks). Block was successful if the patient reported a sensorial block score of 7 or more on an 8-point scale and sensorial and motor block's total score of 14 on a 16-point scale.

Results

The MEV of 0.5% bupivacaine for infraclavicular brachial plexus block was 14 mL. A successful block was achieved in all patients (n = 45) in 9 volume groups, which received 30 mL down to 14 mL. Three blocks were unsuccessful in the 12-mL group. Time to onset of block and time to first postoperative anesthetic administration was 15 (10–15) min and more than 24 h in the 30-mL bupivacaine group, but 40 (30–45) min and 14 (10–24) h were determined for the 14-mL group, respectively.

Conclusions

The MEV of 0.5% bupivacaine for ultrasound-guided infraclavicular brachial plexus block was 14 mL. However, this low-dose block has a long onset time of 40 (30–45) min on average.

Effects of local anaesthetic dilution on the characteristics of ultrasound guided axillary brachial plexus block: a randomised controlled study

AIMS

Ultrasound guidance has led to marked improvement in the success rate and characteristics of peripheral nerve blocks. However, effects of varying the volume or concentration of a fixed local anaesthetic dose on nerve block remains unclear. The purpose of our study was to evaluate whether at a fixed dose of lidocaine, altering the volume and concentration will have any effect on the onset time of ultrasound-guided axillary brachial plexus block.

MATERIAL AND METHODS

Twenty patients were randomised to receive an ultrasound-guided axillary brachial plexus block with either lidocaine 2% with epinephrine (20 ml, Group 2%) or lidocaine 1% with epinephrine (40 ml, Group 1%). The primary endpoint was block onset time. Secondary outcomes included duration of the block, performance time, number of needle passes, incidence of paraesthesia and vascular puncture.

RESULTS

The median [IQR] onset time of surgical anaesthesia was shorter in Group 1% when compared to Group 2% (6.25 [5-7.5] min vs 8.75 [7.5-10] min; p=0.03). The mean (SD) overall duration of surgical anaesthesia was significantly shorter in Group 1% compared to Group 2% (150.9±17.2 min vs 165.1±5.9 min; p=0.02). Group 1% had a shorter performance time with fewer needle passes. The incidence of vascular puncture and paraesthesia was similar in the two groups.

CONCLUSION

 Ultrasound-guided axillary brachial plexus blocks performed using a higher volume of lower concentration lidocaine was associated with shorter onset time and duration of surgical anaesthesia.

Alpha2 -receptor agonists as adjuvants for brachial plexus nerve blocks-A systematic review with meta-analyses

BACKGROUND

We review the efficacy and safety of dexmedetomidine and clonidine as perineural or systemic adjuvants for brachial plexus blocks (BPB).

METHODS

We included randomised controlled trials on upper limb surgery with BPBs in adults, comparing dexmedetomidine with clonidine or either drug with placebo. The primary outcome was duration of analgesia. Secondary outcomes included adverse and serious adverse events. The review was conducted using Cochrane standards, trial sequential analyses (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

We included 101 trials with 6248 patients. Overall, duration of analgesia was prolonged with both clonidine (176 min [TSA adj. 95% CI: 118, 205, p < .00001; 33 trials]) and dexmedetomidine (292 min [TSA adj. 95% CI: 245 329, p < .00001; 53 trials]), but was longer for dexmedetomidine than clonidine (205 min [TSA adj. 95% CI: 157, 254, p < .00001; 19 trials]). Compared with placebo, dexmedetomidine was associated with bradycardia (RR 4.2 [95% CI 2.2, 8.3]), and both clonidine (RR 4.5 [95% CI 1.1, 18.3]) and dexmedetomidine (RR 3.9 [95% CI 2.0, 7.5]) were associated with hypotension. Serious adverse events were mostly related to block technique. GRADE-rated quality of evidence was low or very low.

CONCLUSION

Alpha2-receptor agonists used as adjuvants for BPBs lead to a prolonged duration of analgesia, with dexmedetomidine as the most efficient. Alpha2-receptor agonists were associated with increased risk of cardiovascular adverse events. The quality of evidence was low to very low.

[Interscalene block and shoulder surgery. Literature review and new method of infiltration]

Nowadays, interscalene block is the gold standard for intra- and post-operative analgesia for shoulder surgery. It consists of distributing a sufficient volume of local anesthetics, within the interscalenic space which contains the C5 to C7 nerve roots. Due to its proximity to the area where the anesthetic is injected, the phrenic nerve can be transiently blocked causing a kind of paralysis of an hemidiaphragm. First, the use of ultrasound has reduced the incidence of diaphragmatic hemiparesis especially when the injection is performed at the C7 level rather than the C5 or C6 level. Then, decreasing the doses of local anesthetics has reduced the diffusion to the non-targeted structures, such as the phrenic nerve, causing less diaphragmatic hemiparesis. Finally, Palhais and Lee et al discovered that injecting LA at distance from the nerves roots can be useful in reducing this side effect. Based on their work, we decided to inject the local anesthetic into the muscle fascia. Our experience with this injection into the muscle itself seems to confirm the results described in the literature with less diaphragmatic hemiparesis. Further studies are needed to support our hypothesis and will be the subject of future researches in our institution.

Perineural Versus Intravenous Dexamethasone for Brachial Plexus Block: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Perineural (PN) dexamethasone (DEX) administration can prolong the analgesic time of a brachial plexus block. However, its efficacy and safety are controversial due to its off-label use and different routes of administration.

OBJECTIVES

This meta-analysis aimed to assess the safety and efficacy of PN versus intravenous (IV) dexamethasone.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

SETTING

Relevant studies were found through a comprehensive literature search of PubMed, Web of Science, Ovid, EMBASE, and the Cochrane Library (from the inception until January 2020).

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this meta-analysis was conducted to identify RCTs comparing PN and IV dexamethasone in brachial plexus block. A randomized effect model was used in the meta-analysis and the subgroup analysis was performed with adrenaline stratification. The quality of evidence and the strength of recommendations were graded by GradePro version 3.6.1.

RESULTS

Twelve RCTs with a total of 1,345 subjects were included. We found that PN dexamethasone could prolong the duration of analgesia (mean difference [MD]: 131.82 minutes, 95% confidence interval [CI] [38.96, 224.68], I2 = 82%, P = 0.005), motor block (MD: 218.85 minutes, 95% CI [113.65,324.05], I2 = 72%, P < 0.0001) and sensory block (MD: 209.57 minutes, 95% CI [72.64, 346.50], I2 = 87%, P = 0.003) in the main analysis with significant difference. In the absence of epinephrine, there were no significant differences between PN dexamethasone and IV dexamethasone. Except for adverse-effects, no significant differences were observed in secondary outcomes. PN dexamethasone had slightly higher adverse-effects; however, these could be altered if a sensitivity analysis was conducted.

LIMITATIONS

There was high heterogeneity among included studies.

CONCLUSIONS

PN dexamethasone can prolong the duration of analgesia, sensory block, and motor block, when compared with IV dexamethasone. In a subgroup analysis without epinephrine, the 2 routes of administration were equivalent to topical anesthesia. There were no differences in secondary outcomes, except for adverse effects, which could be altered if a sensitivity analysis was conducted. Therefore, despite the advantages of PN dexamethasone, caution is needed due to its off-label character. While the results of this study are promising, additional large and well-designed RCTs are needed to validate these initial findings and their implications.

A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects

BACKGROUND

Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear.

QUESTIONS/PURPOSES

(1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes?

METHODS

From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway.

RESULTS

On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03).

CONCLUSION

Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Opioid-Free Arthroscopic Rotator Cuff Repair

Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].

Analgesic duration of interscalene block after outpatient arthroscopic shoulder surgery with intravenous dexamethasone, intravenous dexmedetomidine, or their combination: a randomized-controlled trial

PURPOSE

Both intravenous dexamethasone and dexmedetomidine prolong the analgesic duration of interscalene blocks (ISB) after arthroscopic shoulder surgery. This study compared their relative effectiveness and the benefit of their use in combination.

METHODS

This single-centre, double-blinded, parallel three-group superiority trial randomized 198 adult patients undergoing ambulatory arthroscopic shoulder surgery. Patients received preoperative ISB with 30 mL 0.5% bupivacaine and 50 µg dexmedetomidine or 4 mg dexamethasone or both of these agents as intravenous adjuncts. The primary outcome was analgesic block duration. Secondary outcomes included the quality of recovery 15 score (range: 0-150) on day 1 and postoperative neurologic symptoms in the surgical arm.

RESULTS

Block durations (n = 195) with dexamethasone (median [range], 24.5 [2.0-339.5] hr) and both adjuncts (24.0 [1.5-157.0] hr) were prolonged compared with dexmedetomidine (16.0 [1.5-154.0] hr). When analyzed by linear regression after an unplanned log transformation because of right-skewed data, the corresponding prolongations of block duration were 59% (95% confidence interval [CI], 28 to 97) and 46% (95% CI, 18 to 80), respectively (both P < 0.001). The combined adjuncts were not superior to dexamethasone alone (-8%; 95% CI, -26 to 14; P = 0.42). Median [IQR] quality of recovery 15 scores (n = 197) were significantly different only between dexamethasone (126 [79-149]) and dexmedetomidine (118.5 [41-150], P = 0.004), but by an amount less than the 8-point minimum clinically important difference.

CONCLUSION

Dexamethasone is superior to dexmedetomidine as an intravenous adjunct for prolongation of bupivacaine-based ISB analgesic duration. There was no additional benefit to using both adjuncts in combination.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03270033); registered 1 September 2017.