Analgesic effects of low-dose ropivacaine for interscalene brachial plexus block for outpatient shoulder surgery-a dose-finding study

BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block (ISB) with low-dose bupivacaine provides effective postoperative shoulder analgesia in outpatients. The analgesic effect of low-dose ropivacaine for ISB is unknown. METHODS: In this double-blind study, 66 outpatients scheduled to undergo arthroscopic shoulder surgery were randomly assigned to receive an ISB with 10 mL of 0.125%, 0.25%, or 0.5% ropivacaine before surgery. Postoperative verbal pain rating score, analgesic consumption, and the extent of motor and sensory block was assessed for 120 minutes after surgery. RESULTS: The degree of shoulder analgesia was dose dependent. Postoperative pain scores were lowest with 0.5% ropivacaine, and analgesic was not required in the hospital in 70% of the patients who received 0.25% and 0.5% ropivacaine, compared to 30% with 0.125% ropivacaine (P < .03). In the patients who required no analgesic in the hospital, the time to first oral analgesic at home was approximately 10 hours irrespective of ropivacaine concentration. Motor and sensory block distal to the elbow was detected in 25% of the patients in the 0.5% group but none in the 0.125% group. CONCLUSIONS: Interscalene brachial plexus block with low-dose ropivacaine, 10 mL of 0.25% and 0.5%, provides effective long-lasting shoulder analgesia in a majority of patients after arthroscopic surgery.     

Respiratory effects of low-dose bupivacaine interscalene block

In this double-blind study, interscalene brachial plexus (ISBP) block was performed in 11 volunteers using 10 ml of either 0.25% (n = 6) or 0.5% (n = 5) bupivacaine with epinephrine 1:200,000. Diaphragmatic excursion, respiratory function and neural function were assessed for 90 min. Our results showed that hemidiaphragmatic excursion declined significantly after block in the 0.5% group and paradoxical movement during inspiration was more common than in the 0.25% group. Forced vital capacity and forced expiratory volume in 1 s declined significantly in the 0.5% group (mean 74.6 (SD 13.0)% and 78.2 (19.9)% of baseline, respectively) but not in the 0.25% group. Sensory anaesthesia in the upper limb was found consistently in both groups, although biceps paralysis occurred earlier after 0.5% bupivacaine. We conclude that ISBP block using 10 ml of 0.25% bupivacaine provided upper limb anaesthesia to pinprick in C5-6 dermatomes with only occasional interference with respiratory function.      

肩胛上神经阻滞与肌间沟神经阻滞用于肩关节镜手术的Meta分析

目的系统评价肩胛上神经阻滞(suprascapular nerve block, SNB)与肌间沟神经阻滞(interscalene nerve block, ISB)在肩关节镜手术中应用的安全性与有效性。方法检索PubMed、Embase、CENTRAL(2018年第3期)、中国知网、万方数据库、中国生物医学文献数据库(CBM),查找有关SNB与ISB应用于肩关节镜手术的随机对照试验,检索时限定义为建库至2018年4月。根据术后镇痛方法的不同将纳入分析的患者分为两组:SNB组和ISB组。采用RevMan 5.3软件进行Meta分析。结果最终可纳入本系统评价的文献11篇,共978例患者。Meta分析结果显示,静止状态下ISB组PACU疼痛评分明显低于SNB组(SMD=0.89,95%CI 0.50～1.29,P0.01)。术后24 h静止状态下两组疼痛评分差异无统计学意义(SMD=-0.12,95%CI-0.25～0.01,P=0.07)。术后24 h活动状态下两组疼痛评分差异无统计学意义(SMD=-0.03,95%CI-0.56～0.50,P=0.92)。术后24 h内两组阿片类药物用量差异无统计学意义(SMD=0.06,95%CI-0.18～0.29,P=0.62)。SNB组PONV发生率明显低于ISB组(RR=0.56,95%CI 0.34～0.93,P=0.02)。SNB组Horner综合征发生率明显低于ISB组(RR=0.05,95%CI 0.01～0.23,P0.01)。SNB组声音嘶哑发生率明显低于ISB组(RR=0.39,95%CI 0.19～0.81,P=0.01)。SNB组呼吸困难发生率明显低于ISB组(RR=0.25,95%CI 0.11～0.57,P0.01)。结论与肌间沟神经阻滞比较,肩胛上神经阻滞能够为肩关节镜手术患者提供类似的术后镇痛效果且安全性更高,但在麻醉复苏期间镇痛效果欠佳。     

Severe hypotension after interscalene block for outpatient shoulder surgery: a case report

The case of a 43 year-old woman who underwent successful right interscalene brachial plexus block for arthroscopic shoulder surgery is presented. During the surgery, she subsequently exhibited signs of neuraxial spread of local anesthetic. Bilateral motor block was noted postoperatively. Spontaneous ventilation was maintained throughout the case, and she was successfully discharged home several hours after the procedure with no residual symptoms.     

Continuous interscalene block for ambulatory shoulder surgery

Management of acute post-operative pain due to shoulder surgery may be successfully and consistently achieved in ambulatory patients by using continuous interscalene block. This chapter outlines the anterior and posterior approaches to the proximal brachial plexus and describes a method of precisely placing a catheter along the brachial plexus by stimulating the plexus through the needle used for placing the catheter as well as through the catheter itself. A technique for securing the catheter by subcutaneous tunneling to prevent dislodgement is also described. Suggested drugs and dosages for initial boluses, continuous infusions and patient controlled interscalene analgesia are discussed. Sedation for block placement, and special precautions, are outlined.     

Parascalene block for shoulder arthroscopic surgery

OBJECTIVE: To evaluate the effectiveness of a parascalene block of the brachial plexus as the single form of anesthesia for arthroscopic surgery on the shoulder and for postoperative analgesia. MATERIAL AND METHODS: A parascalene block was performed in 151 ASA I-III patients using a plumb-bob technique with the aid of nerve stimulation and with the needle entering at a point 3 cm cephalad to the clavicle and 0.5-1 cm lateral to (and outside) the sternocleidomastoid muscle. We recorded the success or not of blockade, the incidence of side effects, clinical course during and after surgery, and patient and surgeon satisfaction with the technique. RESULTS: A full block was achieved in all patients, although 19 (13%) requiered a second puncture. Midazolam was administered to 34 patients for anxiety and 48 required urapidil to normalize blood pressure. Complications (incidental blocks) were rare, transitory, and mild: 6 patients with Claude Bernard-Horner syndrome, 13 with dysphonia due to recurrent nerve blockade, and 1 with diaphragmatic paresis. Postoperative pain was practically nonexistent. Administration of diclofenac as indicated was sufficient for 91.2% of the patients. The remaining 8.8% needed top-up doses. Patients and surgeons assessed the block as excellent. CONCLUSION: The parascalene technique to provide a brachial plexus block is effective for arthroscopic shoulder surgery.     

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

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

Continuous intralesional infusion combined with interscalene block was effective for postoperative analgesia after arthroscopic shoulder surgery

The purpose of this study was to compare the efficacy of postoperative pain control by intravenous patient-controlled analgesia (IV) and by continuous intralesional infusion of a local anesthetic (IL) with or without an interscalene block (ISB) after arthroscopic shoulder surgery. We allocated 84 patients to 4 groups according to analgesic method: IV, ISB-IV, IL, and ISB-IL. Postoperative pain, side effects, and supplementary analgesics were recorded at 1 hour and then every 8 hours for 48 hours. The interscalene block (groups ISB-IV and ISB-IL) was found to be effective at relieving pain and at reducing supplementary analgesic amounts at 1 and 8 hours postoperatively (P < .05). Patients in group ISB-IL had less pain at 16 and 48 hours postoperatively than those in the other groups (P < .05). Continuous intralesional infusion (groups IL and ISB-IL) was superior in reducing analgesic-related side effects (P < .05). This study suggests that a combination of an interscalene block and continuous intralesional infusion of a local anesthetic is an effective and safe method of postoperative pain control after arthroscopic shoulder surgery.     

Postoperative pain management for arthroscopic shoulder surgery: interscalene block versus patient-controlled infusion of 0.25% bupivicaine

We compared an interscalene block with a patient-controlled regional anesthesia device (Pain Care 2000; Breg, Inc, Vista, Calif) for pain management after outpatient arthroscopic shoulder surgery (subacromial decompression as principal procedure). The 41 patients in this prospective study were randomized to receive either the block or the device. During the postoperative period, all patients in both groups received standardized oral medications and continuous cold therapy and used continuous passive motion machines. Patients were given diaries and instruction in making entries upon waking and before retiring on postoperative days 1, 2, 3, 5, and 10. Data collected were number of pain medications used each day; number of nighttime awakenings; and subjective pain, activity, and quality-of-life levels rated on a visual analog scale. All data were statistically analyzed with the Mann-Whitney test. Compared with patients using the block, patients using the device awoke significantly fewer times the first night after surgery (P = .023), were significantly more active during postoperative days 1 and 2 (Ps = .018, .042), and took significantly fewer pain medications on postoperative day 2 (P = .034). On all other measures, results were equivalent or were better with the device, though these findings were not statistically significant. Patient-controlled subacromial infusion of bupivicaine is an effective alternative to interscalene block for outpatient pain management after arthroscopic shoulder surgery.     

Effect of dexamethasone dose and route on the duration of interscalene brachial plexus block for outpatient arthroscopic shoulder surgery: a randomized controlled trial

Purpose

Dexamethasone prolongs the duration of interscalene block, but the benefits of higher doses and perineural vs intravenous administration remain unclear.

Methods

This factorial design, double-blinded trial randomized 280 adult patients undergoing ambulatory arthroscopic shoulder surgery at a single centre in a 1:1:1:1 ratio. Patients received ultrasound-guided interscalene block with 30 mL 0.5% bupivacaine and 4 mg or 8 mg dexamethasone by either the perineural or intravenous route. The primary outcome (block duration measured as the time of first pain at the surgical site) and secondary outcomes (adverse effects, postoperative neurologic symptoms) were assessed by telephone. In this superiority trial, the predetermined minimum clinically important difference for comparisons between doses and routes was 3.0 hr.

Results

The perineural route significantly prolonged the mean block duration by 2.0 hr (95% confidence interval [CI], 0.4 to 3.5 hr; P = 0.01), but 8 mg of dexamethasone did not significantly prolong the mean block duration compared with 4 mg (1.3 hr; 95% CI, ?0.3 to 2.9 hr, P = 0.10), and there was no significant statistical interaction (P = 0.51). The mean (95% CI) block durations, in hours, were 24.0 (22.9 to 25.1), 24.8 (23.2 to 26.3), 25.4 (23.8 to 27.0), and 27.2 (25.2 to 29.3) for intravenous doses of 4 and 8 mg and perineural doses of 4 and 8 mg, respectively. There were no marked differences in side effects between groups. At 14 postoperative days, 57 (20.4%) patients reported neurologic symptoms, including dyspnea and hoarseness. At six months postoperatively, only six (2.1%) patients had residual symptoms, with four (1.4%) patients’ symptoms unlikely related to interscalene block.

Conclusion

Compared with the intravenous route, perineural dexamethasone prolongs the mean interscalene block duration by a small amount that may or may not be clinically significant, regardless of dose. However, the difference in mean block durations between 8 mg and 4 mg of dexamethasone is highly unlikely to be clinically important, regardless of the administration route.

Trial registration

www.clinicaltrials.gov (NCT02426736). Registered 14 April 2015.

     

The role of interscalene brachial plexus block anaesthesia in arthroscopic shoulder surgery; a prospective study

The choice of anaesthetic in shoulder surgery is an evolving field of research which has important implications for patient outcomes. We have performed a prospective study to assess the usability of an interscalene brachial plexus block (ISBPB) with sedation as the primary anaesthetic and analgesic for arthroscopic shoulder surgery. Our study assessed the requirements of analgesia peri-operatively and post operatively and found that patients had no requirement (n = 30) and minimal requirements with a low pain score (visual analogue score; mean 2.4, range 2–5) respectively. We also found that patients spent a short amount of time in recovery (31 min mean, range 21–48 min) and were able to be discharged on the same day. Our findings suggest that ISBPB with sedation is a viable option in arthroscopic shoulder surgery for a variety of procedures with positive effects for patient outcomes and mobility.     

Clinical evaluation of post-operative analgesia comparing suprascapular nerve block and interscalene brachial plexus block in patients undergoing shoulder arthroscopic surgery

BackgroundShoulder arthroscopic surgeries have a high incidence of severe post-operative pain significant enough to interfere with recovery and rehabilitation. A regional anaesthetic technique combined with general anaesthesia reduces intra-operative requirements of anaesthesia and provides a better post-operative pain relief. As the commonly employed technique of interscalene brachial plexus block (ISB) is associated with potential serious complications, suprascapular nerve block (SSB) can be used as a safer alternative.Methods and materialIn this prospective study, 60 ASA 1 or 2 adult patients undergoing shoulder arthroscopic surgery were randomised into two groups – ISB and SSB. In group ISB, ISB with 20 ml of 0.5% bupivacaine mixed with 75 μg clonidine was given. In the SSB group SSB was given with 15 ml of 0.5% bupivacaine with 75 μg clonidine. Pain was assessed using visual analogue scale and verbal pain scale scores and time to first rescue analgesia was noted. We used Student's t test and Chi-square/Fisher Exact test and used a statistical software to compare data.ResultsIn the present study, the mean duration of analgesia was 2.53 ± 2.26 h in SSB group compared to 7.23 ± 6.83 h in group ISB (p value < 0.05). Overall rescue analgesic requirements were higher in SSB group compared to ISB group (63.3% versus 40.0%) but this was statistically not significant (p value > 0.05).ConclusionBoth interscalene and SSB can be used to provide intra-operative and post-operative analgesia in patients undergoing shoulder arthroscopy.     

超声引导下神经阻滞在肩关节镜手术中的应用进展

肩关节镜手术常伴有严重的术后肿胀疼痛.超声引导下神经阻滞技术能够提供安全有效的镇痛,同时可以辅助术中控制性降压,并且在促进患者早期功能锻炼、实现加速康复外科(ERAS)方面具有重大意义,目前在肩关节镜手术中表现出极大的优势及应用前景.近年来,不同入路的阻滞方法相继报道,为临床应用提供了更多的选择.全文主要描述了肩关节的...     

Continuous interscalene brachial plexus block for postoperative analgesia following shoulder surgery

BACKGROUND: Severe postoperative pain is a well-known problem following shoulder surgery. This study evaluates the clinical efficacy of continuous interscalene brachial plexus block, patient-controlled analgesia, and morphine (i.v. and i.m.) for postoperative analgesia in this setting. METHODS: Thirty patients, scheduled for acromioplasty during general anesthesia, were randomly allocated to one of three different postoperative pain management groups. Group MO received morphine (5 mg i.m. and 2 mg i.v.) when visual analogue pain score (VAS) > 3, group PL received a continuous interscalene brachial plexus block with bupivacaine (1.25 mg kg-1 + 0.25 mg kg-1 h-1) and group PCA received patient-controlled analgesia with morphine (bolus 1 mg). Postoperative pain relief was assessed (24 h) by VAS, circulatory and respiratory stress parameters (heart rate, systemic arterial pressure and respiratory rate) and stress metabolites (glucose, lactate, glycerol by abdominal subcutaneous microdialysis). RESULTS: Pain relief in the PL group was effective (VAS < 3) and significantly more potent than in groups MO and PCA, except at 16 and 20 h. Lactate was significantly increased in the PL group, glucose was significantly increased in all groups, while glycerol showed a variable pattern. There were no significant stress metabolite differences among groups. VAS showed no statistical correlation with microdialysate, respiratory or circulatory data. CONCLUSION: Successful continuous interscalene brachial plexus block provides very good pain relief following shoulder surgery and is superior to the other methods studied. However, we were unable to demonstrate a correlation between VAS pain scores and stress indicators in metabolic, circulatory and respiratory parameters.     

The analgesic effect of interscalene block using clonidine as an analgesic for shoulder arthroscopy

Used as the sole analgesic, clonidine produces analgesia after central neural blockade and intraarticular injection but not after axillary block. In this study, we sought to determine whether interscalene clonidine induces analgesia for shoulder arthroscopy. Forty patients scheduled for shoulder arthroscopy were prospectively included in this double-blinded study. Using a nerve stimulator technique, an interscalene catheter was inserted. The patients were randomly divided into two groups. The interscalene group (n = 20) received clonidine 150 micro g in 15 mL of saline through the catheter and 1 mL of subcutaneous saline, and the systemic group (n = 20) received 15 mL of saline through the catheter and clonidine 150 micro g (1 mL) subcutaneously. All patients underwent general anesthesia for surgery. On completion of arthroscopy, all patients received, via a patient-controlled analgesia, on demand a bolus of 8 mL of ropivacaine 0.2% through the catheter with a 1-h lockout period. Postoperative pain was measured every 4 h using the visual analog scale (VAS) for 24 h. Additional postoperative analgesia was available with parenteral nalbuphine if required until VAS < 3. VAS scores in the recovery room were significantly higher in the systemic group compared with the interscalene group (P < 0.0001). Analgesic duration was significantly longer in the interscalene group (P < 0.00001), and ropivacaine consumption was significantly less than in the systemic group (P < 0.0001). No significant difference was observed between groups for nalbuphine consumption. Side effects were comparable in the two groups. IMPLICATIONS: Clonidine administered via an interscalene catheter enhanced analgesia compared with systemic administration. Nevertheless, the adverse effect of clonidine at this dose limits its use for routine management for postoperative analgesia.     

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

Purpose

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

Methods

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

Results

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

Conclusion

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