Interscalene block anesthesia for shoulder surgery

One hundred patients had major shoulder surgery with interscalene brachial and cervical plexus block anesthesia. Successful anesthesia was obtained by using this method in 82 patients. Failure was the result of incomplete anesthesia in 16 patients or the presence of a complication. Complications from high blood levels of anesthetic included loss of consciousness and respiratory depression in three patients and seizure in one. The block lasted a mean of eight hours, decreasing the need for postoperative analgesic medications. No postoperative medical complication developed. Ninety-one percent of the patients with successful blocks were satisfied with the procedure.     

Interscalene regional anesthesia for arthroscopic shoulder surgery: a safe and effective technique

There has been resistance to the use of interscalene regional block for arthroscopic shoulder surgery because of concerns about potential complications and failed blocks with the subsequent need for general anesthesia. The purpose of this study was to assess whether interscalene regional block is safe and effective and offers many advantages over general anesthesia for outpatient arthroscopic shoulder surgery. Through a retrospective chart review of consecutive arthroscopic shoulder surgeries over a 2.5-year time period, in a tertiary university medical center with an anesthesiology residency, 277 interscalene blocks (96%) were successful; 12 (4%) required general anesthesia because of an inadequate block. There were no seizures, pneumothoraces, cardiac events, or other major complications. There was a 1% rate of minor complications, all of which were transient sensory neuropathies that resolved within 5 weeks on average. We conclude that interscalene block can provide effective anesthesia for arthroscopic shoulder surgery.     

Update in regional anesthesia for shoulder surgery

Recent advances in the application of regional anesthesia to the care of patients undergoing shoulder surgery are discussed. New techniques for the management of postoperative pain are highlighted, with an emphasis on interscalene patient-controlled analgesia and suprascapular block. New developments in the safety and effectiveness of brachial plexus block are presented. The technique of interscalene block used at our institution is discussed in detail. Intraoperative hypotension and bradycardia caused by activation of the Bezold-Jarisch reflex is considered. The ongoing debate regarding the use of paresthesia versus nerve-stimulator techniques is examined.     

Interscalene block for elective shoulder surgery

This study assessed patient experiences with interscalene block anesthesia for elective shoulder surgery. Routine use of interscalene anesthesia was introduced at our institution in 1997. All patients who underwent interscalene anesthesia during the first 3 years of our experience with this regional anesthetic technique were asked to respond to an anesthesia-related questionnaire. Overall patient satisfaction with interscalene anesthesia was 87%, and success rate in achieving a complete motor and sensory block was 79%. The duration of pain relief postoperatively was 10.5 hours for patients with a successful block. Patients consistently reported that having an interscalene block was less painful than anticipated; 90% said they would have interscalene anesthesia again for shoulder surgery. This study demonstrates that interscalene anesthesia for elective shoulder surgery is safe and well accepted in this patient population.     

Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery

Interscalene block (ISB) of the brachial plexus is frequently used for patients undergoing ambulatory shoulder surgery. We previously reported that the incidence of postoperative complaints (neurapraxia) after an ISB was low (3% at 2 weeks), but objective neurologic assessment was not included in the study. The present study combines subjective findings with both preoperative and postoperative objective sensory and motor assessments after an ISB. We prospectively evaluated 133 patients undergoing elective ambulatory shoulder surgery. ISB anesthesia was accomplished by use of 1.5% mepivacaine alone or in combination with bupivacaine (0.5%-0.75%) via a paresthesia technique and a 23-gauge needle. All of the blocks were performed by experienced anesthesiologists. The number of passes with the needle, site of paresthesia, ease of performing the block, and success of the ISB were recorded for each patient. Neurologic assessment was performed preoperatively and up to 2 weeks postoperatively by 1 of 4 health care professionals but not by the anesthesiologists who performed the ISB and included diminished sensation, localized nerve pain, Semmes-Weinstein monofilament pressure threshold sensibility, Weber static 2-point discrimination, and grip strength changes. Patients with postoperative changes were followed up until resolution of symptoms occurred. Successful surgical anesthesia was achieved in 98% of the patients. There was 1 major perioperative complication (0.7%), a seizure that occurred within 5 minutes of the ISB. Two (1.4%) complained of transient postoperative neurapraxias. Neither patient had any changes in objective sensory and motor measurements. Hence, there was no correlation between subjective complaints and objective findings in this study. This study demonstrates that, in the hands of anesthesiologists doing predominantly regional anesthesia, there is a 1.4% incidence of neurologic complications after an ISB. ISB is a safe and effective technique for patients undergoing ambulatory shoulder surgery when an anesthesiologist experienced with regional anesthesia is involved.     

Interscalene brachial plexus anesthesia for shoulder surgery: report of a complicated intraoperative course.

We present a case of abrupt hemodynamic and mental status changes that occurred during shoulder surgery. During interscalene anesthesia for rotator cuff repair, there was abrupt onset of altered mental status and hemodynamic changes, which had a variety of possible contributing causes. Complete recovery occurred during care in the post-anesthesia care unit. A variety of physiologic changes can occurred during interscalene anaesthesia for shoulder surgery, which require prompt identification and management.     

Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital

The first 100 consecutive shoulder arthroscopic procedures performed under interscalene anesthesia at a small community-sized military hospital are the basis of this report. This method of anesthesia was compared with 100 shoulder arthroscopies performed in a previous 2-year time period under general anesthesia. A variety of arthroscopic and subsequent open reconstructive procedures about the shoulder were performed using both techniques. Using the interscalene method, 87 regional blocks were entirely successful. Thirteen patients required conversion to general anesthesia for adequate pain control; however, 4 of these had a complete block in the recovery room and required no postoperative narcotics. Seven patients required supplementation with local anesthetic when an open procedure became necessary. There were no major complications. Minor complications included 5 patients with transient Horner's syndrome, 4 patients who experienced anxiety, which was controlled with sedation, and 3 with nausea or pruritus. Interscalene anesthesia provided excellent intraoperative and postoperative analgesia with low morbidity. On a subsequent questionnaire, all patients with a successful block reported that they were extremely satisfied with their experience. Ten patients who had previous shoulder surgery under general anesthesia preferred the interscalene method. In summary, interscalene anesthesia proved to be an excellent method of anesthesia for shoulder arthroscopy. The technique is reproducible within the resources available in most community-level hospitals.     

Interscalene brachial plexus block anesthesia for upper extremity surgery

Use of the interscalene brachial plexus block for upper extremity anesthesia in a primarily rheumatoid population is reviewed in 88 cases. The interscalene approach described by Winnie was used. Anesthesia was effective in 93% of the cases. Failure to achieve anesthesia was more likely to occur in surgical procedures on the distal upper extremities. The technique allowed effective and reliable anesthesia throughout the upper extremity, including the shoulder. Problems associated with other forms of upper extremity regional anesthesia, such as tourniquet pain, pneumothorax, systemic anesthetic toxicity, and inadequate duration of anesthesia, were not encountered. Difficulties with more distally based block administration due to decreased shoulder motion were obviated.     

New trends in regional anesthesia for shoulder surgery: Avoiding devastating complications

Surgeons and patients are often reluctant to support regional anesthesia (RA) for shoulder and other orthopedic surgeries. This is because of the sometimes true but usually incorrectly perceived "slowing down" of operating room turnover time and the perceived potential for added morbidity. Recently, severe devastating and permanent nerve injury complications have surfaced, and this article attempts to clarify the modern place of RA for shoulder surgery and the prevention of these complications. A philosophical approach to anesthesiology and regional anesthesiology is offered, while a fresh appreciation for the well-described and often forgotten microanatomy of the brachial plexus is revisited to explain and avoid some of the devastating complications of RA for shoulder surgery.     

Interscalene brachial plexus anesthesia and analgesia for open shoulder surgery: a randomized,double-blinded comparison between levobupivacaine and ropivacaine

We compared the onset time and quality of interscalene brachial plexus block produced with levobupivacaine and ropivacaine in 50 patients undergoing open shoulder surgery randomly allocated to receive 30 mL of 0.5% levobupivacaine (n = 25) or 0.5% ropivacaine (n = 25) injected through a 20-gauge catheter placed into the interscalene sheath using a 18-gauge insulated and stimulating Tuohy introducer. The block was also prolonged after surgery using a patient-controlled interscalene analgesia with 0.125% levobupivacaine or 0.2% ropivacaine, respectively (basal infusion rate, 6 mL/h; bolus, 2 mL; lockout period, 15 min; maximum boluses per hour, three). Three patients (two with levobupivacaine [8%] and one with ropivacaine [4%]) failed to achieve surgical block within 45 min after the injection and were excluded. The onset time of surgical block was 20 min (10-40 min) with levobupivacaine and 20 min (5-45 min) with ropivacaine (P = 0.53). Rescue intraoperative analgesia (0.1 mg of fentanyl IV) was required in eight patients in each group (34%) (P = 0.99). Forty-two patients completed the 24-h postoperative infusion (22 with levobupivacaine and 20 with ropivacaine). Postoperative analgesia was similarly effective in both groups. Total consumption of local anesthetic infused during the first 24 h was 147 mL (144-196 mL) with levobupivacaine and 162 mL (144-248 mL) with ropivacaine (P = 0.019), with a ratio between boluses received and requested of 0.8 (0.4-1.0) and 0.7 (0.4-1.0), respectively (P = 0.004). The degree of motor block of the operated limb was deeper with levobupivacaine than ropivacaine when starting postoperative analgesia; however, no further differences in degree of motor function were observed between the two groups. We conclude that 30 mL of levobupivacaine 0.5% induces an interscalene brachial plexus anesthesia of similar onset and intensity as the one produced by the same volume and concentration of ropivacaine. Postoperative interscalene analgesia with 0.125% levobupivacaine results in similar pain relief and recovery of motor function with less volume of local anesthetic than with 0.2% ropivacaine. IMPLICATIONS: This prospective, randomized, double-blinded study demonstrates that 30 mL of 0.5% levobupivacaine produces an interscalene brachial plexus block of similar onset and quality as the one produced by the same volume of 0.5% ropivacaine. When prolonging the block after surgery, 0.125% levobupivacaine provides adequate pain relief and recovery of motor function after open shoulder surgery, with less volume infused during the first 24 h after surgery than 0.2% ropivacaine.     

Scalene regional anesthesia for shoulder surgery in a community setting: an assessment of risk

BACKGROUND: A retrospective review of shoulder procedures using scalene block anesthesia was performed. METHODS: The records of all 218 patients who had undergone scalene block anesthesia over a three-year period at two facilities were retrospectively reviewed. All blocks were performed with use of a standard blunt-needle technique with the patient awake and with use of preoperative nerve stimulation to localize the brachial plexus. RESULTS: Adjunctive general anesthesia was used for 179 (82%) of the 218 patients. Seventy-two patients (33%) required intravenous pain medication immediately on arrival in the recovery room, and twenty-eight blocks (13%) failed. One grand mal seizure, one episode of cardiovascular collapse, and four episodes of severe respiratory distress were noted. Two patients had temporary neurologic injuries that persisted at six weeks. The mean duration of the block was 9 +/- 4.6 hours. Two hundred (92%) of the 218 patients required parenteral narcotics despite the use of scalene block anesthesia. CONCLUSION: Informed consent discussions regarding scalene block anesthesia should include information on the prevalence of complications and the efficacy of the technique.     

Balanced regional anesthesia for hand surgery

In summary, the clinical goal in regional anesthesia for hand surgery is to constantly approach the ideal of a well-conducted, smooth, "balanced regional technique." This begins with the preoperative interview, assurance, and preoperative sedation (po). In the operating room, monitoring (EKG, BP) and safety measures (IV port, nasal oxygen) precede the regional technique. The block is performed with asepsis, minimal "needling," and correct dosages. The complement to neural blockade anxiolytic medication is titrated, thus the balance of IV sedation and regional block is achieved. The patient's symptoms, vital signs, and general comfort should be attended to during the hand surgery. Monitoring is continued in the recovery room, where special attention is given to positioning, cushioning of pressure areas, dressing, analgesia, and specific physical rehabilitation exercises. With a "balanced regional technique," the patient becomes an early participant in his or her own postoperative care and result. This balanced technique reduces the patient's overall operative risk and maximizes the surgical result.