Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study

BackgroundAlthough continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR.MethodsWe retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h.ResultsTwenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group.ConclusionsPMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively.Level of evidenceLevel III.     

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 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.     

罗哌卡因复合舒芬太尼在连续臂丛神经阻滞术后镇痛中的应用

目的 观察罗哌卡因复合舒芬太尼在连续臂从神经阻滞术后镇痛效果及不良反应.方法 上肢手术患者80例,采用套管针行改良肌间沟法连续臂从神经阻滞,并保留套管针术后接患者自控镇痛泵.将患者随机均分成两组:s组为50 μg舒芬太尼加0.225%罗哌卡因镇痛;R组为术毕仪用0.225%罗哌卡因镇痛.两组背景剂最均为4 ml/h,自控药量每次3 ml,锁定时间20 min.观察术后镇痛效果,记录镇痛泵使用情况及不良反应.结果 S组在术后4、8及16 h镇痛效果优于R组(P＜0.05);恶心、呕吐、嗜睡、皮肤瘙痒及呼吸抑制两组差异无统计学意义.结论 罗哌卡因复合舒芬太尼用于连续臂丛神经阻滞术后镇痛效果优于单用罗哌卡因.     

Buprenorphine added to levobupivacaine enhances postoperative analgesia of middle interscalene brachial plexus block

Purpose

The aim of this study was to assess whether addition of epineural buprenorphine prolonged postoperative analgesia of middle interscalene brachial plexus block (MIB) with levobupivacaine.

Methods

One hundred and fifty consenting adult patients, scheduled for shoulder arthroscopic surgery for a rotator cuff tear under MIB with 29.5?ml of 0.75?% levobupivacaine, were randomized to receive additionally either saline or intramuscular buprenorphine 0.15?mg or epineural buprenorphine 0.15?mg. Onset of sensory and motor blocks, duration of postoperative analgesia, and consumption of postoperative analgesics were compared among the groups.

Results

There were significant (P?<?0.05) differences in the onset and the duration of the sensory block and in the duration of postoperative analgesia. Duration of both sensory block and postoperative analgesia was longer (P?<?0.05) in patients who had received epineural buprenorphine (856.1?±?215.2 and 1,049.7?±?242.2?min) than in patients who had received intramuscular buprenorphine (693.6?±?143.4 and 820.3?±?335.3?min) or saline (488.3?±?137.6 and 637.5?±?72.1?min). Requirement of postoperative rescue analgesics was lower in the epineural buprenorphine group than in the other two groups. Few complications occurred from MIB (<1?%) and none from buprenorphine.

Conclusions

Epineural buprenorphine prolonged postoperative analgesia of MIB more effectively than intramuscular buprenorphine, which suggests that buprenorphine acts at a peripheral nervous system site of action.     

Seizure after levobupivacaine for interscalene brachial plexus block

IMPLICATIONS: This case report describes a patient who demonstrated generalized seizure activity after an injection of 30 mL of levobupivacaine 0.5% for interscalene brachial plexus block. No evidence of cardiovascular toxicity was noted.     

Low-volume interscalene brachial plexus block for post-thoracotomy shoulder pain

OBJECTIVES: This study was designed to evaluate the effectiveness of low-volume interscalene brachial plexus block for post-thoracotomy ipsilateral shoulder pain and to compare it with nonsteroidal anti-inflammatory drug treatment. DESIGN: Prospective nonblinded study. SETTING: University hospital. PARTICIPANTS: Sixty adult patients. INTERVENTION: Patients who underwent elective thoracic surgery under combined epidural and general anesthesia, and after surgery were free of incisional pain but complaining of shoulder pain, were included in the study. They were selected in a sequential manner and placed into 2 groups of 30 patients each. Group 1 had a low-volume interscalene brachial plexus block, using 10 mL of bupivacaine 0.5%. Group 2 had an intramuscular injection of diclofenac sodium, 75 mg. MEASUREMENTS AND MAIN RESULTS: Pain was measured during their stay in the postanesthesia care unit (PACU) by using a visual analog score (VAS). Opioids were administered when pain relief was incomplete. Pain intensity was re-estimated the next morning and patient satisfaction was scored. VAS was found to be significantly lower in the low-volume interscalene block group than in the diclofenac group at 30 minutes after treatment and when leaving PACU (p < 0.001 for both). Patients in the interscalene block group stayed longer in the PACU (p = 0.019), and significantly fewer required rescue opioids (p = 0.03). There was no significant difference between the groups in patient satisfaction with the pain treatment. CONCLUSIONS: The authors concluded that low-volume interscalene brachial plexus block is a superior treatment for post-thoracotomy shoulder pain compared with diclofenac injection, although it requires a slightly longer stay in the PACU.     

Pleural effusion and chest pain after continuous interscalene brachial plexus block

Objective: We describe a unique case of a patient who experienced atelectasis of the lower lobe of the left lung and pleural effusion manifested by chest pain after continuous interscalene brachial plexus block for postoperative analgesia.Case Report: A 45-year-old man with no respiratory disease was scheduled for left shoulder arthroscopy for rotator cuff repair under interscalene brachial plexus block and sedation. A continuous interscalene brachial plexus block provided postoperative analgesia. On the first postoperative day, the patient reported left-sided chest pain. The chest x-ray showed elevation of the left hemidiaphragm associated with a left lower lobe atelectasis and a minor pleural effusion. After catheter removal, clinical and radiologic signs resolved within few days without sequela.Conclusion: If chest pain presents after interscalene brachial plexus block, early postoperative chest x-ray is recommended to rule out pneumothorax, atelectasis, and/or pleural effusion secondary to ipsilateral phrenic block.     

肩袖损伤患者术前焦虑状况与肩关节镜术后疼痛的相关性分析

目的 分析肩袖损伤行关节镜下肩袖修复手术的患者术前各因素对术后疼痛的影响.方法 本研究回顾性分析了2018年1月至2019年12月本科室收治的肩袖损伤患者的基本资料,所有患者术前进行视觉模拟评分(visual analogue scale,VAS)、美国肩肘外科协会评分(American shoulder and el...     

Analgesia after arthroscopic rotator cuff repair: subacromial versus interscalene continuous infusion of ropivacaine

OBJECTIVES: A continuous infusion of local anesthetic in the subacromial space has been shown to provide superior pain relief compared with placebo. This technique has been considered as an alternative to a continuous interscalene infusion. The aim of our study is to compare these 2 techniques for pain relief after arthroscopic rotator cuff repair. METHODS: In a prospective randomized trial, 30 consecutive patients undergoing rotator cuff repair were included. An interscalene brachial plexus block was performed in all patients with mepivacaine 1.5% 30 mL. Then, 15 patients had an indwelling interscalene catheter inserted immediately after the block via a needle. Fifteen other patients had a subacromial catheter placed at the end of surgery by the surgeon. In both groups, a 2 mg/mL ropivacaine continuous infusion (5 mL/h) with PCA bolus (5 mL/30 min) was maintained for 48 hours. Pain was assessed in PACU and at 24 and 48 hours after surgery, at rest, and during passive motion. Total amount of oral morphine self-administered as rescue analgesia and cumulative 24-hour and 48-hour local anesthetic consumption were noted. Patient satisfaction and side effects were also noted. RESULTS: Pain during motion in PACU (0 [0 to 60] v 40 [0 to 100] mm) and at 24 hours (10 [0 to 60] v 45 [20 to 100] mm), oral morphine (0 [0 to 6] v 3.5 [0 to 10] morphine capsules), and total amount of local anesthetic at 24 hours (122.5 [120 to 170] v 143 [129 to 250] mg) were lower in the continuous interscalene group. Local anesthetic side effects were less frequent in the continuous subacromial group. Satisfaction was comparable between groups. CONCLUSION: After arthroscopic rotator cuff repair, continuous interscalene block provides better analgesia compared with continuous subacromial infusion but with an increased incidence of minor side effects.     

Projected complex sensations after interscalene brachial plexus block

IMPLICATIONS: The development of projected complex sensations mimicking phantom pain after interscalene block is reported. The recognition of this entity is important because it may be confused with some other cardiac, esophageal, or visceral pathologies.     

Persistent hiccups after attempted interscalene brachial plexus block

OBJECTIVE: We describe a case of persistent hiccups after attempted interscalene brachial plexus block. CASE REPORT: A 38-year-old man was admitted for arthroscopic repair of a right shoulder injury. An interscalene block was attempted in the preoperative area and combined with general anesthesia for surgery. The procedure lasted 5(1/4) hours. After transfer to the recovery room, the patient complained of severe right shoulder pain and had no discernible sensory or motor block. He was noted to be hiccuping. The patient was discharged home the following morning but returned 2 days later complaining of persistent hiccups since surgery, with associated insomnia and nausea. He was readmitted and given chlorpromazine 50 mg intravenously every 8 hours and metoclopramide 10 mg intravenously every 6 hours. The patient was discharged 4 days later on chlorpromazine 25 mg by mouth every 8 hours and baclofen 5 mg by mouth every 12 hours, with hiccups greatly reduced in both intensity and frequency. Hiccups ceased 1 day after discharge. Eighteen days after surgery, he was off all medication with no return of his hiccups; 1 month later he remains hiccup free. CONCLUSIONS: Persistent hiccups have many postulated causes, including several that are common in the perioperative period, but this is the first time to our knowledge that persistent hiccups have been described in association with attempted interscalene brachial plexus block.