Abstract
BackgroundFluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative).MethodsThis single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes.ResultsAggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05).ConclusionDue to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible.Trial registrationClinicalTrials.gov (NCT03657173; September 4, 2018).
Highlights
Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery
Between June 2018 and November 2018, 33 patients undergoing elective, unilateral shoulder arthroscopy were enrolled into the study
Average procedure duration was 81.2 min (Range: 24–162), and the mean irrigation volume used during shoulder arthroscopy was 21.5 l (Range: 12–60 l)
Summary
Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). Considering implications of arthroscopic shoulder surgery - acute inflammation, muscle mobilization, and large volume irrigation - there is a deficiency of data regarding the impact of the arthroscopic surgery on ultrasound image quality during ISB. It is unknown whether the timing of the peripheral nerve block, with respect to the surgical procedure, impacts block efficacy and safety. Patients who do not receive preoperative blockade may be subject to increased perioperative opiate use, increased post anesthesia care unit (PACU) length of stay, and central sensitization to pain [7]
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