Brachial Plexus Block Anesthesia Research Articles

Clinical Application of Ultrasound Microscopy-Guided Pediatric Brachial Plexus Nerve Block Anesthesia.

In order to investigate the anesthetic effect and safety of the ultrasound-guided brachial plexus block in pediatric upper limb surgery, this study retrospectively analyzed the anesthetic effect of the ultrasound-guided brachial plexus block in pediatric upper limb surgery. From January 2016 to December 2017, 82 children undergoing upper limb surgery in hospital A were selected and randomly divided into two groups by the coin method, with 41 children in each group. Ultrasound-guided brachial plexus block anesthesia and conventional anatomic localization brachial plexus block anesthesia were performed. The anesthetic drug dosage of sensory block at anesthesia completion time and motor block at onset time was compared between the two groups; the one-time puncture success rate and incidence of anesthesia complications were compared between the two groups (local anesthesia poisoning, nerve injury, pneumothorax, hematoma, and phrenic nerve palsy). The results showed that the anesthesia completion time in the study group was slightly longer than that in the control group. The sensory and motor block occurred earlier in the study group than in the control group. Low doses of narcotic drugs are used. The one-time puncture success rate of the study group was higher than that of the control group. The incidence of anesthesia complications was lower than that of the control group. The one-time puncture success rate was 92.8% in the study group and 75.7% in the control group. Ultrasound-guided brachial plexus block anesthesia has a significant effect in pediatric upper limb surgery, which can improve the anesthetic effect and reduce the incidence of complications, and is worthy of clinical promotion.

Comparative characteristics of local anesthetics in brachial plexus block for surgery in dogs

The objective of this study was to compare three different local anesthetics in terms of duration and effectiveness of block development in brachial plexus block for osteosynthesis of radius with plate in dogs. The blockade was received a electroneurostimulation-guided Stimuplex HNS 12 with SENSe function by B. Brown for all group. 15 dogs of smallest breeds were divided into three random groups: in the first, 2% lidocaine solution was used as anesthesia; in the second bupivacaine 0.5%, in the third ropivacaine 0.5%. The time to development and the duration of the local block were assessed with a pinch method in several areas. The fastest development of a complete limb block was observed in group 1, which took an average of 7-10 minutes. The development of a complete block in the 2nd group exceeded three times, and in the 3rd - twice, the anesthetic indicators of the 1st group. All patients from group 1 were immediately injected with analgesics after surgery to relieve postoperative pain. The duration of the blockade of the third group was significantly shorter than in the second group, however, the motor block in the second group was significantly longer than in the 3rd group, patients experienced pain, but the motor function of the distal limb has not yet recovered. Thus, ropivacaine, by its properties, is the drug of choice for brachial plexus blockade for periosteal osteosynthesis of the forelimb in dogs and can be used for surgeries longer than 80 minutes.

Simultaneous Brachial Plexus Block and Combined Two-Segment Spinal-Epidural Anesthesia with Fixation of an Epidural Catheter in the Subcutaneous Canal in a Patient with Polytrauma

The article reports an example of the simultaneous use of brachial plexus block and combined two-segment spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal in an 81-year-old patient after receiving a household injury - closed fracture of the olecranon of the right ulna with displacement of fragments and closed transtrochanteric fracture with a fracture of the right femur fragments. After preoperative preparation and examination, the patient underwent two consecutive surgical interventions within a day: open reduction of comminuted transtrochanteric fracture of the right hip, dynamic femoral screw osteosynthesis and open reduction of fracture of the right olecranon, Weber’s osteosynthesis. Surgical interventions were carried out under regional anesthesia: block of the brachial plexus via supraclavicular access and combined two-segment spinal-epidural anesthesia with a method developed in our clinic for fixing an epidural catheter in the subcutaneous canal using a modified spinal needle. After the operation, the patient underwent postoperative pain relief in the form of epidural analgesia for 72 hours. The postoperative period passed without complications. On the 13th day, the patient was discharged for outpatient treatment by a traumatologist. The use of local anesthesia in the form of two methods of regional anesthesia during two consecutive surgical interventions, in an elderly patient with a high anesthetic risk, followed by long-term postoperative anesthesia in the form of epidural analgesia with a reliable method of epidural catheter fixation in the subcutaneous canal without the use of narcotic analgesics, contributed to the successful carrying out two surgical interventions at once, early activation of the patient, absence of complications in the postoperative period. Reliable catheter fixation is very important for the quality of epidural analgesia. Dislocation of catheters by more than 2 cm can lead to migration of catheters from the epidural space, changing the course of anesthesia, deteriorating its quality, or even interrupting it altogether. The new method of catheter fixation in the subcutaneous canal developed by us made it possible to prevent catheter dislocation.

Global Joint Entropy Algorithm-Based Evaluation of Dexmedetomidine Combined Local Anesthetics in Brachial Plexus Block from Ultrasound Images

This paper aimed to explore dexmedetomidine combined local anesthetics in brachial plexus block through ultrasound imaging (UI) under global joint entropy algorithm. Patients who underwent upper limb surgery and brachial plexus block were selected as research objects. Patients in group A were given 0.375% ropivacaine and normal saline, and patients in group B were given 0.375% ropivacaine and 1.0 μg/kg dexmedetomidine. The results of UI were analyzed by global joint entropy-based K-means clustering (GKC) algorithm, and the use effects of the two methods were compared in combination with other postanesthesia manifestations. The results were as follows. The segmentation accuracy (96.21% and 83.52%) of GKC was higher than 82.21% and 70.52% of the local joint entropy-based K-means clustering (LKC) ( P < 0.05 ). The duration of sensory and motor block (352.78 ± 45.89 min and 324.38 ± 41.29 min) in group B was significantly longer than 292.28 ± 35.69 min and 256.58 ± 42.76 min in group A ( P < 0.05 ). Compared with 84.91 ± 8.77 beats/min and 89.58 ± 7.62 beats/min in group A, mean arterial pressure (70.24 ± 9.77 beats/min and 69.89 ± 8.97 beats/min) in group B was lower at T1 and T2 ( P < 0.05 ). The duration of postoperative pain (582.70 ± 51.89 min) in group B was longer than 372.89 ± 49.89 min in group A ( P < 0.05 ). The postoperative pain score (2.98 ± 1.08) in group B was significantly lower than 4.48 ± 2.19 in group A ( P < 0.05 ). Therefore, dexmedetomidine combined local anesthetics could prolong the duration of sensory and motor nerve block. Besides, dexmedetomidine had sedative and analgesic effects, so as to prolong postoperative pain time and reduce pain degree of patients.

What Is the Risk of Intraoperative Cerebral Oxygen Desaturation in Patients Undergoing Shoulder Surgery in the Beach Chair Position?

Previous studies have shown that intraoperative cerebral desaturation in patients undergoing shoulder surgery in the beach chair position varies widely, from 0% to 80%. To our knowledge, the risk of intraoperative cerebral desaturation is not known after all identified intraoperative modifiable physiologic parameters that influence cerebral blood flow have been controlled for. (1) What is the risk of intraoperative cerebral desaturation during shoulder surgery with the patient in the beach chair position when patients received combined general anesthesia and an interscalene block, and what other factors associated with intraoperative cerebral desaturation can be identified? (2) Is intraoperative cerebral desaturation associated with 24-hour cognitive decline? (3) What factors are associated with intraoperative hypotension? Between April and December 2020, 51 patients underwent elective shoulder surgery in the beach chair position at one center. Nine patients were excluded: four patients refused to participate, two patients were unable to receive an interscalene brachial plexus block, and three patients were operated on in less than 70° upright position. A total of 42 patients (aged 63 ± 10 years, of whom 52% [22 of 42] were female) were prospectively recruited into this study. Each patient was diagnosed with a rotator cuff tear and underwent arthroscopic repair in the beach chair position, which was performed in an upright position of 70° to 80°. Near-infrared spectroscopy was used to monitor regional cerebral oxygen saturation. The mean arterial pressure was monitored and controlled so that it was more than 70 mmHg in patients without hypertension and within 20% from the baseline mean arterial pressure in patients with hypertension. All patients received the standardized anesthesia protocol, which consisted of an interscalene brachial plexus block and general anesthesia. Intraoperative cerebral desaturation was defined as a decrease in the regional cerebral oxygen saturation level of more than 20% from the baseline value that lasted longer than 15 seconds after induction of anesthesia. Patients' clinical characteristics such as age, sex, BMI, preoperative hemoglobin level, preexisting medical conditions, and continuing antihypertensive medications on the morning of surgery were analyzed to identify the association with intraoperative cerebral desaturation. We used the Montreal Cognitive Assessment to assess cognitive function at preoperative and 24 hours postoperative. Episodes of hypotension and its treatment after maximum head elevation were recorded. The patients' clinical characteristics were analyzed to determine their association with hypotensive events. In this study, intraoperative cerebral desaturation occurred in 43% (18 of 42) of patients, and female sex was identified as an associated risk (odds ratio 4.3 [95% confidence interval 1.2 to 16.2]; p = 0.03). The median (interquartile range) duration of intraoperative cerebral desaturation was 19 minutes (5 to 38). There was no association between intraoperative cerebral desaturation and 24-hour postoperative cognitive decline (OR 0.6 [95% CI 0.1 to 2.4]; p = 0.44). Risk factors for intraoperative hypotension were a history of hypertension, regardless of whether or not the patient took antihypertensive drugs on the morning of surgery (OR 4.9 [95% CI 1.3 to 18.1]; p = 0.02), and dyslipidemia (OR 4.3 [95% CI 1.2 to 16.3]; p = 0.03). The intraoperative cerebral desaturation risk in the beach chair position was high. Female sex was an intraoperative cerebral desaturation risk factor. However, there was no association between intraoperative cerebral desaturation and postoperative cognitive decline. Patients with hypertension and dyslipidemia are at risk of intraoperative hypotension after positioning. Further large-scale studies are required to identify intraoperative cerebral desaturation-associated adverse neurologic outcome. Level II, therapeutic study.

Additive Effect of Sulfantil to Lidocain and Bupivacain for Supraclavicular Brachial Plexus Block

Purpose: We evaluated the effect of adding Sufentanil to the mixture of Lidocaine and Bupivacaine used for supraclavicular brachial plexus block in reducing postoperative pain.
 Method: This double-blind clinical intervention trial was conducted in 2007. Patients scheduled to undergo upper limb orthopedic surgeries under supraclavicular brachial plexus block were recruited. Participants of one arm were given the mixture of Sufentanil, lidocaine, and bupivacaine (Group S) while those of the other arm were given the mixture of later two drugs (Group C). Postoperative pain assessment was done every hour postoperatively till the first administration of systemic analgesic. We used a subjective pain score and duration of lack of muscle movement as a parameter to judge outcomes. The mean and standard deviation were compared of both arms.
 Result: We included 50 patients in both arms. The mean duration of the motor blockade in group S and C were 342.8 (± 145.4) and 171.1 (±50.2) minutes respectively. The additive effect of Sufentanil in motor blockage was 171.7 (95% CI 128.5–214.9) (p = 0.1×10-6). The mean duration of analgesia in group S and C were 892 (±34.7) and 350 (±72.1) minutes respectively. The additive effect of Sufentanil in analgesia was 542 (95% CI 524–559) (p = 0.1×10-6). In group S, one patient developed cardiac pain following pneumothorax and two had temporary Horner syndrome.
 Conclusion: Analgesia in the postoperative period can be enhanced with the addition of Sufentanil (an opioid) to local anesthetics in supraclavicular brachial plexus block.

Block characteristics of Dexmedetomidine as an adjuvant to local anaesthetic in Infraclavicular brachial plexus block using peripheral nerve stimulator and ultrasound

Introduction: Dexmedetomidine has been frequently used in regional anaesthesia to improve the quality of blocks. Addition of dexmedetomidine to local anaesthetics has been shown to hasten the onset of both sensory and motor blocks and also prolong the duration of analgesia. The objective of this prospective comparative study was to assess the change in characteristics of infraclavicular brachial plexus block after adding Inj. Dexmedetomidine to 2% Lignocaine with Adrenaline.
 Methods: Sixty-six patients, scheduled for upper limb surgeries under ultrasound guided infraclavicular brachial plexus block were randomly allocated to two groups. Group LS received Inj. Lignocaine 2% with Adrenaline, 7mg/kg diluted to 30 ml with saline and Group LD received Inj. Dexmedetomidine 0.75 mcg/kg in addition to Inj. Lignocaine 2% with Adrenaline, 7mg/kg again diluted to a total volume of 30 ml. The parameters studied were: onset of sensory and motor blocks and duration of analgesia.
 Results: Sixty patients completed the study. The demographic variables and motor block were similar between both groups. The mean time to onset of sensory block was significantly faster in Group LD compared to Group LS (9.80±4.85 min vs 12.30±3.97 min, p=0.033). The duration of analgesia was also found to be prolonged in Group LD compared to Group LS (286.73±55.38 min vs 226.53±41.19 min, p < 0.001).
 Conclusion: Addition of 0.75 mcg/kg of Dexmedetomidine to 2% Lignocaine with Adrenaline hastens the onset of sensory block and prolongs the duration of analgesia in ultrasound guided and peripheral nerve stimulator guided infraclavicular block.

Effect of Dexamethasone on The Duration of Analgesia for Supraclavicular Brachial Plexus Block

Background: Brachial plexus block with Bupivacaine provides effective intraoperative anesthesia and analgesia. The use of dexamethasone along with local anesthetic has been shown to improve the duration of analgesia.
 Objective: To observe the effect of Dexamethasone on the duration of analgesia for Supraclavicular Brachial plexus block.
 Materials and Methods: A prospective, double-blind study was undertaken in patients scheduled for upper limb surgeries under supraclavicular brachial plexus block. patients were randomly divided into two groups, Group (BD) and B. Group B received 28 ml of 0.25% bupivacaine with 2 ml normal saline while Group BD received 28 ml of 0.25% bupivacain with 2ml (8mg) dexamethasone for supraclavicular brachial plexus block. The groups were compared regarding quality of sensory and motor blockade. All the information was recorded in data collection sheet. Data was processed and analysed with the help of computer program SPSS and Microsoft excel.
 Results: There was no significant difference between groups in respect of demographic and American Society of Anaesthesiologist (ASA) status. Mean age was found to 34.7±8.53 years. In Group (BD) , 63.3% were ASA I and 36.6% were ASA II. In Group B, 60% were ASA I and 40% were ASA II. It has become evident that satisfactory anaesthesia can be made possible by addition of adjuvant to local anaesthetic in brachial plexus block (in Group-BD). onset of sensory block was faster in Group BD (8.17 ± 1.4 min) than Group B (9.12 ± 1.68 min). Similarly mean onset time of motor block in group A was 12.26 ± 3.96 min, and 11.58 ± 3.68 min in group B. Our study shows that duration of motor block was 408.68±26.96 min and 380.26 ± 24.11 min in group BD and Group B respectively.
 Conclusion: There was significantly prolonged duration of analgesia in addition of Dexamethasone without any unwanted effects.
 KYAMC Journal Vol. 11, No.-4, January 2021, Page 199-203

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.

Study of Comparison of Dexmedetomidine Added to Levobupivacaine versus Alone Levobupivacaine in Supraclavicular Brachial Plexus Blockade

Background: The aim is the current research is the comparison of Dexmedetomidine added to Levobupivacaine versus alone Levobupivacaine in supraclavicular brachial plexus blockade. Subjects and Methods : The current research was performed in the Department of Aneshtesia, Gov- ernment Medical College and SSG Hospital, Vadodara, from October 2014tooctober to 2015. Subjects were separated into 2 groups: Group LD: receives Inj. Levobupivacaine 0.5 %(35ml)+inj.Dexmedetomidine (0.5 l)+Inj.NS(0.5ml)=total 36 ml. Group L: receives Inj.Levobupivacaine0.5
 %( 35ml) + inj. Normal saline(1ml) = 36 ml. Pulse rate, Blood pressure, Respiratory rate and Oxygen saturation (SpO2), Ramsay sedation score
 were monitored before giving the block, immediately after giving the block, each 5 minutes till fifteen minutes, every fifteen minutes thereafter for one hour and each thirty minutes afterward until the conclusion of surgery. Results: Total duration of sensory block was significantly extended in group LD as a contrast to group L. Total duration of motor block was significantly longer in group LD as a contrast to group L. Patients receiving Dexmedetomidine had long-lasting postoperative analgesia as compared to the control group. Thus, the total duration of analgesia was considerably extended in group LD patients as a contrast to group L patients and the dissimilarity was statistically highly significant. Conclusion: Dexmedetomidine can be utilized as a secure and useful aid to local anesthetics in supraclavicular brachial plexus block to give outstanding perioperative analgesia with negligible consequences.

A Comparative Study of Tramadol vs Butorphanol as an Adjuvant with Local Anaesthetic in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries

Brachial plexus block is a versatile and reliable regional anaesthesia technique. It is a block of roots, divisions and cords first performed by Halsted in 1884. It provides a useful alternative to general anaesthesia for upper limb surgery by being safe, decreasing the cost of anaesthetic agents, decrease operation theatre pollution and prolonged post-operative pain relief. Objectives: To study comparative effect of adding tramadol and butorphanol as an adjuvant with local anaesthetic (bupivacaine + xyloadrenaline ) in supraclavicular brachial plexus block in upper limb surgeries. Methods and Material: 60 patients were divided into two groups: Group A: inj. bupivacaine 0.5% (15ml)+inj xyloadrenaline (15ml) +inj tramadol(100mg) 2ml+inj ns 3 ml. Group B: inj. bupivacaine 0.5% (15ml)+inj xyloadrenaline (15)ml +inj butorphanol (1mg)1ml + inj ns 4ml. Assessment of onset of sensory and motor blockade, surgical procedure and duration of surgery. Perioperative complications were recorded and managed accordingly. Results: The onset of sensory block was rapid with Tramadol (4.2 min) as compared to Butorphanol (18.83min). The onset of motor blockade was faster with Tramadol (7.7min) as compared to Butorphanol (24.13min). Tramadol has longer duration of sensory (634.66 min) and motor (458.33 min) blockade as compared with butorphanol group (282.03min) and (350.16min) respectively (p<0.05). Duration of surgery and VAS Score was also similar in both groups and statistically not significant. Conclusion: Tramadol greatly reduce the onset time for sensory and motor block as well prolong the sensory and motor block,while Butorphanol has minimal effect on onset and duration of block but it provide post op analgesia.

Efficacy of Varying Doses of Dexamethasone with Lignocaine in Supraclavicular Brachial Plexus Block in Upper Limb Surgeries

Objectives: To compare the effectiveness of inj. Dexamethasone 4mg added to 1.5% lignocaine with adrenaline with inj Dexamethasone 8mg added to 1.5% lignocaine with adrenaline in Supraclavicular Brachial Plexus Block in terms of onset of sensory and motor blockade andduration of sensory and motor blockade. Materials and Methods: The study was carried out as a Prospective, randomized clinical trial among 150 patients who underwent different surgical procedures under supraclavicular brachial plexus block. They were randomized into three groups. GROUP A: Patients belonging to this group are given supraclavicular brachial plexus block with 4 mg dexamethasone as adjuvant to 1.5 %lignocaine with adrenaline (7mg/kg). GROUP B: Patients belonging to this group received supraclavicular brachial plexus block with 8 mg dexamethasone as adjuvant to 1.5 % lignocaine with adrenaline (7mg/kg). GROUP C: Patients belonging to this group received supraclavicular brachial plexus block with 2ml of normal saline added to 1.5 % lignocaine with adrenaline (7mg/kg). The three groups were compared with regard to onset of sensory and motor blockade andduration of sensory and motor blockade. Results: No statistically significant difference was reported between the three groups in demographic variables. The mean time required for onset of sensory block in Group A and Group B is 11.2 minutes and in Group–C is 14.26, onset of motor block Group A and Group B is 13.0 minutes and in Group–C is 17.0 min. The average duration of sensory block in Group B>A>C. The average duration of Motor block in Group B is 242min, and in Group A with 192 min and with Group C is 153min. Conclusion: In conclusion, addition of dexamethasone to local anaesthetics in supraclavicular brachial plexus block results in a faster onset and prolonged duration of sensory and motor blockade. Higher dose (8mg) of dexamethasone is more efficacious than lower dose (4mg) of dexamethasone as an adjuvant with local anaesthetics in terms of duration of sensory block, motor block and analgesia but equally efficacious in onset of sensory and motor blockade.

Treatment of Calcific Tendinitis around the Elbow

Purpose: This study was performed to evaluate surgical outcomes in calcific tendinitis around the elbow due to persistent pain despite conservative treatment.Methods: The study retrospectively reviewed seven consecutive patients who visited Jeju National University Hospital due to pain around the elbow and underwent operative treatment due to persisting calcific lesion evidenced by radiographs and ultrasonography. The patients’ mean age was 40 years, and the average follow-up was 5 years and 10 months. Surgical procedures were performed under brachial plexus block anesthesia to remove calcific deposits at the common extensor tendon with incision around the lesion along with repair of partially ruptured tendons during the removal using nonabsorbable sutures. The patients were immobilized with a long-arm splint in a neutral position for 2 weeks after operation, followed by rehabilitation involving continuous passive motion and physical therapy for elbow joint range of motion and muscle strengthening, respectively. Intraoperative biopsy revealed inflammatory cells and microcalcification indicative of calcific tendinitis in all patients. Surgical outcome was evaluated based on patient’s subjective satisfaction under five-point grading scale, Mayo Elbow Performance Index (MEPI) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score.Results: The patient’s subjective satisfaction scale revealed “very satisfactory” in three cases and “satisfactory” in four cases. The median MEPI and DASH score were preoperatively 45 and 88.8, which improved to 85 and 36.2 at final follow-up, respectively.Conclusion: In patients with persistent pain despite aggressive conservative treatment in calcific tendinitis, direct surgical removal of calcific deposit is an effective way to resolve symptom and prevent recurrence.

Application of Midazolam Injection in Patients with Intraoperative Nerve Block Anesthesia and Sedation Assisted by Imaging Guidance

In the present study, we explored the clinical effect of midazolam as an adjuvant analgesic and tranquilizer after brachial plexus block anesthesia with the aid of imaging guidance. We selected 106 patients who had undergone elective unilateral upper extremity surgery from January 2017 to December 2019 and randomly divided them into groups A and B, with 53 cases in each group. All the patients had undergone brachial plexus block anesthesia. Group A received imidazole-assisted sedation, and group B received fentanyl plus midazolam-assisted sedation. Under ultrasound-guided intermuscular sulcus brachial plexus block, we observed and recorded the ultrasound anatomical images before injection, including the distance from the lower edge of the upper, middle, and lower trunk of the forearm brachial plexus to the skin. We also recorded the anesthesia and operation times, effects of the anesthetic block, and incidence of adverse reactions. The distance from the lower edge of each nerve trunk to the skin averaged 1.002 cm for the upper stem, 1.598 cm for the middle stem, and 2.26 cm for the lower stem. The average anesthesia procedure time was 3 minutes, 56 seconds and was within 3-5 minutes for 92% of the procedures. The anesthesia effect was excellent, good, and poor in 81%, 11%, and 6%, respectively, and ineffective for 2% and effective for 92%. The ultrasound-guided inferior intermuscular sulcus approach for brachial plexus block is suitable for unilateral upper extremity radial hand surgery. For surgery involving the upper extremity ulnar hand side, a larger dose (concentration) of local anesthetic should be used within a safe range and/or an additional ulnar nerve block might be necessary. Midazolam adjuvant medication can have a good sedative and amnestic effect in brachial plexus block anesthesia, helping to reduce pain and inhibit the increase in stress levels.

Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial.

Rebound pain after brachial plexus block resolution and development of long-lasting pain are problems associated with volar plate fixation for distal radius fractures. The aim of this double-blind study was to evaluate the effect of a single prophylactic intravenous dose of dexamethasone in this setting. The primary endpoint was highest pain score during the first 24 hours after surgery. We included 51 adults of ASA physical status 1-2 due to undergo planned acute fixation of the radius. All received premedication with oral paracetamol and etoricoxib, and a pre-operative brachial plexus block with ropivacaine. Patients were randomly allocated into two groups: a dexamethasone group receiving 16 mg dexamethasone intravenously at start of surgery and a control group receiving 4 ml saline. After surgery, all patients received fixed doses of paracetamol, etoricoxib and oxycodone, with further oxycodone added as needed in the first 48 hours. Pain, analgesic consumption and daily function were registered at predefined times up to 1 year after surgery. Median (IQR [range]) worst pain score in the first 24 hours, as assessed by verbal numeric rating scale (0-10), was 4 (2-6 [0-7]) in the dexamethasone group compared with 8 (5-8 [2-10]) in the placebo group (p < 0.001). Average pain score, 2 (1-4 [0-5]) vs. 5 (3-6 [0-8]), p = 0.001 and rescue oxycodone consumption, 5 (0-10 [0-35]) mg vs. 10 (5-15 [0-50]) mg, p = 0.037), respectively, were both significantly lower in the dexamethasone group compared with control from 8 to 24 hours. Brachial plexus block duration was 69% longer in the dexamethasone group, 21.5 (19.1-23.4 [12.9-24.1]) hours vs. 12.7 (11.9-15.3 [7.4-26.6]) hours, p < 0.001. Two patients (9%) in the dexamethasone group compared with 12 (50%) in the placebo group experienced worst pain scores of 8-10 during the first 36 hours (p = 0.002). At 3 and 7 days postoperatively, there were no significant differences between groups for pain scores or opioid consumption. At 6 months, 27 patients (57%) reported pain at the site of surgery, with significantly higher average pain score (p = 0.024) in the placebo group. At 1 year, two patients in the dexamethasone group reported pain compared with 10 in the placebo group (p = 0.015), and worst pain score was significantly higher in the placebo group (p = 0.018). We conclude that intravenous dexamethasone improves early postoperative analgesia and may also improve clinical outcomes after 6 and 12 months.

Treatment strategy of traumatic posterior dislocation of shoulder joint with concomitant reverse Hill-Sachs lesion of the humeral head

Objective To explore the treatment strategy for traumatic posterior dislocation of shoulder joint with concomitant reverse Hill-Sachs lesion on the humeral head. Methods Data of 8 consecutive traumatic posterior shoulder dislocations with concomitant compression on anteromedial portion of the affected humeral heads (reverse Hill-Sachs lesion), which resulted from the collision between the posterior rim of the glenoid and anterior portion of the humeral head, who had undergone treatment in our department since July 2015 to June 2018 were retrospectively analyzed. Seven males and 1 female have been included in the case series, with the age between 30-70 years (mean 44.5±12.3 years), 6 on the right shoulder and 2 on the left. 7 were acute injuries and 1 chronic. One patient received closed reduction under brachial plexus block anesthesia, and the rest cases underwent open surgeries. Modified Judet approach was performed in one case due to the concomitant fracture on the postero-inferior glenoid. The other 6 patients received modified delto-pectoral approach. 4 concomitant rotator cuffswere found during the procedures, including1 full thickness tears 3 partial. One patient received McLaughlin surgery, allograft and anchor suture fixation. 2 underwent cannulated screw fixation. Allograft and PHILOS fixation was placed on 4 cases. All 8 patients were required maintaining in mild abduction and external rotation the affected arms, with the protection of the casts. All patients were followed up for 20.6±8.4 months (range, 9-36 months). Constant-Murley scores and visual analogue score (VAS) were used to evaluate the clinical outcomes at the latest follow-up. Results Infection occurred in 1 case, the humeral head has been resected subsequently and antibiotic cement spacer was inserted for further arthroplasty. Necrosis of the humeral head has been observed in one CT follow up 9 months after surgery, with no limitation of the range of motion of the shoulder. Stage 1 wound closure and bony union were witnessed on the rest 6 patients. No neuromuscular injures or re-dislocations on the affected shoulders was found. The range of motion of the affected shoulder has been recorded at the latest follow-up: 123.8°±30.1° (90°-180°) in flexion, 124.4°±34.2° (80°-180°) in abduction, 36.9°±20.9° (0°-70°) in external (neutral position), 58.8°±10.9° (50°-80°) in internal rotation (neutral position) and 83.5±12.1 (70-95) in Constant-Murley score. Among the 8 patients, 7 patients were at the rank of VAS 0-3, and 1 of 4-6. Conclusion Optimal treatment options should be chosen based on the humeral head defect status, in case of traumatic posterior shoulder dislocation with concomitant reverse Hill-Sachs lesion. Closed reduction can be tried on < 20% humeral head defect with the help of anesthesia, and surgical option is the optimal one for the defect between 20%-40%. Key words: Shoulder joint; Shoulder dislocation; Wounds and injuries

Comparative study between dexmedetomidine and fentanyl added to bupivacaine for ultrasound-guided brachial plexus block

Background Ultrasonic guided supraclavicular brachial plexus block provides complete and reliable anesthesia for upper limb surgeries. Adjuvants to regional blocks can affect the block characteristics. Aim To evaluate supraclavicular block characteristics and adverse effects of the addition of dexmedetomidine or fentanyl to bupivacaine 0.5% in patients undergoing elective upper limb surgeries. Patients and methods This prospective double-blind trial was conducted on 90 patients scheduled for upper limb surgeries randomized into three equal groups. The patients in group C received 30 ml 0.5% bupivacaine with 1 ml normal saline, in group F received 30 ml bupivacaine 0.5% with fentanyl 50 µg (1 ml), whereas in group D received 30 ml bupivacaine 0.5% with dexmedetomidine 75 µg (1 ml). Sensory and motor block characteristics were assessed as well as the hemodynamics, adverse effects, and complications. Results Group D showed significantly rapid onset and longer duration of sensory and motor block, prolonged duration of anesthesia and analgesia, and higher sedation compared with C and F groups (P Conclusion Dexmedetomidine hastens the onset and prolongs the duration of sensory and motor blocks, as well as the duration of postoperative analgesia with minimal adverse effects compared with fentanyl when added to local anesthetic in supraclavicular brachial plexus block. We recommend further research studies for the determination of the optimum dose of dexmedetomidine used as an additive to local anesthetics.

Comparison of Patient Satisfaction between Brachial Plexus Block (Axillary Approach) and General Anesthesia for Surgical Treatment of Distal Radius Fractures: A Historical Cohort Study

Background: Distal radius fracture surgery is performed under general (GA) or regional anesthesia with brachial plexus block (NB). Whether anesthesia type affects patient outcomes is unclear. This study retrospectively compared patient satisfaction between GA and NB after surgery. Methods: This was a historical cohort study of 80 (34 GA and 46 NB) patients who underwent volar plate fixation of distal radius fractures. Propensity score analysis was used to generate a set of matched cases (NB) and controls (GA), yielding 14 matched patient-pairs. The simplified patient satisfaction scale was compared for primary outcomes. Secondary outcomes were anesthesia and surgery duration, hospital stay length, adverse events, postoperative analgesic requirement, and wrist range of motion (ROM) 2 weeks and 3 months postoperatively. Results: After propensity score matching, patients in almost all cases in both groups were “Satisfied” (effect size: 0.1, p = 0.572), indicating little significant difference. Significant differences in adverse events and postoperative analgesic use observed before matching disappeared after matching. Anesthesia duration and hospital stay length were significantly shorter in the NB group (effect size: -1.27 and -0.77, p = 0.00074 and p = 0.0388, respectively), as was surgery duration (effect size: -0.84, p = 0.0122) after matching. Similar to before matching, wrist ROM significantly improved in the NB group (effect size: 1.11, p = 0.0279) in the early postoperative period, but the difference disappeared at 3 months postoperatively. Conclusions: Patient satisfaction between distal radius fracture surgery under GA and NB was similar. Nerve block could help shorten hospital stay length and surgery duration and improve postoperative functional recovery.

Perioperative management of a female diagnosed with heterozygous X-linked adrenoleukodystrophy for shoulder arthroscopy

Abstract X-linked adrenoleukodystrophy (X-ALD) belongs to a family of rare diseases due to inborn errors of metabolism. It has a wide spectrum of clinical manifestations that anaesthesiologists should recognise during the perioperative period (respiratory centre dysfunction, hypotonia, adrenal or hepatic failure, gastroesophageal reflux disease, osteopenia, seizures). The case is presented of a 42-year-old X-linked adrenoleukodystrophy female carrier, who underwent combined general and an ultrasound-guided interscalene brachial plexus block anaesthesia for shoulder arthroscopy. Induction was performed with thiopentone and fentanyl, and sevoflurane was used as inhaled maintenance agent. No events were recorded during the procedure. Her post-operative recovery was satisfactory and she was later discharged home.

Morphine as an adjuvant to local anesthetics in axillary brachial plexus block in forearm and hand surgery

Background The axillary brachial plexus block is a popular nerve block for forearm, wrist, and hand surgery. The use of local anesthetic peripheral nerve blocks for surgical anesthesia and postoperative pain management has increased significantly with the advent of ultrasound-guided techniques. The discovery of peripheral opioid receptors led to the clinical application of adding opioids to local anesthetics for peripheral nerve blocks. This study is done to evaluate effect of morphine on onset, duration, and quality of analgesia when added to local anesthetics in axillary brachial plexus block and to detect any complications that occurred with this technique. Patients and methods In this prospective controlled clinical trial, 60 adult patients aged 18–60 years scheduled for orthopedic surgery of the forearm and hand with axillary brachial plexus block were selected and randomly allocated to two groups. Placebo group received 24 ml bupivacaine 0.5%, and morphine group received 24 ml bupivacaine 0.5%+5 mg morphine. The onset and duration of sensory and motor blocks, duration of analgesia, and adverse events (such as nausea and pruritus) during perioperative period were recorded. Results Onset of touch and pain block was faster in morphine group, with P values of 0.016 and 0.025, respectively. Onset of motor block was similar in the two groups. Duration of touch block was longer in morphine group, with P value of 0.022. Duration of motor block showed no change between the two groups. Duration of analgesia was longer in the morphine group, with P value of 0.001, with lower consumption of analgesia. No complications were recorded perioperatively. Conclusion We concluded that morphine provide better postoperative analgesia when injected with local anesthetics in ultrasound-guided axillary brachial plexus block without an increase in the frequency of complications.