Interscalene Block For Shoulder Surgery Research Articles

Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial.

Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

Post-operative analgesia for shoulder arthroscopic surgeries: A comparison between inter-scalene block and shoulder block.

Background and Aims:Shoulder arthroscopic surgeries can produce intense post-operative pain. Inter-scalene block (ISB) provides good analgesia after shoulder surgery, but concerns over its associated risks have prompted the search for alternatives. Shoulder block (SHB), which includes suprascapular block along with axillary nerve (AN) block, was recently proposed as an alternative to ISB, but evidence of its efficacy is conflicting. The aim of our study was to compare SHB with ISB in shoulder surgery for post-operative analgesia.Methods:A total of 76 patients scheduled for shoulder arthroscopic surgery were equally divided into 2 groups of 38 patients each: ISB group and SHB group. Both the nerve blocks were achieved by using ultrasound and a nerve stimulator. Visual analogue scale (VAS) scores were evaluated at 1, 4, 6, 12 and 24 h post-operatively. The time to first analgesia request, total analgesic requirement for 24 h post-operatively, patient satisfaction and any complications were recorded.Results:SHB provided equivalent analgesia to ISB in terms of post-operative VAS scores. Time to first analgesic request was 6.2 ± 1.3 h in ISB group and 5.9 ± 1.2 h in SHB group, which was not statistically significant. Complications like subjective dyspnoea and weakness of arm were significantly higher in ISB group compared to SHB group. Patient satisfaction scores were also significantly higher in SHB group compared to ISB group.Conclusion:SHB is as effective as ISB for post-operative pain relief and with fewer complications due to selective blockade of suprascapular and axillary nerves.

Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis.

Interscalene block provides optimal shoulder surgery analgesia, but concerns over its associated risks have prompted the search for alternatives. Suprascapular block was recently proposed as an interscalene block alternative, but evidence of its comparative analgesic effect is conflicting. This meta-analysis compares the analgesic effect and safety of suprascapular block versus interscalene block for shoulder surgery. Databases were searched for randomized trials comparing interscalene block with suprascapular block for shoulder surgery. Postoperative 24-h cumulative oral morphine consumption and the difference in the area under curve for pooled rest pain scores were designated as primary outcomes. Analgesic and safety outcomes, particularly block-related and respiratory complications, were evaluated as secondary outcomes. Results were pooled using random-effects modeling. Data from 16 studies (1,152 patients) were analyzed. Interscalene block and suprascapular block were not different in 24-h morphine consumption. The difference in area under the curve of pain scores for the 24-h interval favored interscalene block by 1.1 cm/h, but this difference was not clinically important. Compared with suprascapular block, interscalene block reduced postoperative pain but not opioid consumption during recovery room stay by a weighted mean difference (95% CI) of 1.5 cm (0.6 to 2.5 cm; P < 0.0001). Pain scores were not different at any other time. In contrast, suprascapular block reduced the odds of block-related and respiratory complications. This review suggests that there are no clinically meaningful analgesic differences between suprascapular block and interscalene block except for interscalene block providing better pain control during recovery room stay; however, suprascapular block has fewer side effects. These findings suggest that suprascapular block may be considered an effective and safe interscalene block alternative for shoulder surgery.

In Response

We thank Dr. Altman and his colleagues for their comments on our quantitative review of the benefits of interscalene block for shoulder surgery.1 The authors raise important points relating to our rationale for pooling data as well as the use of perineural adjuncts in clinical practice. We maintain that the surgical populations, interventions, and comparators included in our review were sufficiently homogenous to warrant pooling. In addition, we duly performed subgroup analysis to examine differences (eg, open versus closed surgery, short-acting versus long-acting local anesthetics, nerve stimulator guidance versus ultrasound guidance) that may have influenced our findings. Importantly, these differences do not preclude pooling, and modern regional anesthesia literature includes numerous examples of landmark meta-analyses2–5 that pooled trials with such differences. It is most important to recognize, acknowledge, and account for these differences, and we believe that we have done so satisfactorily. The effect of perineural local anesthetic adjuncts, such as dexamethasone, on the duration of analgesia associated with interscalene block is an evolving subject of substantial promise. Indeed, although many practitioners consider the addition of dexamethasone to the local anesthetic solution routine, questions regarding its minimal effective dose, route of administration (perineural versus intravenous), and safety persist. As such, studies investigating the use of perineural adjuncts or encapsulated local anesthetics were excluded from our analyses. The latter notwithstanding, our results definitively indicate that interscalene block via the use of local anesthetic alone provides dynamic and rest pain up to 6 and 8 hours, respectively. Interscalene block also provides an opioid-sparing effect and reduces opioid-related side effects up to 12 and 24 hours, respectively. Indeed, single-injection interscalene block with local anesthetic alone remains the care standard for ambulatory shoulder surgery at our home institution. Faraj W. Abdallah, MDDepartment of AnesthesiaUniversity of TorontoToronto, Ontario, CanadaDepartment of AnesthesiaKeenan Research CentreLi Ka Shing Knowledge InstituteSt. Michael’s HospitalToronto, Ontario, Canada Richard Brull, MD, FRCPCDepartment of AnesthesiaUniversity of TorontoToronto, Ontario, CanadaDepartment of AnesthesiaWomen’s College HospitalToronto, Ontario, Canada[email protected]

Pneumothorax as a complication of ultrasound-guided interscalene block for shoulder surgery

Pneumothorax as a complication of ultrasound-guided interscalene block for shoulder surgery

A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia -A case report-

The occurrence of severe hypotension and bradycardia, following placing to the beach chair position from supine during general anesthesia for repair of tendon injury of the rotator cuff of shoulder in a healthy 50 year-old man was described. The Bezold-Jarisch reflex, which is known to inhibit cardiovascular reflex and composed of three kinds of symptoms such as vasodilation, bradycardia and hypotension, has been reported mainly in peripheral nerve block, and may occur during orthostasis, hypovolemia, hemorrhage, supine inferior vena cava compression in pregnancy, interscalene block for shoulder surgery in the sitting position and so on. The bradycardia and hypotension can be more aggravated when causative elements overlaps each other. Anticholinergics and vasopressor were injected intravenously, and position of the patient was changed to the supine position immediately resulting in a normal vital signs dramatically.

Interscalene block for shoulder surgery

Fracture dislocation of the shoulder is a common musculoskeletal injury following road traffic accident. Peripheral nerve block has become a recognized anesthetic technique due to the rapid onset of prolonged analgesia, sufficient for both pain and surgical management. However, interscalene block for shoulder surgery has not been reported as a primary anesthetic technique in our environment. We report its successful use in open reduction and internal fixation of left humeral surgical neck fracture dislocation. The interscalene brachial plexus were localized by a Polystim II nerve stimulator (te me na, Bondy, France) with sustained biceps motor response at 0.2 mA and 40 ml of local anesthetic, comprising 0.25% bupivacaine and 1.0% of lidocaine with 1 : 200,000 epinephrine in equal parts was administered to establish the block. Surgical anesthesia was achieved 18 minutes after instituting the block and surgery lasted 70 minutes without complications. This technique may obviate the use of general anesthesia with its risks.

Interscalene Block for Shoulder Surgery in Physician-Owned Community Ambulatory Surgery Centers

To retrospectively report on a series of patients who had interscalene block regional anesthesia performed for outpatient open and arthroscopic shoulder surgical procedures in a community-based ambulatory surgery center setting. We reviewed the cases of 1,945 patients who had interscalene block regional anesthesia performed during an 8-year period. The complication rate was 0.63%, with all complications occurring in the immediate postoperative period, none of which were permanent. With an expert, experienced anesthesia team, the interscalene block can be a safe method (temporary complication rate, 0.63%) of intraoperative anesthesia and perioperative analgesia for outpatient open and arthroscopic shoulder surgery in physician-owned ambulatory surgery centers. Level IV, therapeutic case series.

36. Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

36. Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

36: Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

36: Low Level, Low Volume Interscalene Block for Shoulder Surgery in Patients With Chronic Obstructive Pulmonary Disease (COPD)

Successful Continuous Interscalene Analgesia for Ambulatory Shoulder Surgery in a Private Practice Setting

Large prospective studies evaluating continuous interscalene block for shoulder surgery have thus far been limited to inpatient and university teaching practices. Shoulder surgery is increasingly being performed on an outpatient basis. The aim of this case series was to prospectively evaluate a large series of interscalene catheters for ambulatory shoulder surgery in a private practice setting. A single operator placed nonstimulating catheters using a combination of ultrasound and nerve stimulation. Following postanesthesia care unit (PACU) discharge, opioid-like analgesic adjuvants other than tramadol were avoided unless patients experienced inadequate pain relief. All patients were assessed in the PACU, on the first postoperative morning, and at 3 weeks for catheter effectiveness and for acute and chronic complications. Pain scores and patient satisfaction were assessed in subgroups of 100 consecutive patients. Three hundred patients were studied. The first attempt catheter success rate was 96%. In all but 1 patient, ineffective catheters in the PACU were effectively reinserted. Thirteen patients experienced inadequate pain relief after leaving the PACU. Of these patients, 5 were rescued with additional ropivacaine, 3 had the catheter effectively reinserted, and 5 were managed with oral opioids. One patient required antibiotic treatment for catheter site infection. Neurological sequelae potentially attributable to the catheter were present in 3 patients at 3 weeks, and remained in 1 patient at 4 weeks. This patient's symptoms resolved at 6 months. Continuous interscalene block for ambulatory shoulder surgery in a private practice setting had a high success rate, a low complication rate, and enabled the avoidance of the use of potent opioids in 98% of patients.

Hypertensive crisis after interscalene block for shoulder surgery

Hernandez, A.; Salgado, I.; Agreda, G.; Botana, C.; Casas, M.; Nogueron, M. Author Information

A Case of Asystolic Cardiac Arrest in the Sitting Position for Shoulder Arthroscopy using an Interscalene Block: A case report

An interscalene block for shoulder surgery provides excellent surgical conditions and is well received by patients. However, a combination of the sitting position, regional anesthesia, an awake patient, and a surgical procedure can result in another side effect, vasovagal episodes, which may lead to cardiac arrest in extreme cases. We experienced a case of 32-year-old male patient with a severe vasovagal episode that led to asystolic cardiac arrest 15 minutes after the changing to the sitting position under an interscalene block for shoulder arthroscopic surgery. (Korean J Anesthesiol 2006; 51: 383~6)

Suprascapular nerve block added to interscalene block for shoulder surgery; quality of postoperative analgesia

Suprascapular nerve block added to interscalene block for shoulder surgery; quality of postoperative analgesia