Interscalene Brachial Plexus Block Research Articles

The efficacy of ultrasound-guided upper thoracic erector spinae plane block for postoperative analgesia in proximal shoulder surgery and its effect on phrenic nerve function: A prospective exploratory study

Abstract Background and Aims: The upper thoracic (T2) erector spinae plane block (UT-ESPB) has been proposed as an alternative to interscalene brachial plexus block for postoperative analgesia in shoulder surgery. The current study was conducted to evaluate the same. Material and Methods: Patients scheduled for shoulder surgery under general anesthesia (GA) received ultrasound-guided UT-ESPB. The outcomes measured were diaphragmatic movements, block characteristics, and quality of recovery at 24 h. Results: A total of 43 patients were recruited. The incidence of phrenic nerve palsy was 0%. The sensory level achieved by the maximum number of patients at the end of 30 min was C7-T5 level, and none had a motor block. Forty-two percent of patients did not require rescue analgesia till 24 h postoperative. In the rest of the patients, the mean (SD) duration of analgesia was 724.2 ± 486.80 min, and the mean postoperative requirement of fentanyl was 98.80 ± 47.02 mg. The median pain score (NRS) during rest and movement is 2 to 3 and 3 to 4, respectively. The median quality of recovery score at the end of 24 h after the block was 14 (15–14). Conclusion: The upper thoracic ESPB resulted in a sensory loss from C7-T5 dermatomes without any weakness of the diaphragm and upper limb. However, the block was moderately effective in terms of the total duration of analgesia, postoperative pain scores, analgesic requirement, and quality of recovery in patients undergoing proximal shoulder surgeries under GA. Further studies are required to establish its role due to its poor correlation with sensory spread.

A prospective randomized comparative study of analgesic effect of dexmedetomidine versus dexamethasone as an adjuvant to 0.75% ropivacaine in ultrasound-guided interscalene block

Abstract Background: Ultrasound (USG)-guided interscalene block (ISB) provides excellent anesthesia and analgesia for humerus surgery. Various adjuvants have been used to improve the quality of block and duration of analgesia. Aim: The aim of the study was to compare the efficacy of dexmedetomidine (DXM) and dexamethasone (DXA) as an adjuvant to 0.75% ropivacaine for interscalene brachial plexus block among patients undergoing humerus surgery. Settings and Design: The study design was a prospective randomized comparative study at a tertiary care teaching hospital. Materials and Methods: After ethical approval and CTRI registration, 52 patients of 18–60 years of age, American Society of Anesthesiology Grade I–II, scheduled for proximal and mid-shaft humerus surgery were randomly allocated in Groups A and B. Group A (n=26) received Ropivacaine 0.75% (20 ml) along with DXM 0.5 µg/ Kg and 2 ml saline (total 22 ml) and Group B (n=26) received Ropivacaine 075% along with DXA 8 mg (total 22 ml). ISB was performed with an in-plane technique using a linear probe. Duration of analgesia, block characteristics (onset, complete sensory, and motor block), and complications were recorded and compared for 24 h. Statistical Analysis: Data were statistically analyzed with Social Science Statistics. Student’s unpaired t-test and Chi-square tests were used, and all statistical tests were examined with P ≤ 0.05 level of significance. Results: The duration of analgesia in Group B was significantly longer than Group A (13 h 12 min ± 2 h 33 min–8 h 48 min ± 1 h 52 min, P < 0.00001). The groups were comparable regarding block characteristics, baseline demographics, and intraoperative hemodynamic parameters. Conclusion: DXA as an adjuvant to ropivacaine provides analgesia for longer duration compared to DXM in USG-guided ISB.

Comment on “Combined thoracic epidural anaesthesia and interscalene brachial plexus block for modified radical mastectomy in a high-risk patient”

Comment on “Combined thoracic epidural anaesthesia and interscalene brachial plexus block for modified radical mastectomy in a high-risk patient”

Evaluation of Analgesia Using Perineural Dexamethasone Compound in Interscalene Brachial Plexus Block After Shoulder Surgery.

The objective of this study was to examine analgesia when using perineural dexamethasone compound in an interscalene brachial plexus block following shoulder surgery. This study was designed as a randomized, double-blind clinical trial. Patients meeting the specified criteria were randomly divided into two groups: The experimental group and the control group, each comprising 30 individuals. Age and gender were matched between the groups. The control group received lidocaine along with 2 cc of 0.5% bupivacaine (20 milligrams) and 2 cc of normal saline; however, the experimental group received lidocaine, along with 2 cc of 0.5% bupivacaine and 2 cc of dexamethasone. Pain levels were assessed using the Visual Analog Scale (VAS), and covariance analysis was applied for data analysis. The results demonstrated that pain intensity was notably lower in the experimental (dexamethasone) group than in the control group at both the 12-hour group (P < 0.001) and 24-hour (P < 0.001) postoperative marks. Dexamethasone significantly reduced pain among the patients. In conclusion, administering dexamethasone to potential candidates for shoulder surgery could lead to prolonged analgesia for up to 24 hours after the surgery. Consequently, this medication can serve as an efficacious analgesic option for pain management in these patients.

Efficacy and safety of extrafascial injection versus intrafascial injection for interscalene brachial plexus block: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to assess the efficacy and safety of interscalene brachial plexus block (ISB) techniques in upper limb and shoulder surgeries. We conducted a comprehensive search of PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, Medline, and Scopus databases up to May 14th, 2023. We employed a search strategy involving keywords such as "brachial plexus block," "interscalene brachial plexus block," "ISB," "extrafascial," and "intrafascial," without applying search restrictions or filters. Eligible studies consisted of randomised controlled trials (RCTs) that compared extrafascial and intrafascial ISB techniques in adult patients undergoing upper limb and shoulder surgeries. Our analysis included six RCTs encompassing 485 participants. Extrafascial injection demonstrated superiority over intrafascial injection in reducing the incidence of hemidiaphragmatic paresis (RR 0.33, 95% CI 0.124 to 0.47, P<0.00001) and preserving respiratory function (MS 0.31, 95% CI 0.1 to 0. 52, P=0.003 FEV<inf>1</inf> in liters). Additionally, extrafascial ISB exhibited a lower risk of block-related complications (RR 0.35, 95% CI 0.25 to 0.50, P<0.00001). However, the intrafascial technique offered a faster sensory and motor block onset. The duration of sensory block did not significantly differ. The incidence of Horner syndrome showed no statistically significant difference. Our findings favor extrafascial ISB techniques because they reduce hemidiaphragmatic paresis, preserve respiratory function, and lower block-related complications. However, further research is necessary to establish their safety and efficacy in specific patient populations.

Liposomal Bupivacaine Provides Superior Pain Control Compared To Bupivacaine With Adjuvants In Interscalene Block For Total Shoulder Replacement: A Prospective Double-Blinded, Randomized Controlled Trial

Optimal pain control methods after total shoulder arthroplasty (TSA) achieve reduced opioid consumption, shortened hospital stay, and improved patient satisfaction in addition to adequate analgesia. Interscalene brachial plexus block is the gold standard for TSA, yet it typically does not provide pain relief lasting beyond 24 hours. Liposomal bupivacaine (LB) purportedly provides prolonged analgesia, yet it has been minimally explored for interscalene block, and it is significantly more expensive than standard bupivacaine. This is a prospective, two-arm, double-blinded randomized controlled trial. Subjects presenting for anatomic or reverse TSA were randomized in a 1:1 ratio to receive interscalene brachial plexus block with either LB plus bupivacaine (LBB group) or bupivacaine plus dexamethasone and epinephrine (BDE group). The primary outcome was 120-hour postoperative opioid consumption. Secondary outcomes were pain scores up to 96 hours postoperatively, pain control satisfaction, complications, level of distress from block numbness, and hospital stay. Ninety patients, 45 per group, were included in the intention-to-treat analysis and randomized. Due to withdrawal of consent and loss to follow-up, 40 in each group completed enrollment through postoperative day 60. Total 120-hour postoperative opioid consumption was similar between groups (p=0.127), with no differences within 24- or 48-hour time intervals. Postoperative pain scores at 24-48 hours, 48-72 hours, 72-96 hours, and day 60 were significantly lower for the LBB group. Liposomal bupivacaine interscalene brachial plexus block before total shoulder arthroplasty did not reduce 120-hour postoperative opioid consumption but significantly reduced postoperative pain between 24 and 96 hours and at postoperative day 60.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

Anterior Glenoid Block as an Alternative Technique to Interscalene Brachial Plexus Block.

Anterior Glenoid Block as an Alternative Technique to Interscalene Brachial Plexus Block.

The effect on the incidence of rebound pain of the application of anterior suprascapular nerve block added to interscalene brachial plexus block for shoulder surgery: A randomized controlled study

This study aimed to compare the incidence of rebound pain applied with anterior suprascapular nerve block (ASSB) added to interscalene brachial plexus block (ISB) as postoperative analgesia in shoulder surgery. This prospective, observer-blinded, randomized study involved 60 patients who were to undergo shoulder surgery. The patients were divided into two groups: group ISB (n=30) received ISB block, while group ISB+ASSB (n=30) received ASSB in addition to ISB. The primary outcome was to determine the occurrence of rebound pain. Secondary outcomes were numerical rating scale (NRS) values of postoperative pain at 6, 8, 12, 16, 18, 24, and 48 hours, 48-hour opioid consumption, sleep scale for the postoperative night and subsequent 6 nights, and the quality of recovery (QoR) scale evaluated on postoperative days 1 and 7. No statistically significant difference was found between the ISB group (56.7%) and the ISB+ASSB group (40%) in the incidence of rebound pain following the resolution of peripheral nerve block (PNB) (p=0.196). The ISB+ASSB group had a significantly longer time to PNB wear off (14.77±2.07 ) compared to the ISB group (12.87±1.94) (p=0.001). The postoperative day 1 QoR-15 values were significantly better in the ISB+ASSB group (122.60±10.79) than in the ISB group (116.33±11.48) (p=0.031). Sleep evaluation on the postoperative night showed a significant difference between the groups; ISB+ASSB (3[2-3])–ISB (2[1-3]). The addition of ASSB to ISB did not have a sufficient effect with respect to the incidence of postoperative rebound pain following shoulder surgery. However, there was seen to be a positive effect on prolonging the PNB and on the QoR day 1 values.

Costoclavicular block – single to double injection – time to see the premiere of triple injection

Sir,Securing the phrenic nerve when achieving effective anesthesia block for the upper limb has been a topic intriguing regional anesthesia enthusiasts ever since. Interscalene brachial plexus block is known to involve the phrenic nerve in 100% of the cases and costoclavicular block which has gained momentum since 2015 is declared to involve the phrenic nerve in 0% of the cases. Besides this the compact, reliable topography of the cords in the triangular costoclavicular space along with an expedited sensorimotor block with local anesthesia deposited in the center of the three cords makes costoclavicular block an attractive option for elbow and below elbow surgeries. According to the studies, the success rate of the blockade is 92.5% with single injection in the center of the cords. Another study by Sebastian, where apart from classical single injection, another injection was given after redirecting the needle, between the medial cord and subclavian artery (labeling it a corner pocket technique) for costoclavicular block. They concluded that the block’s onset time and total anesthesia-related time were significantly shortened with the double injection technique compared with single injection. The basis of this was explanation laid by Dr. Monzo and Hadzic where they proposed in a series of 40 patients a linear septum arising from the lateral part of axillary artery separating the lateral code from the posterior and the medial code, thus compartmentalizing the costoclavicular space. They reported a success rate of 97.5% in their study on 40 patients.4 Hence,double injection is used to overcome the septum “issue.” Pornpatra is defined a high definition ultrasonographic presence of paraneural sheath and facial compartments surrounding the brachial plexus cords at the lateral infraclavicular fossa and the costoclavicular space. We propose that a triple injection with 3rd injection in the vicinity of the lateral cord just before withdrawing the needle apart from the other two injections significantly shortens the onset time of sensory block from 16 min to 9 min. The various sites for injection are shown in the figure below, but the exact point of injection of the second and third is more prominent after giving the first injection. The chances of the median nerve sparing as has been reported in some cases in previous studies are almost nil by this technique - the corner pocket injection that involves the medial root of the median nerve and the lateral cord that is specifically blocked separately covering the lateral root of the median nerve. CONCLUSIONWe did a case series in 15 cases and although the sample size is small and this is definitely not a randomized control trial, to make such a bold statement, we would like to decipher a positive future of the costoclavicular block with triple injection technique with an RCT already underway.

Combined interscalene brachial plexus block and superficial cervical plexus block for shoulder disarticulation surgery in a terminal cancer patient.

Combined interscalene brachial plexus block and superficial cervical plexus block for shoulder disarticulation surgery in a terminal cancer patient.

A comparison of the continuous supraclavicular brachial plexus block using the proximal longitudinal oblique approach and the interscalene brachial plexus block for arthroscopic shoulder surgery: A randomised, controlled, double-blind trial.

Continuous interscalene brachial plexus block (ISB) is widely used for arthroscopic shoulder surgery, but the incidence of hemidiaphragmatic paresis (HDP) has been reported to reach 100%. Several methods, including injections distal to the C5-C6 nerve roots, have been attempted to reduce the HDP incidence. However, catheter placement distal to the C5-C6 nerve roots interferes with the surgical site. Our primary objective was to describe a new technique, the supraclavicular brachial plexus block (SCB), using the proximal longitudinal oblique approach (PLO-SCB), which can facilitate catheter placement and, when compared with ISB, to test whether this would provide noninferior analgesia and spare the phrenic nerve. Prospective, randomised, double-blind study. Operating rooms, postanaesthesia care unit, and wards. Seventy-six patients aged 20 to 80 years scheduled for arthroscopic shoulder surgery. Patients were randomly assigned to the continuous PLO-SCB ( n  = 40) or the continuous ISB ( n  = 40) groups. All patients received an initial low-volume single-injection (5 ml 0.75% ropivacaine) followed by a patient-controlled infusion of 0.15% ropivacaine. The primary outcomes were the incidence of HDP and pain scores. Secondary outcomes were respiratory function, postoperative analgesic consumption, sensory and motor function, and complications. The HDP incidence was significantly lower in the PLO-SCB group than in the ISB group at 30 min after block injection: 0% (0 of 38 patients) and 73.7% (28 of 38 patients), respectively ( P  < 0.001). Similarly, at 24 h after surgery, the incidences were 23.7% (9 of 38 patients) and 47.4% (18 of 38 patients) in the PLO-SCB and ISB groups, respectively ( P  = 0.002). Median [IQR] NRS pain scores at rest measured after surgery in the ISB and PLO-SCB groups were similar: immediately after surgery, 1 [0 to 2] vs. 1 [0 to 1], P  = 0.06); at 30 min, 2 [0.25 to 2] vs. 1 [0 to 2], P  = 0.065); and at 24 h 2 [0.25 to 3] vs. 1 [0 to 3], P  = 0.47, respectively. For major shoulder surgery, compared with continuous ISB, continuous PLO-SCB was more sparing of diaphragmatic and respiratory function while providing noninferior analgesia. Catheter placement via the PLO approach is feasible without interfering with the surgical field. Registered by the Clinical Trial Registry of Korea (Seoul, Korea; KCT0004759, http: cris.nih.go.kr, principal investigator: Hyungtae Kim).

Published- Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy

Background &amp; objective: Inter-scalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. Although, this method has its side-effects and possibly complications. Supra-scapular nerve block and axillary nerve block have also been used in upper limb procedures. We compared ISB with the blockade of supra-scapular and axillary nerves (called shoulder block) for postoperative analgesia after shoulder arthroscopic surgical operation under ultrasound guidance (USG) and nerve stimulators.&#x0D; Methodology: It was a prospective, randomized, comparative study.&#x0D; Results: The VAS pain scores at different times postoperatively were not significantly different between the ISB and ShB groups (P = t 0.071, 0.28, 0.378, 0.358, 0.451 at 2, 4, 8, 16, and 24 h respectively. VAS 0 was significantly difference (P = 0.029) but still the VAS score was less than 3, so no pain killers were given.&#x0D; Conclusion: Ultrasound guided supra-scapular and axillary nerve blocks ae equally effective as inter-scalene brachial plexus block for postoperative analgesia in shoulder arthroscopic surgery with less side-effects.&#x0D; Abbreviations: ANB: Axillary Nerve Block; ISB: Interscalene Block; MAC: Minimum OR: Operating Room; REC: Research Ethics Committee; ShB: Shoulder Block; SSB: Supra-scapular Nerve Block; VAS: Visual Analogue Scale&#x0D; Citation: Elbermway MS, Elshantory SF, Aly RM, Mahran MG. Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy. Anaesth. pain intensive care 2022;26(5):674−680; DOI: 10.35975/apic.v26i5.2026&#x0D;  

Comment on: “Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy”

I read the article that compared the interscalene block (ISB) with the shoulder block (ShB) which is a combination of supra-scapular and axillary nerve block for shoulder arthroscopy procedures published in the current issue and wish to present my reflections on that article as a "Letter to the Editor" manuscript.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block.

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Combined thoracic epidural anaesthesia and interscalene brachial plexus block for modified radical mastectomy in a high-risk patient

In a case of malignancy of the breast, operation is one of best option for the management of the patient. Modified radical mastectomy (MMR) is commonly conducted by giving general anaesthesia (GA). But GA is not a rational choice in patients who are suffering from bronchial asthma and other associated comorbidities. These patients have additional danger of perioperative morbidity and mortality especially because of respiratory complications. We report successful perioperative management of MMR under combined thoracic epidural anaesthesia and ipsilateral interscalene brachial plexus block in a diagnosed case of malignancy of breast with bronchial asthma, type 2 diabetes mellitus and hypertension.

Early clinical efficacy analysis of enhanced recovery following surgery combined with interscalene brachial plexus block for arthroscopic rotator cuff repair.

To explore the early clinical value of enhanced recovery after surgery (ERAS) with interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR). We enrolled 240 patients who underwent arthroscopic rotator cuff repair, randomly divided into 3 groups (n = 80 each). Groups A, B, and C underwent only surgery, surgery + ERAS, and ISB + surgery + ERAS, respectively. We analyzed the clinical data and postoperative indicators for the 3 patient groups. Group comparisons of clinical data and postoperative indicators revealed no significant differences in clinical characteristics (P > .05). Group C showed superior Visual Analog Scale scores at 0-6 and 6-24 hours postoperatively (P < .05), and the shortest length of hospital stay (LOS) (P < .05). At 6 weeks and 3 months postoperatively, Constant-Murley shoulder score and University of California-Los Angeles scores were better in Groups B and C than in Group A (P < .05). Joint swelling was more common in Group A than in Groups B and C (P < .05) but with no significant difference in the incidence of postoperative stiffness (P > .05). ERAS can relieve postoperative pain, shorten LOS, and help restore shoulder joint mobility, thereby reducing postoperative swelling. ISB + ERAS optimized pain control and allowed a shorter LOS, but had similar effects on early functional recovery and complications.

Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens

BACKGROUND: Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE: Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN: Prospective, randomized, controlled trial SETTING: Tertiary university hospital SAMPLE SIZE: 60 patients PATIENTS AND METHODS: Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES: Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0–48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS: The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P =.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4–7]), 8 ([5.75–8]), P &lt;.001, respectively). Those who received IV dexamethasone had less sleep disturbances ( P &lt;.001) and higher QoR-15 on day 1 ( P &lt;.001) and day 7 ( P =.020) postoperatively. CONCLUSIONS: IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS: Single-center study

Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study

PurposeTo assess the effects of intravenous tranexamic acid (TXA) on visual clarity at various surgical stages and the correlation between severity of synovitis and bursitis and visual clarity in patients undergoing arthroscopic shoulder surgery under an interscalene brachial plexus block. MethodsThis double-blind, randomized controlled study included patients undergoing arthroscopic rotator cuff repair. The TXA group was injected 1000 mg of TXA intravenously, and the control group was administered the same volume in normal saline 10 min preoperatively. Visual clarity was rated according to a three-grade visual clarity scoring system from grade 1 (clear) to grade 3 (poor) at four surgical stages (I, intra-articular soft tissue procedure including synovectomy; II, acromioplasty; III, bursectomy; and IV, greater tuberoplasty). The primary outcome was arthroscopic visual clarity. The secondary outcomes were medications administered for hemodynamic stability, length of hospital stay, and thromboembolic events. ResultsAltogether, 63 patients were included in the study and they were divided into the TXA group comprising 32 patients and the control group comprising 31 patients. The TXA group showed significantly better visual clarity than the control group (1(1–2) vs 2(1–2), p=0.027) during stage I, but not during stages II–IV. Spearman correlation analysis revealed a significant correlation between synovitis and visual clarity grade during synovectomy (correlation coefficient, 0.393; p=0.001), but not between bursitis and visual clarity grade during bursectomy. Deep vein thrombosis and pulmonary embolism did not occur in either group. ConclusionsIntravenous TXA can improve visual clarity during intra-articular soft tissue procedures, including synovectomy. However, it does not have a significant effect during acromioplasty, bursectomy, and greater tuberoplasty. TXA can be used to improve visual clarity in patients with suspected severe synovitis. Level of EvidenceLevel I, randomized controlled trial

Ultrasound guided interscalene brachial plexus block.

Peripheral nerve blocks have long been established as a crucial part of the enhanced recovery pathways after surgery. Interscalene brachial plexus block (ISB) is mainly indicated for anaesthesia and analgesia during shoulder and proximal arm surgery. Ultrasound technology has remarkably improved the efficacy and success rates of the ISB while limiting its potential complications.