Interscalene Brachial Plexus Blockade Research Articles

Continuous interscalene versus phrenic nerve-sparing high-thoracic erector spinae plane block for total shoulder arthroplasty: a randomized controlled trial.

The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty. Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption. The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04). This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed. www. gov (NCT03807505); registered 17 January 2019.

Effect of two different dosages of adjunct magnesium sulfate on interscalene nerve blockade: A double blind randomized controlled trial

Interscalene nerve block is very commonly performed for clavicle &amp; proximal humerus surgeries. However very few studies have evaluated the effect of add on magnesium sulphate to local anaesthetic for interscalene nerve block.Sixty patients of American Society of Anaesthesiologist (ASA) physical status I and II undergoing surgeries for fracture clavicle and proximal humerus were recruited in this trial. Following randomisation, ultrasound guided interscalene block was performed with 10ml of 2% lignocaine and 20ml of 0.5% bupivacaine either with adjunct 125 mg (MS 125 group, n=30) or 250 mg (MS 250 group, n=30) magnesium sulphate. Primary outcome was to measure and compare the postoperative analgesia, duration of sensory and motor blockade.There was no significant difference between the groups in the duration of sensory blockade [MS 125 v/s MS 250; Mean±SD [Median]; 505.3±44.6 (500) minutes v/s 501.1±45.9(498) minutes; p= 0.65], duration of motor blockade [MS 125 v/s MS 250; Mean±SD [Median]; 314.9±31.1(307) minutes v/s 311.4±34.2(305) minutes; p= 0.7] and the duration of post-operative analgesia [MS 125 v/s MS 250; Mean±SD [Median]; 519±46.1(512) minutes v/s 498±95.8(507 minutes); p=0.43].Magnesium sulfate at the dose of 125 mg is equally effective as 250 mg for prolonging sensory and motor blockade as well as for post-operative analgesia when used as an adjunct to bupivacaine and lignocaine during interscalene brachial plexus blockade. Our study is limited by small sample size. Further studies with larger sample size are needed.

A comparative study of ropivacaine with dexamethasone and ropivacaine with dexmeditomedine, in ultrasound guided interscalene brachial plexus blockade for adult upper limb surgeries

A comparative study of ropivacaine with dexamethasone and ropivacaine with dexmeditomedine, in ultrasound guided interscalene brachial plexus blockade for adult upper limb surgeries

Interscalene Block with and without Intraoperative Local Infiltration with Liposomal Bupivacaine in Shoulder Arthroplasty: A Randomized Controlled Trial.

Interscalene brachial plexus blockade (ISBPB) is an effective anesthetic technique for shoulder arthroplasty; however, "rebound pain" can increase the patient's postoperative pain experience and narcotic usage. Exparel (liposomal bupivacaine) injected into the soft tissues at the surgical site has theoretical efficacy for up to 72 hours after administration. The purpose of this study was to evaluate postoperative pain scores and narcotic consumption following shoulder arthroplasty performed with either ISBPB alone or ISBPB and intraoperative Exparel. Seventy-eight patients undergoing primary shoulder arthroplasty were randomized to receive an ISBPB with Exparel (39 patients) or without Exparel (39 patients). The primary outcome variable was morphine equivalent units (MEUs) consumed over the first 24 hours after surgery. Secondary outcomes included intraoperative narcotic administration and visual analog scale (VAS) scores for pain (at 0, 8, 16, 24, 48, and 72 hours after surgery). There were no significant demographic differences between the ISBPB and ISBPB + Exparel groups. Total narcotic consumption over the first 24 hours after surgery was significantly lower in the ISBPB group compared with the ISBPB + Exparel group (mean and standard deviation, 18.9 ± 25.6 MEU versus 35.3 ± 36.7 MEU, p = 0.009). VAS pain scores did not differ significantly between groups at any time point during the first 72 hours after surgery. Patients treated with Exparel required significantly more postoperative narcotics and demonstrated no significant reduction in pain scores over the first 72 hours after primary shoulder arthroplasty. Exparel does not appear to have substantial value when added to a pain protocol that includes an ISBPB. Therapeutic Level l. See Instructions for Authors for a complete description of levels of evidence.

Multimodal Pain Management Protocol Versus Patient Controlled Narcotic Analgesia for Postoperative Pain Control after Shoulder Arthroplasty.

Our institution's traditional pain management strategy after shoulder arthroplasty has involved the utilization of postoperative patient-controlled narcotic analgesia. More recently, we have implemented a protocol (TLC) that utilizes a multimodal approach. The purpose of this study was to determine whether this change has improved pain control and decreased narcotic utilization. Patients undergoing primary total shoulder or reverse arthroplasty were retrospectively studied. All patients underwent interscalene brachial plexus blockade. "Traditional" patients were provided a patient-controlled analgesic pump postoperatively. TLC patients were given preoperative and postoperative multimodal, non-narcotic analgesic medications and breakthrough narcotics. Morphine equivalent units (MEU) consumed and Visual Analog Scale (VAS) scores for pain (0, 8, 16, and 24 hours) were considered. There were 108 patients in each group. Total postoperative narcotic consumption in the first 24 postoperative hours was 38.5 +/- 81.1 MEU in the "Traditional group" compared to 59.3 +/- 59.1 MEU in the TLC group (P<0.001). Of patients in the TLC group, 88% utilized breakthrough narcotics. VAS pain was significantly higher in the "Traditional group" at 16 hours (4.1 +/- 2.9 vs 3.2 +/- 2.7, P=0.020) and 24 hours (4.8 +/- 2.7 vs 3.7 +/- 2.6, P=0.004). Those treated with the TLC protocol had greater narcotic utilization but better VAS pain scores at 24 hours after surgery. Both groups experienced rebound pain. While the TLC protocol led to an improved pain experience, further modification of the currently protocol may be necessary to reduce overall narcotic utilization.

Comparison of single- and triple-injection methods for ultrasound-guided interscalene brachial plexus blockade.

Ultrasound-guided interscalene brachial plexus blockade (IBPB) has a relatively high success rate in shoulder surgery; however, whether multiple injections are superior to a single injection (SI) is currently unknown. In the present study, ultrasound-guided SI and triple-injection (TI) IBPBs were compared in a prospective randomized trial. A total of 111 patients undergoing arthroscopic shoulder surgery and presenting with an American Society of Anesthesiologists physical status grading of I-II were randomly allocated to receive IBPB with 15 ml of 1% ropivacaine as a SI or TI. Performance time, procedure-related pain scores, success rate and prevalence of complications were recorded. The distribution of sensory and motor block onset in the radial, median, ulnar and axillary nerves were assessed every 5 min until 30 min post-local anesthetic injection. The duration of sensory and motor blocks were also assessed. A significantly longer performance time was recorded in the TI group (P<0.001). No significant difference was observed in success rate (91% in TI vs. 88% in SI) 30 min post-injection, and the prevalence of complications and procedure-related pain were similar between the two groups. Sensory and motor blocks of the ulnar nerve in the TI group were significantly faster and more successful compared with the SI group at all time points (P<0.041). It was also observed that sensory and motor blocks in the TI group were prolonged compared with the SI group (P<0.041). In conclusion, the TI method exhibited a faster time of onset and resulted in a more successful blockade of the ulnar nerve. TI method may be a more effective approach for IBPB in a clinical setting.

A Prospective Observational Study of Ropivacaine and Ropivacaine with Dexamethasone, in Low Inter Scalene Brachial Plexus Blockade for Adult Upper Limb Orthopedic Surgeries in a Tertiary Care Centre

A Prospective Observational Study of Ropivacaine and Ropivacaine with Dexamethasone, in Low Inter Scalene Brachial Plexus Blockade for Adult Upper Limb Orthopedic Surgeries in a Tertiary Care Centre

Electric Nerve Stimulation Does Not Correctly Predict Needle-Nerve Distance and Potential Local Anesthetic Spread for Interscalene Brachial Plexus Blockade.

This study evaluated electric nerve stimulation as a nerve location tool. After eliciting motor response in 43 patients undergoing shoulder surgery, the needle tip's position, distance from the closest nerve, and spread of saline were evaluated using ultrasound imaging. The needle's tip resided 1 to 4 mm from the closest nerve in 21, in direct contact with it in 7, and 6 to 18 mm away in 15 patients. In 21 patients, subsequent saline dissection did not reach the brachial plexus. Thus, the success rate of electric nerve stimulation for correct needle-nerve distance identification was 48.8%, with correct fluid spread reached in only 51.2% of patients.

Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty

BackgroundCatheter-delivered continuous interscalene anesthesia has demonstrated improved pain control in randomized clinical trials. The purpose of this study is to determine whether the introduction of continuous catheter anesthesia was associated with a change in length of stay (LOS), readmission, rates of discharge home without home health or nursing services, or opioid administration. We hypothesized that the introduction of continuous catheter anesthesia would be associated with a decrease in LOS, readmission, non-home discharge, and opioid administration. MethodsDuring 2012, our center transitioned from ultrasound-guided single-dose interscalene regional anesthesia to combined single-dose anesthesia and additional continuous catheter anesthesia over 48–72hours. This retrospective chart review compared primary shoulder arthroplasties with single-dose anesthesia to those with continuous catheter anesthesia, after excluding the learning curve, with univariate and multivariate analyses. ResultsIn total, 1697 patients met criteria, 41% with single-dose anesthesia and 59% with continuous catheter anesthesia. On univariate analysis, the continuous catheter group LOS was 2.2±0.7 day and single-dose group LOS was 2.5±0.8 days (P≤0.001). One day LOS's comprised 1% of the single-dose group and 27% of the continuous catheter group (P<0.001). Anesthesia type remained a significant predictor on multivariate analysis (P<0.001) Readmission at 30 and 90 days (P=0.091 and 0.576), and home discharge (P=0.456) were not different. Opioid administration was higher in the continuous catheter group on univariate analysis (P<0.001), but not on multivariate analysis (P=0.607). ConclusionIn this retrospective review of 1697 primary shoulder arthroplasties performed at our high-volume, referral center, continuous catheter anesthesia was associated with reduced length of stay when compared to single-dose anesthesia. Level of evidenceTherapeutic, level IV.

Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study

Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study

Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study

Objectives This study aimed to evaluate the effect of the addition of dexamethasone to levobupivacaine on the duration of analgesia in forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients and methods This prospective randomized controlled, double-blind clinical trial was conducted on 60 patients who underwent elective forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients in the levobupivacaine group (group L) received 25 ml of 0.5% levobupivacaine plus 2 ml of normal saline 0.9%. Patients in the levobupivacaine dexamethasone group (group LD) received 25 ml of 0.5% levobupivacaine plus 2 ml of dexamethasone (8 mg). The onset of sensory and motor block, duration of the sensory block, time to first analgesic request, the number of failed block, total morphine consumption, side effects, and complications were recorded and compared. Results Onset of sensory block and motor block was significantly earlier in group LD compared with group L. Duration of sensory block and time to first analgesic request were significantly longer in group LD compared with group L. Total morphine consumption was significantly lower in group LD in comparison with group L. The number of failed blocks was nonsignificantly lower in group LD. The incidence of side effects and complications was low and comparable in both groups. Conclusion Addition of dexamethasone to levobupivacaine significantly shortens the onset of sensory and motor block, prolongs the duration of analgesia, decreases the 24 h morphine consumption, and prolongs the time to first analgesic request with minimal side effects.

A randomised controlled trial of intravenous dexamethasone combined with interscalene brachial plexus blockade for shoulder surgery.

We recruited patients scheduled for shoulder rotator cuff repair or subacromial decompression under general anaesthesia and interscalene brachial plexus blockade (30ml ropivacaine 0.5%). We allocated 240 participants into four groups of 60 that were given pre-operative saline 0.9% or dexamethasone 1.25mg, 2.5mg or 10mg, intravenously. We recorded outcomes for 48h. The median (IQR [range]) time to first postoperative analgesic request after saline was 12.2 (11.0-14.1 [1.8-48])h, which was extended by intravenous dexamethasone 2.5mg and 10mg to 17.4 (14.9-21.5 [7.2-48])h, p<0.0001, and 20.1 (17.2-24.3 [1.3-48])h, p<0.0001, respectively, but not by dexamethasone 1.25mg, 14.0 (12.1-17.7 [2.1-48])h, p=0.05. Postoperative analgesia was given sooner after rotator cuff repair than subacromial decompression, hazard ratio (95% CI) 2.2 (1.6-3.0), p<0.0001, but later in older participants, hazard ratio (95% CI) 0.98 (0.97-0.99) per year, p<0.0001.

Effective Volume of Ropivacaine 0.75% through a Catheter Required for Interscalene Brachial Plexus Blockade

Ultrasound guidance during peripheral nerve blocks has allowed for reduction in dose and volume of local anesthetic required to accomplish successful blockade using multiple injections through a needle. The authors undertook this study to determine the minimal effective volume required to accomplish successful interscalene brachial plexus block (ISB) through the catheter. After obtaining institutional ethics committee approval and written informed consent, patients aged 18-75 yr and scheduled for arthroscopic shoulder surgery under ISB were enrolled. All patients using a step-up/step-down method and the starting dose of 15 ml of 0.75% ropivacaine received an ultrasound-guided ISB catheter. The injection volume was increased or decreased by 1 ml in case of block failure or block success, respectively. The authors found that the proportion of patients with successful blockade increased sharply from approximately 57% at 6 ml to 100% by 7 ml, indicating that a small increase in volume of ropivacaine 0.75% markedly affects the success rate. A total of 12 ISB with injection volume less than 7 ml resulted in successful anesthesia within 30 min, yielding an ED95 of 7 ml (95% CI 6.8-7.2) ropivacaine 0.75%. For the group as a whole, the median (min-max) sensory block onset time was 5 (5-20) min, the median (min-max) motor blocks for the biceps and the deltoid muscles were 7.5 (5-15) min and 10 (5-15) min, respectively. The median (min-max) block duration was 8.9 (3-15) h. An injection of a minimum of 7 ml of ropivacaine 0.75% through the catheter is required for success rate and timely onset of surgical anesthesia with ISB.

Bilateral Loss of Neural Function After Interscalene Plexus Blockade May Be Caused by Epidural Spread of Local Anesthetics

Interscalene brachial plexus blockade is widely used in surgical procedures of the upper limb. Recently, we experienced the complication of a contralateral blockade after ultrasound-guided interscalene block. The clinical appearance was a blockade of both the ipsilateral and the contralateral cervical segments 6 to 8. We hypothesized that epidural spread of local anesthetics could be cause for this phenomenon. We conducted a cadaveric study using ultrasound for needle guidance of interscalene blocks in 5 cadavers by a single investigator using contrast agent. Injections were made either ventral (extrafascial) or dorsal (subfascial) to the prevertebral lamina of the deep cervical fascia. Computed tomography was obtained following each injection with contrast agent immediately after incremental injections of progressively higher volumes. Subsequently, contrast spread to anatomic landmarks was investigated by a radiologist. After ultrasound-controlled injection of contrast agent beneath the prevertebral layer of the deep cervical fascia, 4 of the 5 investigated specimens showed contrast enhancement in the epidural space in the consecutive computed tomography scans. After extrafascial injection, none of the investigated specimens showed contrast enhancement in the epidural space. Contralateral blockade after ultrasound-guided interscalene injection of local anesthetics is very likely to be the effect of epidural spread. Future in vivo studies are needed to understand the implications of needle location and volume on epidural spread in interscalene blockade.

Dexamathasone added to levobupivacaine improves postoperative analgesia in ultrasound guided interscalene brachial plexus blockade for arthroscopic shoulder surgery.

BackgroundThe purpose of this study was to evaluate the effect of the addition of 5 mg dexamethasone to 10 ml of 0.5% levobupivacaine on postoperative analgesic effects of ultrasound guided-interscalene brachial plexus block (ISBPB) in arthroscopic shoulder surgery under general anesthesia.MethodsIn 60 patients scheduled for arthroscopic shoulder surgery that underwent general anesthesia, ISBPB was preoperatively performed with 10 ml of 0.5% levobupivacaine under the guidance of ultrasound and a nerve stimulator. Patients were randomly allocated to receive the same volume of normal saline (Group I), 5 mg of dexamethasone (Group II), or 1 : 400,000 epinephrine (Group III) as an adjuvant to the mixture. A blind observer recorded total analgesic consumption, sleep quality, complication, and patient satisfaction using a verbal numerical rating scale (VNRS) at 0, 1, 6, 12, 24, 48 h after the operation.ResultsAll patients had successful ISBPB and excellent analgesic effects less than VNRS 4 up to discharge time. VNRS in Group II at 12 h and 48 h was statistically much lower than in Group I and III. There were no differences in total analgesic consumption, sleep quality, complications, and patient satisfaction.ConclusionsWe conclude that the addition of 5 mg of dexamethasone to 10 ml of 0.5% levobupivacaine in ISBPB showed improvement of postoperative analgesia for arthroscopic shoulder operation without any specific complications.

Ultrasound guided supraclavicular nerve blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia

Ultrasound guided supraclavicular nerve blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia

Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery

Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery

Comparison of Interscalene brachial plexus blockade by eliciting multiple point paresthesia and electrical nerve stimulation techniques: a prospective, randomized trial

Background: Despite worldwide use of regional blocks, interscalene block has failed to gain widespread acceptance in routine anesthesia practice owing to a higher risk of failure and untoward events. We intend to review its clinical applicability and compare the blockade features using two different techniques.Methods: We evaluated 110 patients of ASA physical status I-III at two centers over 2 years, receiving interscalene brachial plexus block and compared the blockade features of two techniques viz. eliciting paresthesia on multiple points and injecting local anesthetic (group MP, n=55) or injecting total dose of local anesthetic with needle immobilized on a single point after confirming muscular twitches using electrical stimulation at current amplitude of 0.3-0.6 mV (group ES, n=55).Results: Complete success, inadequate block and complete failure of block was observed in [92.7%; 5.45%; 0.9%] cases in MP group and [87.2%; 9%; 1.8%] cases in ES group respectively. The procedural time and time for readiness to surgery was 13±3.5min and 11.4±4.0min in MP group; 6.2±3.0 min and 15±5.6min in ES group p(<0.05). The number of needle pricks and passes was [2.1(1-3); 12 (9-21)] in MP group and [1.2(1-2); 7(5-12)] in ES group (p<0.01). Post-operative neurological dysfunction occurred in 4 cases MP/ES group: 3/1Conclusion: We conclude that either of the techniques is associated with minimal risk of complications and recommend their use in interscalene block depending on choice and experience of attending anesthesiologist.

Interscalene brachial plexus blockade (ISB) appears to be cost effective versus general anaesthesia for arthroscopic shoulder surgery

Interscalene brachial plexus blockade (ISB) appears to be cost effective versus general anaesthesia for arthroscopic shoulder surgery

Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery

This study investigated the cost-effectiveness of ultrasonographic-guided interscalene brachial plexus blockade (ISB) in comparison with general anaesthesia (GA) for arthroscopic shoulder surgery. Forty patients undergoing arthroscopic shoulder surgery received either an ultrasonographic-guided ISB or GA. ISB was performed outside the operation room (OR) and patients were transferred in the OR at the earliest 20 min after block performance. All drugs and disposables were recorded to evaluate the costs for both techniques. The following anaesthesia-related times were defined: ready for surgical preparation (from arrival in the OR until end of anaesthesia induction), OR emergence time (from end of dressing until leaving the OR), anaesthesia control time (from patient's arrival in the OR until readiness for positioning plus time from the end of surgery to patient's discharge from the OR), and post-anaesthesia care unit (PACU) time (from patient's arrival in the PACU to the eligibility for discharge to normal ward). Personnel costs were excluded from statistical analysis. The total costs were [mean (sd)] 33 (9)euro for patients with ISB and 41 (7)euro for those who received GA (P<0.01). The anaesthesia-related workflow was improved in the ISB group when compared with the GA group [ready for surgical preparation 8 (3) vs 13 (5) min, P<0.001; OR emergence time 4 (3) vs 10 (5), P<0.001; anaesthesia control time 12 (4) vs 23 (6), P<0.001; and PACU time 45 (17) vs 70 (20), P<0.001]. Ultrasonographic-guided ISB is a cost-effective method for arthroscopic shoulder surgery.