Interscalene Nerve Block Research Articles

Inadvertent Brachial Plexus Injury after Ultrasound-guided Interscalene Nerve Block: Diagnosis and Recovery

Inadvertent Brachial Plexus Injury after Ultrasound-guided Interscalene Nerve Block: Diagnosis and Recovery

Total Spinal Anaesthesia after Interscalene Brachial Plexus Blockade- A Case Report

Brachial plexus blockade has been used for a variety of procedures on the hand, upper extremities, and shoulder. After giving an effective brachial plexus block, total spinal anaesthesia may develop, perhaps due to epidural or prevertebral diffusion of anaesthetic drugs. When administering regional nerve blocks, the findings should underline the significance of cautious technique, but more significantly, the requirement for good patient monitoring and fast availability of resuscitation equipment. This case report was about a 45-year-old woman who underwent an external fixator application to a forearm injury under an interscalene nerve block. Subsequently, she developed haemodynamic deterioration and respiratory arrest. She was manually ventilated with positive pressure and was administered crystalloids intravenously with complete recovery of neurological function. This is being reported as total spinal anaesthesia, an extremely rare complication of the interscalene brachial plexus block.

Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study.

Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.

Comparison of subomohyoid plane block and interscalene nerve block for arthroscopic shoulder surgery

ABSTRACT Background Ultrasound guided interscalene nerve block (ISB) is a popular procedure for pain relief in shoulder surgery patients. The subomohyoid plane block is a new reliable and technically easy regional technique that can be properly used for pain management with fewer adverse effects. The aim of this study was to validate whether there is a difference in postoperative pain scores and morphine consumption between interscalene and subomohyoid plane blocks. Method Eighty patients scheduled for shoulder arthroscopy were enrolled in this controlled blinded study and randomized to interscalene or subomohyoid plane blocks using 15 ml 0.5% bupivacaine in each group and general anesthesia. The primary outcome was pain severity at rest using VAS. Secondary outcomes were first 24 h total morphine consumption, patient satisfaction and adverse effects. Results All patients completed the study through the primary outcome analysis. VAS scores at PACU 2 h were similar in both groups, and VAS scores at 4, 8, 12,18 and 24 h were statistically lower in the interscalene block group (ISB) than in the subomohyoid group (p < 0.001), with no clinical significance. Total morphine consumption was lower in ISB group than in the subomohyoid group (p < 0.001). Time to the first rescue analgesic request and patients’ satisfaction were similar in both groups. Ipsilateral phrenic nerve was blocked in 37.5% of patients in ISB group vs. 7.5% in the subomohyoid group (p < 0.001). Conclusion Subomohyoid plane block can be considered as an alternative to interscalene block for shoulder arthroscopy surgery.

Liposomal Bupivacaine is not Clinically Superior to a Standard Bupivacaine Mixture for Interscalene Nerve Block for Postoperative Pain Control in Shoulder Arthroplasty/Arthroscopy, but may Still be Beneficial

Liposomal Bupivacaine is not Clinically Superior to a Standard Bupivacaine Mixture for Interscalene Nerve Block for Postoperative Pain Control in Shoulder Arthroplasty/Arthroscopy, but may Still be Beneficial

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center.

A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone. Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. Atotal of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone. Patients undergoing rTSA were older (61.1 vs. 55.7 years, P<.001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P=.050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P=.231) and pain scores at discharge (3.0 vs. 3.0, P=.815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P=.793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P≥.361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P=.091 and P=.818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P<.001), had less pain at discharge (0.2 vs. 3.9, P<.001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P<.001). Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

Regional nerve blocks for relieving postoperative pain in arthroscopic rotator cuff repair.

Rotator cuff tear is the most common cause of shoulder pain in middle-age and older people. Arthroscopic rotator cuff repair (ARCR) is the most common treatment method for rotator cuff tear. Early postoperative pain after ARCR is the primary concern for surgeons and patients and can affect postoperative rehabilitation, satisfaction, recovery, and hospital day. There are numerous methods for controlling postoperative pain including patient-controlled analgesia, opioid, interscalene block, and local anesthesia. Regional blocks including interscalene nerve block, suprascapular nerve block, and axillary nerve block have been successfully and commonly used. There is no difference between interscalene brachial plexus block (ISB) and suprascapular nerve block (SSNB) in pain control and opioid consumption. However, SSNB has fewer complications and can be more easily applied than ISB. Combination of axillary nerve block with SSNB has a stronger analgesic effect than SSNB alone. These regional blocks can be helpful for postoperative pain control within 48 hours after ARCR surgery.

Quality of Recovery After Rotator Cuff Repair With Interscalene Liposomal Bupivacaine Versus Interscalene Nerve Catheter

Interscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations. The purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery. Cohort study; Level of evidence, 2. Enrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints. The liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all). The use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.

Ultrasound-guided and Peripheral Nerve Stimulator-guided Interscalene Brachial Plexus Block in a Patient with Neurofibromatosis during the COVID-19 Pandemic

An 18-year-old female with neurofibromatosis presented for enucleation biopsy of a slow-growing soft tissue masson her right anteromedial arm during the COVID-19 pandemic. Ultrasonography was used in the mapping of thebrachial plexus and the identification of possible neurofibroma along peripheral nerves. An interscalene brachialplexus nerve block was successfully and safely achieved with ultrasonographic and peripheral nerve stimulatorguidance. Ultrasound-guided and nerve stimulator-guided peripheral nerve blocks are safe and viable anestheticmanagement options for patients with neurofibromatosis, especially in this time of the COVID-19 global pandemic.

Liposomal Bupivacaine’s Effect on the Diaphragm: Comment

We read with great interest the article by Berg et al.1 about the evaluation of diaphragmatic excursion after interscalene nerve block with liposomal bupivacaine versus plain bupivacaine.In their study, the authors investigated as a primary outcome the effect of liposomal bupivacaine combined with plain bupivacaine versus plain bupivacaine alone on diaphragmatic excursion during sigh (deep) and sniff (shallow) breathing in patients undergoing total shoulder arthroscopy in the immediate postoperative period and after 24 h.1The study did not detect a difference between the two groups in absolute values of diaphragm excursion during a sigh breath at 24 h (P = 0.112), despite a greater than 1 cm difference observed. In addition, a significant difference between groups was noted in the percentage change with respect to preblock levels: –24% in the liposomal bupivacaine with bupivacaine group compared with +9% in the bupivacaine group.The authors concluded that the addition of liposomal bupivacaine to bupivacaine, in an interscalene block, results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement compared with bupivacaine alone. The accompanying editorial underlined the need for caution in the use of liposomal bupivacaine for interscalene nerve block in patients with any pulmonary compromise.2We have two comments on this study. First, we observed that the two groups were already rather different in their baseline values, as reported in their table 2. This was particularly true for the diaphragmatic excursion (higher in the liposomal bupivacaine with bupivacaine group), the percent change of which at 24 h was the primary outcome of the study.1 The authors did not discuss this issue, but, indeed, this baseline difference might have influenced the finding of a larger percent change in diaphragmatic excursion at 24 h compared with baseline.1Second, the authors used the percentage change in diaphragmatic excursion as a measure of the level of diaphragmatic paralysis, as defined by Renes et al.,3 who proposed that a 0 to 25% reduction from baseline could be considered as no paralysis, 25 to 75% reduced could be considered as partial paralysis, and a greater than 75% reduction could be considered as complete paralysis. However, as recently reported in this journal, 24 h after interscalene nerve block, the level of diaphragmatic paralysis measured with diaphragmatic excursion may be compensated by parasternal muscle activity.4 Therefore, we believe that changes in diaphragmatic excursion alone cannot be considered as an adequate measure of diaphragmatic function.For this reason, we propose that diaphragmatic thickening fraction can be a more appropriate tool for investigating the action of medications on the diaphragm. The thickening fraction is calculated as the maximal diaphragm thickness (assessed using linear probe) during inspiration (Tdi, pi) minus the diaphragm thickness at end-expiration (Tdi, ee) divided by the Tdi, ee and multiplied by 100.5 Compared with diaphragmatic excursion, thickening fraction is a more sensitive and qualitatively accurate parameter and provides a more comprehensive measure of diaphragm contraction.Excursion of the left hemidiaphragm is more difficult to assess than the right one and this is due to interference from gastric contents and the less favorable spleen’s window. Berg et al.1 performed 13 left blocks, but they did not comment on difficulties experienced in the evaluation of the excursion of the left hemidiaphragm. In any case, use of the thickening fraction to measure and evaluate diaphragm activity would overcome this problem and should be used in the research field.Of course, we understand that standard perioperative ultrasound practice does not normally include calculating the thickening fraction, being a more difficult measure to obtain and is mostly used to assess weaning from mechanical ventilation in the intensive care unit.5 As a matter of fact, there is a bit of a schism between point-of-care ultrasound use in the operating room and intensive care settings. However, the skills required to measure thickening fraction are relatively easy to acquire under expert supervision.6In conclusion, considering the aforementioned limitations, we suggest caution in assessing the risk of adverse events in terms of diaphragmatic and pulmonary function, including dyspnea and oxygen need, with the use diaphragmatic excursion only.Dr. Cammarota declares a financial relationship with Getinge MSD (Växjö, Sweden). The other authors declare no competing interests.

Ultrasound guided suprascapular and costoclavicular nerve block versus interscalene nerve block for postoperative analgesia in arthroscopic shoulder surgery: A randomized non-inferiority clinical trial

ABSTRACT Background Suprascapular nerve block (SSB) with costoclavicular nerve block (CCB) could be an ideal hybrid block for arthroscopic shoulder surgery in comparison to interscalene nerve block (ISB) regarding postoperative analgesia. Methods Fifty adult patients scheduled to undergo elective arthroscopic shoulder surgery under general anesthesia were equally randomized and enrolled in this study in a 1:1 ratio either to ISB group or diaphragm sparing block DSB (received combined SSB plus CCB blocks). The first numeric pain score (NRS) on awakening was recorded (1), then every 15 minutes over 3 hours. The time to 1st rescue analgesia and the number of patients who required nalbuphine to decrease pain scores below 4/10 were recorded. The incidence of persistent pain after 1 month was recorded as well. Results Pain NRS was significantly lower in ISB than DSB group during the early 3 hours postoperatively (p < 0.001). The time to rescue analgesia was significantly longer in group ISB than group DSB (179.50 ± 40.9 versus 57.38 ± 19.57 min, respectively, with p = 0.013). The number of patients who required postoperative nalbuphine was significantly fewer in group ISB than group DSB (8 versus 19, respectively, with p = 0.004). The incidence of persistent pain after 1 month was insignificant between the two groups. Conclusions SSB with CCB offered lower analgesia quality compared to ISB in shoulder surgery.

Network Meta-Analysis of Perioperative Analgesic Effects of Different Interventions on Postoperative Pain After Arthroscopic Shoulder Surgery Based on Randomized Controlled Trials

BackgroundShoulder arthroscopic surgery is a common surgical method used in orthopedics. However, severe postoperative pain can significantly limit the early joint movement of patients and adversely affect the impact of the surgery. At present, there is no consistent and effective analgesic scheme for the management of postoperative pain after arthroscopic surgery of the shoulder.PurposeThe aim of this study was to search for the most effective analgesic scheme to control pain in the perioperative period of arthroscopic surgery of the shoulder.Study DesignNetwork meta-analysis.MethodsWe searched 5 different databases (i.e., Medline, PubMed, Embase, Web of Science, and the Cochrane Library) from January 2011 to January 2021 for English literature. Thereafter, we sifted out randomized controlled trials (RCTs), which compared different intervention schemes for pain management after shoulder arthroscopy and selected only 12 h, 24 h, or 48 h after the patient leaves the operating room as an optimal period for administration of analgesic intervention schemes. Only patients with shoulder disease who have undergone arthroscopic shoulder surgery were included in this study. The Cochrane “risk of bias” was used for the quality assessment. Moreover, some additional tests were performed to enhance the credibility of the results.ResultsTwenty-nine RCTs involving 1,885 patients were included in this frequentist network meta-analysis (NMA). These articles mainly were divided into two distinct groups, namely, the nerve block group and the non-nerve block group. Regarding the nerve block group, at postoperative 12 h, the intervention suprascapular nerve block + interscalene nerve block (SSNB + INB) was ranked first, whereas INB + intra-articular injection (INB + IAI) was ranked first at 24 h and 48 h postoperation. In the non-nerve block group, external application (EA) was ranked first at postoperative 12 h, but oral administration (OA) exhibited a better analgesic effect at postoperative 24 h and postoperative 48 h.ConclusionWe conclude that the analgesic effect of SSNB+INB was the best at postoperative 12 h, and INB+IAI was the best at postoperative 24 h and 48 h in the nerve block group. For the non-nerve block group, the effect of EA was the best at postoperative 12 h, and the analgesic effect of OA at postoperative 24 h and 48 h was significantly better than any other interventions.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42021286777.

The Use of a New Device-Assisted Needle Guidance versus Conventional Approach to Perform Ultrasound Guided Brachial Plexus Blockade: A Randomized Controlled Study.

PurposeUltrasound guidance during nerve blockade poses the challenge of maintaining in-plane alignment of the needle tip. The needle guidance device maintains needle alignment and assists with in-plane needle visualization. The purpose of this study is to evaluate the utility of this device by comparing procedure performance during brachial plexus blockade with the conventional approach.MethodsAfter the Institutional Review Board approval and obtaining informed consent, 70 patients receiving either interscalene or supraclavicular nerve blocks were randomly assigned into 2 groups, a conventional approach versus utilizing the needle guidance device. An independent observer recorded: total procedure time; needle insertion time; number of unplanned redirections; and number of reinsertions. Additionally, physician satisfaction and ease of needle visualization were assessed.ResultsData from seventy patients were analyzed. The median [25th percentile-75th percentile] time to complete the block by the device assisted needle guidance group was 3 (2–3.75) minutes and 4 (3–6) minutes in the conventional approach group (p < 0.001). Additionally, subgroup analyses were performed in the supraclavicular block and interscalene block. Supraclavicular blockade, needle insertion time (median [25th percentile-75th percentile] in seconds) (106 [92–162] vs 197 [140–278]), total procedure time (3 [2–3] vs 4.5 [4–6] in minutes) and unplanned needle redirections (2 [1–5] vs 5.5 [3–9]) were significantly lower in needle guidance group (p < 0.001). With interscalene blockade, needle insertion time (86 [76–146] vs 126 [94–295]) and unplanned needle redirections (2 [1–3] vs 4 [2–8.5]) were significantly lower with needle guidance (p < 0.001), but total procedure time was similar. All the physicians reported that they would use the needle guidance again, and 90% would prefer it for in-plane blocks.ConclusionPerforming regional blocks using the needle guidance device reduces needle insertion time and unplanned needle redirections in brachial plexus blockade. Moreover, physician satisfaction also improved compared to the use of the conventional technique.

Incidence, characteristics, and risk factors of venous thromboembolism in shoulder arthroplasty-a systematic review.

The purpose of this study was to investigate the incidence, characteristics, and risk factors for venous thromboembolism (VTE) in patients who underwent shoulder arthroplasty (SA) through systematic review. A search of studies was conducted using the databases for PubMed, EMBASE, Scopus, Ovid, MEDLINE, and Cochrane Library according to the guidelines for PRISMA (Preferred Reporting Items for Systematic Meta-Analyses). Quality assessment was performed using the Methodological Index for Nonrandomized Studies (MINORS). Nine studies (12,566 shoulders) were finally eligible and the mean MINORS score was 13.2 (ranges, 9-18). The overall incidence of VTE was 0.81% (78/9681) including 0.54% (52/9681) for deep vein thrombosis (DVT) and 0.33% (42/12,566) for pulmonary embolism (PE). There were no significant differences in the incidences according to the type of arthroplasty. DVT was detected at an average of 18.8days after index surgery, and PE was detected at an average of 12.7days after index surgery. The risk factors for VTE included age older than 70years, higher BMI, raised Charlson Comorbidity Index, history of DVT, asthma, cardiac arrhythmia, diabetes, lower haemoglobin level, use of general endotracheal anaesthesia without interscalene nerve block, traumatic indication, longer operative time, and revision SA. The mortality rate was 4.1% (2/49) for VTE and 8.3% (2/24) for PE. Despite the fact that the overall incidence of VTE following SA was as low as 0.81%, shoulder surgeons should consider the potential for this serious complication in high-risk patients. Further well-designed large-scale studies are necessary to clarify the consensus for VTE after SA including risk factors, treatment, and prophylaxis.

Single shot interscalene regional anesthesia provides noninferior analgesia and decreased complications compared with an indwelling catheter for arthroscopic and reconstructive shoulder surgery.

There is an abundance of literature comparing the efficacy, safety, and complication rates of regional anesthesia in shoulder surgery. The purpose of this study was to compare analgesia efficacy, and complication rates between single shot and continuous catheters in patients undergoing arthroscopic or reconstructive shoulder surgery in a large cohort. Consecutive patients (n=1888) who underwent shoulder arthroplasty or arthroscopic shoulder surgery and had regional anesthesia were included. Patients had either a single-shot interscalene block (SSIB) or an SSIB with a continuous interscalene nerve block with a catheter (CIB). The decision for SSIB or CIB was selected based on patient risk factors and surgeon preference. Patients received phone calls on postoperative days 1, 2, 7, and 14 to assess for pain levels (numeric rating scale [NRS]) and complications. One hundred sixty patients received SSIB, and 1728 patients received CIB. The postoperative NRS scores at day 1 were also similar. There were 3 complications (2%) in the SSIB group and 172 complications (10%) in the CIB group. Ten patients in the CIB group required emergency department (ED) visits secondary to block complications compared with no ED visits in the SSIB group. In 1888 consecutive patients, SSIB and CIB provided similar pain relief following shoulder surgery. However, patients who received CIB had significantly more complications and ED visits than patients who received SSIB. The potential benefits of longer pain relief may not outweigh the risks of CIB vs. SSIB in common shoulder procedures.

Median Effective Analgesic Concentration of Ropivacaine in Ultrasound-Guided Interscalene Brachial Plexus Block as a Postoperative Analgesia for Proximal Humerus Fracture: A Prospective Double-Blind Up-Down Concentration-Finding Study.

BackgroundThe innervation of the proximal humerus fracture is complicated and unclear. The use of interscalene nerve block has been effective as postoperative analgesia for patients, but the optimal concentration of usage is unknown.MethodThis study was conducted on 30 patients with ASA I or II, who were planning to undergo a proximal humerus fracture operation. A dosage of 10 ml Ropivacaine was administered for the interscalene brachial plexus block (ISBPB) as determined using the up-and-down sequential method. The initial concentration of Ropivacaine in the first patient to receive ISBPB was 0.3%. After a successful or unsuccessful postoperative analgesia, the concentration of local anesthetic was decreased or increased, respectively, by 0.05% in the next patient. We defined successful postoperative analgesia as a visual analog scale (VAS) score of < 4 at rest, within the initial 8 h after ISBPB. The analytic techniques of linear, linear-logarithmic, exponential regressions, and centered isotonic regression were used to determine the EC50 of Ropivacaine, and the residual standard errors were calculated for the comparison of “goodness of fit.”ResultsThe concentration of Ropivacaine ranged from 0.1 to 0.35%. The EC50 (95% confidence interval) from 4 different statistical approaches (linear, linear-logarithmic, exponential regressions, and centered isotonic regression) were 0.222% (0.198%, 0.335%), 0.233% (0.215%, 0.453%), 0.223% (0.202%, 0.436%), and 0.232%, respectively. Among all the 4 models, the linear regression had the least residual standard error (0.1676).ConclusionThe EC50 from the four statistical models for 10 ml Ropivacaine in ultrasound-guided ISBPB for postoperative analgesia was distributed in a narrow range of 0.222–0.233%.Trial Registrationwww.chictr.org.cn/; registration number: ChiCTR2100047231.

Liposomal bupivacaine-No breakthrough in postoperative pain management

One of the main limitations concerning the use of local anesthetics is due to their restricted duration of action. In recent years, liposomal formulations with prolonged release kinetics have been developed to extend the pharmacological duration of action of the 1‑stage peripheral regional anesthesia (single-shot procedure) and thus bring about alonger duration of action. The focus here is particularly on achieving postoperative freedom from pain for at least 24 h (or even better 48 h) and thus early mobilization of patients using on-demand medication causing (at most) minor local sensory blockade without causing motor impairments (at least that is the ideal). Therefore, methods of utilizing slow-release drugs as seen in liposomal carrier systems have experienced increasing scientific attention in the last few years. Acommon modern pharmacological example with atheoretically significantly longer duration of action is liposomal bupivacaine, an amide local anesthetic. Due to amultivesicular liposome structure, the retarded release of the active component bupivacaine HCl leads to atheoretical pharmacological effectiveness of up to 72 h. Previous studies consistently showed asafety profile comparable to conventional bupivacaine HCl. Liposomal bupivacaine has been approved by the U.S. Food and Drug Administration (FDA) under the trade name Exparel© (Pacira Pharmaceuticals, Parsippany, NJ, USA) since 2011; however, its use is currently limited to local wound infiltration, transverse abdominis plane (TAP) blocks, and interscalene nerve blocks of the brachial plexus. In 2020, the European Medicines Agency (EMA) also approved the use of liposomal bupivacaine for blockade of the brachial plexus or the femoral nerve and as afield block or for wound infiltration to treat postoperative pain. So far, studies on the clinical effectiveness of liposomal bupivacaine have been very heterogeneous and there have been no conclusive meta-analyses with sufficient rigor or significance. Recent systematic reviews and meta-analyses, combining the results of clinical studies regarding the analgesic efficiency of liposomal bupivacaine in different fields of application, consistently refuted any benefit of clinical relevance provided by the liposomal formulation. There is currently sufficient evidence to now end the ongoing debate around liposomal bupivacaine. The aim of this work is to give the reader acurrent, evidence-based overview of this substance.

Arthroscopic Cortical-Button Latarjet Procedure for Anterior Shoulder Instability With Glenoid Bone Loss

Background: The Latarjet procedure is a common treatment of anterior shoulder instability associated with glenoid bone loss. Advanced arthroscopic technique provided a safe cortical-button fixation of the coracoid process transferred onto the glenoid neck combined with a Bankart repair. Indications: This is an 18-year old woman, complaining of recurrent right shoulder dislocation and subluxation, which made her unable to play handball at competitive level. Physical examination confirmed anterior apprehension without hyperlaxity. Computed tomography (CT) scan identified a Hill-Sachs lesion and a glenoid bone loss of 11%. Instability Severity Index Score was calculated at 7 points. Technique Description: Patient was placed in a beach-chair position under general anesthesia combined with an interscalene nerve block. A 70° scope and specifically designed instruments were used. The technique required 5 steps: (1) coracoid preparation: pectoralis minor and coracoacromial ligament release, flattening of the undersurface, positioning of the peg button, and osteotomy of the coracoid; (2) glenoid preparation: flattening of the neck of the scapula, insertion of 2 anchors (3 and 6 o’clock), and glenoid drilling with a specific guide; (3) subscapularis split: use of an intra-articular and extra-articular spreader splitting the subscapularis muscle at the level of the glenoid wire (shoulder in neutral rotation) and opening of a “safe window”; (4) fixation step: transfer of the coracoid through the subscapularis split with shuttle suture and permanent fixation with a posterior cortical button (compression controlled at 100 Newtons with a dynamometer); and (5) Bankart repair. The shoulder was protected in a sling 4 weeks, and external rotation recovery was allowed at 6 weeks. Results: Favorable outcomes were reported at 6 months of follow-up without any complication. Full range of motion with limited external rotation deficit was obtained and a negative apprehension test. Radiologic assessment confirmed graft incorporation at 6 months, allowing return to overhead sports at a competitive level. Discussion/Conclusion: Arthroscopic cortical-button Latarjet procedure is a safe option to treat anterior shoulder instability associated with glenoid bone loss in patient with high demand sports. The procedure is safe and combine bone graft and Bankart repair. Using a cortical button fixation avoids screw related complications.

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.

Comparison of propofol and ketofol for sedation in patients undergoing shoulder surgery with interscalene and suprascapular nerve blocks

Introduction and Purpose: We compared propofol and ketofol for sedation in patients who underwent shoulder arthroscopy under anesthesia with interscalene and suprascapular blocks. We evaluated both of agents the intraoperative hemodynamic effects, sedation efficiency, postoperative recovery times and the time to discharge to the service. We aimed to achieve an effective sedation with stable hemodynamics, resulting in rapid recovery with early onset.&#x0D; Methodology: The study was carried out prospectively in a double-blind randomized study on ASA I and II patients aged 18-65, total of 42 shoulder surgeries planned. Anesthesia was provided to the patients by performing interscalene and suprascapular nerve block with USG. Group 1 (Propofol group), 1 mg/kg propofol iv, in Group 2 (Ketofol group), a mixture of ketamine-propofol was prepared in a 1:1 ratio, 1 mg / kg ketofol iv was administered. Processing was started in both groups when Ramsey Sedation Scale (RSS) was 3. SBP, DBP, MBP, heart rate, O2 saturation, RSS, Faces scale were recorded throughout the case. The patients with an Aldrete score of 9 were discharged and sent to the service.&#x0D; Results: A total of 42 patients undergoing planned shoulder surgeries were enrolled. No statistically significant was determined between the groups in respect of demographic data (age, gender, height, weight, ASA), operating time and postoperative length of stay in hospital. More patients required esmolol in the ketofol group compared to propofol group; 15 (71.4%) vs. 7 (33%) patients (p &lt; 0.05). Significant higher mean values of hemodynamic findings in the ketofol group were noted; SBP at 55 min, DBP at 60 min, MBP at 60 min and MBP on discharge (p &lt; 0.05). In the absence of esmolol, the pulse measurements at 0, 1, 3, 25, and 30 min were determined to be statistically significantly higher in the ketofol group than the propofol group (p &lt; 0.05). The mean values of the SpO2 measurements were significantly lower in the ketofol group (p &lt; 0.05). No statistically significant difference was determined in respect of the postoperative modified Aldrete Scores (MAS) at any of the time points (p &gt; 0.05).&#x0D; Conclusion: While a deeper and higher quality sedation was provided with ketofol, we achieved rapid onset and short-acting sedation with propofol. Both agents have different superior properties and can be used safely for sedation.&#x0D; Key words: Brachial plexus block, ketofol, shoulder arthroscopy, propofol, sedation&#x0D; Citation: Akcaalan Y, Sahap M, Gulec H, Horasanli E, Ugurlu M, Akcaalan S. Comparison of propofol and ketofol for sedation in patients undergoing shoulder surgery with interscalene and suprascapular nerve blocks. Anaesth. pain intensive care 2022;26(1):102-109.&#x0D; DOI: 10.35975/apic.v26i1.1775&#x0D; Received: September 24, 2021, Reviewed: October 18, 2021, Accepted: Nov 09, 2021