Interscalene Plexus Research Articles

Effects of propofol versus sevoflurane on surgical field visibility during arthroscopic rotator cuff repair: a randomized trial

BackgroundDuring arthroscopic rotator cuff repair (ARCR), clear surgical field visibility (SFV) is the basis of successful surgery, but the choice of anesthesia maintenance drugs may have different effects on SFV. In this study, we aimed to compare the effects of propofol- and sevoflurane-based general anesthesia on SFV in patients undergoing ARCR.MethodsPatients (n = 130) undergoing elective ARCR in the lateral decubitus position were randomized into either the propofol group or sevoflurane group (65 per group). The duration of surgery and increased pressure irrigation (IPI), Boezaart score, rocuronium consumption and usage of remifentanil were recorded. The time of both spontaneous respiration recovery and extubation and the incidences of postoperative nausea and vomiting and agitation were also recorded.ResultsThe Boezaart score, duration of IPI and ratio of the duration of IPI to the duration of surgery (IPI/S ratio) were similar between the groups (P > 0.05). Rocuronium consumption, number of patients requiring remifentanil infusion and total remifentanil consumption were significantly lower in the sevoflurane group (P < 0.05). The spontaneous respiration recovery time was significantly longer in the propofol group (P < 0.05), but there were no differences in the extubation time between the groups(P > 0.05).ConclusionsCompared with propofol, sevoflurane provides equally clear SFV while improving the convenience of anesthesia maintenance in ARCR patients with interscalene plexus (ISB) combined with general anesthesia.Trial registrationThis single-center, prospective, RCT was retrospective registered at Chinese Clinical Trial Registry with the registration number ChiCTR2300072110 (02/06/2023).

Comparison of pulmonary function during interscalene block vs. supraclavicular block: a single-center, double-blind, randomized trial

BackroundThe supraclavicular plexus block (SCB) and interscalene plexus block (ISB) have the potential to pulmonary function, the duration of the potential remains uncertain. So, we compared the effect of SCB and ISB on pulmonary function, especially the duration time.MethodsNinety-six patients were finally allocated to group I and group S. The ISB and the SCB procedures were performed with ultrasound guidance before anesthesia induction. An investigator recorded the diaphragm mobility and respiratory function test indicators before the block (T0) and at 30 min (T30 min), 4 h (T4), 8 h (T8), and 12 h (T12) after the block. The diaphragmatic paralysis rate was calculated for above timepoint. The VAS, the recovery time for the sensory and motor block, and adverse reactions within 24 h of administering the block were also recorded.ResultsThe recovery times of diaphragm mobility in group I were longer than those in group S. Compared with group I, group S had a significantly lower diaphragmatic paralysis rate during eupnea breathing at T30 min and T8 after the block. Similarly, group S had a significantly lower diaphragmatic paralysis rate at deep breathing at T30 min, T8, and T12 after the block. The recovery times of FEV1 and FVC in group I were longer than those in group S. The other results were not statistically significant.ConclusionsUltrasound-guided ISB resulted in a longer periods with a suppressive effect on pulmonary function than SCB.Trials registration17/12/2019, ChiCTR1900028286.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series

Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis. Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound. Median NRS (0-10) at 1, 3, 6, 8 and 24hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%). The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty.

Do not follow the bone, follow the nerve ultrasound-guided stellate ganglion block: a reconfirmation.

Indirect and direct methods have been used to localize the stellate ganglion. Identifying the C6 and C7 transverse process can be a technical challenge for practitioners when performing an ultrasound-guided stellate ganglion block. Following the nerve roots from the interscalene plexus into the corresponding foramen can serve as a reconfirmation for identifying the C6 and C7 transverse process.

Safety and Success of Ultrasound Guided Interscalene and Cervical Plexus Block as a Sole Anesthesia Method for Acromioclavicular Joint Fixation: A Retrospective Observational Study

Safety and Success of Ultrasound Guided Interscalene and Cervical Plexus Block as a Sole Anesthesia Method for Acromioclavicular Joint Fixation: A Retrospective Observational Study

Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial

BackgroundUltrasound guidance allows for the use of much lower volumes of local anaesthetics for nerve blocks, which may be associated with less aberrant spread and fewer complications. This randomized, controlled study used contrast magnetic resonance imaging to view the differential-volume local anaesthetic distribution, and compared analgesic efficacy and respiratory impairment. MethodsThirty patients undergoing shoulder surgery were randomized to receive ultrasound-guided interscalene block by a single, blinded operator with injection of ropivacaine 0.75% (either 20 or 5 ml) plus the contrast dye gadopentetate dimeglumine, followed by magnetic resonance imaging. The primary outcome was epidural spread. Secondary outcomes were central non-epidural spread, contralateral epidural spread, spread to the phrenic nerve, spirometry, ultrasound investigation of the diaphragm, block duration, pain scores during the first 24 h, time to first analgesic consumption, and total analgesic consumption. ResultsAll blocks provided fast onset and adequate intra- and postoperative analgesia, with no significant differences in pain scores at any time point. Epidural spread occurred in two subjects of each group (13.3%); however, spread to the intervertebral foramen and phrenic nerve and extensive i.m. local anaesthetic deposition were significantly more frequent in the 20 ml group. Diaphragmatic paralysis occurred twice as frequently (n+8 vs 4), and changes from baseline peak respiratory flow rate were larger [Δ+−2.66 (1.99 sd) vs −1.69 (2.0 sd) l min−1] in the 20 ml group. ConclusionsThis study demonstrates that interscalene block is associated with epidural spread irrespective of injection volume; however, less central (foraminal) and aberrant spread after low-volume injection may be associated with a more favourable risk profile. Clinical trial registrationThis study was registered with the European Medicines Agency (Eudra-CT number 2013-004219-36) and with the US National Institutes’ of Health registry and results base, clinicaltrials.gov (identifier NCT02175069).

Does the addition of dexamethason to local anesthetic prolong the analgesia of interscalen plexus brachialis block in patients with shoulder surgery?

Introduction: Peripherial nerve blocks is a suitable alternative to general anesthesia especially for one-day case surgery. Interscalene approach of ple- xus brachialis block as much as supraclavicular and in- fraclavicular provide reliable, safe, effective, low cost and most complete anesthesia with satisfactory postop- erative analgesia for upper limb surgery. Postoperative analgesia of plexus brachialis blocks can be prolonged by using different drugs as adjuvants with local anest- hetics. Dexamethasone has been shown to prolong the duration of postoperative analgesia when given as an adjunct for peripheral nerve blocks. The investigation was randomized, prospective, double blinded and con- trolled study. Objective: The study was designed to compare the effects of dexamethasone administered as an ad- junct to bupivacaine in interscalene brachial plexus block on the onset, duration and postoperative analge- sia in patients under the shoulder surgery. Methods: A prospective, double-blind study was undertaken in patients scheduled for shoulder surgeries under the interscalene brachial plexus block. We enrolled 60 patients, ASA I-II both sexes, aged 19-65 years, weig- hing 54-89 kg, divided to two groups G1 and G2. The brachial plexus block was performed by interscalene ap- proach and mixture of 2% lidocaine (12 ml) and 0.5% bu- pivacaine (22 ml) either alone or combined with dexa- methasone (4 mg). The block was performed by using double technique neurostimulator/ultrasound technique. Results: In our investigation we found a signifi- cant increase in onset and duration of motor and sen- sory block in Group G2 (with dexamethasone) as com- pared to Group G1 patients (p < 0.01). Conclusion: Addition of dexamethasone to local anesthetic drugs in interscalene plexus brachialis block, significantly prolongs the duration of analgesia and motor block in patients undergoing shoulder arthro- scopy. Moreover, it is a remarkably safe and cost effec-

Dexamethasone as an Additive to Low Volume Interscalene Plexus Blockade: A Randomized Controlled Study

Background: Interscalene Blockade is widely used to ensure analgesia in surgery involving the shoulder. Both i.v. and perineural dexamethasone seem to be able to prolong the block duration and can therefore be used to reduce the use of analgesics. However most of the studies focusing on dexamethasone as an additive use large volumes (20 ml) of local anesthetic agent. Larger volumes may be associated with a higher rate of complications. Therefore the hypothesis of this study is to prove whether dexamethasone is also able to prolong the pain free time when given together with a low volume (10 ml) of anesthetic agent. Methods: The study was conducted as a prospective, double-blinded randomized trial. Patients with arthroscopic surgery of the shoulder were included in our study. The blockade was performed using ultrasound guidance to ensure a low rate of block failure. We used eight milligrams of dexamethasone (free of preservative) and ten millilitres of ropivacaine in a concentration of 0.75%. The primary endpoint was analgesic duration defined as the time between performance of the block and first analgesic request. The primary variable was analyzed using a log rank test. Secondary endpoints were the assessment of the pain at the surgical site ten hours after operation at rest and movement. Results: 104 patients were included in our study. The ethics committee of Lower Austria approved the study and patients signed an informed consent in order to participate in our study. During the study five patients were excluded due to block failure. Using a log-rank test, we observed a prolongation of pain free time of 310 minutes. The analysis of the NRS-score ten hours after surgery yielded a significant difference between the control and active group at rest. Unexpectedly the NRS – score at movement does not differ between the control and active group. Conclusion: Dexamethasone used in a low volume plexus brachialis blockade is able to prolong the pain free time.

Separation of stimulating catheters for continuous peripheral regional anesthesia during their removal - two case reports and a critical appraisal of the use of steel-coil containing stimulating catheters.

PurposeStimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia. The incidence of reported complications is somewhat similar to that for non-stimulating catheters. However, as many stimulating catheters contain a coiled steel wire for optimal stimulation, they may cause specific complications.Clinical featuresIn this report, we present two cases of complicated removals of stimulating catheters. During both removals, a part of the metal wire was left “decoiled” next to the supraclavicular and interscalene plexus, respectively. The strategies used to determine steel wire localization and a description of the successful removal of these steel wires are included in this report.ConclusionCatheter separation and problems with residual metal wire components of stimulating catheters seem to be a rare but specific problem during removal. Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer’s instructions, and take care during catheter removal. Manufacturers should focus on technical solutions to avoid rare but relevant complications such as catheter tip decoiling and separation of stimulating catheters during removal.

The effect of ondansetron in preventing the hypotensive bradycardic events during shoulder arthroscopy done under interscalene block in the sitting position

PurposeThis study was conducted to test whether blocking the serotonin receptors by intravenous [IV] ondansetron; can help in reducing the hypotensive bradycardic events [HB events] associated with shoulder arthroscopy done in the sitting position under interscalene plexus block [ISB].MethodsOne hundred and fifty patients, scheduled for shoulder arthroscopy in the sitting position under ISB, were randomly assigned to one of three groups receiving either: 4 mg ondansetron, or 8 mg ondansetron or saline.ResultsIV injection of ondansetron 4 mg or 8 mg significantly reduced the incidence of HB events from 20.4% in the saline group to 6.1% after injection of 4 mg ondansetron and 6% after injection of 8 mg ondansetron; p value [0.030].ConclusionIV ondansetron either 4 mg or 8 mg reduces the HB events during shoulder arthroscopy in the sitting position under ISB.

The effect of adding magnesium sulfate to lidocaine in an interscalene plexus block for shoulder arthroscopic acromioplasty

Background Incorporation of adjuvants into local anesthetics could potentially aid in producing satisfactory prolonged postoperative analgesic duration and reducing postoperative adverse reactions associated with excessive systemic analgesic intake. The aim of this trial was to study the effect of incorporating magnesium sulfate as an adjuvant into lidocaine in an interscalene plexus block (ISPB) for arthroscopic acromioplasty. Materials and methods Sixty ASA I and II grade patients scheduled for elective arthroscopic acromioplasty under ultrasound guidance and peripheral nerve stimulation technique were allocated randomly to two groups: group L, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml 0.9% NaCl, and group LM, which included patients who received 20 ml of lidocaine 2% with epinephrine 1 : 200 000 plus 5 ml of 10% MgSO 4 (500 mg MgSO 4 ). The following data were collected: the onset of sensory block, the occurrence of satisfactory motor block, sensory block duration, Numeric Rating Scale (NRS) at the first analgesic dose, motor block duration, total morphine consumption in the first 24 h, and the presence of any adverse reactions. Results Patients in the magnesium sulfate group showed a prolonged postoperative analgesic duration, the NRS records decreased significantly on the first analgesic dose, and morphine consumption was reduced, and no adverse events related to its use in ISPB were recorded. Conclusion The addition of magnesium sulfate to lidocaine in ISPB significantly prolongs the analgesic duration and reduces the NRS score and postoperative opioid requirements in shoulder arthroscopic acromioplasty without side effects.

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.

Chirurgie arthroscopique de l’épaule et complications ischémiques cérébrales

The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.

„Diagnostischer“ Interskalenusblock

The dedicated target region should be systematically examined before performing an ultrasound-guided nerve block so that the anatomy can be assessed and anatomic variants or pathologic findings are not missed. In the case described an ultrasound-guided interscalene plexus block was performed in a 73-year-old man. During this examination a cystic structure was detected within the thyroid gland. The further diagnostic procedure showed a metastasis of a renal cell carcinoma which had been treated by resection 10 years before.

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

Epidurale Fehllage eines interskalenären Plexuskatheters

A patient received an interscalene plexus catheter before shoulder surgery. After induction of general anesthesia catheter placement was performed with Winnie's technique and 5ml of ropivacaine was injected via the catheter. In the recovery room slight dyspnea without wheezing was observed which improved spontaneously. Following another bolus of ropivacaine, dyspnea and paralysis of the contralateral arm developed and the patient became hypotensive. The tomography scan showed epidural malpositioning of the catheter. Neuraxial complications of interscalene regional anesthesia are especially possible with medially directed insertion of the needle and have been described many times in the literature. The symptoms and recommendations for prevention are discussed.

Prospective randomized comparison of interscalene plexus block and general anaesthesia for ambulatory arthroscopic shoulder surgery

Department of Anaesthesiology and Intensive Care, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany

Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system

Interscalene brachial plexus block (ISB) is widely used as an adjuvant regional pain therapy in patients undergoing major shoulder surgery and has proved its effectiveness on postoperative pain reduction and opioid-sparing effect. This single-center, prospective, double-blind, randomized and placebo-controlled study was to compare the effectiveness of a single-shot and a patient-controlled catheter insertion ISB system after major open-shoulder surgeries. Seventy patients were entered to receive an ISB and a patient-controlled interscalene catheter. The catheter was inserted under ultrasound guidance. Patients were then assigned to receive one of two different postoperative infusions, either 0.2% ropivacaine (catheter group) or normal saline solution (single-shot group) via a disposable patient-controlled infusion pump. The study variables were amount of rescue medication, pain at rest and during physiotherapy, patient satisfaction and incidence of unwanted side effects. The ropivacaine group revealed significantly less consumption of rescue medication within the first 24 h after surgery. Incidence of side effects did not differ between the two groups. Based on our results, we recommend the use of interscalene plexus block in combination with a patient-controlled catheter system under ultrasound guidance only for the first 24 h after major open-shoulder surgery.

Anomalous Anatomy of the Brachial Plexus Identified During Ultrasound-Guided Interscalene Plexus Block

Anomalous Anatomy of the Brachial Plexus Identified During Ultrasound-Guided Interscalene Plexus Block

Surgical stress index as a measure of nociception/antinociception balance during general anesthesia

No validated monitoring method is available for evaluating the nociception/antinociception balance. We assessed the surgical stress index (SSI), computed from finger photoplethysmographic waveform amplitudes and pulse-to-pulse intervals, in patients undergoing shoulder surgery under general anesthesia (GA) and interscalene plexus block and in patients with GA only. In this prospective, randomized study in 26 patients, increased blood pressure (BP) or heart rate, movement, and coughing were considered to be signs of intraoperative nociception and were treated with alfentanil. GA was maintained with desflurane aiming at a State Entropy level of 50. Photoplethysmographic waveforms were collected from the contra-lateral arm to the surgery and SSI values from 0 (no surgical stress) to 100 (maximal surgical stress) were calculated off-line. Two minutes after skin incision, SSI had not increased in the plexus group and was lower in the plexus group (38 +/- 13) compared with the controls (58 +/- 13, P<0.005). Among the controls, 1 min before alfentanil administration, the SSI value was higher than during periods of adequate antinociception, 59 +/- 11 vs. 39 +/- 12 (P<0.01). The total cumulative need for alfentanil was higher in controls (2.7 +/- 1.2 mg) compared with the plexus group (1.6 +/- 0.5 mg; P=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among the patients with plexus block not covering the site of the stimulation. SSI values were lower in patients with plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI had better performance than heart rate, BP, or response entropy.