Major Shoulder Surgery Research Articles

Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5–6 root/superior trunk perineural ambulatory catheter

In this prospective, randomized, triple-blinded study, we tested the hypothesis that a 48 h continuous C5-6 root/superior trunk patient-controlled infusion of ropivacaine 0.4% would provide superior analgesia after shoulder surgery compared with the same infusion of ropivacaine 0.2%. Patients presenting for painful shoulder surgery were recruited. A perineural catheter was placed under ultrasound guidance immediately adjacent to the C5-6 roots/superior trunk. Ropivacaine 5 mg ml(-1) (30 ml) was administered via this catheter before surgery under general anaesthesia. At the end of surgery, patients were randomized to receive ropivacaine 2 mg ml(-1) (0.2%) (n=32) or 4 mg ml(-1) (0.4%) (n=33) via an elastomeric pump delivering 2 ml h(-1) with on-demand patient-controlled boluses of 5 ml as required. Acetaminophen and diclofenac were administered if any postoperative pain occurred, ropivacaine boluses for a numerical rating pain score (NRPS, 0-10) of >2, and rescue tramadol for an NRPS >3. All patients were phoned on postoperative days 1 and 2 and questioned for indices of treatment effectiveness and adverse effects. NRPS, patient ropivacaine demands, and supplemental tramadol consumption were similar in each group [median 'average daily pain' days 1/2 (0.2%=1/3, 0.4%=2/3)]. Episodes of an insensate/densely blocked arm occurred only with ropivacaine 0.4% (5 vs 0 episodes, P=0.05). Satisfaction (numerical rating scale, 0-10) was higher for ropivacaine 0.2% [mean difference (95% confidence interval)=1.3 (0.3-2.4), P=0.01)]. After major shoulder surgery, ropivacaine 0.2% at 2 ml h(-1) with on-demand 5 ml boluses administered via an ultrasound-guided C5-6 root/superior trunk perineural catheter produces similar analgesia, but higher patient satisfaction compared with ropivacaine 0.4%. ANZCTR: ACTRN12608000591358. URL: www.anzctr.org.au/registry/trial_review.aspx?ID=83028.

Ultrasound-guided posterior approach for the placement of a continuous interscalene catheter.

The posterior approach to performing a continuous brachial plexus block at the level of the nerve roots has been described using traditional superficial landmarks. We describe an ultrasound-guided approach for the placement of a continuous interscalene brachial plexus catheter at the level of the nerve roots using a posterior approach. In addition, we provide the clinical characteristics of the first 16 catheters placed at our institution utilizing this approach. Sixteen patients having major shoulder surgery underwent ultrasound-guided placement of a posterior interscalene catheter at the level of the nerve roots. After generation of an optimized short axis image of the neural and vascular structures in the midneck, a 17-gauge Tuohy needle was directed into the skin between the levator scapulae and middle scalene muscles. Using the in plane approach, the needle was advanced until the tip was located between C5 and C6 nerve roots. Following a bolus injection of local anesthetic, a catheter was threaded 2 to 4 cm and secured. Visualization of the spread of local anesthetic through the catheter was used to dynamically confirm correct perineural catheter location. The characteristics of these catheters were assessed including dislodgment, postoperative opioid consumption, complications, and patient satisfaction. All 16 catheters were successfully placed. There were no unintended catheter dislodgments. Patient satisfaction was high and postoperative opioid consumption was minimal. Results suggest the use of ultrasound for placing a continuous interscalene nerve catheter via the posterior approach is a viable technique that offers an alternative to the more conventional non-image-guided superficial landmark techniques.

Can Ultrasound Impact the Risk–Benefit Ratio for Nerve Blocks?

Wayne State University, Detroit, Michigan. rkbaumgarten@comcast.netTo the Editor:— Dr. Hebl’s editorial1is thought provoking. The real potential of ultrasound lies in the opportunity to approach nerve blocks in entirely new ways. Regional anesthesia for hand surgery provides an example. Many anesthesiologists consider it axiomatic that one should avoid performing nerve blocks close to the tourniquet. This is partially defensive because “when the site of the block is close to the tourniquet, electromyographic and conduction nerve studies cannot allow such differentiation and by default, the anesthesiologist is usually blamed.”2Despite this caveat, the most commonly used regional technique for hand surgery with an upper arm tourniquet is the axillary block. If one subscribes to the theory that serious nerve damage from axillary block is often the result of vascular trauma and a medial brachial fascial compartment syndrome,3rather than direct needle–nerve trauma, it is even more imperative to avoid axillary block with an upper arm tourniquet.Ultrasound should permit the near total abandonment of the axillary block. With ultrasound, peripheral nerve blocks in the mid forearm become straightforward.4,5These blocks should replace the axillary block for minor hand surgery (e.g. , carpal tunnel, digit fractures).6Before ultrasound, many anesthesiologists avoided supraclavicular and infraclavicular blocks for fear of pneumothorax. With ultrasound, the lung and major vessels are directly visualized, so the proceduralist avoids them as a matter of course. For major hand, wrist, and elbow surgery, ultrasound-guided supraclavicular or infraclavicular blocks should be the first choice whenever an upper arm tourniquet is used.The gist of Hebl’s editorial and Koff et al. ’s case report7seems to be that this patient had an unfavorable risk–benefit ratio due to preexisting neurologic disease. But, where was the benefit in the first place? For total shoulder replacement, the requirement for significant pain control will far outlast any single-shot nerve block. The “tip-of-the iceberg” reports of permanent diaphragmatic paralysis8after uneventful interscalene blocks offer another reason to demure the use of single-shot interscalene blocks for shoulder surgery. Ultrasound may allow more use of suprascapular blocks, either single shot or continuous.9The ultrasound-guided suprascapular block may not be quite as effective, but it avoids the interscalene’s dreaded complications. For major shoulder surgery without evidence of preexisting brachial plexopathy, continuous brachial plexus blocks are still encouraged. The risk of a continuous block can be justified to the patient because it provides prolonged analgesia matched to the requirements of major surgery.Ultrasound allows the abandonment of some, but not all, traditional practices associated with nerve blocks. Many ultrasonographers no longer aspirate before injection, because ultrasound is a far more sensitive detector of intravascular injection than any aspiration test. The same cannot be said for potential intrafascicular injection. As Dr. Hebl notes, the precise position of the tip and the nerve is not always apparent until one has injected 2–3 ml of local anesthetic. In the unlikely situation where one has actually placed the needle tip into a nerve fascicle, the damage may already be done before anything shows up on ultrasound. Therefore, ultrasound may not obviate the need for injection pressure monitoring during nerve blocks. Injection pressure can be monitored with an inexpensive proprietary device (BSmart; Concert Medical, Norwell, MA) or by assessing the compression of an air bubble above the local anesthetic in the syringe.10Only when we thoroughly rethink our approach to surgical nerve blocks will ultrasound fulfill its potential for improved safety.Wayne State University, Detroit, Michigan. rkbaumgarten@comcast.net

The Use of a Continuous Interscalene Brachial Plexus Block for Pain Control following Shoulder Surgery

Background: Pain following shoulder surgery is usually severe and difficult to control using conventional postoperative pain control maneuvers. Therefore, we investigated the pain control efficacy, PONV (postoperative nausea vomiting) and complications by the use of a continuous brachial plexus block in patients who had undergone shoulder surgery. Methods: Thirty three shoulder surgery patients were enrolled in this study. According to the Borgeatimodified lateral technique, 30 ml of 0.37% ropivacaine were injected into the patients, which was followed by insertion of a continuous brachial plexus catheter into the plexus sheath. The operation was then conducted under general anesthesia, and postoperative pain was evaluated in the recovery room 12, 24, 36, and 48 hr after surgery. In addition, nausea and vomiting was calculated using the visual analogue scale (VAS) and sedation was evaluated using the modified Ramsay score. A total of 400 ml of 0.2% Ropivacaine was administered at a rate of 8 ml/hr to control the postoperative pain for 2 days. In addition, other neurological complications were investigated, and the catheter tips were cultured after they were removed to determine if any infection had occurred. Results: The postoperative pain scores were below 2 on the 10 cm VAS, and the level of nausea and vomiting was also satisfactorily (＜ 2/10 cm VAS). In addition, the mean sedation score of the patients in the recovery room was 2. There were complications including motor weakness (24%), dyspnea (15%), Hornorisyndrome (9%), postauricular numbness (9%) and metallic taste (3%), however, there were no patients who complained of n eurological symptoms after one month of follow-up, and no signs of infection were found when the results of catheter tip cultures were evaluated. Conclusions: The use of a continuous interscalene brachial plexus block is a feasible method of postoperative pain control for patients who undergo major shoulder surgery. (Korean J Anesthesiol 2007; 53: 733∼9)

Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure

There are logistical and financial advantages to undertaking shoulder surgery in a day case setting. However, this approach is limited by postoperative pain being inadequately controlled by oral medication alone. We describe a pilot study investigating the feasibility and acceptance of community based continuous interscalene brachial plexus blockade (CIBPB) to provide effective analgesia for day case shoulder surgery. Phase 1 consisted of five patients who received CIBPB for shoulder surgery. Following an overnight hospital stay they were assessed for discharge home with the interscalene catheter in situ. Once the safety and feasibility of the approach was documented, five more patients were recruited to Phase 2. These patients had the adequacy of analgesia assessed in the postoperative period and were discharged home on the same day as surgery. A district nurse visited twice daily and removed the catheter on the third day. Patient satisfaction was assessed using a discovery interview. Nine of the 10 patients experienced good analgesia. One patient was re-admitted because the catheter fell out. No patient experienced complications and the discovery interviews showed that the patients were satisfied with their management and pleased to be treated as a day case. POSSI proved that it was feasible to manage these patients in the community with support and training of the district nurses. Although extra community nursing hours are required, this technique has the potential for significant cost benefits with at least three bed days saved per patient.

131: Ultrasound-guided supraclavicular brachial plexus block for major shoulder surgery

131: Ultrasound-guided supraclavicular brachial plexus block for major shoulder surgery

Pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: a prospective, randomized, double-blind comparison between levobupivacaine 0.25%, and ropivacaine 0.25% or 0.4%

To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery. Seventy-two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient-controlled interscalene analgesia (basal infusion rate: 5 mL h-1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment. No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient-controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24-h patient-controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups (P = 0.0005). The hand strength recovered to >or=90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups. When providing patient-controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient-controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

Ambulatory open Bankart repair under a single general anesthesia: A prospective study of the immediate outcome

The interscalenic block technique is widely used for ambulatory shoulder surgery despite a substantial number of failures and adverse effects. We prospectively evaluated satisfaction in 40 consecutive patients who underwent open Bankart repair under a single general anesthesic performed in an ambulatory care unit. The mean age of the patients was 23 years. There were 29 men and 11 women. Patients were evaluated postoperatively with a visual analog scale of pain (in the recovery room, at the time of discharge, and the day after and 1 week after surgery) via a home assessment questionnaire that included the following: effectiveness of oral pain medication, ability to perform activities of daily life, and overall satisfaction. One patient failed to be discharged because of a feeling of faintness not related to pain. None of the 39 patients would have preferred an overnight hospital stay. This study confirms that the open Bankart procedure is feasible as a same-day technique and indicates that a single anesthesic with proper management of analgesia is a reliable technique for major shoulder surgery in an ambulatory care unit.

Joint Range of Motion After Total Shoulder Arthroplasty With and Without a Continuous Interscalene Nerve Block: A Retrospective, Case-Control Study

Although a continuous interscalene nerve block (CISB) has been shown to provide potent analgesia after major shoulder surgery, its potential effects on postoperative rehabilitation remain uninvestigated. Therefore, this retrospective case-control study was undertaken to determine the association between CISB and joint range-of-motion after total shoulder arthroplasty (TSA). The medical records for patients who underwent TSA at our institution in the previous 3 years were examined. Each patient with a CISB (cases) was matched with a patient without a CISB (controls) for the following variables: age, gender, and TSA type (primary v revision). Data collected included maximum shoulder elevation and external rotation (primary endpoints), along with pre- and postoperative pain scores. Of 134 charts reviewed, 25 cases were matched with an equal number of controls. On postoperative day 1, patients with or without a CISB achieved a median (5th-95th percentiles) of 85% (51-100) and 33% (11-56) of their surgeon-defined goal for elevation (P = .048), respectively, and attained 100% (33-100) and 17% (-81-68) for external rotation (P < .001), respectively. The median numeric rating pain score (NRS) during shoulder movement for patients with CISB was 2.0 (0.0-8.7) versus 8.5 (1.8-10.0) for patients without CISB (P < .001). Least, median, and highest resting NRS for the 24 hours after surgery were 0.0 (0.0-5.8), 1.0 (0.0-6.4), and 3.0 (0.0-9.0) for patients with CISB, respectively, versus 2.0 (0.0-7.7), 6.0 (0.3-9.6), and 8.0 (0.0-10.0) for patients without CISB (P = .030, P < .001, and P < .001 between groups, respectively). The day after TSA, a CISB is associated with increased shoulder range of motion, most likely resulting from the potent analgesia these nerve blocks provide.

The Use of cervical paravertebral block as the sole anesthetic for shoulder surgery in a morbid patient: a case report

Objectives The purpose of this case report is to describe the use of the cervical paravertebral block as the sole anesthetic for shoulder surgery in a patient unable to tolerate general anesthesia. Recent literature describes the continuous cervical paravertebral block as an effective alternative to the interscalene block for the management of postoperative pain after shoulder surgery. Case report An 85-year-old man with severe respiratory and cardiac disease presented for major shoulder surgery. The patient’s complex medical history required an anesthetic technique that would avoid general anesthesia and preserve phrenic nerve function. This case report describes, to our knowledge, the first successful use of the continuous cervical paravertebral block as the sole anesthetic for shoulder surgery. Conclusions Continuous cervical paravertebral block provided excellent surgical conditions and postoperative pain relief for this patient and allowed gradual and intermittent dosing of the catheter and continuous assessment of the anesthetic impact on respiratory function.

Ambulatory continuous interscalene brachial plexus blockade

Single-injection interscalene blocks provide excellent operating conditions, extended pain relief, and an advantageous side effect profile. As a result, anesthesiologists frequently perform them on an outpatient basis and are likely to discharge them insensate after using a long-acting local anesthetic. 1 However, a disadvantage to this practice is the regression of analgesia that often occurs after 12 to 24 hours when a single-injection technique is used. A significant portion of the pain relief and narcotic sparing is reduced when the block recedes rapidly after discharge. Depending on standard oral pharmacologic management for this transition is often insufficient to achieve the dense level of pain relief provided by the initial dose of local anesthetic. For shoulder surgery, this often results in severe pain. This is especially true for major shoulder surgery that typically requires a hospital stay for IV opioids. Ambulatory continuous interscalene brachial plexus block (CISB) can provide a solution for the rapid resolution of analgesia after a single injection block. This is especially true for major shoulder, clavicle, and humerus surgery. More importantly, CISB also provides continuous site-specific local anesthetic delivery, resulting in intense surgical anesthesia, effective long-term postoperative analgesia, reduced opioid requirements, an enhanced side effect profile, and may facilitate rehabilitation. Even relatively minor surgery, such as shoulder arthroscopy or rotator cuff repair, may benefit from this technique.

(iii) Anaesthesia for shoulder surgery

Pain after major open shoulder surgery, which maybe severe or very severe, is the major factor compromising early physical therapy. Interscalene block is a well recognised and efficient technique to control such pain. Various approaches are described; the modified lateral technique is the safest to perform and the most amenable for interscalene catheter insertion. This latter permits continuous infusion of local anaesthetic, the best technique available to achieve postoperative pain relief both at rest and on movement.

(iii) Anaesthesia for shoulder surgery

Pain after major open shoulder surgery, which maybe severe or very severe, is the major factor compromising early physical therapy. Interscalene block is a well recognised and efficient technique to control such pain. Various approaches are described; the modified lateral technique is the safest to perform and the most amenable for interscalene catheter insertion. This latter permits continuous infusion of local anaesthetic, the best technique available to achieve postoperative pain relief both at rest and on movement.

Wound Infiltration with Ropivacaine Using a Continuous-Flow Infusion Pump Reduces Pain and Opioid Requirement in Patients after Major Shoulder Surgery

Wound Infiltration with Ropivacaine Using a Continuous-Flow Infusion Pump Reduces Pain and Opioid Requirement in Patients after Major Shoulder Surgery

Anaesthesia for shoulder surgery

Early and efficient rehabilitation is necessary for improving outcome after shoulder surgery. Pain, which is severe to very severe in this condition, is the major factor which compromises early physical therapy. Interscalene block is a well recognized and efficient technique for controlling pain after major open shoulder surgery. Among the different approaches which have been described, the modified lateral technique is the safest to perform and the most suitable for insertion of an interscalene catheter.A number of different techniques have been tried to control pain after shoulder surgery. However, the application of a continuous infusion of local anaesthetics through an interscalene catheter is actually the best technique available to achieve pain relief at rest and on movement after this type of surgery. This chapter emphasizes the advantages of the modified lateral approach, the use of patient-controlled interscalene analgesia and the traps and tricks of the interscalene block. Thus, this chapter demonstrates why interscalene anaesthesia and analgesia are the most appropriate techniques for shoulder surgery.

Room F, 10/16/2000 2: 00 PM - 4: 00 PM (PS) Continuous Interscalene Brachial Plexus Block at Home after Major Shoulder Surgery

Room F, 10/16/2000 2: 00 PM - 4: 00 PM (PS) Continuous Interscalene Brachial Plexus Block at Home after Major Shoulder Surgery

The Art and Science of Peripheral Nerve Blocks

In this issue of Anesthesia and Analgesia, Marhofer et al. (1) have clearly demonstrated both the art and science of peripheral nerve blocks. Their magnetic resonance imaging (MRI) study of the distribution of local anesthetic after three-in-one block has laid to rest one of the most frequently discussed issues in regional anesthesia during the past 25 yr. They demonstrated that local anesthetic spread can be observed on MRI and that, after the injection of the femoral nerve in the inguinal region by using nerve stimulation, it is lateral, caudal, and slightly medial. This finding contradicts the long-standing teaching that the solution reliably spreads cephalad and bathes the lumbar plexus. This is the most objective evidence of local anesthetic distribution after peripheral nerve blockade. MRI opens a window to the rigorous scientific examination of peripheral nerve blockade that has not previously been available. Haven’t you ever wondered why microscopic changes of needle position can change the “twitch” observed with nerve stimulation, what difference bevel orientation makes to the success of peripheral nerve blocks, and whether additives change the distribution of local anesthetics during peripheral nerve blockade? This technology should help answer some of these basic questions. Why do we care about these questions? Regional anesthesia has never been more popular or in more demand by surgeons. Peripheral nerve blocks have enjoyed a resurgence because of their ability to improve home readiness after ambulatory surgery. A variety of factors influence discharge times after ambulatory surgery, but the most common reasons for delay in discharge are persistent pain, nausea, and drowsiness. Peripheral nerve blocks reduce the incidence of these factors by reducing the use of narcotics and eliminating the need for general anesthesia. In a study of factors influencing home readiness, peripheral nerve blockade for upper extremity surgery improved home readiness time by more than 70 min compared with “fast track” general anesthesia techniques (2). D’Alessio et al. (3) documented a 30-min improvement in street readiness after shoulder arthroscopy with interscalene block compared with general anesthesia. For lower extremity surgery, peripheral nerve blockade techniques are less well established but likely to be at least as effective as upper extremity peripheral nerve blockade. Ankle block has long been recognized as a safe and effective technique with a very high patient satisfaction rating (4). Vloka et al. (5) recently compared popliteal block to spinal anesthesia for short-vein stripping. The patients who received peripheral nerve blockade were discharged 70 min faster than those who received spinal anesthesia. Continuous peripheral nerve blocks improve rehabilitation scores and improve patient satisfaction compared with IV narcotic therapy after orthopedic surgery for both upper and lower extremity procedures. Borgeat et al. (6) improved pain scores and improved satisfaction for patients receiving continuous interscalene blockade for analgesia after major shoulder surgery compared with patients receiving IV narcotics. These authors particularly noted the improvement in analgesia during physical therapy. Rehabilitation is particularly important after total knee arthroplasty. Two studies have recently shown improvement in rehabilitation outcome after this procedure when continuous peripheral nerve blockade was compared with IV narcotics analgesia (7,8). Both studies confirmed lumbar plexus blockade to be as efficacious as epidural analgesia after total knee arthroplasty. However, continuous lumbar plexus blockade has several distinct advantages compared with epidural analgesia, including unilateral block, reduced urinary retention, and reduction of the low but real risk of spinal hematoma in the anticoagulated patient receiving epidural analgesia. Clearly, the time to spread the gospel of peripheral nerve blockade techniques has arrived. The importance of these techniques in providing safe and highly effective analgesia is no longer questioned. Our challenge now is to obtain a deeper understanding of the nuances of peripheral nerve blockade in order to demystify it for the rest of the world. Regional anesthesia has enjoyed a unique niche in the anesthesia world. It has defied scientific innovation in our technology-obsessed specialty. It remains a mystery to most of our anesthesia brethren. Regional anesthesia enthusiasts are viewed as part shaman, part acupuncturist, and part artist by many of their colleagues. Nonregional enthusiasts are usually that because of the inconsistencies that have seemed inherent in the practice of regional anesthesia. Even in the study of Marhofer et al. (1), there is objective evidence of local anesthetic distribution encompassing the femoral and lateral femoral cutaneous nerve in all patients. Yet only two of seven patients had complete obliteration of all sensation in the distribution of these nerves. As we are pushed to be more cost effective and time efficient, we must rigorously study the nuances of peripheral nerve blockade technique. Marhofer et al. (1) are to be congratulated for opening this window and shedding some scientific light on this timely topic.

Wound Infiltration and Drain Lavage with Ropivacaine After Major Shoulder Surgery

Subcutaneous infiltration and wound lavage with ropivacaine is an alternative to opioids after major shoulder surgery. However, the efficacy and potential toxicity of this method remain unclear. We therefore evaluated plasma ropivacaine concentrations after shoulder infiltration and wound lavage. We subsequently quantified the efficacy of two ropivacaine concentrations. Patients undergoing major shoulder surgery were anesthetized with alfentanil and propofol. The initial patients (n = 18) received ropivacaine 7.5 mg/mL and ropivacaine plasma concentrations were measured in 15-min intervals. The subsequent 45 patients were randomly assigned to: 1) isotonic saline, 2) 3.75 mg/mL ropivacaine, or 3) 7.5 mg/mL ropivacaine. Ten milliliters of each solution was administered subcutaneously and 20 mL was injected into the wound drain which was clamped for 10 min. Supplemental postoperative pain relief was provided by patient-controlled anesthesia using the opioid piritramid (3.5 -mg boluses, 6-min lock-out). Postoperative pain scores were recorded on a 100-mm visual analog scale for 4 h in the initial patients and for 10 h in the second part of the study. Unbound ropivacaine plasma concentrations peaked after 15 min at 0.08 ± 0.09 μg/mL; the maximum was 0.30 μg/mL, compared with a toxic threshold of 0.6 μg/mL. In the second part of the study, pain scores were significantly lower after 3.75 mg/mL (20 ± 15 mm) or 7.5 mg/mL (10 ± 9 mm) ropivacaine than saline (35 ± 10 mm). Piritramid requirements differed significantly in the three groups, being highest with saline and lowest with ropivacaine 7.5 mg/mL. We conclude that wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement. Implications Wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement.

A new technique of continuous interscalene nerve block.

To describes a technique of indwelling interscalene catheter placement and to evaluate its complications. One hundred and twenty patients undergoing major shoulder surgery received interscalene nerve block (ISNB) and were studied in three groups. Group 1 ISNB using Winnie's technique; group 2 by Winnie's technique with nerve stimulator and group 3 by epidural needle and catheter technique with nerve stimulator. All patients received 20 mL bupivacaine 0.5% and group 3 patients received an additional bupivacaine 0.25% infusion. Diaphragmatic movements were measured sonographically on emergence from anesthesia. Complications were noted. A visual analogue scale (0-10) was used to assess pain four hours postoperatively. Mean ipsilateral diaphragmatic movements were 4+/-8, 14+/-11 and 18+/-8 mm (mean +/- SD) in groups 1, 2 and 3 respectively. This was less than contralateral movements in all three groups (P < 0.05). None of the patients in groups 2 and 3 reported postoperative pain. The block failed in 10% of group 1 patients. Complete ipsilateral phrenic nerve block occurred in 85% of the patients in group 1, 35% of group 2 and 20% of group 3 (P < 0.05). Ipsilateral recurrent laryngeal nerve paralysis occurred in 20% of the patients in group 1, 5% of group 2 and in none of the patients in group 3 (P < 0.05). Horner's syndrome was noted in group 1 (30%), group 2 (12%) but not in group 3. None of the catheters in group 3 patients dislodged after an average use of 2.8+/-2.1 days. Indwelling catheter placement into the brachial plexus sheath as described in this communication was effective and associated with few complications.

Patient-Controlled Analgesia After Major Shoulder Surgery

Patient-Controlled Analgesia After Major Shoulder Surgery