Ultrasound-guided Interscalene Brachial Plexus Block Research Articles

Cost Analysis of Low-Volume Versus Standard-Volume Ultrasound-Guided Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.

Background Economic evaluation has become an essential decision-making tool for health systems worldwide. This study was aimed at estimating the difference in the use of healthcare resources, days on sick leave, and costs between patients undergoing a standard-volume versus a low-volume ultrasound-guided interscalene brachial plexus block. Methods This is a post-hoc cost analysis of a double-blind, randomized, and controlled clinical trial. Forty-eight patients undergoing ultrasound-guided interscalene block received either 10 ml or 20 ml of levobupivacaine 0.25%. Analyses involved the public healthcare payer perspective (including visits to general practitioners, nursing staff, physiotherapy facilities, hospital admissions, outpatient diagnostic tests, etc.) and the limited societal perspective, including productivity losses (days on sick leave). Measurements were made at one-month and one-year follow-ups post-intervention. Differences in costs were estimated using two-part models adjusted by the costs incurred in the previous year. Results Subjects in the 10 ml group made greater use of general practitioner visits (mean difference [95% CI]: 3.35 [0.219 to 6.49]; p=0.036) and diagnostic tests (2.43 [0.601 to 4.26]; p=0.009), but less use of physical therapy (-12.9 [-21.7 to -4.06]; p=0.004). Mean (SD) cost differences from the public healthcare payer's perspective were 1,461.34 $ (1,541.62) and 1,024.08$ (943.83) for the 10 ml and 20 ml groups, respectively (p=0.293). From the limited societal perspective, the differences were as follows: 7,036.53$ (8,077.58) and 8,666.56$ (9,841.10), respectively (p=0.937). While there were no differences in the above parameters at the one-month follow-up. Conclusion The volume reduction proposed following interscalene block resulted in meaningful, albeit not statistically significant, clinical benefits and lower costs from a limited societal perspective for shoulder surgery. Thus, healthcare use and days on sick leave are variables to be taken into consideration when calculating the economic impact of surgical procedures.

Comparison of the anesthesia effect of ultrasound-guided middle and low interscalene brachial plexus block: a randomized, controlled, non-inferiority trial

BackgroundUltrasound-guided low interscalene brachial plexus block (LISB) can provide satisfactory anesthesia for surgery at or below the elbow. However, the anesthesia effect of ultrasound-guided middle interscalene brachial plexus block (MISB) has not been fully investigated. We hypothesized that MISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow.MethodsA total of 82 patients with ASA I-III (18–65 years) scheduled for elective surgery at or below the elbow were randomized to the MISB group or the LISB group equally, located 1/2 or 2/3 of the caudal distance from C6 to the clavicle. Both groups were administered 15 mL 0.5% ropivacaine at the lower part of the brachial plexus with the first injection and equivalent volume at the upper part with the second injection.ResultsFor the primary outcome, 92.3% in the MISB group experienced successful anesthesia compared to 94.6% in the LISB group [difference: –2.3%, 95% confidence interval (CI) –13.4% to 8.8%], exceeding the predefined non-inferiority margin -15%. For the secondary outcomes, the incidence of pleura suppression for the first injection (7.7% vs. 45.9%, P < 0.001) and the time to perform the block (9.9 ± 1.3 vs. 10.7 ± 1.3 min, P = 0.006) were significantly less in MISB compared to LISB. No significant differences were observed in the consumption of perioperative rescue analgesics, VAS score, and adverse events within the two groups.ConclusionsMISB provides a non-inferior anesthesia effect to LISB for surgery at or below the elbow.Trial registrationChinese Clinical Trial Register (identifier: ChiCTR2100054196).

Effects of Low Dose Dexamethasone as an Adjuvant to Levobupivacaine in Ultrasoundguided Interscalene Brachial Plexus Block: A Randomised Clinical Trial

Introduction: Ultrasound-guided Interscalene Brachial (USGISB) plexus block is known to provide effective analgesia for upper limbs surgery. Low-dose dexamethasone as additive with levobupivacaine in USG-ISB plexus block is known to provide effective analgesia for upper limbs surgery. Aim: To evaluate whether dexamethasone, use as an additive with levobupivacaine during an USG-ISB plexus block for upper limb surgery, has sufficient analgesic effect. Materials and Methods: The randomised clinical trial was conducted at GGS Medical College and Hospital, Faridkot, Punjab, India, from March 2018 to August 2019. Sixty patients who were scheduled to have upper limb surgery using USG-ISB with 0.5% levobupivacaine were randomly assigned to one of two groups. Group A (n=30) received one ml of normal saline, while group B (n=30) received 4 mg of dexamethasone. A fourpoint Verbal Numerical Rating Scale (VNRS) for pain was used to evaluate postoperative analgesia. The duration of analgesia, time to onset and duration of sensory and motor blockade, and pain ratings were measured. Unpaired student's t-test, Chisquare and Fisher’s-exact tests were used to analyse the data. Results: The mean duration of analgesia was significantly longer for group B than for group A (854.67±10.08 min vs 743.00±23.22 min; p-value&lt;0.001). The onset of sensory and motor blocks in group B began to develop earlier (8.42±0.35 min, and 9.72±0.55 min) than those in group A (10.10±0.80 min, and 11.02±0.84 min; p-value&lt;0.001). The duration of the sensory and motor block in group B was longer (653±16.17 min and 582.83±14.18 min) than that in group A (595±17.29 min and 487.33±21.04 min; p-value&lt;0.001). Conclusion: Perineural dexamethasone with levobupivacaine provides greater postoperative analgesia, also speed up the onset of sensory and motor effects, and prolongs the duration of interscalene brachial plexus block.

Comparison of Continuous and Programmed Intermittent Bolus Infusion of 0.2% Ropivacaine after Ultrasound-Guided Continuous Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.

Despite the clinical effectiveness of the programmed intermittent bolus (PIB) method for epidural analgesia, evidence for this method in continuous interscalene brachial plexus block (CIBPB) is unclear. This study aimed to investigate the pain relief effect after arthroscopic shoulder surgery according to the administration method by comparing the PIB and continuous infusion methods among the administration methods of local anesthetics. Sixty-four patients aged >19 years scheduled for elective arthroscopic shoulder surgery were enrolled and divided into two groups. Ultrasound-guided CIBPB was performed to control postoperative pain. The infusion pump was programmed so that 0.2% ropivacaine was continuously injected at 1.1 mL/h in group A, whereas in group B, 0.1 mL/h was continuously injected and 4 mL was periodically injected at 4 h intervals. In both groups, a further infusion of 4 mL of 0.2% ropivacaine was administered if the patient requested additional analgesia, and the lockout time was set at 30 min. Postoperative pain quality was assessed using a visual analog scale (VAS), and the incidence of patients requiring additional analgesics, motor blockade using a modified Bromage scale (MBS), and consumed doses of local anesthetic were assessed. The VAS and incidence of rescue analgesics were performed when the patient could communicate voluntarily after admission to the post-anesthetic care unit, and at 24 and 48 h after surgery showed no significant difference between the two groups. The MBS at 24 h after surgery was significantly higher in group B (p = 0.038). In the comparison of consumed doses of local anesthetic, group B had a significantly higher bolus injection dose (p = 0.047) and frequency of bolus use in the 24 h after surgery (p = 0.034). The PIB method in CIBPB after arthroscopic shoulder surgery provided a similar analgesic effect, with a higher bolus injection dose of local anesthetic and increased motor blockade than the continuous infusion method.

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.

Regional Anesthesia for Clavicle Fracture Surgery- What is the Current Evidence: A Systematic Review

Introduction: The sensory innervation of the clavicle remains controversial. It might come from both the cervical plexus and brachial plexus. Peripheral nerve blocks used to anesthetize the clavicle include cervical plexus blocks, brachial plexus blocks, and combined cervical and brachial plexus blocks. Objectives: The review was to determine whether there is a difference in pain scores and pain medication consumption intraoperatively and postoperatively among these blocks. Secondary endpoints were block success and serious adverse events. Methods: A comprehensive literature search of PubMed and Web of Science was performed. Only English-written randomized controlled studies were included. Results: Compared with patients with general anesthesia, patients with combined ultrasound-guided superficial cervical and interscalene brachial plexus block spent a shorter time in PACU (35.60 ± 5.59 min vs. 53.13 ± 6.95 min, P &lt; 0.001), had a more extended pain-free period (324.67 ± 41.82 min vs. 185.27 ± 40.04 min, P &lt; 0.001), and received less opioid consumption (Tramadol 213.33 ± 57.13 mg vs. 386.67 ± 34.57 mg, P &lt; 0.001) in first 24 h postoperatively. Compared with patients with ultrasound-guided superficial cervical and interscalene brachial plexus block, patients with ultrasound-guided intermediate cervical and interscalene brachial plexus block had a higher success rate (100% vs. 80%) and longer duration of post-operative analgesia (7.5±0.8 h vs. 5.7± 0.4 h, P&lt;0.001). Without ultrasound guidance, patients with combined superficial, deep cervical, and interscalene brachial plexus block had a higher success rate (96% vs. 60%), lower pain score at two h postoperatively (1.96±0.17 vs. 3.22±0.88, p=0.000), and a more extended pain-free period (1h vs 6h) compared to combined superficial cervical and interscalene brachial plexus block. There were no regional anesthesia-related complications reported in all studies. Conclusion: Patients with regional anesthesia have a more significant pain-free period and less intraoperative and postoperative opioid consumption than patients with general anesthesia. Combined intermediate or deep cervical plexus and Interscalene brachial plexus blocks provide better analgesia than combined superficial cervical plexus and Interscalene brachial plexus blocks. Ultrasound guidance improved the success rate of regional anesthesia. Combined cervical plexus and brachial plexus block can be used as sole anesthesia for clavicle fracture surgery.

The median effective analgesic concentration of ropivacaine in ultrasound-guided interscalene brachial plexus block after arthroscopic rotator cuff repair.

Background: The median effective analgesic concentration (MEAC) of ropivacaine in interscalene brachial plexus block (ISBPB) for postoperative analgesia after arthroscopic rotator cuff repair (ARCR) has not been determined. Therefore, this study aimed to evaluate the MEAC after ARCR using 10 ml ropivacaine. Method: This study was conducted on 40 patients with American Society of Anesthesiologists grade I or II who had selective ARCR. The 10 ml ropivacaine was administered for determined, with an initial concentration of 0.3% using up-and-down sequential allocation. After successful or unsuccessful postoperative analgesia, the concentration of ropivacaine was decreased or increased by 0.05% in the next patient. We defined successful postoperative analgesia as a visual analog scale 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 for calculating MEAC. The secondary outcomes was sufentanil consumption, time to 1st rescue analgesic, onset time of sensory block and motor block. Results: The concentration of ropivacaine administered ranged from 0.1% to 0.35%. The MEAC from the four different methods (linear, linear-logarithmic, exponential regressions and centered isotonic regression) were 0.207% (95% CI, 0.168–0.355%), 0.182% (95% CI, 0.165–0.353%), 0.196% (95% CI, 0.154–0.356%), and 0.163%, respectively. Of the four models, exponential regression had the least residual standard error (0.0990). Conclusion: The MEAC derived from the four statistical models for 10 ml ropivacaine in ultrasound-guided ISBPB for postoperative analgesia was distributed within a narrow range of 0.163%–0.207%. The exponential regression model calculated by the goodness-of-fit test at a concentration of 0.196% best fits the study data. Clinical Trial Registration: http://www.chictr.org.cn/showproj.aspx?proj=127449, identifier ChiCTR2100047978

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.

Injection of local anesthetic lateral to vertebral transverse process instead of conventional method for interscalene block in difficult cases with poor view

Ultrasound guided (USG) peripheral nerve block techniques have become increasingly popular in regional anesthesia in the recent few years. USG interscalene brachial plexus block provides effective analgesia after a variety of of surgeries and have been shown to reduce opioid consumption, decrease postoperative nausea and vomiting (PONV), improve patient satisfaction, and decrease recovery room length of stay.1 Regardless of all of these advantages, there have been some complications associated with this technique. The most important complication is the phrenic nerve block. Therefore, impaired respiratory function is considered a relative contraindication to interscalene plexus block. It has been shown to cause ipsilateral hemidiaphragmatic paresis almost always due to phrenic nerve block.2, 3&#x0D; Key words: Nerve Block/methods; Anesthetics, Local; Peripheral Nerves / diagnostic imaging; Ultrasonography, Interventional / methods &#x0D; Citation: Heidarifar R, Amini SM, Lotfi S, Ahmadi A. Injection of local anesthetic lateral to vertebral transverse process instead of conventional method for interscalene block in difficult cases with poor view. Anaesth. pain intensive care 2021;26(1):126-127.&#x0D; DOI: 10.35975/apic.v26i1.1783

Ultrasound-Guided Clavipectoral Fascial Plane Block With Intermediate Cervical Plexus Block for Midshaft Clavicular Surgery: A Prospective Randomized Controlled Trial.

Regional anesthesia such as interscalene brachial plexus block (ISBPB) with intermediate cervical plexus block (ICPB) is generally a preferred choice for clavicular surgery. However, various studies have shown that these blocks, especially ISBPB, could cause phrenic nerve paralysis and decrease diaphragmatic motion. The study aimed to evaluate the efficacy of clavipectoral fascial plane block (CPB), an alternative technique to ISBPB, with ICPB, in reducing hemidiaphragmatic paralysis during midshaft clavicular surgery. Forty patients scheduled for right midshaft clavicular surgery were randomized (1:1) into an ultrasound-guided ISBPB with ICPB (BC) group or ultrasound-guided CPB with ICPB (CC) group. Five milliliter of 0.375% ropivacaine was used for ICPB, another 20 mL for ISBPB or CPB, and no administration of additional sedative or general anesthetic was planned. Primary outcome was measured by the incidence of hemidiaphragmatic paralysis using M-mode ultrasonography, while secondary outcomes were measured by bedside pulmonary function test, the success rate of block, the time required for the block procedure and onset of block, and motor block score in right upper extremity. In comparison with BC group, the incidence of hemidiaphragmatic paralysis postblock was decreased in CC group (50% vs 0%; P < .001), and measurement of bedside pulmonary function was significantly improved. There was a 100% success rate for anesthetic block in both BC and CC groups, and CC group showed lower motor block score in upper extremity and less block procedure time than BC group (7.1 ± 1.2 vs 3.2 ± 0.6 minutes; P < .001). Moreover, no significant differences were found between time of onset of block and other anesthetic complications in the 2 groups. Ultrasound-guided CPB with ICPB could significantly reduce hemidiaphragmatic paralysis and provide an adequate surgical anesthesia with fewer complications such as motor block in upper extremity during right midshaft clavicular surgery.

Quantitative evaluation of the effects of interscalene block on physiological responses to the balance between nociception and anti-nociception among inpatients undergoing total shoulder arthroplasty under general anesthesia.

Although the suppression of physiological responses to the balance between nociception caused by surgical trauma and anti-nociception due to anesthesia during total shoulder arthroplasty (TSA) is relevant for better perioperative managements, quantitative evaluations of the effects of ultrasound-guided interscalene brachial plexus block (ISB) on physiological responses have not been performed. Physiological responses were assessed using the nociceptive response (NR) index. In this multi-institutional observational study, associations between ISB and NR values were examined among inpatients undergoing TSA under general anesthesia between March 2019 and January 2021. The effects of ISB on acute postoperative pain and major complications within 30days after surgery were also examined. NR values after skin incision clearly showed significant suppressions of physiological responses in patients undergoing TSA with ISB (n = 60), compared to those without ISB (n = 24). Acute postoperative pain on the day of surgery was also significantly less in patients with ISB than in those without ISB. Postoperative complications, classified by Clavien-Dindo grades, showed no significant differences between patients with and without ISB. A propensity score-matched sensitivity analysis confirmed the same results in patients with (n = 21) and without ISB (n = 21). In conclusion, suppression of physiological responses to the balance between nociception and anti-nociception by ISB can be quantitatively evaluated by NR index during TSA.

Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial

This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block. 208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner's syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting. Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2-6] vs. 6 min [4-10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome. The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.

Dexamethasone as a bupivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: a prospective randomized study

BackgroundFinding adjuvants to local anesthetic used in interscalene block that could efficiently extend the analgesia duration has recently been the focus of researchers. The aim of the work was to determine whether the addition of perineural dexamethasone to bupivacaine in-ultrasound guided interscalene block would prolong the duration of sensory analgesia in patients undergoing shoulder surgery.ResultsThis prospective, randomized, double-blinded study comprised 50 patients. They were randomly subdivided into 2 groups: group C [control] and group D [dexamethasone]. We noted a significant difference regarding the timing for the first rescue analgesia being shorter in group C than in group D with a P value < 0.001. Regarding postoperative analgesia, higher Ketolac consumption was noticed in group C than in group D. Patients from both groups showed excellent analgesic effects with VAS score less than 2 points up to 6 h postoperative then patients in group C had a higher VAS score compared to group D, and the difference was statistically significant (P value < 0.05). We also noticed an increase in the heart rate and mean arterial blood pressure in group C than in group D at 12 h and 24 h postoperatively.ConclusionWe concluded that the addition of 8 mg of perineural dexamethasone to 30 ml of 0.5% bupivacaine showed improvement in the postoperative analgesia in shoulder surgery without obvious complications.

Differential lung ventilation assessed by electrical impedance tomography in ultrasound-guided anterior suprascapular nerve block vs. interscalene brachial plexus block: A patient and assessor-blind, randomised controlled trial.

Ultrasound-guided interscalene brachial plexus block (ISB) is used to control pain after shoulder surgery. Though effective, drawbacks include phrenic nerve block and motor block of the hand. The ultrasound-guided anterior approach to perform suprascapular nerve block (SSNB) may provide a good alternative. To compare lung ventilation and diaphragmatic activity on the operated side in ISB and SSNB. Randomised, controlled patient-blinded and assessor-blinded trial. Outpatient surgical clinic with recruitment from June 2017 to January 2018. Fifty-five outpatients scheduled for arthroscopic shoulder surgery were allocated randomly to receive SSNB or ISB. Technical problems with monitoring devices unrelated to the intervention led to exclusion of seven patients. The remaining 48 (n=24 in each group) were followed up for 24 h without drop-outs. Patients received 10 ml of ropivacaine 1.0% wt/vol for both procedures. Percentage lung ventilation on the operated side was the primary endpoint as assessed with electrical impedance tomography (EIT). Secondary endpoints were hemidiaphragmatic motion on the operated side, pain, opioid use, hand strength and numbness, and patient satisfaction. Before regional anaesthesia, the lung on the operated side contributed a median [IQR] of 50 [42 to 56]% of the total lung ventilation. Postoperatively, it was 40 [3 to 50]% (SSNB) vs. 3 [1 to 13]% (ISB) for an adjusted difference of 23 (95% CI, 13 to 34)%, (P < 0.001). Hemidiaphragmatic motion was 1.90 (95% CI, 1.37 to 2.44 cm), (P < 0.001) lower in the ISB group compared with the SSNB group. Hand strength was 11.2 (95% CI 3.6 to 18.9), (P = 0.0024) kg greater for SSNB and numbness was observed in 0% (SSNB) vs. 46% (ISB) of patients, P < 0.001. Pain was low in the first 6 h after surgery in both groups with slightly, but not significantly, lower values for ISB. No meaningful or significant differences were found for opioid use or patient satisfaction. An ultrasound-guided anterior approach to SSNB preserves ipsilateral lung ventilation and phrenic function better than a standard ISB. drks.de identifier: DRKS00011787.

Anatomical variations detected during ultrasound-guided interscalene brachial plexus block and clinical implications

Objective: Our aim was to evaluate the anatomic variations detected during ultrasound-guided interscalene brachial plexus block (US-ISB) and present their clinical implications. Materials and Methods: After the ethical approval for the study was obtained from the local ethics committee, the files and US records of patients who underwent US-ISB for anesthesia of the shoulder surgery were retrospectively analyzed. Results: Anatomical variations which were considered to affect the block technique were detected in 13 (11.8%) of 110 patients. C5 cervical root pierced the anterior scalene muscle (ASM) in 4.5%, and ventral rami of C5 and/or C6 were located in ASM in 3.6% of patients. There was a muscle bridge between C5 to C6 and C5 to C7 roots in 1.8% of the patients. The brachial plexus was located medial to ASM and missing from interscalene groove in 1.8% of patients. In one case (C5 root was located in ASM), US-ISB resulted in incomplete brachial plexus anesthesia, and so general anesthesia (GA) was performed. Conclusion: Some of the brachial plexus variations in the interscalene area may be associated with further needle manipulation/ redirection and block failure. We consider that prospective studies including more populations are needed to elucidate the effects of these variations on block parameters.

Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial

Background and objectivesIn shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting. MethodsAfter approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D – blockade performed with 30mL of 0.5% levobupivacaine with vasoconstrictor and 6mg (1.5mL) of dexamethasone and Group C – 30mL of 0.5% levobupivacaine with vasoconstrictor and 1.5mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS). ResultsSeventy-four patients were recruited and 71 completed the study (Group C, n=37; Group D, n=34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440±0min vs. 1267±164min, p<0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08±1.72 vs. 0.02±0.17, p<0.001) and a greater number of patients (68.4% vs. 0%, p<0.001) required rescue analgesia in the first 24hours. The incidence of postoperative nausea and vomiting was not statistically significant. ConclusionPerineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.

Comparison between two different concentrations of a fixed dose of ropivacaine in interscalene brachial plexus block for pain management after arthroscopic shoulder surgery: a randomized clinical trial

BackgroundOnly a few studies have evaluated the differences between varying concentrations of a fixed dose of local anesthetics. This study was conducted to compare the effects of two different concentrations of a fixed dose of ropivacaine used in ultrasound-guided interscalene brachial plexus block. MethodsThis prospective, randomized, double-blind study included 62 patients who underwent arthroscopic surgery under general anesthesia. The patients were randomly assigned to receive ultrasound-guided interscalene block with 75 mg of ropivacaine at one of two concentrations: 0.75% (10 ml; Group C) or 0.375% (20 ml; Group V). Time to onset of sensory blockade, degree of blockade, pulmonary function changes, analgesic duration of the interscalene block, postoperative opioid requirement within 24 h, postoperative pain scores, satisfaction, and incidence of complications were recorded. ResultsAlthough the time to onset of sensory blockade was shorter for Group C (P = 0.015), successful blockade was achieved at 30 min after the interscalene block in both groups. The analgesic duration of the interscalene block was not significantly different between the groups. The amount of opioid used within 24 h after surgery was significantly reduced for Group V compared with Group C (P = 0.016). The rest of the parameters did not show any significant differences between the two groups.ConclusionsCompared with 10 ml of 0.75% ropivacaine, interscalene block with 20 ml of 0.375% ropivacaine could be effective for the reduction of postoperative opioid requirement within 24 h after surgery despite it might not prolong the analgesic duration.

Severe and persistent nerve palsy after ultrasound-guided continuous interscalene brachial plexus block in a teenager undergoing shoulder surgery: a case report

BackgroundAlthough neurologic sequela is a recognized complication after interscalene brachial plexus block (ISB), there is a paucity of information on how severe and persistent neuropathy occurs and develops.Case presentationA healthy high school soccer goalkeeper was scheduled for an arthroscopic Bankart repair. After continuous ISB for 2 days, sensation in the C5 and C6 areas and motor function did not return. With symptomatic drug treatment for neuropathic pain and rigorous rehabilitation, recovery of sensory loss and muscle weakness were gradually observed around 1 to 2 months after surgery. He returned to sport 1 year after surgery.ConclusionThis report is the first detailed description of a case who incurred severe and persistent nerve injury after continuous ISB yet recovered nearly fully to return to being an athlete. The present case should also underscore the importance of close observation after surgery in cases where a patient receives continuous ISB.

Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair.

Interscalene brachial plexus block (ISB) is one of the most commonly used regional blocks in relieving postoperative pain after arthroscopic rotator cuff repair. Dexmedetomidine (DEX) is an alpha 2 agonist that can enhance the effect of regional blocks. The aim of this study was to compare the effects of DEX combined with ISB with ISB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48h after arthroscopic rotator cuff repair. Fifty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single center, double-blinded randomized controlled trial study. Twenty-five patients were randomly allocated to group 1 and received ultrasound-guided ISB using a mixture of 1ml (100μg) of DEX and 8ml of 0.75% ropivacaine preemptively. The other 25 patients were allocated to group 2 and underwent ultrasound-guided ISB alone using a mixture of 1ml of normal saline and 8ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were checked within 48h postoperatively. The plasma interleukin (IL)-6, -8, -1β, cortisol, and substance P levels were also measured within 48h, postoperatively. Group 1 showed a significantly lower mean VAS score and a significantly higher mean SAT score than group 2 at 1, 3, 6, 12, and 18h postoperatively. Compared with group 2, group 1 showed a significantly lower mean plasma IL-6 level at 1, 6, 12, and 48h postoperatively and a significantly lower mean IL-8 level at 1, 6, 12, 24, and 48h postoperatively. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (12.7h > 9.4h, p = 0.006). Ultrasound-guided ISB with DEX in arthroscopic rotator cuff repair led to a significantly lower mean VAS score and a significantly higher mean SAT score within 48h postoperatively than ISB alone. In addition, ISB with DEX showed lower mean plasma IL-6 and IL-8 levels than ISB alone within 48h postoperatively, with delayed rebound pain. I. 2013-112, ClinicalTrials.gov Identifier: NCT02766556.

Study on median effective dose of ropivacaine combined with dexmedetomidine for ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery

Study on median effective dose of ropivacaine combined with dexmedetomidine for ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery