Bloqueo interescalénico en el contexto de la recuperación acelerada para artroscopía de hombro: serie de casos / Interscalene block in the context of enhanced recovery for shoulder: A case series

Introducción La aplicación de la recuperación acelerada en cirugía de hombro no ha tenido una aceptación tan favorable. Por ello, el objetivo de este estudio fue presentar y describir el uso de bloqueo interescalénico para favorecer la recuperación acelerada en una serie de pacientes sometidos a cirugía artroscopica de hombro. Métodos Se incluyeron 35 pacientes sometidos a cirugía artroscópica de hombro, en quienes se administró bloqueo interescalénico y sedación. Posteriormente se evaluó la intensidad del dolor, náuseas, vómito, disnea, presencia de síndrome de Horner, visión borrosa, ronquera, tiempo transcurrido hasta el alta, reingresos no planeados, satisfacción del paciente y cumplimiento de los criterios de alta hospitalaria en las primeras 12 horas siguiendo los criterios de una recuperación acelerada. Resultados En total, 27 pacientes (77,1%) tuvieron clasificación de la (ASA) I y 8 pacientes (22,9%) ASA II. Además, 97,1% fueron reparaciones de manguito rotador. Previo al alta, dos pacientes (5,7%) presentaron náuseas. Al momento del alta ningún paciente presentó disnea o visión borrosa, dos pacientes (5,7%) presentaron ronquera y la mediana de intensidad del dolor fue de 1,0 (0,0 a 7,0). Entre las 24 y 48 horas solo un (2,8%) paciente presentó náuseas y la mediana de intensidad del dolor fue de 1,0 (0,0 a 8,0). Todos los pacientes se mostraron satisfechos con disposición a repetir la experiencia. El 100% de pacientes cumplió los criterios médicos de alta a las 12 horas y 30 pacientes (85,7%) se dieron de alta el mismo día. La estancia fue de 12 (11,5 a 12,5) horas y ningún paciente reingresó. Conclusión En pacientes seleccionados, con un equipo quirúrgico-anestésico comprometido, capacitado y con experiencia, hay una alta posibilidad de que el bloqueo interescalénico favorezca la realización de programas de recuperación acelerada en cirugía artroscópica de hombro.

Introduction The application of enhanced recovery in shoulder surgery has not had such a favorable acceptance, therefore, the objective of this study was to present and describe the use of interscalene block to promote enhanced recovery in a series of patients undergoing shoulder arthroscopic surgery. Methods Thirty-five patients undergoing arthroscopic shoulder surgery were included, in whom interscalene blockade and sedation were administered. Subsequently, pain intensity, nausea, vomiting, dyspnea, presence of Horner's syndrome, blurred vision, hoarseness, time elapsed to discharge, unplanned readmissions, patient satisfaction, and compliance with hospital discharge criteria in the first 12 weeks were evaluated, hours following the criteria of an enhanced recovery. Results 27 patients (77,1%) had ASA I and 8 patients (22,8%) ASA II, 97,1% were rotator cuff repairs. Before discharge, two patients (5.7%) had nausea. At discharge, no patient had dyspnea or blurred vision, two patients (5.7%) developed hoarseness, and the median pain intensity was 1.0 (0.0-7.0). Between 24 and 48 hours only one patient (2.8%) presented nausea and the median pain intensity was 1.0 (0.0-8.0). All the patients were satisfied with their willingness to repeat the experience, 100% of the patients met the criteria for medical discharge after 12 hours, 30 patients (85.7%) were discharged the same day, the stay was 12 (11.5 to 12.5) hours, and no patient was readmitted. Conclusion In selected patients with a committed, trained and experienced surgical-anesthetic team, there is a high possibility that the interscalene block will favor the performance of enhanced recovery programs in shoulder arthroscopic surgery.

A randomized comparison between interscalene block and dexmedetomidine for arthroscopic shoulder surgery / Una comparación aleatoria entre el bloqueo interescalénico y dexmedetomidina para la cirugía artroscópica de hombro

Abstract Introduction: Management of intraoperative hemodynamics and postoperative analgesia during arthroscopic shoulder surgeries remains a challenge. Although interscalene brachial plexus block (ISB) is considered ideal for shoulder anesthesia it requires skill and proficiency unlike intravenous (IV) dexmedetomidine. Objective: This randomized trial was performed to observe the efficacy of dexmedetomidine infusion which is less invasive and demands lesser skills than plexus block. Methodology: All patients scheduled for elective arthroscopic shoulder surgery under general anesthesia were assigned either to group DEX, which received an IV dexmedetomidine bolus of 0.5 mcg/kg over 20 minutes, followed by an infusion of 0.5 mcg/kg/hour that was stopped 30 minutes before surgery the end of surgery or to group BLOCK which received ultrasound guided ISB with 20ml of 0.25% bupivacaine. The primary outcome assessed was intraoperative hemodynamics; the secondary outcomes were immediate postoperative pain, operating condition as assessed by the surgeon, recovery time, and patient satisfaction after 24 hours. Blinded investigator and composite scores were used for the assessment. Results: Both groups displayed equivalent scores for intraoperative hemodynamics whereas ISB resulted in a better post-operative analgesia (p < 0.001). Surgeon's opinion and recovery time were comparable. Overall, the patients had a satisfactory experience with both techniques, according to the quality assessment. Conclusions: IV dexmedetomidine infusion is an effective alternative to ISB for reconstructive shoulder surgeries under general anesthesia.

Resumen Introducción: El manejo hemodinámico intraoperatorio y la analgesia postoperatoria durante la cirugía artroscópica de hombro sigue siendo un desafío. Aun cuando el bloqueo interescalénico del plexo braquial (BIE) se considera ideal para la anestesia del hombro, a diferencia del uso de la dexmedetomidina intravenosa (IV), el BIE requiere destreza y maestría. Objetivo: El presente estudio aleatorizado se llevó a cabo para observar la eficacia de la infusión de dexmedetomidina que es menos invasiva y exige menos destreza que el bloqueo del plexo. Metodología: Todos los pacientes programados para cirugía artroscópica electiva de hombro bajo anestesia general, se asignaron o bien al grupo DEX, para recibir un bolo de dexmedetomidina IV de 0,5 mcg/kg en 20 minutos, seguido de una infusión de 0,5 mcg/kg/hora que se detuvo 30 minutos antes del final de la cirugía; o, al grupo BLOQUEO al cual se le administró un BIE ecoguiado con 20ml debupivacaína 0,25%. El desenlace primario evaluado fue la hemodinamia intraoperatoria; los desenlaces secundarios fueron el dolor postoperatorio inmediato, la condición operatoria evaluada por el cirujano, el tiempo de recuperación y la satisfacción del paciente después de 24 horas. Para la evaluación se utilizaron el investigador ciego y puntajes compuestos. Resultados: Ambos grupos mostraron puntajes equivalentes en la hemodinamia intraoperatoria, en tanto que el BIE dio como resultado una mejor analgesia en el postoperatorio (p < 0.001). La opinión del cirujano y el tiempo de recuperación fueron comparables. En general, la experiencia de los pacientes fue satisfactoria con ambas técnicas, de acuerdo con la evaluación de calidad. Conclusiones: La infusión de dexmedetomidina IV es una alternativa efectiva al BIE para cirugías reconstructivas de hombro bajo anestesia general.

Comparison of interscalene brachial plexus block and superior trunk block with ropivacaine in shoulder arthroscopic surgery / 药学实践杂志

Objective To compare the clinical effects of interscalene brachial plexus block and superior trunk block in arthroscopic shoulder surgery with 0.25% ropivacaine. Methods 46 patients undergoing shoulder arthroscopy surgery were included and randomly divided into group ISB (n=23) and group ST (n=23). Patients in group ISB received 10 ml 0.25% ropivacaine on the lateral side of C5 and C6. Patients in group ST were treated with 5 ml 0.25% ropivacaine on both sides of the superior trunk of brachial plexus. The diaphragmatic excursion, Numerical Rating Scale(NRS), duration of the block, handgrip strength were recorded at different time. Results No statistical difference was detected between the two groups in the reduction of diaphragmatic excursion within 30 min after block (P>0.05). Compared with ISB patients, ST patients had significantly less diaphragmatic excursion at 3 h after block（P<0.05). 30 minutes after block, 8.7% patients in ISB group reached complete HDP and 52.2% patients reached partial HDP. At the same time, no complete HDP and 26.1% partial HDP were detected in ST group. 3 hours after block, patients in ST group had lower complete HDP rate (0.0% vs 17.4%) and lower partial HDP rate (39.1% vs 65.2%) than patients in ISB group. At 30 minutes and 3 h after block, the reduction of grip strength in ST group was significantly lower than that in ISB group (P<0.001). ST group had lower NRS than ISB group (P<0.05). The average block time in ISB group (8.3±1.97 )h was significantly lower than that in ST group (10.9±1.26)h (P<0.01). Conclusion Superior trunk block with 10 ml 0.25% ropivacaine is superior compared to interscalene brachial plexus block in occurrence of HDP, decrease of grip strength, postoperative pain and block duration.

Hemidiaphragmatic paralysis with continuous interscalene block and diluted solutions of levobupivacaine / Bloqueo interescalénico y parálisis diafragmática con dosis diluidas de levobupivacaína

The continuous interscalene block represents the analgesic standard for shoulder surgery. However, the incidence of hemidiaphragmatic paralysis can reach up to 100% of cases. We hypothesized that more dilute local anesthetics would decrease the phrenic palsy at 24 hours. METHODS: Prospective series of patients undergoing arthroscopic shoulder surgery with continuous interscalene block. A 15-ml bolus of lidocaine 1%-levobupivacaine 0.25% plus an infusion of levobupivacaine 0.04% at an 8 mL/h rate plus 5 mL boluses on-demand with a 20-minutes lockout was used until discharge. Hemidiaphragmatic excursion was evaluated with M-mode ultrasound in the subcostal region before blocks, in the post-anesthetic unit, and at 24 h. The primary outcome was the presence of hemidiaphragmatic paralysis at 24 hours. Secondary outcomes included postoperative pain, amount of rescue boluses, postoperative opioids consumption, and side effects. RESULTS: Thirty patients were recruited and analyzed. The incidence of diaphragm paralysis at 24 h was 96.7%. The median [IQR] of pain at rest (patients with shoulder immobilizer) in a NRS from 0 to 10 at 0.5; 1; 3; 6; 12; 24; 48; 72 hours were 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2], respectively. The median [IQR] consumption of LA boluses was 1.5 [0-7]. There were no postoperative morphine requirements. The most frequent side effect was Horner´s syndrome. CONCLUSIONS: Continuous interscalene block with 0.04% levobupivacaine provides adequate analgesia for arthroscopic shoulder surgery but does not prevent hemidiaphragmatic paralysis at 24 hours under the conditions of this study.

El bloqueo interescalénico representa el estándar analgésico para cirugía de hombro. No obstante, la incidencia de parálisis hemidiafragmática puede alcanzar 100% de los casos. Nuestra hipótesis es que infusiones con anestésicos locales más diluidos disminuirían la PHD 24 horas postbloqueo. MÉTODOS: Serie prospectiva de pacientes sometidos a cirugía artroscópica electiva de hombro con bloqueo interescalénico continuo. Un bolo de 15 mL de lidocaína 1%-levobupivacaína 0,5% más infusión postoperatoria de levobupivacaína al 0,04% a 8 ml/h más bolos a demanda de 5 mL con intervalo de 20 minutos hasta el alta. La excursión hemidiafragmática se evaluó con ultrasonido con transductor curvo 2-5 MHz en modo M en la región infracostal antes del bloqueo, en la unidad postanestésica y a las 24 h, antes del alta. El outcome primario fue la presencia de parálisis hemidiafragmática 24 horas postbloqueo. Los resultados secundarios incluyeron dolor postoperatorio, total de bolos de rescate, requerimiento de opioides postoperatorios y efectos secundarios. RESULTADOS: Treinta pacientes fueron reclutados y analizados. La incidencia de PHD a las 24 h fue 96,7%. La mediana [RIC] de dolor en reposo (pacientes con inmovilizador de hombro) medido en escala numérica de 0 a 10, a las 0,5; 1; 3; 6; 12; 24; 48; 72 horas fueron 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2] respectivamente. La mediana [RIC] de consumo de bolos de rescate fue 1,5 [0-7]. No hubo pacientes con requerimientos de morfina postoperatoria. El efecto colateral más frecuente fue el síndrome de Horner. CONCLUSIONES: El bloqueo interescalénico continuo con levobupivacaína 0,04% proporciona analgesia postoperatoria adecuada, pero no evita la PHD a las 24 h en las condiciones de esta serie.

Ultrasound Guided Interscalene Block & Shoulder Block for Postoperative Analgesia for Shoulder Surgeries

Shoulder arthroscopic surgeries can produce intense postoperative pain. Interscalene block provides good analgesia after shoulder surgery, but concerns over its associated risks have prompted the search for alternatives. Suprascapular block along with axillary nerve block was recently proposed as an alternative to interscalene block, but evidence of its comparative efficacy is conflicting. The aim of our study was to compare suprascapular and axillary nerve blocks with interscalene block in shoulder surgery for postoperative analgesia. Methods: A total of 76 patients scheduled for shoulder arthroscopic surgery were equally divided into two groups of 38patients each: Interscalene (ISB) group and suprascapular with axillary nerve (SHB) group. Both the nerve block was achieved by both ultrasound and nerve stimulator guidance. Visual analogue scale score was evaluated at 1, 4, 6, 12, and 24 h postoperatively. The time to first analgesia request, total analgesic requirement for 24 hr postoperatively, patient satisfaction, and any complications were recorded. Results: SHB provided equivalent analgesia to ISB in terms of post operative VAS scores.Time to 1st analgesia request was 7.2±1.3 hr in ISB group and 5.9±1.2 hr in SHB group which was not statistically significant.Patient satisfaction scores were significantly higher in SHB group compared to ISB group. Complication like subjective dyspnea and weakness of arm was significantly higher in ISB group compared to SHB group. Conclusions: SHB was as effective as ISB for postoperative pain relief but with fewer complications due to selective blockade of suprascapular and axillary nerve.

Comparative Evaluation of Efficacy of Interscalene Block vs. Interscalene Block and Superficial Cervical Plexus Block for Fixation of Clavicular Fractures

Introduction: Regional anaesthesia is seldom used forclavicle fractures considering the anatomical location of thebone. We aim to compare the efficacy of two techniques ofregional anaesthesia as sole anaesthesia technique for fixationsof clavicular fractures.Material and methods: 60 Adult patients with claviclefractures were divided randomly in two groups (1 and 2) andwere administered interscalene block (ISB) only or interscaleneblock and superficial cervical plexus block(ISB+SCPB) assole anaesthetic, respectively. Patients were monitored forefficacy of block and adequacy of anaesthesia and analgesiaat the surgical site. Side effects and hemodynamic parameterswere also monitored.Results:. ISB+SCPB provides excellent anaesthesia forclavicle fixation. Only 1 patient in group 2 required GeneralAnaesthesia(GA) whereas in Group 1, 8 patients required someform of supplemental anaesthesia. There was no statisticallysignificant difference in side-effects and hemodynamic profilein both the groups.Conclusion: ISB+SCPB is significantly better than ISB onlyfor anaesthesia for fixation of clavicular surgeries.

Interscalene Brachial Plexus Block With and Without Dexamethasone: A comparative Study

Interscalene block is commonly used for anesthesia and analgesia in patients undergoing surgeries of shoulder and upper arm. Combination of lignocaine and bupivacaine is commonly used for this purpose. Addition of dexamethasone to local anesthetic drugs is reported to cause rapid onset and enhance the duration of anesthesia and analgesia. We conducted this study to compare the analgesic effect in interscalene block with local anesthetic versus local anesthetic and steroid. Methods: This was a prospective comparative study conducted in the department of anesthesiology of a tertiary care medical college situated in an urban area. In this study total 120 patients undergoing upper limb surgery under interscalene block were included on the basis of a predefined inclusion and exclusion criteria. Out of these 120 patients 60 patients received lignocaine, adrenaline, bupivacaine and dexamethasone (Group A) whereas remaining 60 patients were given lignocaine, adrenalin, bupivacaine and distilled water (Group B). The comparison of onset of analgesia, onset and duration of motor blockade as well as onset and duration of sensory blockade was compared in both the groups. For statistical analysis SSPE 21.0 software was used and P value less than 0.05 was taken as statistically significant. Results: Majority of the studied cases belonged to the age group of 21-30 years (24.17%) followed by 31-40 years (23.33%). The mean age of patients in both the group was found to be comparable with no statistically significant difference between mean age of both the groups (P>0.05). The mean time for onset of analgesia in Group A and Group B was found to be 7.43 +/- 1.65 and 6.01+/- 1.55. The difference was found to be statistically significant (P<0.0001). The duration of sensory and motor blockade was found to be 14.6+/-12.5 and 11.93+/- 1.48 in group A. where as in group B it was found to be 11.8+/-0.8614 and 8.85 +/- 1.15 respectively. Onset of sensory blockade was found to be 7.01 +/-2.12 and 9.09 +/- 3.08 in group A and group B respectively. The difference was found to be statistically significant for duration of sensory and motor blockade. Onset of motor blockade was found to be comparable in both the groups with no statistically significant difference (P>0.05). Conclusion: Addition of dexamethasone to local anesthetic agent for interscalene block is associated with rapid onset of analgesia and a prolonged duration of motor and sensory blockade.

Comparison of Two Different Technique of Interscalene Block in Orthopedic Patients Undergoing Shoulder Surgery

The traditional Interscalene brachial plexus block has a 100% incidence of diaphragmatic paralysis, resulting in a 25-30% reduction in forced vital capacity (FVC). A modified or low Interscalene block is defined as a brachial plexus nerve block below C6 but above the supraclavicular fossa. The purpose of our study was to determine if a modified Interscalene block would prevent diaphragmatic paralysis while providing an adequate pain control for patients undergoing shoulder surgery. Methods: 50 patients who were scheduled to undergo shoulder surgery were incorporated in the study. Patients were randomized to receive either a low (LI) or a traditional (TI) interscalene nerve block. Both groups received 15ml of 0.5% Bupivacaine diluted to 30ml for brachial plexus block. Post-block lung function was assessed using incentive spirometry. Results: The average decrease in lung volume in the group receiving the low-modified interscalene block was 900ml, while the decrease in the traditional group was 860ml. The decrease in lung volumes between the two groups was determined to be not significant (p= 0.525). Conclusion: Low interscalene brachial plexus blockade is often described as a technique used to prevent phrenic nerve blockade and hemi-diaphragmatic paralysis. Our study found that phrenic nerve blockade was low in LI group as compared to TI group. Postoperative pain scores, respiratory complications, need for supplemental oxygen, and delay in discharge did not occur in either group. We found that LI interscalene brachial plexus blockade not better than TI interscalene block.

El bloqueo interescalénico en la era de la anestesia regional guiada por ecografía / Interscalene block in the era of ultrasound guided regional anesthesia

INTRODUCTION: The introduction of ultrasound to regional anesthesia has redefined our understanding on this field; moreover, through ultrasound, regional anesthesia techniques have developed rapidly in response to more specific and complex needs. In this context, some changes and new concepts have raised around interscalene block. OBJECTIVE: To revise recent advances as regards our knowledge of interscalene block since the ultrasound was introduced to regional anesthesia; as well as to evaluate different strategies to avoid hemidiaphragmatic paralysis. MATERIAL AND METHODS: A search was carried out in medical data bases (PubMed and Cochrane) and anesthesiology journals (Regional Anesthesia and Pain Medicine, Anesthesiology Journal, British Journal of Anesthesiology, among others). Search terms were as follows: interscalene block, hemidiaphragmatic paralysis, shoulders surgery, ultrasound guided interscalene block. DISCUSSION: New concepts around interscalene block are quoted (traffic lighter sign-long thoracic and dorsal scapular nerve), as well as a short review about the respiratory compromise that follows this regional anesthesia technique and some strategies to avoid it. CONCLUSIONS: The introduction of ultrasound to regional anesthesia has redefined our understanding towards this field. It is mandatory for the regional anesthesiologist to comprehend these new concepts in order to provide a safe and effective regional anesthesia.

INTRODUCCIÓN: La introducción del ultrasonido a la anestesia regional ha redefinido nuestro entendimiento hacia estas prácticas, las cuales han crecido en complejidad y cantidad en respuesta a necesidades cada vez más técnicas y específicas. En este contexto es que han surgido múltiples variaciones y nuevos conceptos en torno al abordaje clásico a nivel interescalénico del plexo braquial. OBJETIVO: Revisar los recientes avances en el entendimiento del bloqueo interescalénico desde la llegada del ecógrafo así como evaluar las diferentes estrategias para evitar la parálisis hemidiafragmática asociado a este abordaje. MATERIAL Y MÉTODOS: Se ha realizado una búsqueda bibliográfica vinculada a bloqueo interescalénico en bases de datos médicas (Cochrane, PubMed) y revistas especializadas (Regional Anesthesia and Pain Medicine, Anesthesiology Journal, British Journal of Anesthesiology, entre otras). Las palabras claves que se han utilizado son: bloqueo interescalénico, parálisis hemidiafragmática, cirugía de hombro, bloqueo interescalénico ecoguiado. DISCUSIÓN: Se describen nuevos conceptos en torno al abordaje interescalénico del plexo braquial (signo del semáforo-identificación sistemática de los nervios dorsal de la escápula y torácico largo) como así también una pequeña reseña del compromiso respiratorio que caracteriza la realización de este bloqueo y estrategias para evitarlo. CONCLUSIÓN: La llegada del ultrasonido a la anestesia regional ha redefinido nuestro entendimiento hacia este campo de la anestesia. Resulta necesario conocer estos nuevos conceptos en torno al bloqueo interescalénico para hacer de esta técnica una práctica segura y efectiva para nuestros pacientes.

Ultrasound guided interscalene brachial plexus block via lower approach for upper limb surgeries

Background: Brachial plexus block via interscalene approach is an excellent option for upper limb surgeries, but due to sparing of ulnar nerve (lower trunk, C8-T1) and its’ complications, it is not so popular. To overcome this problem, interscalene block via lower approach has been tried which has more advantage in view of ulnar nerve blockage and also less complications. In addition, ultrasound provides reliability, ease, rapidity and also patient comfort during block procedure. This prospective study was performed to evaluate the anaesthetic effect of lower approach interscalene block with the help of ultrasound and peripheral nerve stimulator.Methods: Ultrasound guided interscalene brachial plexus block via lower approach was given in randomly selected 30 patients, undergoing upper limb orthopaedic surgeries. After localisation of brachial plexus with ultrasound, the nerve roots were confirmed with the help of peripheral nerve stimulator, before injecting drug. At 5 and 15 min after block, all patients were assessed for the effect. Postoperatively they were assessed for any complication and also for their satisfaction level by Likert’s scale.Results: In territories of ulnar, radial and musculocutaneous nerve there was 100% effect while in median nerve territory 92.8% motor block was there. There was no need of analgesics during intra operative period in any patient and there were no major complications with this approach.Conclusions: Ultrasound guided interscalene block via lower approach is an excellent alternative for upper limb surgeries over classical approach in view of ulnar nerve blockage without any major complication.

Determination of ECs0 of ropivacaine for postoperative analgesia under general anesthesia combined with single interscalene brachial plexus block / 临床麻醉学杂志

Objective To determine the 50％ minimum effective concentration (EC50) of ropivacaine for postoperative analgesia after shoulder arthroscopy under general anesthesia combined with interscalene brachial plexus block.Methods Patients undergoing selective shoulder arthroscopy were included in this study.There were 9 males and 13 females,BMI 18-28 kg/m2,falling into ASA physical status Ⅰ or Ⅱ.The interscalene brachial plexus block was achieved under the guidance of ultrasound and nerve stimulator at the level of C6.The upper trunk of interscalene brachial plexus was blocked with 5 ml ropivacaine.The concentration of ropivacaine intially was 0.5 ％ and then depended on the response of the previous patient's postoperative NRS scale.The target ropivacaine concentration was determined by up and down sequential method.The ratio of two consecutive ropiva caine was 1.2.Two termination conditions were,firstly,to achieve seven negative-positive up-anddown deflections required to calculate EC50,and secondly,to deriminate if 7 were positive outcomes using 5 ml of 0.1 ％ ropivacaine or 7 were negative outcomes using 5 ml of 1 ％ ropivaciane.EC50 and 95％CI of ropivacaine was calculated using the formula of Dixon-Massey sequential method.The incidence of hemidiaphragmatic paresis was evaluated.Pre-and post-operative pulmonary function was compared using paired t test.Results The EC50 of ropivacaine was 0.21％ (95 ％CI 0.18％-0.25 ％).The incidence of hemidiaphragmatic paresis was 9 cases(40.90％).Postoperative FVC and FEV1/FVC was significantly decreased than preoperative,but FEV1 (P =0.116) was not.Conclusion For patients undergoing shoulder arthroscopy under general anesthesia and interscalene brachial plexus block,the minimum effective concentration of ropivacaine for analgesia of EC50 is 0.21％,95％ CI 0.18％-0.25％.

Artroplastía total de hombro bajo monitoreo de la perfusión cerebral. Reporte del primer caso en México / Total shoulder arthroplasty under monitoring of cerebral perfusion. Report of the first case in Mexico

Resumen: Introducción: Desde hace algún tiempo es tema de controversia el mantenimiento de la perfusión cerebral durante la cirugía de hombro realizada en posición de silla de playa. El objetivo de este reporte es presentar el primer caso en México de una artroplastía total de hombro realizada con bloqueo interescalénico y monitoreo de la saturación cerebral de oxígeno. Este monitoreo se describió en 1977, pero sólo hasta la última década ha alcanzado relevancia desde el punto de vista clínico. Caso clínico: Paciente de 84 años programado para artroplastía total de hombro en posición de silla de playa bajo anestesia regional tipo bloqueo interescalénico guiado por ultrasonido, en la cual se monitoreó la saturación regional de oxígeno (CrSO2). Discusión: El monitoreo de la oximetría cerebral es una herramienta adecuada que nos permite tener una valoración continua durante todo el transanestésico, con lo que podemos tomar decisiones de forma más expedita. Con base en esto consideramos que este tipo de monitoreo debe ser básico en pacientes colocados en posición de silla de playa, así como el uso preponderante de anestesia regional; en los casos donde ésta no se pueda utilizar, este monitor es primordial.

Abstract: Introduction: The maintenance of cerebral perfusion during shoulder surgery performed in the beach chair position is controversial. The aim of this report is to present the first case in Mexico of a total shoulder arthroplasty performed with interscalene block and monitoring of the cerebral oxygen saturation. This monitoring was described in 1977, but only until the last decade has it reached relevance from the clinical point of view. Clinical case: We present an 84-year-old patient scheduled for total shoulder arthroplasty in beach chair position under regional anesthesia (ultrasound-guided interscalene block) in which the regional oxygen saturation (CrSO2) was monitored. Discussion: Monitoring of cerebral oximetry is a suitable tool that allows us to have a continuous assessment throughout the transanesthetic, so we can make decisions more expeditiously. On this basis, we believe that this type of monitoring should be fundamental in patients placed in a beach chair position, as well as predominantly use regional anesthesia. In cases where it cannot be used, this monitor is absolutely essential.

Application of ultrasound-guided selective cervical nerve root block for patients undergoing arthroscopic surgery in perioperative period / 临床麻醉学杂志

Objective To compare effectiveness,performance,and complications between ultrasound-guided selective cervical nerve root block and interscalene brachial plexus block for patients undergoing arthroscopic surgery in perioperative period.Methods Seventy patients scheduled for arthroscopic surgery,25 males and 45 females,aged 18-75 years,were randomly divided into two groups.They were given either selective cervical nerve root block (group S,n =35) or interscalene brachial plexus block (group ISB,n=35).In group S,C5 and C6 nerve roots were given 0.5％ ropivacaine 5 ml respectively;In group ISB,patients were given 0.5％ ropivacaine 10 ml under ultrasound guidance.The primary outcome:VAS score and forearm modified Bromage scale (MBS) score were recorded at 4,12 and 24 hours after surgery;Secondary outcomes:cumulative tramadol consumption,the patients' satisfaction rate and adverse effects were recorded.Results The VAS scores in group S was significantly lower than that in group ISB at 12 hours after surgery (1.7±0.8 vs 3.6±0.7,P＜0.05).The forearm MBS scores in group S was significantly higher than that in group ISB 4 hours after surgery (P＜0.01).Compared with group ISB,the amount of tramadol consumption was lower at 24 hours after surgery [(37.5±35.9) mg vs (112.5±43.5) mg,P＜0.05)].The satisfaction rate of group S was higher than group ISB (88％ vs 56％,P＜0.05).There was no significant difference in side effects between the two groups.Conclusion In arthroscopic surgery,the selective cervical nerve root block is superior to the brachial plexus block.

Aphonia after shoulder surgery: case report / Afonia após cirurgia do ombro: relato de caso

ABSTRACT In this case report we highlight the uniqueness of aphonia as, to the best of our knowledge, cases of aphonia related to interscalene brachial plexus block (IBPB) are not described in the literature. Although hoarseness is a common complication of IBPB, aphonia is not. Therefore, we think it is important to publicize the first case of aphonia after IBPB, which may have arisen only because of a recurrent laryngeal nerve chronic injury contralateral to the IBPB site.

RESUMO Relativamente a este relato de caso destacamos a sua singularidade, uma vez que não se encontram descritos na literatura, tanto ou quanto os autores puderam investigar, casos de afonia após uma anestesia combinada com bloqueio do plexo braquial via interescalénica (BPBI). Embora a rouquidão seja uma complicação frequente do BPBI, a afonia não o é. Desse modo, pensamos ser importante dar a conhecer o primeiro caso de afonia após o BPBI, que na opinião dos autores surgiu apenas por causa de uma lesão crônica do nervo laríngeo recorrente contralateral ao local do BPBI.

A Comparative Evaluation of Techniques in Interscalene Brachial Plexus Block: Conventional blind, Nerve Stimulator Guided and Ultrasound Guided.

Background: This study was conducted to compare the three technique Conventional blind, Nerve stimulator guided and Ultrasound guided for Interscalene brachial plexus block in surgeries of upper limb. Methods: Total 60 patients were included in our study which were randomly allotted by closed envelope technique into either of the three groups namely Conventional blind (group CB), US-guided (group US) or NS-guided (group NS). The drug bupivacaine 0.5% (2 mg/kg) was used and diluted with normal saline to make a total volume of 30 ml. Results: Comparison between the Conventional blind (CB), Nerve Stimulator (NS) and Ultrasound guided (US) technique of interscalene brachial plexus block revealed that the block execution time, time of onset of sensory and motor block was significantly less in ultrasound group as compare to other groups. The mean duration of analgesia too, was significantly higher in both NS and US group (3 hr & 23 min ,3 hrs 30 min respectively), while it was 2 hr 47 min in CB group. The incidence of patchy effect (3 cases) and blockade failure requiring general anesthesia (4 cases) were significantly higher in CB group compared to NS group (2 cases each) and US group (1 case each). Conclusion: The success rate and effective quality of the block were more satisfactory with ultrasound technique than the nerve stimulator or conventional blind technique.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

BACKGROUND: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. METHODS: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. RESULTS: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. CONCLUSIONS: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Ultrasound Guided Low Approach Interscalene Brachial Plexus Block for Upper Limb Surgery

BACKGROUND: The interscalene brachial plexus block is widely used for pain control and anesthetic purposes during shoulder arthroscopic surgeries and surgeries of the upper extremities. However, it is known that interscalene brachial plexus block is not appropriate for upper limb surgeries because it does not affect the lower trunk (C8-T1, ulnar nerve) of the brachial plexus. METHODS: A low approach, ultrasound-guided interscalene brachial plexus block (LISB) was performed on twenty-eight patients undergoing surgery of the upper extremities. The patients were assessed five minutes and fifteen minutes after the block for the degree of block in each nerve and muscle as well as for any complications. RESULTS: At five minutes and fifteen minutes after the performance of the block, the degree of the block in the ulnar nerve was found to be 2.8 +/- 2.6 and 1.1 +/- 1.8, respectively, based on a ten-point scale. Motor block occurred in the median nerve after fifteen minutes in 26 of the 28 patients (92.8%), and in all of the other three nerves in all 28 patients. None of the patients received additional analgesics, and none experienced complications. CONCLUSIONS: The present study confirmed the achievement of an appropriate sensory and motor block in the upper extremities, including the ulnar nerve, fifteen minutes after LISB, with no complications.

Comparison between ultrasound-guided cervical transverse process block and interscalene brachial plexus block in patients undergoing proximal humeral surgeries / 临床麻醉学杂志

Objective To compare effectiveness,performance,onset time and complications between ultrasound-guided cervical transverse process block and interscalene brachial plexus block in patients undergoing proximal humeral surgeries.Methods Sixty patients,27 males and 33 females, aged 18-70 years,scheduled for proximal humeral surgeries were randomly divided into two groups. They were given either cervical transverse process block (group T,n =30)or ultrasound-guided in-terscalene brachial plexus block (group I,n =30).All patients received a total of 8 ml of 0.5% ropiv-acaine.The performance, anesthetic onset time, the side effects and block success rate were evaluated.Results Block procedure was quicker in group T than in group I [(8.73 ±3.1 7)min vs. (14.40±8.21)min,P <0.01].The severity of diaphragmatic paralysis in group T was significantly lower than in group I (P <0.01).The ultrasound-guided cervical transverse process block was more effective than the interscalene brachial plexus block in patients undergoing proximal humeral surgeries (100% vs.80%,P <0.05).Conclusion The ultrasound-guided cervical transverse process block has a higher success rate and fewer incidence of diaphragmatic paralysis than the interscalene brachial plexus block in patients undergoing proximal humeral surgeries.

Postoperative Analgesia for Shoulder Surgery：a Review of Current Techniques / 中国微创外科杂志

[Summary] Following shoulder surgery , proper regional anesthesia is usually required to minimize the use of opioids .Regional anesthesia techniques commonly used include subacromial or intra-articular local anesthetic infiltration , suprascapular nerve block with or without axillary nerve block , and interscalene block .This paper summarized literatures on the three abovementioned techniques in respect with performance , merits and flaws , and future perspectives .

Effect of ultrasound-guided interscalene brachial plexus block and nervre stimulator on operation around shoulder joints / 实用医学杂志

Objective To evaluate the effect of ultrasound-guided interscalene brachial plexus block and nerve stimulator on operation around shoulder joints. Methods Sixty cases of patients scheduled for operation around shouler joints were randomly divided into group A and B , with 30 cases in each group. Patients in group A underwent interscalend brachial plexus block guided by nerve stimulator with 0.5% ropivacaine and those in group B interscalend brachial plexus block guided by ultrasound and nerve stimulator with 0.5% ropivacaine 30 mL. The number of puncture, the effect of anesthesia and complication of anesthesia in both groups were recorded. Results The number of puncture of group B was less than that of group A (P﹤0.05) while the effect of anesthesia and the duration of anesthesia of group B were similar to those of group A (P﹥0.05). There was no serious complications in two groups. Conclusion With definite anesthesia effect and less pain , ultrasound-guided interscalene brachial plexus block and nerve stimulator is simple and safe for operation around shouler joints.