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.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

A clinical comparison of continuous interscalene brachial plexus block with different basal infusion rates of 0.2% ropivacaine for shoulder surgery / 대한마취과학회지

BACKGROUND: A continuous interscalene brachial plexus block is a highly effective postoperative analgesic modality after shoulder surgery. However, there is no consensus regarding the optimal basal infusion rate of ropivacaine for a continuous interscalene brachial plexus block. A prospective, double blind study was performed to compare two different basal rates of 0.2% ropivacaine for a continuous interscalene brachial plexus block after shoulder surgery. METHODS: Sixty-two patients receiving shoulder surgery under an interscalene brachial plexus block were included. The continuous interscalene brachial plexus block was performed using a modified lateral technique with 30 ml of 0.5% ropivacaine. Surgery was carried out under an interscalene brachial plexus block or general anesthesia. After surgery, the patients were divided randomly into two groups containing 32 each. During the first 48 h after surgery, groups R8 and R6 received a continuous infusion of 0.2% ropivacaine at 8 ml/h and 6 ml/h, respectively. The pain scores at rest and on movement, supplemental analgesia, motor block, adverse events and patient's satisfaction were recorded. RESULTS: The pain scores, supplemental analgesia, motor block, adverse events and patient's satisfaction were similar in the two groups. CONCLUSIONS: When providing continuous interscalene brachial plexus block after shoulder surgery, 0.2% ropivacaine at a basal rate of 8 ml/h or 6 ml/h produces similar clinical efficacy. Therefore, decreasing the basal rate of CISB is more appropriate considering the toxicity of local anesthetics.

Comparison of Analgesic Efficacy between Single Interscalene Block Combined with a Continuous Intra-bursal Infusion of Ropivacaine and Continuous Interscalene Block after Arthroscopic Rotator Cuff Repair

BACKGROUND: This study evaluated the effectiveness of a continuous interscalene block (CISB) by comparing it with that of a single interscalene block combined with a continuous intra-bursal infusion of ropivacaine (ISB-IB) after arthroscopic rotator cuff repair. METHODS: Patients who had undergone CISB (CISB group; n = 25) were compared with those who had undergone ISB-IB (ISB-IB group; n = 25) for more than 48 hours after surgery. The visual analog scale (VAS) for pain, motor and/or sensory deficit, supplementary analgesics and adverse effects were recorded. RESULTS: There were no significant differences between the postoperative VAS of the CISB and ISB-IB groups, except at 1 hour after surgery. Their supplementary analgesics of the two groups were similar. Transient motor weakness (52%) and sensory disturbance (40%) of the affected arm were observed in patients in the CISB group. The catheters came out accidentally in 22% of the CISB group but in only 4% of the ISB-IB group. CONCLUSIONS: ISB-IB provides similar analgesia to CISB. However, the ISB-IB group had a lower incidence of neurological deficits and better catheter retention.

El bloqueo interescalénico provee mejor calidad e índice de satisfacción que la analgesia intra-articular en el manejo del dolor postoperatorio en las cirugías de hombro / Interscalenic block provides for higher quality and improved satisfaction indexes than intraarticular analgesia in managing post surgery shoulder pain

Introducción: La analgesia intra-articular (AI) y el Bloqueo Interescalénico Continuo (BIEC) se utilizan para el manejo del dolor postoperatorio de las cirugías de hombro. La utilidad e índice de satisfacción obtenidos por su empleo son controversiales. Objetivo: Evaluar la utilidad de la AI versus el BIEC, comparando la calidad de la analgesia postoperatoria e índice de satisfacción e incidencia de complicaciones asociadas en pacientes beneficiarios de una cirugía del hombro asistido por artroscopia. Material y Método: Estudio prospectivo controlado de 47 pacientes ASA I-II, divididos en dos grupos. Grupop 1 AI: (n=23)Ropivacaína 0,20 por ciento 25 ml + Morfina 2mg.; Grupo 2: BIEC (n=24) Bupivacaína 0,0625 por ciento + Sufentanyl 1 up/ml con un débito de 7 ml/hr en IC. El dolor posquirúrgico se registro entre las 2 y 48 horas mediante Escala Visual Análoga (EVA). Se utilizó morfina endovenosa postoperatoria. Se registro el consumo de morfina, la incidencia de efectos adversos, el grado de satisfacción experimentados por los pacientes a las 48 hrs. Resultados: No hubo diferencias estadísticamente significativas en los parámetros demográficos de ambos grupos . El EVA postoperatorio y el consumo de Morfina (CM) entre las 4 y 12 horas fueron similares entre los dos grupos. El EVA entre las 24 y 48 hrs. fue significativamente menor en el grupo BIEC (25 +/- 4 mm) versus el grupo AI (47 +/-6 mm), (p=0,001). el CM entre las 24 y 48 hrs.fue de 13,5 +/- 3 mg en el grupo AI versus 6 +/- 3 mg en el grupo 2 (p=0,001). El grado de satisfacción experimentado por los pacientes fue superior en el grupo BIEC (p=0,03). HUbo mayor incidencia de náuseas y/o vómitos en el grupo AI. Conclusiones: El manejo del dolor postoperatorio mediante las técnicas de AI y BIEC es adecuado en cirugías de hombro. El BIEC se demuestra más efectivo que la AI después de las 12 hrs. postoperatorias, presentando los pacientes menor dolor y NVPO y un mayor índice de satisfacción.

Introduction: Intraarticular analgesia (IA) and Continuous Interscalenic Block (CIB) methods are used as analgesia in post shoulder surgery. The results obtained and the satisfaction index are rather controversial. Objective: To evaluate the usefulness of IA vs. CIB by comparing the post surgery analgesia and degree of satisfaction to the complications associated to arthroscopic shoulder surgery (ASS). Materials and Method: Controlled clinical trial with 47 ASS I and II patients separated in two groups. Group one, IA method: (n=23): 25ml of 0.2 percent ropivacaine plus 2 mgs of morphine; Group two, CIB method: (n=24) 0.0625 percent bupivacaine and 1 up/ml continuous sufentatil supply at 7ml/hr. Post surgery pain was recorded after 2 to 48 hours by means of a Visual Analogue Scale (VAS) and intravenous morphine was used for pain management. The use of morphine was recorded as well as adverse effects and the degree of satisfactions of patients after 48 hours. Results: There were no significant differences in demographic data between these two groups. Post surgery VAS and morphine use after 4 and 12 hours were similar between the two groups. VAS recorded after 24 and 48 hours was significantly lower in Group CIB (25+- 4mm) compared to Group IA (47+- 6mm), (p=0.001). The use of morphine from 24 to 48 hours was 13.5 +- 3mg in Group IA while use in Group CIB was 6 +- 3mg (p=0.01).The degree of satisfaction of patients was higher in Group CIB (p=0.03). Patients in Group IA experienced nausea and/or vomiting. Conclusions: The IA and CIB methods for pain management are adequate in post shoulder surgery. CIB proves to be more effective than IA after 12 hours with patients feeling less pain, a lower nvpo and a higher degree of satisfaction.