A randomised controlled trial in patients undergoing arthroscopic shoulder surgery comparing interscalene block with either 10 ml or 20 ml levobupivacaine 0.25.

The interscalene brachial plexus block is recommended for analgesia after shoulder surgery but it may cause hemidiaphragmatic dysfunction. We tested whether ipsilateral hemidiaphragmatic contraction was better after a smaller dose of local anaesthetic without impairing analgesic effect. We randomly allocated 48 adults to 10 ml or 20 ml levobupivacaine 0.25% before arthroscopic shoulder surgery. The primary outcome was hemidiaphragmatic paralysis, defined as inspiratory thickness < 1.2 times expiratory thickness, measured by ultrasound 4 h after block. Hemidiaphragmatic paralysis was recorded for 6/24 vs. 23/24 supine participants after 10 ml vs. 20 ml levobupivacaine 0.25%, respectively, and for 4/24 vs. 23/24 sitting participants, respectively, p < 0.001 for both. Pain scores after 10 ml injectate were not worse than after 20 ml injectate. Median (IQR [range]) morphine doses in the first 24 postoperative hours after 10 ml and 20 ml levobupivacaine 0.25% were 2 (0-6 [0-23]) mg vs. 1 (0-2 [0-11]) mg, respectively, p = 0.12. No participant had a complication after 10 ml interscalene levobupivacaine, whereas seven had complications after 20 ml levobupivacaine, p = 0.009. Hemidiaphragmatic function was better after 10 ml vs. 20 ml interscalene levobupivacaine 0.25% without impairing analgesia for 24 postoperative hours.

Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study.

BACKGROUND: Arthroscopic shoulder surgery causes severe postoperative pain. An interscalene brachial plexus block provides adequate analgesia, but unintended spread of the local anesthetic administered may result in a phrenic nerve block, usually associated with a nonnegligible incidence of acute hemidiaphragmatic paralysis. The main purpose of this trial will be to analyze the incidence of hemidiaphragmatic paralysis ensuing after interscalene brachial plexus block in patients undergoing arthroscopic shoulder surgery administered a standard volume (20 ml) vs. a low volume (10 ml) of levobupivacaine 0.25%. METHODS: This will be a prospective double-blind randomized controlled single-center two-arm comparative trial. Forty-eight patients will be included. The primary goal will be to ultrasonographically determine the incidence of hemidiaphragmatic paralysis by calculating the diaphragmatic thickness ratio in each group. The secondary goals will be to compare the two arms in terms of (1) decrease in forced vital capacity and (2) in forced expiratory volume at 1 s by spirometry; (3) decrease in diaphragmatic excursion by ultrasound; (4) 24-h total intravenous morphine consumption; (5) time to first opioid request of a patient-controlled analgesia pump; and (6) postoperative complications. DISCUSSION: This trial will demonstrate that a low-volume interscalene brachial plexus block decreases hemidiaphragmatic paralysis following arthroscopic shoulder surgery according to spirometry and ultrasound measurements and does not provide inferior postoperative analgesia to the standard volume, as measured by opioid requirements. TRIAL REGISTRATION: EudraCT and Spanish Trial Register (REec) registration number: 2019-003855-12 (registered on 7 January 2020). ClinicalTrials.gov identification number: NCT04385966 (retrospectively registered on 8 May 2020). Ethics Committee approval: EC19/093 (18 December 2019).

[The utility of digital infiltration of mepivacaine and ketorolac in postoperative analgesia of the unilateral hallux valgus]. / Utilidad de la infiltración digital con mepivacaína y ketorolaco en la analgesia postoperatoria del hallux valgus unilateral.

OBJECTIVES: To determine whether locally injected ketorolac provides analgesia additional to that of mepivacaine, and also to prevent, diminish or delay the peripheral hypersensitivity response of postoperative pain. PATIENTS AND METHODS: Prospective, randomized, double-blind study of 72 patients scheduled for surgery to correct unilateral hallux valgus. Group 1 (n = 24) received median infiltration at the first metatarsus of 5 ml of 2% mepivacaine and 1 ml (30 mg) of ketorolac. Group 2 (n = 21) received local infiltration of 5 ml of 2% mepivacaine and 1 ml of saline solution. Group 3, the control group (n = 27) received the same solution as did group 2, plus 30 mg of ketorolac intravenously. The postoperative analgesia prescribed was 10 mg of ketorolac orally every 8 hours. Pain was measured on a visual analog scale (VAS) 0, 1, 4, 8 and 24 hours after surgery. Time elapsed until the appearance of pain, number of ketorolac pills consumed and overall patient satisfaction were recorded. RESULTS: There were no differences in anthropometric characteristics. Time until pain appeared was significantly longer in group 1 than in groups 2 and 3 (14.66 +/- 7.19, 5.90 +/- 2.27 and 8.70 +/- 5.02 hours, respectively). The VAS scores were significantly lower in group 1 after the fourth postoperative hour. Analgesic consumption was significantly lower in group 1. CONCLUSIONS: Infiltration of 30 mg of ketorolac along with mepivacaine delays the appearance of postoperative pain and diminishes it in the first 24 hours after surgery to correct hallux valgus, in comparison with infiltration of mepivacaine alone plus intravenous ketorolac.