Ultrasound-Guided Interscalene Brachial Plexus Nerve Block With an Ultralow Volume of Local Anesthetic for Post-Thoracotomy Shoulder Girdle Pain

Assessing the Clinical Impact of Emergency Physician-performed Ultrasound-guided Peripheral Nerve Blocks in a Level 1 Trauma Center: A Retrospective Analysis

Introduction

Effective pain management is crucial in the emergency department (ED), particularly for trauma patients. Ultrasound-guided regional analgesia (UGRA) has emerged as a promising technique for acute pain relief. The objective of this study is to describe the various UGRA performed and assess their effectiveness among trauma patients in our Level 1 Trauma Center ED over the past 2.5 years.

Methods

Data from 485 trauma patients who underwent UGRA over 2.5 years were analyzed retrospectively. The primary outcome was the median Defense and Veterans Pain Rating Scale (DVPRS) reduction at 30 min and 1 h after nerve block administration. Patient characteristics, types of nerve blocks administered, procedural details, and outcomes were also noted. Statistical analysis was performed to determine the median reduction in pain scores and evaluate the success of UGRA.

Results

UGRA demonstrated a significant reduction in pain scores, with a median DVPRS decrease from 9 (interquartile range [IQR]: 9-10) preprocedure to 4 (IQR: 2-5) at 30 min and 1 (IQR: 0-2) at 1 h postprocedure. Sixteen types of nerve blocks were administered in our ED, with the serratus anterior block (n = 91) and fascia iliaca compartment block (n = 58) being the most common. Pain relief was the most common indication for block administration. A higher volume was injected for plane blocks compared to nerve-specific blocks. No complications or failed blocks were reported.

Conclusion

This study describes 16 different UGRA that can be performed by emergency physicians (EPs) in ED for trauma patients. UGRA is effective in providing substantial pain relief for trauma patients in the ED. UGRA performed by EPs offers a safe and feasible approach for managing acute pain in the ED.

Efficacy of Ultrasound-Guided Interscalene Brachial Plexus Block for Acute Post-Hepatectomy Shoulder Pain: A Randomized Controlled Trial

Objective

To investigate the efficacy of ultrasound-guided interscalene brachial plexus block in the treatment of shoulder pain following hepatectomy.

Design

A randomized controlled trial.

Methods

We conducted a single-center, randomized controlled trial. Forty-four patients with shoulder pain scores of at least 5 were randomly assigned to two groups: the treatment group, which received 0.5% ropivacaine (5mL) combined with dexamethasone (5 mg) (n=22), and the control group, which received normal saline (5mL) (n=22). The intervention was performed in the postanesthesia care unit after shoulder pain was identified by using the visual analogue scale. The shoulder pain was re-evaluated 15 minutes after intervention. The incidence of effective pain relief, defined as at least 75% reduction in pain intensity, was the primary outcome. Secondary outcomes included shoulder pain intensity within 2 days after surgery, the timing of the first rescue analgesia, total additional analgesic use, arterial oxygen saturation, intervention-related adverse reactions, and patient satisfaction regarding shoulder pain.

Results

The incidence of effective pain relief was significantly higher in the treatment group compared to the control group (15 (68.2%) vs 2 (9.1%), P<0.001). The interscalene brachial plexus block not only prolonged the time to first analgesic request (P <0.001), but also reduced the number of analgesic requests (P <0.001). In the comparison between groups, arterial oxygen saturation was lower in the control group than that in the treatment group, attributed to the use of sufentanil for remedial analgesia (92.4% vs 94.5%, P=0.014).

Conclusion

Interscalene brachial plexus block can effectively relieve post-hepatectomy shoulder pain without clinically significant hypoxemia.

Effect of remifentanil on post-operative analgesic consumption in patients undergoing shoulder arthroplasty after interscalene brachial plexus block: a randomized controlled trial

PURPOSE

Remifentanil is useful in balanced anesthesia; however, there is concern regarding opioid-induced hyperalgesia. The effect of remifentanil on rebound pain, characterized by hyperalgesia after peripheral nerve block has rarely been studied. This study evaluated whether intraoperative remifentanil infusion may increase postoperative analgesic requirement in patients receiving preoperative interscalene brachial plexus block (IBP).

METHODS

Sixty-eight patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly allocated to remifentanil (R) or control (C) group. Preoperative IBP with 0.5% ropivacaine 15 mL was performed in all patients. Intraoperative remifentanil was administered only in the R group. Postoperative pain was controlled using intravenous patient-controlled analgesia (IV-PCA) and rescue analgesics. The primary outcome was the dosage of fentanyl-nefopam IV-PCA infused over 24 h postoperatively. The secondary outcomes included the numeric rating scale (NRS) score recorded at 4-h intervals over 24 h, amount of rescue analgesics and total postoperative analgesics used over 24 h, occurrence of intraoperative hypotension, postoperative nausea and vomiting (PONV) and delirium.

RESULTS

The dosage of fentanyl-nefopam IV-PCA was significantly less in C group than R group for postoperative 24 h. Fentanyl 101 [63-158] (median [interquartile range]) µg was used in the C group, while fentanyl 161 [103-285] µg was used in the R group (median difference 64 µg, 95% CI 10-121 µg, P = 0.02). Nefopam 8.1 [5.0-12.6] mg was used in the C group, while nefopam 12.9 [8.2-22.8] mg was used in the R group (median difference 5.1 mg, 95% CI 0.8-9.7 mg, P = 0.02). The total analgesic consumption: the sum of PCA consumption and administered rescue analgesic dose, converted to morphine milligram equivalents, was higher in the R group than C group (median difference 10.9 mg, 95% CI 3.0-19.0 mg, P = 0.01). The average NRS score, the incidence of PONV and delirium, were similar in both groups. The incidence of intraoperative hypotension was higher in R group than C group (47.1% vs. 20.6%, P = 0.005).

CONCLUSIONS

Remifentanil administration during arthroscopic shoulder surgery in patients undergoing preoperative IBP increased postoperative analgesic consumption.

Post-thoracotomy analgesia

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.