A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series

Advancing pain management for extremity trauma: the evolution of ultrasound-guided nerve blocks for patients in the supine position in trauma centers

PURPOSE

Trauma, particularly extremity trauma, poses a considerable challenge in healthcare, especially among young adults. Given the severity of patient pain and the risks associated with excessive opioid use, managing acute pain in trauma centers is inherently complex. This study aims to investigate the application and benefits of ultrasound-guided nerve blocks for early pain management in patients with extremity trauma positioned supine.

METHODS

A comprehensive literature review was conducted to assess the effectiveness and advantages of ultrasound-guided peripheral nerve blocks in the acute pain management of extremity trauma patients in the supine position. Special emphasis was placed on evaluating the selection criteria, indications, contraindications, adverse reactions, and potential complications associated with these nerve block techniques.

RESULTS

Ultrasound-guided nerve blocks represent a safer and more precise option for managing pain in extremity trauma patients placed in the supine position. These techniques offer significant advantages in terms of reducing healthcare expenses, diminishing reliance on opioid medications, and mitigating opioid-related complications. Nonetheless, challenges may arise due to the necessity for patient cooperation during specific nerve block procedures.

CONCLUSION

Ultrasound-guided nerve blocks present a promising avenue for early pain management in extremity trauma patients positioned supinely. Their implementation can lead to improved patient outcomes by alleviating pain severity, reducing opioid consumption, and cutting down healthcare costs. Further research and clinical integration of these techniques is imperative to enhance pain management protocols in trauma centers.

Efficacy of Infraclavicular Brachial Plexus Block Alone Versus Combination With Suprascapular Nerve Block in Patients Undergoing Shoulder Surgeries: A Single-Blind, Randomized Trial

Background and aim The regional anesthesia technique is commonly used for upper extremity surgery as an alternative to general anesthesia. The study aimed to compare the efficacy of infraclavicular brachial plexus block (BPB) and a combination of infraclavicular brachial plexus block with suprascapular nerve block for postoperative analgesia in patients undergoing shoulder surgeries. Method A total of 62 patients of both sexes with the American Society of Anaesthesiologists (ASA) physical status I/II/III, aged between 18 and 65 years, and undergoing shoulder surgery, were included in this prospective, single-blinded, randomized controlled trial. Patients were equally allocated into two groups: 31 in group A and 31 in group B. After pre-anesthetic evaluation, the purpose and protocol of the study were explained to patients, and informed consent was obtained. Thirty-one patients in group A were given infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine while 31 patients in group B were given a combination of infraclavicular brachial plexus block using 30 ml 0.375% bupivacaine and suprascapular nerve block using 5 ml 0.375% bupivacaine. Blocks were given using ultrasound guidance and a peripheral nerve stimulator; the suprascapular block was given in the sitting position while the infraclavicular block was provided in the supine position. General anesthesia was administered in the operation theatre in the supine position after the administration of blocks. The pain was assessed using the visual analog scale (VAS) and the satisfaction score was assessed by the numeric rating scale (NRS). The Mann-Whitney U test was applied for comparison of pain between the two groups. The chi-square test was utilized for comparing the categorical variables. Result The postoperative pain was significantly lower (p<0.001) in group B as compared to group A at all the periods of observation, i.e., 0h (2.77±0.72 vs. 5.42±0.77), 6h (3.89±0.70 vs. 5.94±0.73), 12h (5.66±0.93 vs. 6.58±0.88), and 24h (6.16±0.80 vs. 6.74±0.90). These findings illustrate that group B patients who received a combination of infraclavicular brachial plexus block and suprascapular nerve block for shoulder surgeries had better pain relief than group A patients who received only the infraclavicular approach. The mean NRS score of patient satisfaction in group B (7.26±0.58) was significantly higher (p<0.001) in comparison to group A (6.16±0.64). Diaphragmatic palsy was observed in only one case in group A and none in group B. No other complication was observed in any of the patients during the study period. Conclusion The combination of infraclavicular brachial plexus block and suprascapular nerve block displays a positive postoperative analgesic profile with less usage of rescue analgesic doses and better patient satisfaction after shoulder surgery.

Regional Anesthesia Techniques for Shoulder Surgery in High-Risk Pulmonary Patients

Patients with pre-existing pulmonary conditions are at risk for experiencing perioperative complications and increased morbidity. General anesthesia has historically been used for shoulder surgery, though regional anesthesia techniques are increasingly used to provide anesthesia and improved pain control after surgery. Relative to regional anesthesia, patients who undergo general anesthesia may be more prone to risks of barotrauma, postoperative hypoxemia, and pneumonia. High-risk pulmonary patients, in particular, may be exposed to these risks of general anesthesia. Traditional regional anesthesia techniques for shoulder surgery are associated with high rates of phrenic nerve paralysis which significantly impairs pulmonary function. Newer regional anesthesia techniques have been developed, however, that provide effective analgesia and surgical anesthesia while having much lower rates of phrenic nerve paralysis, thereby preserving pulmonary function.

Dyspnea induced by hemidiaphragmatic paralysis after ultrasound-guided supraclavicular brachial plexus block in a morbidly obese patient

RATIONALE

Hemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function.

PATIENT CONCERNS

A 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia.

DIAGNOSES

After ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia.

INTERVENTIONS

It led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation.

OUTCOMES

The unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital.

LESSONS

This case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.