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Perineural Low-Dose Dexamethasone Prolongs Interscalene Block Analgesia With Bupivacaine Compared With Systemic Dexamethasone: A Randomized Trial. Reg Anesth Pain Med 2019; 43:572-579. [PMID: 29889698 DOI: 10.1097/aap.0000000000000817] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Perineural dexamethasone and intravenous (IV) dexamethasone have been shown to prolong peripheral nerve block duration. The effects of perineural and IV dexamethasone have only been compared at doses of 4 mg or greater. This triple-blind, randomized trial examined the effect of 1 mg IV versus perineural dexamethasone on interscalene block (ISB) analgesia duration. METHODS Patients undergoing ambulatory shoulder arthroscopy received an ultrasound-guided ISB with 15 mL bupivacaine 0.5% and 1 mg preservative-free dexamethasone that was administered perineurally (PeriD) or IV (IVDex). All patients received IV ketorolac and were discharged on naproxen 500 mg 2 times a day plus oxycodone/acetaminophen as needed. Peripheral nerve block duration, pain, opioid consumption, and block satisfaction were assessed via telephone follow-ups. RESULTS There were 63 PeriD patients and 62 IVDex patients who completed the primary outcome follow-up. The median time until analgesia from the ISB completely wore off was 3.5 hours (95% confidence interval, 1.0-6.0 hours) longer in the PeriD versus IVDex groups; P = 0.007). Time until the pain relief from the ISB began to wear off was also longer in the PeriD versus IVDex group (5.5 hours [95% confidence interval, 2.1-9.0 hours]; P = 0.002). Other secondary outcomes, including opioid consumption, satisfaction, and pain scores, were not different between groups. CONCLUSIONS In patients undergoing shoulder arthroscopy, low-dose perineural dexamethasone (1 mg) in combination with 15 mL of 0.5% bupivacaine prolonged the median time until pain relief from the ISB completely wore off compared with 1 mg IV dexamethasone. However, the degree of prolongation was smaller than the a priori-defined minimal clinically meaningful difference of 5 hours. CLINICAL TRIAL REGISTRATION This study was registered at Clinicaltrials.gov, identifier NCT02506660.
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Affiliation(s)
- Neel Desai
- Specialist Registrar in Anaesthetics, Department of Anaesthetics, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP
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Fredrickson M, Leightley P, Wong A, Chaddock M, Abeysekera A. Interscalene catheters for shoulder surgery - a reply. Anaesthesia 2016; 71:1493-1494. [PMID: 27870184 DOI: 10.1111/anae.13750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M Fredrickson
- Auckland Southern Cross Hospital Group, Auckland, New Zealand
| | - P Leightley
- Auckland Southern Cross Hospital Group, Auckland, New Zealand
| | - A Wong
- Auckland Southern Cross Hospital Group, Auckland, New Zealand
| | - M Chaddock
- Auckland Southern Cross Hospital Group, Auckland, New Zealand
| | - A Abeysekera
- Auckland Southern Cross Hospital Group, Auckland, New Zealand
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Shin HJ, Na HS, Oh AY, Hwang JW, Kim BG, Park HP, Jeon YT, Min SW, Ryu JH. A prospective, randomized and controlled study of interscalene brachial plexus block for arthroscopic shoulder surgery: A comparison of C5 and conventional approach, a CONSORT-compliant article. Medicine (Baltimore) 2016; 95:e4921. [PMID: 27631270 PMCID: PMC5402613 DOI: 10.1097/md.0000000000004921] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The shoulder area is mainly innervated with the C5 and C6 nerve roots, and interscalene brachial plexus block (ISB) is widely used for postoperative analgesia after shoulder surgery. However, it is associated with adverse effects, such as numbness and weakness in the blocked arm due to an unwanted block of the lower brachial plexus (C7-T1). We hypothesized that the C5 approach during ISB would provide postoperative analgesia while minimizing adverse events after arthroscopic shoulder surgery. METHODS A total of 92 patients scheduled for arthroscopic shoulder surgery were enrolled and randomly assigned to 1 of the 3 groups: The control (no ISB, n = 31), conventional ISB (ISB with the conventional approach, n = 31), or C5 ISB (ISB with the C5 approach, n = 30) group. ISB was performed before the induction of anesthesia, and a subacromial catheter was placed in all patients at the end of the surgery. Postoperative pain scores, numbness, and weakness were recorded at 2, 8, and 24 hours after surgery. Oxygen saturation and overall patient satisfaction scores were also assessed at 1 and 48 hour after surgery, respectively. RESULTS The pain scores were lower in the conventional ISB group and the C5 ISB group than in the control group at postoperative 2 and 8 hours (P < 0.05). The incidence and degree of numbness and weakness of the blocked arm were significantly lower in the C5 ISB group than in the conventional ISB group (P < 0.05). Oxygen saturation were lower in the conventional ISB group and C5 ISB group than in the control group (P = 0.01). Overall patient satisfaction scores were higher in the C5 ISB group than in the control or conventional ISB group (P < 0.01). CONCLUSION The C5 approach for ISB provides analgesia as effectively as the conventional approach following arthroscopic shoulder surgery, with the advantages of minimal numbness and weakness.
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Affiliation(s)
- Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
| | - Jung-Won Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
| | - Byung-Gun Kim
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
| | - Seong-Won Min
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
- Department of Anesthesiology and Pain Medicine, SNU-SMG Boramae Medical Center, Seoul
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul
- Correspondence: Jung-Hee Ryu, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea (e-mail: )
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Malik T, Mass D, Cohn S. Postoperative Analgesia in a Prolonged Continuous Interscalene Block Versus Single-Shot Block in Outpatient Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study. Arthroscopy 2016; 32:1544-1550.e1. [PMID: 27107906 DOI: 10.1016/j.arthro.2016.01.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 01/11/2016] [Accepted: 01/21/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the analgesic efficacy of 3-day continuous interscalene brachial plexus block versus a single-shot block for arthroscopic rotator cuff repair. METHODS Eighty-five patients scheduled for arthroscopic rotator cuff repair were randomly assigned to either the single-shot group (SSG) or continuous interscalene brachial block group (CG). Patients in the SSG received 2.5 mg/kg of 0.5% bupivacaine up to 25 mL; the CG received the same dose as a loading dose via catheter followed by an infusion of 0.125% bupivacaine at 5 mL/h and a patient-controlled bolus of 5 mL hourly for 72 hours. Follow-up after discharge was with telephone calls over the next 3 days. Pain was measured on a visual analog scale. Also measured were sleep disturbance, number of opioid doses taken, adverse effects, and level of patient satisfaction. RESULTS The median rest pain scores on the 3 days of follow-up measured on a scale of 0 to 10 (with 10 equal to greatest pain) were 0, 0, and 3 in the CG compared with 4, 4, and 3 in the SSG (P < .001) for days 1, 2, and 3, respectively. The median maximum scores were 2, 2, and 4 in the CG compared with 8, 7, and 6 in the SSG (P < .001) for the same time period. CONCLUSIONS A 3-day continuous interscalene brachial plexus block provides better analgesia than a single-shot block. Sleep patterns were better, and less opioid was needed after arthroscopic rotator cuff repair in patients given a continuous plexus block. LEVEL OF EVIDENCE Level I, prospective randomized study.
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Affiliation(s)
- Tariq Malik
- Department of Anesthesia and Critical Care, The University of Hospitals, Chicago, Illinois, U.S.A..
| | - Daniel Mass
- Department of Orthopedics and Rehabilitation Medicine, The University of Hospitals, Chicago, Illinois, U.S.A
| | - Stephan Cohn
- Department of Anesthesia and Critical Care, The University of Hospitals, Chicago, Illinois, U.S.A
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Kim JY, Song KS, Kim WJ, Park YH, Kang H, Woo YC, Shin HY. Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2016; 24:931-9. [PMID: 26063452 DOI: 10.1007/s00167-015-3667-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/29/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE Randomized controlled trials, Therapeutic study, Level I.
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Affiliation(s)
- Jae-Yoon Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Won-Joong Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Young-Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hwa-Yong Shin
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea.
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Kessler J, Marhofer P, Hopkins P, Hollmann M. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth 2015; 114:728-45. [DOI: 10.1093/bja/aeu559] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Salviz EA, Xu D, Frulla A, Kwofie K, Shastri U, Chen J, Shariat AN, Littwin S, Lin E, Choi J, Hobeika P, Hadzic A. Continuous Interscalene Block in Patients Having Outpatient Rotator Cuff Repair Surgery. Anesth Analg 2013; 117:1485-92. [DOI: 10.1213/01.ane.0000436607.40643.0a] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract 2012; 2012:560879. [PMID: 22761615 PMCID: PMC3385590 DOI: 10.1155/2012/560879] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 12/29/2022] Open
Abstract
A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.
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Affiliation(s)
- José Aguirre
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Alicia Del Moral
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Irina Cobo
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Alain Borgeat
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Stephan Blumenthal
- Department of Anesthesiology, Triemli Hospital, 8063 Zurich, Switzerland
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Regional Anesthesia Procedures for Shoulder and Upper Arm Surgery Upper Extremity Update—2005 to Present. Int Anesthesiol Clin 2012; 50:26-46. [DOI: 10.1097/aia.0b013e31821a0284] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bilateral ultrasound-guided supraclavicular block☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240040-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia 2010; 65:608-624. [DOI: 10.1111/j.1365-2044.2009.06231.x] [Citation(s) in RCA: 234] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Analgesic Effectiveness of a Continuous Versus Single-Injection Interscalene Block for Minor Arthroscopic Shoulder Surgery. Reg Anesth Pain Med 2010; 35:28-33. [DOI: 10.1097/aap.0b013e3181c771bd] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Smith HM, Duncan CM, Hebl JR. Clinical utility of low-volume ultrasound-guided interscalene blockade: contraindications reconsidered. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:1251-1258. [PMID: 19710225 DOI: 10.7863/jum.2009.28.9.1251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE The purpose of this series is to describe cases in which ultrasound guidance was used to allow patients to receive the benefits of regional anesthesia while safely circumventing traditional contraindications to interscalene blockade (ISB). METHODS Targeted low-volume ISB was performed in 3 patients in whom this procedure would typically be contraindicated because of phrenic nerve blockade or risk of local anesthetic toxicity. A patient with severe respiratory dysfunction, a patient undergoing bilateral shoulder surgery, and a patient requiring awake fiberoptic intubation underwent low-volume ultrasound-guided ISB. The ultrasound technique involved the use a low local anesthetic volume, anatomic identification of the brachial plexus trunk, needle placement opposite the phrenic nerve position, and control over local anesthetic spread. RESULTS In both patients in whom diaphragmatic paralysis was a concern, postoperative respiratory parameters indicated successful regional analgesia without evidence of phrenic nerve blockade. In the patient requiring an additional regional anesthetic procedure, ISB was performed with a local anesthetic volume low enough to avoid exceeding toxic safety thresholds. CONCLUSIONS Although further studies are warranted, we report on 3 cases in which ultrasound guidance was used to allow patients to receive the benefits of regional anesthesia while safely avoiding standard contraindications to ISB. Ultrasound technology may allow providers to perform low-volume brachial plexus blockade while avoiding issues related to phrenic nerve blockade and systemic local anesthetic toxicity.
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Affiliation(s)
- Hugh M Smith
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905 USA.
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