Interscalene Brachial Plexus Anesthesia and Analgesia for Open Shoulder Surgery: A Randomized, Double-Blinded Comparison Between Levobupivacaine and Ropivacaine

Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review

OBJECTIVE

Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB.

METHODS

Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery.

RESULTS

Fifty-five studies totalling 6,236 participants (median, 69; range, 30-910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences.

CONCLUSION

These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB.

STUDY REGISTRATION

PROSPERO (CRD42020148496); registered 10 February 2020.

A prospective comparison of the efficacy of 0.5% bupivacaine vs 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery

Purpose:

To date, there is no information on the comparison of the effect of 0.5% bupivacaine with 0.75% ropivacaine solution for vitreoretinal surgery. The aim of the study was to compare the efficacy of 0.5% bupivacaine with 0.75% ropivacaine in peribulbar anesthesia for vitreoretinal surgery. This was a prospective randomized double-blinded observational study in a hospital setting. Sixty patients planned for vitreoretinal surgery were randomized into two groups based on the peribulbar injection administered either with 0.5% bupivacaine or 0.75% ropivacaine solution, as Group B (n = 30) and Group R (n = 30), respectively. Time of onset of analgesia, akinesia, and the need for supplemental anesthesia were noted. Student's t-test or Mann-Whitney U test were used for comparing continuous variables and Chi-square or a Fischer exact test were used as appropriate for comparing two proportions.

Results:

The patients in Group R showed an earlier onset of both, analgesia (1.97 min vs. 2.10 min, P = 0.002) and akinesia (2.77 min vs. 4.20 min, P < 0.001) compared with the patients in Group B. The efficacy of the block attained was Grade 5 (adequate anesthesia and akinesia without supplementation) in about 97% of the patients in Group R while only 90% in Group B. However, the differences between the groups for the efficacy of the block were not statistically significant (P = 0.301) neither for Grades 5 nor for Grade 4 and 3 (P = 1.00 for both). The onset of postoperative pain was similar for both groups (P = 1.00).

Conclusion:

We concluded that 0.75% ropivacaine is a better choice of local anesthetic solution for patients undergoing primary vitreoretinal surgery compared with 0.5% bupivacaine.

Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons

The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].

Randomized Controlled Trial of Interscalene Block Compared with Injectable Liposomal Bupivacaine in Shoulder Arthroplasty

BACKGROUND

Shortcomings of interscalene brachial plexus blockade include technical failure and rebound pain. Bupivacaine liposome injectable suspension, a sustained release preparation, is used for surgical-site administration. The purpose of this study was to evaluate these 2 postoperative pain management strategies in patients undergoing shoulder arthroplasty.

METHODS

In a non-blinded, randomized controlled trial of participants undergoing primary shoulder arthroplasty, patients were randomized to interscalene brachial plexus blockade or intraoperative soft-tissue infiltration of bupivacaine liposome injectable suspension. The primary outcome variable was morphine equivalent units consumed over the first 24 hours postoperatively. Secondary outcomes included morphine equivalent units consumed intraoperatively and a visual analog scale (VAS) for pain at 0, 8, 16, and 24 hours.

RESULTS

Seventy-eight patients were randomized to interscalene brachial plexus blockade treatment (the blockade group) and 78 patients were randomized to bupivacaine liposome injectable suspension treatment (the suspension group). The mean total postoperative narcotic consumption (and standard deviation) over 24 hours after the surgical procedure was 14.8 ± 11.3 morphine equivalent units in the blockade group compared with 14.4 ± 16.8 morphine equivalent units in the suspension group (p = 0.849). Intraoperative narcotics were significantly lower (p < 0.001) in the blockade group (8.9 ± 4.1 morphine equivalent units) compared with the suspension group (16.2 ± 7.0 morphine equivalent units). The mean VAS pain score was significantly lower in the blockade group than in the suspension group at 0 hours postoperatively (0.8 ± 2.2 compared with 3.3 ± 2.7 points; p < 0.001) and at 8 hours postoperatively (1.4 ± 2.4 compared with 3.2 ± 2.2 points; p < 0.001), but it was not significantly different at 16 hours postoperatively (4.3 ± 2.8 compared with 3.8 ± 2.4 points; p = 0.348). The VAS pain scores were significantly higher (p = 0.021) in the blockade group (4.9 ± 2.7 points) compared with the suspension group (3.9 ± 2.3 points) at 24 hours postoperatively.

CONCLUSIONS

Patients treated with bupivacaine liposome injectable suspension required an equivalent amount of postoperative narcotics and greater intraoperative narcotics compared with patients treated with interscalene brachial plexus blockade. Although interscalene brachial plexus blockade provided improved pain scores for the first 8 hours after the surgical procedure, pain scores were worse at 24 hours. The optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ropivacaine versus levobupivacaine in peripheral nerve block: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

To determine which is more potent in peripheral nerve block between ropivacaine and levobupivacaine.

METHODS

A literature search was performed in the EMBASE, Medline, the Cochrane Library, and the Web of Science. The trials that were found were then evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses.

RESULTS

Twelve studies including 556 patients were included for final analysis. No statistically significant difference was observed between the 2 drugs with respect to onset time of surgical anesthesia, onset time of sensory block, onset time of motor block, duration of motor block, and patients overall satisfaction. Levobupivacaine provided more long-term anesthesia (weighted mean difference [WMD], -2.94; 95% confidence interval [CI], -5.56 to -0.32; I = 93%) and significantly lower incidence of postoperative rescue analgesia (odds ratio [OR], 2.11; 95% CI 1.18-3.74; I = 21%) than ropivacaine. There was a trend toward greater duration of sensory block in the levobupivacaine group (WMD, -1.16; 95% CI, -1.89 to -0.43; I = 14%).

CONCLUSION

Levobupivacaine is more potent than ropivacaine in peripheral nerve block to some extent. Otherwise, more rigorous randomized control trials are required in the future.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial

BACKGROUND

On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block.

METHODS

A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2.

RESULTS

There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups.

CONCLUSIONS

There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery

PURPOSE

The goal of the study was to evaluate the efficacy of additional axillary nerve block (ANB) with suprascapular nerve block (SSNB) and patient-controlled anaesthesia (PCA) with no device assistance after arthroscopic rotator cuff repair. The hypothesis is that patients with intravenous (IV) PCA and the blockade of the two main nerves (SSNB + ANB) experienced lesser pain than patients with IV PCA or IV PCA + SSNB.

METHODS

The 114 patients undergoing arthroscopic rotator cuff repair were allocated randomly to three groups as follows: group I, intravenous PCA pumps (only PCA); group II, IV PCA + SSNB using a blind technique (PCA + SSNB); and group III, IV PCA + SSNB + ANB using a blind technique (PCA + SSNB + ANB). Pain visual analogue scale (VAS) scores were evaluated at 1, 6, 12, 24, 36, and 48 post-operative hours. Furthermore, the degree of pain was compared according to cuff tear size.

RESULTS

The pain VAS score of group III was lower than that of the other two groups and was significantly lower at post-operative hours 1, 6, and 12. In addition, the larger cuff tear tended to be indicative of greater pain. However, all groups experienced rebound pain.

CONCLUSION

PCA + SSNB + ANB using a blind technique is a better pain control method than PCA + SSNB and only PCA during the initial 12 post-operative hours. PCA + SSNB + ANB is a cost-effective, time-saving, and easily performed method for post-operative pain control as an axis of multimodal pain control strategy.

LEVEL OF EVIDENCE

II.

Fully Awake Breast Reduction

The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial-only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial

The aim of this study was to compare the effect of intravenous (I.V.) dexamethasone with that of perineural dexamethasone on the prolongation of analgesic duration of single-shot interscalene brachial plexus blocks (SISB) in patients undergoing arthroscopic shoulder surgery. We performed a prospective, randomized, double-blind, placebo-controlled study. Patients undergoing elective arthroscopic shoulder surgery with ultrasound-guided SISB were enrolled and randomized into 2 groups. A total volume of 12 mL of the study drug was prepared with a final concentration of 0.5% ropivacaine. In the I.V. group, patients received SISB using ropivacaine 5 mg mL with normal saline (control) with dexamethasone 5 mg I.V. injection. In the perineural group, patients received SISB using ropivacaine 5 mg mL with dexamethasone 5 mg, with normal saline 1 mL I.V. injection. The primary outcome was the time to the first analgesic request, defined as the time between the end of the operation and the first request of analgesics by the patient. The secondary outcomes included patient satisfaction scores, side effects, and neurological symptoms. Patients were randomly assigned to 1 of the 2 groups using a computer-generated randomization table. An anesthesiologist blinded to the group assignments prepared the solutions for injection. The patients and the investigator participating in the study were also blinded to the group assignments. One hundred patients were randomized. Data were analyzed for 99 patients. One case in the I.V. group was converted to open surgery and was therefore not included in the study. Perineural dexamethasone significantly prolonged analgesic duration (median, standard error: 1080 minutes, 117.5 minutes) compared with I.V. dexamethasone (810 minutes, 48.1 minutes) (P = 0.02). There were no significant differences in side effects, neurological symptoms, or changes in blood glucose values between the 2 groups. Our results show that perineural dexamethasone 5 mg is more effective than I.V. dexamethasone 5 mg with regard to analgesic duration of SISB for arthroscopic shoulder surgery.

Efficacy and safety of 1% ropivacaine for postoperative analgesia after lower third molar surgery: a prospective, randomized, double-blinded clinical study

OBJECTIVES

The purpose of this study was to investigate postoperative analgesic effect of ropivacaine administered as main or supplemental injection for the inferior alveolar nerve block (IANB) in patients undergoing lower third molar surgery.

MATERIALS AND METHODS

The double-blind randomized study comprised 72 healthy patients. All patients received two blocks, the IANB for surgical procedure + IANB after surgery for postoperative pain control, and were divided into three groups: (1) 2 % lidocaine/epinephrine + 1 % ropivacaine, (2) 2 % lidocaine/epinephrine + saline, and (3) 1 % ropivacaine + saline. The occurrence of postoperative pain, pain intensity and analgesic requirements were recorded. Data were statistically analyzed using chi-square, Fisher, and Kruskal-Wallis tests and analysis of variance (ANOVA) with Bonferroni and Tukey correction.

RESULTS

Ropivacaine was more successful than lidocaine/epinephrine in obtaining duration of postoperative analgesia, reduction of pain, and analgesic requirements whether ropivacaine was used for surgical block or administered as a supplemental injection after surgery.

CONCLUSIONS

Ropivacaine (1 %, 2 ml) resulted in effective postoperative analgesia after lower third molar surgery.

CLINICAL RELEVANCE

Since pain control related to third molar surgery requires the effective surgical anesthesia and postoperative analgesia, the use of 1 % ropivacaine could be clinically relevant in a selection of appropriate pain control regimen for both surgical procedure and early postsurgical treatment.

Continuous postoperative pain control using a multiple-hole catheter after iliac bone grafting: comparison between ropivacaine and levobupivacaine

The aim of this study was to compare the analgesic effects of ropivacaine and levobupivacaine in continuous infiltration anaesthesia delivered via a multiple-hole catheter for the purpose of postoperative analgesia after iliac bone grafting. Thirty-four patients scheduled for iliac bone grafting in the maxillofacial region participated in this study. The patients were randomized to a ropivacaine group (Ropi group) and a levobupivacaine group (Levo group). After harvesting the iliac bone for grafting, a multiple-hole catheter was placed on the periosteum of the iliac bone. When surgery was completed, continuous administration was started at 4 ml/h of 0.2% ropivacaine (Ropi group) or 0.25% levobupivacaine (Levo group). Pain was evaluated in the recovery room and at 4h after surgery, as well as at 9:00 and 18:00 on postoperative days 1, 2, and 3, using a visual analogue scale. Side effects were also recorded. No significant difference in the visual analogue scale scores at rest or in motion was observed between the two groups. In addition, there were no side effects in the two groups. Both 0.2% ropivacaine and 0.25% levobupivacaine provided comparable analgesic effects in continuous infiltration anaesthesia delivered via a multiple-hole catheter after iliac bone grafting.

Comparative study related to cardiovascular safety between bupivacaine (S75-R25) and ropivacaine in brachial plexus block

BACKGROUND AND OBJECTIVES

Bupivacaine is a first choice for regional anesthesia considering its effectiveness, long duration and less motor blockade. Bupivacaine (S75-R25) is a mixture of optical isomers containing 75% levobupivacaine (S-) and 25% dextrobupivacaine (R+) created by a Brazilian pharmaceutical company. This investigation compared cardiac safety and efficacy of bupivacaine S75-R25 with vasoconstrictor and ropivacaine for brachial plexus blockade.

METHODS

Patients were randomized to receive brachial plexus anesthesia with either bupivacaine S75-R25 with epinephrine 1:200,000 (bupi) or ropivacaine (ropi), both at 0.50%, in 30 mL solution. We registered a continuous Holter ECG throughout the procedure, as well as the Lovett scale of force in addition to monitoring (heart rate, pulse oximetry and non-invasive blood pressure). The incidence of adverse events was compared with the chi-square or Fisher test.

RESULTS

We allocated forty-four patients into two groups. They did not show any difference related to age, weight or height, gender, as well as for surgical duration. Supraventricular arrhythmias were not different before or after the plexus blockade, independent of the local anesthetic chosen. Loss of sensitivity was faster for the bupivacaine group (23.1 ± 11.7 min) compared to the ropivacaine one (26.8 ± 11.5 min), though not significant (p = 0.205, Student t). There was a reduction in the cardiac rate, observed during the twenty-four-hour Holter monitoring.

CONCLUSIONS

This study showed similar efficacy between bupivacaine S75-R25 for brachial plexus blockade and ropivacaine, with similar incidences of supraventricular arrhythmias.

Comparative study related to cardiovascular safety between bupivacaine (S75-R25) and ropivacaine in brachial plexus block

BACKGROUND AND OBJECTIVES

Bupivacaine is a fi rst choice for regional anesthesia considering its effectiveness, long duration and less motor blockade. Bupivacaine (S75-R25) is a mixture of optical isomers containing 75% levobupivacaine (S-) and 25% dextrobupivacaine (R+) created by a Brazilian pharmaceutical company. This investigation compared cardiac safety and efficacy of bupivacaine S75-R25 with vasoconstrictor and ropivacaine for brachial plexus blockade.

METHODS

Patients were randomized to receive brachial plexus anesthesia with either bupivacaine S75-R25 with epinephrine 1:200,000 (bupi) or ropivacaine (ropi), both at 0.50%, in 30 mL solution.We registered a continuous Holter ECG throughout the procedure, as well as the Lovett scale of force in addition to monitoring (heart rate, pulse oximetry and non-invasive blood pressure). The incidence of adverse events was compared with the chi-square or Fisher test.

RESULTS

We allocated forty-four patients into two groups. They did not show any difference related to age, weight or height, gender, as well as for surgical duration. Supraventricular arrhythmias were not different before or after the plexus blockade, independent of the local anestheticchosen. Loss of sensitivity was faster for the bupivacaine group (23.1 ± 11.7 min) compared to the ropivacaine one (26.8 ± 11.5 min), though not significant (p = 0.205, Student t). There was a reduction in the cardiac rate, observed during the twenty-four-hour Holter monitoring.

CONCLUSIONS

This study showed similar efficacy between bupivacaine S75-R25 for brachial plexus blockade and ropivacaine, with similar incidences of supraventricular arrhythmias.

Clinical comparisons of 0.5% and 0.375% levobupivacaine for ultrasound-guided axillary brachial plexus block with nerve stimulation

Background

In an axillary brachial plexus block (ABPB), where relatively large doses of local anesthetics are administered, levobupivacaine is preferred due to a greater margin of safety. However, the efficacy of levobupivacaine in ABPB has not been studied much. We performed a prospective, double-blinded study to compare the clinical effect of 0.375% levobupivacaine with 0.5% levobupivacaine for ultrasound (US)-guided ABPB with nerve stimulation.

Methods

Forty patients undergoing elective upper limb surgery were randomized into two groups: Group I (0.375% levobupivacaine) and Group II (0.5% levobupivacaine). All four main terminal nerves of the brachial plexus were blocked separately with 7 ml of levobupivacaine using US guidance with nerve stimulation according to study group. A blinded observer recorded the onset time for sensory and motor block, elapsed time to be ready for surgery, recovery time for sensory and motor block, quality of anesthesia, patient satisfaction and complications.

Results

There were no significant differences in the time to find nerve locations, time to perform block and number of skin punctures between groups. Insufficient block was reported in one patient of Group I, but no failed block was reported in either group. There were no differences in the onset time for sensory and motor block, elapsed time to be ready for surgery, patient satisfaction and complications.

Conclusions

0.375% levobupivacaine produced adequate anesthesia for ABPB using US guidance with nerve stimulation, without any clinically significant differences compared to 0.5% levobupivacaine.

Ropivacaine: A review of its pharmacology and clinical use

Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer. It produces effects similar to other local anaesthetics via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade. Thus, ropivacaine has a greater degree of motor sensory differentiation, which could be useful when motor blockade is undesirable. The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity. The drug displays linear and dose proportional pharmacokinetics (up to 80 mg administered intravenously). It is metabolised extensively in the liver and excreted in urine. The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in the group.

Continuous peripheral nerve blocks in the hospital and at home

A single-injection peripheral nerve block using long-acting local anesthetic provides analgesia for 12 to 24 hours; however, many surgical procedures result in pain that lasts far longer. One relatively new option is a continuous peripheral nerve block (CPNB): local anesthetic is perfused via a perineural catheter directly adjacent to the peripheral nerve(s) supplying the surgical site, providing potent, site-specific analgesia. CPNB results in decreased pain, opioid requirements, opioid-related side effects, and sleep disturbances; in some cases, accelerating resumption of tolerated passive joint range-of-motion and increasing patient satisfaction. Ambulatory perineural infusion may be provided using a portable infusion pump, in some cases resulting in decreased hospitalization duration and related costs. Serious complications are rare, but may result in significant morbidity.

Comparison of 0.25% levobupivacaine and 0.25% bupivacaine for posterior approach interscalene brachial plexus block

PURPOSE

This study compares the onset time and quality of posterior approach interscalene brachial plexus block produced by 0.25% levobupivacaine and 0.25% bupivacaine.

METHODS

Sixty adult patients undergoing open or closed shoulder surgery were enrolled in this double-blind, randomized study, and they were randomly allocated to receive 40 ml of 0.25% levobupivacaine (Group L, n = 30) or 0.25% bupivacaine (Group B, n = 30). The patients were assessed at 5 min intervals after local anesthetic injection in order to determine loss of shoulder abduction and loss of pinprick sensation in the C(5-6) dermatomes. The mean onset time of motor and sensory block and onset time of complete motor and sensory block were documented in both groups.

RESULTS

In both groups, mean onset time of sensory block was <5 min and mean onset time of complete sensory block was <25 min. The onset times for sensory block and complete sensory block were not statistically different between the groups (P > 0.05). In both groups, mean onset time of motor block was <10 min but the mean onset time of complete motor block was <30 min. The onset times of motor block and complete motor block were not statistically different among the groups (P > 0.05). After the injection of the local anesthetic, 27% of Group L and 87% of Group B had complete motor block. Four patients in Group L had no motor block.

CONCLUSION

We conclude that 0.25% levobupivacaine and 0.25% bupivacaine have similar motor and sensory block onset times and qualities when used in posterior approach interscalene brachial plexus block, and provide comfortable anesthesia and analgesia for shoulder surgery.

Upper extremity regional anesthesia: essentials of our current understanding, 2008

Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine's commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.

Comparison of vertical infraclavicular brachial plexus block with 0.5% levobupivacaine and 0.5% ropivacaine for upper limb surgery

BACKGROUND

We performed a prospective, double blind study to compare the clinical effect of vertical infraclavicular brachial plexus block produced by 0.5% levobupivacaine and 0.5% ropivacaine for upper limb surgery.

METHODS

We included 60 patients receiving upper limb surgery under infraclavicular brachial plexus block. The infraclavicular brachial plexus block was performed via the vertical technique with 30 ml of 0.5% levobupivacaine or 0.5% ropivacaine. We observed which nerve type was stimulated and scored the sensory and motor block. The quality of block was assessed intraoperatively. The duration of sensory and motor block and complications were assessed.

RESULTS

There were no significant differences in frequencies of stimulated nerve type, evolution of sensory and motor block quality, or success of block. There were no significant difference in duration of sensory block, but duration of motor block was prolonged after 0.5% levobupivacaine. There were no complications.

CONCLUSIONS

Both 0.5% levobupivacaine and 0.5% ropivacaine had similar effects in the vertical infraclavicular brachial plexus block.

Efficacy of Low Dose Levobupivacaine (0.1%) for Axillary Plexus Block using Multiple Nerve Stimulation

The purpose of this study was to investigate if low doses of levobupivacaine (0.1%) produce complete sensory blockade in preoperative axillary brachial plexus block and to compare the effect of different doses of levobupivacaine on sensory and motor blockade.

A total of 110 patients scheduled for elective forearm or hand surgery were randomly allocated to receive 36 ml or 72 ml of levobupivacaine 0.1% or 36 ml of levobupivacaine 0.25%. In each group, volumes were equally distributed in the four nerve territories. In all patients, the sensory and motor block was assessed at five, 10, 20 and 30 minutes after the placement of axillary block.

Complete sensory block was obtained in 94.4% of patients receiving 36 ml of levobupivacaine 0.1%, 92.1% of those receiving 72 ml of levobupivacaine 0.1%, and 97.1% of those receiving 36 ml of levobupivacaine 0.25%. There was no significant difference either in the onset of the sensory and motor block or duration of the sensory and motor block.

This study demonstrates that 36 ml of levobupivacaine 0.1% (36 mg) is as effective as higher doses and volumes in axillary brachial plexus blockade.

Total spinal anaesthesia after an attempted brachial plexus block using the posterior approach

A 66-year-old patient scheduled for elective shoulder surgery underwent a brachial plexus block using the posterior approach. Shortly after injection of the local anaesthetic, he rapidly became unresponsive and apnoeic. We identify the possible reasons for this occurrence and discuss the place of the posterior approach in brachial plexus anaesthesia.

A comparison of patient-controlled subacromial and i.v. analgesia after open acromioplasty surgery

BACKGROUND

The aim of this study was to compare three patient-controlled analgesia (PCA) techniques for pain relief after acromioplasty. These techniques included use of subacromial ropivacaine, subacromial fentanyl or i.v. fentanyl.

METHODS

Forty-eight patients scheduled for open acromioplasty surgery were prospectively randomized to receive ropivacaine 0.2% (Group R) or fentanyl 4 microg ml(-1) (Group F) for subacromial analgesia, or fentanyl 4 microg ml(-1) (Group C) for i.v. analgesia. All patients received background infusion at a rate of 5 ml h(-1) plus a PCA bolus dose of 3 ml with a lockout time of 20 min. In addition, rescue analgesia with tramadol 50-100 mg i.v. was available on demand. Pain relief was regularly assessed using a visual analogue scale (0-10 cm) and side-effects were noted.

RESULTS

The postoperative pain scores at 2, 4, 6 and 12 h after the start of PCA were higher in Group F compared with Group R and Group C (P<0.001), However, the pain scores at the other time points were similar between the three groups. Pain scores, incremental dose requested and received, total volume of analgesic solution infused and rescue tramadol were similar between Group R and Group C. Specific side-effects were similar in the three groups.

CONCLUSION

The PCA techniques using subacromial ropivacaine or fentanyl i.v. provided similar and adequate pain relief and minimal side-effects after open acromioplasty surgery. The PCA using subacromial fentanyl was not as effective as either subacromial ropivacaine or i.v. fentanyl.

Comparison of the Haemodynamic Effects of Interscalene Block Combined with General Anaesthesia and Interscalene Block Alone for Shoulder Surgery

Interscalene brachial plexus block (ISB) anaesthesia is widely used with or without general anaesthesia in patients undergoing shoulder surgery, which is generally done with the patient in a sitting position. This position affects haemodynamics, and supplementing ISB with general anaesthesia can exaggerate these haemodynamic changes. This study compared ISB combined with general anaesthesia, with ISB alone, in 29 patients undergoing elective shoulder surgery. Heart rate and oxygen saturation remained stable throughout the study in both groups. Mean arterial pressure was significantly decreased when the patient moved into the sitting position in those given combined anaesthesia, whereas in those given ISB alone mean arterial pressure did not change significantly. Neither pain scores nor patient satisfaction scores differed significantly between the two groups. All of the patients were either satisfied or entirely satisfied with their anaesthesia/analgesia. There were no significant differences in side-effects and no severe complications in either group. We advocate using ISB alone for patients undergoing shoulder surgery, but further larger studies are needed to confirm the present results.