Regional Anesthesia With Noninvasive Ventilation for Shoulder Surgery in a Patient With Severe Chronic Obstructive Pulmonary Disease: A Case Report

Intraoperative use of noninvasive ventilation during spinal anaesthesia in patients with severe chronic obstructive pulmonary disease undergoing orthopaedic surgery: A case report

Compared with invasive mechanical ventilation, noninvasive ventilation (NIV) improves patient comfort and neurocognitive function; and reduces the likelihood of nosocomial infections and the need for sedation. NIV can also be used perioperatively to prevent postoperative pulmonary complications. This current report describes a case of a 64-year-old female patient with chronic obstructive pulmonary disease and chronic respiratory failure that underwent spinal anaesthesia during surgery. She was sedated with propofol. She brought her home ventilator equipment to the operating room and it was used in biphasic-positive airway pressure mode for immediate treatment of respiratory depression.

Proximal vs Distal Approach of Ultrasound-guided Suprascapular Nerve Block for Patients With Adhesive Capsulitis of the Shoulder: Prospective Randomized Controlled Trial

OBJECTIVES

To evaluate the early clinical outcomes of ultrasound (US)-guided suprascapular nerve block (SSNB) using a proximal approach compared with a distal approach for outpatient treatment of adhesive capsulitis.

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinic PARTICIPANTS: Participants (N=47) with symptomatic adhesive capsulitis.

INTERVENTIONS

Participants were randomly assigned to either US-guided SSNB using a proximal approach (n=23, proximal group) or a distal approach (n=24, distal group).

MAIN OUTCOME MEASURES

The primary outcome measure was the visual analog scale (VAS) for pain at week 12. Secondary outcomes included the American Shoulder Elbow Surgeon's (ASES) score, University California Los Angeles score, Short Form-36 mental and physical component summaries, and range of motion. All patients completed clinical follow-up at 2, 6, and 12 weeks after treatment. On US images, depth and insertion angle of needle during injection were measured.

RESULTS

The VAS significantly improved in both groups at week 12. After treatment, no significant differences were found in early clinical outcomes (weeks 2, 6, and 12) between groups (all P>.05), except that ASES at 2 weeks showed a significantly higher score in the distal group than in the proximal group (87.1±4.8 and 83.0±6.3, respectively; P=.014). The mean depth and insertion angle of needle was significantly lower (depth: 13.4±3.9 and 30.6±4.3 mm, respectively; P<.001; insertion angle: 19.6°±6.4° and 38.7°±5.8°; P<.001) in the proximal group than in the distal group.

CONCLUSIONS

This study demonstrated that proximal approach of US-guided SSNB provided favorable short-term outcomes of pain and functional improvement and that outcomes were comparable to those of the distal approach in adhesive capsulitis. The suprascapular nerve was located more superficially and easily identified in the proximal approach, suggesting that this method might improve the accuracy of injection.

[Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study]

BACKGROUND AND OBJECTIVES

The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block.

METHODS

Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥ 25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed.

RESULTS

Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale (NRS) at 24 hours did not differ between groups.

CONCLUSIONS

Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Ultrasound-Guided Proximal and Distal Suprascapular Nerve Blocks: A Comparative Cadaveric Study

Objectives

The primary aim of our study was to evaluate and compare the accuracy of ultrasound (US)-guided distal suprascapular nerve (dSSN) and proximal SSN (pSSN) blocks. Secondary aims were to compare the phrenic nerve involvement between groups and to describe the anatomical features of the sensory branches of the dSSN.

Methods

pSSN and dSSN blocks were performed in 14 cadavers (28 shoulders). Ten mL of 0.2% ropivacaine colored with methylene blue was injected under US guidance. Accuracy was determined using SSN staining and the distance between predefined anatomical landmarks and the targeted SSN. The phrenic nerve (PN) was judged to be colored or not. The distribution of the sensory branches that originate from the 14 dSSNs is described. Quantitative data are expressed as median (range).

Results

The pSSN was dyed more frequently than the dSSN (13 vs 11, P = 0.59). The targeted SSN was close to the suprascapular notch (1.3 [0–5.2] cm) and the origin of the SSN (1.4 [0.2–4.5] cm) for dSSN and pSSN blocks, respectively (P = 0.62). For dSSN blocks, the most frequent injection site was the supraspinous fossa. Three PNs were marked in pSSN blocks, compared with none in dSSN blocks (P = 0.22). Three sensory branches were identified for all 14 dSSNs: the medial subacromial branch, the lateral subacromial branch, and the posterior glenohumeral branch.

Conclusions

US-guided pSSN and dSSN blocks can be realized with accuracy. A distal approach to the SSN could be an alternative to interscalene brachial plexus block for the management of postoperative pain after shoulder surgery in high–respiratory risk patients.