Diaphragm-sparing nerve blocks for shoulder surgery

Copyright © 2016 by American Society of Regional Anesthesia and Pain Medicine. Shoulder surgery can result in significant postoperative pain. Interscalene brachial plexus blocks (ISBs) constitute the current criterion standard for analgesia but may be contraindicated in patients with pulmonary pathology due to the inherent risk of phrenic nerve block and symptomatic hemidiaphragmatic paralysis. Although ultrasound-guided ISB with small volumes (5 mL), dilute local anesthetic (LA) concentrations, and LA injection 4 mm lateral to the brachial plexus have been shown to reduce the risk of phrenic nerve block, no single intervention can decrease its incidence below 20%. Ultrasound-guided supraclavicular blocks with LA injection posterolateral to the brachial plexus may anesthetize the shoulder without incidental diaphragmatic dysfunction, but further confirmatory trials are required. Ultrasound-guided C7 root blocks also seem to offer an attractive, diaphragm-sparing alternative to ISB. Ho

Comparaison randomise´e entre le bloc interscale´nique et le bloc combine´ infraclaviculaire et suprascapulaire pour une chirurgie arthroscopique de l’e´paule

Background This randomized trial aimed to evaluate combined infraclavicular-suprascapular blocks (ICB-SSBs) as a diaphragm-sparing alternative to interscalene blocks (ISBs) for arthroscopic shoulder surgery. We hypothesized that ICB-SSB would provide equivalent postoperative analgesia to ISB 30 min after surgery without the risk of hemidiaphragmatic paralysis. Methods Following research ethics board approval and written informed consent, participants in the ISB group received an ultrasound-guided ISB with 20 mL of levobupivacaine 0.25% and epinephrine 5 A mu g center dot mL(-1). In the ICB-SSB group, ultrasound-guided ICB (20 mL) and SSB (10 mL) were carried out using the same local anesthetic. Thirty minutes after the block was performed, a blinded investigator assessed the presence of hemidiaphragmatic paralysis. Subsequently, all patients underwent general anesthesia. Postoperatively, a blinded investigator recorded pain scores at rest at 0.5, 1, 2, 3, 6, 12 and 24 hr. Consumption of intra- and postoperative narcotics was also tabulated. Results Compared to its ICB-SSB counterpart, the ISB group displayed non-equivalent (i.e., lower) postoperative pain scores at 30 min (difference of the medians, -4; 99% confidence interval [CI], -6 to -3), required less cumulative morphine iv at 24 hr (difference of the means, -6.1 mg; 95% CI, -10.5 to -1.6), and resulted in a higher incidence of hemidiaphragmatic paralysis (18/20 vs 0/20 patients, respectively; P < 0.001). Although postoperative pain scores at one, two, and three hours appeared lower in the ISB group, the upper bounds of the 99% CIs did not exceed the equivalence margin. Conclusion Compared with ICB-SSB, ISB provided non-equivalent (i.e., lower) postoperative pain scores 30 min after arthroscopic shoulder surgery. Thereafter, postoperative analgesia was comparable between the two groups. Further trials are required to compare ISB with ICB-SSB using a proximal (i.e., costoclavicular) technique for ICB.Contexte Cette étude randomisée avait pour objectif d’évaluer l’efficacité des blocs combinés des nerfs infraclaviculaires et suprascapulaires (BIC-BSS), en tant qu’alternative épargnant le diaphragme, aux blocs interscaléniques (BIS), pour les chirurgies arthroscopiques de l’épaule. Nous avons émis l’hypothèse qu’un BIC-BSS procurerait une analgésie postopératoire équivalente à un BIS 30 min après la chirurgie et sans risque de paralysie hémidiaphragmatique. Méthode Après avoir obtenu l’approbation du comité d’éthique de la recherche et le consentement éclairé écrit, les participants du groupe BIS ont reçu un BIS échoguidé à l’aide de 20 mL de lévobupivacaïne 0,25 % et de 5 µg·mL−1 d’épinéphrine. Les participants du groupe BIC-BSS ont reçu un BIC (20 mL) et un BSS (10 mL) échoguidés avec les mêmes anesthésiques locaux. Trente minutes après la réalisation du bloc, un chercheur en aveugle a évalué la présence de paralysie hémidiaphragmatique. Par la suite, tous les patients ont reçu une anesthésie générale. Un chercheur en aveugle a enregistré les scores de douleur postopératoire au repos, à 30 min, et à une, deux, trois, six, 12 et 24 h. La satisfaction des patients à 24 h et la consommation d’agents narcotiques per- et postopératoires ont également été enregistrées. Résultats Par rapport au groupe BIC-BSS, le groupe BIS a manifesté des scores de douleur postopératoire non équivalents (c.-à-d. plus bas) à 30 min (différence médiane, −4; intervalle de confiance [IC] 99 %, −6 à −3; P = 0,001). Ils ont également nécessité une dose moindre de morphine iv cumulée à 24 h (différence moyenne, −6,1 mg; IC 95 %, −10,5 à −1,6; P = 0,010). En outre, comme nous l’avions anticipé, l’incidence de paralysie hémidiaphragmatique était plus élevée (18/20 vs 0/20 patients, respectivement; P < 0,001) dans le groupe BIS. Bien que les scores de douleur postopératoire à une, deux et trois heures ont semblé plus bas dans le groupe BIS, les limites supérieures des IC 99 % n’ont pas excédé la marge d’équivalence. Conclusion Par rapport à un BIC-BSS, un BIS a entraîné des scores de douleur postopératoire non équivalents (c.-à-d. plus bas) 30 min après une arthroscopie de l’épaule. À partir de ce moment-là, toutefois, l’analgésie postopératoire était comparable entre les deux groupes. Des études supplémentaires sont nécessaires pour comparer les BIS aux BIC-BSS en utilisant une technique proximale (soit costoclaviculaire) pour réaliser le BIC

Traitement du syndrome douloureux régional complexe : étude systématique actualisée et synthése narrative

Although multiple treatments have been advocated for complex regional pain syndrome (CRPS), the levels of supportive evidence are variable and sometimes limited. The purpose of this updated review is to provide a critical analysis of the evidence pertaining to the treatment of CRPS derived from recent randomized-controlled trials (RCTs). The MEDLINE, EMBASE, Psychinfo, and CINAHL databases were searched to identify relevant RCTs conducted on human subjects and published in English between 1 May 2009 and 24 August 2017. The search yielded 35 RCTs of variable quality pertaining to the treatment of CRPS. Published trials continue to support the use of bisphosphonates and short courses of oral steroids in the setting of CRPS. Although emerging evidence suggests a therapeutic role for ketamine, memantine, intravenous immunoglobulin, epidural clonidine, intrathecal clonidine/baclofen/adenosine, aerobic exercise, mirror therapy, virtual body swapping, and dorsal root ganglion stimulation, further confirmatory RCTs are warranted. Similarly, trials also suggest an expanding role for peripheral sympathetic blockade (i.e., lumbar/thoracic sympathetic, stellate ganglion, and brachial plexus blocks). Since our prior systematic review article (published in 2010), 35 RCTs related to CRPS have been reported. Nevertheless, the quality of trials remains variable. Therefore, further research is required to continue investigating possible treatments for CRPS

Randomized comparison between interscalene and costoclavicular blocks for arthroscopic shoulder surgery

Background This randomized trial compared ultrasound-guided interscalene block (ISB) and costoclavicular brachial plexus block (CCB) for arthroscopic shoulder surgery. We hypothesized that CCB would provide equivalent analgesia to ISB 30 min after surgery without the risk of hemidiaphragmatic paralysis. Methods All 44 patients received an ultrasound-guided block of the intermediate cervical plexus. Subsequently, they were randomized to ISB or CCB. The local anesthetic agent (20 mL of levobupivacaine 0.5% and epinephrine 5 μg/mL) and pharmacological block adjunct (4 mg of intravenous dexamethasone) were identical for all study participants. After the block performance, a blinded investigator assessed ISBs and CCBs every 5 min until 30 min using a composite scale that encompassed the sensory function of the supraclavicular nerves, the sensorimotor function of the axillary nerve and the motor function of the suprascapular nerve. A complete block was defined as one displaying a minimal score of six points (out of a maximum of eight points) at 30 min. Onset time was defined as the time required to reach the six-point minimal composite score. The blinded investigator also assessed the presence of hemidiaphragmatic paralysis at 30 min with ultrasonography. Subsequently, all patients underwent general anesthesia. Postoperatively, a blinded investigator recorded pain scores at rest at 0.5, 1, 2, 3, 6, 12, and 24 hours. Patient satisfaction at 24 hours, consumption of intraoperative and postoperative narcotics, and opioid-related side effects (eg, nausea/vomiting, pruritus) were also tabulated. Results Both groups displayed equivalent postoperative pain scores at 0.5, 1, 2, 3, 6, 12, and 24 hours. ISB resulted in a higher incidence of hemidiaphragmatic paralysis (100% vs 0%; P &lt; 0.001) as well as a shorter onset time (14.0 (5.0) vs 21.6 (6.4) minutes; p&lt;0.001). However, no intergroup differences were found in terms of proportion of patients with minimal composite scores of 6 points at 30 min, intraoperative/postoperative opioid consumption, side effects, and patient satisfaction at 24 hours. Conclusion Compared to ISB, CCB results in equivalent postoperative analgesia while circumventing the risk of hemidiaphragmatic paralysis. Further confirmatory trials are required. Future studies should also investigate if CCB can provide surgical anesthesia for arthroscopic shoulder surgery. Clinical Trials Registration NCT03411343

Dural puncture epidural analgesia for labor: A randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial. Methods One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 μg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed. A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0-10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache. Results Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means:-3.2 to-0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache. Conclusion Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies. Trial registration number NCT03389945

A multicenter, randomized comparison between 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular block

© 2019 American Society of Regional Anesthesia & Pain Medicine.Background and objectives This multicenter, randomized trial compared 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular brachial plexus block. Our research hypothesis was that all three doses of dexamethasone would result in equivalent durations of motor block (equivalence margin=3.0 hours). Methods Three hundred and sixty patients undergoing upper limb surgery with ultrasound-guided infraclavicular block were randomly allocated to receive 2, 5, or 8 mg of preservative-free perineural dexamethasone. The local anesthetic agent (35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 μg/mL) was identical in all subjects. Patients and operators were blinded to the dose of dexamethasone. During the performance of the block, the performance time, number of needle passes, procedural pain, and complications (vascular puncture, paresthesia) were recorded. Subsequently a blinded observer assessed t