Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles

Vorobeichik, Leon; Brull, Richard; Bowry, Richard; Laffey, John G.; Abdallah, Faraj W.

doi:10.1016/j.bja.2017.11.104

Cited by 53 publications

(32 citation statements)

References 78 publications

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“…According to the American Pain Society guidelines, the use of continuous, rather than single-injection, peripheral regional analgesic techniques is strongly recommended for postoperative pain management, as it can offer more prolonged duration of analgesia. [4][5][6] Thoracic epidural analgesia (TEA) and paravertebral blocks (PVBs) was the earliest regional anesthetic techniques for the thoracic surgery. 7 Due to the side-effects and the fact that it is challenging to perform, TEA may not be the best choice in the management of postoperative pain.…”

Section: Introductionmentioning

confidence: 99%

<p>Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults</p>

Yang

et al. 2020

JPR

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This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults. Patients and Methods: Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUC VAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes. Results: At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUC VAS-time at rest (44.0±17.1 vs 68.9±11.8 cm•h, P<0.001) and AUC VAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm•h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group. Conclusion: cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

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Section: Introductionmentioning

confidence: 99%

<p>Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults</p>

Yang

et al. 2020

JPR

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“…Shoulder surgery is known to be associated with severe pain not only postoperatively but also during rehabilitation. Continuous interscalene block, incorporating the basal infusion of a local anesthetic and patient-controlled boluses, is one of the most effective and frequently used analgesic techniques after both major and minor shoulder surgeries [1][2][3][4]. Many authors have supported the efficacy and safety of continuous interscalene block in ambulatory patients [5][6][7][8][9].…”

Section: Introductionmentioning

confidence: 99%

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

Tanizima¹,

Takechi²,

Nakanishi³

et al. 2019

Preprint

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Background: Continuous interscalene block is widely used for pain management in shoulder surgery. However, continuous interscalene block performed using the catheter-through-needle method is reportedly associated with adverse events such as pericatheter leakage of the local anesthetic, phrenic nerve paralysis, and hoarseness. Because we expected that the catheter-over-needle method would reduce these adverse events, we examined cases in which continuous interscalene block was performed using the catheter-over-needle method to determine what adverse events occurred and when. Methods: We retrospectively reviewed the anesthesia and medical records of adult patients who underwent catheter insertion to receive a continuous interscalene block performed using the catheter-over-needle method at our hospital from July 2015 to July 2017. Results: During the surveillance period, 122 adult patients underwent catheter insertion to receive a continuous interscalene block administered using the catheter-over-needle method. No case of pericatheter local anesthetic leakage was observed. Adverse events, such as dyspnea, hoarseness, insufficient anesthetic effect, dizziness, cough reflex during drinking, or ptosis, were observed in 42 patients (34.4%; 95% confidence interval 26–42.7). Most of the adverse events occurred on postoperative day 2. The median time between surgery and the onset of adverse events was 28.5 h. Conclusions: The catheter-over-needle method may prevent the pericatheter leakage of the local anesthetic. However, adverse events occurred in more than one-third of the patients. During continuous interscalene block, patients must be carefully observed for adverse events, especially on postoperative day 2. Trial registration: This study was registered at the UMIN Clinical Trials Registry on August 13th, 2019 (UMIN000037673).

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“…There has been no doubt that continous interscalene block (CISB) provides superior analgesia, compared with single-injection interscalene block, for up to 48 h after major shoulder surgery but the importance of CISB-related changes in respiratory indices has always been questionable. 11 This study highlights the fact that the limitations faced by the clinicians due to phrenic nerve block can be avoided by choosing lower doses.…”

Section: Discussionmentioning

confidence: 80%

Incidence of Hemidiaphragmatic Paralysis with Patient Controlled Infusion of Low Volume of Ropivacaine after Ultrasound Guided Low Dose Interscalene Brachial Plexus Block, A Prospective Observational Study

kushal¹,

Samra²,

Saini

et al. 2019

Preprint

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BACKGROUND Hemidiaphragmatic paralysis is a complication of single shot and continuous interscalene brachial plexus block that can be minimised by ultrasound guided extrafascial catheter placements and by limiting the amount of local anaesthetic administered. We hypothesized that patient controlled infusion of low volume of ropivacaine for a period of 24 hours would not cause hemidiaphragmatic paralysis and would provide adequate analgesia.METHODS 54 patients aged 18-65 years undergoing surgery for shoulder dislocation or proximal humerus fracture were recruited and allocated into two groups of 27 each, patient controlled interscalene analgesia (PCIA) and multimodal analgesia (MA). Interscalene catheter was inserted at end of surgery and 10 ml of 0.5% ropivacaine was administered as single bolus dose. PCIA was initiated after four hours to deliver background infusion of 2 ml/hr, bolus of 5ml (0.2% of ropivacaine) with lockout interval of 30 minutes for a total duration of 24 hours. Incidence of hemidiaphragmatic paralysis using M-mode ultrasonography was recorded at extubation,4,6,12 and 24hrs. Numerical rating scale (NRS) for pain, patient satisfaction score and complications were also recorded. Acetaminophen (1 gm) and diclofenac 75 gm were used in MA group.RESULT No diaphragmatic paresis was reported in patients administered the background infusion or single bolus doses of ropivacaine and scanned at 4, 6,12 and 24 hrs. Partial paresis was noted in all patients in which two bolus doses/hour were administered 30 minutes after the second bolus. All patients with paresis had diaphragmatic excursion normalized in the next recording made at 4 hours and no complication was reported in any patient. NRS was below 3 at all time points in PCIA and the cumulative fentanyl and tramadol consumption was significantly higher in MA group. The incidence of complete and partial paresis of diaphragm was 85%and 3.7% after single shot bolus dose respectively and had resolved before start of infusion after 4 hours.CONCLUSION Patient controlled low volume continous infusion of ropivacaine (2 ml/hr of 0.2% of ropivacaine) with administration of a single bolus dose of 5ml in an hour does not cause unilateral phrenic paresis. Partial paresis is reported with two bolus doses/hour.Clinical trial number NCT03081728 (clinicaltrials.gov;)

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Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles

Abstract: High-level evidence indicates that CISB provides superior analgesia up to 48 h after major shoulder surgery, without increasing side-effects, compared with SISB. The importance of CISB-related changes in respiratory indices is questionable.

Cited by 53 publications

References 78 publications

<p>Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults</p>

<p>Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults</p>

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

Incidence of Hemidiaphragmatic Paralysis with Patient Controlled Infusion of Low Volume of Ropivacaine after Ultrasound Guided Low Dose Interscalene Brachial Plexus Block, A Prospective Observational Study

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