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Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Guillain-Barré Syndrome (GBS) is an autoimmune disorder which can present in acute and chronic forms. It is an inflammatory demyelinating polyneuropathy. These patients pose potential perioperative risks of autonomic dysfunction and respiratory muscle weakness. The current case report shows a 66-year-old female with a history of a fall at home eight days prior to surgery, diagnosed with a right-sided proximal humerus fracture. The patient was a diagnosed case of GBS and hypertension since five years. For GBS, she had a history of Intensive Care Unit (ICU) admission for both upper and lower limb muscle weakness and breathlessness. She recovered with treatment of Intravenous Immunoglobulin (IVIg) and oxygen therapy. The weakness improved gradually over time but did not fully recover. The patient continued to have weakness in both lower and upper limbs prior to surgery. The patient underwent Joshi’s External Stabilising System (JESS) fixation surgery for the right proximal humerus fracture. Ultrasound-guided (USG) interscalene and superficial cervical plexus block were performed in view of pre-existing muscle weakness and to reduce the requirement of postoperative ventilator support. The intraoperative course was uneventful. The patient’s sensory and motor power returned to the same prior to surgery after the block’s effects subsided.

Background: The interscalene block in shoulder arthroscopy is a well-established procedure. Many drugs have been used as adjuvants to local anesthetics to increase the quality of block in regional anesthesia, with variable results. Aims and Objectives: The present study was designed to evaluate the effect of dexmedetomidine as an adjuvant to bupivacaine during interscalene block in terms of intraoperative hemodynamic changes and postoperative analgesia. Materials and Methods: Thirty patients, aged 20–55 years of either sex, American Society of Anesthesiologists physical status I-II, scheduled for shoulder arthroscopic surgery for

Background: Brachial plexus catheter placement at the interscalene level is beneficial for shoulder analgesia but presents logistical challenges due to the superficial nature of the plexus at this level, increased patient movement in the neck, and therefore higher likelihood for catheter dislodgement. Methods: Patients requiring shoulder arthroscopy and suprascapular nerve decompression were identified. Under arthroscopic guidance, a catheter was placed percutaneously into the scalene medius muscle next to the suprascapular nerve and the upper trunk of the brachial plexus. Patients were followed postoperatively for perioperative analgesic outcomes. Results: Ten patients were identified and consented for intraoperative brachial plexus catheter placement. Patient demographics and surgical details were determined. Postoperative adjunctive pain management and pain scores were variable. Two patients required catheter replacement using ultrasound guidance in the perioperative anesthesia care unit due to poorly controlled pain. There were no incidents of catheter failure due to dislodgement. Discussion: This study presents the first description of arthroscopically-assisted brachial plexus catheter placement. This method may present an alternative to traditional ultrasound guided interscalene catheter placement. Further study is needed to determine if analgesic outcomes, block success, and dislodgement rates are improved with this method.

Background: The interscalene block in shoulder arthroscopy is a well-established procedure. Many drugs have been used as adjuvants to local anesthetics to increase the quality of block in regional anesthesia, with variable results. Aims and Objectives: The present study was designed to evaluate the effect of dexmedetomidine as an adjuvant to bupivacaine during interscalene block in terms of intraoperative hemodynamic changes and postoperative analgesia. Materials and Methods: Thirty patients, aged 20–55 years of either sex, American Society of Anesthesiologists physical status I-II, scheduled for shoulder arthroscopic surgery for <2 h, were allocated into two equal groups to receive inj. bupivacaine (0.25%) with inj. dexmedetomidine 1 μg/kg (Group BD, n=15) or inj. bupivacaine (0.25%) with 1 mL normal saline (Group BS, n=15), total volume 20 mL in each case. After settlement of the interscalene block, both groups received general anesthesia as per standard protocol. Hemodynamic parameters (heart rate [HR] and systolic blood pressure [SBP]) were assessed in the intraoperative period, and postoperative pain was assessed using a visual analog scale score in the postoperative period at stipulated time points. Results: The mean values of HR and SBP were considerably low at all observed time points in the intraoperative period (i.e., at 10 min, 30 min, 60 min, 90 min, and120 min), in comparison with the saline group (P<0.0001). VAS scores between the two groups were considerably lower only at 8, 12, and 18 h in patients receiving dexmedetomidine (P<0.001). Conclusion: Dexmedetomidine as an adjuvant with bupivacaine can achieve a better hemodynamic profile (lower HR and SBP) in the intraoperative period. Also, the use of dexmedetomidine provides better postoperative analgesia profiles in the later part of the postoperative period (8–18 h), and the effect usually wanes by 24 h. [ABSTRACT FROM AUTHOR]

Copyright of Arthroskopie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Sibel Seckin Pehlivan,1 Ozlem Oz Gergin,1 Recep Aksu,1 Ahmet Guney,2 Emel Guler,3 Karamehmet Yildiz1 1Department of Anaesthesiology and Reanimation, Erciyes University, Medical Faculty, Kayseri, Turkey; 2Department of Orthopedic Surgery, Erciyes University, Medical Faculty, Kayseri, Turkey; 3Department of Pain, Cumhuriyet University, Medical Faculty, Sivas, TurkeyCorrespondence: Sibel Seckin Pehlivan, Erciyes University Medical Faculty Talas, Kayseri, Turkey, Tel +90 352 2076666- 24048, Fax +90-352-4377333, Email sibelpehlivan@erciyes.edu.trBackground: To compare the analgesic effect of ISB with a combination of ISB-SSNB and patients who were given opioids with PCA without block in adult patients undergoing shoulder surgery, as measured by opioid consumption and pain intensity in the first 24 hours postoperatively.Methods: Ninety patients who underwent shoulder surgery were randomly divided into three groups. Group I in which ISB was performed and patient-controlled analgesia (PCA) was inserted, Group II with; ISB and SSNB combined, and PCA was inserted, and Group III where; only PCA was used. Visual analog scale (VAS) pain scores at the second, fourth, sixth, 12th, and 24th hours, morphine consumption, additional analgesic requirement, and patient satisfaction were evaluated.Results: Compared with Group III, the VAS pain score was significantly lower in Group I and Group II at 2, 4, 6, 12, and 24 hours postoperatively. In Group I, the VAS score at rest at the 6th hour was found to be higher than in Group II. The 24-hour total morphine consumption was higher in the control group than in Group I and Group II. The satisfaction score of the control group was lower than Group I and Group II.Conclusion: The combined application of ISB and SSNB block is beneficial in shoulder surgery to provide both intraoperative and postoperative analgesia and opioid consumption.Level of Evidence: Level I; Randomized Controlled Trial; Treatment Study.Keywords: interscalene block, suprascapular nerve block, shoulder arthroscopic surgery, postoperative analgesia

Guillain-Barré Syndrome (GBS) is an autoimmune disorder which can present in acute and chronic forms. It is an inflammatory demyelinating polyneuropathy. These patients pose potential perioperative risks of autonomic dysfunction and respiratory muscle weakness. The current case report shows a 66-year-old female with a history of a fall at home eight days prior to surgery, diagnosed with a right-sided proximal humerus fracture. The patient was a diagnosed case of GBS and hypertension since five years. For GBS, she had a history of Intensive Care Unit (ICU) admission for both upper and lower limb muscle weakness and breathlessness. She recovered with treatment of Intravenous Immunoglobulin (IVIg) and oxygen therapy. The weakness improved gradually over time but did not fully recover. The patient continued to have weakness in both lower and upper limbs prior to surgery. The patient underwent Joshi’s External Stabilising System (JESS) fixation surgery for the right proximal humerus fracture. Ultrasound-guided (USG) interscalene and superficial cervical plexus block were performed in view of pre-existing muscle weakness and to reduce the requirement of postoperative ventilator support. The intraoperative course was uneventful. The patient’s sensory and motor power returned to the same prior to surgery after the block’s effects subsided. [ABSTRACT FROM AUTHOR]

ABSTRACTBackground In patients at high risk, regional anesthesia (RA) is a viable substitute for general anesthesia (GA). For a modified radical mastectomy that included axillary lymph node dissection (MRM-ALND), we assumed that a combination erector spinae plane block (ESPB) and interscalene block (IBPB) could offer a sufficient anesthesia.Methods After clinical trial registration (No. NCT04239716), this pilot study included thirteen consecutive female, 40–85 years old, and scheduled for MRM-ALND. Patients received ESPB at T4 level (5 ml of 2% lidocaine, 10 ml of 0.5% bupivacaine, and 5 ml of normal saline), IBPB (5 ml each of 2% lidocaine and 0.5% bupivacaine), and sedation with dexmedetomidine. The primary aim was to assess the success rate of our technique as a sole anesthesia for MRM-ALND in high-risk patients. Secondary outcomes included intraoperative vital signs measurements. Postoperative measurements were numeric rating scale (NRS) score, analgesic duration, the consumption of morphine, patients’ satisfaction, and adverse effects.Results Our technique succeeded in 11 out of 13 patients. In whom RA were succeeded, the analgesia lasted 360–720 minutes, they received morphine 3–9 mg and had low NRS scores. The two failure cases received GA, the analgesia lasted 60–120 minutes postoperative, they received morphine 9 mg and had high NRS scores. The reduction of hemodynamic parameters intraoperative responded to reduce dexmedetomidine infusion rate. Two patients had postoperative vomiting treated with ondansetrone.Conclusions The combined ESPB and IBPB could be utilized as an alternative to GA for MRM-ALND, which reduced the potential risks of GA in high-risk patients; furthermore, it provides satisfactory postoperative analgesia with limited opioid consumption.

OBJECTIVE: The administration of interscalene block (ISB) may lead to several hemodynamic effects, likely due to the diffusion of local anesthetic to nearby structures such as carotid sinus baroreceptors. This study aimed to compare hemodynamic and respiratory changes resulting from right and left-sided ISB. PATIENTS AND METHODS: A retrospective analysis was conducted on adults who had ultrasound-guided ISB for upper limb surgery between January 2020 and December 2021. All patients had ISB with bupivacaine 0.5% and lidocaine 2% mixture following premedication. Demographic data, arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO2) were measured before and after the block at regular intervals. Block characteristics, surgical and post-anesthesia care unit (PACU) durations, intraoperative analgesic requirements, and side effects were analyzed. RESULTS: A total of 94 patients had ISB for upper limb surgery, 54 for the right and 40 for the left-sided surgeries. Patients' data were analyzed in two groups according to the block side. Increased arterial blood pressure was observed in both groups after the block compared to the control values. Systolic arterial pressure from 10 to 30 minutes, diastolic arterial pressure at the 25th minute, and mean arterial pressure at the 15th, 20th, and 25th minutes were significantly higher on the right-sided blocks. Heart rate, SpO2, analgesic requirements, block characteristics, and PACU durations did not differ between the groups. CONCLUSIONS: Ultrasound-guided ISB-applied patients demonstrated increased blood pressure compared to control values. This increase, without concurrent changes in heart rate, was more pronounced in right-sided ISB. These findings indicate that careful hemodynamic monitoring is necessary whenever hypertension should be avoided for the patients. [ABSTRACT FROM AUTHOR]

Background: In patients at high risk, regional anesthesia (RA) is a viable substitute for general anesthesia (GA). For a modified radical mastectomy that included axillary lymph node dissection (MRM-ALND), we assumed that a combination erector spinae plane block (ESPB) and interscalene block (IBPB) could offer a sufficient anesthesia. Methods: After clinical trial registration (No. NCT04239716), this pilot study included thirteen consecutive female, 40-85 years old, and scheduled for MRM-ALND. Patients received ESPB at T4 level (5 ml of 2% lidocaine, 10 ml of 0.5% bupivacaine, and 5 ml of normal saline), IBPB (5 ml each of 2% lidocaine and 0.5% bupivacaine), and sedation with dexmedetomidine. The primary aim was to assess the success rate of our technique as a sole anesthesia for MRM-ALND in highrisk patients. Secondary outcomes included intraoperative vital signs measurements. Postoperative measurements were numeric rating scale (NRS) score, analgesic duration, the consumption of morphine, patients' satisfaction, and adverse effects. Results: Our technique succeeded in 11 out of 13 patients. In whom RA were succeeded, the analgesia lasted 360-720 minutes, they received morphine 3-9 mg and had low NRS scores. The two failure cases received GA, the analgesia lasted 60-120 minutes postoperative, they received morphine 9 mg and had high NRS scores. The reduction of hemodynamic parameters intraoperative responded to reduce dexmedetomidine infusion rate. Two patients had postoperative vomiting treated with ondansetrone. Conclusions: The combined ESPB and IBPB could be utilized as an alternative to GA for MRMALND, which reduced the potential risks of GA in high-risk patients; furthermore, it provides satisfactory postoperative analgesia with limited opioid consumption. [ABSTRACT FROM AUTHOR]

Background: Painless and early aggressive mobilization of the shoulder can give good outcomes in a frozen shoulder (FS).Objectives: Our objective is to compare the early and late clinical and functional outcomes of mobilization under continuous interscalene block (CISB) and mobilization and intraarticular steroid injection (IASI) and to determine the effect of the addition of IASI on mobilization and CISB in adults with FS.Methods: We conducted a prospective comparative study. Participants were divided into 3 groups of 20 patients. The allocation was performed by simple randomization. The primary outcomes of pain and patient satisfaction were assessed using VAS scores. Outcome measures such as pain, patient satisfaction, range of motion, and UCLA scores within the groups were assessed.Results: The majority of patients were females. There was a significant improvement in early pain relief and range of motion in patients treated using mobilization under CISB. The late functional outcomes were similar in all groups irrespective of the method of treatment. The IASI had no significant effect on the early or late outcomes of mobilization under CISB.Conclusion: Mobilization under CISB provides early pain relief, improvement in the range of movements, and good long-term functional outcomes in frozen shoulders. IASI does not affect early pain relief or improvement in the range of movements.

Abstract Background Interscalene approach for brachial plexus block is recognized as the gold standard technique for postoperative pain control after shoulder scope surgeries. However, it is associated with major adverse effects and patient discomfort due to paralysis of the hand muscles. The suprascapular nerve block is considered to be a safe and effective alternative to interscalene nerve block for shoulder surgery without affecting the motor function of the hand muscles and other serious complications of interscalene nerve block, especially in ambulatory surgery. The aim of this study is to compare interscalene and suprascapular nerve block in terms of postoperative pain, opioid consumption, and hand grip strength in shoulderscopic surgeries. This prospective, randomized trial was done in Ain Shams University Hospitals. A sample of 50 patients was divided into two groups; 25 patients in each group, namely Group ISB (interscalene approach of brachial plexus block) and Group SSNB (suprascapular nerve block). Visual analogue scale (VAS) was used to assess shoulder pain at rest and upon flexion in the first 24 h. The degree of hand motor power affection, the total amount of opioids used as rescue analgesia, and the incidence of complications were also recorded. Results The findings revealed no statistically significant difference between groups (P-value > 0.05) in pain control all over the 24 h by VAS score at rest and at arm flexion. SSNB received a larger total narcotic dose (60 ± 26.02) mg of pethidine than ISB (52 ± 22.73). However, there was no statistical difference between them throughout the 24 h regarding total narcotic consumption and 1st time for pethidine administration. The ISB group showed a statistically significant reduction in the hand power grip strength postoperatively (83.68 ± 4.75%). Conclusions The results of the present study favor SSNB as the first choice of pain control after shoulderscopic surgeries for a patient scheduled for early home discharge because of the complete recovery of the hand muscles’ motor power. Trial registration This study was registered on PACTR ( www.pactr.org ) database; identification number for the registry is PACTR202201840526231.

Objective: Rotator cuff repair consists of surgical tendon re-fix to the bone. Once the lesion has been identified, loco-regional anesthesia and general anesthesia are the anesthesiologic techniques preferentially used in the intervention for the resolution of the injury, but their use involves several side effects, such as hemidiaphragmatic paralysis, laryngeal nerve block, and pneumothorax. In literature, only one case report presents an arthroscopic repair of massive rotator cuff tears performed under local anesthesia and sedation: in this case, local anesthesia was preferred because of the failure of the locoregional block. Case presentation: In our work, we performed a mini-open rotator cuff repair on a 56-year-old woman with the use of simple local anesthesia, which allowed us to obtain a satisfactory result bypassing side effects deriving from other anesthetic techniques usually used. The patient recovered optimal abduction and good internal rotation of the limb, with a significant reduction in pain mobility. Conclusions: The prospect of performing surgical repair of the rotator cuff under local anesthesia is very interesting, allowing to avoid problems that can occur with general anesthesia administration or regional interscalene block.

Introduction: Brachial plexus block is the cornerstone of anaesthesia and analgesia in the management of upper limb surgeries. Different approaches to this block can be used and compared for efficacy and safety using the same volume of local anaesthetics. AIM: To compare the efficacy of supraclavicular block, interscalene block and combination of supraclavicular and low interscalene block in upper limb orthopaedic surgeries. Materials and Methods: 60 patients of ASA Grade I, II & III of age group 18-65 years of either sex undergoing orthopaedic upper limb surgeries under regional anaesthesia were randomly divided into 3 groups of 20 patients each. In Group SR, supraclavicular block was given using 20ml of Ropivacaine 0.5% with 0.05mg of Dexmedetomidine, In Group IR, Interscalene block was given using 20ml of Ropivacaine 0.5% + 0.05mg of Dexmedetomidine and in Group ISR, a combination of low interscalene and supraclavicular block using 20 ml of Ropivacaine 0.5% + 0.05 mg Dexmedetomidine (10 ml in low interscalene and 10 ml in supraclavicular block) was administered. Results: The demographic profile was comparable in the three groups. The mean time of onset of sensory block was earlier in group ISR (5.77± 1.51 mins) than in SR group (12.77± 2.55 mins) and IR group (7.52 ± 1.50 mins). The mean time of onset of motor block was also significantly shorter in the combination group ISR (7.91± 1.45 mins) than in SR (16.94 ± 3.03 mins) and IR group (11.82 ± 2.81 mins). The mean duration of sensory block (893.56±20.10 mins), as well as motor block (782.50±33.17 mins) in group ISR, was significantly prolonged than the other two groups. Conclusion: The combination of supraclavicular and low interscalene block is more efficacious than supraclavicular and interscalene blocks alone in terms of onset and duration of block without any significant side effects. [ABSTRACT FROM AUTHOR]

It is entirely possible that the patients who received dexmedetomidine in the study by Kang et al. did not ask for rescue opioid until postoperative day 3 because they received twice as much overall opioid in 24 h as the patients in the study by Albrecht et al. did in 48 h (median 20 mg vs. 10 mg). Keywords: analgesia; dexmedetomidine; interscalene block; reliability; reproducibility EN analgesia dexmedetomidine interscalene block reliability reproducibility 1067 1070 4 08/07/23 20230901 NES 230901 I am a mediocre cook, but my baking is pretty good (at least according to my children). Kang et al. [[6]] studied patients having interscalene brachial plexus block for shoulder surgery in combination with intravenous dexamethasone and found that adding intravenous dexmedetomidine extended median time to rescue analgesia from 17 h to nearly 3 days. These investigators found that not only did the addition of intravenous dexmedetomidine fail to prolong analgesia, but patients also had a reduction in time to rescue analgesia. [Extracted from the article]

Background: The use of regional anesthesia in shoulder arthroscopy improves perioperative pain control, thereby reducing the need for opioids and their recognized side effects. Occasionally one type of block is not suitable for a patient’s anatomy or comorbidities or requires a specially trained anesthetist to safely perform. The primary aim of this study is to compare the efficacy of 3 different nerve blocks for pain management in patients undergoing shoulder arthroscopy. Methods: A 3-arm, blinded, randomized controlled trial in patients undergoing elective, unilateral shoulder arthroscopic procedures between August 2018 and November 2020 was conducted at a single center. One hundred and thirty participants were randomized into 1 of 3 regional anesthesia techniques. The first group received an ultrasound-guided interscalene block performed by an anesthetist (US + ISB). The second group received an ultrasound-guided suprascapular nerve block and an axillary nerve block by an anesthetist (US + SSANB). The final group received a suprascapular nerve block without ultrasound and an axillary nerve block under arthroscopic guidance by an orthopedic surgeon (A + SSANB). Intraoperative pain response, analgesia requirements, and side effects were recorded. Visual analogue pain scores and opioid doses were recorded in the Post Anaesthesia Care Unit (PACU) and daily for 8 days following the procedure. Results: Twelve patients withdrew from the study after randomization, leaving 39 participants in US + ISB, 40 in US + SSANB, and 39 in A + SSANB. The US + ISB group required significantly lower intraoperative opioid doses than US + SSANB and A + SSANB (P

Interscalene block is usually performed using either ultrasound (US) or nerve stimulator (NS) guidance. This single-blinded, prospective, randomised study was performed to find out whether US was able to offer distinct advantages over conventional NS guidance. 100 patients in the American Society of Anaesthesiology (ASA) physical status I to III, aged 18–70 years were randomised into US guided or NS guided group for interscalene block with 15 ml 0.5% bupivacaine and 5 ml 2% lignocaine. Patients were premedicated with midazolam 0.03 mg/kg (maximum 2 mg) and fentanyl 2 mcg/kg (max 100 mcg) was used as rescue analgesia. Mean time of onset of sensory block in the NS group was 6.2 min (3.1), the US group 4.7 min (1.1), p value (<0.001). Mean duration of post-operative analgesia in NS group 323.6 min (98.6), US group 558.6 min (144.3), (p < 0.001). Mean time for performance of block NS Group 7.3 min (2.0), and in the US group 4.9 min (1.3), (p < 0.001). Number of needle passes NS group 1.7(0.9), US group 1.3 (1.0), (p < 0.005). Total cost per surgery with NS was Rs 363.10 less than in the US-guided block. Incremental cost effectiveness ratio for ultrasound group for onset of block was Rs −242.07, Rs 92.0 for duration of block and Rs −151.29 for time for performance of block. No incident of post-operative neurological complications seen in either group. Ultrasound use offers faster onset, longer duration of block, reduces time for performance of blocks with comparable complication rates. For most of the measured parameters it was superior but more costly than nerve stimulator for directly measured costs. [ABSTRACT FROM AUTHOR]

Background: Interscalene approach for brachial plexus block is recognized as the gold standard technique for postoperative pain control after shoulder scope surgeries. However, it is associated with major adverse effects and patient discomfort due to paralysis of the hand muscles. The suprascapular nerve block is considered to be a safe and effective alternative to interscalene nerve block for shoulder surgery without affecting the motor function of the hand muscles and other serious complications of interscalene nerve block, especially in ambulatory surgery. The aim of this study is to compare interscalene and suprascapular nerve block in terms of postoperative pain, opioid consumption, and hand grip strength in shoulderscopic surgeries. This prospective, randomized trial was done in Ain Shams University Hospitals. A sample of 50 patients was divided into two groups; 25 patients in each group, namely Group ISB (interscalene approach of brachial plexus block) and Group SSNB (suprascapular nerve block). Visual analogue scale (VAS) was used to assess shoulder pain at rest and upon flexion in the first 24 h. The degree of hand motor power affection, the total amount of opioids used as rescue analgesia, and the incidence of complications were also recorded. Results: The findings revealed no statistically significant difference between groups (P-value > 0.05) in pain control all over the 24 h by VAS score at rest and at arm flexion. SSNB received a larger total narcotic dose (60 ± 26.02) mg of pethidine than ISB (52 ± 22.73). However, there was no statistical difference between them throughout the 24 h regarding total narcotic consumption and 1st time for pethidine administration. The ISB group showed a statistically significant reduction in the hand power grip strength postoperatively (83.68 ± 4.75%). Conclusions: The results of the present study favor SSNB as the first choice of pain control after shoulderscopic surgeries for a patient scheduled for early home discharge because of the complete recovery of the hand muscles' motor power. Trial registration: This study was registered on PACTR (www.pactr.org) database; identification number for the registry is PACTR202201840526231. [ABSTRACT FROM AUTHOR]

En-Bo Wu,1,&ast; Chia-Chi Hsiao,2,&ast; Kuo-Chuan Hung,3 Chao-Ting Hung,1 Chih-Chun Chen,1 Shao-Chun Wu,1 Jo-Chi Chin,4 I-Wen Chen,3 Sheng-Dean Luo5 1Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; 2Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; 3Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan; 4Department of Anesthesiology, Park One International Hospital, Kaohsiung, Taiwan; 5Division of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Kaohsiung, Taiwan&ast;These authors contributed equally to this workCorrespondence: Sheng-Dean Luo, No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City, 833, Taiwan, Tel +886-7-7317123 (ext. 2788), Email rsd0323@cgmh.org.tw I-Wen Chen, No. 901, Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan, Tel +886-6-2812811, Email mavising@gmail.comPurpose: Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB.Patients and Methods: In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery.Results: Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward.Conclusion: Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.Graphical Abstract: Keywords: interscalene block, multimodal analgesia, opioid-sparing anesthesia, shoulder arthroscopy, volatile-sparing anesthesia

Background: Classical interscalene approach of brachial plexus block with superficial cervical plexus block has become the anesthetic technique of choice in the upper arm, shoulder, and clavicle surgery but there is high risk of complications and sparing of C8-T1 nerve roots. Here, we used low approach of interscalene block (ISB) with superficial cervical plexus block for lateral one-third of clavicle and proximal humerus surgeries. Previously, none of the study compare ultrasonography (USG) guided low ISB (LISB) to the conventional approach for lateral one-third of clavicle and proximal humerus surgeries. Aims and Objectives: The aim of the study was to compare onset, duration, density of sensory-motor block, and severity of complication between ISB and LISB with superficial cervical plexus block. Materials and Methods: Patients with fracture of lateral end of clavicle and proximal humerus of 18–60 years of 324, American Society of Anesthesiologists I and II patients, were randomly assigned into two groups ISBS and LISB with superficial cervical plexus block (LISBS) to find out the difference in density of sensory-motor blockade associated with any complications between two groups. Results: The degree of the ulnar block after 5 and 15 min was found to be 2.8±2.6 and 1.1±1.8 in LISBS, respectively, for ISBS 3.0±1.5 and 1.8±2.0, respectively, based on a ten-point scale. After 15 min, motor block occurred in the median nerve in 151 patients out of 162 (92.8%), and in all of the other three nerves in all 162 patients. Horner syndrome and hoarseness were less frequent in LISB with superficial cervical plexus block patients than in ISB with superficial cervical plexus block patients (P=0.0009 and 0.003, respectively) which was statistically significant. Conclusion: The present study confirmed the achievement of an appropriate sensory and motor block in the lateral one-third of clavicle with proximal humerus surgery, including the ulnar nerve with no complications than ISB.

Purpose: Infraclavicular block (ICB) and interscalene block (ISB) accompanied by ultrasonography imaging (USI) are the most frequently used brachial plexus block techniques in upper extremity surgeries. It is already known that sympathetic blockage occurs after the application of these blocks, and blood flow increases with vasodilatation caused by the blockage. This study aimed to compare the effect of ICB and ISB, which are applied together with USI, on forearm tissue oxygenation. Materials and Methods: A hundred-four patients were included in this study belonging to ASA I-III risk groups, aged 18–65 years, who were scheduled for elective or emergency arm, elbow, or forearm surgery. The patients were divided into two groups: Group ICB and Group ISB. In addition to the baseline hemodynamic measurements, PI, time average velocity (TAV), brachial artery diameter (BAD), brachial arterial area (BAA), brachial artery beat flow (BF), and tissue oxygen saturation (rSO2) data were recorded before block and at the 10th, 20th, and 30th min after the block was completed. Results: The demographic data of the patients in the Group ICB and Group ISB were compared, no significant differences were detected between the groups. When the distribution of the percentage increase in PI and rSO2 values according to time was examined, significant differences were found between the groups. There were no significant differences in the percentage increases in BF, TAV, BAA, and BAD values between the 0th minute and at 10th, 20th, and 30th min (p>0.05). Horner syndrome was observed in 8 patients (15%) and sudden hoarseness was observed in 3 patients (5%) in Group ISB. No complications developed in the Group ICB. Conclusion: This study shows that the effects of ICB and ISB on forearm tissue oxygenation were compared and it was found that ICB increased rSO2 and PI values.

The traditional interscalene block has evolved over time to lower, lateral and posterior approaches, coinciding with the advent of Peripheral Nerve Stimulator and Ultrasonography. In limited infrastructure settings, such technology remains elusive and the classical paresthesia technique comes to the rescue. This approach is however very difficult to elicit in pediatric patients. It is here that the grassroot approach of a fascial “click” or “pop” emerges as the savior to administer a satisfactory block. We describe a case of a young boy with successful conduct of anaesthesia for K wire fixation of supracondylar fracture of humerus under lower interscalene block with loss of resistance technique. In light of recent research showing about 40-50% variation in the brachial plexus anatomy around the subclavian artery, use of technology in anaesthesia is the future. However, till such technology is made universally affordable, it is pertinent to remember the roots of interscalene block!

Introduction The application of enhanced recovery in shoulder surgery has not had such a favorable acceptance, therefore, the objective of this study was to present and describe the use of interscalene block to promote enhanced recovery in a series of patients undergoing shoulder arthroscopic surgery. Methods Thirty-five patients undergoing arthroscopic shoulder surgery were included, in whom interscalene blockade and sedation were administered. Subsequently, pain intensity, nausea, vomiting, dyspnea, presence of Horner’s syndrome, blurred vision, hoarseness, time elapsed to discharge, unplanned readmissions, patient satisfaction, and compliance with hospital discharge criteria in the first 12 weeks were evaluated, hours following the criteria of an enhanced recovery. Results 27 patients (77,1%) had ASA I and 8 patients (22,8%) ASA II, 97,1% were rotator cuff repairs. Before discharge, two patients (5.7%) had nausea. At discharge, no patient had dyspnea or blurred vision, two patients (5.7%) developed hoarseness, and the median pain intensity was 1.0 (0.0-7.0). Between 24 and 48 hours only one patient (2.8%) presented nausea and the median pain intensity was 1.0 (0.0-8.0). All the patients were satisfied with their willingness to repeat the experience, 100% of the patients met the criteria for medical discharge after 12 hours, 30 patients (85.7%) were discharged the same day, the stay was 12 (11.5 to 12.5) hours, and no patient was readmitted. Conclusion In selected patients with a committed, trained and experienced surgical-anesthetic team, there is a high possibility that the interscalene block will favor the performance of enhanced recovery programs in shoulder arthroscopic surgery.

The article offers information on comparing the efficacy of single-dose versus continuous infusion of 0.2 percent ropivacaine in interscalene brachial plexus nerve blocks for pain relief following rotator cuff repair surgery. Topics discussed include the methodology of administering the nerve blocks; the evaluation of pain relief using the Visual Analog Scale (VAS); and the assessment of motor and sensory function post-surgery.

Background: Classical interscalene approach of brachial plexus block with superficial cervical plexus block has become the anesthetic technique of choice in the upper arm, shoulder, and clavicle surgery but there is high risk of complications and sparing of C8-T1 nerve roots. Here, we used low approach of interscalene block (ISB) with superficial cervical plexus block for lateral one-third of clavicle and proximal humerus surgeries. Previously, none of the study compare ultrasonography (USG) guided low ISB (LISB) to the conventional approach for lateral one-third of clavicle and proximal humerus surgeries. Aims and Objectives: The aim of the study was to compare onset, duration, density of sensory-motor block, and severity of complication between ISB and LISB with superficial cervical plexus block. Materials and Methods: Patients with fracture of lateral end of clavicle and proximal humerus of 18-60 years of 324, American Society of Anesthesiologists I and II patients, were randomly assigned into two groups ISBS and LISB with superficial cervical plexus block (LISBS) to find out the difference in density of sensory-motor blockade associated with any complications between two groups. Results: The degree of the ulnar block after 5 and 15 min was found to be 2.8±2.6 and 1.1±1.8 in LISBS, respectively, for ISBS 3.0±1.5 and 1.8±2.0, respectively, based on a ten-point scale. After 15 min, motor block occurred in the median nerve in 151 patients out of 162 (92.8%), and in all of the other three nerves in all 162 patients. Horner syndrome and hoarseness were less frequent in LISB with superficial cervical plexus block patients than in ISB with superficial cervical plexus block patients (P=0.0009 and 0.003, respectively) which was statistically significant. Conclusion: The present study confirmed the achievement of an appropriate sensory and motor block in the lateral one-third of clavicle with proximal humerus surgery, including the ulnar nerve with no complications than ISB. [ABSTRACT FROM AUTHOR]

Background: Interscalene blocks are becoming increasingly common for shoulder surgeries. This study primarily aimed to demonstrate the efficacy and complications and the secondarily to investigate the anesthesia-related time and patient satisfaction of an ultrasound-guided interscalene block performed by an orthopedic surgeon. Methods: We retrospectively reviewed the medical records of 1322 consecutive patients (arthroscopic, 1225 cases; open, 97 cases) with a mean age of 64.2 years, who underwent shoulder surgery (arthroscopic or opensurgery) under an ultrasound-guided interscalene block performed by an orthopedic surgeon at a single institution between December 2012 and December 2019. We investigated patient satisfaction, block success rates, and complications and also compared the anesthesia-related time of an interscalene block with that of general anesthesia (428 cases, arthroscopic, 257 cases; open, 171 cases) for shoulder surgery with patients in the beach chair position during the same period. Difference between total anesthesia time and surgical time was defined as anesthesia-related time. Results: Approximately 98.3% of patients were satisfied with an interscalene block, and the block success rate on the first attempt was 99.9%. Total complication incidence was 2.3%, with no recorded life-threatening complications. Anesthesia-related times were significantly shorter in the interscalene block group than those in the general anesthesia group (45 ± 14 min vs. 100 ± 26 min, P

We conducted a retrospective study of the effectiveness of liposomal bupivacaine for analgesia in interscalene block for patients undergoing ambulatory rotator cuff repair. Postoperative opioid use, the primary outcome measure, was markedly reduced, and pain scores were significantly lower, as compared to use of plain bupivacaine block in a historical control group. Furthermore, most patients found that the duration of pain control was longer than their own prior plain bupivacaine interscalene block. [ABSTRACT FROM AUTHOR]

Introduction: Management of intraoperative hemodynamics and postoperative analgesia during arthroscopic shoulder surgeries remains a challenge. Although interscalene brachial plexus block (ISB) is considered ideal for shoulder anesthesia it requires skill and proficiency unlike intravenous (IV) dexmedetomidine. Objective: This randomized trial was performed to observe the efficacy of dexmedetomidine infusion which is less invasive and demands lesser skills than plexus block. Methodology: All patients scheduled for elective arthroscopic shoulder surgery under general anesthesia were assigned either to group DEX, which received an IV dexmedetomidine bolus of 0.5 mcg/kg over 20 minutes, followed by an infusion of 0.5 mcg/kg/hour that was stopped 30 minutes before surgery the end of surgery or to group BLOCK which received ultrasound guided ISB with 20ml of 0.25% bupivacaine. The primary outcome assessed was intraoperative hemodynamics; the secondary outcomes were immediate postoperative pain, operating condition as assessed by the surgeon, recovery time, and patient satisfaction after 24 hours. Blinded investigator and composite scores were used for the assessment. Results: Both groups displayed equivalent scores for intraoperative hemodynamics whereas ISB resulted in a better post-operative analgesia (p < 0.001). Surgeon's opinion and recovery time were comparable. Overall, the patients had a satisfactory experience with both techniques, according to the quality assessment. Conclusions: IV dexmedetomidine infusion is an effective alternative to ISB for reconstructive shoulder surgeries under general anesthesia. [ABSTRACT FROM AUTHOR]

Background & objective: Inter-scalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. Although, this method has its side-effects and possibly complications. Suprascapular nerve block and axillary nerve block have also been used in upper limb procedures. We compared ISB with the blockade of supra-scapular and axillary nerves (called shoulder block) for postoperative analgesia after shoulder arthroscopic surgical operation under ultrasound guidance (USG) and nerve stimulators. Methodology: It was a prospective, randomized, comparative study. Results: The VAS pain scores at different times postoperatively were not significantly different between the ISB and ShB groups (P = t 0.071, 0.28, 0.378, 0.358, 0.451 at 2, 4, 8, 16, and 24 h respectively. VAS 0 was significantly difference (P = 0.029) but still the VAS score was less than 3, so no pain killers were given. Conclusion: Ultrasound guided supra-scapular and axillary nerve blocks ae equally effective as inter-scalene brachial plexus block for postoperative analgesia in shoulder arthroscopic surgery with less side-effects. [ABSTRACT FROM AUTHOR]

Background: Interscalene catheters (ISC) are considered as the gold standard for perioperative pain control after total shoulder arthroplasty (TSA). Liposomal bupivacaine (LB) for interscalene blocks (ISB) or the addition of dexamethasone to ISBs have both presented as additional options for extended analgesia. We aimed to compare the efficacy of LB to a single shot ISB (SISB) with added dexamethasone to an ISC. We hypothesized that a single injection of LB or an ISB with a dexamethasone will provide non-inferior duration and quality of analgesia compared to ISC., Methods: A single centered triple blinded randomized controlled trial evaluated patients undergoing elective primary TSA. Patients were randomized to 3 groups, Group A (control): 0.5% bupivacaine 15 ml with a rescue catheter left in situ (0.125% bupivacaine infusion), Group B: 0.5% bupivacaine 14 ml with 4mg (1 ml) dexamethasone with a catheter left in situ (saline infusion), Group C: 10 ml of liposomal bupivacaine (133 mg) with 0.5% bupivacaine 5 ml, with a catheter left in situ (saline infusion). The primary outcome was the worst NRS (numeric rating scale) measured on arrival to PACU, 6 hours, 12 hours, 24 hours, and 36 hours postoperatively. Secondary outcomes recorded were time to first analgesic request, intraoperative opioid consumption, total inpatient opioid consumption, arm weakness, arm numbness, time of analgesia duration, time of motor recovery, sensory testing using pinprick on POD1, Q36, Q48, hand strength assessment using dynamometer POD1, Q36, Q48, PACU and hospital length of stay., Results: We analyzed 72 patients in 3 groups (Group A 24, group B 24, Group C 24). The pre-surgery physical function scores were similar between groups. The change in postoperative pain was not different among the three groups. All 3 groups demonstrated an increase in the postoperative values, a change that was not statistically significant between groups. Likewise, no difference in the mental function score was seen within or between groups. No differences in sleep quality or satisfaction were seen among groups (P values 0.405 and 1.00, respectively). No adverse events were reported in all groups., Conclusions: No significant difference was demonstrated between a single injection ISB with dexamethasone, a LB injection and an ISC. Given the equivalence in analgesia provided with these three modalities, providers should carefully consider the option that best fits each patient. Thus, a single injection of LB or single injection of bupivacaine with dexamethasone provides similar analgesic efficacy compared to ISC., (Copyright © 2024. Published by Elsevier Inc.)

General anaesthesia has a priority in surgical interventions of clavicle; however, regional techniques may come to the fore in the presence of increased risk factors. The innervation of the clavicle region is very complex and has not been fully described; therefore, only a limited number of different regional anaesthesia approaches should be considered. Here, we present the management of a clavicle fracture with a combination of an interscalene block (ISB) and deep cervical plexus block (dCPB) in a patient with severe maxillo-facial trauma (MFT) and diaphragmatic hernia due to combat injury. A 35-year-old male admitted to the emergency room as a war-wounded patient had suffered MFT and an unstable clavicle defect during the Syrian War. A diaphragmatic hernia was also detected during examination. The patient underwent operation with regional anaesthesia of the clavicle under spontaneous respiration. With standard monitoring and sedation, ISB and dCPB were performed under ultrasound guidance with a mixture of 0.25% bupivacaine (20 mL) and 0.5% lidocaine (10 mL). In the perioperative period, the patient's vital signs remained stable. The patient had no pain during the surgery. We suggest that the combination of ISB and dCPB is an efficient option for management of clavicle fracture in patients with multiple comorbidities.

Objectives: The pain sensation of the clavicle is innervated by two separate plexuses. Regional anesthesia techniques for this area are challenging and complicated. Interscalene block, superficial cervical block, or a combination of these two is commonly used for regional anesthesia in clavicle surgery. The aim of this study was to investigate the efficacy of C5 nerve root block for clavicle surgery. Methods: Patients were divided into two groups: Group C5B (patients who received C5 nerve root block + superficial cervical plexus block) and Group ISB (patients who received interscalene block + superficial cervical plexus block). Motor block was assessed by the Medical Research Council Scale for Muscle Strength, while the sensory block of the areas corresponding to the nerve trace was assessed using the pinprick and cold testing. Furthermore, ultrasound was employed to evaluate phrenic nerve paralysis. Results: There was no difference between the groups in terms of mean age. The mean age of Group ISB was higher; however, the comparison of comorbidities revealed no significant difference between the groups. This statistically significant difference was clinically insignificant. Group C5B had lower 6-hour pain at rest, lower 0, 2, 4-hour pain on movement, and less postoperative analgesic consumption. Moreover, the time to first analgesic requirement was significantly longer in Group C5B. The motor examination of the peripheral nerves showed a significant difference in Group C5B. Conclusions: We are of the opinion that C5 nerve root block can be used instead of interscalene block since it does not produce a motor block in hand movements and preserves diaphragmatic functions. C5 nerve root block may therefore be considered an alternative to conventional interscalene block for clavicle surgery [ABSTRACT FROM AUTHOR]

Purpose: Infraclavicular block (ICB) and interscalene block (ISB) accompanied by ultrasonography imaging (USI) are the most frequently used brachial plexus block techniques in upper extremity surgeries. It is already known that sympathetic blockage occurs after the application of these blocks, and blood flow increases with vasodilatation caused by the blockage. This study aimed to compare the effect of ICB and ISB, which are applied together with USI, on forearm tissue oxygenation. Materials and Methods: A hundred-four patients were included in this study belonging to ASA I-III risk groups, aged 18–65 years, who were scheduled for elective or emergency arm, elbow, or forearm surgery. The patients were divided into two groups: Group ICB and Group ISB. In addition to the baseline hemodynamic measurements, PI, time average velocity (TAV), brachial artery diameter (BAD), brachial arterial area (BAA), brachial artery beat flow (BF), and tissue oxygen saturation (rSO2) data were recorded before block and at the 10th, 20th, and 30th min after the block was completed. Results: The demographic data of the patients in the Group ICB and Group ISB were compared, no significant differences were detected between the groups. When the distribution of the percentage increase in PI and rSO2 values according to time was examined, significant differences were found between the groups. There were no significant differences in the percentage increases in BF, TAV, BAA, and BAD values between the 0th minute and at 10th, 20th, and 30th min (p>0.05). Horner syndrome was observed in 8 patients (15%) and sudden hoarseness was observed in 3 patients (5%) in Group ISB. No complications developed in the Group ICB. Conclusion: This study shows that the effects of ICB and ISB on forearm tissue oxygenation were compared and it was found that ICB increased rSO2 and PI values. [ABSTRACT FROM AUTHOR]