The effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery: a double-blind, randomized controlled trial
Craig T Hartrick, Yeong-Shih Tang, Don Siwek, Robert Murray, David Hunstad, Greg Smith, Craig T Hartrick, Yeong-Shih Tang, Don Siwek, Robert Murray, David Hunstad, Greg Smith
Abstract
Background: Interscalene block (ISB) is commonly performed using 20-40 mL of local anesthetic. Spread to adjacent structures and consequent adverse effects including paralysis of the ipsilateral hemidiaphragm are frequent. Pain ratings, analgesic requirements, adverse events, satisfaction, function and diaphragmatic excursion were compared following interscalene block (ISB) with reduced initial bolus volumes.
Methods: Subjects undergoing arthroscopic rotator cuff repair were randomized to receive 5, 10, or 20 mL ropivacaine 0.75% for ISB in a double-blind fashion (N = 36). Continuous infusion with ropivacaine 0.2% was maintained for 48 h. Pain and diaphragmatic excursion were assessed before block and in the recovery unit.
Results: Pain ratings in the recovery room were generally less than 4 (0-10 NRS) for all treatment groups, but a statistically significant difference was noted between the 5 and 20 mL groups (NRS: 2.67 vs. 0.62 respectively; p = 0.04). Pain ratings and supplemental analgesic use were similar among the groups at 24 h, 48 h and 12 weeks. There were no differences in the quality of block for surgical anesthesia. Dyspnea was significantly greater in the 20 mL group (p = 0.041). Subjects with dyspnea had significant diaphragmatic impairment more frequently (Relative risk: 2.5; 95%CI: 1.3-4.8; p = 0.042). Increased contralateral diaphragmatic motion was measured in 29 of the 36 subjects. Physical shoulder function at 12 weeks improved over baseline in all groups (baseline mean SST: 6.3, SEM: 0.6; 95%CI: 5.1-7.5; 12 week mean SST: 8.2, SEM: 0.46; 95%CI: 7.3-9.2; p = 0.0035).
Conclusions: ISB provided reliable surgical analgesia with 5 mL, 10 mL or 20 mL ropivacaine (0.75%). The 20 mL volume was associated with increased complaints of dyspnea. The 5 mL volume was associated with statistically higher pain scores in the immediate postoperative period. Lower volumes resulted in a reduced incidence of dyspnea compared to 20 mL, however diaphragmatic impairment was not eliminated. Compensatory increases in contralateral diaphragmatic movement may explain tolerance for ipsilateral paresis.
Trial registration: clinicaltrials.gov. identifier: NCT00672100.
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References
- Swenson JD, Bay N, Loose E, Bankhead B, Davis J, Beals TC, Bryan NA, Burks RT, Greis PE. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg. 2006;103:1436–1443. doi: 10.1213/01.ane.0000243393.87912.9c.
- Urmey WF, McDonald M. Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics. Anesth Analg. 1992;74:352–357.
- Sala-Blanch X, Lázaro JR, Correa J, Gómez-Fernandez M. Phrenic nerve block caused by interscalene brachial plexus block: effects of digital pressure and a low volume of local anesthetic. Reg Anesth Pain Med. 1999;24:231–235.
- Roessel T, Wiessner D, Heller AR, Zimmermann T, Koch T, Litz RJ. High-resolution ultrasound-guided high interscalene plexus block for carotid endarterectomy. Reg Anesth Pain Med. 2007;32:247–253.
- Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294. doi: 10.1016/S0304-3959(00)00339-0.
- Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery. Anesthesiology. 2000;92:102–108. doi: 10.1097/00000542-200001000-00020.
- Godfrey J, Hamman R, Lowenstein S, Briggs K, Kocher M. Reliability, validity, and responsiveness of the simple shoulder test: Psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16:260–267. doi: 10.1016/j.jse.2006.07.003.
- Norquist BM, Goldberg BA, Matsen FA. Challenges in evaluating patients lost to follow-up in clinical studies of rotator cuff tears. J Bone Joint Surg Am. 2000;82:838–842.
- Romeo AA, Mazzocca A, Hang DW, Shott S, Bach BR. Shoulder scoring scales for the evaluation of rotator cuff repair. Clin Orthop Rel Res. 2004;427:107–114.
- Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008;101:549–556. doi: 10.1093/bja/aen229.
- Sinha SK, Abrams JH, Barnett JT, Muller JG, Lahiri B, Bernstein BA, Weller RS. Decreasing the local anesthetic volume from 20 mL to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2011;36:17–20. doi: 10.1097/AAP.0b013e3182030648.
- McNaught A, Shastri U, Carmichael N, Awad IT, Columb M, Cheung J, Holtby RM, McCartney CJ. Ultrasound reduces the minimum effective local anesthetic volume compared with peripheral nerve stimulation for interscalene block. Br J Anaesth. 2011;106:124–130. doi: 10.1093/bja/aeq306.
- Renes SH, van Geffen GJ, Rettig HC, Gielen MJ, Scheffer GJ. Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at C7 with assessment of pulmonary function. Reg Anesth Pain Med. 2010;35:529–534. doi: 10.1097/AAP.0b013e3181fa1190.
Source: PubMed