Comparative Evaluation of Diaphragmatic Function Following Interscalene, Anterior Suprascapular, and Costoclavicular Nerve Blocks in Shoulder Surgery
Shoulder surgery causes significant postoperative pain, and ultrasound-guided regional anesthesia is central to its management. The interscalene block (ISB) is the gold standard but frequently causes phrenic nerve paralysis and hemi-diaphragmatic paresis, limiting its use in patients with reduced pulmonary reserve. The suprascapular (SSNB) and costoclavicular (CCB) blocks are proposed diaphragm-sparing alternatives, but data directly comparing all three are limited.
This randomised, double-blinded trial will compare the incidence of hemi-diaphragmatic paresis among ultrasound-guided ISB, SSNB, and CCB in elective shoulder surgery. Seventy-five ASA I-II patients aged 18-70 will be allocated 1:1:1 to one block. The primary outcome is the incidence of hemi-diaphragmatic paresis, measured by ultrasound diaphragmatic excursion before induction and after recovery in the PACU. Secondary outcomes include postoperative pain, analgesic consumption, and patient satisfaction. The investigators hypothesise that SSNB and CCB will cause less hemidiaphragmatic paresis than ISB while providing comparable analgesia.
Descripción general del estudio
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Descripción detallada
This randomized, double-blinded, parallel-group trial compares the effect of three ultrasound-guided regional anesthesia techniques on diaphragmatic function in elective shoulder surgery. The interscalene block (ISB), the gold standard, frequently causes phrenic nerve paralysis and hemi-diaphragmatic paresis. The suprascapular (SSNB) and costoclavicular (CCB) blocks preserve analgesia while sparing the phrenic nerve, but direct comparative data among all three are limited.
Seventy-five ASA I-II patients aged 18-70 scheduled for elective shoulder surgery will be randomized 1:1:1 (25 per group) using computer-generated allocation with sealed opaque envelopes. ISB: 10 mL 0.25% bupivacaine with dexmedetomidine 0.5 µg/kg; SSNB: 10 mL of the same mixture; CCB: 20 mL of the same mixture. All blocks are ultrasound-guided and performed before a standardised general anaesthetic.
Diaphragmatic excursion is measured by M-mode ultrasound of both hemidiaphragms at baseline (pre-induction), 30 minutes after the block, and in the PACU at a train-of-four ratio ≥0.9. Hemi-diaphragmatic paresis is graded as Complete (>75% reduction or paradoxical movement), Partial (25-75%), or Normal (0-25%). The primary outcome is its incidence. Secondary outcomes include VAS pain at rest and movement (1, 3, 6, 12, 24 h), analgesic consumption, time to first rescue analgesia, block performance time, complications, and patient satisfaction.
Tipo de estudio
Inscripción (Estimado)
Fase
- Fase 4
Criterios de participación
Criterio de elegibilidad
Edades elegibles para estudiar
- Adulto
- Adulto Mayor
Acepta Voluntarios Saludables
Descripción
Inclusion Criteria:
Adults of both sexes, aged 18 to 70 years American Society of Anesthesiologists (ASA) physical status I-II Scheduled for elective shoulder surgery
Exclusion Criteria:
Pulmonary disease or baseline diaphragmatic dysfunction Refusal to provide informed consent Pre-existing neuropathy in the operated limb Allergy to local anesthetics Infection at the injection site Coagulopathy Pregnancy
Plan de estudios
¿Cómo está diseñado el estudio?
Detalles de diseño
- Propósito principal: Tratamiento
- Asignación: Aleatorizado
- Modelo Intervencionista: Asignación paralela
- Enmascaramiento: Doble
Armas e Intervenciones
Grupo de participantes/brazo |
Intervención / Tratamiento |
|---|---|
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Comparador activo: Interscalene Block (ISB)
Ultrasound-guided interscalene brachial plexus block targeting the C5-C6 roots, performed approximately 1 hour before surgery.
Injectate: 10 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg.
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Ultrasound-guided interscalene brachial plexus block performed ~1 hour before surgery.
With the patient supine and head rotated contralaterally, a high-frequency linear transducer identifies the C5-C6 roots between the anterior and middle scalene muscles.
Using an in-plane technique, 10 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg is injected with frequent aspiration.
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Experimental: Suprascapular Nerve Block (SSNB)
Ultrasound-guided suprascapular nerve block was performed proximal to the transverse scapular ligament, approximately 1 hour before surgery.
Injectate: 10 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg.
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Ultrasound-guided suprascapular nerve block performed ~1 hour before surgery.
A linear high-frequency probe in the supraclavicular region identifies the suprascapular nerve.
A 22-gauge echogenic needle is advanced in-plane to the nerve proximal to the transverse scapular ligament, and 10 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg is injected under real-time ultrasound, confirming circumferential spread.
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Experimental: Costoclavicular Block (CCB)
Ultrasound-guided costoclavicular brachial plexus block targeting the brachial plexus cords in the costoclavicular space, approximately 1 hour before surgery.
Injectate: 20 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg.
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Ultrasound-guided costoclavicular brachial plexus block performed ~1 hour before surgery.
With the operative arm abducted ~60°, a linear probe inferior to the mid-clavicle visualizes the three brachial plexus cords lateral to the axillary artery.
An echogenic needle is advanced in-plane into the interfascial plane, and 20 mL of 0.25% bupivacaine combined with dexmedetomidine 0.5 µg/kg is injected with aspiration and ultrasound confirmation of homogeneous spread.
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¿Qué mide el estudio?
Medidas de resultado primarias
Medida de resultado |
Medida Descripción |
Periodo de tiempo |
|---|---|---|
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Incidence of hemi-diaphragmatic paresis
Periodo de tiempo: From pre-induction baseline to PACU assessment at train-of-four ratio ≥0.9 (up to approximately 24 hours after the block
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Incidence of hemi-diaphragmatic paresis assessed by M-mode ultrasound measurement of diaphragmatic excursion, comparing post-block values to the pre-induction baseline.
Hemi-diaphragmatic paresis is defined as a >75% reduction in diaphragmatic excursion from baseline or paradoxical diaphragmatic movement (complete paresis); a 25-75% reduction is classified as partial paresis.
Measured in the PACU after recovery of muscle power (train-of-four ratio ≥0.9).
Reported as the number/percentage of participants with hemi-diaphragmatic paresis in each group.
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From pre-induction baseline to PACU assessment at train-of-four ratio ≥0.9 (up to approximately 24 hours after the block
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Medidas de resultado secundarias
Medida de resultado |
Medida Descripción |
Periodo de tiempo |
|---|---|---|
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Postoperative pain score at rest (static VAS)
Periodo de tiempo: At 1, 3, 6, 12, and 24 hours postoperatively
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Pain intensity at rest was measured on a visual analogue scale (VAS), where 0 = no pain and 10 = worst imaginable pain.
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At 1, 3, 6, 12, and 24 hours postoperatively
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Patient satisfaction
Periodo de tiempo: 24 hours postoperatively
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Overall satisfaction with the procedure and postoperative analgesia, assessed on a 5-point scale (very satisfied, satisfied, neutral, dissatisfied, very dissatisfied).
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24 hours postoperatively
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Colaboradores e Investigadores
Patrocinador
Publicaciones y enlaces útiles
Publicaciones Generales
- Renard Y, Grape S, Gonvers E, Rossel JB, Goetti P, Albrecht E. Respiratory impact of local anaesthetic volume after interscalene brachial plexus block with extrafascial injection: a randomised controlled double-blinded trial. Br J Anaesth. 2025 Apr;134(4):1153-1160. doi: 10.1016/j.bja.2024.12.010. Epub 2025 Jan 23.
- Lee Y, Bang S, Chung J, Chae MS, Shin J. Costoclavicular block as a diaphragm-sparing nerve block for shoulder surgery: a randomized controlled trial. Korean J Anesthesiol. 2025 Feb;78(1):30-38. doi: 10.4097/kja.24595. Epub 2024 Dec 10.
Fechas de registro del estudio
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Publicado por primera vez (Actual)
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Última actualización enviada que cumplió con los criterios de control de calidad
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Palabras clave
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Otros números de identificación del estudio
- ANESTH50 (Otro identificador: Menoufia university)
Plan de datos de participantes individuales (IPD)
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Información sobre medicamentos y dispositivos, documentos del estudio
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