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.
調査の概要
状態
詳細な説明
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.
研究の種類
入学 (推定)
段階
- フェーズ 4
参加基準
適格基準
就学可能な年齢
- 大人
- 高齢者
健康ボランティアの受け入れ
説明
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
研究計画
研究はどのように設計されていますか？
デザインの詳細
- 主な目的：処理
- 割り当て：ランダム化
- 介入モデル：並列代入
- マスキング：ダブル
武器と介入
参加者グループ / アーム |
介入・治療 |
|---|---|
|
アクティブコンパレータ：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.
|
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.
|
|
実験的：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.
|
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.
|
|
実験的：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.
|
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.
|
この研究は何を測定していますか？
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Incidence of hemi-diaphragmatic paresis
時間枠：From pre-induction baseline to PACU assessment at train-of-four ratio ≥0.9 (up to approximately 24 hours after the block
|
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.
|
From pre-induction baseline to PACU assessment at train-of-four ratio ≥0.9 (up to approximately 24 hours after the block
|
二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Postoperative pain score at rest (static VAS)
時間枠：At 1, 3, 6, 12, and 24 hours postoperatively
|
Pain intensity at rest was measured on a visual analogue scale (VAS), where 0 = no pain and 10 = worst imaginable pain.
|
At 1, 3, 6, 12, and 24 hours postoperatively
|
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Patient satisfaction
時間枠：24 hours postoperatively
|
Overall satisfaction with the procedure and postoperative analgesia, assessed on a 5-point scale (very satisfied, satisfied, neutral, dissatisfied, very dissatisfied).
|
24 hours postoperatively
|
協力者と研究者
スポンサー
出版物と役立つリンク
一般刊行物
- 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.
研究記録日
主要日程の研究
研究開始 (推定)
一次修了 (推定)
研究の完了 (推定)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (実際)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
本研究に関する用語
その他の研究ID番号
- ANESTH50 (その他の識別子：Menoufia university)
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