UNASSIGNED: The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound.
UNASSIGNED: In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted.
UNASSIGNED: At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea.
UNASSIGNED: There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

UNASSIGNED: The purpose of this study is to determine if using a combination of dexamethasone and dexmedetomidine (Dex-Dex) in a single-shot perineural local anesthestic provides an increased duration of pain relief and reduced consumption of opioids for patients undergoing shoulder surgery.
UNASSIGNED: This is a retrospective trial of adult patients without major comorbidities undergoing elective, upper arm orthopedic procedures with regional nerve block for post-operative analgesia. Patients underwent nerve block with either 0.5% ropivacaine or 0.2% ropivacaine with 5mg dexamethasone and 25mg dexmedetomidine (\"dex-dex\"). Patients were assessed in 1-week intervals for two weeks for duration of block analgesia, pain scores, and opioid use.
UNASSIGNED: 31 patients were included, 12 controls and 19 in the dex-dex group. These patients underwent one of arthroscopic rotator cuff repair, reverse total shoulder repair or repair of humerus fractures. Dex-dex blocks provided significantly longer analgesia (median block time 3.5 versus 1.5 days, p<0.0001), significantly better analgesia (mean NRS 2.32 versus 8.58 on post-operative day 1, p<0.0001), and significantly reduced opioid requirements (108.16mg vs 275.63mg in MME, p<0.0001). One patient experienced transient hypotension and prolonged paresthesia in the dex-dex group.
UNASSIGNED: Preoperative single-shot interscalene nerve blocks with preservative-free dexamethasone and dexmedetomidine added as adjuvants to ropivicaine provide approximately two additional days of benefit versus ropivicaine alone. Additionally, postoperative opioid consumption is reduced.

The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty.
Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption.
The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04).
This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed.
www.
gov (NCT03807505); registered 17 January 2019.
RéSUMé: OBJECTIF: Le bloc des muscles érecteurs du rachis du haut thorax (BMER-HT) a été rapporté comme une modalité analgésique efficace pour la région de l’épaule et ce, sans paralysie du nerf phrénique. L’objectif de cette étude était de comparer ce bloc en tant qu’alternative épargnant le nerf phrénique à un bloc interscalénique pour l’arthroplastie totale de l’épaule. MéTHODE: Trente patients bénéficiant d’une arthroplastie totale de l’épaule au centre de soins Stanford Health Care (Palo Alto, CA, États-Unis) ont été recrutés dans une étude randomisée contrôlée à double insu. Nous avons randomisé 28 patients à recevoir un cathéter périneural interscalénique ou un BMER-HT en préopératoire; 26 patients ont été inclus dans l’analyse finale. Le calcul de puissance de l’étude a été effectué pour répondre au critère d’évaluation principal, qui était l’incidence de paralysie hémidiaphragmatique en salle de réveil. Les autres issues mesurées comprenaient les volumes de spirométrie, les examens moteurs et sensoriels du plexus brachial, les événements indésirables, les scores de douleur et la consommation d’opioïdes. RéSULTATS: L’incidence de paralysie hémidiaphragmatique dans le groupe cathéter BMER-HT était significativement plus faible que dans le groupe cathéter interscalénique (0/12, 0 % vs 14/14, 100 %; P < 0,001). Aucune différence statistiquement significative n’a été observée dans les scores de douleur et la consommation d’opioïdes (en équivalents morphine par voie orale) entre les groupes interscalénique et BMER-HT jusqu’au jour postopératoire (JPO) 2. Néanmoins, en salle de réveil, les estimations ponctuelles moyennes (écart type) de la consommation d’opioïdes pour le groupe BMER-HT étaient plus élevées que pour le groupe interscalénique (BMER-HT : 24,8 [26,7] mg; interscalénique : 10,7 [21,7] mg), ainsi qu’au JPO 0 (BMER-HT : 20,5 [25,0] mg; interscalénique: 6,7 [12,0] mg). De plus, la consommation cumulative d’opioïdes postopératoires était significativement plus élevée au JPO 0 (salle de réveil jusqu’au JPO 0) dans le groupe BMER-HT (45,3 [39,9] mg) que dans le groupe interscalénique (16,6 [21,9] mg; P = 0,04). CONCLUSION: Cette étude suggère que le BMER-HT continu peut être une alternative au bloc interscalénique continu du plexus brachial pour épargner le nerf phrénique, bien que le bloc interscalénique ait fourni une épargne d’opioïdes supérieure en période postopératoire immédiate. Il s’agissait d’une étude de petite taille d’échantillon, et d’autres études visant à détecter les différences dans les scores des critères d’évaluation en matière d’analgésie et de qualité de la récupération sont nécessaires. ENREGISTREMENT DE L’éTUDE: www.clinicaltrials.gov (NCT03807505); enregistrée le 17 janvier 2019.

The choice of anaesthetic in shoulder surgery is an evolving field of research which has important implications for patient outcomes. We have performed a prospective study to assess the usability of an interscalene brachial plexus block (ISBPB) with sedation as the primary anaesthetic and analgesic for arthroscopic shoulder surgery. Our study assessed the requirements of analgesia peri-operatively and post operatively and found that patients had no requirement (n = 30) and minimal requirements with a low pain score (visual analogue score; mean 2.4, range 2-5) respectively. We also found that patients spent a short amount of time in recovery (31 min mean, range 21-48 min) and were able to be discharged on the same day. Our findings suggest that ISBPB with sedation is a viable option in arthroscopic shoulder surgery for a variety of procedures with positive effects for patient outcomes and mobility.

Both intravenous dexamethasone and dexmedetomidine prolong the analgesic duration of interscalene blocks (ISB) after arthroscopic shoulder surgery. This study compared their relative effectiveness and the benefit of their use in combination.
This single-centre, double-blinded, parallel three-group superiority trial randomized 198 adult patients undergoing ambulatory arthroscopic shoulder surgery. Patients received preoperative ISB with 30 mL 0.5% bupivacaine and 50 µg dexmedetomidine or 4 mg dexamethasone or both of these agents as intravenous adjuncts. The primary outcome was analgesic block duration. Secondary outcomes included the quality of recovery 15 score (range: 0-150) on day 1 and postoperative neurologic symptoms in the surgical arm.
Block durations (n = 195) with dexamethasone (median [range], 24.5 [2.0-339.5] hr) and both adjuncts (24.0 [1.5-157.0] hr) were prolonged compared with dexmedetomidine (16.0 [1.5-154.0] hr). When analyzed by linear regression after an unplanned log transformation because of right-skewed data, the corresponding prolongations of block duration were 59% (95% confidence interval [CI], 28 to 97) and 46% (95% CI, 18 to 80), respectively (both P < 0.001). The combined adjuncts were not superior to dexamethasone alone (-8%; 95% CI, -26 to 14; P = 0.42). Median [IQR] quality of recovery 15 scores (n = 197) were significantly different only between dexamethasone (126 [79-149]) and dexmedetomidine (118.5 [41-150], P = 0.004), but by an amount less than the 8-point minimum clinically important difference.
Dexamethasone is superior to dexmedetomidine as an intravenous adjunct for prolongation of bupivacaine-based ISB analgesic duration. There was no additional benefit to using both adjuncts in combination.
www.clinicaltrials.gov (NCT03270033); registered 1 September 2017.
RéSUMé: OBJECTIF: La dexaméthasone et la dexmédétomidine intraveineuses prolongent toutes deux la durée analgésique des blocs interscaléniques (BIS) après une chirurgie arthroscopique de l’épaule. Cette étude a comparé leur efficacité relative et les avantages d’une utilisation des deux agents en combinaison. MéTHODE: Cette étude de supériorité monocentrique en trois groupes parallèles à double insu a randomisé 198 patients adultes subissant une chirurgie arthroscopique de l’épaule en ambulatoire. Les patients ont reçu un BIS préopératoire composé de 30 mL de bupivacaïne 0,5 % avec 50 μg de dexmédétomidine, 4 mg de dexaméthasone, ou la combinaison de ces deux agents comme adjuvants intraveineux. Le critère d’évaluation principal était la durée analgésique du bloc. Les critères d’évaluation secondaires comprenaient le score de qualité de récupération (QoR) 15 (plage : 0-150) au jour 1 et les symptômes neurologiques postopératoires dans le bras opéré. RéSULTATS: Les durées des blocs (n = 195) avec la dexaméthasone (médiane [plage], 24,5 [2,0-339,5] heures) et la combinaison des deux adjuvants (24,0 [1,5-157,0] heures) ont été prolongées par rapport à la dexmédétomidine (16,0 [1,5-154,0] heures). Lorsqu’elles ont été analysées par régression linéaire après une transformation logarithmique non planifiée en raison de données biaisées vers la droite, les prolongations correspondantes de la durée du bloc étaient de 59 % (intervalle de confiance [IC] 95 %, 28 à 97) et de 46 % (IC 95 %, 18 à 80), respectivement (les deux P < 0,001). La combinaison des adjuvants n’était pas supérieure à la dexaméthasone seule (-8 %; IC 95 %, -26 à 14; P = 0,42). Les scores médians [ÉIQ] de qualité de récupération 15 (n = 197) n’étaient significativement différents qu’entre la dexaméthasone (126 [79-149]) et la dexmédétomidine (118,5 [41-150], P = 0,004), mais la différence observée était inférieure à la différence minimale de 8 points nécessaire pour être considérée cliniquement importante. CONCLUSION: La dexaméthasone est supérieure à la dexmédétomidine en tant qu’adjuvant intraveineux pour prolonger la durée analgésique d’un BIS à base de bupivacaïne. Aucun avantage supplémentaire n’a été observé lors de l’utilisation combinée des deux adjuvants. ENREGISTREMENT DE L’éTUDE: www.clinicaltrials.gov (NCT03270033); enregistrée le 1er septembre 2017.

Arthroscopic shoulder surgery (ASS) is often followed by severe pain. Interscalene brachial plexus block (ISB) was used to relieve such pain. The aim of the study was to compare the effect of adding either dexamethasone or ketamine to ISB on time to the fi rst request for analgesia.
Sixty patients scheduled for ASS were enrolled in this study. Before induction of general anaesthesia, patients were randomly allocated to two groups; in Group D, patients received ISB with bupivacaine 0.3%, 5 mL lidocaine 2% plus 8 mg dexamethasone. Whereas in Group K, patients received ISB with bupivacaine 0.3%, 5 mL lidocaine 2% plus 50 mg ketamine. Time to the fi rst administration of supplemental analgesic postoperative was our primary concern. Secondary outcomes included pain score, patient satisfaction, and side effects of either block or drugs. Student\'s t-test was utilized for comparison between the two groups. Chi-square test was used to test the association between categorical variables.
Time to the first request of analgesia was statistically significantly longer in Group D when compared to Group K. The onset of sensory and motor blocks, number of patients requiring rescue analgesia and patient satisfaction showed no difference between the two groups. Pain score in Group K, compared to Group D, was statistically signifi cant less early postoperatively.
We conclude that addition of dexamethasone to local anesthetic in ISB for patients undergoing ASS resulted in longer time elapsed to the first request of analgesia when compared with ketamine. Pain score in the early postoperative period was statistically improved in ketamine group, but this might be of no clinical signifi cance, when compared with dexamethasone.

Both low volume interscalene and infraclavicular-subomohyoid blocks were suggested to provide shoulder analgesia with low risk of phrenic nerve block. The aim of this study was to compare the frequency of the phrenic nerve block between these two techniques.
Seventy-two patients scheduled for shoulder arthroscopy were included in this randomized controlled blind study. Before induction of general anesthesia, patients received low volume interscalene block using 5 mL of ropivacaine 0.5% (LVS group) or infraclavicular-subomohyoid block using 25 mL of ropivacaine 0.5% (ISO group). The diaphragmatic excursion was measured (using ultrasound) before the block and after surgery. If the ratio of postoperative to pre-block excursions was <25%, a phrenic nerve block was concluded. Secondary outcomes were: the duration of analgesia, the 24-hour morphine requirement, and patient satisfaction.
The phrenic nerve was blocked in 88.9% of patients in LVS group vs 5.6% in ISO group (P < 0.001). There was no significant difference between the two groups with regard to the duration of analgesia, the morphine consumption, and the patient satisfaction.
Compared with the low volume interscalene block, the infraclavicular subomohyoid block resulted in a significantly less frequent phrenic nerve block and with no difference in postoperative analgesia. Therefore, it may be relevant to consider for patients who cannot tolerate a phrenic nerve block.