Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation.
We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5-10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

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: Interscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations.
UNASSIGNED: The purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery.
UNASSIGNED: Cohort study; Level of evidence, 2.
UNASSIGNED: Enrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints.
UNASSIGNED: The liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all).
UNASSIGNED: The use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.

暂无摘要。

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.

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

Interscalene nerve blocks are common procedures performed before upper extremity surgeries in order to provide post-op pain relief and improve recovery time. Here we present two cases of patients who underwent a unilateral supraclavicular and bilateral interscalene nerve block, respectively. The first patient had no risk factors but the second presented with a body mass index of 45.5 and a history of symptoms consistent with obstructive sleep apnea but never diagnosed. Both patients experienced some form of respiratory distress diagnosed via changes in chest x-ray and clinical presentation. The mechanism of injury that occurs in these procedures is typically from inadvertent damage to the phrenic nerve. Mild adverse effects in interscalene nerve block are relatively common. However, there is minimal data in regards to performing bilateral interscalene nerve blocks. The purpose of this study is to highlight that severe complication in both high and low-risk patients can occur but may be reduced with a safer approach and more effective communication among multidisciplinary team members.

暂无摘要。

A 78-year-old patient received an interscalene plexus catheter for perioperative pain therapy during implantation of an inverse shoulder prothesis. After stimulation-assisted puncture under sonographic control, 25 ml of local anesthetic (LA) were first administered and then the catheter was placed using the through the needle technique. Immediately after the administration of another 5 ml of local anesthetic via the inserted catheter, the patient showed symptoms of total spinal anesthesia, so that she had to be intubated and ventilated. The following computed tomographic diagnostics of the neck revealed an intrathecal misalignment of the plexus catheter, the tip of which was lying dorsal to the vertebral artery at the level of the 5/6 cervical vertebrae. The catheter could then be removed without any problems and there were no neurological sequelae. The use of ultrasound with clear identification of the nerve roots C5-C7 and the surrounding structures provides additional security when installing an intrascalene catheter. The spread of the LA should be traceable at all times using ultrasound and should otherwise be immediately terminated. Furthermore, a strict adherence to the needle position while inserting the catheter without manipulation of the needle depth is necessary. The first injection of the catheter has to be performed under controlled conditions, preferably connected to surveillance monitors with neurological monitoring of the awake patient and control of vital signs with direct access to the emergency equipment.
Eine 78-jährige Patientin erhält zur perioperativen Schmerztherapie bei Implantation einer inversen Schulterprothese einen interskalenären Plexuskatheter (ISK). Nach stimulationsgestützter Punktion unter sonographischer Kontrolle werden zunächst 25 ml Lokalanästhetikum (LA) verabreicht und anschließend der Katheter mittels „Durch-die-Nadel-Technik“ platziert. Unmittelbar nach der Gabe von weiteren 5 ml LA über den einliegenden Katheter zeigt die Patientin Symptome einer hohen Spinalanästhesie, sodass sie intubiert und beatmet werden muss. In der folgenden computertomographischen Diagnostik des Halses zeigt sich eine intrathekale Fehllage des Plexuskatheters, dessen Spitze dorsal der A. vertebralis auf Höhe der HWK 5/6 liegt. Im Verlauf kann der Katheter problemlos entfernt werden; neurologische Folgeschäden bestehen keine. Die Verwendung von Ultraschall, insbesondere in Kombination mit der Nervenstimulation, erhöht die Sicherheit bei Anlage eines interskalinären Kathetes, da eine eindeutige Identifikation der Nervenwurzeln C5–C7 und deren umgebende Strukturen möglich ist. Sofern die Ausbreitung des LA während der Injektion nicht visualisierbar sein sollte, muss die Injektion sofort abgebrochen werden. Des Weiteren darf die Nadelspitze bzw. die Eindringtiefe der Nadel während der Katheteranlage nicht verändert werden. Die erstmalige Gabe eines LA über den Kathteter sollte unter kontrollierten Bedingungen stattfinden, vorzugsweise unter Überwachung der Vitalwerte sowie unter fortlaufender klinisch-neurologischer Kontrolle des wachen Patienten. Eine Notfallausrüstung muss unmittelbar verfügbar sein.