Background and Aims: Hemidiaphragmatic paresis occurs in almost all patients undergoing interscalene block for proximal upper limb surgeries. This study tested hypothesis that ultrasound-guided extrafascial approach of interscalene block under nerve stimulator guidance reduces incidence of hemidiaphragmatic paresis in comparison to intrafascial approach by achieving same degree of anaesthesia and analgesia. Methods: Sixty patients undergoing proximal upper limb surgeries were randomised to receive an ultrasound-guided interscalene brachial plexus block (ISB) with the aid of nerve stimulator for surgical anaesthesia and analgesia using 20 mL 0.5% ropivacaine by extrafascial (Group E) or intrafascial (Group I) approach. The incidence of hemidiaphragmatic paresis was measured by M-mode ultrasound before and 30 min after the procedure. Secondary outcomes such as respiratory functions (forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate) were measured, and complications were recorded and compared. The statistics was obtained using SPSS Version 19. Levene's test and paired and unpaired t -test were used. P value <0.05 was considered significant. Results: The incidence of hemidiaphragmatic paresis was 17% and 46% in Group E and Group I, respectively ( P < 0.0001). All other respiratory outcomes were preserved in Group E compared with Group I. Conclusion: Ultrasound-guided ISB with the aid of nerve stimulator through extrafascial approach reduces the incidence of hemidiaphragmatic paresis and also reduces respiratory function impairment when compared with intrafascial approach.

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Background and Aims: Transversus abdominis plane (TAP) and Ilioinguinal/Iliohypogastric (IL/IH) nerve blocks have been advocated in reducing postoperative pain and additional analgesic requirement following lower abdominal surgeries with varied effect. The aim of this study was to determine post-operative analgesic efficacy by comparing dual TAP [combining TAP and IL/IH nerve blocks] and IL/IH nerve block alone for open inguinal hernia repair. Methods: Two hundred patients undergoing elective primary unilateral open inguinal hernia repair with a mesh were included in to this trial. Ultrasound-guided dual TAP (D-TAP Group) or IL/IH (IL/IH Group) nerve block were administered to patients following subarachnoid block according to their group allocation, with 0.5% ropivacaine. Post operatively patients were monitored for visual analogue scale (VAS) scores at rest (at 4, 12, 24 and 48h) and during movement (at 24, 48 h, 3 and 6 months). Pain scores at 3 and 6 months were assessed by telephonic interview, using the DN4 questionnaire for neuropathic pain. The statistics was obtained using Chi-square test for proportions in qualitative data and student's unpaired t test for quantitative data. P value <0.05 was considered significant. Results: The pain scores at rest (VAS-R) were significantly lower at 12 hours and 24 hours ( P < 0.001) in D-TAP group, while pain scores at movement were significantly lower ( P < 0.001) in D-TAP group at 24 and 48 hours compared to IL/IH group. The mean time required for first rescue analgesic was longer in D-TAP group (5.590 ± 2.386 hr) in comparison to IL/IH group (3.1053 ± 1.1822h). Conclusion: Ultrasound-guided dual TAP block provides more effective post-operative analgesia in open inguinal hernia repair.

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