Decreasing the Local Anesthetic Volume From 20 to 10 mL for Ultrasound-Guided Interscalene Block at the Cricoid Level Does Not Reduce the Incidence of Hemidiaphragmatic Paresis

Sinha, Sanjay; Abrams, Jonathan; Barnett, John T.; Muller, John G.; Lahiri, Bimalin; Bernstein, Bruce; Weller, Robert S.

doi:10.1097/aap.0b013e3182030648

Cited by 89 publications

(71 citation statements)

References 14 publications

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“…[1][2][3][4] For instance, as little as 5 ml of ropivacaine 0.75%, or 1.7 ml for each of three trunks of the brachial plexus (superior, middle, and inferior), may be sufficient to accomplish successful ultrasound-guided interscalene brachial plexus block (ISB) through three separate injections. 1 However, no data are available on the volume of lA required to accomplish successful ISB anesthesia with an injection through the catheter.…”

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confidence: 99%

Effective Volume of Ropivacaine 0.75% through a Catheter Required for Interscalene Brachial Plexus Blockade

Vandepitte

Gautier

Xu³

et al. 2013

Anesthesiology

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Background: Ultrasound guidance during peripheral nerve blocks has allowed for reduction in dose and volume of local anesthetic required to accomplish successful blockade using multiple injections through a needle. The authors undertook this study to determine the minimal effective volume required to accomplish successful interscalene brachial plexus block (ISB) through the catheter. Methods: After obtaining institutional ethics committee approval and written informed consent, patients aged 18-75 yr and scheduled for arthroscopic shoulder surgery under ISB were enrolled. All patients using a step-up/step-down method and the starting dose of 15 ml of 0.75% ropivacaine received an ultrasound-guided ISB catheter. The injection volume was increased or decreased by 1 ml in case of block failure or block success, respectively. Results: The authors found that the proportion of patients with successful blockade increased sharply from approximately 57% at 6 ml to 100% by 7 ml, indicating that a small increase in volume of ropivacaine 0.75% markedly affects the success rate. A total of 12 ISB with injection volume less than 7 ml resulted in successful anesthesia within 30 min, yielding an ED95 of 7 ml (95% CI 6.8-7.2) ropivacaine 0.75%. For the group as a whole, the median (min-max) sensory block onset time was 5 (5-20) min, the median (min-max) motor blocks for the biceps and the deltoid muscles were 7.5 (5-15) min and 10 (5-15) min, respectively. The median (min-max) block duration was 8.9 (3-15) h. Conclusions: An injection of a minimum of 7 ml of ropivacaine 0.75% through the catheter is required for success rate and timely onset of surgical anesthesia with ISB.

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confidence: 99%

Effective Volume of Ropivacaine 0.75% through a Catheter Required for Interscalene Brachial Plexus Blockade

Vandepitte

Gautier

Xu³

et al. 2013

Anesthesiology

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“…Incidence of hemidiaphragmatic paralysis, along with reduction of the functional vital capacity, was reported to occur in almost all patients receiving an interscalene plexus block [10,34]. Of note, the volume of local anesthetic injected seems to have very little influence on this outcome unless very low volumes (\5 mL) are utilized [28]. Puncture of large vessels can result in hematoma or local anesthetic systemic toxicity [36], while puncture of the pleura can lead to pneumothorax [3].…”

Section: Discussionmentioning

confidence: 99%

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

Stundner

Rasul

Chiu

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Background Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery. Questions/purposes Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups? Methods We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. The institution of one of the authors (SGM) has received, during the study, funding from the Anna-Maria and Stephen Kellen Physician-Scientist Career Development Award provided by the Hospital for Special Surgery. One or more of the authors (RR, YLC, XS, MM) has received, during the study,

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“…Recent studies are demonstrating that the speed and success of sciatic nerve blocks are improved by the use of ultrasound but, in spite of this, there is few data that attempt to describe the ideal morphology and pattern of local anesthetic spread during injections as observed under ultrasound imaging [2,4,5] . Whereas the evidence has shown the importance of perineural circumferential spread, and the consequences of intraneural injection, the real-time, dynamic distribution of local anesthetic is relatively undefined and still debated [3,6] .…”

Section: Discussionmentioning

confidence: 99%

“…Cadaveric studies by Andersen et al, specifically mention local anesthetic extravasation during their experiment involving dye injection beneath the sciatic paraneural sheath [10] . Recent work is demonstrating that much smaller amounts of local anesthetic can provide satisfactory blocks [5,11] . This evidence in conjunction with our own observations suggest that it may be possible to use a substantially lower volume of local anesthetic and achieve a successful clinical block.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound guidance showing real-time local anesthetic extravasation during injection of two lateral popliteal sciatic nerve blocks

Osman¹,

Missair

Weisman³

et al. 2013

JBGC

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Objective: The purpose of this case report is to describe an observation of local anesthetic extravasation while performing single-shot lateral sciatic popliteal blocks on two patients using ultrasound guided imaging. This under-reported phenomenon may have clinical implications and warrants further examination of conventional practice techniques. Case report:We performed lateral sciatic popliteal blocks under ultrasound guidance for post-operative pain in two patients having surgery in the left lower extremity. Both blocks involved sequential, real-time scans during the injection beneath the complex fascial sheath of the sciatic nerve. Observations included extrafascial extravasation of local anesthetic away from the nerve, up the needle path, and also concentrically outside the nerve sheath. Both blocks had 100% sensory block but slower clinical onset than expected. Conclusions:Ultrasound imaging is an evolving technology gaining popularity for performing peripheral nerve blocks. The incidence and volume of local anesthetic extravasation with single shot nerve blocks are unknown. This phenomenon may be common but frequently undetected given the limited resolution and the two-dimensional nature of current ultrasound imaging technology. The clinical consequences of local anesthetic injection into tissues outside of the nerve sheath are unknown, however our observations suggest speed of onset and quality of blocks may be affected. Further investigation evaluating the extravasation of local anesthetics during ultrasound blockade is needed to re-evaluate injection speeds and the use of conventional volumes for injection.

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Decreasing the Local Anesthetic Volume From 20 to 10 mL for Ultrasound-Guided Interscalene Block at the Cricoid Level Does Not Reduce the Incidence of Hemidiaphragmatic Paresis

Abstract: Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.

Cited by 89 publications

References 14 publications

Effective Volume of Ropivacaine 0.75% through a Catheter Required for Interscalene Brachial Plexus Blockade

Effective Volume of Ropivacaine 0.75% through a Catheter Required for Interscalene Brachial Plexus Blockade

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

Ultrasound guidance showing real-time local anesthetic extravasation during injection of two lateral popliteal sciatic nerve blocks

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