Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study

Abstract

Background Arthroscopic shoulder surgery causes severe postoperative pain. An interscalene brachial plexus block provides adequate analgesia, but unintended spread of the local anesthetic administered may result in a phrenic nerve block, usually associated with a nonnegligible incidence of acute hemidiaphragmatic paralysis. The main purpose of this trial will be to analyze the incidence of hemidiaphragmatic paralysis ensuing after interscalene brachial plexus block in patients undergoing arthroscopic shoulder surgery administered a standard volume (20 ml) vs. a low volume (10 ml) of levobupivacaine 0.25%. Methods This will be a prospective double-blind randomized controlled single-center two-arm comparative trial. Forty-eight patients will be included. The primary goal will be to ultrasonographically determine the incidence of hemidiaphragmatic paralysis by calculating the diaphragmatic thickness ratio in each group. The secondary goals will be to compare the two arms in terms of (1) decrease in forced vital capacity and (2) in forced expiratory volume at 1 s by spirometry; (3) decrease in diaphragmatic excursion by ultrasound; (4) 24-h total intravenous morphine consumption; (5) time to first opioid request of a patient-controlled analgesia pump; and (6) postoperative complications. Discussion This trial will demonstrate that a low-volume interscalene brachial plexus block decreases hemidiaphragmatic paralysis following arthroscopic shoulder surgery according to spirometry and ultrasound measurements and does not provide inferior postoperative analgesia to the standard volume, as measured by opioid requirements. Trial registration EudraCT and Spanish Trial Register (REec) registration number: 2019-003855-12 (registered on 7 January 2020). ClinicalTrials.gov identification number: NCT04385966 (retrospectively registered on 8 May 2020). Ethics Committee approval: EC19/093 (18 December 2019).

Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block or interscalene brachial plexus block in clavicle surgery: a single-centre, double-blind, randomized controlled trial

“…Although SCPB combined with ISBP can provide sufficient analgesia in clavicle surgery, it can lead to serious adverse reactions, such as hemidiaphragmatic paresis [15][16][17]. To reduce the incidence of hemidiaphragmatic paresis, anaesthesiologists have conducted a series of clinical studies, including the use of ultrasound-guided visualization technology [6,18]; different brachial plexus block technologies, even targeting specific cervical nerve roots [19]; and the use of low concentrations and large volumes of local anaesthetics [20,21].…”

Efficacy and adverse effects of peripheral nerve blocks and local infiltration anesthesia after arthroscopic shoulder surgery: A Bayesian network meta-analysis

“…Following ISB, ipsilateral phrenic nerve block is a well-known complication, of which the rates of 16.6–38% have been reported in previous studies. The root cause is the interscalene insertion site is close to the phrenic nerve, and the unintended spread of local anesthesia could cause diaphragm paresis, thus reducing vital capacity and leading to dyspnea ( 59 ). Therefore, ISB would have been a relative contraindication in patients with serious pulmonary disease.…”

Incidencia de parálisis diafragmática secundaria a bloqueo supraclavicular de plexo braquial medida por ecografía en una institución de cuarto nivel

“…Se encontró diferencia significativa entre la concentración del anestésico local usada y el grado de parálisis diafragmática; sin embargo, la diferencia no está en relación directa con la concentración del anestésico local, sino con el volumen, ya que la concentración se calcula a partir de la masa anestésica respecto al volumen diluyente, y al usar mayores volúmenes totales administrados se logra disminuir la concentración (7). En relación con esto, estudios muestran en cirugía de miembro superior una relación entre la dosis utilizada y el nivel de parálisis diafragmática (11).…”

“…La disfunción diafragmática se puede detectar como una disminución de la Capacidad Vital Forzada (CVF) y el Volumen Espiratorio Forzado en 1 s (VEF 1) en la espirometría, o como Excursión Diafragmática (ED) más baja en ultrasonografía en los pacientes con una evaluación inicial previo al deterioro respiratorio (10,11).…”

“…En comparación con otro tipo de técnicas regionales (bloqueo interescalénico) en cirugía de miembro superior, inicialmente la incidencia de esta técnica producía un bloqueo diafragmático ipsilateral agudo con disminución de la función pulmonar en un 100% de los pacientes, y posterior al uso de ultrasonografía su incidencia disminuyó entre el 10% y 26% (11).…”