Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial

Palhais, Nuno; Brull, Richard; Kern, Christian; Jacot-Guillarmod, Alain; Charmoy, Alexia; Farron, Alain; Albrecht, Éric

doi:10.1093/bja/aew028

Cited by 69 publications

(43 citation statements)

References 20 publications

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“…They observed an incidence of 21% hemidiaphragmatic paresis following exatrafascial injection of 20 mL of 0.5% bupivacaine with epinephrine 1:200,000 [Figure 3]. [1318] In our study, block was administered for both surgical anaesthesia and analgesia. In the same study, they also observed that respiratory function was better preserved in the extrafascial group which was concordant with our study.…”

Section: Discussionmentioning

confidence: 77%

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Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial

et al. 2019

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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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Section: Discussionmentioning

confidence: 77%

“…It has been suggested based on the anatomic characteristics that lowering of incidence can be achieved by reducing the volume of local anaesthetics[171920] or by placing the tip of the needle away from C3–5 roots. [18] The distance of 4 mm from the brachial plexus sheath has been observed to be effective. [1118] Albrecht et al .…”

Section: Discussionmentioning

confidence: 99%

Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial

et al. 2019

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“…Though well tolerated in healthy patients, patients with decreased respiratory function may experience symptomatic dyspnea or hypoxia. Various methods to avoid this adverse effect, including low-volume [10] and extra-fascial injections [11], have been attempted with limited success. Blockade of the suprascapular nerve, alone or in combination with the axillary nerve, have been suggested as an alternative means of analgesia, which could minimize the risk of phrenic nerve paresis [12,13].…”

Section: Discussionmentioning

confidence: 99%

Randomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery

Lim

Koo

et al. 2020

Korean J Anesthesiol

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BackgroundInterscalene brachial plexus block (ISB) provides excellent analgesia for arthroscopic shoulder surgeries but is associated with adverse effects including hemidiaphragmatic paresis. We aimed to compare the respiratory effects, forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) between suprascapular nerve block (SSB) and ISB.MethodsSixty patients were recruited and randomized into ISB, anterior SSB, and posterior SSB groups. FVC, FEV1, and diaphragmatic excursion were evaluated at baseline and 30 minutes after intervention. Blocks were performed under ultrasound guidance with 15 ml of 0.5% ropivacaine. Pain scores were assessed at 6, 12, and 24 hours postoperatively.ResultsThe ISB group showed a reduced FVC of 31.2% ± 17.5% (mean ± SD), while the anterior and posterior SSB groups had less reduction of 3.6% ± 18.6% and 6.8% ± 6.5%, respectively (P < 0.001). The ISB group showed more reduction in diaphragmatic excursion than the anterior and posterior SSB groups (median [IQR]): −85.7% (−95.3% to −63.3%) vs. −1.8% (−13.1% to 2.3%) and −1.2% (−8.8% to 16.8%), respectively (P < 0.001). The median pain scores (IQR) in the ISB and anterior SSB groups were lower than those in the posterior SSB group at 6 hours on movement: 0 (0–2), 1.8 (0–4.5) vs. 5 (2.5–8), respectively (P = 0.002). There was no significant difference in oxycodone consumption postoperatively.ConclusionsAnterior SSB preserves lung function and has a comparable analgesic effect as ISB. Thus, it is recommended for arthroscopic shoulder surgeries, especially in patients who have reduced lung function.

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“…The incidence of PNP following BPB is associated with several factors, mainly dependent on the approach to the brachial plexus. It is 21% to 100% for interscalene BPB, [ 8 , 9 ] 28% to 67% for supraclavicular BPB, [ 10 , 11 ] and 5% to 13% for infraclavicular BPB. [ 12 , 13 ] The effect of axillary BPB on the incidence of PNP has not yet been studied.…”

Section: Discussionmentioning

confidence: 99%

Bilateral brachial plexus block in a patient with cervical spinal cord injury

Kim

Yang²,

Lee³

et al. 2020

Medicine

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Rationale: Bilateral brachial plexus block (BPB) generally requires a relatively large dose of local anesthetic for a successful block, resulting in a high risk of local anesthetic systemic toxicity. It can also result in inadvertent bilateral phrenic nerve palsy, leading to respiratory failure. Hence, it has not been widely used. However, it can be performed in selected patients. In this report, we present a case of ultrasound-guided BPB for bilateral upper extremity surgery in a patient with cervical spinal cord injury (SCI). Patient concerns: A 25-year-old woman with SCI secondary to traumatic fifth cervical spine fracture scheduled for surgical treatment of bilateral elbow fracture received bilateral BPB. Diagnoses: Due to the complications of SCI, the patient had incomplete sensory loss, loss of motor function, and complete diaphragmatic paralysis on the right side. Interventions: Right infraclavicular and left axillary BPB was performed as the sole anesthetic procedure for bilateral upper extremity surgery. Outcomes: Bilateral BPB was successful for bilateral upper extremity surgery. The surgery was uneventful and without further complications. Lessons: Patients with cervical SCI have a high risk of respiratory complications. Bilateral BPB can be a suitable option for bilateral upper extremity surgery in selected patients. It is imperative to select an appropriate anesthetic technique that preserves respiratory function to minimize the potential risk of respiratory complications.

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Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial

Abstract: NCT02074397.

Cited by 69 publications

References 20 publications

Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial

Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial

Randomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery

Bilateral brachial plexus block in a patient with cervical spinal cord injury

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