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

Abstract

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.

Perioperative respiratory and analgesic effects of ultrasound-guided extrafascial versus interfacial interscalene brachial plexus block in patients undergoing shoulder arthroscopy

“…The different dose can explain the difference between the two studies. Ayyanagouda and his colleagues [15] disagreed with our findings as they proved that post-procedural FVC, FEV 1 and PEF in the extrafascial injection group was significantly higher compared to intrafascial injection group. This difference may be due to the different type and volumes of anesthesia used (ropivacaine versus bupivacaine).…”

“…These results are supported by findings of Palhais et al [9] Furthermore, Sowmiya et al ([12] proved that onset of motor and sensory blockage were substantially delayed in ~ 8 ~ extrafascial injection than intrafascial injection. In another study, [15] the onset of motor and sensory blockage was faster after intrafascial contrasted to extrafascial ISBPB. The current study showed that the time to first analgesic request and numerical rating scale (NRS) were similar for both groups in the 1 st 24 hours.…”

“…Compatible with our results, Palhais et al [9] found that numeric rating scale (NRS) at 24 hours postoperatively were insignificantly different between intrafascial and extrafascial injection groups. Furthermore, Ayyanagouda et al [15] concluded that pain scores at 6 hr (NRS) was insignificantly different between intrafascial and extrafascial group.…”

Statistical fragility of reporting hemidiaphragmatic paralysis after brachial plexus blocks in randomized controlled trials: a systematic review

“…2.274 L LVISB vs ISO block P < 0.001 73 1 HDP in the PACU; 32 vs 2 23 0.315 Bao et al, [ 26 ] 2019 Reg Anesth Pain Med. 5.564 L 20 mL vs 30 mL SCB P = 0.03 74 6 HDP at 30 min after block; 14 vs 23 0 0 Ayyanagouda et al, [ 40 ] 2019 Indian J Anaesth. / L IF- vs EF-ISB P < 0.001 60 1 HDP at 30 min after block; 14 vs 5 1 0.017 Kang et al, [ 41 ] 2018 Reg Anesth Pain Med.…”

Respiratory Failure Following Interscalene Block for the Treatment of Shoulder Dislocation in a Patient with COVID-19

“…These techniques have reduced the chance of paresis to as low as 20% (7). Ultrasound-guided ISB with the aid of nerve stimulator through extrafascial approach reduces the risk of diaphragmatic paresis and pulmonary impairment when compared with intrafascial approach (8).…”