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Back to Journal »Local and Regional Anesthesia» Volume 14
Intermuscular groove block in orthopedic treatment of shoulder trauma for analgesia: single-dose bupivacaine liposome and perineural catheter
Author Kwater AP, Hernandez N, Artime C, de Haan JB
Published on December 7, 2021, Volume 2021: 14 pages, pages 167-178
DOI https://doi.org/10.2147/LRA.S303455
Single anonymous peer review
Editor who approved for publication: Dr. Stefan Wirz
Andrzej P Kwater, Nadia Hernandez, Carlos Artime, Johanna Blair de Haan, Department of Anesthesiology, McGovern School of Medicine, UTHealth, Houston, Texas, USA Corresponding author: Andrzej P Kwater Department of Anesthesiology and Perioperative Medicine, University of Texas Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77030, USA Tel +01 713 792 6911 Email [email protected] Background: Intermuscular brachial plexus block is often used for patients undergoing shoulder surgery Provide perioperative analgesia to optimize recovery, reduce opioid consumption, and reduce total hospital stay. The use of an indwelling perineural scalene intermuscular catheter can provide prolonged analgesia and can effectively control severe postoperative pain after major shoulder surgery. Currently, the only alternative to perineural catheters for prolonged analgesia using intermuscular sulcus block involves perineural infiltration of liposomal bupivacaine. However, there are limited published data on the overall analgesic effect of the use of intramuscular groove liposomal bupivacaine in shoulder surgery. Methods: We retrospectively reviewed 43 acute trauma patients who underwent major shoulder surgery and received perioperative intermyogenic brachial plexus block and indwelling continuous catheter or single-dose bupivacaine liposome for prolonged analgesia Research to determine whether a comparable analgesic effect can be obtained. The main results of interest are the postoperative pain score and opioid consumption. Due to the ability to titrate and inject local anesthetics to achieve the desired clinical effect, we hypothesize that the consumption of opioids and pain scores will be lower when using continuous catheter technology. Results: After statistical analysis, our results showed that there was no significant difference between the two techniques in terms of opioid consumption and pain digital scores during the 48 hours postoperative period, but it did notice that the patients receiving continuous treatment of the perineural intermuscular groove The incidence of complications is higher in patients. catheter. Secondary results showed an increase in the time required to complete regional block surgery using indwelling catheters. Conclusion: Intermuscular brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters and can provide prolonged analgesia for patients undergoing major shoulder surgery. Keywords: brachial plexus, analgesia, perineural, postoperative pain, retrospective
Major shoulder surgeries, including total shoulder replacement and rotator cuff repair, are characterized by severe acute postoperative pain and require a multidisciplinary approach to achieve effective multimodal pain management. Inadequate postoperative analgesia can lead to longer hospital stays, delayed recovery, increased costs, and persistent pain in the acute phase, which puts patients at risk of chronic pain and adhesions of the shoulder joint capsule (also known as "frozen shoulder"). Regional anesthesia has had a significant impact on the perioperative outcomes of orthopedic surgery, including improved postoperative analgesia and recovery, reduced opioid requirements, shorter hospital stays, and better functional outcomes and range of motion. 1,2
In shoulder surgery, intermuscular brachial plexus block (ISB) has been used as an effective analgesic technique for postoperative pain. 3,4 Specifically, ISB and continuous catheter system (ISB-CC) have been proven to be an effective analgesic technique in the postoperative environment after major shoulder surgery by extending the duration of analgesia and overall patient satisfaction , Reduce the length of hospital stay, and minimize the consumption of opioids. 5,6 However, despite these proven benefits, the literature shows that peripheral nerve blocks are generally underutilized in inpatient and outpatient orthopedic surgery. 1 This may be due in part to the time required to perform peripheral nerve blocks and the increased labor associated with managing acute perioperative pain, especially indwelling catheters. Although a single peripheral nerve block is technically easier and less time-consuming, it is limited by the duration of analgesia. Even with additives, the duration of analgesia usually subsides within the first 24 hours after surgery. 7,8 This ultimately leads to significant rebound pain and prolonged hospital stay due to insufficient perioperative pain control. 9
As a potential alternative to prolonged analgesia in the form of a single peripheral nerve block, in 2018, the U.S. Food and Drug Administration (FDA) approved liposomal bupivacaine (Exparel: Pacira BioSceinces Inc., Parsippany, NJ, USA) Used in ISB, the theoretical analgesic effect 72 hours after the initial injection. Bupivacaine liposome is an injectable suspension that can release bupivacaine slowly and continuously for a long time after administration. Therefore, the use of liposomal bupivacaine in the treatment of ISB has attracted great interest as a potential alternative to the use of indwelling catheters for prolonged analgesia.
In shoulder surgery, there are limited published data comparing the analgesic effects of ISB-CC and intramuscular groove liposomal bupivacaine (ISB-LB). Since there is no clear consensus on which method is more effective for prolonged perioperative analgesia, the decision to use a particular technique usually depends on the availability of resources, clinician preferences, and overall workflow. This study examined the postoperative course of trauma patients who underwent ISB after major shoulder surgery. Our main goal is to compare the efficacy of ISB-CC and ISB-LB by evaluating the numerical score of postoperative pain and opioid consumption. Due to the ability to titrate and inject local anesthetics to achieve the desired clinical effect, we hypothesized that compared with ISB-LB in shoulder trauma, the opioid consumption and postoperative pain of ISB-CC during the first 48 hours after surgery The score is low and patience.
This is a retrospective case-control study that examined the postoperative results after ISB-CC or ISB-LB was used for ISB in open shoulder surgery. The study was conducted at the Memorial Herman Hospital-Texas Medical Center (Houston, Texas, USA), which is one of the busiest level 1 trauma centers in the United States. The Institutional Review Board (IRB) Exemption Status (HSC-MS-19-0186) of the University of Texas Health Science Center and Memorial Herman Health System (Clinical Innovation and Research Institute) hospital approval was granted to start research. The IRB exempt status was granted because there is no risk associated with the retrospective study of the study, and the data is collected through electronic medical record review after the patient's treatment process, and has no impact on clinical care or results. Therefore, patient consent is not required to view medical records, and all collected data is safely maintained and stored without any identifier to maintain the confidentiality of patient data. In addition, this research was conducted in accordance with the principles of the Declaration of Helsinki.
Initially, we identified all patients undergoing open ISB shoulder surgery during the 14-month period from January 2018 to February 2019. Research. The inclusion criteria were patients who were 18 years of age or older, American Society of Anesthesiologists (ASA) physical condition 1-4, received open shoulder surgery, and received perioperative ISB-CC or ISB-LB. Exclusion criteria include: 1) local anesthetic contraindications or the patient refuses treatment, 2) a history of allergic reactions to local anesthetics, 3) nerve block time does not match the day of the operation, 4) the patient receives additional surgical intervention or the area within 48 hours Anesthesia procedures, and 5) Have a history of chronic pain and record opioid prescriptions in our Texas Prescription Monitoring Program (texas.pmpaware.net) (e.g., hydrocodone, oxycodone, morphine, hydromorphine) Ketone, methadone) before admission to the hospital.
All nerve blocks were performed under ultrasound guidance under ASA standard monitoring and supervised by an anesthesiologist trained in regional and acute pain specialists. Each patient is a candidate for regional anesthesia, and there is no contraindication to placing a peripheral nerve block.
In order to place the ISB-CC, a high-frequency linear transducer ultrasound probe is placed in the supraclavicular fossa in the transverse plane to identify the subclavian artery and brachial plexus. Track the brachial plexus from the cephalic side until the C5 and C6 nerve roots are identified on the short axis between the anterior scalene muscle and the middle scalene muscle. 10 Identify the dorsal scapular nerve and the long thoracic nerve in the muscle abdomen of the middle scalene muscle to avoid causing trauma to these nerves. Use normal saline for water separation and advance the 18 gauge Tuohy needle in the plane until the needle is outside the brachial plexus sheath (Figure 1). Then inject 20 mL of 0.25% bupivacaine hydrochloride in 5 mL aliquots while confirming negative inhalation before each injection. Subsequently, a 20-gauge perineural catheter was advanced through the needle, and the position of the catheter tip was confirmed by ultrasound visualization of the injection fluid spreading around the nerve root through the catheter. Then fix the catheter with a topical skin adhesive (Dermabond) at the catheter insertion site to prevent leakage, liquid adhesive (Mastisol) and a sealing strip, and then use a chlorhexidine gluconate fixation dressing (3M CHG) to prevent the catheter from shifting or migrate. Figure 1 Ultrasound image of scalene nerve block showing the direction of the brachial plexus relative to the surrounding structures (sternocleidomastoid muscle, middle scalene muscle, anterior scalene muscle).
Figure 1 Ultrasound image of scalene nerve block showing the direction of the brachial plexus relative to the surrounding structures (sternocleidomastoid muscle, middle scalene muscle, anterior scalene muscle).
After the catheter is placed, continuous infusion of 0.2% ropivacaine (basic rate of 6–8 mL/hr) is started, and the bolus administration setting is adopted (the bolus dose is 3 mL, the lock-in time is 30 minutes, and the 1-hour limit is set to Baseline hourly infusion) volume plus 6 mL). The use of 0.2% ropivacaine for continuous infusion is based on its efficacy in providing postoperative analgesia compared with other local anesthetics. 11 Depending on clinical results or discharge, catheter infusion lasts for 24 to 96 hours. The infusion pump is adjusted by the acute pain service by increasing or decreasing the rate, stopping the infusion, and/or changing the bolus dose as instructed. If deemed appropriate, the patient can choose to use an elastic pump to discharge from the hospital. The pump will continuously infuse 0.2% ropivacaine at a rate of 6 mL/hr until the dispensed volume is complete (400 mL 0.2% ropivacaine provides approximately 66 hours of continuous infusion). After discharge from the hospital, a follow-up was conducted by telephone to ensure the smooth removal of the catheter, elimination of nerve block without complications, and a smooth transition to oral analgesics.
For a single ISB-LB, the same technique is used to identify the brachial plexus at the level of the C5 and C6 nerve roots. Use normal saline for water separation, and advance the 20-gauge blunt tip echo needle in the plane until the needle is outside the brachial plexus sheath. After negative aspiration, 10 mL of a mixed solution of 1.3% bupivacaine liposomes and 10 mL of 0.25% bupivacaine hydrochloride was slowly injected through a needle, divided into 5 mL.
The block is performed after the neurological examination is completed and the patient is removed by the plastic surgeon. Nursing staff used the oral digital pain scale (NPS, 0-10 range) to assess postoperative pain. A combination of a significant reduction in shoulder pain to mild (NPS 0-3) and exercise examination after the intervention confirmed the success of the block.
During the postoperative period, each patient received an assessment of acute pain services twice a day, and received a standardized multimodal oral medication pain treatment plan during hospitalization. Taking into account the comorbidities of each patient, the multimodal pain regimen includes acetaminophen 1000 mg every 6 hours, celecoxib 200 mg every 12 hours, gabapentin 300 mg every 8 hours, tramadol 50 mg every 6 hours, Methoxycarbamol 1000 mg every 8 hours and oxycodone for moderate (NPS 4-6) or severe pain (NPS 7-10) as needed, 5 mg or 10 mg every 4 hours.
For each patient included in the study, electronic medical records were reviewed to collect data including type of intervention, pain score, and opioid consumption within 48 hours after surgery. The 48 hours postoperatively was set as the timeline for data analysis, because many patients were discharged on the second postoperative day (POD 2), resulting in inconsistent and unreliable records of clinical results for comparison after the specified time period. In addition, demographic data (age, gender, BMI, ASA classification) and type of shoulder surgery for each patient were recorded (Tables 1 and 2). The time required to complete the local nerve block technique is also recorded. Any perioperative events or complications associated with each intervention were identified. Table 1 Patient demographic data Table 2 List of surgical procedures between study groups
Table 2 List of surgical procedures in each study group
After ISB, report the pain score (0-10, where 0 means no pain and 10 means the most severe pain imaginable) according to the NPS and at approximately the postoperative time point (6 hours, 12 hours, 24 hours, 36 hours and 48 hours) collection hours) within the range of 1-2 hours according to the nursing staff's report. For any patient receiving ISB before surgery, the time point of these pain scores is measured from the time the patient arrives in the post-anaesthesia care unit (PACU) after the surgery. The postoperative opioid consumption was also collected and converted into morphine milligram equivalents (MME) using a set of recommended conversion factors (Table 3). These MME conversion factors are based on published guidelines collected from a range of international sources and provide a consistent method for quantifying equivalent opioid consumption. 12 For postoperative day 0 (POD 0), any preoperative drugs (such as tramadol, oxycodone, hydrocodone, morphine), long-acting intraoperative opioids (such as hydromorphone) and postoperative Opioids (eg tramadol, hydrocodone, oxycodone, codeine, hydromorphone, morphine) are included in the total measured amount of opioid consumption. The total doses of short-acting opioids (such as fentanyl) and any analgesic adjuvants (such as ketamine, dexmedetomidine) administered intraoperatively or in the PACU were excluded and provided as a separate data analysis (Table 4). Table 3 Conversion table of opioids-morphine milligram equivalent (MME) Table 4 Perioperative drug management
Table 3 Conversion table of opioids-morphine milligram equivalent (MME)
All eligible patients who met the inclusion criteria were included in the data analysis. The main results measured in this study are the postoperative pain score and opioid consumption within 48 hours after surgery.
Use Student's t-test or Welch's t-test to compare normally distributed continuous variables (for example, age, BMI, intraoperative fentanyl administration). Categorical variables (intraoperative dexmedetomidine or ketamine administration, gender) were compared with the chi-square test. The Wilcoxon rank sum is used to evaluate non-normally distributed data, including the total number of postoperative MMEs and interval pain scores, and the time required to complete the local nerve block. The significance level P <0.05 was used during the statistical analysis to establish statistically significant differences.
It is worth noting that when planning our retrospective study in 2018, there was no evidence-based measure of effect size based on quantity and variance to perform prior sample size calculations. Therefore, the sample size is determined by retrospective convenience sampling. 13 In the end, our sample size was limited to a designated 14-month period, based on specific clinical manifestations and compliance with the inclusion and exclusion criteria of a single primary trauma center.
During the study period, 47 patients met the inclusion criteria for inclusion in our study. Among these 47 patients, 2 patients with chronic pain, 1 patient who received surgical intervention within 48 hours after ISB, and 1 patient who received ISB for pain control 2 days before surgery were excluded. Therefore, a total of 43 patient charts were reviewed to collect data, of which 19 patients received ISB-CC and 24 patients received ISB-LB.
Of the total of 43 patients, 4 patients (1 in the ISB-CC group and 3 in the ISB-LB group) received ISB before the operation on the day of surgery, while all other patients received ISB immediately after the PACU. It is worth noting that 2 patients in the ISB-LB group received a combined scalene-supraclavicular brachial plexus block to provide additional analgesia at the distal humerus. 14 Regarding the types of shoulder surgery, each patient in the two groups received a subset of the major shoulder surgery in Table 2 of the surgical intervention listed below.
For the ISB-CC group, 2 patients needed to increase the infusion rate of 0.2% ropivacaine from 6 mL/hr to 8 mL/hr to improve the analgesic effect, and 1 patient needed to increase the infusion rate from 6 mL /hr was reduced to 4 mL/hr to reduce motor block. In addition, a total of 6 patients in the ISB-CC group received a bolus injection (10-20 mL 0.25% bupivacaine hydrochloride, 0.2% ropivacaine or 0.5% ropivacaine) before removing the indwelling catheter to provide Prolonged analgesia. Three patients from the ISB-CC group were sent home, using a disposable elastic pump, continuously infused 0.2% ropivacaine at a rate of 6 ml/hour until the dispensed volume (400 ml) was completed.
The demographic data of each group of patients are shown in Table 1. Overall, there were no significant differences between the two groups in terms of age or BMI. Except for the two ASA 1 patients in the ISB-LB group, the gender (male/female) distribution and ASA physical condition of the two groups were also very similar, while the ISB-CC group did not (Table 1). Table 4 shows the perioperative use of fentanyl, ketamine, and dexmedetomidine in each patient population. No significant difference between the two groups was observed.
Table 5 shows the median pain scores of patients with ISB-CC and ISB-LB during the 48 hours postoperatively. The reporting interval is approximately 6 hours, 12 hours, 24 hours, 36 hours, and 48 hours after ISB or ISB. PACU arrival time for patients undergoing preoperative nerve block. For the ISB-CC group, the median pain score at 6 hours was 0 (interquartile range 0–4/10), at 12 hours it was 1 (interquartile range 0–5/10), and at 24 hours It is 2 (interquartile range 0-4/10), 1 at 36 hours (interquartile range 0-6.5/10), and 1.5 at 48 hours (interquartile range 0-4.5/10). In contrast, for the ISB-LB group, the median pain score was 0 at 6 hours (interquartile range 0-3/10) and 2 at 12 hours (interquartile range 0-7/10 ), 3.5 at 24 hours (interquartile range 0–7/10), 0 at 36 hours (interquartile range 0–2/10), and 0 at 48 hours (interquartile range 0–2/ 10). Based on the analysis of these results, when comparing the two patient groups (ISB-CC and ISB-LB), the median pain score during the 48-hour postoperative period did not appear to be significantly different. Table 5 Postoperative pain score-NPS with interquartile range
Table 5 Postoperative pain score-NPS with interquartile range
Calculate the median opioid consumption (measured by MME) of the two groups of patients during the period of postoperative days (POD) 0-2. The opioid consumption reported in Table 6 and shown in Figure 2 includes 48 hours postoperatively. For the ISB-CC group, the median opioid consumption for POD 0 was 22.5 MME (interquartile range 12-45 MME), POD 1 was 30 MME (interquartile range 0-52.5 MME), and POD 2 It is 30 MME (Interquartile range is 0-45 MME). On the other hand, for the ISB-LB group, the median opioid consumption for POD 0 was 28.5 MME (interquartile range 11-39.25 MME), and POD 1 was 37.5 MME (interquartile range 15-47.5 MME) ), and POD 2 is 25 MME (interquartile range is 15-40 MME). Based on these results, there was no significant difference in the median opioid consumption between the ISB-CC and ISB-LB patient groups during the 48-hour postoperative period. Table 6 Postoperative opioid consumption-MME with interquartile range Figure 2 Box plot of postoperative opioid consumption (in milligram equivalents of morphine). Abbreviation: POD, postoperative day.
Table 6 Postoperative opioid consumption-MME with interquartile range
Figure 2 Box plot of postoperative opioid consumption calculated in morphine milligram equivalents.
As part of the secondary comparison, the time (in minutes) required for the ISB-CC and ISB-LB groups to complete each area block intervention was recorded. The median block time with interquartile range is shown in Figure 3. The median block time in the ISB-CC group was 9 minutes (interquartile range 6-16 minutes), while the median block time in the ISB-LB group was 3.5 minutes (interquartile range 2-5 minute). These results showed a significant difference in the time required to complete each regional block intervention (ISB-CC and ISB-LB) (p <0.001). Figure 3 A box plot of the duration of the regional block intervention.
Figure 3 A box plot of the duration of the regional block intervention.
For the ISB-CC group, three complications related to catheter placement and maintenance were recorded (Table 7). A patient with severe comorbidities (ASA 3), the ISB catheterization site continued bleeding, so it was decided to remove the catheter after injecting 20 mL of 0.25% bupivacaine hydrochloride and a 3 mg bolus. Preservative-free dexamethasone . For the same patient, the PACU hospitalization was complicated by respiratory distress and required supplemental oxygen. Bedside ultrasound examination showed that ISB caused hemiplegia of the diaphragm on the same side and a small amount of pre-existing bilateral pleural effusion. In the second patient, due to persistent neuropathic pain in the C5-C6 dermatome secondary to POD 1, the indwelling catheter needs to be removed. The patient then required repeated single injections of ISB with 20 mL of 0.25% bupivacaine hydrochloride and 3 mg of preservative-free dexamethasone. Finally, in the third patient, even after reconfirming the position of the catheter tip in the ultrasound examination, due to insufficient clinical effects, there is still concern that the catheter may be displaced. As a result, the catheter was removed on the POD 1 due to possible failure of the catheter device. For the ISB-LB group, no complications related to the impact of a single ISB technique were observed, and no heart, nerve, or lung damage events were reported. For these two patient groups, there were no reports of returning to the emergency room or re-admission due to regional anesthesia intervention-related complications or uncontrolled pain complaints. Table 7 Complications of intermuscular sulcus brachial plexus block
Table 7 Complications of intermuscular sulcus brachial plexus block
ISB-LB is a promising technique to provide extended shoulder analgesia, although its analgesic effect is compared with a continuous interscalene catheter or liposomal bupivacaine local infiltration during shoulder surgery The published data is limited. 15,16 Effective multimodal management of pain after major shoulder surgery is essential for improving patient satisfaction, reducing hospital stay and costs, improving postoperative recovery and functional outcomes, and reducing the risk of chronic pain development.
The use of ISB-CC has been extensively studied and is a common technique used to provide prolonged analgesia after shoulder surgery to minimize rebound pain and hospital stay and improve patient satisfaction. 17-19 Using a single ISB, even with additives such as dexamethasone, can only provide up to about 22 hours of analgesia, which puts the patient at risk of rebound pain and needs to rely on oral or intravenous opioids To further control the pain. 3,7,8 The use of the indwelling continuous catheter system includes the ability to titrate the continuous infusion rate, inject local anesthetics, and stop or restart the infusion as needed to achieve the desired clinical effect during postoperative recovery.
However, the use of ISB continuous catheters is associated with a large number of potential complications. 20 It has been reported that the use of indwelling intermuscular groove catheters leads to a significant increase in the relative risk of major complications (almost four times higher), including respiratory distress secondary to respiratory distress. Long-term phrenic nerve block, pneumonia, persistent neuritis, cardiac events, catheter incarceration, and catheter failure such as leakage, displacement, and blockage. 21 In a study that evaluated 1505 patients who received continuous intermuscular groove catheters after outpatient shoulder surgery, patients reported mild dyspnea (27%), numbness and/or tingling in the neck/arm/hand ( 14%), erythema, pain or discharge at the catheter site (8.5%), and persistent hand weakness (5%) after the catheter was placed for 1 week. twenty two
Therefore, although ISB-CC has proven to be effective in prolonging the analgesia time after shoulder surgery, there are still concerns about various potential complications. It is worth noting that in our study, complications were observed in 3 patients in the ISB-CC group, including catheter failure, bleeding at the catheter insertion site, cervical neuropathy, and respiratory depression secondary to diaphragmatic hemiplegia. There is a small amount of bilateral pleural effusion (Table 7). In addition, 3 patients from the ISB-CC group required a catheter bolus or repeated use of the intermuscular groove to rescue the block after the catheter was removed. These events and/or complications did not occur in patients in the ISB-LB group, although there was a larger cohort. Therefore, the risk factors associated with ISB-CC, coupled with the time required to place the indwelling catheter and the need for skilled anesthesiologists, prompt people to find alternative regional techniques to minimize risk while providing extended analgesia after ISB the benefits of.
Several studies have evaluated the effectiveness of liposomal bupivacaine (LB) in local peri-articular infiltration in shoulder surgery, but there is no clear consensus on the relative effectiveness and duration of analgesia provided by this technique, which may be due to Method heterogeneity 15, 21, 23, 24 In a randomized controlled trial, the use of LB as a local periarticular injection during surgery proved to provide minimal clinical benefit, if any, when used as an assistive technology to control For pain, except for a single injection of ISB. 25 Therefore, per-articular injection of LB as an alternative to a single injection of ISB or ISB-CC has shown inconsistent results and is not a reliable analgesic technique. 23,26 However, the use of ISB-LB has been shown to be superior to placebo in a prospective, double-blind, randomized controlled trial. 27 In addition, a small prospective study of 52 patients showed that compared with ISB using only bupivacaine hydrochloride, patients with major shoulder surgery were more satisfied with the pain score in the first week after surgery. Slightly improved. 28 Pharmacokinetic studies have shown that the plasma concentration of bupivacaine reaches its peak LB 12-36 hours after administration. Therefore, the addition of bupivacaine hydrochloride to LB injection can reduce the amount of bupivacaine hydrochloride from lipids. Provides analgesia within the time window of initial release in the body29.
Regarding the use of liposomal bupivacaine and ISB, Patel et al. reported that no complications of this technique were observed because it was related to respiratory distress or the need for supplemental oxygen, which was clearly noticed when using ISB-CC. 27 This may be due to a large number of local anesthetics and catheters produced by the combined effect of a single injection, infusion and bolus injection. In addition, a retrospective chart review of 1,518 patients who underwent various upper-limb surgical interventions showed that there were no differences in complications when comparing ISB-LB and ISB with bupivacaine hydrochloride. 30 However, in a recent retrospective review of 352 patients undergoing ISB-LB after shoulder surgery, 16.5% of patients experienced postoperative complications related to the long-term clinical effects of the intervention, of which 6% of patients Need to return to the emergency department, and half of the patients need to be readmitted to the hospital for supportive care. 31 The most common symptoms included dyspnea and chest pain (12.5%) and some patients (1.7%) who reported swelling, dermatitis, and hematoma at the ISB injection site. It is worth noting that a higher ASA physical condition score is the strongest predictor of complications, which includes patients with a history of cardiopulmonary disease and elderly patients. This particular study shows that ISB-LB is not without complications or side effects. Patient selection is important, and close monitoring is essential to assess these clinical effects before discharge.
A recent retrospective review evaluated the postoperative opioid consumption of patients receiving ISB-LB and ISB-CC after total shoulder replacement. 32 The authors report that ISB-LB patients had significantly lower opioid consumption in the first 24 hours after surgery, and compared with ISB-CC patients, the total length of hospital stay was shorter, but the average pain after the first 4 hours There is no significant difference in the scores. Although the difference in average opioid consumption (33.2 MME vs. 21.1 MME) in opioid-naïve patients was statistically significant in this study, clinically this translates into a difference of 12 MME, which is about one or two tablets Oxycodone 5 mg tablets. The average length of stay of these patients was 29.3 hours, so there is not enough information to explain the long-term analgesic effect of these local techniques immediately after surgery. However, compared with the ISB-CC group, the ISB-LB group had significantly lower opioid consumption at 8 weeks postoperatively (402 MME vs. 582 MME).
Our goal is to further examine the extent of prolonged analgesia provided by ISB-LB and ISB-CC by evaluating the pain score and opioid consumption in the case of shoulder trauma that requires open shoulder surgery within 48 hours after surgery. The results showed that ISB-LB provided comparable postoperative pain relief compared to ISB-CC when measuring speech pain scores and opioid consumption during the 48-hour postoperative period. In addition, ISB-LB did not cause serious or minor complications, while three patients from the ISB-CC group experienced some degree of frustration related to catheter failure, insertion site bleeding, neuralgia, and semidiaphragmatic paralysis (Table 7) .
Compared with the use of ISB indwelling continuous catheters, single ISB has many advantages. First, compared to the longer time required to place, confirm, and secure the catheter, a single peripheral nerve block requires less time. In our research, we observed significant differences in the time required to complete the regional block intervention. Compared with the ISB-CC group (median time 9 minutes), the block in the ISB-LB group required a shorter total time (median time 3.5 minutes). In addition, ISB-CC placement requires more technical skills and training. Catheter management also requires a service, which can answer calls in the outpatient clinic or establish an acute pain team to manage and resolve ISB-CC complications in an inpatient setting. In our trauma patients, a potential advantage of ISB-LB over ISB-CC is the ability to administer local anesthetics farther along the upper trunk, which can provide prolonged analgesia and may reduce the incidence of diaphragmatic paralysis. 33 The porous catheter does not provide the opportunity to guide the local anesthetic further in a precise manner. On the other hand, one of the main disadvantages of ISB-LB is that the duration of action is limited, and the analgesic effect cannot be further adjusted according to the clinical effect after the initial administration. There are theoretical concerns about long-term phrenic nerve palsy after ISB-LB surgery. However, in our patient population, we have not observed any impaired respiratory function or readmission due to complications after ISB-LB surgery.
Although we can draw some conclusions from our retrospective study, there are still some important limitations to be aware of. These include the retrospective nature of the research and the attendant reviewer bias. In addition, when retrospectively reviewing patients with multiple injuries in a large level 1 trauma center, it is expected that there will be a lack of homogeneity in the type of surgery and coexisting injuries between the two study groups. Therefore, this may introduce additional variables for each patient's perioperative analgesia requirements and degree of recovery. However, based on our experience, the postoperative pain trajectories of the surgical procedures evaluated in this study are very similar and can be compared to draw meaningful conclusions. For all shoulder surgeries included in this study, postoperative pain scores are often in the severe range, requiring long-term strong analgesia management. It is worth noting that shoulder arthroscopic surgery also has a similar pain trajectory, and the postoperative pain lasts up to 72 hours. 34
Another limitation of this study is that the long-term prognosis of patients with ISB-CC or ISB-LB cannot be assessed due to insufficient data in the 48-hour window after operation and lack of detailed follow-up records after discharge. On the other hand, since our patient population is composed of trauma patients, the existence of contralateral lung lesions has become a contraindication to ISB in some cases. Therefore, it is necessary to preserve the analgesic strategy of the diaphragm, which limits the treatment of some patients in our review. Included.
Although the retrospective nature of the study and the set time for observing patients provided a limited sample size, the results provided insight into the clinical efficacy of the two ISB regional techniques in patients undergoing shoulder surgery. Even in a small sample size, the upper quartile of opioid consumption between the two groups on each day after surgery differed by only about 5 MME. This only translates to subtle differences in the use of opioids in the clinical setting. In addition, if the sample size is large, there is no consistent trend in pain scores indicating that one technique is better than another. This retrospective study provided important initial data, highlighted the comparable efficacy of the two ISB regional techniques, and provided motivation for future prospective randomized studies.
In summary, this retrospective study provides valuable information about the efficacy of liposomal bupivacaine and continuous catheter systems for intermuscular brachial plexus block in patients undergoing shoulder surgery. This is the first study to evaluate and compare these two regional anesthesia techniques in a traumatic environment. However, in order to establish further conclusions and confirm these findings through prospective studies, it is still necessary to review a larger patient sample size. In the end, the two ISB techniques produced comparable postoperative pain scores and opioid consumption within 48 hours after surgery, and the time required to complete the regional intervention in the ISB-LB group was shorter. Therefore, ISB with liposomal bupivacaine may be a viable alternative to ISB indwelling a continuous catheter, which can provide prolonged analgesia for patients undergoing major shoulder surgery.
The authors report no conflicts of interest in this work.
1. Cozowicz C, Poeran J, Memtsoudis SG. Epidemiology, trends and differences of regional anesthesia in orthopedic surgery. Br J Anaesth. 2015; 115 (Supplement 2): ii57-67. doi:10.1093/bja/aev381
2. Egol KA, Forman J, Ong C, Rosenberg A, Karia R, Zuckerman JD. Regional anesthesia can improve the prognosis of patients undergoing repair of proximal humeral fractures. Bull Hospital Jt Dis. 2014;72(3):231–236.
3. Abdallah FW, Halpern SH, Aoyama K, Brull R. Is the real benefit of a single oblique stop, please stand up? Systematic reviews and meta-analysis. Anesthesia analysis. 2015;120(5):1114–1129. doi:10.1213/ANE.0000000000000688
4. Bishop JY, Sprague M, Gelber J, etc. Anesthesia of the intermuscular sulcus area for shoulder surgery. J Bone Joint Surg Am. 2005;87(5):974–979. doi:10.2106/JBJS.D.02003
5. Chalmers PN, Salazar D, Fingerman ME, Keener JD, Chamberlain A. Continuous intermuscular sulcus brachial plexus block is associated with shortened hospital stay after shoulder arthroplasty. Orthop Traumatol Surg Res. 2017; 103(6): 847–852. doi:10.1016/j.otsr.2017.06.007
6. Goebel S, Stehle J, Schwemmer U, Reppenhagen S, Rath B, Gohlke F. Intermuscular brachial plexus block in rotator cuff surgery: randomized, double-blind, placebo-controlled between single anesthesia and patient control Experiment with the catheter system. Arch orthopedic trauma surgery. 2010;130(4):533–540. doi:10.1007/s00402-009-0985-7
7. Cummings KC 3rd, Napierkowski DE, Parra-Sanchez I and others. The effect of dexamethasone on the duration of ropivacaine or bupivacaine intermuscular sulcus nerve block. Br J Anaesth. 2011;107(3):446–453. doi:10.1093/bja/aer159
8. Kirkham KR, Jacot-Guillarmod A, Albrecht E. Perineural dexamethasone to extend the optimal dose of brachial plexus analgesia: a systematic review and meta-analysis. Anesthesia analysis. 2018;126(1):270–279. doi:10.1213/ANE.0000000000002488
9. Lavand'homme P. Rebound pain after local anesthesia in an outpatient. Curr Opin anesthetic. 2018;31(6):679–684. doi:10.1097/ACO.0000000000000651
10. Soffer RJ, Rosenblatt, Massachusetts. Teaching ultrasound-guided intermuscular sulcus block: Describe a simple and effective technique. J Clinical anesthesia. 2007;19(3):241-242. doi:10.1016/j.jclinane.2007.02.001
11. Casati A, Vinciguerra F, Scarioni M, etc. Lidocaine versus ropivacaine is used for continuous intermuscular sulcus brachial plexus block after open shoulder surgery. Acta anesthetic scan. 2003;47(3):355–360. doi:10.1034/j.1399-6576.2003.00065.x
12. Nielsen S, Degenhardt L, Hoban B, Gisev N. Synthesis of Oral Morphine Equivalent (OME) for Opioid Utilization Research. Pharmacoepidemiol drug Saf. 2016;25(6):733–737. doi:10.1002/pds.3945
13. Hu Z, Qin J. The universality of causal inference in observational studies under retrospective convenience sampling. Statistical medicine. 2018;37(19):2874–2883. doi:10.1002/sim.7808
14. Guttman OT, Soffer RJ, Rosenblatt MA. Ultrasound guided interclavian muscle mesothelial (UGSCIS) block: a case report. Pain exercises. 2008;8(1):62–64. doi:10.1111/j.1533-2500.2007.00156.x
15. Kolade O, Patel K, Ihejirika R, etc. The efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis. J Shoulder and elbow surgery. 2019;28(9):1824–1834. doi:10.1016/j.jse.2019.04.054
16. Orebaugh SL, Dewasurendra A. Has the future arrived? Liposome bupivacaine with peripheral catheters and additives for brachial plexus nerve block. Curr Opin anesthetic. 2020; 33(5): 704–709. doi:10.1097/ACO.0000000000000913
17. Mariano ER, Afra R, Loland VJ, etc. Ultrasound-guided posterior continuous intermuscular brachial plexus block: a randomized, triple-blind, placebo-controlled study. Anesthesia analysis. 2009;108(5):1688-1694. doi:10.1213/ane.0b013e318199dc86
18. Salviz EA, Xu D, Frulla A, etc. Continuous intermuscular sulcus block in patients undergoing outpatient rotator cuff repair surgery: a prospective randomized trial. Anesthesia analysis. 2013;117(6):1485–1492. doi:10.1213/01.ane.0000436607.40643.0a
19. Vorobeichik L, Brull R, Bowry R, Laffey JG, Abdallah FW. Should major shoulder surgery routinely use continuous injections instead of a single injection of scalene muscle block? Meta-analysis of analgesia and side effects. Br J Anaesth. 2018;120(4):679–692. doi:10.1016/j.bja.2017.11.104
20. Lenters TR, Davies J, Matsen FA 3rd. The type and severity of complications associated with intermyogenic brachial plexus block anesthesia: local and national evidence. J Shoulder and elbow surgery. 2007;16(4):379–387. doi:10.1016/j.jse.2006.10.007
21. Weller WJ, Azzam MG, Smith RA, Azar FM, Throckmorton TW. Compared with the indwelling interscalene catheter in total shoulder arthroplasty, the liposomal bupivacaine mixture has similar pain relief and significantly fewer complications, and is lower in cost. J Arthroplasty. 2017;32(11):3557–3562. doi:10.1016/j.arth.2017.03.017
22. Fredrickson MJ, Leightley P, Wong A, Chadock M, Abeysekera A, Frampton C. Analysis of 1505 consecutive patients receiving continuous intramuscular groove analgesia at home: a multicenter prospective safety study. anaesthetization. 2016;71(4):373–379. doi:10.1111/anae.13385
23. Abildgaard JT, Lonergan KT, Tolan SJ, etc. Liposome bupivacaine and indwelling scalene intermuscular nerve block for pain control after shoulder arthroplasty: a prospective randomized controlled trial. J Shoulder and elbow surgery. 2017;26(7):1175–1181. doi:10.1016/j.jse.2017.03.012
24. Sabesan VJ, Shahriar R, Petersen-Fitts GR, etc. A prospective randomized controlled trial to determine the best postoperative pain management for shoulder arthroplasty: liposomal bupivacaine and continuous intermuscular groove catheter. J Shoulder and elbow surgery. 2017;26(10):1810-1817. doi:10.1016/j.jse.2017.06.044
25. Namdari S, Nicholson T, Abboud J, Lazarus M, Steinberg D, Williams G. Intermuscular groove block with or without bupivacaine liposome local infiltration during shoulder arthroplasty: a randomized controlled trial . J Bone Joint Surg Am. 2018;100(16):1373–1378. doi:10.2106/JBJS.17.01416
26. Namdari S, Nicholson T, Abboud J, Lazarus M, Steinberg D, Williams G. Randomized controlled trial of intermuscular groove block in shoulder arthroplasty compared with liposomal bupivacaine injection. J Bone Joint Surg Am. 2017; 99(7): 550–556. doi:10.2106/JBJS.16.00296
27. Patel MA, Gadsden JC, Nedeljkovic SS, etc. Bupivacaine liposomal brachial plexus block for shoulder surgery can improve analgesia and reduce opioid consumption: results from a multicenter, randomized, double-blind, controlled trial. Pain medicine. 2020;21(2):387–400. doi:10.1093/pm/pnz103
28. Vandepitte C, Kuroda M, Witvrouw R, etc. The addition of liposomal bupivacaine to bupivacaine hydrochloride is used for intermuscular brachial plexus block in patients with major shoulder surgery compared with bupivacaine hydrochloride alone. Reg Anesth Pain Medicine. 2017; 42(3): 334–341. doi:10.1097/AAP.0000000000000560
29. Hu D, Onel E, Singla N, Kramer WG, Hadzic A. Pharmacokinetic characteristics of liposomal bupivacaine injection after a single administration at the surgical site. Clinical drug research. 2013;33(2):109-115. doi:10.1007/s40261-012-0043-z
30. Hutchins JL, Habeck J, Novaczyk Z, etc. Complications of patients with delayed intermuscular groove block: a retrospective comparison of liposomal bupivacaine and non-liposomal bupivacaine. Anesthesiol Res practice. 2020; 2020: 6704303. doi:10.1155/2020/6704303
31. Malige A, Yeazell S, Ng-Pellegrino A, Carolan G. Risk factors for complication of intramuscular sulcus obstruction using liposomal bupivacaine for shoulder surgery and return to the emergency room. J Shoulder and elbow surgery. 2020;29(11):2332-2338. doi:10.1016/j.jse.2020.03.012
32. Weir TB, Simpson N, Aneizi A, etc. In total shoulder arthroplasty, single injection of liposomal bupivacaine intermuscular groove block and continuous intermuscular groove catheter: opioid administration, pain score and complications. J Orthotics. 2020; 22:261-267. doi:10.1016/j.jor.2020.05.006
33. Kim DH, Lin Y, Beath JC, etc. Upper Trunk Block: Diaphragm-preserving Alternative to Intermuscular Block: A Randomized Controlled Trial. Anesthesiology. 2019;131(3):521–533. doi:10.1097/ALN.0000000000002841
34. Mariano ER, El-Boghdadly K, Ilfeld BM. Use postoperative pain trajectory to define the role of regional analgesia in personalized pain medicine. anaesthetization. 2021; 76(2): 165–169. doi:10.1111/anae.15067
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