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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.
Br J Anaesth. 2016 Apr; 116(4):531-7.BJ

Abstract

BACKGROUND

Hemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We tested the hypothesis that an injection lateral to the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with a conventional intrafascial injection, while providing similar analgesia.

METHODS

Forty ASA I-III patients undergoing elective shoulder and clavicle surgery under general anaesthesia were randomized to receive an ultrasound-guided interscalene brachial plexus block for analgesia, using 20 ml bupivacaine 0.5% with epinephrine 1:200 000 injected either between C5 and C6 within the interscalene groove (conventional intrafascial injection), or 4 mm lateral to the brachial plexus sheath (extrafascial injection). The primary outcome was incidence of hemidiaphragmatic paresis (diaphragmatic excursion reduction >75%), measured by M-mode ultrasonography, before and 30 min after the procedure. Secondary outcomes were forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow. Additional outcomes included time to first opioid request and pain scores at 24 h postoperatively (numeric rating scale, 0-10).

RESULTS

The incidences of hemidiaphragmatic paresis were 90% (95% CI: 68-99%) and 21% (95% CI: 6-46%) in the conventional and extrafascial injection groups, respectively (P<0.0001). Other respiratory outcomes were significantly better preserved in the extrafascial injection group. The mean time to first opioid request was similar between groups (conventional: 802 min [95% CI: 620-984 min]; extrafascial: 973 min [95% CI: 791-1155 min]; P=0.19) as were pain scores at 24 h postoperatively (conventional: 1.6 [95% CI: 0.9-2.2]; extrafascial: 1.6 [95% CI: 0.8-2.4]; P=0.97).

CONCLUSIONS

Ultrasound-guided interscalene brachial plexus block with an extrafascial injection reduces the incidence of hemidiaphragmatic paresis and impact on respiratory function while providing similar analgesia, when compared with a conventional injection.

CLINICAL TRIAL REGISTRATION

NCT02074397.

Links

Publisher Full Text (DOI)

Authors+Show Affiliations

Palhais N
Department of Anaesthesia.
Brull R
Department of Anaesthesia, Toronto Western Hospital and Women's College Hospital, University of Toronto, Toronto, Canada.
Kern C
Department of Anaesthesia.
Jacot-Guillarmod A
Department of Anaesthesia.
Charmoy A
Department of Anaesthesia.
Farron A
Department of Orthopaedic, Lausanne University Hospital, Lausanne, Switzerland.
Albrecht E
Department of Anaesthesia eric.albrecht@chuv.ch.

MeSH

AdultAnesthetics, LocalBrachial Plexus BlockBupivacaineClavicleDouble-Blind MethodFasciaFemaleHumansIntraoperative ComplicationsKaplan-Meier EstimateMalePain MeasurementPain, PostoperativeRespiration DisordersRespiratory MechanicsRespiratory ParalysisShoulderTreatment OutcomeUltrasonography, Interventional

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

26994230

Clinical Trial Links

Does Saline Injection Around Phrenic Nerve Reduce Incidence of Diaphragmatic Paresis Following Interscalene Block?

Citation

Palhais, N, et al. "Extrafascial Injection for Interscalene Brachial Plexus Block Reduces Respiratory Complications Compared With a Conventional Intrafascial Injection: a Randomized, Controlled, Double-blind Trial." British Journal of Anaesthesia, vol. 116, no. 4, 2016, pp. 531-7.
Palhais N, Brull R, Kern C, et al. Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial. Br J Anaesth. 2016;116(4):531-7.
Palhais, N., Brull, R., Kern, C., Jacot-Guillarmod, A., Charmoy, A., Farron, A., & Albrecht, E. (2016). Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial. British Journal of Anaesthesia, 116(4), 531-7. https://doi.org/10.1093/bja/aew028
Palhais N, et al. Extrafascial Injection for Interscalene Brachial Plexus Block Reduces Respiratory Complications Compared With a Conventional Intrafascial Injection: a Randomized, Controlled, Double-blind Trial. Br J Anaesth. 2016;116(4):531-7. PubMed PMID: 26994230.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial. AU - Palhais,N, AU - Brull,R, AU - Kern,C, AU - Jacot-Guillarmod,A, AU - Charmoy,A, AU - Farron,A, AU - Albrecht,E, PY - 2016/3/20/entrez PY - 2016/3/20/pubmed PY - 2016/7/23/medline KW - analgesia KW - anesthesia, regional KW - brachial plexus block KW - diaphragm KW - postoperative pain SP - 531 EP - 7 JF - British journal of anaesthesia JO - Br J Anaesth VL - 116 IS - 4 N2 - BACKGROUND: Hemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We tested the hypothesis that an injection lateral to the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with a conventional intrafascial injection, while providing similar analgesia. METHODS: Forty ASA I-III patients undergoing elective shoulder and clavicle surgery under general anaesthesia were randomized to receive an ultrasound-guided interscalene brachial plexus block for analgesia, using 20 ml bupivacaine 0.5% with epinephrine 1:200 000 injected either between C5 and C6 within the interscalene groove (conventional intrafascial injection), or 4 mm lateral to the brachial plexus sheath (extrafascial injection). The primary outcome was incidence of hemidiaphragmatic paresis (diaphragmatic excursion reduction >75%), measured by M-mode ultrasonography, before and 30 min after the procedure. Secondary outcomes were forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow. Additional outcomes included time to first opioid request and pain scores at 24 h postoperatively (numeric rating scale, 0-10). RESULTS: The incidences of hemidiaphragmatic paresis were 90% (95% CI: 68-99%) and 21% (95% CI: 6-46%) in the conventional and extrafascial injection groups, respectively (P<0.0001). Other respiratory outcomes were significantly better preserved in the extrafascial injection group. The mean time to first opioid request was similar between groups (conventional: 802 min [95% CI: 620-984 min]; extrafascial: 973 min [95% CI: 791-1155 min]; P=0.19) as were pain scores at 24 h postoperatively (conventional: 1.6 [95% CI: 0.9-2.2]; extrafascial: 1.6 [95% CI: 0.8-2.4]; P=0.97). CONCLUSIONS: Ultrasound-guided interscalene brachial plexus block with an extrafascial injection reduces the incidence of hemidiaphragmatic paresis and impact on respiratory function while providing similar analgesia, when compared with a conventional injection. CLINICAL TRIAL REGISTRATION: NCT02074397. SN - 1471-6771 UR - https://www.unboundmedicine.com/medline/citation/26994230/Extrafascial_injection_for_interscalene_brachial_plexus_block_reduces_respiratory_complications_compared_with_a_conventional_intrafascial_injection:_a_randomized_controlled_double_blind_trial_ DB - PRIME DP - Unbound Medicine ER -
Grapherence [↓19 ↑1]

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