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Evaluation of the lateral modified approach for continuous interscalene block
2
Best Free Papers
Best Free Papers 78. Spinal anaesthesia for elective surgery: a comparison of plain and hyperbaric solutions of ropivacaine
97. Evaluation of the lateral modified approach for continuous interscalene block
Fettes PDW University Department of Anaesthesia, Ninewells Hospital & Medical School, Dundee, United Kingdom
Dullenkopf A Orthopaedic University Clinic Zurich/Balgrist, Zurich, Switzerland
Background: ‘Hyperbaric’ ropivacaine has been shown to provide reliable spinal anaesthesia of shorter duration than bupivacaine1 (which may be of particular interest in the day case setting). However, there are few data comparing the action of ‘plain’ and ‘hyperbaric’ ropivacaine.
Background: Continuous interscalene block is an accepted method for providing pain relief during and after shoulder surgery1. We prospectively assessed the clinical practicability, efficacy, and complications up to 6 months of the modified lateral approach for insertion of the interscalene catheter in 700 patients.
Methods: 40 ASA grade I-II patients having elective surgery under spinal anaesthesia, and randomised to receive 3ml of ropivacaine 5 mg.ml-1 either with no glucose, or with glucose 50 mg.ml-1. Patients were placed in the left lateral position, and the injection was made over 10-15s through a 25swg Whitacre needle. The patients were then turned supine. Bilateral sensory (pinprick with 27swg short bevel needle) and motor block (Bromage scale 0-3), pulse rate and blood pressure were recorded at 2, 5, 10, 15, 20, 25 and 30 min, and then at 30 min intervals until regression of the block was complete.
Methods: During a 15 month period 700 adult patients scheduled for elective shoulder surgery with planned insertion of an interscalene catheter (ISC) were included in the study. The ISC procedure was standardised for all patients, local anaesthetics were applied through the catheter. Difficulties in catheter placement, clinical efficacy, patient satisfaction, acute and chronic complications were recorded. Patients were observed daily (for 10 d), and 1, 3, and 6 months after surgery for any complications. Electroneuromyography was performed after 1, 3, and 6 months in symptomatic patients.
Results: Two patients (one per group) were withdrawn after total block failure, leaving 19 patients in each group. While there were no statistically significant demographic differences between the two groups, mean duration of surgery was longer for those receiving ‘plain’ ropivacaine (‘hyperbaric’ 39 min; ‘plain’ 25 min; p ⬍ 0.05). There were significant differences in mean time to onset of sensory block at T10 (‘hyperbaric’ 4.5 min; ‘plain’ 10.6 min; p ⬍ 0.01), median maximum extent of the block (‘hyperbaric’ T4; ‘plain’ T8; p ⬍ 0.05), and mean duration of sensory block at T10 (an indicator of useful block for surgery: ‘hyperbaric’ 120 min; ‘plain’ 54 min; p ⬍ 0.001). However, mean time to complete regression of sensory block (‘hyperbaric’ 227 min, n⫽16; ‘plain’ 272 min, n ⫽ 17; p ⬍ 0.05), and motor block (‘hyperbaric’ 113 min; ‘plain’ 182 min; p ⬍ 0.001) was longer in the ‘plain’ group. Patients therefore mobilised sooner in the ‘hyperbaric’ group (‘hyperbaric’ 222 min; ‘plain’ 281 min; p ⬍ 0.02). While all ‘hyperbaric’ blocks were adequate for surgery, 3 patients receiving ‘plain’ ropivacaine required general anaesthesia.
Results: 700 patients were included in the study, 86% of all ISC were placed by one attempt. Resistance to thread the catheter was observed in 6%. No major complication was observed during initial bolus application of local anaesthetics. Clinical success rate for anaesthesia was 97%. Postoperative analgesia was sufficient in 99%, taken into account, that ropivacaine infusion rate had to be increased in 31 patients. In 5 patients (0.7%) local infection of the insertion point was noted, in 1 patient (0.1%) drainage of an abscess had to be performed. Mean patient satisfaction was 9.6 (VAS 0-10). Minor neurologic complications were observed in 2.4%, 0.3%, and 0% after 1, 3, and 6 months, respectively. At 1 month 3 sulcus ulnaris syndromes, 1 carpal tunnel syndrome and 1 complex regional pain syndrome were diagnosed. 2 patients (0.2%) showed severe sensory-motor deficit, which took 18 and 19 weeks to resolve, respectively. Electromyography was suggestive of partial axonotmesis.
Conclusion: Addition of glucose 50 mg.ml-1 to ropivacaine 15 mg improves block reliability, speed of onset, and duration of useful block for surgery, while also increasing speed of recovery. Acknowledgement: Funding from AstraZeneca Pharmaceuticals.
Reference 1. Whiteside JB, Burke D, Wildsmith JAW. Comparison of ropivacaine 0.5% (in glucose 5%) with bupivacaine 0.5% (in glucose 8%) for spinal anaesthesia for elective surgery. British Journal of Anaesthesia. 2003;90:304-308.
Discussion and conclusion: The lateral modified approach provides good conditions for interscalene catheter placement. Anaesthesia and analgesia performed through the catheter are efficient. Using a standardised technique the rates of infection and neurologic complications are low, and patient satisfaction is high.
Reference 1. Borgeat, et al. Anesthesiology. 1997;87:1343-1347.
Best Free Papers
Best Free Papers 78. Spinal anaesthesia for elective surgery: a comparison of plain and hyperbaric solutions of ropivacaine
97. Evaluation of the lateral modified approach for continuous interscalene block
Fettes PDW University Department of Anaesthesia, Ninewells Hospital & Medical School, Dundee, United Kingdom
Dullenkopf A Orthopaedic University Clinic Zurich/Balgrist, Zurich, Switzerland
Background: ‘Hyperbaric’ ropivacaine has been shown to provide reliable spinal anaesthesia of shorter duration than bupivacaine1 (which may be of particular interest in the day case setting). However, there are few data comparing the action of ‘plain’ and ‘hyperbaric’ ropivacaine.
Background: Continuous interscalene block is an accepted method for providing pain relief during and after shoulder surgery1. We prospectively assessed the clinical practicability, efficacy, and complications up to 6 months of the modified lateral approach for insertion of the interscalene catheter in 700 patients.
Methods: 40 ASA grade I-II patients having elective surgery under spinal anaesthesia, and randomised to receive 3ml of ropivacaine 5 mg.ml-1 either with no glucose, or with glucose 50 mg.ml-1. Patients were placed in the left lateral position, and the injection was made over 10-15s through a 25swg Whitacre needle. The patients were then turned supine. Bilateral sensory (pinprick with 27swg short bevel needle) and motor block (Bromage scale 0-3), pulse rate and blood pressure were recorded at 2, 5, 10, 15, 20, 25 and 30 min, and then at 30 min intervals until regression of the block was complete.
Methods: During a 15 month period 700 adult patients scheduled for elective shoulder surgery with planned insertion of an interscalene catheter (ISC) were included in the study. The ISC procedure was standardised for all patients, local anaesthetics were applied through the catheter. Difficulties in catheter placement, clinical efficacy, patient satisfaction, acute and chronic complications were recorded. Patients were observed daily (for 10 d), and 1, 3, and 6 months after surgery for any complications. Electroneuromyography was performed after 1, 3, and 6 months in symptomatic patients.
Results: Two patients (one per group) were withdrawn after total block failure, leaving 19 patients in each group. While there were no statistically significant demographic differences between the two groups, mean duration of surgery was longer for those receiving ‘plain’ ropivacaine (‘hyperbaric’ 39 min; ‘plain’ 25 min; p ⬍ 0.05). There were significant differences in mean time to onset of sensory block at T10 (‘hyperbaric’ 4.5 min; ‘plain’ 10.6 min; p ⬍ 0.01), median maximum extent of the block (‘hyperbaric’ T4; ‘plain’ T8; p ⬍ 0.05), and mean duration of sensory block at T10 (an indicator of useful block for surgery: ‘hyperbaric’ 120 min; ‘plain’ 54 min; p ⬍ 0.001). However, mean time to complete regression of sensory block (‘hyperbaric’ 227 min, n⫽16; ‘plain’ 272 min, n ⫽ 17; p ⬍ 0.05), and motor block (‘hyperbaric’ 113 min; ‘plain’ 182 min; p ⬍ 0.001) was longer in the ‘plain’ group. Patients therefore mobilised sooner in the ‘hyperbaric’ group (‘hyperbaric’ 222 min; ‘plain’ 281 min; p ⬍ 0.02). While all ‘hyperbaric’ blocks were adequate for surgery, 3 patients receiving ‘plain’ ropivacaine required general anaesthesia.
Results: 700 patients were included in the study, 86% of all ISC were placed by one attempt. Resistance to thread the catheter was observed in 6%. No major complication was observed during initial bolus application of local anaesthetics. Clinical success rate for anaesthesia was 97%. Postoperative analgesia was sufficient in 99%, taken into account, that ropivacaine infusion rate had to be increased in 31 patients. In 5 patients (0.7%) local infection of the insertion point was noted, in 1 patient (0.1%) drainage of an abscess had to be performed. Mean patient satisfaction was 9.6 (VAS 0-10). Minor neurologic complications were observed in 2.4%, 0.3%, and 0% after 1, 3, and 6 months, respectively. At 1 month 3 sulcus ulnaris syndromes, 1 carpal tunnel syndrome and 1 complex regional pain syndrome were diagnosed. 2 patients (0.2%) showed severe sensory-motor deficit, which took 18 and 19 weeks to resolve, respectively. Electromyography was suggestive of partial axonotmesis.
Conclusion: Addition of glucose 50 mg.ml-1 to ropivacaine 15 mg improves block reliability, speed of onset, and duration of useful block for surgery, while also increasing speed of recovery. Acknowledgement: Funding from AstraZeneca Pharmaceuticals.
Reference 1. Whiteside JB, Burke D, Wildsmith JAW. Comparison of ropivacaine 0.5% (in glucose 5%) with bupivacaine 0.5% (in glucose 8%) for spinal anaesthesia for elective surgery. British Journal of Anaesthesia. 2003;90:304-308.
Discussion and conclusion: The lateral modified approach provides good conditions for interscalene catheter placement. Anaesthesia and analgesia performed through the catheter are efficient. Using a standardised technique the rates of infection and neurologic complications are low, and patient satisfaction is high.
Reference 1. Borgeat, et al. Anesthesiology. 1997;87:1343-1347.