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      Local anesthetic volume in ultrasound-guided interscalene block and opioid consumption during shoulder arthroscopic surgery : A retrospective comparative study

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          Abstract

          Interscalene block (ISB) is commonly performed for regional anesthesia in shoulder surgery. Ultrasound-guided ISB enables visualization of the local anesthetic spread and a reduction in local anesthetic volume. However, little is known about the appropriate local anesthetic dose for surgical anesthesia without sedation or general anesthesia. The purpose of our study was to evaluate the appropriate local anesthetic volume by comparing intraoperative analgesics and hemodynamic changes in ISB in arthroscopic shoulder surgery.

          Overall, 1007 patients were divided into groups 1, 2, and 3 according to the following volume of local anesthetics: 10–19, 20–29, and 30–40 mL, respectively. The use of intraoperative analgesics and sedatives, and the reduction in intraoperative maximum blood pressure and heart rate were compared through retrospective analysis.

          Fentanyl was used in 55.6% of patients in group 1, which was significantly higher than in those groups 2 and 3 (22.3% and 30.7%, respectively); furthermore, it was also higher than those in groups 2 and 3 in dose-specific comparisons ( P < .05). The percent of the maximum reduction in intraoperative systolic blood pressure and heart rate in group 3 was significantly higher than those in groups 1 and 2. Ephedrine administration was lower in group 2 than that in other groups ( P < .05). The incidence of hypotensive bradycardic events was lowest (9.1%) at the local anesthetic volume of 24 mL as revealed by the quadratic regression analysis ( R 2 = 0.313, P = .003).

          Decreasing the local anesthetic volume to less than 20 mL for ultrasound-guided ISB as the sole anesthesia increases the opioid consumption during shoulder arthroscopic surgery. Local anesthetics >30 mL or increased opioid consumption with <20 mL of local anesthetics could increase the risk of cardiovascular instability intraoperatively. Our findings indicate that 24 mL of local anesthetic could be used to lower the incidence of hypotensive bradycardic events.

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          Advances in and limitations of up-and-down methodology: a précis of clinical use, study design, and dose estimation in anesthesia research.

          Sequential design methods for binary response variables exist for determination of the concentration or dose associated with the 50% point along the dose-response curve; the up-and-down method of Dixon and Mood is now commonly used in anesthesia research. There have been important developments in statistical methods that (1) allow the design of experiments for the measurement of the response at any point (quantile) along the dose-response curve, (2) demonstrate the risk of certain statistical methods commonly used in literature reports, (3) allow the estimation of the concentration or dose-the target dose-associated with the chosen quantile without the assumption of the symmetry of the tolerance distribution, and (4) set bounds on the probability of response at this target dose. This article details these developments, briefly surveys current use of the up-and-down method in anesthesia research, reanalyzes published reports using the up-and-down method for the study of the epidural relief of pain during labor, and discusses appropriate inferences from up-and-down method studies.
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            Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block.

            Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. We examined the incidence of phrenic nerve palsy with a low-volume ISBPB compared with a standard-volume technique both guided by ultrasound. Forty patients undergoing shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 5 or 20 ml ropivacaine 0.5%. General anaesthesia was standardized. Both groups were assessed for respiratory function by sonographic diaphragmatic assessment and spirometry before and after receiving ISBPB, and after surgery. Motor and sensory block, pain, sleep quality, and analgesic consumption were additional outcomes. Statistical comparison of continuous variables was analysed using one-way analysis of variance and Student's t-test. Non-continuous variables were analysed using chi(2) tests. Statistical significance was assumed at P<0.05. The incidence of diaphragmatic paralysis was significantly lower in the low-volume group compared with the standard-volume group (45% vs 100%). Reduction in forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow at 30 min after the block was also significantly less in the low-volume group. In addition, there was a significantly greater decrease in postoperative oxygen saturation in the standard-volume group (-5.85 vs -1.50, P=0.004) after surgery. There were no significant differences in pain scores, sleep quality, and total morphine consumption up to 24 h after surgery. The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.
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              Interscalene brachial plexus block.

              A Winnie (1970)
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Lippincott Williams & Wilkins (Hagerstown, MD )
                0025-7974
                1536-5964
                09 July 2021
                09 July 2021
                : 100
                : 27
                : e26527
                Affiliations
                [a ]Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
                [b ]Department of Medical Statistics, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea.
                Author notes
                []Correspondence: Woon Seok Roh, Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Republic of Korea (e-mail: usno@ 123456cu.ac.kr ).
                Article
                MD-D-21-01024 26527
                10.1097/MD.0000000000026527
                8270626
                34232187
                b2710754-f6ba-4926-8018-b8b6c99a5517
                Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

                History
                : 4 February 2021
                : 31 May 2021
                : 15 June 2021
                Categories
                3300
                Research Article
                Observational Study
                Custom metadata
                TRUE

                arthroscopic surgery,brachial plexus block,bradycardia,hypotension,shoulder,ultrasound

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