Article

Ultrasound guided interscalene brachial plexus block with low dose sedation – Technique of choice for reducing shoulder dislocation

Correspondence / American Journal of Emergency Medicine 36 (2018) 715732 717

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    Ultrasound guided interscalene brachial plexus block with low dose sedation – Technique of choice for reducing Shoulder dislocation

    To the Editor,

    We read with great interest the recent article by Raeyat Doost et al. [1] on “Ultrasound-guided interscalene nerve block vs procedural sedation

    with propofol and fentanyl for anterior Shoulder dislocations“. They con- clude that using ultrasound guided interscalene brachial plexus block (ISB) reduces Time to discharge from emergency department (ED) but pain scores are lower using procedural sedation method. We beg to differ with their second statement on the Analgesic efficacy. Our second author has successfully performed more than 50 ISBs in his ED, with or without low dose sedation, for reducing shoulder dislocation over the past 5 years. A single-shot ISB has been widely considered as the gold standard and main component of multimodal analgesic strategy for pain relief after shoulder surgery. A recent meta-analysis [2] showed that a sin- gle-shot ISB can provide effective analgesia for up to 6 h with movement and 8 h at rest after shoulder surgery. ISB also produces opioid sparing and reduces postoperative opioid-related side effects [2]. In the context of shoulder dislocation reduction, the procedure requires Short duration of pain relief and adequate Muscle relaxation. ISB has been shown to pro- vide superior analgesia and minimizes side effects of procedural sedation [1,3]. Most of these reports used Intravenous fentanyl (2 ug/kg) and propofol (1 mg/kg) with further titrated doses to achieve moderate seda- tion during the reduction procedure. In our opinion such doses are close to that used for induction of anesthesia. This may explain the transient hy- potension, hypoventilation, and the prolonged length of stay in the ED in the procedural sedation group in the report by Raeyat Doost and col- leagues [1]. We also believe that even with the above mentioned doses, some patients may still struggle during the procedure because fentanyl and propofol do not provide muscle relaxation. In contrast an ISB affects the sensory and motor innervation to the shoulder and thereby provides

    effective analgesia and muscles relaxation for the procedure.

    The current recommendation for ISB is to use ultrasound guidance, with the block needle inserted in-plane and from a lateral to medial di- rection. Local anesthetic (LA) is injected between the C5 and C6 nerve roots (with no needle contact with the nerve roots), and using relatively small volumes (10-15 ml) [4]. To identify the nerve roots of the brachial plexus in the interscalene groove, we recommend performing a dynam- ic traceback scanning method (Fig. 1) instead of using anatomical land- marks and starting the scan at the level of the cricoid cartilage [1]. The dynamic traceback technique allows consistent imaging of the brachial plexus elements and thus higher success rate. It is particularly useful in patients with difficult anatomy and for practitioners with little experi- ence in ultrasound guided regional anesthesia (UGRA) [5]. With this

    Fig. 1. sonographic appearance of the brachial plexus at the interscalene groove. Needle shall be inserted from lateral to medial, with local anesthetic 10-15 ml deposited in between C5 and C6 nerve roots (without the need for the needle tip in contact the nerve roots). Ultrasound image depicting the “stoplight” sign, referring to 3 hypoechoic structures found between the anterior and middle scalene muscles. ASM, anterior scalene muscle; CA, carotid artery; MSM, middle scalene muscle; SCM, sternocleidomastoid muscle. The figure has been modified with permission [4].

    718 Correspondence / American Journal of Emergency Medicine 36 (2018) 715732

    approach, the ultrasound transducer is initially positioned at the supraclavicular fossa and the image is optimized to visualize the ele- ments of the brachial plexus as a “cluster of grapes” lying posterolateral to the pulsating subclavian artery. The brachial plexus is then traced cephalad to the interscalene grooves where the nerve elements are vi- sualized as three hypoechoeic structures lying between the anterior and middle scalene muscles, also referred to as the “stoplight sign” [4]. Ultrasound guidance, when compared to peripheral nerve stimulation alone [6] for ISB results in fewer needle passes, faster block perfor- mance, lower LA volume requirement, faster onset of sensory block, higher success rate, and fewer incidence of vascular puncture. A suc- cessful block renders the shoulder area insensate (C5 and C6 dermato- mal distribution) with inability to abduct the Shoulder joint. As the pain is alleviated, it is our experience that patient require minimal or no sedation during the manipulation.

    However ISB should be performed by a practitioner competent with UGRA. There are vital structures, such as pleura, lung, vertebral artery, ca- rotid sheath, in the vicinity of the interscalene groove and potential com- plications such as pneumothorax, vascular puncture, etc. may occur. The use of short acting LA like lidocaine is desirable for shoulder dislocation reduction procedure because the pain is short-lived. It is recommended to use low LA volume i.e. 10 ml to minimize the incidence of phrenic nerve block (PNB), a common side effect following ISB from high LA vol- ume usage [7]. Gautier et al. [8] showed that 5 ml of 0.75% ropivacaine for ultrasound guided ISB was sufficient to accomplish surgical anesthesia for shoulder surgery. Although most cases of PNB are transient and asymp- tomatic, those with underlying lung pathology or morbidly obese may de- velop respiratory compromise. Therefore ISB is not recommended in patient with severe chronic lung disease and it is important to rule out lung pathology in a patient with shoulder dislocation before considering ISB. Following ISB, Lung ultrasound should be performed routinely to look for sonographic evidence of PNB and rule out pneumothorax [9].

    Acknowledgements

    Nil.

    Zhi Yuen Beh, MD, M. Anes, EDRA

    Department of Anesthesia & Surgical Intensive Care, Changi General

    Hospital, Singapore Corresponding author at: Department of Anesthesia & Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.

    E-mail address: [email protected].

    Adi Osman, MD, MMed (Emergency Medicine)

    Department of Trauma & Emergency Medicine, Raja Permaisuri Bainun

    Hospital, Ipoh, Malaysia

    Shahridan Fathil, MBBS, FRCA, AM

    Department of Anesthesia, Gleneagles Medini Hospital,

    Iskandar Puteri, Malaysia

    Manoj Kumar Karmakar, MD, FRCA, FHKCA, FHKAM Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China

    4 December 2017

    http://dx.doi.org/10.1016/j.ajem.2018.01.013

    References

    Raeyat Doost E, Heiran MM, Mohadevi M, Mirafzal A. Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dis- locations. Am J Emerg Med 2017;35:1435-9.

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  13. El-Boghdadly K, Chan VWS. Interscalene brachial plexus block. In: Karmakar MK, ed- itor. Musculoskeletal Ultrasound for Regional Anesthesia and pain medicine. 2nd edi- tion. Hong Kong: The Chinese University of Hong Kong; 2016. p. 265-73.
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  15. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic nerve palsy and regional anesthesia for shoulder surgery: anatomical, physiologic, and clinical considerations. Anesthesiology 2017;127:173-91.
  16. Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. The minimum ef- fective anesthetic volume of 0.75% ropivacaine in ultrasound-guided interscalene bra- chial plexus block. Anesth Analg 2011;113:951-5.
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    Physician expertise and cultural issues may play role in the results of ultrasound guided inter-scalene brachial plexus block

    We read the letter which was written by a number of our colleagues in response to our article [1]. In our study, ultrasound guided inter- scalene brachial plexus block (ISBPB) using 1% lidocaine was superior to Procedural sedation with propofol and fentanyl in terms of length of stay (LOS) in the emergency department (ED) for reducing Anterior shoulder dislocations. However, procedural sedation gained superiority regarding pain scores during the reduction process [2]. The authors of the letter, however, raised disagreement to the latter finding based on the current available articles in the literature; a disagreement which had been mentioned in our article as well, with reference to the study performed by Blavias et al. [3]. One of the authors of the letter was re- ported to have a 5 year experience on ultrasound guided ISBPB; a time period which was far more than our 1 year experience.

    As we stated in our article, this study was performed by two emer- gency physicians qualified for but did not have a long time experience on ISBPB. We also did not use low dose sedation as an adjunct to the nerve block. After reading the correspondence, we consulted with one of our major anesthesiologists with a long time experience in several nerve block procedures in the operating room including ISBPB. He was agreed with the authors of the corresponding letter in terms of pain scores in the setting of an elective surgery. This may mean that, in the presence of a so called “real expert” in the procedure, ISBPB (with or without low dose sedation) may be superior to proce- dural sedation in terms of pain scores, either in the ED (referring to the experience of the authors of the letter and Blavias et al.) or in the OR. In our opinion, however, this conclusion needs more studies to be performed in the ED than those currently available in the literature. Our anesthesiologist was also agreed with us regarding some cultural is- sues in the Iranian population, which may lead to less subjective pain perception during procedural sedation in the ED; a procedure which is more favorable to and more frequently chosen by the patients in our experience.

    As a conclusion, we reported our results as emergency physicians with relatively short to moderate experience in ISBPB; the results may be different if the procedure is performed by a more experienced physi- cian. Currently in Iran there are few emergency physicians experienced in ultrasound guided ISBPB, and we think this may be the case in many other parts of the world. Emergency physicians, however, should consider and recommend the best options for analgesia and muscle re- laxation during reduction of shoulder dislocations according to their ca- pabilities and the condition of the patient along with responsibly raising their expertise in useful analgesia techniques.

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