الفهرس 
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Abstract
Shoulder arthroscopy is one of the most common orthopedic surgeries and technological improvements allowing for the care of novel disorders. On the other hand, postoperative pain is a common complaint, and alternative therapeutic options are becoming more important given the rise in opiate abuse among orthopedic patients. Patients who experience severe surgical pain experience delayed release, unexpected hospital readmission, and significant pain.
Inter-scalene block (ISB) is the most utilized procedure for post-operative pain following shoulder surgeries. Although it has been shown to give great post-operative analgesia, it can have negative side effects such as phrenic nerve blocking (PrNB), which can cause diaphragmatic paresis and respiratory discomfort in the patient.
During intraoperative anesthesia and postoperative pain management in shoulder arthroscopy under general anesthesia, the isolated supra-scapular nerve block is an efficient substitute for inter-scalene block. With decreased complication rates, particularly pneumothorax. Because the supra-scapular nerve does not entirely control the sensory and motor nerve supply to the shoulder joint, it cannot be used as a single surgical anesthetic approach. The major joint innervation is supplemented by the axillary nerve. So, the combined suprascapular nerve block and axillary nerve block (SSNB+ANB) has recently been presented as a safe alternative to ISB for providing anesthesia and postoperative analgesia for shoulder surgery.
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The present study was designed to compare the effect of an ultrasound-guided low volume interscalene block versus an ultrasound-guided combined supra-scapular and axillary nerve block (shoulder block) in patients undergoing shoulder arthroscopy in terms of the amount of postoperative analgesia required as a primary goal, and patient satisfaction, Post-Anesthesia Care Unit (PACU) stay, postoperative complications, and hospital discharge time as a secondary goal.
A randomized blinded clinical trial was performed at Faculty of Medicine, Menoufia University. The study was approved by the ethical committee of the faculty of Medicine, Al-Menoufia University. Each patient recruited in the trial completed an informed consent form.
The participants were divided into two groups: group A: consisting of 25 patients who received a pre-operative low-volume interscalene block guided by ultrasound. group B: 25 patients received a combination of supra-scapular and axillary nerve block (shoulder block) using ultrasound guidance prior to surgery.
In both groups, after finishing the block, 5 ml bupivacaine were infiltrated subcutaneously over the dorsal border of SCM.
Then, general anesthesia with controlled laryngeal masks airway ventilation. After surgery, patients were transferred to the post-anesthesia care unit (PACU) and monitored until they meet the PACU discharge requirements.
Measurements:
1. Vital signs: Heart rate (beats per minute) and mean arterial blood pressure (mmHg) were measured upon entering the operating room, after the block was performed, every 5 minutes
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throughout the procedure, every 15 minutes in the PACU, and every 4 hours in the ward.
2. Block time: the time gap between the first penetration of the skin with the needle and the accurate injection of local anesthetic.
3. Pain assessment: using the VAS score every 15 minutes on the PACU and every two hours in the ward until home discharge.
The total amounts of intra-operative and postoperative morphine rescue analgesia (mg) as well as the time from the initial analgesia request were determined throughout the hospital stay.
4. Patient satisfaction: (1.Excellent, 2. Good, 3. Fair and 4. Poor).
5. Complications: Postoperative complications associated with nerve block technique or with opioid usage were evaluated and treated. Postoperative nausea and vomiting (PONV) was assessed by using the following scale: (0. none, 1. Mild: no treatment needed, 2. Moderate: treatment is effective, 3. Severe: treatment not effective).
Results:
Most of the study participants were in the age groups 41-50 years (42%) and 31-40 years (40%). Male patients constituted 56% of the sample, while female patients constituted 44%. The mean body mass index (BMI) was 24.8±3.7 kg/cm2, 40% of patients were overweight and 12 % were obese.
The mean baseline HR of all study participants was 72.5±6.3 bpm, in ultrasound guided low volume interscalene block group (group A) was 75.2±6.2 bpm, and in ultrasound guided supra-scapular and axillary nerve block (group B) was 93.9±6.2. There were no
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statistically significant differences between the studied groups in all the vital signs measured preoperatively, intraoperatively and post-operatively. Also, VAS score revealed no significant difference at all measured times.
By comparing the mean PACU stay between group A and group B, the mean in group A was 44.80+/- 10.56 minutes while in group B was 44.40+/- 9.82 minutes and this difference was not statistically significant (p= 0.890).
By comparing the mean hospital stay between group A and group B, the mean in group A was 8.55+/- 2 .10 hours while in group B was 8.44+/- 2.16 hours and this difference was not statistically significant (p= 0.895).
By comparing the mean PONV scale between group A and group B, the mean scale in group A was 0.18±0.4 while it was 0.48±0.5 in group B and this difference was not statistically significant (p=0.58)
The mean block performance time in group A (6.4±1.3) min. was lower than the mean block performance time in group B (14.4±2.7) min. and this difference was statistically significant (p<0.001).
There were no statistically significant differences in operation time, IOP morphine consumption, and total morphine consumption over 12 hours. Most participants in group A (92%) and group B (88%) experienced no pain with needle insertion, however the difference between the two groups regarding pain with needle insertion was not statistically significant. Most patients in group A (92%) and group B (96%) reported excellent satisfaction with anesthesia, however the difference between the two groups was not statistically significant.
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We concluded that, except for the fact that combined supra-scapular and axillary nerve block (shoulder block) consumes a longer block performance time than ISB, it can be concluded that shoulder block is equivalent to low-volume ISB in terms of VAS score, morphine consumption and patient satisfaction. It is a safe and effective alternative to ISB especially in patients who cannot tolerate phrenic nerve block.