Regional anaesthesia: Overview

Abstract
Background: Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis.

Methods: Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15 mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound.

Results: Median NRS (0-10) at 1, 3, 6, 8 and 24 hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5 mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%).

Conclusions: The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty.

Abstract
Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue, and as such, creates additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in these vulnerable population.