From the Departments of Anesthesiology.
Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Anesth Analg. 2019 Aug;129(2):536-542. doi: 10.1213/ANE.0000000000004233.
Axillary pain is common after arthroscopic shoulder surgery with an open subpectoral biceps tenodesis. We hypothesized that adding a pectoral nerve block II (Pecs II) to an interscalene block (ISB) would improve postoperative analgesia in this surgical population.
Forty patients were enrolled in this prospective, randomized, observer and patient-blinded, single-institution trial. All 40 patients received a single-injection ISB with 20 mL of 0.25% bupivacaine with 1:400,000 epinephrine and 1:600,000 clonidine. The intervention arm (ISB + Pecs II) consisted of 20 patients who also received a Pecs II block using 30 mL of 0.25% bupivacaine with 1:400,000 epinephrine and 1:600,000 clonidine. The 20 control group patients (ISB) received a sham Pecs II block. The primary outcome was postoperative pain scores at 6 hours using the numeric rating scale (NRS; range, 0-10) and was analyzed using the Mann-Whitney U test. Secondary outcomes included the presence of axillary pain at 6 hours, the need for postanesthesia care unit (PACU) opioids, PACU length of stay (LOS) (minutes), NRS pain scores at 24 hours, cumulative opioid usage postdischarge through 24 hours, the presence of nausea or vomiting during the first 24 hours, and Pecs II block duration (in hours, based on time to onset of axillary pain). Data were analyzed using a modified intention-to-treat (ITT) methodology.
Pain scores (NRS, 0-10) at 6 hours differed significantly between groups: ISB 3.0 (0.25-5.0) (1.7-4.3) versus ISB + Pecs II 0.0 (0-2.0) (0.0-1.1) (median [IQR] [95% CI]); P = .026. Hodges-Lehmann estimator of the difference was 2.0 (95% CI, 0.0-4.0). Fewer patients in the ISB + Pecs II group reported axillary pain at 6 hours and fewer required opioids in the PACU. There were no differences in any of the remaining secondary outcomes.
The addition of a Pecs II block to an ISB for patients undergoing arthroscopic shoulder surgery with an open subpectoral biceps tenodesis significantly improved postoperative analgesia and reduced the need for opioids in the PACU.
关节镜下肩关节手术后腋窝疼痛很常见，开放性肱二头肌经胸肌下固定术也是如此。我们假设在经斜角肌间隙阻滞（ISB）中加入第二胸神经阻滞（Pecs II）会改善该手术人群的术后镇痛效果。
本前瞻性、随机、观察者和患者盲法、单机构试验纳入了 40 名患者。所有 40 名患者均接受单次注射 ISB，药物为 20ml0.25%布比卡因+1：400000 肾上腺素+1：600000 可乐定。干预组（ISB+Pecs II）由 20 名患者组成，他们还接受了 Pecs II 阻滞，使用 30ml0.25%布比卡因+1：400000 肾上腺素+1：600000 可乐定。20 名对照组患者（ISB）接受假 Pecs II 阻滞。主要结局是使用数字评分量表（NRS；范围 0-10）评估术后 6 小时的疼痛评分，并使用 Mann-Whitney U 检验进行分析。次要结局包括术后 6 小时的腋窝疼痛、需要 PACU 阿片类药物、PACU 住院时间（分钟）、术后 24 小时 NRS 疼痛评分、出院后 24 小时内累积阿片类药物使用情况、术后 24 小时内恶心或呕吐的发生情况以及 Pecs II 阻滞持续时间（以发生腋窝疼痛的时间计算，单位为小时）。使用改良意向治疗（ITT）方法进行数据分析。
两组间 6 小时疼痛评分（NRS，0-10）差异有统计学意义：ISB 3.0（0.25-5.0）（1.7-4.3）vs ISB+Pecs II 0.0（0-2.0）（0.0-1.1）（中位数[IQR] [95%CI]）；P=0.026。差异的 Hodges-Lehmann 估计值为 2.0（95%CI，0.0-4.0）。ISB+Pecs II 组报告术后 6 小时腋窝疼痛的患者更少，在 PACU 需要阿片类药物的患者更少。其余次要结局无差异。
在关节镜下肩关节手术后开放性肱二头肌经胸肌下固定术患者中，ISB 中加入 Pecs II 阻滞可显著改善术后镇痛效果，减少 PACU 中阿片类药物的需求。
