From the Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio.
Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
Anesth Analg. 2020 May;130(5):1304-1319. doi: 10.1213/ANE.0000000000004692.
Interscalene block (ISB) is the acute pain management technique of choice for shoulder surgery, but its undesirable respiratory side effects have prompted seeking alternatives. Supraclavicular block (SCB) is proposed as an ISB alternative, but evidence of comparative analgesic and respiratory-sparing effects is inconsistent. We compared the analgesic and respiratory effects of SCB and ISB for shoulder surgery.
Trials comparing ISB to SCB for shoulder surgery were sought. We decided a priori that SCB would be an acceptable alternative if it were noninferior for (1) postoperative 24-hour cumulative oral morphine equivalent consumption (primary outcome, noninferiority margin Δ = -25 mg) and (2) postoperative pain (secondary outcome, noninferiority margin Δ = 4.0 cm·hour); and superior for (3) postblock respiratory dysfunction (primary outcome). Opioid-related side effects and block-related complications were also evaluated.
Fifteen studies (1065 patients) were analyzed. In single-injection blocks, SCB was noninferior to ISB for 24-hour morphine consumption (mean difference for SCB-ISB, MD [95% confidence interval {CI}] = -3.11 mg [-9.42 to 3.19], Δ = -25 mg); it was also noninferior for 24-hour pain scores (MD = 0.78 cm·hour [0.07-1.49], Δ = 4.0 cm·hour); and decreased the odds of respiratory dysfunction (odds ratio [OR] [95% CI] = 0.08 [0.01-0.68]). Similarly, in continuous blocks, SCB was noninferior to ISB for 24-hour morphine consumption (MD = 0.46 mg [-6.08 to 5.15], Δ = -25 mg), and decreased the odds of respiratory dysfunction (OR = 0.22 [0.08-0.57]). SCB also decreased odds of minor block-related complications (OR = 0.36 [0.20-0.68] and OR = 0.25 [0.15-0.41] for single-injection and continuous blocks, respectively). Consequently, the null joint-hypothesis was rejected, and SCB can be considered an acceptable alternative to ISB.
For acute pain control following shoulder surgery, high-quality evidence indicates that SCB can be used as an effective ISB alternative. SCB is noninferior for postoperative opioid consumption and acute pain, and it reduces the odds of postblock respiratory dysfunction.
经锁骨下（ISB）阻滞是肩部手术急性疼痛管理的首选技术，但它会引起不良的呼吸副作用，促使人们寻找替代方法。锁骨上（SCB）阻滞被提议作为 ISB 的替代方法，但比较其镇痛和呼吸保护作用的证据并不一致。我们比较了 SCB 和 ISB 在肩部手术中的镇痛和呼吸作用。
我们寻找了比较 ISB 与 SCB 用于肩部手术的试验。我们预先决定，如果 SCB 在以下方面不劣于 ISB（1）术后 24 小时累积口服吗啡等效消耗量（主要结局，非劣效性边界 Δ = -25mg）和（2）术后疼痛（次要结局，非劣效性边界 Δ = 4.0cm·小时）；并且在（3）阻滞后呼吸功能障碍方面优于 ISB（主要结局），则 SCB 可以被认为是一种可接受的替代方法。还评估了阿片类药物相关的副作用和阻滞相关的并发症。
分析了 15 项研究（1065 例患者）。在单次注射阻滞中，SCB 在 24 小时吗啡消耗量方面不劣于 ISB（SCB-ISB 的平均差值 [MD] [95%置信区间 {CI}] = -3.11mg [-9.42 至 3.19]，Δ = -25mg）；在 24 小时疼痛评分方面也不劣于 ISB（MD = 0.78cm·小时 [0.07-1.49]，Δ = 4.0cm·小时）；并且降低了呼吸功能障碍的几率（比值比 [OR] [95%CI] = 0.08 [0.01-0.68]）。同样，在连续阻滞中，SCB 在 24 小时吗啡消耗量方面不劣于 ISB（MD = 0.46mg [-6.08 至 5.15]，Δ = -25mg），并且降低了呼吸功能障碍的几率（OR = 0.22 [0.08-0.57]）。SCB 还降低了轻微阻滞相关并发症的几率（OR = 0.36 [0.20-0.68] 和 OR = 0.25 [0.15-0.41]，分别用于单次注射和连续阻滞）。因此，零假设联合被拒绝，SCB 可以被认为是 ISB 的一种可接受的替代方法。
对于肩部手术后的急性疼痛控制，高质量证据表明 SCB 可以作为 ISB 的有效替代方法。SCB 在术后阿片类药物消耗和急性疼痛方面不劣于 ISB，并且降低了阻滞后呼吸功能障碍的几率。
