A randomised controlled trial in patients undergoing arthroscopic shoulder surgery comparing interscalene block with either 10 ml or 20 ml levobupivacaine 0.25.

The interscalene brachial plexus block is recommended for analgesia after shoulder surgery but it may cause hemidiaphragmatic dysfunction. We tested whether ipsilateral hemidiaphragmatic contraction was better after a smaller dose of local anaesthetic without impairing analgesic effect. We randomly allocated 48 adults to 10 ml or 20 ml levobupivacaine 0.25% before arthroscopic shoulder surgery. The primary outcome was hemidiaphragmatic paralysis, defined as inspiratory thickness < 1.2 times expiratory thickness, measured by ultrasound 4 h after block. Hemidiaphragmatic paralysis was recorded for 6/24 vs. 23/24 supine participants after 10 ml vs. 20 ml levobupivacaine 0.25%, respectively, and for 4/24 vs. 23/24 sitting participants, respectively, p < 0.001 for both. Pain scores after 10 ml injectate were not worse than after 20 ml injectate. Median (IQR [range]) morphine doses in the first 24 postoperative hours after 10 ml and 20 ml levobupivacaine 0.25% were 2 (0-6 [0-23]) mg vs. 1 (0-2 [0-11]) mg, respectively, p = 0.12. No participant had a complication after 10 ml interscalene levobupivacaine, whereas seven had complications after 20 ml levobupivacaine, p = 0.009. Hemidiaphragmatic function was better after 10 ml vs. 20 ml interscalene levobupivacaine 0.25% without impairing analgesia for 24 postoperative hours.

Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia.

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion; and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.

Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study.

BACKGROUND: Arthroscopic shoulder surgery causes severe postoperative pain. An interscalene brachial plexus block provides adequate analgesia, but unintended spread of the local anesthetic administered may result in a phrenic nerve block, usually associated with a nonnegligible incidence of acute hemidiaphragmatic paralysis. The main purpose of this trial will be to analyze the incidence of hemidiaphragmatic paralysis ensuing after interscalene brachial plexus block in patients undergoing arthroscopic shoulder surgery administered a standard volume (20 ml) vs. a low volume (10 ml) of levobupivacaine 0.25%. METHODS: This will be a prospective double-blind randomized controlled single-center two-arm comparative trial. Forty-eight patients will be included. The primary goal will be to ultrasonographically determine the incidence of hemidiaphragmatic paralysis by calculating the diaphragmatic thickness ratio in each group. The secondary goals will be to compare the two arms in terms of (1) decrease in forced vital capacity and (2) in forced expiratory volume at 1 s by spirometry; (3) decrease in diaphragmatic excursion by ultrasound; (4) 24-h total intravenous morphine consumption; (5) time to first opioid request of a patient-controlled analgesia pump; and (6) postoperative complications. DISCUSSION: This trial will demonstrate that a low-volume interscalene brachial plexus block decreases hemidiaphragmatic paralysis following arthroscopic shoulder surgery according to spirometry and ultrasound measurements and does not provide inferior postoperative analgesia to the standard volume, as measured by opioid requirements. TRIAL REGISTRATION: EudraCT and Spanish Trial Register (REec) registration number: 2019-003855-12 (registered on 7 January 2020). ClinicalTrials.gov identification number: NCT04385966 (retrospectively registered on 8 May 2020). Ethics Committee approval: EC19/093 (18 December 2019).

Bloqueo erector de la espina y sedación con dexmedetomidina en nivats (non intubated video-assisted thoracoscopic surgery) / Erector spinae block and sedation with dexmedetomidine in nivats (non intubated video-assisted thoracoscopic surgery)

La vía aérea difícil (VAD) es una de las principales causas de morbimortalidad en anestesia. La posibilidad de realizar una cirugía toracoscopica en ventilación espontánea con el uso de fármacos como la dexmedetomidina y remifentanilo, proporcionandoademás, analgesia con un bloqueo ecoguiado del erector de la espina han facilitado y/o posibilitado la realización de cirugía toracoscopica sin necesidad de intubación endotraqueal disminuyendo por tanto la necesidad de manipular la vía aérea, siendo una gran alternativa ante una VAD. (AU)

Difficult airway (DAV) is one of the main causes of morbidity and mortality in anesthesia. The possibility of performing spontaneously ventilated thoracoscopic surgery with the use of drugs such as dexmedetomidine and remifentanil, also providing analgesiawith an ultrasound-guided erector spinae block, has favoured and / or made possible thoracoscopic surgery without the need forendotracheal intubation, thus reducing the need to manipulate the airway, being a great alternative to VAD. (AU)

Validación de la ecografía Point-of-Care para el diagnóstico de hernia diafragmática: a propósito de un caso / Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia

La ecografía Point-of-Care (POCUS) es una herramienta sensible y específica para diagnosticar de manera precoz la patología del diafragma en pacientes críticos. Presentamos un caso clínico de un paciente con antecedentes de hernia diafragmática iatrogénica que ingresó en la unidad de reanimación tras una laparotomía exploradora de emergencia. Aprovechando el diagnóstico conocido de hernia diafragmática, describimos los signos clínicos que debemos encontrar en la evaluación POCUS para establecer el diagnóstico de hernia diafragmática: 1)fracción de acortamiento diafragmático normal bilateral; 2)excursión diafragmática reducida, y 3)posición cefálica de la cúpula diafragmática 4)mayor en supino que en sedestación. Igualmente, proponemos una sistemática de exploración ecográfica del diafragma y una clasificación diferencial de la disfunción diafragmática evaluada mediante POCUS en función de la correcta integridad y el buen funcionamiento del músculo periférico y del tendón central diafragmáticos en el paciente crítico.(AU)

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1)normal bilateral diaphragmatic shortening fraction; (2)decreased diaphragmatic excursion, and (3)cephalic position of the diaphragmatic dome (4)greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.(AU)