Original Contribution
Efficacy and safety of interscalene block combined with general anesthesia for arthroscopic shoulder surgery: A meta-analysis

https://doi.org/10.1016/j.jclinane.2018.03.008Get rights and content

Highlights

  • ISB + GA in arthroscopic shoulder surgery with lower heart rate compare with GA alone

  • ISB + GA in arthroscopic shoulder surgery with lower pain score compare with GA alone

  • ISB + GA in arthroscopic shoulder surgery with lower intraoperative systolic blood pressure compare with GA alone

  • ISB + GA in arthroscopic shoulder surgery with shorter extubation time compare with GA alone

  • ISB + GA in arthroscopic shoulder surgery with lower incidence of adverse events compare with GA alone

Abstract

Study objective

There is controversy regarding the efficacy and safety of using interscalene block (ISB) combined with general anesthesia (GA) for arthroscopic shoulder surgery. Our meta-analysis was undertaken to evaluate the utility of this approach.

Measurements

We searched the PubMed, Cochrane Library, EMBASE, CNKI, VIP and ClinicalTrials.gov databases for randomized controlled trials. The primary endpoint was extubation time. Secondary endpoints included intraoperative heart rate, pain scores on the day of and 1 day after the operation, intraoperative systolic blood pressure and adverse events.

Main results

Ten RCTs involving 746 patients undergoing arthroscopic shoulder surgery met inclusion criteria. Compared with GA alone, ISB + GA was associated with a shorter extubation time(WMD = −6.13; 95% CI = −8.68 to −3.57; P < 0.00001; I2 = 94%), a lower pain score on the day of the operation (WMD = −2.46; 95% CI = −4.53 to −0.40; P = 0.02; I2 = 97%), a lower pain score 1 day after the operation (WMD = −1.49; 95% CI = −2.46 to −0.52; P = 0.003; I2 = 88%), a lower intraoperative systolic blood pressure (WMD = −12.64; 95% CI = −20.90 to −4.39; P = 0.003; I2 = 95%), a lower heart rate (WMD = −8.81; 95% CI = −15.34 to −2.28; P = 0.008; I2 = 95%) and a lower incidence of adverse events (RR = 0.31; 95% CI = 0.15–0.66; P = 0.002; I2 = 32%).

Conclusions

In patients undergoing arthroscopic shoulder surgery, ISB + GA is associated with a lower heart rate, lower pain scores on the day of and 1 day after the operation, a lower intraoperative systolic blood pressure, a shorter extubation time and a lower incidence of adverse events compared with GA alone.

Introduction

Arthroscopic shoulder surgery is often performed with the patient in a semi-reclining position with the upper body elevated, and 0.9% sodium chloride solution must be continuously injected to ensure a clear surgical field of vision. Those operative characteristics will affect respiratory function and perfusion, so advanced anesthesia technology is needed. Interscalene block (ISB) provides effective anesthesia and analgesia for shoulder surgery, but it is challenging to keep a patient that is awake in a semi-reclining position while controlling blood pressure; performing the surgery in this way also may lead to joint perfusion fluid extravasation, which can compress the trachea [[1], [2], [3]].

General anesthesia (GA) may require tracheal intubation and may be associated with more pain in the postoperative period. Intubation, extubation, stress stimulation and a large number of applications of intraoperative anesthesia can affect the respiratory cycle and endanger the health of patients, especially those with poor anesthesia tolerance [4]. Combining ISB and GA (ISB + GA) may increase the risks of anesthesia, and there remains controversy about the optimal way to perform anesthesia for arthroscopic shoulder surgery [2].

Our meta-analysis was undertaken to analyze the efficacy and safety of ISB + GA compared with GA alone for arthroscopic shoulder surgery.

Section snippets

Data sources and searches

PubMed, Cochrane Library, EMBASE, CNKI, VIP and ClinicalTrials.gov databases were searched from database inception until July 2017 using the keywords “arthroscopic shoulder surgery”, “interscalene block”, “general anesthesia” and “anesthesia”. Randomized controlled trial was used as a sensitive filter for the search. In addition, references from randomized trials and relevant reviews were hand-searched for additional trials that were not identified in the database search.

Study selection

Studies were selected

Search results

Out of a total of 327 articles identified, 10 trials [[6], [7], [8], [9], [10], [11], [12], [13], [14], [15]] satisfied our inclusion criteria. Details of the selection procedure are depicted in Fig. 1. There were 377 patients randomized to the ISB + GA (experimental) group and 369 randomized to the GA (control) group. Baseline demographic characteristics of the included studies are detailed in Table 1. Quality assessment data are presented in sFigure 1, sFigure 2. All included trials had a low

Discussion

The use of arthroscopic shoulder surgery is increasing, and patients undergoing this operation have special anesthesia requirements. Some experts have suggested that ISB combined with GA performs well clinically when used for arthroscopic shoulder surgery, but the approach may increase risks associated with anesthesia.

In the study by Janssen et al. [15], ISB + GA provided similar results compared with GA in terms of heart rate, pain score, extubation time and adverse events. The more recent

Conclusion

In patients undergoing arthroscopic shoulder surgery, ISB + GA is associated with a lower heart rate, lower pain scores on the day of and 1 day after the operation, a lower intraoperative systolic blood pressure, a shorter extubation time and a lower incidence of adverse events compared with GA alone.

The following are the supplementary data related to this article.

. Risk of bias graph.

. Risk of bias summary.

Acknowledgement

No funding.

Conflict of interest statements

All the authors declare that they have no conflict of interest.

References (15)

  • C.S. Degoute

    Controlled hypotension: a guide to drug choice

    Drugs

    (2007)
  • C. Dippmann et al.

    Severe cerebral desaturation during shoulder arthroscopy in the beach-chair position

    Arthroscopy

    (2010)
  • R. Gillespie et al.

    The safety of controlled hypotension for shoulder arthroscopy in the beach-chair position

    J Bone Joint Surg Am

    (2012)
  • W. Liu

    Effect of different anesthesia methods on postoperative anesthesia recovery in elderly patients

    China Pract Med

    (2013)
  • S. Walther et al.

    Quality of reporting of systematic reviews and meta-analyses: PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)

    RöFo

    (2011)
  • H. Bin

    Brachial plexus block combined with general anesthesia in arthroscopic shoulder surgery

    Chin J Minimal Invasive Surg

    (2011)
  • Z. Dailing et al.

    Application of pentazocine and ropivacaine combined with general anesthesia in brachial plexus block for perioperative effects of shoulder arthroscopy

    Modern Ins Med Treat

    (2016)
There are more references available in the full text version of this article.

Cited by (13)

  • Early postoperative pain and opioid consumption after arthroscopic shoulder surgery with or without open subpectoral biceps tenodesis and interscalene block

    2020, Journal of Orthopaedics
    Citation Excerpt :

    In a meta-analysis of 136 patients from 5 studies, Yan et al. compared patient reported pain scores on the day of surgery between patients receiving GA and ISB with GA. Mean pain NRS in the GA group ranged from 3.2 to 7.3 while patients who received ISB with GA reported pain NRS ranging from 1.8 to 3.9 (overall effect Z = 2.34, p = .02) yielding the conclusion that the addition of ISB to GA results in significant improvement in day of surgery pain management for patients undergoing arthroscopic shoulder surgery.10 Similarly, Bosco et al. performed a retrospective cohort study of 425 patients comparing GA, ISB only, ISB with GA, and GA with postoperative ISB, and concluded that patients receiving ISB alone or preoperatively with GA experienced shorter PACU times, less pain and less narcotics compared to GA alone.12

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1

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