Intervention Review

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Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery

  1. Hameed Ullah*,
  2. Khalid Samad,
  3. Fauzia A Khan

Editorial Group: Cochrane Anaesthesia Group

Published Online: 4 FEB 2014

Assessed as up-to-date: 10 DEC 2012

DOI: 10.1002/14651858.CD007080.pub2


How to Cite

Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD007080. DOI: 10.1002/14651858.CD007080.pub2.

Author Information

  1. Aga Khan University Hospital, Department of Anaesthesiology, Karachi, Pakistan

*Hameed Ullah, Department of Anaesthesiology, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan. hameed.ullah@aku.edu.

Publication History

  1. Publication Status: New
  2. Published Online: 4 FEB 2014

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of the condition

The sensation of pain is one of the vital functions of the human body's nervous system that enables protection of an injured area while healing and repair occur. All surgical procedures are followed by pain, which may trigger or amplify endocrine and metabolic responses, autonomic reflexes, nausea, ileus and muscle spasm to increase postoperative morbidity and mortality (Desborough 2000). The current armamentarium of analgesic drugs and techniques for the management of postoperative pain continues to grow at a rapid rate. However, effective treatment of acute postsurgical pain still poses unique challenges for practitioners (White 2005). Major shoulder surgery is often associated with severe postoperative pain, greater than after gastrectomy or thoracotomy, especially within the first 48 hours. One of the characteristics of this pain is its dynamic component (exacerbation on movement); therefore moderate pain at rest can become severe during rehabilitation. Optimal postoperative pain treatment is, therefore, helpful in enabling early mobilization and rehabilitation, enhancing recovery and reducing morbidity (Borgeat 2007).

 

Description of the intervention

Different options are available for the management of postoperative pain after major shoulder surgery. These include enteral or parenteral administration of opioid and non-opioid (including non-steroidal anti-inflammatory drugs) analgesics, infiltration of local anaesthetics into the joint (intra-articular) or around the joint (bursal or sub-bursal) and use of regional analgesia (Borgeat 2007), including interscalene brachial plexus block (ISBPB), through different techniques. Patient-controlled analgesia (PCA) is a technique that allows patients to have autonomy in controlling their pain by timing the administration of small doses of an analgesic or local anaesthetic drug. PCA can be used with both parenteral and regional analgesic techniques (Macintyre 2001).

 

How the intervention might work

Traditionally, parenteral analgesia, which is used for postoperative pain relief, includes intravenous, transdermal, subcutaneous and intramuscular routes for administration of opioids and non-opioids, depending on the type of surgery. Opioid analgesics are commonly associated with opioid-related adverse effects such as nausea and vomiting, pruritus, sleep disturbance and constipation. Interscalene block provides effective anaesthesia and analgesia for shoulder surgery (Fredrickson 2010a).

Winnie was the first to describe the single-injection technique of interscalene brachial plexus block (Winnie 1970). ISBPB, alone or in combination with general anaesthesia, is a very suitable technique for shoulder surgery. The catheter technique for ISBPB, which was first described by Touminen in 1987 (Tuominen 1987), offers many advantages over single-injection ISBPB. These include early and aggressive mobilization, extension of analgesia for prolonged periods and use of smaller doses of local anaesthetics to prevent motor block and reduce opioid requirements and associated side effects (Bishop 2005; Fredrickson 2010a; Russon 2006).

However, ISBPB is an invasive procedure that may lead to serious complications. In addition to commonly associated risks, such as failure, nerve injury, vascular injury, bleeding, phrenic nerve block and Horner's syndrome, interscalene block is associated with risks of pleural puncture, central neuraxial needle placement, cervical spinal cord damage and permanent paralysis (Benumof 2000). The introduction of ultrasound to locate the brachial plexus has helped to reduce these adverse events.

 

Why it is important to do this review

This review will attempt to distinguish between the effectiveness of continuous ISBPB and that of parenteral opioid in providing better analgesia with minimal adverse effects in patients undergoing major shoulder surgery. This will help anaesthetists, as well as patients, to choose from the two techniques to obtain better pain control with fewer side effects after major shoulder surgery.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomized controlled trials (RCTs) that compared continuous ISBPB with any form of parenteral opioid analgesia after major shoulder surgery.

 

Types of participants

We included adult patients (aged over 18 years) undergoing elective major shoulder surgery (shoulder arthroplasty or total shoulder replacement, open rotator cuff repair and internal fixation of shoulder fractures) who received either continuous ISBPB or any form of parenteral opioid analgesia for postoperative pain relief.

We excluded patients undergoing arthroscopic procedures, those who had undergone previous shoulder surgery and those coming in for daycare surgery.

 

Types of interventions

We included any RCT that compared continuous ISBPB with any form of parenteral opioid analgesia after major shoulder surgery with a minimum duration of follow-up of 12 hours postoperatively ( Table 1).

We included studies with:

  1. any method of localization of the brachial plexus by an interscalene approach.
  2. any local anaesthetic, in any concentration with or without any other drug(s), given by the ISBPB technique.
  3. any form(s) of parenteral (intravenous, intramuscular, subcutaneous) opioid analgesia technique.
  4. any parenteral opioid analgesic drug(s), given in any dosage.

 

Types of outcome measures

 

Primary outcomes

  1. The effectiveness of pain relief after major shoulder surgery using continuous ISBPB or parenteral opioid analgesia for the entire follow-up period (minimum 12 hours).
  2. Complications related to ISBPB including those related to technique (failure, pneumothorax, nerve injury, Horner's syndrome, vascular injury, haematoma, bleeding, catheter dislocation, infection, facial nerve palsy) and those related to drugs (nausea, vomiting, pruritus, metallic taste, motor block, sedation, respiratory depression, central nervous system excitation).
  3. Complications related to parenteral analgesia (nausea, vomiting, pruritus, sedation, respiratory depression).

 

Secondary outcomes

  1. Effectiveness of pain relief at mobilization.
  2. Supplemental analgesia, if used.
  3. Time to mobilization.
  4. Participant satisfaction.
  5. Length of stay in postanaesthesia care unit (PACU).
  6. Length of stay in hospital.

 

Search methods for identification of studies

 

Electronic searches

We searched the following databases.

  1. The Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12) (Appendix 1).
  2. MEDLINE (via PubMed) (1950 to December 2012) (Appendix 2).
  3. EMBASE (1980 to December 2012) (Appendix 3).
  4. ISI Web of Science (1954 to December 2012) (Appendix 4).
  5. CINAHL (EBSCO host) (1982 to December 2012) (Appendix 5).

We imposed no language restrictions.

 

Searching other resources

We included all relevant studies irrespective of the language of publication. We manually checked the reference lists of relevant studies to identify trials missed by the electronic search strategy.

We contacted primary authors of identified trials to ask for more information, if required.

We searched for ongoing trials on the following websites.

 

Data collection and analysis

 

Selection of studies

We (HU and KS) independently reviewed the titles and abstracts identified by the searches. We obtained full copies of potentially relevant trials and assessed all full copies according to the parameters outlined in Criteria for considering studies for this review. We assessed only trials meeting these criteria for methodological quality. No disagreement arose during this process; therefore we did not consult the third review author (FK).

 

Data extraction and management

Two review authors (HU and KS) independently extracted data using a data extraction form (Appendix 6) modified from one developed by the Cochrane Anaesthesia Review Group (CARG). We resolved discrepancies by discussion. We extracted data (as far as was possible) on the basis of an intention-to-treat (ITT) analysis. We contacted primary investigators to ask for missing data. Two review authors (HU and KS) independently entered all data into Review Manager (RevMan 5.1).

 

Assessment of risk of bias in included studies

We assessed trial quality using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We observed whether inclusion and exclusion criteria were clearly defined in the text. Criteria included the following.

  1. Random sequence generation.
  2. Allocation concealment.
  3. Blinding of participants, personnel and outcome assessors.
  4. Incomplete outcome data.
  5. Selective reporting.

Based on the above, we rated study validity as follows.

  1. Low risk of bias: if most of the above criteria are met.
  2. High risk of bias: if most of the above criteria are not met.
  3. Unclear risk of bias: if criteria are expressed in an unclear manner.

We (HU and KS) resolved any disagreements regarding the assessment by discussion and by coming to consensus.

 

Measures of treatment effect

We planned to express the treatment effect as a pooled risk ratio and 95% confidence interval (CI) for dichotomous data, and as a mean difference and 95% CI for continuous data. We planned to use a fixed-effect model when minimal heterogeneity existed; otherwise a random-effects model was planned. In cases in which such data combination was not possible or was inappropriate (in the presence of significant clinical heterogeneity or for other reasons), we provided a narrative synthesis.

 

Unit of analysis issues

In the studies included in the review, participants were randomly assigned to either group (ISBPB or parenteral opioid), and a measurement for each outcome from each participant was recorded and analysed. In cases of multiple observations for the same outcome, we computed the effect measure for each individual participant that incorporated all time points.

 

Dealing with missing data

Intention-to-treat analysis is recommended to minimize bias. No consensus has been reached on how to handle missing data in ITT analysis in systematic reviews (Higgins 2011). We excluded all participants for whom outcome data were missing.

 

Assessment of heterogeneity

We planned statistical heterogeneity using the Chi2 test (significant at P < 0.1) before considering the appropriateness of pooling the data and proceeding with a meta-analysis.

 

Assessment of reporting biases

We looked at the number of outcomes presented in the methods section of the included studies and confirmed this number in the results section of the trial. We planned to provide a funnel plot to detect publication bias or a difference between smaller and larger studies expressed by asymmetry (Egger 1997). However, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions, Chapter 10 (Higgins 2011), at least 10 studies are needed to create a funnel plot.

 

Data synthesis

We planned to enter the data extracted from the studies into Review Manager 5.1.

We also planned to:

  1. pool the data from various trials, when appropriate, and perform analysis in both groups;
  2. record either the means of an event or the number of participants experiencing an event in each group;
  3. express the treatment effect as a pooled risk ratio and 95% CI for dichotomous data, and as a mean difference and 95% CI for continuous data;
  4. use a fixed-effect model when minimal heterogeneity existed, otherwise a random-effects model; and
  5. generate forest plots when only a single study was available for a particular outcome. In situations in which variables were presented differently, we planned to equate each variable by methods prescribed by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

 

Subgroup analysis and investigation of heterogeneity

If appropriate data were found, we planned subgroup analysis based on:

  1. the type of local anaesthetic used;
  2. the type of analgesic drug used;
  3. a combination of drugs in either technique;
  4. any technique for localization of brachial plexus; and
  5. the type of surgery performed (in cases of multiple surgical procedures, we will subanalyse each procedure).

Heterogeneity was assessed as mentioned in the section Assessment of heterogeneity.

 

Sensitivity analysis

We planned a sensitivity analysis if methodological quality or characteristics of participants in the studies differed significantly and adequate data were available.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of studies

 

Results of the search

We identified 122 abstracts from the 2774 results obtained by searching according to the methods mentioned in Search methods for identification of studies. The details are presented in Figure 1. Of these, 47 abstracts qualified for full-paper analysis after mutual discussion. We accessed all 47 full-text papers, and 45 were excluded because of inappropriate participants or comparison groups. Thus two studies (Hofmann-Kiefer 2008; Wei 2012) qualified to be included in the final analysis, of which one study was written in Chinese and required translation for extraction of data.

 FigureFigure 1. Abstracts search flow diagram.

 

Included studies

We included two studies in the review. The sample size was 147 participants (87 in Hofmann-Kiefer 2008 and 60 in Wei 2012). See Characteristics of included studies for details. Because of the small number of studies included in the review and significant clinical heterogeneity among them, we were unable to perform meta-analysis in this review.

 

Excluded studies

Upon the advice of Dr Mathew Zacharia and Professor Nathan Pace, we have listed in the Excluded studies section all studies that we retrieved as full-text papers from literature searches that did not meet the eligibility criteria for inclusion in the review. Forty-five studies have been excluded, and the reasons for their exclusion are mentioned in the Characteristics of excluded studies. These studies did not include appropriate interventions or appropriate participants, as mentioned in the Criteria for considering studies for this review.

 

Risk of bias in included studies

The overall quality of each study was evaluated according to the methodology mentioned in Assessment of risk of bias in included studies. The different bias domains are presented in Characteristics of included studies. A graph and a summary of the risk of bias of included studies are presented in Figure 2 and Figure 3.

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Effects of interventions

Hofmann-Kiefer 2008 enrolled 87 participants. In all, 17 participants were excluded for reasons mentioned in Characteristics of included studies, and they were removed from the analysis. A total of 16 participants received continuous ISBPB as postoperative analgesia, and one was given parenteral opioids. The authors of the study used a nerve stimulator to locate the brachial plexus.

Wei 2012 enrolled 60 participants, all of whom completed the study. Four participants were excluded according to exclusion criteria. Investigators used ultrasound technique to perform brachial plexus block.

 

Outcomes

 
Primary outcomes
 
Effectiveness of pain relief

The effectiveness of pain relief was assessed by visual analogue scale (VAS) (Hofmann-Kiefer 2008) and numerical rating pain scale (NRPS) (Wei 2012). Study authors reported observations at different time points (Hofmann-Kiefer 2008 reported at four time points and Wei 2012 at three time points). Because only two studies qualified for inclusion in the review and because significant clinical heterogeneity was present among the studies, we did not perform the meta-analysis; hence, the results are reported in a narrative form.

One hundred thirty participants received continuous ISBPB (66) or parenteral opioid analgesia (64). Hofmann-Kiefer 2008 followed participants for 72 hours postoperatively, whereas Wei 2012 followed participants for 48 hours postoperatively.

Hofmann-Kiefer 2008 reported pain scores at six, 24, 48 and 72 hours after surgery, and pain scores were significantly lower at six, 24 and 72 hours in the ISBPB group than in the group given parenteral opioids. However, pain scores were similar at 48 hours among the two groups. In the Wei 2012 study, pain scores were reported at arrival to the PACU and 24 and 48 hours after surgery; scores were significantly lower in the ISBPB group at all time points.

 
Adverse effects

Incomplete block did not occur in any participant; therefore, no participants were excluded before surgery. Postoperatively, 17 participants were withdrawn (Hofmann-Kiefer 2008) because of one or another adverse event (see Risk of bias in included studies) and were not included in the analysis. Of these, 16 were from the ISBPB group (one for no C5 block, nine for catheter dislocations, one for Horner's syndrome, four for diaphragmatic paresis leading to dyspnoea and one on the participant's choice) and one from the parenteral opioid group (pruritus). Four participants were excluded from the Wei 2012 study, according to exclusion criteria.

 
Secondary outcomes

Of the secondary outcomes listed in the Types of outcome measures, only the following have been found to be reported in the included studies. The remaining are not reported at all or are mentioned only in narrative rather than numerical form.

Hofmann-Kiefer 2008 mentions that VAS scores were lower in the ISBPB group during physiotherapy at day two (P = 0.016) but were similar at day three. Investigators used piritramide boluses (3.75 to 7.5 mg intravenously) when the pain score exceeded 40 on a scale of 100. Six of 36 participants (16.6%) in the ISBPB group and 11 of 34 (32.3%) in the parenteral opioid group required boluses of piritramide; this was statistically significant (P < 0.01). Regarding nausea and/or vomiting, two of 36 (5.5%) participants in the continuous ISBPB group versus nine of 34 (26.4%) in the parenteral opioid group developed nausea and/or vomiting during the study; this again was statistically significant. No catheter infections were reported.

Wei 2012 looked at participant satisfaction, which was significantly greater (P < 0.01) in the ISBPB group. This study also reported nausea and/or vomiting as an adverse event that was significantly more frequent in the parenteral opioid group (one of 30 (3.3%) in the ISBPB group vs eight of 30 (26.6%) in the parenteral opioid group). The drug used for postoperative analgesia was sufentanil.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Summary of main results

The primary focus of this review was to look at clinically and statistically significant differences in postoperative pain management following major shoulder surgery when continuous ISBPB is compared with parenteral opioids. We also looked at adverse effects related to both techniques, use of supplemental analgesia, participant satisfaction and length of hospital stay.

We included two randomized controlled trials (Hofmann-Kiefer 2008; Wei 2012) consisting of 147 participants, of whom 17 were excluded from analysis—all from the Hofmann-Kiefer 2008 study. Of these 17, 16 had complications related to continuous ISBPB (one no C5 block, nine catheter dislocation, one Horner's syndrome, four diaphragmatic paresis leading to dyspnoea and one poor choice by the participant) and one had complications related to parenteral opioid analgesia (pruritus). Therefore 130 participants were included in the analysis (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The included studies carried a high risk of bias, mainly for the reasons of absence of allocation concealment, lack of blinding and large numbers of dropouts. Both mentioned primary outcomes and several secondary outcomes. A nerve stimulator was used to locate the brachial plexus in all participants in the Hofmann-Kiefer 2008 study, and Wei 2012 used ultrasound to perform brachial plexus block, which may be the reason why no complications related to ISBPB were reported in this study. Because of the small number of studies included in the review, high risk of bias and significant clinical heterogeneity, no concrete conclusions can be drawn. However, following is the summary reported by these two studies.

Effectiveness of pain relief was assessed at different time points for up to 72 hours by Hofmann-Kiefer 2008, and up to 48 hours by Wei 2012. Hofmann-Kiefer 2008 used VAS and Wei 2012 used NRPS to evaluate postoperative pain. Pain scores were significantly lower in the ISBPB group at six, 24 and 72 hours, whereas they were similar at 48 hours in the Hofmann-Kiefer 2008 study. Pain scores were significantly lower in the ISBPB group, as reported by Wei 2012, at all time points (upon arrival to PACU and 24 and 48 hours postoperatively).

Supplemental analgesia was used in the Hofmann-Kiefer 2008 study; the drug used was piritramide, whereas Wei 2012 used sufentanil as supplemental analgesia. The number of boluses was significantly greater in the parenteral opioid group. Adverse effects mentioned included nausea and vomiting, which was significantly more frequent in the parenteral opioid group, as reported by both studies (Hofmann-Kiefer 2008; Wei 2012).

 

Overall completeness and applicability of evidence

Both studies included in this review had participants, interventions and outcomes that were appropriate to our objectives and outcomes, both primary and secondary. The main issues with the applicability of this evidence include the small number of studies, the high risk of bias in these studies and the presence of significant clinical heterogeneity. Another important point is the method used to perform brachial plexus block. It is evident that ISBPB-related complications were significantly more frequent when a nerve stimulator was used when compared with ultrasound technique. Another aspect worth mentioning is the usual current practice of using ultrasound for performing brachial plexus block; one study in this review did not use ultrasound and may not represent usual current practice.

 

Quality of the evidence

Generally, the quality of evidence included in our review was limited by a high risk of bias of the included studies, as evaluated from the information provided by the papers. The included studies were prospective randomized clinical trials in which randomization was done by computer or by random number tables. These studies were not placebo-controlled, and sham catheters were not used for ethical reasons, thus making the studies unblinded. These studies were heterogeneous clinically, as different methods were used to perform ISBPB. We were unable to retrieve the protocol and thus were unable to compare published outcomes versus proposed ones.

 

Potential biases in the review process

We strictly followed the protocol to perform the review and could think of no source of potential bias in the review process.

 

Agreements and disagreements with other studies or reviews

We found only one review article, which is actually a critical appraisal of current techniques (Fredrickson 2010a), that reviewed the postoperative analgesic techniques used for shoulder surgery. The results of this review are similar to those reported in our review. This review also does not include a meta-analysis.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

 

Implications for practice

Based on the evidence generated by this review, no reasonable conclusions can be drawn. Because of the presence of significant clinical heterogeneity among the two included studies, meta-analysis could not be performed. Current practice is to perform single-shot ISBPB as well as placement of ISBPB catheters by using ultrasound assistance; for this reason, the study by Hofmann-Kiefer 2008 is unlikely to be performed again.

 
Implications for research

Further randomized controlled trials with low risk of bias are needed to generate good-quality evidence on the topic. Future research should focus on blinding studies to make them stronger and using ultrasound to perform ISBPB.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

We would like to thank Mathew Zacharias (content editor); Cathal Walsh (statistical editor); Nathan Pace (co-ordinating editor), Jean Pierre Estebe, Jeff Swenson and Thomas Fichtner Bendtsen (peer reviewers) and Janet Wale (consumer editor) for help and editorial advice provided during the preparation of this systematic review. We would also like to thank Karen Havhannisyan (trials search Co-ordinator, CARG) for developing the search strategies and running them and for helping us to acquire the full text of several papers, and Jane Cracknell (managing editor, CARG) for co-ordinating this review.

We are grateful to Dr Xiaoli Ge for extracting data from the Chinese study (Wei 2012).

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Appendix 1. CENTRAL search strategy


Search terms

#1           (shoulder or rotator cuff):ti,ab

#2           MeSH descriptor Shoulder, this term only

#3           MeSH descriptor Shoulder Joint explode all trees

#4           MeSH descriptor Rotator Cuff explode all trees

#5           MeSH descriptor Arthroplasty, this term only

#6           MeSH descriptor Arthroplasty, Replacement explode all trees

#7           (#1 OR #2 OR #3 OR #4 OR #5 OR #6)

#8           MeSH descriptor Analgesia, Patient-Controlled explode all trees

#9           MeSH descriptor Anesthetics, Intravenous, this term only

#10         MeSH descriptor Anesthesia, Intravenous, this term only

#11         MeSH descriptor Nerve Block explode all trees

#12         (intravenous or intramuscular or transdermal or subcutaneous):ti,ab

#13         (ISBPB or ISNB or (interscalene near (block or an?esth* or analg* or continuous)))

#14         (#8 OR #9 OR #10 OR #11 OR #12 OR #13)

#15         (#7 AND #14)



 

Appendix 2. MEDLINE (via PubMed) search strategy


Search terms

#1 shoulder in TI, AB
#2 shoulder near (surg* or replac* or arthroplasty)
#3 rotator cuff in TI, AB
#4 explode Shoulder / all subheadings
#5 explode Shoulder Joint/ all subheadings
#6 explode Rotator Cuff/ all subheadings
#7 "Arthroplasty-" / all SUBHEADINGS in MIME,MJME,PT
#8 "Arthroplasty-Replacement" / all SUBHEADINGS in MIME,MJME,PT
#9 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8
#10 interscalene near block
#11 Patient control* near analgesia
#12 interscalene near (block or an?esth* or analg* or continuous or (brachial plexus)
#13 explode "Analgesia-Patient-Controlled" / all SUBHEADINGS in MIME,MJME,PT
#14 (explode "Anesthetics-Intravenous" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Anesthesia-Intravenous" / all SUBHEADINGS in MIME,MJME,PT)
#15 interscalene
#16 explode Injections-Intramuscular/ all subheadings
#17 explode Administration-Cutaneous/ all subheadings
#18 explode Injections-Subcutaneous/ all subheadings
#19 explode Infusions-Intravenous/ all subheadings
#20 parenteral near (an?esth* or analg*)
#21 ISBPB or ISNB
#22 explode nerve block/ all subheadings
#23 (parenteral or intravenous or intramuscular or transdermal or subcutaneous) in TI, AB
#24 #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23
#25 #9 and #24



 

Appendix 3. EMBASE search strategy


Search terms

1     shoulder/ or exp rotator cuff/ or exp shoulder arthroplasty/ or arthroplasty/ or (shoulder or rotator cuff).ti,ab. (32445)

2     exp patient controlled analgesia/ or intravenous anesthetic agent/ or intravenous anesthesia/ or exp nerve block/ or postoperative pain/ or brachial plexus anesthesia/ or local anesthetic agent/ or (intravenous or intramuscular or transdermal or subcutaneous).ti,ab. or (ISBPB or ISNB or (interscalene adj3 (block or an?esth* or analg* or continuous))).mp. (274975)

3     1 and 2 (1699)

4     (randomized-controlled-trial/ or randomisation/ or controlled-study/ or multicenter-study/ or phase-3-clinical-trial/ or phase-4-clinical-trial/ or double-blind-procedure/ or single-blind-procedure/ or (random* or cross?over* or factorial* or placebo* or volunteer* or ((singl* or doubl* or trebl* or tripl*) adj3 (blind* or mask*))).ti,ab.) not (animals not (humans and animals)).sh. (3269130)

5     4 and 3 (659)

6     from 5 keep 1-659 (659)



 

Appendix 4. ISI Web of Science search strategy


Search terms

1     shoulder/ or exp rotator cuff/ or exp shoulder arthroplasty/ or arthroplasty/ or (shoulder or rotator cuff).ti,ab. (32445)

2     exp patient controlled analgesia/ or intravenous anesthetic agent/ or intravenous anesthesia/ or exp nerve block/ or postoperative pain/ or brachial plexus anesthesia/ or local anesthetic agent/ or (intravenous or intramuscular or transdermal or subcutaneous).ti,ab. or (ISBPB or ISNB or (interscalene adj3 (block or an?esth* or analg* or continuous))).mp. (274975)

3     1 and 2 (1699)

4     (randomized-controlled-trial/ or randomisation/ or controlled-study/ or multicenter-study/ or phase-3-clinical-trial/ or phase-4-clinical-trial/ or double-blind-procedure/ or single-blind-procedure/ or (random* or cross?over* or factorial* or placebo* or volunteer* or ((singl* or doubl* or trebl* or tripl*) adj3 (blind* or mask*))).ti,ab.) not (animals not (humans and animals)).sh. (3269130)

5     4 and 3 (659)

6     from 5 keep 1-659 (659)



 

Appendix 5. CINAHL (EBSCO host) search strategy


Search terms

S1           TX ( shoulder or rotator cuff ) and AB ( shoulder or rotator cuff )

S2           (MH "Shoulder")

S3           (MH "Shoulder Joint+")

S4           (MH "Rotator Cuff+")

S5           (MH "Arthroplasty") or (MH "Arthroplasty, Replacement+")

S6           S1 or S2 or S3 or S4 or S5

S7           (MH "Patient-Controlled Analgesia")

S8           (MH "Anesthetics, Intravenous") or (MH "Anesthesia, Intravenous")

S9           (MM "Nerve Block")

S10         AB intravenous or intramuscular or transdermal or subcutaneous

S11         TX ISBPB or ISNB

S12         TX interscalene and TX ( block or an?esth* or analg* or continuous )

S13         S7 or S8 or S9 or S10 or S11 or S12

S14         S6 and S13

S15         TX ( random* or placebo* or clinical trial* ) or TX ( (single or double or triple) and (blind* or mask*) )

S16         TX animal* not TX ( (animal* and human*) )

S17         S15 not S16

S18         S14 and S17



 

Appendix 6. Data extraction form

Continuous interscalene blockade versus parenteral analgesia for postoperative pain relief after major shoulder surgery


Study ID:

Authors:

MEDLINE journal ID:

Year of publication:

Language:

 RCTCCTObservational

Type of study:   

 

Comments on study design:



Quality of concealment of random allocation


Allocation was not concealed                                                                        

(e.g. quasi-randomization)                                                           
 

Allocation concealment was inadequate                                                    

                                                                                                 
 

Methods of concealment were unclear or were not stated                                                          

                                                                                                 
 

Concealment was adequate                                                                             

(e.g. numbered, sealed opaque envelopes; central assignment by co-ordinating centre)
 



 


Inclusion and exclusion criteria were not clearly defined in the text                

 
 



 


Outcomes of participants who withdrew or were excluded after allocation were NEITHER detailed separately NOR included in an intention-to-treat analysis            

Outcomes of participants who withdrew or were excluded after allocation were EITHER detailed separately OR included in an intention-to-treat analysis     

OR the text stated there were no withdrawals    
 



 


Treatment and control groups were NOT adequately described at entry          

Treatment and control groups were adequately described at entry

A minimum of four admission details were described                                          
 



Methods


 Low risk of biasHigh risk of biasUnclear

Subject-blinded   

Physician type one-blinded             

Physician type two-blinded   

Outcome assessor-blinded   



Participants 


Number of eligible participants Number enrolled in study 

Number of males Number of females 



 


Intervention

 
Drugs (specify)                         DoseDurationRoute

Interscalene group    

Parenteral group    



 

Comment on treatment


 



 


 Interscalene group
n
Parenteral group

n

Withdrawals  

Lost to follow-up  



 


Primary outcome  Effectiveness of pain relief
# (%)                    
Total participants
n

Interscalene group  

Parenteral group  



 


Secondary outcome

complications
Interscalene groupParenteral group


n (%) 

n
(%)

Block failure    

Pneumothorax    

Nerve injury    

Horner’s syndrome    

Vascular injury    

Haematoma    

Bleeding    

Catheter dislocation    

Infection    

Metal taste    

Motor block    

Cardiovascular depression    

Central nervous system excitation    

Nausea and vomiting    

Pruritus    

Sedation    

Respiratory depression    

Others    



 


Secondary outcomeInterscalene groupParenteral group


n (%) 

n
(%)

Duration of analgesia (hours)    

LOS PACU (hours)    

Continuous outcomes:
LOS hospital (days)
    

Participant satisfaction    

Supplemental analgesia    



 


Changes in protocol:

 

Contact with author:

 

Other comments on the study: 

 

 



 

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

Conceiving of the review: Hameed Ullah (HU).
Co-ordinating the review: HU.
Undertaking manual searches: HU, Khalid Samad (KS).
Screening search results: HU, KS.
Organizing retrieval of papers: HU, KS.
Screening retrieved papers against inclusion criteria: HU, KS.
Appraising quality of papers: HU, KS.
Abstracting data from papers: HU.
Writing to authors of papers to ask for additional information: KS.
Providing additional data about papers: HU, KS.
Obtaining and screening data on unpublished studies: HU, KS.
Managing data for the review: HU, KS.
Entering data into Review Manager (RevMan 5.1): HU.
Handling RevMan statistical data: HU, KS.
Performing other statistical analyses not using RevMan: HU, KS.
Entering data double: data entered by person one, HU; data entered by person two, KS.
Interpreting data: HU, KS, Fauzia A Khan (FK).
Making statistical inferences: HU, KS, FK.
Writing the review: HU.
Securing funding for the review: not applicable.
Performing previous work that was the foundation of the present study: HU.
Servind as guarantor for the review (one author): HU.
Taking responsibility for reading and checking the review before submission: KS, FK,

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

Hameed Ullah: none known.

Khalid Samad: none known.

Fauzia A Khan: none known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Internal sources

  • Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

  1. The title has undergone a minor change. "Continuous interscalene blockade" has been changed from the protocol (Ullah 2008) to "Continuous interscalene brachial plexus block" in the review.
  2. In the review, we searched CENTRAL, MEDLINE, EMBASE, CINAHL and ISI Web of Science, whereas we mentioned only the first three databases in the protocol.
  3. The risk of bias tool has been updated and the methods amended to reflect this.

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Hofmann-Kiefer 2008 {published data only}
  • Hofmann-Kiefer K, Eiser T, Chappell D, Leuschner S, Conzen P, Schwender D. Does patient-controlled continuous interscalene brachial plexus block improve early functional rehabilitation after open shoulder surgery?. Anesthesia and Analgesia 2008;106:991-6.
Wei 2012 {published data only}
  • Wei Y, Guo X-Y, Yang L, Rong Y-L, Xu CY, Li M. Effects of continuous interscalene brachial plexus block plus general anesthesia versus general anesthesia alone on perioperative management of arthroscopic rotator cuff repair surgery. National Medical Journal of China 2012;92:2327-30.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Al-Kaisy 1998 {published data only}
  • Al-Kaisy A, McGuire G, Chan VWS, Bruin G, Peng P, Miniaci A, et al. Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery. Regional Anesthesia and Pain Medicine 1998;23:469-73.
Bain 2001 {published data only}
  • Bain GI, Rudkin G, Comley AS, Heptinstall RJ, Chittleborough M. Digitally assisted acromioplasty: the effect of interscalene block on this new surgical technique. Arthroscopy 2001;17:44-9.
Barber 2002 {published data only}
Beaudet 2008 {published data only}
  • Beaudet V, Williams SR, Tétreault P, Perrault MA. Perioperative interscalene block versus intra-articular injection of local anesthetics for postoperative analgesia in shoulder surgery. Regional Anesthesia and Pain Medicine 2008;33:134-8.
Birnbaum 2007 {published data only}
  • Birnbaum J, Kip M, Spies CD, Hein OV, Labs K, Moeckel G, et al. The effect of stimulating versus nonstimulating catheters for continuous interscalene plexus blocks in short-term pain management. Journal of Clinical Anesthesia 2007;19:434-9.
Blumenthal 2005 {published data only}
Borgeat 1997 {published data only}
  • Borgeat A, Schäppi B, Biasca N, Gerber C. Patient-controlled analgesia after major shoulder surgery: patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997;87:1343-7.
Borgeat 1998 {published data only}
  • Borgeat A, Tewes E, Biasca N, Gerber C. Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA. British Journal of Anaesthesia 1998;81:603-5.
Borgeat 2000 {published data only}
  • Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: effects on diaphragmatic and respiratory function. Anesthesiology 2000;92:102-8.
Ciccone 2008 {published data only}
  • Ciccone WJ II, Busey TD, Weinstein DM, Walden DL, Elias JJ. Assessment of pain relief provided by interscalene regional block and infusion pump after arthroscopic shoulder surgery. Arthroscopy 2008;24:14-9.
Contreras-Domínguez 2008 {published data only}
  • Contreras-Domínguez V, Carbonell-Bellolio P, Sanzana ES, Ojeda-Greciet A, Orrego-Santos A. Efficacy of a continuous interscalene block vs intra-articular analgesia for postoperative pain in arthroscopic acromioplasty. Revista Española de Anestesiología y Reanimación 2008;55:475-80.
Culebras 2001 {published data only}
  • Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z. Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes. Anesthesia and Analgesia 2001;92:199-204.
Delaunay 2005 {published data only}
  • Delaunay L, Souron V, Lafosse L, Marret E, Toussaint B. Analgesia after arthroscopic rotator cuff repair: subacromial versus interscalene continuous infusion of ropivacaine. Regional Anesthesia and Pain Medicine 2005;30:117-22.
Dewees 2006 {published data only}
  • Dewees JL, Schultz CT, Wilkerson FK, Kelly JA, Biegner AR, Pellegrini JE. Comparison of two approaches to brachial plexus anesthesia for proximal upper extremity surgery: interscalene and intersternocleidomastoid. American Association of Nurse Anesthetists 2006;74:201-6. [: 16786913]
Esteves 2002 {published data only}
  • Esteves S, Sá P, Figueiredo D, Pèrez Souto A. Duration and quality of postoperative analgesia after brachial plexus block for shoulder surgery: ropivacaine 0.5% versus ropivacaine 0.5% plus clonidine. Revista Española de Anestesiologíay Reanimación 2002;49:302-5.
Fontana 2009 {published data only}
  • Fontana C, Di Donato A, Di Giacomo G, Costantini A, De Vita A, Lancia F, et al. Postoperative analgesia for arthroscopic shoulder surgery: a prospective randomized controlled study of intraarticular, subacromial injection, interscalenic brachial plexus block and intraarticular plus subacromial injection efficacy. European Journal of Anaesthesiology 2009;26:689-93.
Fredrickson 2010 {published data only}
  • Fredrickson MJ, Ball CM, Dalgleish AJ. Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Regional Anesthesia and Pain Medicine 2010;35:28-33.
Fredrickson 2011 {published data only}
  • Fredrickson MJ, Abeysekera A, Price DJ, Wong AC. Patient-initiated mandatory boluses for ambulatory continuous interscalene analgesia: an effective strategy for optimizing analgesia and minimizing side-effects. British Journal of Anaesthesia 2011;106:239-45.
Goebel 2010 {published data only}
  • Goebel S, Stehle J, Schwemmer U, Reppenhagen S, Rath B, Gohlke F. Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system. Archives of Orthopaedic and Trauma Surgery 2010;130:533-40.
Gohl 2001 {published data only}
  • Gohl MR, Moeller RK, Olson RL, Vacchiano CA. The addition of interscalene block to general anesthesia for patients undergoing open shoulder procedures. American Association of Nurse Anesthetists 2001;69:105-9.
Gonano 2009 {published data only}
  • Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. British Journal of Anaesthesia 2009;103:428-33.
Grossi 1998 {published data only}
  • Grossi P, Calliada S, Braga A, Caldara P, D'Aloia A, Coluccia R. Interscalene brachial plexus block combined with total intravenous anaesthesia and laryngeal mask airway for shoulder surgery. Anaesthesia 1998;53:20-1.
Hadzic 2005 {published data only}
  • Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005;102:1001-7.
Ilfeld 2003 {published data only}
  • Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesia and Analgesia 2003;96:1089-95.
Ilfeld 2006 {published data only}
  • Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 2006;105:999-1007.
Iskandar 2003 {published data only}
  • Iskandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B. The analgesic effect of interscalene block using clonidine as an analgesic for shoulder arthroscopy. Anesthesia and Analgesia 2003;96:260-2.
Kean 2006 {published data only}
  • Kean J, Wigderowitz CA, Coventry DM. Continuous interscalene infusion and single injection using levobupivacaine for analgesia after surgery of the shoulder. A double-blind, randomised controlled trial. The Journal of Bone and Joint Surgery. British volume 2006;88:1173-7.
Kinnard 1994 {published data only}
  • Kinnard P, Truchon R, St-Pierre A, Montreuil J. Interscalene block for pain relief after shoulder surgery. A prospective randomized study. Clinical Orthopaedics and Related Research 1994;304:22-4.
Klein 2000 {published data only}
  • Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KP, White W, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesthesia and Analgesia 2000;91:1473-8.
Klein 2001 {published data only}
  • Klein SM, Nielsen KC, Martin A, White W, Warner DS, Steele SM, et al. Interscalene brachial plexus block with continuous intraarticular infusion of ropivacaine. Anesthesia and Analgesia 2001;93:601-5.
Klein 2003 {published data only}
  • Klein SM, Steele SM, Nielsen KC, Pietrobon R, Warner DS, Martin A, et al. The difficulties of ambulatory interscalene and intra-articular infusions for rotator cuff surgery: a preliminary report. Canadian Journal of Anaesthesia 2003;50:265-9.
Laurila 2002 {published data only}
Le 2008 {published data only}
  • Le LT, Loland VJ, Mariano ER, Gerancher JC, Wadhwa AN, Renehan EM, et al. Effects of local anesthetic concentration and dose on continuous interscalene nerve blocks: a dual-center, randomized, observer-masked, controlled study. Regional Anesthesia and Pain Medicine 2008;33:518-25.
Lehtipalo 1999 {published data only}
Mahmoodpoor 2011 {published data only}
  • Mahmoodpoor A, Abedini N, Parish M, Jannati A, Baradaran R. Efficacy of low dose interscalene brachial plexus block on post anesthesia recovery parameters after shoulder surgery. Pakistan Journal of Medical Sciences 2011;27:265-8.
Mariano 2009 {published data only}
  • Mariano ER, Afra R, Loland VJ, Sandhu NS, Bellars RH, Bishop ML, et al. Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triple-masked, placebo-controlled study. Anesthesia and Analgesia 2009;108:1688-94.
Muittari 1998 {published data only}
  • Muittari P, Kirvelä O. The safety and efficacy of intrabursal oxycodone and bupivacaine in analgesia after shoulder surgery. Regional Anesthesia and Pain Medicine 1998;23:474-8.
Nisar 2008 {published data only}
  • Nisar A, Morris MW, Freeman JV, Cort JM, Rayner PR, Shahane SA. Subacromial bursa block is an effective alternative to interscalene block for postoperative pain control after arthroscopic subacromial decompression: a randomized trial. Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons 2008;17:78-84.
Patacsil 2008 {published data only}
  • Patacsil JA, Wemette JP, Eborn TW, Daniel CA, Pellegrini JE. Intraartciular infusion pump vs an interscalene brachial plexus block for improved pain control in arthroscopic shoulder surgery. American Association of Nurse Anesthetists 2008;76:386.
Pennekamp 2004 {published data only}
  • Pennekamp PH, Pless V, Kraft CN, Stütz A, Schmitt O, Diedrich O. Effectiveness of interscalene plexus block for open subacromion decompression. Deutsche Gesellschaft für Orthopädie und Orthopädische Chirirurgie 2004;142:598-602.
Pere 1993 {published data only}
  • Pere P. The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine plus fentanyl on diaphragmatic motility and ventilatory function. Regional Anesthesia 1993;18:93-7.
Sia 2003 {published data only}
  • Sia S, Sarro F, Lepri A, Bartoli M. The effect of exogenous epinephrine on the incidence of hypotensive/bradycardic events during shoulder surgery in the sitting position during interscalene block. Anesthesia and Analgesia 2003;97:583-8.
Singelyn 1999 {published data only}
  • Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder surgery: continuous versus patient-controlled infusion. Anesthesia and Analgesia 1999;89:1216-20.
Singelyn 2004 {published data only}
  • Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesthesia and Analgesia 2004;99:589-92.
Tamosiūnas 2004 {published data only}
  • Tamosiūnas R, Gudas R, Karbonskiene A, Marchertiene I. Bupivacaine for continuous interscalene brachial plexus analgesia after shoulder surgery. Medicina 2004;40:351-7.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Benumof 2000
Bishop 2005
  • Bishop JY, Sprague M, Gelber J, Krol M, Rosenblatt MA, Gladstone J, et al. Interscalene regional anaesthesia for shoulder surgery. The Journal of Bone and Joint Surgery. American volume 2005;87(5):974-9. [MEDLINE: 15866958]
Borgeat 2007
  • Borgeat A. New insights of anesthesia for shoulder surgery. Journal of Medical Science 2007;27:47-54.
Desborough 2000
Egger 1997
  • Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315(7109):629-34. [MEDLINE: 9310563]
Fredrickson 2010a
Higgins 2011
  • Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2008.
Macintyre 2001
RevMan 5.1
  • Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Russon 2006
  • Russon K, Sardesai AM, Ridgway S, Whitear J, Sildown D, Boswell S, et al. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. British Journal of Anaesthesia 2006;97(6):869-73. [MEDLINE: 17065168]
Tuominen 1987
  • Tuominen M, Pitkanen M, Rosenberg PH. Postoperative pain relief and bupivacaine plasma levels during continuous interscalene brachial plexus block. Acta Anaesthesiologica Scandinavica 1987;31(4):276-8. [MEDLINE: 3591249]
White 2005
Winnie 1970
  • Winnie AP. Interscalene brachial plexus block. Anesthesia and Analgesia 1970;49(3):455-66. [MEDLINE: 5534420]