Is There a Real Diaphragm-Sparing Nerve Block for Arthroscopic Shoulder Surgery?

Material and Methods This study will be performed according to the declaration of Helsinki. The institutional review board of the hospital (Clinique Médipôle Garonne, 45 rue de Gironis, 31036, Toulouse) gave its approval (registration n° 2016-202). Written consent for publication will been obtained from each patient.

Patients This prospective study will be conducted in the Department of Orthopedic surgery of Clinique Médipôle Garonne. Patients will be included from June 2017 to July 2017. Patients undergoing ambulatory arthroscopic shoulder surgery (acromioplasty and supraspinatus tendon repair) will be screened. Exclusion criteria are: age <18 years, brachial plexus neuropathies, acute respiratory distress, coagulopathies, systemic glucocorticoid use, pregnancy, routine use of opioid medications, intolerance for one or more medication of the study protocol and diabetes. All the patients will be operated on by the same surgeon (Dr Duport M.) and regional anesthesia will performed by experienced anesthetists (PM, CC, FF and MM).

Settings Before regional anesthesia (T1), the first sonographic evaluation of the diaphragm will performed.

All patients will be monitored in accordance with current guidelines, including non-invasive blood pressure as well as continuous electrocardiogram and pulse oximetry. The combination of infraclavicular brachial plexus block (ICB) (ropivacaine 0.375%, 20 mL), suprascapular nerve block (SSNB) (ropivacaine 0.375%, 5 mL) and supraclavicular nerve block (SCNB) (ropivacaine 0.375%, 5 mL) will performed. Systemic dexamethasone (10mg) will be administrated in all patients to prolong the analgesic effect of regional anesthesia. Shoulder arthroscopy will be performed in lateral decubitus position. Patients will then be transferred to the post-anesthesia care unit (PACU). Paracetamol (1 g each 6 hours) and Ketoprofen (100mg twice a day) will be systematically administered. Rescue analgesia with tramadol (100mg each 8 hours) will be administered if necessary (verbal rating scale (VRS) >3). Before PACU discharge (T2), a new ultrasonographic diaphragmatic function assessment will be done. Incidence of dyspnea will also be reported.

Patients will be contacted by phone once a day during the first two days after surgery to analyze the time period to the first opioids request, consumption of tramadol tablets and overall satisfaction. Patients will be instructed to keep a diary or write down the time when they took painkillers. Patient satisfaction concerning the procedure will be assessed using an 11-point scale (0: totally unsatisfied, I would definitively want a different anesthesia / analgesia method for the next surgery; 10: totally satisfied, I would definitively want the same anesthesia / analgesia method for the next surgery).