Diaphragm Sparing Effect of Subomohyoid Block With Infraclavicular or Subscapularis Blocks in Comparison With Interscalen Block for Postoperative Analgesia in Shoulder Surgeries

Study Overview
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Brief Summary
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The gold standard for shoulder analgesia is the interscalene block (ISB), but it has its own share of disadvantages such as phrenic nerve block, recurrent laryngeal nerve involvement and Horner's syndrome may lead to patient discomfort .Others, such as intrathecal spread and systemic toxicity of local anesthetic, can have serious consequences. Phrenic nerve injury is a common complication with regional anesthesia. Its either temporary with Transient Phrenic Nerve Palsy leading to hemidiaphragmatic paresis after interscalene block or other injections of local anesthetic in the neck . Although studies of ISB have shown a reduction in the incidence in hemidiaphragmatic paralysis with low-volume ISB, the risk of phrenic paralysis is not completely eliminated. To bypass this complication, distal block of the shoulder innervation is recommended such as subomohyoid infraclavicular and subomohyoid subscapularis blocks.

Detailed Description
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Ultrasound has a significant role in recent anesthesia. It plays a significant role in detecting diaphragmatic mobility and detecting phrenic nerve palsy after regional anesthesia . the common and standard technique for shoulder analgesia is interscalen block. but it has its own complications like phrenic nerve palsy. to bypass this complications ,several ways had been tried to overcome this complications. in this study, the investigator compare between the standard interscalen block with distal blocks like infraclavicular subomohyoid block and subomohyoid subscapularis blocks according to diaghragm affection , duration of analgesia , side effects occured with blocks. For infraclavicular subomohyoid block, the infraclavicular approach targets the posterior and lateral cords, thus anesthetizing the axillary nerve (which supplies the anterior and posterior shoulder joint), whereas the suprascapular nerve block done by blocking subomohyoid muscle anesthetizes the posterior shoulder. For subscapularis subomohyoid block, subscapularis is done before subomohyoid block. Subscapularis block target subscapular nerve which arise from posterior cord and present on ventral surface of subscapularis muscle .

Official Title
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Diaphragm Sparing Effect of Subomohyoid Block With Infraclavicular or Subscapularis Blocks in Comparison With Interscalen Block for Postoperative Analgesia in Shoulder Surgeries

Conditions
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Shoulder Surgeries Operations

Intervention / Treatment
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* Procedure: diaghragm affection by ultrasound before and after the blocks


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient acceptance. ASA I and ASA II. Age 21-60 years old. Both gender. BMI < 35 Kg/m2. Accepted mental state of the patient. Elective Unilateral upper limb surgeries at the level of the shoulder. Time of surgery less than 2 hours Exclusion Criteria: - Patient refusal. Peripheral neuropathy. Pathological coagulopathy. Infection at the injection site. Untreated pneumothorax. Disturbed conscious level. An allergy to local anesthetics used in this study

Ages Eligible for Study
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Minimum Age: 21 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: interscalen group<br>(29) patients will receive interscalene block before induction of general anethesia. patients will receive 30 ml of bupivacaine 0.25 %+250 mg of magnesium sulphate. | Procedure: diaghragm affection by ultrasound before and after the blocks<br>* the participant will assess diaphragm sparing in each block and evaluate effectiveness of infraclavicular subomohyoid blocks and subomohyoid subscapularis blocks according to intraoperative and postoperative analgesia and diaphragm affection and comparing them with interscalen and with each others<br>|
| Experimental: subomohyoid infracavicular group<br>(29) patients will receive subomohyoid infraclavicular block before induction of general anethesia. patients will receive 30 m lof bupivacaine 0.25 %+250 mg of magnesium sulphate. | Procedure: diaghragm affection by ultrasound before and after the blocks<br>* the participant will assess diaphragm sparing in each block and evaluate effectiveness of infraclavicular subomohyoid blocks and subomohyoid subscapularis blocks according to intraoperative and postoperative analgesia and diaphragm affection and comparing them with interscalen and with each others<br>|
| Experimental: subomohyoid subscapularis group<br>(29) patients will receive subomohyoid subscapularis block before induction of general anethesia . patients will receive 30 ml of bupivacaine0.25 %+250 mg of magnesium sulphate. | Procedure: diaghragm affection by ultrasound before and after the blocks<br>* the participant will assess diaphragm sparing in each block and evaluate effectiveness of infraclavicular subomohyoid blocks and subomohyoid subscapularis blocks according to intraoperative and postoperative analgesia and diaphragm affection and comparing them with interscalen and with each others<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change is being assessed (Diaphragm excursion) | As shown before diaphragm excursion will be examined preoperative as basal measurement, immediately postoperative in the PACU and 6 hours postoperatively to detect diaghragm excursion.If ratio of post to pre-block is < 25% this means that phrenic nerve block is included. | basal preoperatively , immediately postoperatively in the pacu and 6 hours postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Onset time of sensory block | Time between injection of local anesthetics mixture and loss of pin prick sensation in the median, radial, ulnar and musculocutaneous nerve distributions, pin prick test done with sterile 25G needle | 30 minutes after local anesthetic injection | 
| Visual Analogue Scale (VAS) at different intervals within and between the studied groups | Time between onset of sensory block to the first report of postoperative pain at the surgical site by visual analogue scale score. the investigators ask patient to estimate degree of pain on scale from 1-10 and ask patient to report degree of pain from 0 to 10 with 0 no pain to 10 worst pain and the investigator will give analgesic requirement once vas >3 which will be the first analgesic requirement by the patient. | immediately postoperative in the PACU , 6 hours postoperatively up to 24 hour postoperatively | 
| Duration of analgesia and total pethidine consumption in 24 hours of the studied groups | time between onset of sensory block to first recorded pain will be represented as duration of analgesia and the investigator will calculate total amount of pethidine consumed over 24 hours. | 24 hours | 
| postoperative complication of the studied groups | the investigator will record patients with complications from the blocks like hypoxemia with saturation <90% , bradycardia with heart rate <50, nausea and vomiting | 24 hours |