Ultrasound-guided Interscalene Nerve Block vs Procedural Sedation by Propofol and Fentanyl for Anterior Shoulder Dislocations

 

Doost ES, Heiran MM, Movahedi M et al.

American Journal of Emergency Medicine 2017; 35: 1435–1439

Aim of Study

To compare ultrasound guided interscalene brachial plexus block (ISBPB) with procedural sedation analgesia (PSA) for reduction of shoulder dislocations in the Emergency Department (ED)

Design and Location

Randomized clinical trial in Bahonar Hospital, academic level 2 trauma center, Iran

Methodology

Random 6- block assignment of 2 groups of 30:

Group 1: Procedural sedation with propofol (1mg/kg) and fentanyl (2mcg/kg)

VS

Group2: interscalene brachial plexus block

to reduce confirmed anterior shoulder dislocation. Time measured from start of ISBPB or PSA until discharge from ED.

Primary Outcome

  • Emergency Room Length of Stay (ERLOS) from beginning of the ISBPB or

PSA to discharge,

  • pain score during reduction [measured by a Numeric Rating Scale (NRS)]

Secondary Outcomes

  • total number of attempts at reduction,
  • number of techniques used for reduction,
  • occurrence of complications
  • patient satisfaction with the procedure (measured as a score of 1 to 4: poor, intermediate, good, and excellent, respectively).

Statistics

Quantitative variables with normal and non-normal distribution, mean (±SD) and median (±inter quartile range) were used, respectively.

Qualitative (categorical) variables, percent of frequency was used.  Odds ratio (OR) and 95% confidence interval (CI) for expressing the severity of this association was utilized.

p<0.05 was considered statistically significant in all statistical tests.

SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) was used for analysis.

Results

  • No significant difference between baseline characteristics of each group

Primary outcomes:

  • EDLOS: Group 1 (PSA): 108.6 mins (mean 42.1), Group 2 (ISBPB) 80.2 mins (mean 25.2),  p<0.005
  • Pain during procedure (/5): Group 1 (PSA) 0.38, Group 2 (ISBPB) 3.43, = p<0.001

Secondary Outcomes:

  • Total Number attempts at reduction – no significant difference, p=0.10
  • Number of techniques used for reduction – no significant difference, p=0.72
  • Occurrence of complications – no significant difference, 0
  • Patient satisfaction score (/5) – Group 1(PSA): 3.6, Group 2 (ISBPB) 3.0 = P<0.001

Conclusions/Discussion

Interscalene block significantly reduced ED length of stay compared with procedural sedation analgesia, therefore may lead to increased patient flow through busy ED departments.

Procedural sedation analgesia associated with significantly reduced patient pain scores during procedure and satisfaction afterwards

ERLOS outcomes consistent with other similar smaller studies  but patient satisfaction not comparable

Stated Limitations from the Study

  • Only looked at anterior shoulder dislocations in ages >18
  • Males >females
  • Convenience sampling use
  • Titration of sedation/LA  to effect – no fixed doses – individual variation
  • No blinding
  • Ultrasound experience/qualifications – 2 day course, with at least 1 block performed/week for 1 year
  • Limited information given on adverse events
  • Small sample size n=60
  • Not generalizable worldwide

Discussion from Journal Club Meeting (?Change of Practice)

Need to define what the adverse effects were and quantify them

ED length of stay – variable definitions therefore maybe best to start at time of first contact with health care provider until ED discharge

Lag between performing ISBPB and procedure vs no delay with sedation but takes longer to wake up

No information on how long the block lasted for or any outpatient follow up post block

Needs further studies

Needs structured dedicated USS teaching ?appropriate exposure in ED to keep skills up and can be potentially risky block

Summary by Dr A Harris. Journal Club meeting 22nd November 2018.

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