BJA Advance Access published online on August 4, 2008
British Journal of Anaesthesia, doi:10.1093/bja/aen229
Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block
1 Department of Anesthesia
2 Department of Orthopedic Surgery, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Venue, Toronto, Ontario, Canada M4N 3M5
* Corresponding author. E-mail: colin.mccartney{at}utoronto.ca
Background: Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. We examined the incidence of phrenic nerve palsy with a low-volume ISBPB compared with a standard-volume technique both guided by ultrasound.
Methods: Forty patients undergoing shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 5 or 20 ml ropivacaine 0.5%. General anaesthesia was standardized. Both groups were assessed for respiratory function by sonographic diaphragmatic assessment and spirometry before and after receiving ISBPB, and after surgery. Motor and sensory block, pain, sleep quality, and analgesic consumption were additional outcomes. Statistical comparison of continuous variables was analysed using one-way analysis of variance and Student’s t-test. Non-continuous variables were analysed using 
2 tests. Statistical significance was assumed at P<0.05.
Results: The incidence of diaphragmatic paralysis was significantly lower in the low-volume group compared with the standard-volume group (45% vs 100%). Reduction in forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow at 30 min after the block was also significantly less in the low-volume group. In addition, there was a significantly greater decrease in postoperative oxygen saturation in the standard-volume group (–5.85 vs –1.50, P=0.004) after surgery. There were no significant differences in pain scores, sleep quality, and total morphine consumption up to 24 h after surgery.
Conclusions: The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.
Keywords: anaesthetic techniques, regional, brachial plexus; analgesics, postoperative; complications, respiratory
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  H. M. Smith, C. M. Duncan, and J. R. Hebl Clinical Utility of Low-Volume Ultrasound-Guided Interscalene Blockade: Contraindications Reconsidered J. Ultrasound Med., September 1, 2009; 28(9): 1251 - 1258. [Abstract] [Full Text] [PDF]
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 K. J. Chin, C. J. L. McCartney, N. M. Carmichael, S. Riazi, and I. T. Awad Does low-volume inter-scalene block attenuate the severity of diaphragmatic paresis? Br. J. Anaesth., January 1, 2009; 102(1): 142 - 143. [Full Text] [PDF]
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