Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia: a randomized controlled unblinded trial

Introduction Previous trials favored a continuous interscalene brachial plexus block over a single injection for major shoulder surgery. However, these trials did not administer a multimodal analgesic regimen. This randomized, controlled unblinded trial tested the hypothesis that a continuous infusion of local anesthetic for an interscalene brachial plexus block still provides superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac.Methods Sixty patients undergoing shoulder arthroplasty or arthroscopic rotator cuff repair were randomized to receive a bolus of ropivacaine 0.5%, 20 mL, with or without a continuous infusion of ropivacaine 0.2% 4-8 mL/hour, for an interscalene brachial plexus block. Patients were provided with intravenous morphine patient-controlled analgesia. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary outcomes included pain scores at rest and on movement, and functional outcomes, measured over 48 hours after surgery.Results Median (IQR) cumulative intravenous morphine consumption at 24 hours postoperatively was 10 mg (4-24) in the continuous infusion group and 14 mg (8-26) in the single injection group (p=0.74). No significant between-group differences were found for any of the secondary outcomes.Conclusions A continuous infusion of local anesthetic for an interscalene brachial plexus block does not provide superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. The findings of this study are limited by performance and detection biases.