Hemidiaphragmatic paralysis after ultrasound-guided brachial plexus blocks for shoulder surgery: A systematic review and meta-analysis of randomized clinical trials

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia Pub Date : 2025-06-09 DOI:10.1016/j.jclinane.2025.111874

P. Oliver-Fornies PhD , C. Aragon-Benedi PhD , R. Gomez Gomez PhD , Cristina Anton Rodriguez , Blanca San-Jose-Montano , Ece Yamak Altinpulluk , M. Fajardo Perez

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引用次数: 0

Abstract

Study objective

This review aimed to explore whether diaphragm-sparing regional techniques are more effective at preventing hemidiaphragm paralysis than conventional interscalene brachial plexus blockade (ISB) following shoulder surgery.

Design

Systematic review of randomized clinical trials (RCTs) including meta-analyses, meta-regression, trial sequential analyses (TSA) and GRADE methodology.

Setting

Online databases (Cochrane Library; MEDLINE; EMBASE; Scopus; Web of Science; and international trial registries) were searched for RCTs up to December 2022.

Patients

Adult patients undergoing shoulder surgery following ultrasound-guided brachial plexus blockade, where incidence of hemidiaphragmatic paralysis was reported.

Interventions

Diaphragm-sparing techniques following ultrasound-guided brachial plexus blockade were included: modifications of ISB (low-volume, extrafascial, and lower concentration); superior trunk block; supraclavicular brachial plexus block, infraclavicular brachial plexus block; costoclavicular brachial plexus block; and anterior and posterior approaches to the suprascapular nerve block.

Measurements

The primary endpoint was the incidence of complete hemidiaphragmatic paralysis. Secondary endpoints included postoperative analgesia and safety-related outcomes.

Main results

Twenty-eight RCTs involving 1737 subjects were identified. Of these, 22 were eligible for meta-analysis. Six regional techniques were analysed. The low-volume technique significantly reduced the incidence of hemidiaphragmatic paralysis as compared with the conventional ISB (risk ratio 0.62; 95 % CI 0.42 to 0.91; p = 0.02; absolute risk difference − 0.30 [95 % CI -0.39 to −0.20]; I² = 80 %) at short-term follow-up. TSA confirmed the results of this meta-analysis but did not reach the required sample size by 19.5 %, indicating that the result was not definitive.

The combined infraclavicular-suprascapular blocks, the extrafascial technique, the lower concentration technique, and the supraclavicular block reduced the incidence of hemidiaphragmatic paralysis by 97 %, 64 %, 57 % and 46 %, respectively. For the superior trunk block, TSA did not reach statistical significance.

Conclusions

There is conclusive evidence that the extrafascial technique (high-level); lower concentration technique (moderate-level); and the supraclavicular blockade (low-level) are less detrimental to hemidiaphragmatic paralysis than the conventional ISB. However, the results for other comparisons were not definitive.

Systematic review protocol: PROSPERO CRD42022335056.

查看原文本刊更多论文

超声引导臂丛神经阻滞肩关节手术后半膈肌瘫痪：随机临床试验的系统回顾和荟萃分析

研究目的：本综述旨在探讨在肩部手术后，保留膈肌区域技术是否比传统的斜角肌间臂丛阻滞（ISB）更有效地预防半膈肌麻痹。设计对随机临床试验（RCTs）进行系统评价，包括meta分析、meta回归、试验序列分析（TSA）和GRADE方法学。设置在线数据库(Cochrane Library；MEDLINE;EMBASE;斯高帕斯;Web of Science；和国际试验注册中心)检索截至2022年12月的随机对照试验。患者超声引导下臂丛神经阻滞后接受肩部手术的成年患者，其中报道了半膈肌麻痹的发生率。超声引导下臂丛神经阻滞后保留膈肌技术包括：改变ISB（低容量、筋膜外和低浓度）；高级主干块；锁骨上臂丛阻滞，锁骨下臂丛阻滞；肋锁骨臂丛阻滞；肩胛上神经阻滞的前后通路。主要终点是完全性半膈肌麻痹的发生率。次要终点包括术后镇痛和安全相关结果。主要结果共纳入随机对照试验28项，受试者1737人。其中22例符合meta分析。分析了六种区域技术。与传统ISB相比，小容积技术显著降低了半膈肌麻痹的发生率(风险比0.62；95% CI 0.42 ~ 0.91；p = 0.02；绝对风险差- 0.30 [95% CI -0.39 ~ - 0.20]；I2 = 80%)。TSA确认了该荟萃分析的结果，但未达到所需样本量的19.5%，表明结果不确定。锁骨下-肩胛上联合阻滞、筋膜外技术、低浓度技术和锁骨上联合阻滞可使半膈肌麻痹的发生率分别降低97%、64%、57%和46%。对于上主干阻滞，TSA差异无统计学意义。结论有确凿的证据表明，筋膜外技术（高水平）；低浓度技术（中等水平）；锁骨上阻断术（低水平）对半膈肌麻痹的危害小于传统的ISB。然而，其他比较的结果并不确定。系统评价方案：PROSPERO CRD42022335056。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of Clinical Anesthesia 医学-麻醉学

CiteScore

7.40

自引率

4.50%

发文量

346

审稿时长

23 days

期刊介绍： The Journal of Clinical Anesthesia (JCA) addresses all aspects of anesthesia practice, including anesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, cost issues, and similar concerns anesthesiologists contend with daily. Exceptionally high standards of presentation and accuracy are maintained. The core of the journal is original contributions on subjects relevant to clinical practice, and rigorously peer-reviewed. Highly respected international experts have joined together to form the Editorial Board, sharing their years of experience and clinical expertise. Specialized section editors cover the various subspecialties within the field. To keep your practical clinical skills current, the journal bridges the gap between the laboratory and the clinical practice of anesthesiology and critical care to clarify how new insights can improve daily practice.