title: Ultrasound-Guided Out-of-Plane vs. In-Plane Interscalene Catheters: A Randomized, Prospective Study.
abstract: BACKGROUND
  Continuous interscalene blocks provide excellent analgesia after shoulder surgery. Although the safety of the ultrasound-guided in-plane approach has been touted, technical and patient factors can limit this approach. We developed a caudad-to-cephalad out-of-plane approach and hypothesized that it would decrease pain ratings due to better catheter alignment with the brachial plexus compared to the in-plane technique in a randomized, controlled study.
  
  
  OBJECTIVE
  To compare an out-of-plane interscalene catheter technique to the in-plane technique in a randomized clinical trial.
  
  
  METHODS
  Eighty-four patients undergoing open shoulder surgery were randomized to either the in-plane or out-of-plane ultrasound-guided continuous interscalene technique. The primary outcome was VAS pain rating at 24 hours. Secondary outcomes included pain ratings in the recovery room and at 48 hours, morphine consumption, the incidence of catheter dislodgments, procedure time, and block difficulty. Procedural data and all pain ratings were collected by blinded observers.
  
  
  RESULTS
  There were no differences in the primary outcome of median VAS pain rating at 24 hours between the out-of-plane and in-plane groups (1.50; IQR, [0 - 4.38] vs. 1.25; IQR, [0 - 3.75]; P = 0.57). There were also no differences, respectively, between out-of-plane and in-plane median PACU pain ratings (1.0; IQR, [0 - 3.5] vs. 0.25; IQR, [0 - 2.5]; P = 0.08) and median 48-hour pain ratings (1.25; IQR, [1.25 - 2.63] vs. 0.50; IQR, [0 - 1.88]; P = 0.30). There were no differences in any other secondary endpoint.
  
  
  CONCLUSIONS
  Our out-of-plane technique did not provide superior analgesia to the in-plane technique. It did not increase the number of complications. Our technique is an acceptable alternative in situations where the in-plane technique is difficult to perform.
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Schwenk
authors.affiliation: Princeton University Medical Center, Princeton University, Plainsboro Township, USA.
authors.forename: Kishor
authors.initials: K
authors.lastname: Gandhi
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Jaime L
authors.initials: JL
authors.lastname: Baratta
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Torjman
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Jaeyoon
authors.initials: J
authors.lastname: Chung
authors.affiliation: Holy Cross Hospital, Philadelphia, USA.
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Vaghari
authors.affiliation: Department of Anesthesiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA.
authors.forename: David
authors.initials: D
authors.lastname: Beausang
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Jacksonville, USA.
authors.forename: Elird
authors.initials: E
authors.lastname: Bojaxhi
authors.affiliation: Department of Nursing, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, USA.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Grady
keywords: Brachial Plexus Block; Nerve Block; Peripheral Nerve; Regional Anesthesia; Shoulder Pain