Comparison of the Interscalene Block Alone Versus Combined With Superior Truncus Block During Shoulder Surgery in Diaphragmatic Function

Comparison between interscalene block alone versus combined with superior truncus block inproducing diaphragmatic paralysis

Assessment of diaphragmatic function by diaphragm excursion (DE) and diaphragm thickening fraction (TF) will be measured both before and 30 minutes post-block. To measure DE, patients will be placed in a supine position, a convex transducer (3.5 \~ 5 MHz) will be used to scan while the right diaphragm through the hepatic window and the left diaphragm through the splenic window, which located near the anterior-axillary line. The craniocaudal movement of the diaphragm will be documented during deep inspiration using M-mode. * Complete diaphragmatic paralysis was defined as a 75% \~ 100% reduction in DE, including the occurrence of paradoxical movement. * Partial diaphragmatic paralysis was defined as a 25% \~ 75% reduction in DE. * No diaphragmatic paralysis was indicated by a DE reduction of less than 25%. To measure TF, patients will be placed in the same position with the head of the bed at 45°degree

Evaluation of the interscalene block alone versus combined with superior truncus block during shoulder surgery on the pulmonary function

Assessment of pulmonary function by a handheld spirometer to measure forced vital capacity (FVC), forced expiratory volume ( FEV1, FEV2) with patients in an upright-seated position pre-block and 30 minutes post-block as well as 2-hours post-surgery. Spirometry will be performed three times, with the best effort recorded.

Duration of the sensory and motor block onset, duration of the interscalene block alone versus combined with superior truncus block during shoulder surgery

Sensory block onset time will be assessed at the time from local anesthetics injection by pinprick test which will be preformed with 22-gauge short beveled needle every minute. Sensory block recovery time will be noted every hour in 1st 6 hours, every 2 hours in 2nd 6 hours till recovery of all pain sensation in all dermatomes performed by pinprick test. Motor block onset time will be assessed at the time from local anesthetics injection until complete motor block which will be assessed by absence of voluntary movement on asking the patient to elevate his arm every minute. Motor block recovery time will be noted as the time of return of voluntary movement in the arm every hour in 1st 6 hours, every 2 hours in 2nd 6 hours.

Evaluation of postoperative analgesic consumption

Pain will be evaluated Postoperative immediately every hour in 1st 6 hours, every 2 hours in 2nd 6 hours by Visual Analogue Scale ( VAS) by instructing the patient to point to the position on the line to indicate how much pain they are currently feeling(10). * VAS (zero) indicates no pain. * VAS ( 1, 2, 3) indicates mild pain. * VAS ( 4, 5, 6) indicates moderate pain. * VAS ( 7, 8, 9, 10) : indicates severe pain.

Evaluation of any complications or side effects during shoulder surgery

Any local or systemic complications or side effects will be recorded every 2 hours post operative for 24 hours such as local anesthetic systemic toxicity (LAST), Horner's syndrome, hypoxia, dyspnea, pneumothorax and post-operative nausea and vomiting (PONV).