Ultrasound-Guided Erector Spinae Plane Block for Arthroscopic Shoulder Surgery

• Day Surgery Unit resting pain score[ Time Frame: At 5 hours post-operatively ]
  Using the patient-reported numeric rating scale (0-10) (0 is no pain and 10 is worst pain imaginable).
• Pain scores with movement[ Time Frame: At 30 minutes post-admission to recovery room and 5 hours post-operatively ]
  Using the patient-reported numeric rating scale (0-10). (0 is no pain and 10 is worst pain imaginable). Participants will be asked to sit up from lying down position.
• Opioid usage[ Time Frame: At 2 hours post-operatively and 5 hours post-operatively ]
  All opioids administered in recovery room and day surgery unit will be converted into Morphine Equivalent Units per patient according to accepted standards.
• Incidence of moderate to severe postoperative nausea-vomiting[ Time Frame: At 2 hours post-operatively and 5 hours post-operatively ]
  Using a 0-3 scale (0 is none and 3 severe nausea-vomiting)
• Incidence of moderate to severe itching[ Time Frame: At 2 hours post-operatively and 5 hours post-operatively ]
  Using a 0-3 scale (0 is none and 3 severe itching)
• Incidence of ipsilateral diaphragmatic paralysis[ Time Frame: 30 minutes post-admission to recovery room ]
  Diagnosed based on the findings in an anterior posterior chest using ultrasound , with the criteria of "a right hemidiaphragm sitting >2 cm higher than its left counterpart or a left hemidiaphragm sitting equal or higher than the right hemidiaphragm".
• Incidence of respiratory depression[ Time Frame: At 2 hours post-operatively and 5 hours post-operatively ]
  Opioids discontinued by the Acute Pain Service or recovery room nursing due to concerns of respiratory depression by nursing staff.
• Incidence of local anesthetic toxicity[ Time Frame: At 2 hours post-operatively and 5 hours post-operatively ]
  Based on clinical symptoms and signs of local anesthetic toxicity as diagnosed by the attending physician.
• Sensory blockade[ Time Frame: At 30 minutes post-admission to recovery room ]
  Seven sensory dermatomes corresponding to shoulder and upper arm and their blockade to cold sensation will be noted. The extent of blockade between the two groups will be compared by their median and range.
• Patient Satisfaction with Postoperative Analgesia[ Time Frame: At 5 hours post-operatively and 24 hours post-operatively ]
  Using a 7-item Likert scale (1 is extremely satisfied and 7 is extremely dissatisfied)

Arthroscopic shoulder surgery is a common and minimally invasive procedure utilized for different shoulder pathologies, but it is often associated with moderate to severe postoperative pain that may interfere with patients' well-being and course of recovery. By using an effective analgesic technique with few side effects, a patient may experience less pain after surgery, have a shortened hospital stay, and endure less nausea, vomiting, or excessive drowsiness that are associated with the use of opioids to manage postoperative pain. Periarticular infiltration (PAI) with local anesthetic (LA) has been used for shoulder surgery pain management, but the more effective interscalene nerve block (ISNB) is the current gold standard analgesic modality despite risk of significant side effects including diaphragm paralysis and rebound pain. In this study, the investigators want to look at the effectiveness and safety profile of a novel technique for pain management after shoulder surgery that has the potential to provide successful pain relief with minimal risk of side effects. Half of the patients will be randomly selected to receive the novel nerve block called the Erector Spinae Plane (ESP) block while the other half will receive a more standard PAI of local anesthetic to numb the shoulder. Patients' pain intensity and opioid consumption in the post-anesthesia care unit (PACU) as well as during the first 24 hours after surgery will be evaluated. Any complications from the interventions will also be noted. The investigators predict that the ESP block will provide superior analgesia compared to PAI for these shoulder arthroscopy patients.

• Procedure: Erector Spinae Plane (ESP) Block
  Preoperative US guided ESP blockade using 30 mL of 0.25% bupivacaine with 5 mcg/mL of epinephrine, injected in 5-mL aliquots through the needle (maximum of 3 mg/kg) PAI of 30 mL of saline at the end of the surgical procedure on the operated side rotator cuff, injected in 5-mL aliquots through the needle
• Procedure: Periarticular Infiltration (PAI)
  Preoperative US guided ESP blockade using 30 mL of saline, injected in 5-mL aliquots through the needle PAI of 30 mL of 0.25% bupivacaine with 5 mcg/mL of epinephrine at the end of the surgical procedure on the operated side rotator cuff, injected in 5-mL aliquots through the needle

• Active Comparator: ESP Block
  Preoperative US guided active Erector Spinae Plane (ESP) block and a saline PAI
• Other: PAI with LA
  Preoperative US guided ESP blockade with saline and an active Periarticular Infiltration (PAI)