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Ultrasonographic image of interscalene nerve block. The C5 nerve root ( arrow ) and block needle ( arrowheads ) are indicated.
Source publication
Background
Appropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.
Questions/purposes
This prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.
Methods
Ten TSA patients received an interscalene nerve block (25 cm3 0.375% ropivacaine) wit...
Context in source publication
Context 1
... anesthesia, patients received intrave- nous midazolam sedation and an ultrasound-guided interscalene block using a single injection of 25cm 3 0.375% ropivacaine. The nerve block needle (22 G Chiba (Hakko Co Ltd., Chikuma-shi, Nagano-ken, Japan) or Stimuplex (B. Braun, Meisungen AG, Meisungen, Germany)) was placed between the C5 and C6 nerve roots (Fig. 1). Propofol was used to induce general anesthesia. A LMA (The Laryngeal Mask Company, Limited., Le Rocher, Victoria, Mahe, Seycelles) was placed, and anesthesia was maintained with a propofol infusion and inhaled nitrous oxide and ...
Citations
... The ultrasound guided interscalene approach, using a single injection or a continuous infusion through a peripheral nerve catheter, is most commonly used when regional anesthesia is desired as an adjuvant for shoulder surgery ( Fig. 1 A and B). 13 Incorporating the use of regional anesthetic techniques within a multimodal analgesic approach of an established orthopedic based clinical pathway appears to improve perioperative outcomes and analgesia, enhance postoperative recovery, and reduce opioid consumption. 7,11 Continuous regional analgesia that is provided via perineural catheters can provide additional benefit as they can prolong neural blockade with a resulting decrease in postoperative opioid requirements beyond 24 hours, potentially altering opioid prescribing practices. 4,10 Furthermore, for outpatient surgery, ambulatory pumps can allow prolonged analgesia which may improve patient satisfaction, reduce hospital resource utilization and improve hospital financial performance by facilitating same day dismissal. ...
Background
Brachial plexus catheter placement at the interscalene level is beneficial for shoulder analgesia but presents logistical challenges due to the superficial nature of the plexus at this level, increased patient movement in the neck, and therefore higher likelihood for catheter dislodgement.
Methods
Patients requiring shoulder arthroscopy and suprascapular nerve decompression were identified. Under arthroscopic guidance, a catheter was placed percutaneously into the scalene medius muscle next to the suprascapular nerve and the upper trunk of the brachial plexus. Patients were followed postoperatively for perioperative analgesic outcomes.
Results
Ten patients were identified and consented for intraoperative brachial plexus catheter placement. Patient demographics and surgical details were determined. Postoperative adjunctive pain management and pain scores were variable. Two patients required catheter replacement using ultrasound guidance in the perioperative anesthesia care unit due to poorly controlled pain. There were no incidents of catheter failure due to dislodgement.
Discussion
This study presents the first description of arthroscopically-assisted brachial plexus catheter placement. This method may present an alternative to traditional ultrasound guided interscalene catheter placement. Further study is needed to determine if analgesic outcomes, block success, and dislodgement rates are improved with this method.
... The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1,2,7,14), block duration, patient-oriented pain questions (postoperative day 1,2,7,14), and patient and physician adherence to pathway. Results On postoperative day 1, pathway patients had lower worst pain with movement (3.3 6 3.1) compared with control patients (5.6 6 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1. 9 Conclusion Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. ...
... The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1,2,7,14), block duration, patient-oriented pain questions (postoperative day 1,2,7,14), and patient and physician adherence to pathway. Results On postoperative day 1, pathway patients had lower worst pain with movement (3.3 6 3.1) compared with control patients (5.6 6 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1. 9 Conclusion Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. ...
... A multimodal pain management protocol was recently shown to improve the quality of recovery after ambulatory shoulder surgery [4]. A pathway for total shoulder arthroplasty demonstrated low pain scores and minimal intravenous opioid use when a peripheral nerve block and preemptive nonopioid analgesia were combined [7,20]. ...
Background:
Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear.
Questions/purposes:
(1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes?
Methods:
From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway.
Results:
On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03).
Conclusion:
Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption.
Level of evidence:
Level II, therapeutic study.
... Although this kind of local infiltration was effective within their protocols, an interscalene brachial plexus block provides superior analgesic efficacy and is the preferred technique for arthroscopic shoulder surgery [12][13][14][15][16]. A multimodal analgesia clinical pathway developed for total shoulder arthroplasty featuring interscalene brachial plexus blocks has demonstrated feasibility and shown promise in one study, but as a pilot study, it was not designed to make comparisons or draw conclusions [17]. All of these studies were conducted using inpatient procedures with extended postoperative medical supervision and intravenous patientcontrolled analgesia, which are not options in the outpatient setting. ...
Objectives:
Pain control after shoulder arthroscopy can be challenging, often relying on opioids. The study aims to measure the quality of recovery (QoR) before and after implementation of a "Multimodal Perioperative Pain Protocol" (MP3) in patients undergoing ambulatory shoulder arthroscopy.
Design:
Prospective cohort study.
Setting:
Free-standing ambulatory surgery facility of a tertiary care academic center.
Subjects:
Patients undergoing ambulatory shoulder arthroscopy.
Methods:
The primary end point of the study was the QoR-9 score at 24 hours, 48 hours, and one week after surgery. Secondary end points included 1) measuring the quality of pain management using the Revised American Pain Society Patient Oriented Questionnaire (APS-POQ-R) and 2) postoperative opioid requirements.
Results:
Data from132 patients in the control group (pre-intervention) and 120 patients in the MP3 group were analyzed. The QoR-9 scores were significantly higher for the MP3 group at all time points, but only met the minimal clinical important difference threshold at 24 hours (13.4 vs 14.9, P < 0.05) and 48 hours (14.0 vs 15.0, P < 0.05) postoperatively. Patients reported better quality of pain management after implementation of the MP3 in the domains of pain intensity, pain interference with activity, and sleep, and they reported the presence of negative emotions up to two days after ambulatory shoulder surgery. In addition, this protocol significantly reduced opioid consumption up to three days after surgery.
Conclusions:
Implementation of the MP3 improved the overall QoR and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery.
... 临床路径作为一种标准化的诊疗模式，被视为 20世纪末发展的最重要的医疗模式，在保证医疗质 量的同时，又可缩短住院时间，减少住院费用，减 轻患者的负担，促进患者的预后 [7][8] 。本研究选择湖 南省内自然临产阴道分娩作为实证研究病种，研究 发现：临床路径组患者的经济学指标均明显低于对 照组，说明实施临床路径可降低医疗成本，减少花 费。诸多国外研究 [9][10] 也表明临床路径能减少住院时 间，降低住院费用。 本研究发现：临床路径组的临床指标中的合并 症发生率、并发症发生率、医院感染率均明显低于 对照组，国外Lau等 [11] 也发现临床路径可降低死亡 率，提高治愈率，减少并发症发生率。但是，本研 究中治愈率、非计划性再手术发生率、31 d再入院发 生率两组比较差异无统计学意义，可能与产科疾病 风险性较低，治愈率较高，孕检普及等有关。 诊疗合理性指标耗材费用比两组差异无统计学意 义，检查费用比、药品费用比、预防性使用抗生素率 和预防性使用抗生素天数，临床路径组低于对照组。 Goon等 [12] 研究指出临床路径可减少药品的使用。抗生 素是目前临床上用量最大的一类药物，通过对此类药 物的临床路径管理，能较大程度地减少药物的不合理 使用 [13] 。可见，临床路径对促进抗生素的合理使用， 防止抗生素滥用现象具有积极意义。 患者和医护人员是临床路径实施过程必备元 素，其满意度水平直接影响临床路径能否顺利进 行。临床路径组患者满意度水平明显高于对照组， 说明临床路径的实施提高了患者的满意度，与王凤 等 [14] 的研究结果相似。临床路径组医护人员工作满 意度水平显著低于对照组，这与国外学者研究结果 不同，Ronellenfitsch等 [15] 研究指出，在产科，临床 路径的实施不仅能使医护人员的工作满意度增加， 还能使医护人员更加满意自己对患者提供的治疗， 但与王丹等 [16] ...
Objective:
In order to apply the index system for clinical evaluation of implementation effect in hospitals.
Methods: A total of 862 patients with vaginal delivery from 9 hospitals were randomly divided into an clinical pathway group (n=496) and a control group (n=366). The patients in the control group received traditional treatment procedure while the patients in the clinical pathway group experienced procedure of the clinical treatment. The index system was used for clinical evaluation of implementation effect.
Results: There were obvious advantages in 15 indicators in the clinical pathway group than those in the control group (P<0.05). The comprehensive score of the clinical pathway group was higher than the control group of the corresponding grade and nature of the hospital. The comprehensive score for secondary hospitals (Ci=0.7967) were higher than that for the tertiary hospitals (Ci=0.2033). The comprehensive score for the general hospitals (Ci=0.8948) were higher than that for the specialized hospitals (Ci=0.1052). As for clinical implementation effect, the secondary hospitals were better than the tertiary hospital, and the general hospitals were better than the specialized hospitals.
Conclusion: The index system for clinical evaluation could quantify the implementation effect, and compare the implementation effect in different hospitals, which provides reference for the management of clinical pathway.
... Evaluating the pharmacokinetics of INB, Busch et al found that the time of pain onset after single-injection ropivacaine INB was 10 hours. 6 Weber and Jain similarly evaluated the 10 Our study found similar findings with a peak in pain level seen 21 to 24 hours postoperatively in the INB group. Whereas INB was more effective at controlling pain in the first 8 hours postoperatively, there was a trend toward acute rebound pain at the end of POD 0 as the block's effects declined. ...
HYPOTHESIS:
Our hypothesis was that in patients undergoing shoulder arthroplasty, a prospective randomized trial would find no significant differences in average daily pain scores of those treated with interscalene nerve block (INB) vs. local liposomal bupivacaine (LB).
METHODS:
Sixty patients undergoing primary shoulder arthroplasty were assessed for eligibility. Study arms included either intraoperative local infiltration of LB (20 mL bupivacaine/20 mL saline) or preoperative INB, with a primary outcome of postoperative average daily visual analog scale scores for 4 days. Secondary outcomes assessed included opioid consumption, length of stay, and complications. Randomization was by a computerized algorithm. Only the observer was blinded to the intervention.
RESULTS:
Three patients were excluded, all before randomization. A total of 57 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups.
CONCLUSION:
An increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day. After the day of surgery, there were no significant differences found in any variables. These findings suggest that LB provides similar overall pain relief as INB, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery.
... Evaluating the pharmacokinetics of INB, Busch et al found that the time of pain onset after single-injection ropivacaine INB was 10 hours. 6 Weber and Jain similarly evaluated the 10 Our study found similar findings with a peak in pain level seen 21 to 24 hours postoperatively in the INB group. Whereas INB was more effective at controlling pain in the first 8 hours postoperatively, there was a trend toward acute rebound pain at the end of POD 0 as the block's effects declined. ...
Hypothesis:
Our hypothesis was that in patients undergoing shoulder arthroplasty, a prospective randomized trial would find no significant differences in average daily pain scores of those treated with interscalene nerve block (INB) vs. local liposomal bupivacaine (LB).
Methods:
Sixty patients undergoing primary shoulder arthroplasty were assessed for eligibility. Study arms included either intraoperative local infiltration of LB (20 mL bupivacaine/20 mL saline) or preoperative INB, with a primary outcome of postoperative average daily visual analog scale scores for 4 days. Secondary outcomes assessed included opioid consumption, length of stay, and complications. Randomization was by a computerized algorithm. Only the observer was blinded to the intervention.
Results:
Three patients were excluded, all before randomization. A total of 57 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups.
Conclusion:
An increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day. After the day of surgery, there were no significant differences found in any variables. These findings suggest that LB provides similar overall pain relief as INB, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery.
... Pain scores after ISB for TSA are low until the block wears off. However, ISB reduces motor strength and typically ISB does not provide sufficient duration of analgesia unless significant systemic opioids are also administered [2]. ...
... Patients were deemed to have responded if they had mild or no shoulder pain on arrival to the PACU (NRS < 3 with shoulder movement) and minimal need for PCA (defined as activation of the PCA no more than four times in the first 24 hours after the operation) [2]. ...
... ISB with bupivacaine and clonidine was associated with pain scores at 24 hours of 6 which were reduced to 3 by addition of perineural dexamethasone [15]-suggesting that perineural additives can reduce pain at 24 hours. Median pain scores with movement after TSA Buprenorphine, Clonidine, Dexamethasone, and Ropivacaine Nerve Blockade were 0 on the POD0, but changed to 3.8 by POD1 AM [2], which further indicates that an effective ISB will dramatically reduce pain with movement after TSA. We anticipated the mean 6 standard deviation (SD) NRS score with movement at 24 hours from end of block administration to be 3.8 6 2.7 in the control group, with this estimate obtained from a previous study [2]. ...
Objective . This study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade.
Design . Prospective, double-blind, randomized controlled trial.
Setting . University-affiliated orthopedic hospital.
Methods . Patients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and “Control”; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); “High Dose”; 0.375% ropivacaine, perineural additives; “Medium Dose”; 0.2% ropivacaine, perineural additives; and “Low Dose”; 0.1% ropivacaine, perineural additives.
Results . Pain with movement at 24 hours was 4.9 ± 2.5 (mean ± standard deviation [SD]) (Control), 4.5 ± 3.0 (High Dose), 3.4 ± 1.8 (Medium Dose), 4.2 ± 2.4 (Low Dose). The difference between Medium Dose and Control was −1.5 (95% CI: −2.9, −0.1) ( P = 0.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9 ± 2.5 vs 4.9 ± 2.7; P = 0.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9 ± 1.4 vs 0 ± 0, P = 0.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (mean ± SD of pre-operative strength: 44.0 ± 20.3%) compared to Control (27.5 ± 24.5%) ( P = 0.031).
Conclusions . For maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.
Introduction:
Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature, however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge versus inpatient SA in a cohort of patients considered higher-risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3.
Methods:
Data from a US-based healthcare system's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018-2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge versus ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism (VTE), and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10.
Results:
The cohort included a total of 1,814 SA patients, of whom 1,005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR]=0.64, one-sided 95% upper bound [UB]=0.89) and overall complications (OR=0.67, 95% UB=1.00). We lacked evidence in support of non-inferiority for 90-day ED visit (OR=0.96, 95% UB=1.18), cardiac event (OR=0.68, 95% UB=1.11), or VTE (OR=0.91, 95% UB=2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis.
Conclusions:
In a cohort of over 1,800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.
Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge (P=.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m2, American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low preoperative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty.
Background
Interscalene nerve block and liposomal bupivacaine have been found to provide adequate pain control following shoulder arthroplasty. We hypothesized that local infiltration of a periarticular cocktail would provide equivalent pain control compared to interscalene nerve block and liposomal bupivacaine.
Methods
Eighty-seven patients undergoing primary shoulder arthroplasty were treated with local infiltration of a periarticular cocktail (200 mg of 0.5% ropivacaine, 1 mg epinephrine, and 30 mg ketorolac), local infiltration of liposomal bupivacaine, or preoperative interscalene nerve block. The outcomes of the study were postoperative visual analog scale scores, opioid consumption, length of stay, and complications.
Results
A total of 30 patients receiving local infiltration of a periarticular cocktail, 26 receiving liposomal bupivacaine, and 31 receiving interscalene nerve block were included in the study. Patients who received local infiltration of a periarticular cocktail had a significantly lower mean visual analog scale when compared to interscalene nerve block and liposomal bupivacaine on postoperative day 0 (2.5 versus 4.0 versus 4.8, P = 0.001 and P < 0.001). Pain scores between postoperative day 0–3 were lower in patients who received local infiltration of a periarticular cocktail, but not significantly. Patients who received local infiltration of a periarticular cocktail required significantly less opioids than the interscalene nerve block group on postoperative day 0 ( P < 0.001).
Discussion
A decrease in early postoperative pain and opioid consumption was found with local infiltration of a periarticular cocktail when compared with interscalene nerve block and liposomal bupivacaine after shoulder arthroplasty. Level of evidence: Level II
