Monday, July 17, 2017

Continuous interscalene block - is it of value?

Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty

These authors sought to determine whether the introduction of continuous catheter anesthesia was associated with a change in length of stay (LOS), readmission, rates of discharge home without home health or nursing services, or opioid administration. They call attention to the problem of a “rebound” effect witnessed ~20 hours after administration of a single-dose interscalene anesthesia which can delay discharge. During 2012, their center transitioned from ultrasound-guided single-dose interscalene regional anesthesia to combined single-dose anesthesia and additional continuous catheter anesthesia over 48-72hours. They compared these two non-concurrent groups.
1697 patients met their criteria, 41%with single-dose anesthesia and 59%with continuous catheter anesthesia. On univariate analysis the continuous catheter group length of stay (LOS) was 2.2±0.7 day and single-dose group LOS was 2.5±0.8 days (p=<0.001). One day LOS's comprised 1% of the single-dose group and 27% of the continuous catheter group (p<0.001). Anesthesia type remained a significant predictor on multivariate analysis (p<0.001) Readmission at 30 and 90 days (p=0.091 and 0.576), and home discharge (p=0456) were not different. Opioid administration was higher in the continuous catheter group on univariate analysis (p<0.001), but not on multivariate analysis (p=0.607).

They concluded that continuous catheter anesthesia was associated with reduced length of stay when compared to single-dose anesthesia. 

Comment:  In the comparison of two chronological groups (i.e. before and after 2012), factors other than the type of anesthesia (i.e. changes in nursing and surgical care, changes in discharge criteria) may have affected the observed lengths of stay. 
The authors concluded that continuous catheter anesthesia was associated with reduced length of stay – in particular, number of patients discharged within one day of admission increased from 1% to 27%. However the mean difference in the length of stay was only 0.3 days; it would be of interest to balance the incremental cost of continuous catheter anesthesia against this reduction of average length of stay. No cost data were available and thus the authors were not able to determine whether the reduced length of stay offset the increased cost associated with the catheter.
In their discussion of continuous catheter anesthesia the authors point out that many anesthesia providers lack the skill to place the catheter, these patients require substantial monitoring effort, and there is an increased potential for additional complications such as pulmonary complications. Furthermore, catheter migration intrathecally, resulting in death, has been described. 
The authors state that their data set does not include complication rates so the safety of this approach in their hands is not determined.

In our practice, we avoid inter scalene blocks altogether, transitioning our patients to oral medications on the evening of surgery. With this approach we are able to implement immediate postoperative continuous passive motion and active assisted patient-conducted range of motion exercises which are vital to the success of procedures such as the ream and run (see below). 

The 'non-block' approach also reduces the risk of block-related complications, the incremental cost, concerns about 'rebound', additional monitoring and the need for specialized anesthesiologists. Our patients are routinely discharged at 2 days after surgery.

This blog contains many other posts on inter scalene blocks. One of which is reproduced below:

Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay

These authors conducted a retrospective review of 697 patients undergoing upper extremity arthroplasty comparing the rate of complications and incidence of potential barriers to discharge and length of stay of patients receiving continuous vs. single-shot perineural brachial plexus block.

The complication rate was 12% (n=63) for the indwelling group and 17% (n=30) for the single-shot group.

The majority of complications were pulmonary, 72% attributable to oxygen desaturation. The indwelling catheter group had 1.61 times higher odds (95% confidence interval, 1.07-2.42; P = .023) of exhibiting any potential barrier to discharge and exhibited a longer length of stay (P = .002).

Our thoughts on interscalene block anesthetics can be viewed here:

Why not just do an interscalene nerve block anesthetic?

and here

The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence.

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