Saturday, March 17, 2018

Pain management and shoulder joint replacement

Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study

These authors compared the pain scores, opioid use, and length of stay for shoulder arthroplasty patients receiving either a standard opioid-based regimen or a multimodal analgesia regimen.

Patients treated with the multimodal analgesia regimen had lower postoperative day 0 pain scores and  lower opioid use on all days: 47% lower on postoperative day 0, 37% on day 1, and 44% on day 2 (all P < .01). The length of inpatient stay was significantly shorter for multimodal patients than for patients treated with the standard regimen (1.44 days vs 1.91 days, P < .01). There was no difference in the rate of 30- or 90-day emergency department visits or readmission.

Comment: Narcotic pain medications place patients at risk for nausea/vomiting, respiratory depression, constipation, falling, urinary retention, and confusion. Multimodal analgesia appears to be effective in reducing the amount of opioid medication patients receive after shoulder arthroplasty.

We employ a multimodal approach very similar to that presented here; however we avoid the inconvenience, cost and complications of an interscalene brachial plexus block. Without a block our patients have minimal difficulty in starting their immediate postoperative range of motion exercises as is shown here for a 63 year old man on the morning after his total shoulder arthroplasty.

Our reasons for avoiding interscaline blocks for shoulder arthroplasty include (1) desire for documentation of neurological status immediately after surgery, (2) wanting to avoid having a flail unprotected arm as we start immediate postoperative motion exercises, (3) eliminating the risk of block-related neurologic or pulmonary complications, (4) avoiding phrenic nerve paresis with the attendant respiratory compromise, (5) eliminating the inconvenience of a failed block, (6) reducing the cost associated with two different anesthetics (block + general), (7) avoiding the problem of acute rebound pain in the middle of the first postoperative night, and (8) the reluctance of some patients to have a needle placed in their neck.

Here is a bit more discussion regarding the issues with blocks:

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.

The reader may also be interested in these posts:

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