These authors compared two methods of pain management after shoulder arthroplasty, noting that the often advocated interscalene block can be associated with technical problems with administration that could lead to inadequate pain control, failure of nerve blockade, residual neurapraxia, displacement of the catheter postoperatively, systemic toxicity, and respiratory and neurologic complications.
Liposomal bupivacaine (Exparel) is a long-acting, local anesthetic for single-dose infiltration into the surgical site. It is manufactured by Pacira Pharmaceuticals who sponsored this study comparing Exparel combined with a single bolus interscalene block to a continuous interscalene nerve block.
The costs associated with the single bolus interscalene nerve block and continuous interscalene nerve block were $1532 and $1850, respectively. In addition to procedure costs, the use of an infusion pump can cost up to $300. The cost of Exparel at that institution was $315.
These authors point out that although they can be effective at decreasing opioid requirements, "peripheral nerve blocks expose the patient to an additional procedure with associated complications. Interscalene blocks have been associated with cardiovascular instability (ie, bradycardia and hypotension) in up to 29% of patients operated on in a beach chair position. Neurologic complications, including persistent neurologic pain, dysesthesia down the arm, postoperative paralysis, perineural entrapment of the catheter, vocal cord paralysis, and hemidiaphragmatic paralysis from phrenic nerve palsy, have also been described. Finally, there is a significant cost to regional management of pain" and that "liposomal bupivacaine has previously been shown to provide a cost savings compared with nerve blocks ranging from $1300 to $1600 per case"
Visual analog scale pain scores were statistically higher in the liposomal bupivacaine cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the liposomal bupivacaine cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000).
The two groups had equivalent narcotic use, pain scores, and time to first narcotic rescue within the first 24 hours (P > .05).
The costs associated with the single bolus interscalene nerve block and continuous interscalene nerve block were $1532 and $1850, respectively. In addition to procedure costs, the use of an infusion pump can cost up to $300. The cost of Exparel at that institution was $315.
Comment: In our practice pain management after shoulder arthroplasty is critical, because we implement immediate postoperative range of motion exercises and continuous passive motion starting in the PACU. In our hands the most effective approach involves neither inter scalene blocks or Exparel, but rather patient controlled analgesia for the afternoon of surgery and then transition to oral analgesics that evening. In this manner rebound in pain is avoided, motion is facilitated, complications are avoided, and patients are routinely ready for discharge on the second postoperative morning.
Our method of pain management is routinely successful for patients having the ream and run procedure, CTA arthroplasty, and total shoulder arthroplasty, enabling patients to successfully establish their self-assisted range of motion on the first postoperative day as shown by the two examples below.
At our institution, we are cost aware. Coincidentally, we just received this email: "Just an update on the plan to try to curtail the exploding Exparel costs at the Medical Center. The $315 per dose for Exparel is unreimbursed by most insurers at present."
Readers may also wish to review: Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial
These authors point out that although they can be effective at decreasing opioid requirements, "peripheral nerve blocks expose the patient to an additional procedure with associated complications. Interscalene blocks have been associated with cardiovascular instability (ie, bradycardia and hypotension) in up to 29% of patients operated on in a beach chair position. Neurologic complications, including persistent neurologic pain, dysesthesia down the arm, postoperative paralysis, perineural entrapment of the catheter, vocal cord paralysis, and hemidiaphragmatic paralysis from phrenic nerve palsy, have also been described. Finally, there is a significant cost to regional management of pain" and that "liposomal bupivacaine has previously been shown to provide a cost savings compared with nerve blocks ranging from $1300 to $1600 per case"
They compared the use of liposomal bupivacaine (Exparel) to an indwelling inter scalene nerve block in 83 shoulder arthroplasty patients: 36 patients received liposomal bupivacaine and a “bridge” of 30 mL of 0.5% bupivacaine, and 47 patients received an ndwelling inter scalene nerve block.
Visual analog scale pain scores were statistically higher in the liposomal bupivacaine cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the liposomal bupivacaine cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000).
The lengths of stay were comparable:
While both methods appear to be effective in the PACU and for post operative day 0, both were associated with an increase in the need for opiates on post operative day 1, indicating rebound pain which needed management.
===
The reader may also be interested in these posts:
Information about shoulder exercises can be found at this link.
Use the "Search" box to the right to find other topics of interest to you.
You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'See from which cities our patients come.
