These authors sought to evaluate whether liposomal bupivacaine would provide superior pain relief for shoulder replacement patients over bupivacaine alone. Patients received two anesthetics, a general anesthetic and a block with one of the two bupivacaine formulations.
They found no clinically relevant advantage to the use of liposomal bupivacaine over plain bupivacaine. Complications from the blocks were not reported.
Comment: There is no question that narcotic pain medications place patients at risk for nausea/vomiting, respiratory depression, constipation, falling, urinary retention, and confusion.
While some authors use plexus blocks to minimize narcotics, as shown below, plexus blocks have potentially serious risks as well.
Our practice is to avoid the risks, time and cost of plexus blocks for shoulder arthroplasty. Instead, we employ preoperative education and a multimodal approach including Tylenol, Celebrex and Gabapentin. Assisted motion is started for all anatomic arthroplasties immediately after surgery in the recovery room.
With this "block-less" program 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 ream and run arthroplasty immediately prior to his discharge.
Our reasons for avoiding interscalene 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 (professional and materials) 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:
In a randomized study, these authors compared continuous interscalene block (CIB) with single-shot interscalene block for postoperative control in 76 patients having shoulder arthroplasty.
Pain scores (P = 0.010) and opioid use (P = 0.003) on the first postoperative day were lower in the CIB group, but there was no difference in length of stay. Note that over half of the patients had a length of stay over one day.
Adverse events were more common in the CIB group; 10% of catheters pulled out prematurely. One patient required pacemaker implantation after syncopal episodes that may have been related to inadvertent intravascular injection.The authors point out that with plexus block anesthesia, the potential for serious complication remains and that centers with great experience in regional anesthesia have reported serious complications including pneumothorax and intravascular injection as well as transient and permanent postoperative loss of nerve function.
They conclude that the benefits of CIB may not justify the complication rate and higher costs*.
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?
Our thoughts on interscalene block anesthetics can be viewed here:
Why not just do an interscalene nerve block anesthetic?
and here
How you can support research in shoulder surgery Click on this link.
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
