Multimodal Local Infiltration Analgesia in Total Shoulder Replacement

Abstract

253 ISSN 1758-1869 10.2217/PMT.13.17 © 2013 Future Medicine Ltd Pain Manage. (2013) 3(4), 253–255 Shoulder replacement surgery is associ­ ated with significant postoperative pain. In fact, shoulder surgeries are among the most painful in orthopedics [1]. Interscalene brachial plexus blocks have historically been the mainstay of providing pain relief in arthroscopic and shoulder replacement surgery. Some of the reported advantages of local blocks include high patient com­ fort and satisfaction [2], less postoperative nausea/vomiting [3] and shorter intra­ operative times [3,4] and hospital stays [5,6]. In addition, continuous postopera­ tive infusion of interscalene anesthetic has been shown to be superior to morphine and patient controlled analgesia in controlling postoperative pain [7]. Although effective, interscalene blocks are not without potential complications. Interscalene blocks can be associated with transient sensory neuropathies [8], as well as more serious complications such as pneumothorax and CNS toxicity [9] if not performed by appropriately trained anesthesia staff [4]. As a result, surgeons have looked for other alternatives that provide adequate pain relief and have fewer potential complications. In 2008, Kerr and Kohan reported the effects of a multimodal analgesic mixture, termed local infiltration analgesia (LIA), on postoperative pain following total hip and hip resurfacing arthroplasties [10]. The authors utilized a mixture of ropivocaine HCl (2.0 mg/ml mixed with 30 mg ketorolac 10 μg/ml adrenaline, for a mixture of 150–200 ml). In their study of 325 patients, they reported that two­thirds of patients did not require narcotics postoperatively. Their multimodal mixture of ropivocaine, ketorolac and epinephrine had a favorable side effect profile as no serious side effects were reported. Mild side effects included orthostatic hypotension in 9% of knee surgery patients. Kerr and Kohan’s noteworthy results with LIA have led to greater adoption of the therapy in hip and knee replacement surgery with various groups also reporting decreased postoperative pain [11,12]. Similarly, a 2010 study by Essving et al. found a significant reduction in postoperative morphine consumption in the LIA group compared with the control (18 mg vs 87 mg, respectively) as well as higher patient satisfaction than the control group [13].