Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty.

Abstract

Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8±36.1 MMEs vs. 60.9±42.1 MMEs, P=.01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6±1.8 vs. 3.3±3.0, P=.06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9±3.1 hours vs. 4.6±2.7 hours, P=.008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3±26.8 vs. 38.5±27.8, P=.01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P=.16) and sleep management (82.1% vs. 76.8%, P=.48). There was no difference in the length of inpatient stay (32.2±14.8 hours vs. 34.1±12.8 hours, P=.44). In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.