Paper #27 - Liposomal marcaine combined with intravenous decadron results in decreased length of hospital stay and decreased narcotic use after elective shoulder arthroplasty

Abstract

Background: The medical consequences of using narcotic pain medication for postoperative pain after shoulder arthroplasty are well documented. Alternatives to narcotics have been developed to manage postoperative pain. The purpose of this study was to evaluate length of hospitalization, narcotic use, and visual analog scale (VAS) pain scores of patients undergoing elective shoulder arthroplasty before and after a change in a perioperative multimodal pain medication protocol that included adding liposomal Marcaine (Exparel) and intravenous dexamethasone (Decadron). Materials and Methods: We performed this retrospective review of two consecutive cohorts of patients undergoing elective shoulder arthroplasty by a single surgeon. Cohort 1 consisted of 24 consecutive patients who underwent surgery in 2013 and received perioperative multimodal management comprising preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, and acetaminophen and single-shot interscalene block. Cohort 2 consisted of 31 consecutive patients who underwent surgery in 2014 and received perioperative multimodal management identical to cohort 1 with the exception of the addition of 8 to 10 mg of intravenous Decadron given intraoperatively after skin incision and liposomal Marcaine injected with a consistent technique at the time of surgery. Patients using preoperative narcotics were analyzed together and separately from patients who were not using preoperative narcotics. Postoperative length of hospitalization, narcotics requirement, and VAS pain scores during hospitalization were measured. Results: Cohort 1 had higher median VASs on postoperative days 0 and 1 (6.5 and 7.5, respectively) than cohort 2 (3.5 and 3.5, respectively) (P < .001 for both). Cohort 1 required more median narcotic medication postoperatively on day 1 and days 0 and 1 cumulatively (21.0 mg and 30.5 mg, respectively) than cohort 2 (10.0 mg and 17.5 mg, respectively) (P < .001 and P = .001, respectively). Median length of hospitalization was 2 days for cohort 1 and 1 day for cohort 2 (P < .001). When the patients who were using preoperative narcotics (29% overall) were evaluated separately, VAS pain was higher on postoperative day 1 for cohort 1 than cohort 2 (7.0 versus 3.5; P = .006), cumulative narcotics requirement during hospitalization was much less in cohort 2 (20 mg) than cohort 1 (58.5 mg; P = .027), and length of hospitalization also was less in cohort 2 (1 day) than cohort 1 (2 days; P = .052). Conclusion: The addition of intraoperative intravenous Decadron and the intraoperative use of Exparel with a consistent injection technique to a multimodal pain program for elective shoulder arthroplasty resulted in a decreased length of hospitalization, VAS pain, and narcotic requirement. These findings were similar for patients using and not using preoperative narcotics. Level of Evidence: Level III. Retrospective Cohort Study.