Outpatient Shoulder Surgery Research Articles

Optimizing Outpatient Shoulder Surgery: A Review of Anesthetic Options.

With the recent trends toward outpatient shoulder surgery, standardized protocols for perioperative analgesia are critical for reducing length of stay and optimizing outcomes. There are a variety of described anesthetic and analgesic options for shoulder surgery, and the literature is variable regarding optimal choice as patient, provider, and institutional factors often play a role. With general anesthesia alone becoming less utilized, regional methods require critical examination. Knowledge of the differing, and novel, regional anesthetic procedures in conjunction with recent orthopaedic and anesthetic literature is imperative to providing patients with optimal and efficient care.

Surgeon-administered intraoperative brachial plexus block for open shoulder surgery - a novel and safe technique.

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials.

This systematic review aimed to compare the analgesic effectiveness and complications rates for anterior suprascapular nerve blocks (ASSB) compared to interscalene brachial plexus blocks (ISB) for arthroscopic and outpatient shoulder surgery. Only randomized controlled trials (RCTs) comparing the ASSB versus ISB in the context of arthroscopic shoulder surgery were eligible for inclusion. The primary outcomes included pain scores (Numeric Rating Scale of 0 to 10) up to 24h postoperatively and analgesic consumption. Secondary outcomes included block complications. Meta-analysis was performed using random-effects modeling and result certainty was determined using the GRADEpro tool. Six RCTs (709 patients) were included for analysis. ISB displayed a statistically significant reduction in pain scores by 0.40 (95%CI = 0.36 to 0.45; p < 0.00001) but not morphine equivalent consumption (mean difference = 0.74mg; 95%CI = -0.18 to 1.66mg; I2 = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24h were not significantly different. There was no difference in respiratory events postblock. ASSB demonstrated a significantly lower incidence of Horner's syndrome (relative risk (RR) = 0.17; 95%CI = 0.08 to 0.39; p < 0.00001; high certainty), voice hoarseness (RR = 0.24; 95%CI = 0.10 to 0.57; p < 0.00001; high certainty) and impaired respiratory function (p < 0.00001). The ASSB could be considered an appropriate analgesic option for arthroscopic shoulder surgery with potentially fewer complications than the ISB.

The impact of chronic steroid use on early postoperative complications in shoulder surgery

ABSTRACT Objectives Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications. Results We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51–3.21], p < 0.001), minor (OR 2.32[1.13–3.2], p < 0.001), and infectious complications (OR 1.90[1.13–3.2], p = 0.01). Conclusions Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.

ANALGESIC EFFECTIVENESS OF CONTINUOUS INTERSCALENE CATHETER USE FOR AMBULATORY SHOULDER SURGERY IN PEDIATRIC AND ADOLESCENT PATIENTS

BACKGROUND Continuous interscalene catheters are utilized for inpatient and outpatient postoperative pain control after shoulder surgery. Although prior studies have primarily been limited to adult populations, benefits of peripheral nerve catheters in ambulatory surgical centers have been shown to reduce post operative pain scores, opioid requirements, and post operative nausea. However, their use in a solely pediatric ambulatory setting has not been investigated. The purpose of this study was to retrospectively review the adverse events, analgesic effectiveness, and opioid use after continuous interscalene catheters for ambulatory shoulder surgery in pediatric and adolescent patients. METHODS A retrospective review was performed of 15 pediatric and adolescent patients (4 female, 11 male), mean age 16 years (range, 12-18 years), and mean weight 78.3 kg (range 53-130 kg), who underwent ultrasound-guided interscalene catheter placement for outpatient shoulder surgery from April 2017 through May 2018. All but one surgery were performed at a dedicated pediatric ambulatory surgery center. Catheters were initially dosed with 0.5% ropivacaine (n = 13) or 0.2% ropivacaine (n = 2) at volumes of 0.1-0.2ml/kg (total, 6-20 ml). By the conclusion of surgery, all catheters were continuously infusing 0.2% ropivacaine at 3-6ml/hr with the majority (n = 10) at 4ml/hr via elastomeric pumps. Time for catheter placement, intraoperative and postoperative intravenous opioids, post-anesthesia recovery unit (PACU) length of stay (LOS), PACU maximum pain scores and rescue medications for post-operative nausea and vomiting (PONV) were recorded. After discharge, all patients received multimodal analgesia (ibuprofen, acetaminophen, and rescue oxycodone). Patients were assessed on postoperative days (POD) 1-3 for numerical rating pain scores (0-10) at rest and with movement, supplemental oxycodone use in the past 24 hours, satisfaction, and adverse effects of treatment. RESULTS Catheter placement was 100% successful; no procedure had to be aborted during placement because of inability to place catheter. The average time for catheter placement was 11.8 minutes (range, 3-19 minutes). There were 3 adverse events, including one accidental catheter removal in PACU, one dressing failure requiring removal of catheter on POD 2, and one case of Horner’s Syndrome. There were no signs of infection, local anesthetic toxicity, or shortness of breath described in any patients. Short acting opioids (Alfentanil and Fentanyl) were used intraoperatively in all but 2 patients, with average dose of 8.5mcg/kg Alfentanil and 0.7mcg/kg Fentanyl. Two patients received long-acting opioids intraoperatively. The mean PACU maximum pain score was 1.4 (range, 0-9). Only 3 patients received rescue intravenous morphine in the PACU with a mean dose of 0.035mg/kg. Mean PACU LOS was 112 minutes (range, 85 – 210 minutes). No patients required any rescue PONV medications in the PACU. Mean pain scores for POD 1- 3 at rest were 2.1, 2.3, and 2.6, respectively; scores with movement were 3.6, 3, and 4.4, respectively. Mean doses (i.e., times of administration) of oxycodone on POD 1-3 respectively were 1.5, 1.3 and 0.5 (range 0-5 doses). All but one patient was very satisfied and would have the catheter placed again. CONCLUSIONS Outpatient use of continuous interscalene catheters in pediatric and adolescent patients provides excellent intraoperative and early postoperative analgesia during and following shoulder surgery. Their routine use should be considered as they minimize perioperative opioid use with minimal adverse events, adding only small delay to surgical time.

Safety of Outpatient Shoulder Surgery at a Freestanding Ambulatory Surgery Center in Patients Aged 65 Years and Older: A Review of 640 Cases

Introduction:With increasing utilization of surgery centers, it is important to demonstrate the safety of outpatient shoulder surgery in freestanding ambulatory surgery centers. No studies have specifically looked at the Medicare-age population and the rate of outpatient shoulder procedure complications in these patients at an ambulatory surgery center.Methods:Six hundred forty patients were included in our study between 2000 and 2015. The incidence of major complications was identified, including acute infection requiring intravenous antibiotics or irrigation and débridement, postoperative transfer to a hospital, wrong-site surgical procedures, retention of a foreign object, postoperative symptomatic thromboembolism, medication errors, and bleeding/wound complications.Results:There was a total of seven occurrence reports in seven patients, for a reported adverse event rate of 1.01%.Conclusions:Our findings are consistent with currently reported outpatient hospital-based data and illustrate the safety of outpatient shoulder procedures at a freestanding ambulatory surgery center in Medicare-age patients.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits

Background: In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills. Purpose: To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution. Study Design: Case series; Level of evidence, 4. Methods: In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication. Results: For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal. Conclusion: Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR). We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored. Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P= .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initialARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P<.001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001). We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery. Level III, retrospective comparative study.

IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial.

Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery. Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated. Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P < 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P < 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade. Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.

Peripheral nerve blocks for outpatient surgery

There has been an increasing use of peripheral nerve blocks (PNBs) in ambulatory surgery. Several recent reports have contributed to our understanding of the optimal PNB technique for specific surgical procedures in this setting. In this review, we have summarized the available literature on indications of PNBs for outpatient surgery of the upper extremity. Although many of the recent studies focus on technical aspects of PNBs, few center on evidence-based indications or their utility in the ambulatory setting. The available literature suggests that although multiple techniques have been reported for outpatient shoulder surgery, interscalene brachial plexus block (ISBPB) is currently the most preferred technique. Supraclavicular, infraclavicular, and axillary brachial plexus blocks, however, are all commonly used and effective PNBs for outpatient surgery and analgesia of the arm, forearm, and hand. ISBPB is currently the most beneficial PNB for outpatient shoulder surgery. Supraclavicular block functionally can be considered an alternative to the traditional ISBPB; however, additional studies are required before routine use can be recommended. Although the review identified several reports with benefits of one PNB technique over the others, the existing literature suggests that many of these techniques may be interchangeable with regards to procedures of the distal upper extremity. Future studies are indicated to help standardize the techniques, selection, and postoperative management of PNBs for specific surgical indications.

Severe hypotension after interscalene block for outpatient shoulder surgery: a case report

The case of a 43 year-old woman who underwent successful right interscalene brachial plexus block for arthroscopic shoulder surgery is presented. During the surgery, she subsequently exhibited signs of neuraxial spread of local anesthetic. Bilateral motor block was noted postoperatively. Spontaneous ventilation was maintained throughout the case, and she was successfully discharged home several hours after the procedure with no residual symptoms.

This Month in Anesthesiology

This Month in Anesthesiology

Interscalene Block Superior to General Anesthesia

Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts. scott.reuben@bhs.orgI read with interest the article by Hadzic et al. 1about the use of interscalene block compared with general anesthesia for outpatient rotator cuff surgery. Although I agree that there are advantages to using nerve block anesthesia for outpatient shoulder surgery, I believe the comparator group receiving general anesthesia in the current Clinical Investigation1was a recipe for failure. I am not surprised by the 16% hospital admission rate for refractory pain observed in those patients receiving general anesthesia. I would hope with our current understanding of the pathophysiology of acute pain that we as anesthesiologists will offer our patients more effective perioperative analgesic techniques. I was surprised that the current clinical investigation failed to use nonopioid analgesics, including nonsteroidal antiinflammatory drugs, in a multimodal approach to perioperative pain management as outlined by the recent American Society of Anesthesiologists Practice Guidelines for acute pain management in the perioperative setting state.2A more aggressive preventive multimodal pharmacologic approach3including the use of nonsteroidal antiinflammatory drugs, acetaminophen, intraarticular local anesthetics, opioids, and α2agonists and postoperative cold therapy may have resulted in a less dramatic benefit compared with interscalene block. Failure to do so may result in inadequate analgesia for our patients, as demonstrated in the current study by Hadzic et al. 1Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts. scott.reuben@bhs.org

The effectiveness of an anesthetic continuous-infusion device on postoperative pain control

Purpose: To evaluate the effectiveness of an anesthetic continuous-infusion device on postoperative pain after outpatient shoulder surgery. Type of Study: Double-blinded randomized trial. Methods: A prospective, double-blinded, randomized study of 50 consecutive patients undergoing outpatient arthroscopic shoulder surgery was performed. Patients were assigned by computer-generated randomized permuted block of four to 2 groups (25 each) receiving either a saline or 0.5% bupivacaine solution via an infusion pump after surgery. All patients gave informed consent and were randomized immediately before surgery. The surgical team, patient, clinic staff, and data collector were blinded to the randomization. Procedures performed included arthroscopic rotator cuff repairs, SLAP lesion repairs, subacromial decompressions, and capsular reefings. The infusion pump that was tested was used continuously for 48 hours and administered 2 mL each hour. For subacromial and rotator cuff surgery, the catheter was placed in the subacromial space. For glenohumeral surgery, the catheter was placed in the glenohumeral joint. Routine pain-control efforts were continued. Interviews were conducted at 1, 2, and 8 hours after surgery, followed by daily telephone interviews for 1 week. Visual analog scale (VAS), categorical pain scale (Likert) data, and oral medication use data were recorded. Results: Complete data sets were collected from 25 bupivacaine and 24 saline patients because 1 pump malfunctioned and was removed early. The average age of the bupivacaine group patients was 47.4 ± 16.3 years (range, 16 to 84); patients in the saline group had an average age of 46.0 ± 15.5 years (range, 19 to 73). There were 17 men and 8 women in the bupivacaine group and 16 men and 8 women in the saline group. The Likert and VAS mean values showed lower pain scores for the patients using the pump containing bupivacaine than for the saline group at all recorded times ( P < .05) throughout the 7 days of data collection. The interval of greatest pain was on day 2. Postoperative oral medication use was always greater for the saline group than for those receiving bupivacaine. Conclusions: Postoperative pain control after arthroscopic shoulder surgery is essential so that these procedures can be successfully carried out in an outpatient setting. The first 2 postoperative days is the period of greatest pain. Continuous postoperative bupivacaine infusion is effective during this critical period, and the effect lingers even after the infusion is discontinued. The administration of bupivacaine via a continuous-infusion anesthetic pump statistically reduced postoperative pain after outpatient arthroscopic rotator cuff repairs, SLAP lesion repairs, subacromial decompressions, and capsular reefings.

A Comparison of 0.5% Bupivacaine, 0.5% Ropivacaine, and 0.75% Ropivacaine for Interscalene Brachial Plexus Block

The onset time and duration of action of ropivacaine during an interscalene block are not known.The potentially improved safety profile of ropivacaine may allow the use of higher concentrations to try and speed onset time. We compared bupivacaine and ropivacaine to determine the optimal long-acting local anesthetic and concentration for interscalene brachial plexus block. Seventy-five adult patients scheduled for outpatient shoulder surgery under interscalene block were entered into this double-blind, randomized study. Patients were assigned (n = 25 per group) to receive an interscalene block using 30 mL of 0.5% bupivacaine, 0.5% ropivacaine, or 0.75% ropivacaine. All solutions contained fresh epinephrine in a 1:400,000 concentration. At 1-min intervals after local anesthetic injection, patients were assessed to determine loss of shoulder abduction and loss of pinprick in the C5-6 dermatomes. Before discharge, patients were asked to document the time of first oral narcotic use, when incisional discomfort began, and when full sensation returned to the shoulder. The mean onset time of both motor and sensory blockade was <6 min in all groups. Duration of sensory blockade was similar in all groups as defined by the three recovery measures. We conclude that there is no clinically important difference in times to onset and recovery of interscalene block for bupivacaine 0.5%, ropivacaine 0.5%, and ropivacaine 0.75% when injected in equal volumes. Implications: In this study, we demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 0.75% fails to improve the onset or duration of interscalene brachial plexus block. (Anesth Analg 1998;87:1316-9)