1
|
Lorentz S, Levin JM, Warren E, Hurley ET, Mills FB, Crook BS, Poehlein E, Green CL, Bullock WM, Gadsden JC, Klifto CS, Anakwenze O. Single-shot interscalene block with liposomal bupivacaine vs. non-liposomal bupivacaine in shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00499-3. [PMID: 39033958 DOI: 10.1016/j.jse.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB. METHODS This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use. RESULTS Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P > .05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P < .05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale-11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P = .57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P = .33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P > .05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P > .05). CONCLUSION LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.
Collapse
Affiliation(s)
- Samuel Lorentz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Eric Warren
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Frederic B Mills
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Bryan S Crook
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | | | - Jeff C Gadsden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| |
Collapse
|
2
|
Sudah S, Menendez M, Jawa A, Levy J, Denard P. Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty. Orthop Rev (Pavia) 2023; 15:38653. [PMID: 36843859 PMCID: PMC9946799 DOI: 10.52965/001c.38653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
Background There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts. Objective The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States. Methods The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as "substantial" variation. Geographic maps were created for visual representation of the data. Results There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West). Conclusions There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.
Collapse
Affiliation(s)
| | | | - Andrew Jawa
- Orthopedic Surgery New England Baptist Hospital
| | | | - Patrick Denard
- Orthopedic Surgery Oregon Shoulder Institute at Southern Oregon Orthopedics
| |
Collapse
|
3
|
Lee R, Lee D, Ramamurti P, Fassihi S, Heyer JH, Stadecker M, Webber M, Hughes A, Pandarinath R. Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures. Eur J Trauma Emerg Surg 2022; 48:4569-4576. [PMID: 34050773 PMCID: PMC8164052 DOI: 10.1007/s00068-021-01704-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/13/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs. METHODS A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018-these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts. RESULTS Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579). CONCLUSION With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.
Collapse
Affiliation(s)
- Ryan Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University in Washington, 2300 M St, Washington, DC 20037 USA
| | - Danny Lee
- Department of Orthopaedic Surgery, University of Miami-Jackson Memorial Health System in Miami, Miami, FL USA
| | - Pradip Ramamurti
- The George Washington University School of Medicine and Health Sciences, The George Washington University in Washington, 2300 M St, Washington, DC 20037 USA
| | - Safa Fassihi
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Jessica H. Heyer
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Monica Stadecker
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Michael Webber
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Alice Hughes
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| | - Rajeev Pandarinath
- Department of Orthopaedic Surgery, The George Washington University Hospital in Washington, Washington, DC USA
| |
Collapse
|
4
|
Goltz DE, Burnett RA, Levin JM, Helmkamp JK, Wickman JR, Hinton ZW, Howell CB, Green CL, Simmons JA, Nicholson GP, Verma NN, Lassiter TE, Anakwenze OA, Garrigues GE, Klifto CS. A validated preoperative risk prediction tool for extended inpatient length of stay following anatomic or reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2022; 32:1032-1042. [PMID: 36400342 DOI: 10.1016/j.jse.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/08/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent work has shown inpatient length of stay (LOS) following shoulder arthroplasty to hold the second strongest association with overall cost (after implant cost itself). In particular, a preoperative understanding for the patients at risk of extended inpatient stays (≥3 days) can allow for counseling, optimization, and anticipating postoperative adverse events. METHODS A multicenter retrospective review was performed of 5410 anatomic (52%) and reverse (48%) total shoulder arthroplasties done at 2 large, tertiary referral health systems. The primary outcome was extended inpatient LOS of at least 3 days, and over 40 preoperative sociodemographic and comorbidity factors were tested for their predictive ability in a multivariable logistic regression model based on the patient cohort from institution 1 (derivation, N = 1773). External validation was performed using the patient cohort from institution 2 (validation, N = 3637), including area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values. RESULTS A total of 814 patients, including 318 patients (18%) in the derivation cohort and 496 patients (14%) in the validation cohort, experienced an extended inpatient LOS of at least 3 days. Four hundred forty-five (55%) were discharged to a skilled nursing or rehabilitation facility. Following parameter selection, a multivariable logistic regression model based on the derivation cohort (institution 1) demonstrated excellent preliminary accuracy (AUC: 0.826), with minimal decrease in accuracy under external validation when tested against the patients from institution 2 (AUC: 0.816). The predictive model was composed of only preoperative factors, in descending predictive importance as follows: age, marital status, fracture case, ASA (American Society of Anesthesiologists) score, paralysis, electrolyte disorder, body mass index, gender, neurologic disease, coagulation deficiency, diabetes, chronic pulmonary disease, peripheral vascular disease, alcohol dependence, psychoses, smoking status, and revision case. CONCLUSION A freely-available, preoperative online clinical decision tool for extended inpatient LOS (≥ 3 days) after shoulder arthroplasty reaches excellent predictive accuracy under external validation. As a result, this tool merits consideration for clinical implementation, as many risk factors are potentially modifiable as part of a preoperative optimization strategy.
Collapse
Affiliation(s)
- Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joshua K Helmkamp
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John R Wickman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Zoe W Hinton
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Claire B Howell
- Performance Services, Duke University Medical Center, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - J Alan Simmons
- Rush Research Core, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Tally E Lassiter
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
5
|
Testa EJ, Lemme NJ, Li LT, DeFroda S. Trends in operative duration of total shoulder arthroplasty from 2008 to 2018: a national database study. Shoulder Elbow 2022; 14:534-543. [PMID: 36199510 PMCID: PMC9527484 DOI: 10.1177/17585732211008900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 01/17/2023]
Abstract
Background As total shoulder arthroplasty has emerged as the fastest growing joint replacement performed, optimizing surgical efficiency and patient outcomes is essential. The goals of the current study were to identify trends and factors affecting the operative time of total shoulder arthroplasty over a 10-year period. Methods The National Surgical Quality Improvement Program database was analyzed to determine the operative time and 30-day complications of total shoulder arthroplasty from 2008 to 2018. Factors affecting total shoulder arthroplasty operative time were also assessed. Multivariable linear regression was used to analyze operative time over years studied while controlling for patient demographics and comorbidities. Results A total of 20,587 total shoulder arthroplasty cases from 2008 to 2018 were included. Mean operative time in 2008 was 139.0 min, while in 2018, mean operative time decreased to 105.6 min (P < .001). Male sex, outpatient surgery, increased body mass index, and low preoperative hematocrit were associated with longer operative times, while elevated international normalized ratio, resident involvement, and elective surgeries were associated with decreased operative duration. Discussion Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. Patient factors and comorbidities are associated with operative time, and such factors are important to consider in operative planning to ensure appropriate patient and surgeon expectations.
Collapse
Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Lambert T Li
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Steven DeFroda
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| |
Collapse
|
6
|
Wang CT, Zhu LM, Wu JL, Kang FF, Lin ZJ. Application of Dexmedetomidine Sedation Combined With Suprascapular Nerve Block and Axillary Nerve Block in Shoulder Arthroscopy, A Randomized Single-Blind Study. Front Pharmacol 2021; 12:740385. [PMID: 34987386 PMCID: PMC8721275 DOI: 10.3389/fphar.2021.740385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of the present study was to evaluate the anesthetic and analgesic effects of dexmedetomidine combined with suprascapular nerve block and axillary nerve block in shoulder arthroscopy.Methods: A total of 60 patients were randomly divided into the experimental group (DEX group) and the control group (GA group) via a random number table method. Dexmedetomidine sedation combined with suprascapular nerve block and axillary nerve block was used in the DEX group, while general anesthesia with tracheal intubation combined with interscalene brachial plexus block was used in the GA group. The perioperative indexes, intraoperative hemodynamics, cerebral oxygen saturation, and postoperative pain score, as well as any complications, were compared between the two groups.Results: The anesthesia duration (p < 0.05) and postoperative monitoring time (p < 0.05) in the DEX group were significantly shorter than those in the GA group. At most time points during the anesthesia, the cerebral oxygen saturation (p < 0.05) and mean arterial pressure (p < 0.05) in the DEX group were significantly higher than those in the GA group. Additionally, the decrease in the cerebral oxygen saturation and mean arterial pressure in the GA group was significantly higher than that in the DEX group (p < 0.05). The pain score of DEX group 12 h after operation significantly lower than that in the GA group (p < 0.05), and the incidence of postoperative hypoxemia along with nausea and vomiting in the GA group was significantly higher than that in the DEX group (p < 0.05).Conclusion: Dexmedetomidine combined with suprascapular nerve block and axillary nerve block could reduce the incidence of hypoxemia, while the approach demonstrated better hemodynamic stability, fully ensured the cerebral blood perfusion, and exhibited better anesthetic and analgesic effects, meaning it could be safely and effectively applied in shoulder arthroscopy procedures.
Collapse
Affiliation(s)
- Chu-Ting Wang
- Department of Anesthesiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Liang-Ming Zhu
- Department of Emergency, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ji-Ling Wu
- Department of Anesthesiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Fen-Fen Kang
- Department of Anesthesiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Zhi-Jian Lin
- Department of Anesthesiology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
- *Correspondence: Zhi-Jian Lin,
| |
Collapse
|
7
|
Boin MA, Mehta D, Dankert J, Umeh UO, Zuckerman JD, Virk MS. Anesthesia in Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev 2021; 9:01874474-202111000-00001. [PMID: 34757963 DOI: 10.2106/jbjs.rvw.21.00115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. » Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. » There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. » Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. » Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.
Collapse
|
8
|
Ramesh K, Yusuf M, Makaram N, Milton R, Mathew A, Srinivasan M. Safety and Cost-Effectiveness of Interscalene Brachial Plexus Block With Sedation in Reverse Total Shoulder Replacement. Cureus 2021; 13:e14106. [PMID: 33907646 PMCID: PMC8067774 DOI: 10.7759/cureus.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Patients and methods This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59-82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2-4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results The mean (range) duration of anaesthesia was 38.66 (20-60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130-210 and 75-145 mmHg, respectively (mean [range] drop, 74.13 [33-125] mmHg). Mean (range) propofol dose was 1.74 (1-3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20-50) min. The mean (range) postoperative recovery score (local scale, range 5-28 where lower values are superior) was 5.2 (5-8). The mean (range) length of stay was 8 (1-20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions Our data demonstrate that rTSA under ISB-RA is safe, comfortable, and cost-effective. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours. Clinical relevance rTSA under ISB-RA is potentially a safe, cost-effective, and viable alternative for patients with multiple comorbidities.
Collapse
Affiliation(s)
- Kiran Ramesh
- Orthopedics and Traumatology, Wirral Teaching Hospitals NHS Trust, Wirral, GBR
| | - Muhammad Yusuf
- Orthopedics and Traumatology, Pennine Acute Hospitals NHS Trust, Manchester, GBR
| | - Navnit Makaram
- Orthopedics and Traumatology, Royal Infirmary of Edinburgh, Edinburgh, GBR
| | - Ross Milton
- Anaesthesiology, Lancashire Teaching Hospitals NHS Trust, Preston, GBR
| | - Aji Mathew
- Anaesthesia, East Lancashire Hospitals NHS Trust, Blackburn, GBR
| | - Makaram Srinivasan
- Orthopedics and Traumatology, East Lancashire Hospitals NHS Trust, Blackburn, GBR
| |
Collapse
|
9
|
Johnston DF, Turbitt LR. Defining success in regional anaesthesia. Anaesthesia 2021; 76 Suppl 1:40-52. [PMID: 33426663 DOI: 10.1111/anae.15275] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.
Collapse
Affiliation(s)
- D F Johnston
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - L R Turbitt
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| |
Collapse
|
10
|
A National Registry Analysis of the Association of Perioperative Regional Anesthesia with hospital length of stay following open reduction and internal fixation of the ankle. J Clin Anesth 2020; 67:110008. [PMID: 32829110 DOI: 10.1016/j.jclinane.2020.110008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVES To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay. DESIGN Multicenter retrospective cohort study. SETTING Inpatient perioperative. PATIENTS 12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control. INTERVENTIONS Regional Anesthesia for postoperative pain control. MEASUREMENTS Hospital length of stay along with multiple covariates. MAIN RESULTS The median [quartiles] hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day [0, 2 days] and 0 days [0, 1 day], respectively (p < 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03-1.14, p = 0.002). Using 1:2 propensity score matching, the median [quartiles] hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days [0, 1 day] (range = 0-56 days) and 0 day [0, 1 day] (range = 0-33 days), respectively (p = 0.013). CONCLUSION The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF.
Collapse
|
11
|
Chan JJ, Cirino CM, Vargas L, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Cagle PJ. Peripheral nerve block use in inpatient and outpatient shoulder arthroplasty: a population-based study evaluating utilization and outcomes. Reg Anesth Pain Med 2020; 45:818-825. [DOI: 10.1136/rapm-2020-101522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
BackgroundPeripheral nerve block (PNB) is an effective pain management option after shoulder arthroplasty with increasing popularity over the past decade. Large-scale US data in shoulder arthroplasties are lacking, especially regarding impacts on opioid utilization. This population-based study aimed to evaluate PNB utilization patterns and their effect on outcomes after inpatient and outpatient shoulder arthroplasty.MethodsThis retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006–2016). This study includes n=94 787 and n=3293 inpatient and outpatient (total, reverse and partial) shoulder arthroplasty procedures. Multivariable mixed-effects models estimated associations between PNB use and opioid utilization in oral morphine equivalents and cost of hospitalization/stay. For the inpatient group, additional outcome measures were length of stay (LOS), admission to a skilled nurse facility, 30-day readmission, combined complications and naloxone use (as a proxy for opioid-related complications). We report OR (or % change for continuous variables) and 95% CIs.ResultsOverall, PNB was used in 19.1% (n=18 144) and 20.8% (n=685) of inpatient and outpatient shoulder arthroplasties, respectively, with an increasing trend for inpatient procedures. PNB utilization was consistently associated with lower (up to −14.0%, 95% CI −15.4% to −12.5% decrease, with median 100 and 90 oral morphine equivalents for inpatient and outpatient procedures) opioid utilization on the day of surgery with more potent effects seen for inpatient shoulder arthroplasties. Other outcomes were minimally impacted.DiscussionIn this first national study on PNB use in shoulder arthroplasty, we found increasing PNB use among specifically, inpatient procedures, resulting in particularly reduced opioid use on the day of surgery. While our findings may support PNB use in shoulder arthroplasty, its current low utilization and trends towards more outpatient procedures necessitate continuous monitoring of more extensive benefits.
Collapse
|
12
|
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.
Methods
We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators.
Results
We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups.
Conclusions
In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.
Collapse
|
13
|
Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2019; 27:e696-e701. [PMID: 30499894 DOI: 10.5435/jaaos-d-18-00244] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility. METHODS We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility. RESULTS Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS. DISCUSSION Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission. LEVEL OF EVIDENCE Prognostic level IV.
Collapse
|
14
|
Chi D, Mariano ER, Memtsoudis SG, Baker LC, Sun EC. Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesth Analg 2019; 128:1319-1327. [PMID: 31094807 PMCID: PMC6605076 DOI: 10.1213/ane.0000000000003830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown. METHODS Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications. RESULTS After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses. CONCLUSIONS Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.
Collapse
Affiliation(s)
- Debbie Chi
- From the Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
15
|
Hamilton GM, Ramlogan R, Lui A, McCartney CJL, Abdallah F, McIsaac DI. Association of peripheral nerve blocks with postoperative outcomes in ambulatory shoulder surgery patients: a single-centre matched-cohort study. Can J Anaesth 2018; 66:63-74. [DOI: 10.1007/s12630-018-1234-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 12/27/2022] Open
|