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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Anesthesiol Clin 2024; 42:219-231. [PMID: 38705672 DOI: 10.1016/j.anclin.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Eng E, Mowers C, Sachdev D, Yerke-Hansen P, Jackson GR, Knapik DM, Sabesan VJ. ChatGPT-3.5 Responses Require Advanced Readability for the General Population and May Not Effectively Supplement Patient-Related Information Provided by the Treating Surgeon Regarding Common Questions About Rotator Cuff Repair. Arthroscopy 2024:S0749-8063(24)00369-4. [PMID: 38777000 DOI: 10.1016/j.arthro.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/23/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE To investigate the accuracy of ChatGPT's responses to frequently asked questions prior to rotator cuff repair surgery. METHODS The 10 most common frequently asked questions related to rotator cuff repair were compiled from 4 institution websites. Questions were then input into ChatGPT-3.5 in 1 session. The provided ChatGPT-3.5 responses were analyzed by 2 orthopaedic surgeons for reliability, quality, and readability using the Journal of the American Medical Association Benchmark criteria, the DISCERN score, and the Flesch-Kincaid Grade Level. RESULTS The Journal of the American Medical Association Benchmark criteria score was 0, indicating the absence of reliable source material citations. The mean Flesch-Kincaid Grade Level was 13.4 (range, 11.2-15.0). The mean DISCERN score was 43.4 (range, 36-51), indicating that the quality of the responses overall was considered fair. All responses cited making final decision-making to be made with the treating physician. CONCLUSIONS ChatGPT-3.5 provided substandard patient-related information in alignment with recommendations from the treating surgeon regarding common questions around rotator cuff repair surgery. Additionally, the responses lacked reliable source material citations, and the readability of the responses was relatively advanced with a complex language style. CLINICAL RELEVANCE The findings of this study suggest that ChatGPT-3.5 may not effectively supplement patient-related information in the context of recommendations provided by the treating surgeon prior to rotator cuff repair surgery.
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Affiliation(s)
- Emma Eng
- Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, Florida, U.S.A
| | - Colton Mowers
- Rush University Medical College, Chicago, Illinois, U.S.A
| | | | - Payton Yerke-Hansen
- Department of Orthopaedic Surgery, Louisiana State University Health-Shreveport, Shreveport, Louisiana, U.S.A
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A..
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Vani J Sabesan
- HCA JFK/University of Miami Miller School of Medicine Orthopaedic Residency Program Palm Beach, Lake Worth, Florida, U.S.A
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Hones KM, Hao KA, Wright JO, Wright TW, Hartzell J, Myara DA, Levings PP, Badman B, Ghivizzani SC, Watson Levings RS. Toxic effects of local anesthetics on rat fibroblasts: An in-vitro study. J Orthop Sci 2024:S0949-2658(24)00060-5. [PMID: 38670825 DOI: 10.1016/j.jos.2024.04.003] [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: 01/10/2024] [Revised: 03/25/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Infusion catheters facilitate a controlled infusion of local anesthetic (LA) for pain control after surgery. However, their potential effects on healing fibroblasts are unspecified. METHODS Rat synovial fibroblasts were cultured in 12-well plates. Dilutions were prepared in a solution containing reduced-serum media and 0.9% sodium chloride in 1:1 concentration. Each well was treated with 500 μl of the appropriate LA dilution or normal saline for 15- or 30-min. LA dilutions included: 0.5% ropivacaine HCl, 0.2% ropivacaine HCl, 1% lidocaine HCl and epinephrine 1:100,000, 1% lidocaine HCl, 0.5% bupivacaine HCl and epinephrine 1:200,000, and 0.5% bupivacaine HCl. This was replicated three times. Dilution of each LA whereby 50% of the cells were unviable (Lethal dose 50 [LD50]) was analyzed. RESULTS LD50 was reached for lidocaine and bupivacaine, but not ropivacaine. Lidocaine 1% with epinephrine is toxic at 30-min at 1/4 and 1/2 sample dilutions. Bupivacaine 0.5% was found to be toxic at 30-min at 1/2 sample dilution. Bupivacaine 0.5% with epinephrine was found to be toxic at 15- and 30-min at 1/4 sample dilution. Lidocaine 1% was found to be toxic at 15- and 30-min at 1/2 sample dilution. Ropivacaine 0.2% and 0.5% remained below LD50 at all time-points and concentrations, with 0.2% demonstrating the least cell death. CONCLUSIONS Though pain pumps are generally efficacious, LAs may inhibit fibroblasts, including perineural fibroblast and endoneurial fibroblast-like cells, which may contribute to persistent nerve deficits, delayed neurogenic pain, and negatively impact healing. Should a continuous infusion be used, our data supports ropivacaine 0.2%. LEVEL OF EVIDENCE Basic Science Study; Animal model.
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Affiliation(s)
- Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Jeffrey Hartzell
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - David A Myara
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Padraic P Levings
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Brian Badman
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Steven C Ghivizzani
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Rachael S Watson Levings
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA.
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O'Donnell EA, Best MJ, Simon JE, Liu H, Zhang X, Armstrong AD, Warner JJP, Khan AZ, Fedorka CJ, Gottschalk MB, Kirsch J, Costouros JG, Fares MY, Beck da Silva Etges AP, Srikumaran U, Wagner ER, Jones P, Haas DA, Abboud JA. Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list. J Shoulder Elbow Surg 2024; 33:841-849. [PMID: 37625696 DOI: 10.1016/j.jse.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. METHODS Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. RESULTS Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001). CONCLUSIONS There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.
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Affiliation(s)
- Evan A O'Donnell
- Department of Orthopaedic Surgery, Harvard Medical School, Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason E Simon
- Department of Orthopaedic Surgery, Harvard Medical School, Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - April D Armstrong
- Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jon J P Warner
- Department of Orthopaedic Surgery, Harvard Medical School, Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Adam Z Khan
- Department of Orthopedics, Northwest Permanente PC, Portland, OR, USA
| | | | | | - Jacob Kirsch
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | | | - Mohamad Y Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | | | - Joseph A Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA.
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Soeding P, Morris A, Soeding A, Hoy G. Effect of intravenous magnesium on post-operative pain following Latarjet shoulder reconstruction. Shoulder Elbow 2024; 16:46-52. [PMID: 38435030 PMCID: PMC10902413 DOI: 10.1177/17585732231158805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 01/24/2023] [Accepted: 02/04/2023] [Indexed: 03/05/2024]
Abstract
Background Single injection ropivacaine interscalene anesthesia (ISA) is frequently used in Latarjet reconstruction to enhance post-operative analgesia. A potential limitation is the occurrence of severe rebound pain on block resolution. We investigated the effect of intravenous magnesium on post-operative pain, particularly at the transition of block resolution to multimodal analgesia. Methods Elective patients (n = 40) having Latarjet open shoulder reconstruction were randomised to receive either intravenous magnesium sulphate 50 mg/kg (M) or normal saline (S) before induction. Post-operatively, a standardised analgesic regimen was used, and post-operative pain was recorded using a verbal numerical rating assessment (VNRA) score. Requirement for injected opioid analgesia was recorded. Results ISA provided longstanding analgesia in all patients with block duration slightly prolonged in the magnesium group (16.7(1.0) (S), 17.8(1.3) h (M), p = 0.049). Magnesium resulted in less rebound pain following ISA resolution (VNRA 4.0 (0.6) M, 6.2 (0.8) S, p = 0.03) and lower pain intensity at 24 h. Four patients had nausea and two required rescue opioid injection. Conclusion Magnesium before Latarjet surgery results in less rebound pain following ropivacaine block and improves post-operative analgesia. Magnesium may be indicated in major upper limb surgery, where significant pain intensity is anticipated. Level of evidence Treatment study; Randomised blinded; Level 2.
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Affiliation(s)
- Paul Soeding
- FANZCA Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Pharmacology and Therapeutics, The University of Melbourne, Victoria, Australia
| | - Alex Morris
- The University of Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Adam Soeding
- Department of Preventative Medicine, The Alfred Centre Monash University, Prahran, Australia
| | - Gregory Hoy
- Melbourne Orthopaedic Group, Monash University Department of Surgery, Windsor, Australia
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Caliskan B, Ataoglu C, Ok M, Yamak Altinpulluk E. Comparison of shoulder anterior capsular block and interscalene brachial plexus block for shoulder arthroscopy: a preliminary analysis. Minerva Anestesiol 2024; 90:22-30. [PMID: 37997303 DOI: 10.23736/s0375-9393.23.17536-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND This study aims to reveal the perioperative analgesic efficacy of a new technique, anterior capsular shoulder block, in treating pain after shoulder arthroscopy compared to the interscalene brachial plexus block. METHODS The study design is randomized, prospective, interventional, standardized and double-blind in the setting of orthopedic operating room and orthopedic postoperative ward. Forty patients between 18-90 years of age and with American Society of Anesthesiologists Physical Status classification I to III who received arthroscopic cuff repair surgery were randomized into two (1:1 distribution; N.=20) groups. The interventions were interscalene brachial plexus block for Group A and shoulder anterior capsular block for Group B. Primary measurements were pain scores within 48 hours. Secondarily total analgesia requirement, intraoperative heart rate and blood pressure, arthroscopic image quality were evaluated. RESULTS Pain scores within postoperative 48 hours were similar between SHAC and ISB groups with no significant difference (P>0.05). Total analgesia requirement, intraoperative and postoperative rescue analgesia, was also similar with no significance (P>0.05). CONCLUSIONS This study demonstrated that the anterior capsular shoulder block is an effective alternative with similar results to the interscalene brachial plexus block for managing pain after shoulder arthroscopy.
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Affiliation(s)
- Berna Caliskan
- Department of Anesthesiology and Reanimation, Haseki Training and Research Hospital, Istanbul, Türkiye -
| | - Cüneyt Ataoglu
- Department of Orthopedic and Traumatology, Haseki Training and Research Hospital, Istanbul, Türkiye
| | - Mesut Ok
- Department of Orthopedic and Traumatology, Haseki Training and Research Hospital, Istanbul, Türkiye
| | - Ece Yamak Altinpulluk
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, Spain
- Outcomes Research Consortium, Cleveland, OH, USA
- Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Türkiye
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Frost S, Rodrigues D, Amadeo RJJ, Wolfe S, Funk F, Ferguson C, Brown H, MacDonald P, Dufault B, Mutter TC. Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data. Reg Anesth Pain Med 2023; 48:553-560. [PMID: 37295793 DOI: 10.1136/rapm-2022-104086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Postoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled trial participants. METHODS Data were pooled from two randomized controlled trials of analgesia after interscalene block with perineural or intravenous adjuvants (NCT02426736, NCT03270033). Participants were at least 18 years of age and undergoing arthroscopic shoulder surgery at a single ambulatory surgical center. PONS were assessed by telephone follow-up at 14 days and 6 months postoperatively, and defined as patient report of numbness, weakness, or tingling in the surgical limb, alone or in combination, and regardless of severity or etiology. RESULTS At 14 days, PONS occurred in 83 of 477 patients (17.4%). Among these 83 patients, 10 (12.0%) continued to have symptoms a half-year after surgery. In exploratory univariate analyses, no patient, surgical or anesthetic characteristics were significantly associated with 14-day PONS except for lower postoperative day 1 Quality of Recovery-15 questionnaire total score (OR 0.97 (95% CI, 0.96 to 0.99), p<0.01). This result was driven largely by the emotional domain question scores (OR 0.90 95% CI 0.85 to 0.96, p<0.001). Report of all three of numbness, weakness and tingling at 14 days vs other 14-day symptom combinations was associated with persistent PONS at 6 months (OR 11.5 95% CI 2.2 to 61.8, p<0.01). CONCLUSION PONS are common after arthroscopic shoulder surgery performed with single injection ultrasound-guided interscalene blocks. No definitive mitigating risk factors were identified.
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Affiliation(s)
- Samantha Frost
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Daniel Rodrigues
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Ryan J J Amadeo
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Scott Wolfe
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Faylene Funk
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Celeste Ferguson
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Holly Brown
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Peter MacDonald
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Brenden Dufault
- George and Fay Yee Centre for Health Care Innovation, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Thomas Charles Mutter
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Kim HJ, Koh KH, Park JI, Kim YJ, Kim MJ, Kim H, Kim H, Ro YJ, Koh WU. Comparison of the Analgesic Efficacy between Arthroscopically Placed Continuous Suprascapular Nerve Block and Ultrasound-guided Continuous Superior Trunk Block: A Double-blinded Randomized Controlled Trial. Anesthesiology 2023; 139:591-601. [PMID: 37450621 DOI: 10.1097/aln.0000000000004691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Single-shot suprascapular nerve block and superior trunk block have been reported to provide a noninferior analgesic effect after shoulder surgery with a lesser incidence of hemidiaphragmatic paresis compared with interscalene brachial plexus block. This study hypothesized that continuous suprascapular nerve block provides noninferior analgesia with minimal effects on diaphragmatic movement compared with continuous superior trunk block in patients undergoing arthroscopic shoulder surgery. METHODS 100 patients were randomized undergoing arthroscopic shoulder surgery between December 2020 and October 2021 into continuous suprascapular nerve block and continuous superior trunk block groups. Before the surgery, patients received either a single-shot superior trunk block or subomohyoid suprascapular nerve block. Thereafter, a superior trunk catheter was inserted by anesthesiologists in patients in the continuous superior trunk block group, and a posterior suprascapular nerve catheter was inserted with arthroscopic assistance during the surgery by surgeon in the continuous suprascapular nerve block group. The primary outcome was the postoperative pain score at postoperative 24 h, and the incidence of hemidiaphragmatic paresis was also compared. RESULTS Overall, 98 patients were included in the final analysis. The worst and resting pain scores at postoperative 24 h in the continuous suprascapular nerve block group were inferior compared with those in the continuous superior trunk block group in the test with a noninferiority margin of 1 (worst pain score: mean difference, 0.9; 95% CI, 0.1 to 1.7; resting pain score: mean difference, 0.5; 95% CI, 0.0 to 1.0). However, the continuous suprascapular nerve block group had a significantly lower incidence of hemidiaphragmatic paresis at postoperative 24 h than the continuous superior trunk block group. CONCLUSIONS Continuous suprascapular nerve block provides statistically inferior analgesia compared to the continuous superior trunk block; however, the continuous suprascapular nerve block had a minimal effect on the phrenic nerve function. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji In Park
- Department of Anesthesiology and Pain Medicine, Bundang Seoul National University Hospital, Kyounggi-do, Korea
| | - Yeon Ju Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyojune Kim
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Jin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Amaral S, Arsky Lombardi R, Medeiros H, Nogueira A, Gadsden J. Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e48217. [PMID: 38050517 PMCID: PMC10693833 DOI: 10.7759/cureus.48217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
The interscalene block (ISB) is the standard regional anesthesia for shoulder arthroscopy. However, the superior trunk block (STB) is an alternative with a potentially safer profile. This meta-analysis aimed to compare the incidence and degree of hemidiaphragmatic paralysis and block efficacy of these techniques. We searched MEDLINE, EMBASE, Scopus, and Cochrane databases to identify randomized controlled trials (RCTs). The main outcome was total hemidiaphragmatic paralysis. We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence. Four RCTs and 359 patients were included. The STB group showed lower total hemidiaphragmatic paralysis (RR 0.07; 95% CI 0.04 to 0.14; p<0.0001). The incidence of subjective dyspnea (p = 0.002) and Horner's syndrome (p<0.001) was significantly lower with STB relative to ISB. There was no significant difference between groups in block duration (p = 0.67). There was a high certainty of evidence in the main outcome as per the GRADE framework. Our findings suggest that STB has a better safety profile than ISB, resulting in lower rates of hemidiaphragmatic paralysis and dyspnea while providing a similar block. Therefore, STB could be preferred to ISB, especially in patients susceptible to phrenic nerve paralysis complications.
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Affiliation(s)
- Sara Amaral
- Anesthesiology, Hospital Regional Deputado Afonso Guizzo, Ararangua, BRA
| | | | - Heitor Medeiros
- Anesthesiology, Hospital Universitário Onofre Lopes, Natal, BRA
| | - Alleh Nogueira
- Anesthesiology, Escola Bahiana de Medicina e Saúde Pública, Salvador, BRA
| | - Jeff Gadsden
- Anesthesiology, Duke University Medical Center, Durham, USA
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Uppal V, Barry G, Ke JXC, Kwofie MK, Trenholm A, Khan M, Shephard A, Retter S, Shanthanna H. Reducing rebound pain severity after arthroscopic shoulder surgery under general anesthesia and interscalene block: a two-centre randomized controlled trial of pre-emptive opioid treatment compared with placebo. Can J Anaesth 2023:10.1007/s12630-023-02594-0. [PMID: 37833472 DOI: 10.1007/s12630-023-02594-0] [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: 01/23/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE Although a single-injection interscalene block provides effective early postoperative analgesia following shoulder surgery, patients may experience "rebound pain" when the block resolves. Our objective was to determine if oral hydromorphone (2 mg) given six hours after a single-injection interscalene block for arthroscopic shoulder surgery leads to a clinically significant reduction in the severity of rebound pain. METHODS After approval from research ethics boards, we conducted a two-centre, parallel-group, double-blind, randomized, placebo-controlled superiority trial. Patients received preoperative interscalene block, general anesthesia, and either hydromorphone or placebo six hours after the block. The primary outcome was the worst pain score in the first 24 hr postoperatively, measured on an 11-point (0-10) numerical rating scale. RESULTS A total of 73 participants were randomly assigned to either the hydromorphone or placebo group. There was no statistically significant difference in the mean (standard deviation) worst pain score within 24 hr between the hydromorphone and placebo groups (6.5 [2.4] vs 5.9 [2.3]; mean difference, 0.6; 95% confidence interval, -0.5 to 1.8). Similarly, we did not find any significant difference in the pain trajectory, opioid use, or incidence of nausea and vomiting between the groups. The mean time to worst pain was 14.6 hr, and the mean time to first rescue analgesia was 11.3 hr after interscalene block. CONCLUSION Hydromorphone 2 mg given six hours after interscalene block did not reduce the severity of rebound pain postoperatively compared with placebo in patients undergoing arthroscopic shoulder surgery. STUDY REGISTRATION ClinicalTrials.gov (NCT02939209); registered 19 October 2016.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
- Nova Scotia Health Authority, Halifax, NS, Canada.
- IWK Health Centre, Halifax, NS, B3H 2Y9, Canada.
| | - Garrett Barry
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
| | - Janny X C Ke
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, St. Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
| | - M Kwesi Kwofie
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
| | - Andrew Trenholm
- Nova Scotia Health Authority, Halifax, NS, Canada
- Division of Orthopaedic Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Aaron Shephard
- Department of Psychology & Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Susanne Retter
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
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11
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Turk R, Hamid N. Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids. Orthop Clin North Am 2023; 54:453-461. [PMID: 37718084 DOI: 10.1016/j.ocl.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.
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Affiliation(s)
- Robby Turk
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Nady Hamid
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA; OrthoCarolina, Charlotte, NC, USA
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12
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Ali MI, Tang Y, Hou J, Long Y, Zhou C, Wang Z, Yang R. Modified Continuous Arthroscopy-Guided Suprascapular Nerve Block for Postoperative Pain Control Following Rotator Cuff Repair: Surgical Technique. Arthrosc Tech 2023; 12:e1701-e1706. [PMID: 37942096 PMCID: PMC10627854 DOI: 10.1016/j.eats.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/28/2023] [Indexed: 11/10/2023] Open
Abstract
Arthroscopic rotator cuff repair is one of the most painful surgical procedures; patients complain of pain especially during the first 48 hours postoperatively. Pain management is an essential goal to reduce the demand for analgesic agents and patient discomfort. Various methods have been introduced for arthroscopic rotator cuff repair, including continuous arthroscopy-guided suprascapular nerve blocks (SSNB) and interscalene nerve blocks. However, the aforementioned procedures have shown disadvantages such as catheter mobilization, which may cause injury to the artery, a weak analgesic effect, and Horner syndrome, as well as phrenic nerve paralysis. A modification of the continuous arthroscopy-guided SSNB has been introduced at our hospital: the modified continuous arthroscopy-guided SSNB technique. The aim of this technique is to immobilize the catheter to reduce the chance of injury and minimize postsurgical analgesic needs and patient discomfort.
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Affiliation(s)
- Maslah Idiris Ali
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiyong Tang
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingyi Hou
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Long
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuanhai Zhou
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiling Wang
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Yang
- Department of Orthopedic Surgery, Sport Medicine Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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13
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid has no effect on postoperative pain control after arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 33:32-35. [PMID: 37693817 PMCID: PMC10491640 DOI: 10.1016/j.asmart.2023.08.003] [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: 07/07/2022] [Revised: 04/11/2023] [Accepted: 08/05/2023] [Indexed: 09/12/2023] Open
Abstract
Background The purpose of this study was to compare the efficacies of tranexamic acid (TXA) versus placebo after arthroscopic rotator cuff repair (ARCR). Methods This prospective, double-blind, and randomized study was conducted in 70 patients who underwent ARCR from 2021 to 2022 at our hospital. Thirty-four shoulders were randomly assigned to the TXA group, and 36 to the control group; TXA (10 mL) and normal saline (10 mL) were administered locally after surgery and in the control group, respectively. We evaluated visual analog scale pain scores at rest, during activity, and at night and the circumference and diameter of the shoulder joint in both groups preoperatively and at 1, 2, and 3 days, and 1 week after the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. Results There was no significant difference in the visual analog scale scores at rest, during activity, and at night between the groups (p > 0.05). The circumference and diameter of the shoulder joint were not also significantly different between both groups (p > 0.05). Conclusion Local TXA administration in patients who undergo ARCR does not significantly impact postoperative pain levels and the circumference and diameter of the shoulder joint.
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Affiliation(s)
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan
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14
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Descamps J, Le Hanneur M, Bouché PA, Boukebous B, Duranthon LD, Grimberg J. Do web-based follow-up surveys have a better response rate than traditional paper-based questionnaires following outpatient arthroscopic rotator cuff repair? A randomized controlled trial. Orthop Traumatol Surg Res 2023; 109:103479. [PMID: 36403889 DOI: 10.1016/j.otsr.2022.103479] [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: 02/22/2022] [Revised: 08/24/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Considering the extensive use of smartphones in current societies, web-based applications could be considered as a new option for patient follow-up in surgery. By means of such tool, automated and periodic questionnaires could improve the rigor, accuracy and the comprehensiveness of postoperative monitoring, as well as early detection of complications, especially in the current context of evolving ambulatory surgery. HYPOTHESIS The web-based surveys would improve the quality of immediate postoperative monitoring. MATERIAL AND METHODS For 7 months, we included all patients who underwent outpatient arthroscopic rotator cuff repair. After preoperative randomization, each patient was asked postoperatively to complete either paper-based forms or digital questionnaires via a website (Orthense.com®, Digikare Inc. Blagnac, France). Both media (i.e. paper and digital) followed the same postoperative agenda (i.e., D+3, D+14, D+28, D+45, D+90) and had the same content, including pain and discomfort assessments, functional scores (i.e. Shoulder subjective value, simple shoulder test and auto-constant scores). The main objective was to investigate the quality of postoperative follow-up after outpatient arthroscopic rotator cuff surgery, using either printed questionnaires or web-based surveys. The hypothesis was that using a web-based survey would result in greater response rates and increased patient satisfaction regarding follow-up. Primary outcomes were questionnaire response rates at D+45 and D+90, while secondary outcomes were overall response rates, patient recommendation for the monitoring medium and overall patient satisfaction regarding their follow-up using the net promoter score (NPS). RESULTS Among the 59 consecutive patients who were included, there were 27 females and 26 males with a mean age of 57±10.2 years; 27 patients completed the web-based survey (Group A) and 26 patients answered paper-based questionnaires (Group B). Regarding the D+45 questionnaire, response rates were 85.2% (n=23) in group A and 42.3% (n=11) in group B (p=.005); a similar significant difference was observed regarding the D+90 questionnaire, with response rates of 70.4% and 34.6%, respectively (p=.027). The mean NPS for the survey was 10 in Group A and 8.29 in Group B (p=.016). Overall, satisfaction regarding postoperative care did not differ between the two groups. DISCUSSION Compared to traditional paper-based forms, web-based surveys appear to increase patient adherence to short-term postoperative monitoring. If these findings were to be confirmed in long-term follow-up, such straightforward and cost-effective tool could be of great use in clinical care and research. LEVEL OF EVIDENCE I; Randomized controlled clinical trial.
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Affiliation(s)
- Jules Descamps
- Orthopedics Department, Beaujon-Bichat Hospital, Paris University, APHP, 46, rue Henri Huchard, 75018 Paris, France.
| | - Malo Le Hanneur
- Centre main épaule Méditerranée, Clinique Bouchard, Elsan, Marseille, France
| | | | - Baptiste Boukebous
- Orthopedics Department, Beaujon-Bichat Hospital, Paris University, APHP, 46, rue Henri Huchard, 75018 Paris, France
| | - Louis-Denis Duranthon
- Department of Orthopedic Surgery, Clinique Jouvenet-Ramsay-Générale de Santé, Paris, France, Institute of Research in Orthopedics and Sports Surgery (IRCOS), Paris, France
| | - Jean Grimberg
- Department of Orthopedic Surgery, Clinique Jouvenet-Ramsay-Générale de Santé, Paris, France, Institute of Research in Orthopedics and Sports Surgery (IRCOS), Paris, France
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15
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Wu EB, Hsiao CC, Hung KC, Hung CT, Chen CC, Wu SC, Chin JC, Chen IW, Luo SD. Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study. J Pain Res 2023; 16:119-128. [PMID: 36660557 PMCID: PMC9844143 DOI: 10.2147/jpr.s397282] [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] [Received: 11/11/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
Purpose Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. Patients and Methods In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Results Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Conclusion Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Chi Hsiao
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chao-Ting Hung
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chun Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan,I-Wen Chen, No. 901, Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan, Tel +886-6-2812811, Email
| | - Sheng-Dean Luo
- Division of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Kaohsiung, Taiwan,Correspondence: Sheng-Dean Luo, No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City, 833, Taiwan, Tel +886-7-7317123 (ext. 2788), Email
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16
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Liu Z, Li YB, Wang JH, Wu GH, Shi PC. Efficacy and adverse effects of peripheral nerve blocks and local infiltration anesthesia after arthroscopic shoulder surgery: A Bayesian network meta-analysis. Front Med (Lausanne) 2022; 9:1032253. [PMID: 36438028 PMCID: PMC9684667 DOI: 10.3389/fmed.2022.1032253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
Study objective To quantitatively assess and compare the efficacy and adverse effects of six different peripheral nerve block techniques after arthroscopic shoulder surgery (ASS). Design Bayesian network meta-analysis. Methods The PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure database, Chinese Scientific Journal database, Wan Fang databases were searched to retrieve randomized clinical trials comparing interscalene brachial plexus block, continuous interscalene brachial plexus block, supraclavicular brachial plexus block, suprascapular nerve block, combined suprascapular and axillary nerve block and local infiltration analgesia on postoperative pain, opioid consumption, and adverse effects (defined as Horner’s syndrome, dyspnea, hoarseness, vomiting, and nausea) after ASS under general anesthesia (GA). Two reviewers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies. Results A total of 1,348 articles were retrieved initially and 36 randomized clinical trials involving 3,124 patients were included in the final analysis. The network meta-analysis showed that interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to the five other interventions. However, adverse effects were reduced using suprascapular nerve block and combined suprascapular and axillary nerve block compared to interscalene brachial plexus block. Conclusion Interscalene brachial plexus block was superior in reducing pain and opioid consumption compared to other peripheral nerve blocks but had a higher frequency of adverse events.
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Affiliation(s)
- Zheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi-bo Li
- Huaiyin District Center for Disease Control and Prevent, Jinan, China
| | - Ji-hua Wang
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Guang-han Wu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Peng-cai Shi
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- *Correspondence: Peng-cai Shi,
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17
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Meta F, Khalil LS, Ziedas AC, Gulledge CM, Muh SJ, Moutzouros V, Makhni EC. Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair. Arthroscopy 2022; 38:2787-2797. [PMID: 35398483 DOI: 10.1016/j.arthro.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR). METHODS A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated. RESULTS In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01). CONCLUSIONS Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery. LEVEL OF EVIDENCE III, retrospective comparative trial.
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Affiliation(s)
- Fabien Meta
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A..
| | - Lafi S Khalil
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | | | - Caleb M Gulledge
- Wayne State University School of Medicine, Detroit, Michigan, U.S.A
| | - Stephanie J Muh
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Vasilios Moutzouros
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Eric C Makhni
- Department of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
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18
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Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice. Orthop Clin North Am 2022; 53:483-490. [PMID: 36208890 DOI: 10.1016/j.ocl.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.
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19
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Levin JM, Charalambous LT, Girden A, Twomey-Kozak J, Goltz D, Wickman J, Bullock WM, Gadsden JC, Klifto CS, Anakwenze OA. Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:e473-e479. [PMID: 35472576 DOI: 10.1016/j.jse.2022.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA. METHODS This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization. RESULTS The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P < .001) and 36 hours (3 vs. 2, P < .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P < .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038). CONCLUSIONS LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.
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Affiliation(s)
- Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | - Alex Girden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Daniel Goltz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - John Wickman
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | - Jeff C Gadsden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
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20
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Alaia MJ, Hurley ET, Vasavada K, Markus DH, Britton B, Gonzalez-Lomas G, Rokito AS, Jazrawi LM, Kaplan K. Buccally Absorbed Cannabidiol Shows Significantly Superior Pain Control and Improved Satisfaction Immediately After Arthroscopic Rotator Cuff Repair: A Placebo-Controlled, Double-Blinded, Randomized Trial. Am J Sports Med 2022; 50:3056-3063. [PMID: 35905305 DOI: 10.1177/03635465221109573] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. PURPOSE To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This was a US Food and Drug Administration-sanctioned, multicenter, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients aged from 18 to 75 years undergoing ARCR were prospectively enrolled and randomized to the control and experimental groups. The experimental group received an oral, buccally absorbed tablet containing 25 mg of CBD 3 times a day if <80 kg, or 50 mg of CBD 3 times a day if >80 kg, for 14 days postoperatively, while the control group received an identical placebo. Patients were followed up on days 1, 2, 7, and 14, and visual analog scale (VAS) for pain scores, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests were conducted on days 7 and 14 to assess safety, and nausea was monitored. P < .05 was considered to be statistically significant. RESULTS Overall, 100 patients were recruited, with 1 patient being excluded, for a total of 99 patients. There were no significant differences in patient demographics between the 2 groups. On day 1, the VAS pain score was significantly lower in the CBD group than in the control group (4.4 ± 3.1 vs 5.7 ± 3.2, respectively; P = .04), although this difference was no longer present on day 2 (4.7 ± 2.8 vs 5.3 ± 2.6, respectively; P = .32). On both days 1 and 2, patient satisfaction with pain control was significantly higher in the CBD group than in the control group (day 1: 7.0 ± 3.0 vs 5.6 ± 3.7, respectively [P = .04]; day 2: 7.3 ± 2.5 vs 6.0 ± 3.3, respectively [P = .03]). The quantity of opioids consumed was low in both groups, and there were no statistically significant differences in opioid consumption (P > .05). On days 7 and 14, there were no statistically significant differences in VAS scores, opioid consumption, or patient satisfaction with pain control between the CBD and control groups (P > .05 for all). There were no significant differences in liver function test results postoperatively (P > .05). CONCLUSION Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. REGISTRATION NCT04672252 (ClinicalTrials.gov identifier).
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Affiliation(s)
| | | | | | | | - Briana Britton
- Jacksonville Orthopaedic Institute, Jacksonville, Florida, USA
| | | | | | | | - Kevin Kaplan
- Jacksonville Orthopaedic Institute, Jacksonville, Florida, USA
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21
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Xu C, Gu F, Liu Y, Chen R, Wang C, Lu J. The median effective analgesic concentration of ropivacaine in ultrasound-guided interscalene brachial plexus block after arthroscopic rotator cuff repair. Front Pharmacol 2022; 13:928227. [PMID: 36059976 PMCID: PMC9428620 DOI: 10.3389/fphar.2022.928227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The median effective analgesic concentration (MEAC) of ropivacaine in interscalene brachial plexus block (ISBPB) for postoperative analgesia after arthroscopic rotator cuff repair (ARCR) has not been determined. Therefore, this study aimed to evaluate the MEAC after ARCR using 10 ml ropivacaine. Method: This study was conducted on 40 patients with American Society of Anesthesiologists grade I or II who had selective ARCR. The 10 ml ropivacaine was administered for determined, with an initial concentration of 0.3% using up-and-down sequential allocation. After successful or unsuccessful postoperative analgesia, the concentration of ropivacaine was decreased or increased by 0.05% in the next patient. We defined successful postoperative analgesia as a visual analog scale score of <4 at rest within the initial 8 h after ISBPB. The analytic techniques of linear, linear-logarithmic, exponential regressions and centered isotonic regression were used for calculating MEAC. The secondary outcomes was sufentanil consumption, time to 1st rescue analgesic, onset time of sensory block and motor block. Results: The concentration of ropivacaine administered ranged from 0.1% to 0.35%. The MEAC from the four different methods (linear, linear-logarithmic, exponential regressions and centered isotonic regression) were 0.207% (95% CI, 0.168–0.355%), 0.182% (95% CI, 0.165–0.353%), 0.196% (95% CI, 0.154–0.356%), and 0.163%, respectively. Of the four models, exponential regression had the least residual standard error (0.0990). Conclusion: The MEAC derived from the four statistical models for 10 ml ropivacaine in ultrasound-guided ISBPB for postoperative analgesia was distributed within a narrow range of 0.163%–0.207%. The exponential regression model calculated by the goodness-of-fit test at a concentration of 0.196% best fits the study data. Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx?proj=127449, identifier ChiCTR2100047978
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Affiliation(s)
| | | | | | | | | | - Jie Lu
- *Correspondence: Chengyu Wang, ; Jie Lu,
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22
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Jiangping W, Xiaolin Q, Han S, Zhou X, Mao N, Zhibo D, Ting G, Shidong H, Xiangwei L, Xin Y, Guoyin S. Network Meta-Analysis of Perioperative Analgesic Effects of Different Interventions on Postoperative Pain After Arthroscopic Shoulder Surgery Based on Randomized Controlled Trials. Front Med (Lausanne) 2022; 9:921016. [PMID: 35872801 PMCID: PMC9304654 DOI: 10.3389/fmed.2022.921016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundShoulder arthroscopic surgery is a common surgical method used in orthopedics. However, severe postoperative pain can significantly limit the early joint movement of patients and adversely affect the impact of the surgery. At present, there is no consistent and effective analgesic scheme for the management of postoperative pain after arthroscopic surgery of the shoulder.PurposeThe aim of this study was to search for the most effective analgesic scheme to control pain in the perioperative period of arthroscopic surgery of the shoulder.Study DesignNetwork meta-analysis.MethodsWe searched 5 different databases (i.e., Medline, PubMed, Embase, Web of Science, and the Cochrane Library) from January 2011 to January 2021 for English literature. Thereafter, we sifted out randomized controlled trials (RCTs), which compared different intervention schemes for pain management after shoulder arthroscopy and selected only 12 h, 24 h, or 48 h after the patient leaves the operating room as an optimal period for administration of analgesic intervention schemes. Only patients with shoulder disease who have undergone arthroscopic shoulder surgery were included in this study. The Cochrane “risk of bias” was used for the quality assessment. Moreover, some additional tests were performed to enhance the credibility of the results.ResultsTwenty-nine RCTs involving 1,885 patients were included in this frequentist network meta-analysis (NMA). These articles mainly were divided into two distinct groups, namely, the nerve block group and the non-nerve block group. Regarding the nerve block group, at postoperative 12 h, the intervention suprascapular nerve block + interscalene nerve block (SSNB + INB) was ranked first, whereas INB + intra-articular injection (INB + IAI) was ranked first at 24 h and 48 h postoperation. In the non-nerve block group, external application (EA) was ranked first at postoperative 12 h, but oral administration (OA) exhibited a better analgesic effect at postoperative 24 h and postoperative 48 h.ConclusionWe conclude that the analgesic effect of SSNB+INB was the best at postoperative 12 h, and INB+IAI was the best at postoperative 24 h and 48 h in the nerve block group. For the non-nerve block group, the effect of EA was the best at postoperative 12 h, and the analgesic effect of OA at postoperative 24 h and 48 h was significantly better than any other interventions.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42021286777.
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Affiliation(s)
- Wu Jiangping
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Quan Xiaolin
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Shu Han
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
- *Correspondence: Shu Han
| | - Xiaolan Zhou
- Medical Record Statistics Section, The Second Hospital of Chongqing Medical University, Chongqing, China
- Xiaolan Zhou
| | - Nie Mao
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Deng Zhibo
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Gong Ting
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Hu Shidong
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Li Xiangwei
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Yuan Xin
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Shu Guoyin
- Center for Joint Surgery, Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
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Mutter T, Logan GS, Neily S, Richardson S, Askin N, Monterola M, Abou-Setta A. Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review. Can J Anaesth 2022; 69:736-749. [PMID: 35289378 DOI: 10.1007/s12630-022-02229-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB. METHODS Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery. RESULTS Fifty-five studies totalling 6,236 participants (median, 69; range, 30-910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences. CONCLUSION These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB. STUDY REGISTRATION PROSPERO (CRD42020148496); registered 10 February 2020.
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Affiliation(s)
- Thomas Mutter
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Gabrielle S Logan
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam Neily
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Scott Richardson
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Askin
- Neil John Maclean Health Sciences Library, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Marita Monterola
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ahmed Abou-Setta
- George and Fay Yee Centre for Healthcare Innovation, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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24
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Siegel MG. Published Multimodal Anesthetic Protocols Using Gabapentin Risk Substantial Side Effects and Are Not Recommended. Arthroscopy 2022; 38:1381-1382. [PMID: 35501001 DOI: 10.1016/j.arthro.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 02/02/2023]
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25
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Zeeni C, Abou Daher L, Shebbo FM, Madi N, Sadek N, Baydoun H, Al-Taki M, Aouad MT. Predictors of postoperative pain, opioid consumption, and functionality after arthroscopic shoulder surgery: A prospective observational study. J Orthop Surg (Hong Kong) 2022; 30:10225536221094259. [PMID: 35393908 DOI: 10.1177/10225536221094259] [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: 11/16/2022] Open
Abstract
PURPOSE This study aims to identify predictors of postoperative pain and opioid consumption after shoulder surgery to help optimize postoperative pain protocols. STUDY DESIGN Observational cohort study. METHODS One thirty-four patients undergoing arthroscopic shoulder repair were included. Variables related to the patient, surgery and anesthesia were collected and correlated with postoperative pain intensity, analgesic consumption, and functionality up to 1-month post-surgery. We used mixed-effect linear models to estimate the association of gender, interscalene block (ISB), preoperative shoulder pain, non-steroidal anti-inflammatory drugs (NSAIDs) consumption before surgery, and type of surgery with each of the following outcomes: postoperative pain scores, opioid consumption, and functionality. We further analyzed the data for pain scores and opioid consumption per body weight using the multiple linear regression analysis to demonstrate the aforementioned associations specifically at 1 h, 6 h, 12 h, 24 h, 72 h, 1 week and 1 month after surgery. RESULTS Omitting the ISB was associated with higher postoperative pain and cumulative opioid consumption over the first 24 h after surgery. Rotator cuff repair and stabilization surgeries were found to be predictive of higher postoperative pain at 24 h, 72 h, and 1 week and lower functionality at 1 week after surgery. Preoperative shoulder pain and NSAIDs consumption were also predictive of postoperative pain and cumulative opioid consumption. CONCLUSION Omitting a single shot ISB is a strong predictor of postoperative pain and opioid consumption in the early postoperative phase, beyond which the type of surgery, particularly rotator cuff repair and stabilization surgery, emerges as the most important predictor of postoperative pain and functionality.
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Affiliation(s)
- Carine Zeeni
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Layal Abou Daher
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadia M Shebbo
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Naji Madi
- Department of Orthopedic Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Nada Sadek
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Hasan Baydoun
- Department of Surgery, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Muhyeddine Al-Taki
- Department of Surgery, 11238American University of Beirut Medical Center, Beirut, Lebanon
| | - Marie T Aouad
- Department of Anesthesiology, 11238American University of Beirut Medical Center, Beirut, Lebanon
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26
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Jildeh TR, Abbas MJ, Hasan L, Moutzouros V, Okoroha KR. Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial. Arthroscopy 2022; 38:1077-1085. [PMID: 34838987 DOI: 10.1016/j.arthro.2021.11.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/13/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair. METHODS Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events. RESULTS Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group. CONCUSSION The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management. LEVEL OF EVIDENCE Level I, prospective randomized controlled trial.
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Affiliation(s)
- Toufic R Jildeh
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Muhammad J Abbas
- Henry Ford Hospital, Department of Orthopaedic Surgery, Detroit, Michigan, U.S.A
| | - Laith Hasan
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Vasilios Moutzouros
- Henry Ford Hospital, Department of Orthopaedic Surgery, Detroit, Michigan, U.S.A
| | - Kelechi R Okoroha
- Mayo Clinic, Department of Orthopedic Surgery, Minneapolis, Minnesota, U.S.A..
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27
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Paul RW, Szukics PF, Brutico J, Tjoumakaris FP, Freedman KB. Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e721-e746. [PMID: 35494281 PMCID: PMC9042766 DOI: 10.1016/j.asmr.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Affiliation(s)
- Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Patrick F. Szukics
- Rowan University School of Osteopathic Medicine, Department of Orthopaedic Surgery, Stratford, New Jersey, U.S.A
| | - Joseph Brutico
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
- Address correspondence to Kevin B. Freedman, M.D., Rothman Orthopaedic Institute, Thomas Jefferson University, 825 Old Lancaster Rd., Suite 200, Bryn Mawr, PA, 19010, U.S.A.
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28
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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Clin Sports Med 2022; 41:219-231. [PMID: 35300836 DOI: 10.1016/j.csm.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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29
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Huang L, Li P, Zhang L, Kang G, Zhou H, Zhao Z. Analgesic comparison between perineural and intravenous dexamethasone for shoulder arthroscopy: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:103. [PMID: 35177116 PMCID: PMC8851776 DOI: 10.1186/s13018-022-02952-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 01/21/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The analgesic comparison between perineural and intravenous dexamethasone on interscalene block for pain management after shoulder arthroscopy remains controversial. We conduct this meta-analysis to explore the influence of perineural versus intravenous dexamethasone on interscalene block for pain control after shoulder arthroscopy. Methods We have searched PubMed, Embase, Web of science, EBSCO and Cochrane library databases through April 2021 and included randomized controlled trials (RCTs) assessing the effect of perineural and intravenous dexamethasone on interscalene block in patients with shoulder arthroscopy. Results Five RCTs were included in the meta-analysis. Overall, compared with intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone led to similar block duration (SMD = 0.12; 95% CI − 0.12 to 0.35; P = 0.33), pain scores at 12 h (SMD = − 0.67; 95% CI − 1.48 to 0.15; P = 0.11), pain scores at 24 h (SMD = − 0.33; 95% CI − 0.79 to 0.14; P = 0.17), opioid consumption (SMD = 0.01; 95% CI − 0.18 to 0.19; P = 0.95) and incidence of nausea/vomiting (OR = 0.74; 95% CI 0.38–1.44; P = 0.38). Conclusions Perineural and intravenous dexamethasone demonstrated comparable pain relief after shoulder arthroscopy.
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Affiliation(s)
- Liangku Huang
- Department of Hand Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710054, Shaanxi, China
| | - Peng Li
- Department of Hand Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710054, Shaanxi, China
| | - Liang Zhang
- Sports Medicine Center, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 555 Youyidong Street, Beilin District, Xi'an, 710054, Shaanxi, China
| | - Guangming Kang
- Department of Hand Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710054, Shaanxi, China
| | - Haizhen Zhou
- Department of Orthopaedic Oncology, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, 710054, Shaanxi, China
| | - Zandong Zhao
- Sports Medicine Center, Xi'an Honghui Hospital, Xi'an Jiaotong University Health Science Center, No. 555 Youyidong Street, Beilin District, Xi'an, 710054, Shaanxi, China.
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30
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Miyoshi S, Hamada K, Utsunomiya H, Nakayama K, Kizaki K, Horishita T, Uchida S. Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery. J Orthop Sci 2022; 28:560-566. [PMID: 35184956 DOI: 10.1016/j.jos.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/25/2021] [Accepted: 01/05/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND The minimally invasive approach of arthroscopic shoulder surgery is beneficial; however, for optimal outcomes, perioperative pain management is essential. This cross-sectional study aimed to examine the analgesic effectiveness of intra-articular injection (IA) versus interscalene brachial plexus block (ISPB) among patients treated with arthroscopic shoulder surgeries. METHODS We reviewed 100 consecutive patients who underwent shoulder arthroscopic surgery, of whom 50 each underwent IA (February 2019─January 2020; IA group) and ISPB (October 2018─July 2019; ISPB group). The primary outcome was the postoperative pain score measured using a Wong-Baker FACES Pain Rating Scale preoperatively and at 2, 6, 12, 24, and 48 h postoperatively. We performed multiple regression analysis to examine whether IA/ISPB selection is associated with acute-phase postoperative pain and adjusted for intra-articular injection, interscalene brachial plexus block, postoperative pain management, arthroscopic shoulder surgery, IA with 10 mg of morphine previously reported prognostic factors for postoperative pain (e.g., surgical procedures, operative time, older age, and preoperative pain). Furthermore, we examined induction time, total pentazocine dosage, and total postoperative nausea and vomiting (PONV) events. RESULTS There were no significant differences between the IA and ISPB groups in perioperative pain control during the acute-phase periods (p = 0.12, repeated analysis of variance). The difference in anesthesia method was not a prognostic factor for acute-phase postoperative pain (p = 0.11). The IA group (15.06 ± 4.00 min) had a significantly shorter mean anesthesia induction time than the ISPB group (29.23 ± 9.22 min) (p = 0.0001). There was no significant between-group difference in the total pentazocine dosage during the first 7 days (p = 0.3934) postoperatively. PONV was observed in eight (17.0%) and two (4.2%) patients in the IA and ISPB groups, respectively. There was no significant between-group difference in the PONV incidence (p = 0.1582). CONCLUSIONS There was no significant difference in acute-phase postoperative pain management between the IA and ISPB groups. The induction time was significantly shorter in IA. IRB: Approval number: UOEHCRB20-078, IRB approval date: September 9th, 2020; study duration: October 2018 to January 2020.
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Affiliation(s)
- Saki Miyoshi
- Dept. of Anesthesiology, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan
| | - Kotaro Hamada
- Dept. of Anesthesiology, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan
| | - Hajime Utsunomiya
- Dept. of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan
| | - Keisuke Nakayama
- Dept. of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan
| | - Kazuha Kizaki
- Dept. of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan
| | - Takafumi Horishita
- Dept. of Anesthesiology, Hospital of the University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishi, Kitakyushu, Fukuoka, 807-8556, Japan
| | - Soshi Uchida
- Dept. of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, 1-17-1, Hamamachi Wakamatsu, Kitakyushu, Fukuoka, 808-0024, Japan.
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Vujović KS, Vučković S, Stojanović R, Divac N, Medić B, Vujović A, Srebro D, Prostran M. Interactions between Ketamine and Magnesium for the Treatment of Pain: Current State of the Art. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2022; 20:392-400. [PMID: 33475079 DOI: 10.2174/1871527320666210121144216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/20/2020] [Accepted: 09/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Over the past three decades, NMDA-receptor antagonists have been shown to be efficient drugs for treating pain, particularly pain resistant to conventional analgesics. Emphasis will be on the old-new drugs, ketamine and magnesium, and their combination as a novel approach for treating chronic pain. METHODS The MEDLINE database was searched via PubMed for articles that were published up to March 1, 2020, with the keywords 'ketamine', 'magnesium', and 'pain' (in the title/abstract). RESULTS Studies in animals, as well as humans, have shown that interactions of ketamine and magnesium can be additive, antagonistic, and synergistic. These discrepancies might be due to differences in magnesium and ketamine dosage, administration times, and the chronological order of drug administration. Different kinds of pain can also be the source of divergent results. CONCLUSION This review explains why studies performed with a combination of ketamine and magnesium have given inconsistent results. Because of the lack of efficacy of drugs available for pain, ketamine and magnesium in combination provide a novel therapeutic approach that needs to be standardized with a suitable dosing regimen, including the chronological order of drug administration.
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Affiliation(s)
- Katarina S Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Radan Stojanović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nevena Divac
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milica Prostran
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Farladansky E, Hazan S, Maman E, Reuveni AM, Cattan A, Matot I, Cohen B. Perioperative Oral Pregabalin Results in Postoperative Pain Scores Equivalent to Those of Interscalene Brachial Plexus Block After Arthroscopic Rotator Cuff Repair: A Randomized Clinical Trial. Arthroscopy 2022; 38:31-37. [PMID: 34052386 DOI: 10.1016/j.arthro.2021.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the analgesic effects of pregabalin to those of single-shot interscalene brachial plexus block (ISBPB) in adults having arthroscopic rotator cuff (RC) repair, as well as ISBPB's effect on postoperative opioid consumption, patient satisfaction, and opioid-related adverse effects. METHODS In this randomized trial, 79 adults having arthroscopic RC repair were randomized to receive perioperative oral pregabalin (Lyrica, twice daily starting the evening before surgery, for a total of 4 doses) or single-shot ISBPB (20 ml of bupivacaine 0.25%). Intra- and postoperative management was standardized. The primary outcome was median self-reported pain score (on a visual analog scale of 0 to 100) at rest during the initial 10 postoperative days. Other outcomes included pain during activity, postoperative opioid consumption, opioid-related adverse effects, quality of recovery, and pain satisfaction score. RESULTS Of 71 eligible patients, 59 were analyzed, of whom 29 received pregabalin and 30 received ISBPB. Groups were similar regarding demographic, baseline, and intraoperative variables. Median pain score at rest over the 10 postoperative days was 51 (interquartile range 26, 76) in the pregabalin group and 52 (22, 74) in the ISBPB group (difference 0.5 points; 95% confidence interval [CI] -3.2 to 6.3; P = .53). Opioid consumption during the initial 10 postoperative days was also similar (difference in median 90 mg of morphine equivalents; 95% CI -32 to 177.5; P = .12). No differences were found in any other outcome. CONCLUSIONS Perioperative use of pregabalin in adults undergoing arthroscopic RC repair provided analgesia comparable to that of ISBPB for 10 days after surgery. LEVEL OF EVIDENCE II, randomized controlled trial (high dropout rate).
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Affiliation(s)
- Elena Farladansky
- Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shoshana Hazan
- Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Maman
- Shoulder Surgery Unit, Orthopedics Division, Tel Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Anat Cattan
- Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, Ohio, U.S.A..
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Shanthanna H, Czuczman M, Moisiuk P, O'Hare T, Khan M, Forero M, Davis K, Moro J, Vanniyasingam T, Foster G, Thabane L, Alolabi B. Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial. Anaesthesia 2021; 77:301-310. [PMID: 34861745 DOI: 10.1111/anae.15625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.
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Affiliation(s)
- H Shanthanna
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - M Czuczman
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - P Moisiuk
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - T O'Hare
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - M Khan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Surgery, Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - M Forero
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - K Davis
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - J Moro
- Department of Surgery, Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - T Vanniyasingam
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada
| | - G Foster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Research Institute of St Joes, Hamilton, ON, Canada
| | - L Thabane
- Department of Anesthesia, St Joseph's Health Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - B Alolabi
- Department of Surgery, Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
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Smith JRH, Kraeutler MJ, Keeling LE, Scillia AJ, McCarty EC, Mei-Dan O. Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials. Am J Sports Med 2021; 49:4042-4049. [PMID: 33710936 DOI: 10.1177/0363546521996713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy. PURPOSE To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption. STUDY DESIGN Systematic review. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption. RESULTS Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities. CONCLUSION In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.
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Affiliation(s)
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - Laura E Keeling
- Department of Orthopaedics, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA.,New Jersey Orthopaedic Institute, Wayne, New Jersey, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Yang J, Ni B, Fu X. Efficacy of intra-articular ketorolac for pain control in arthroscopic surgeries: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:688. [PMID: 34809647 PMCID: PMC8607634 DOI: 10.1186/s13018-021-02833-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The current systematic review and meta-analysis aimed to synthesize evidence on the efficacy of intra-articular ketorolac for patients undergoing arthroscopic surgeries. METHODS PubMed, Embase, ScienceDirect, and Google Scholar databases were searched for randomized controlled trials assessing the analgesic effect of intra-articular ketorolac for arthroscopic surgery of hip/knee or shoulder joint. RESULTS Six studies were included. Two studies were on shoulder arthroscopy, while others were on knee joint. Meta-analysis revealed that patients receiving intra-articular ketorolac had significantly lower pain scores at 2-4 h (MD: - 0.58 95% CI: - 0.88, - 0.19 I2 = 49% p = 0.002), 6-8 h (MD: - 0.77 95% CI: - 1.11, - 0.44 I2 = 31% p < 0.00001), 12 h (MD: - 0.94 95% CI: - 1.21, - 0.67 I2 = 0% p < 0.00001), and 24 h (MD: - 1.28 95% CI: - 1.85, - 0.71 I2 = 84% p < 0.00001) as compared to the control group (Certainty of evidence: low-moderate). Analysis of three studies revealed a tendency of reduced analgesic consumption in patients receiving intra-articular ketorolac, but the difference did not reach statistical significance (MD: - 0.53 95% CI: - 1.07, 0.02 I2 = 55% p = 0.06). CONCLUSIONS Preliminary evidence from a limited number of studies indicates that additional intra-articular ketorolac to multimodal analgesia results in reduced pain scores up to 24 h after arthroscopic surgery. The clinical relevance of small changes in pain scores is debatable. Also, scarce data suggest that consumption of analgesics may not be reduced with intra-articular ketorolac. Since pain scores can be influenced by the primary diagnosis and dose of ketorolac, the results should be interpreted with caution. The certainty of the evidence is low-moderate. There is a need for future RCTs to further strengthen current evidence.
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Affiliation(s)
- Jingjing Yang
- Department of Pharmacy, Hangzhou Third People's Hospital, 38 Xihu Ave, Shangcheng District, Hangzhou, 310009, Zhejiang Province, China
| | - Bin Ni
- Department of Pharmacy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Shangcheng District, Hangzhou, 310003, Zhejiang Province, China
| | - Xiaoyan Fu
- Department of Pharmacy, Hangzhou Third People's Hospital, 38 Xihu Ave, Shangcheng District, Hangzhou, 310009, Zhejiang Province, China.
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Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study. Anesthesiology 2021; 135:829-841. [PMID: 34525173 DOI: 10.1097/aln.0000000000003962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. METHODS This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. RESULTS The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. CONCLUSIONS This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients. EDITOR’S PERSPECTIVE
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Jildeh TR, Khalil LS, Abbas MJ, Moutzouros V, Okoroha KR. Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial. J Shoulder Elbow Surg 2021; 30:2445-2454. [PMID: 34391876 DOI: 10.1016/j.jse.2021.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/26/2021] [Accepted: 07/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study aimed to compare postoperative pain and patient satisfaction in patients undergoing primary arthroscopic labral surgery managed with either a nonopioid alternative pain regimen or a traditional opioid pain regimen. METHODS Sixty consecutive patients undergoing primary arthroscopic shoulder labral surgery were assessed for participation. In accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement, a prospective randomized controlled trial was performed. The 2 arms of the study were a multimodal nonopioid analgesic protocol as the experimental group and a standard opioid regimen as the control group. The primary outcome was postoperative pain scores (on a visual analog scale [VAS]) for the first 10 days postoperatively. Secondary outcomes included patient satisfaction, patient-reported outcomes, and complications. Randomization was performed with a random number generator, and all data were collected by blinded observers. Patients were not blinded. RESULTS Twelve patients did not meet the inclusion criteria or declined to participate. Thus, 48 patients were included in the final analysis: 24 in the nonopioid group and 24 in the opioid group. There was no significant difference in VAS or PROMIS (Patient-Reported Outcomes Measurement Information System) scores between patients in the 2 cohorts on any postoperative day (P > .05). When we controlled for confounding factors with repeated-measures mixed models, the nonopioid cohort reported significantly lower VAS and PROMIS (Patient-Reported Outcomes Measurement Information System) Pain Interference scores (P < .01) at all time points. No difference was found in reported adverse events (constipation, diarrhea, drowsiness, nausea, and upset stomach) between cohorts at any time point (P > .05). CONCLUSION This study found that a multimodal nonopioid pain regimen provided, at the minimum, equivalent pain control, an equivalent adverse reaction profile, and equivalent patient satisfaction when compared with a standard opioid-based regimen following arthroscopic shoulder labral surgery.
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Affiliation(s)
- Toufic R Jildeh
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Lafi S Khalil
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Muhammad J Abbas
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI, USA
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Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials. J Anesth 2021; 36:17-25. [PMID: 34533639 DOI: 10.1007/s00540-021-03000-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
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 24 h 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 = 0.74 mg; 95%CI = - 0.18 to 1.66 mg; I2 = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24 h 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.
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González-Arnay E, Galluccio F, Pérez-Santos I, Merlano-Castellanos S, Bañón-Boulet E, Jiménez-Sánchez L, Rivier-Julien C, Barrueco-Fernández M, Olea MS, Yamak-Altinpulluk E, Teles AS, Fajardo-Pérez M. Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder. Ann Anat 2021; 239:151814. [PMID: 34536540 DOI: 10.1016/j.aanat.2021.151814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.
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Affiliation(s)
- Emilio González-Arnay
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Division of Pathology, General Hospital of La Palma (HGLP) Buenavista de Arriba s/n PC48713 La Palma, Canary Islands, Spain.; MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Felice Galluccio
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Division of Rheumatology, Medical-geriatric Department, University Hospital AOU Careggi, Largo Piero Palagi, 1, 50139 Florence, Italy.
| | - Isabel Pérez-Santos
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Sebastián Merlano-Castellanos
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Elena Bañón-Boulet
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Lorena Jiménez-Sánchez
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Wellcome Translational Neuroscience Ph.D. Program, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, Scotland, UK.
| | - Clotilde Rivier-Julien
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Manuel Barrueco-Fernández
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Marilina S Olea
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Hospital Interzonal General Dr. José Penna, Av. Lainez 2401, B8000 Bahía Blanca, Buenos Aires, Argentina.
| | - Ece Yamak-Altinpulluk
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Outcomes Research Anesthesiology Institute Cleveland Clinic, 2049 East 100th Street, Cleveland, OH 44195, USA; Department of Anesthesiology and Reanimation, University of Istambul-cerrahpasa School of Medicine, Cerrahpaşa Campus, Kocamustafapaşa Cad. No:34/E, Istanbul, Turkey; Anaesthesiology Clinical Research Office, Ataturk University, Üniversite Atatürk Üniversitesi Kampüsü, 25030 Yakutiye, Erzurum, Turkey.
| | - Ana S Teles
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Anesthesia, Instituto Português de Oncologia Do Porto Francisco Gentil, R. Dr. António Bernardino de Almeida 62, 4200-072 Porto, Portugal.
| | - Mario Fajardo-Pérez
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Anesthesia and Chronic Pain, Móstoles University Hospital, C. Gladiolo, s/n, 28933 Móstoles, Spain.
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Acuña AJ, Mengers SR, Raji Y, Janes JL, Gillespie RJ, Voos JE, Karns MR. Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines. J Shoulder Elbow Surg 2021; 30:e531-e538. [PMID: 33421561 DOI: 10.1016/j.jse.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/13/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. METHODS In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal. RESULTS A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. DISCUSSION To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.
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Affiliation(s)
- Alexander J Acuña
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Sunita R Mengers
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yazdan Raji
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jessica L Janes
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Robert J Gillespie
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James E Voos
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael R Karns
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Yun S, Jo Y, Sim S, Jeong K, Oh C, Kim B, Lee WY, Park S, Kim YH, Ko Y, Chung W, Hong B. Comparison of continuous and single interscalene block for quality of recovery score following arthroscopic rotator cuff repair. J Orthop Surg (Hong Kong) 2021; 29:23094990211000142. [PMID: 33745379 DOI: 10.1177/23094990211000142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Continuous interscalene brachial plexus block (CISB) is well known to reduce postoperative pain and to improve patient satisfaction. However, the effect of CISB on the quality of postoperative recovery is unknown. We Compared the quality of recovery from arthroscopic rotator cuff repair in patients who received CISB or single interscalene brachial plexus block (SISB). METHODS This prospective non-randomized controlled trial with propensity score matching enrolled 134 patients undergoing arthroscopic surgery for rotator cuff repair. Each patient received an interscalene block before surgery. One group had a catheter insertion 30 min after the end of surgery and started patient-controlled regional analgesia (PCRA, n = 49). The other group received intravenous patient-controlled analgesia (IV-PCA, n = 85). The primary outcome was the quality of recovery (QoR-40) score. Also, postoperative analgesia, sleep quality, and postoperative complications were evaluated. RESULTS The two groups had similar QoR-40 score on postoperative day-1 (POD1), but the PCRA group had a significantly greater QoR-40 score on POD2 (156.0, IQR: 143.0, 169.0 vs. 171.0, IQR: 159.0, 178.0; p < 0.001). The IV-PCA group received more analgesics during the 2 days after surgery, especially during night-time, and had a higher prevalence of sleep disturbances. The time to first additional analgesics request was significantly longer in PCRA group (14 hours, 95% CI: 13-16 vs. 44 hours, 95% CI: 28-not applicable). The incidence of postoperative nausea and vomiting significantly lower in the PCRA group (16.3% vs 46.9%, p = 0.002). CONCLUSION CISB showed a higher quality of recovery score than SISB with IV-PCA in arthroscopic rotator cuff repair, probably related to the effective analgesia, improved sleep quality, and reduced opioid-related complications.
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Affiliation(s)
- Sangwon Yun
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
| | - Yumin Jo
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea
| | - Seojin Sim
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea
| | - Kuhee Jeong
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
| | - Byungmuk Kim
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea
| | - Woo-Yong Lee
- Department of Orthopedic Surgery, 90159Chungnam National University Hospital and College of Medicine, Daejeon, Korea
| | - Seyeon Park
- College of Nursing, 26715Chungnam National University, Daejeon, Republic of Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, 65409Chungnam National University Hospital, Daejeon, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, 26715Chungnam National University, Daejeon, Korea
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42
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Hurley ET, Maye AB, Thompson K, Anil U, Resad S, Virk M, Strauss EJ, Alaia MJ, Campbell KA. Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis. Am J Sports Med 2021; 49:2262-2271. [PMID: 33321046 DOI: 10.1177/0363546520971757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. PURPOSE To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. RESULTS Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions. CONCLUSION Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.
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Affiliation(s)
| | - Andrew B Maye
- New York University Langone Health, New York, New York, USA
| | | | - Utkarsh Anil
- New York University Langone Health, New York, New York, USA
| | - Sehar Resad
- New York University Langone Health, New York, New York, USA
| | - Mandeep Virk
- New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- New York University Langone Health, New York, New York, USA
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Abstract
BACKGROUND The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. METHODS This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. RESULTS Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). CONCLUSIONS There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors. EDITOR’S PERSPECTIVE
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44
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. [The impact of unilateral diaphragmatic paralysis on sleep-disordered breathing: a scoping review]. Can J Anaesth 2021; 68:1064-1076. [PMID: 33725316 DOI: 10.1007/s12630-021-01970-y] [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: 07/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Unilateral diaphragm paralysis (UDP) may potentially worsen sleep-disordered breathing (SDB). Unilateral diaphragm paralysis has been associated with proximal brachial plexus blockade, such as interscalene and supraclavicular block. The impact of UDP in patients with SDB is not known in this context. The objectives of this scoping review were to explore the associations between UDP and worsening SDB severity, oxygenation, and pulmonary function. METHODS A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to include studies involving adult patients (≥ 18 yr) with SDB, where the effects of UDP on SDB severity, oxygenation, and pulmonary function were examined. RESULTS Six studies (n = 100 patients) with UDP and SDB were included. The sample population was derived exclusively from respirology-sleep clinics, and none were surgical patients. Compared with control (no UDP), UDP was associated with an increased respiratory disturbance index, most pronounced during rapid eye movement (REM) sleep and supine sleep. Supine and REM sleep were associated with obstructive and mixed (both obstructive and central) events, respectively. Compared with control, UDP was associated with a lower mean and minimum oxygen saturation and arterial oxygen tension during all sleep stages and in all body positions. The majority of UDP patients were found to have clinically significant reductions in mean forced expiratory volume in one second and forced vital capacity values, consistent with restrictive ventilatory pattern. CONCLUSION We observed an association between UDP and increasing SDB severity, particularly during REM sleep and while sleeping in the supine position. Although we identified weaknesses in study design and lack of perioperative data, anesthesiologists should be aware of this association when considering proximal brachial plexus blockade in patients with SDB.
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Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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45
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Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial. PLoS One 2021; 16:e0246792. [PMID: 33600437 PMCID: PMC7891753 DOI: 10.1371/journal.pone.0246792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022] Open
Abstract
Background This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block. Methods 208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner’s syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting. Results Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2–6] vs. 6 min [4–10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome. Conclusion The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.
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46
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Wang FS, Shahzad K, Zhang WG, Li J, Tian K. Atypical presentation of shoulder brucellosis misdiagnosed as subacromial bursitis: A case report. World J Clin Cases 2021; 9:927-934. [PMID: 33585641 PMCID: PMC7852647 DOI: 10.12998/wjcc.v9.i4.927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/10/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Brucella infections in the shoulder joint are uncommon, and few have been reported in the literature.
CASE SUMMARY A 26-year-old male was admitted to our hospital with complaint of recurrent pain and limited movement of the right shoulder. The patient reported the pain to have first occurred as an isolated event 6 mo previously and to have reoccurred 5 mo later, when it was accompanied by limited movement of the shoulder. Findings from physical examination and magnetic resonance imaging (referred to as MRI) suggested the diagnosis of subacromial bursitis, and diagnostic paracentesis and arthroscopic debridement were performed. Surprisingly, synovial fluid culture detected brucella, and the finding was confirmed by mass spectrometry of a colony sample. The diagnosis was corrected to brucellosis of the shoulder joint, and antibiotic drug treatment (oral rifampicin and doxycycline) was administrated for 6 wk. The 4-mo postoperative follow-up examination (MRI) yielded normal findings. The 2-year follow-up showed no signs of recurrence.
CONCLUSION This rare case of brucellosis infection in shoulder highlights the importance of increasing awareness to help avoid misdiagnosis.
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Affiliation(s)
- Fu-Sheng Wang
- Department of Bone and Joint, First Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Khurram Shahzad
- Department of Bone and Joint, First Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Wei-Guo Zhang
- Department of Bone and Joint, First Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Jie Li
- Department of Bone and Joint, First Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Kang Tian
- Department of Bone and Joint, First Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
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48
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Khazi ZM, Lu Y, Cregar W, Shamrock AG, Gulbrandsen TR, Mascarenhas R, Forsythe B. Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis. Arthroscopy 2021; 37:42-49. [PMID: 32721541 DOI: 10.1016/j.arthro.2020.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- Zain M Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A..
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - William Cregar
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Alan G Shamrock
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
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Garcia FL, Williams BT, Maheshwer B, Bedi A, Wong IH, Martin HD, Nho SJ, Chahla J. Pain management practice patterns after hip arthroscopy: an international survey. J Hip Preserv Surg 2020; 7:537-546. [PMID: 33948210 PMCID: PMC8081420 DOI: 10.1093/jhps/hnaa050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/16/2022] Open
Abstract
Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons’ responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.
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Affiliation(s)
- Flávio L Garcia
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA.,Department of Orthopaedic Surgery, Instituto Brasil de Tecnologias da Saúde, Rio de Janeiro, RJ, Brazil, Rua Visconde de Pirajá, 407 Rio de Janeiro, RJ, 22410-003, Brazil.,Department of Orthopaedics and Anesthesiology, Ribeirão Preto Medical School of the University of São Paulo, Ribeirão Preto, Avenida Bandeirantes, 3900 Ribeirão Preto, SP, 14049-900, Brazil
| | - Brady T Williams
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Bhargavi Maheshwer
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, 1500 E Medical Center Drive Ann Arbor, MI, 48109, USA
| | - Ivan H Wong
- Department of Surgery, Dalhousie University, Halifax, 6299 South St Halifax, NS, B3H 4R2, Nova Scotia, Canada
| | - Hal D Martin
- Hip Preservation, aylor University Medical Center, 411 N Washington Ave, Suite 7300 Dallas, TX, 75246, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
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Caldwell GL, Selepec MA. Surgeon-Administered Nerve Block During Rotator Cuff Repair Can Promote Recovery with Little or No Post-operative Opioid Use. HSS J 2020; 16:349-357. [PMID: 33376459 PMCID: PMC7749895 DOI: 10.1007/s11420-019-09745-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of opioid analgesia is common in both the acute and extended post-operative periods after rotator cuff repair. The current opioid crisis has prompted surgeons to seek alternatives that minimize or even eliminate the need for oral opioids after surgery. QUESTIONS/PURPOSES We sought to investigate the effects on post-operative opioid use of a surgeon-administered block of the suprascapular and axillary nerves in arthroscopic rotator cuff repair (ARCR), in particular to quantify outpatient opioid consumption and duration. METHODS In this prospective observational study, all patients undergoing primary ARCR performed under general anesthesia by a single surgeon were studied over a 15-month period. Of 91 ARCRs performed, 87 patients were enrolled and followed prospectively. At the conclusion of the procedure, the surgeon performed "local-regional" nerve blockade with injections to the sensory branches of the suprascapular nerve and the axillary nerve, as well as local infiltration about the shoulder. Use of medications in the post-anesthesia care unit was left up to the anesthesiologist. Patients were prescribed oral opioids (hydrocodone/acetaminophen 5/325 mg) for analgesia after discharge. The quantity and duration of opioid use and pain scores were recorded for 4 months. Statistical analysis was performed to evaluate factors that could account for greater opioid use. RESULTS Total opioid consumption ranged from 0 to 30 opioid tablets (average, 4.2 tablets) over the 4-month period. Post-operatively, 91% of patients took between ten or fewer tablets, and 39% took no opioids. The average duration of opioid use was 2.4 days. No patients were taking opioids at the 4- to 6-week or 4-month follow-up visits, none required refills, and none received prescriptions from outside prescribers. No statistically significant differences were seen in opioids taken or duration of use in regard to tear size, sex, body mass index, surgery location, or procedure time. There was a significant inverse correlation between opioid use and age. In addition, the cost of the surgeon-performed procedure was substantially lower than that associated with pre-operative nerve blockade performed by an anesthesiologist. All patients were satisfied with the post-operative pain management protocol. Average reported post-operative pain scores were low and decreased at each visit. CONCLUSION With this local-regional nerve-blocking protocol, opioid use after ARCR was unexpectedly low, and a large proportion of patients recovered without any post-surgical opioids. The correlation seen between opioid use and age may not be clinically significant, given the low use of post-operative opioids overall. These results may be useful in guiding post-operative opioid prescribing after ARCR, as well as in lowering costs associated with ARCR.
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Affiliation(s)
- George L. Caldwell
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
| | - Michael A. Selepec
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
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