Regional anesthesia decreases complications and resource utilization in shoulder arthroplasty patients

Single-shot interscalene block with liposomal bupivacaine vs. non-liposomal bupivacaine in shoulder arthroplasty

BACKGROUND

Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB.

METHODS

This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use.

RESULTS

Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P > .05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P < .05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale-11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P = .57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P = .33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P > .05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P > .05).

CONCLUSION

LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.

Regional Anesthesia is Associated with Improved Mortality and Morbidity in Patients with Congestive Heart Failure Undergoing Lower Extremity Amputation

BACKGROUND

While existing literature reports variable results of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing lower extremity amputation (LEA), the effect of RA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this vulnerable population.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program files between 2005 and 2022, all patients receiving LEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. The association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis.

RESULTS

A total of 5,831 patients (4,779 undergoing GA, 1,052 undergoing RA) with a diagnosis of CHF undergoing LEA were identified. On multivariable logistic regression analysis, RA was associated with lower mortality (adjusted odds ratio [aOR] 0.79, 95% CI 0.65-0.97), pneumonia (aOR 0.76, 95% CI 0.58-0.99), septic shock (aOR 0.64, 95% CI 0.47-0.88), post-operative blood transfusion (aOR 0.82, 95% CI 0.70-0.97), and 30-day readmission (aOR 0.79, 95% CI 0.64-0.97).

CONCLUSIONS

This study demonstrates that RA for LEA in patients with CHF is associated with decreased morbidity and mortality compared to GA. While furthermore research is needed to confirm this association, RA should be at least considered in CHF patients undergoing LEA when feasible.

Early clinical efficacy analysis of enhanced recovery following surgery combined with interscalene brachial plexus block for arthroscopic rotator cuff repair

To explore the early clinical value of enhanced recovery after surgery (ERAS) with interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR). We enrolled 240 patients who underwent arthroscopic rotator cuff repair, randomly divided into 3 groups (n = 80 each). Groups A, B, and C underwent only surgery, surgery + ERAS, and ISB + surgery + ERAS, respectively. We analyzed the clinical data and postoperative indicators for the 3 patient groups. Group comparisons of clinical data and postoperative indicators revealed no significant differences in clinical characteristics (P > .05). Group C showed superior Visual Analog Scale scores at 0-6 and 6-24 hours postoperatively (P < .05), and the shortest length of hospital stay (LOS) (P < .05). At 6 weeks and 3 months postoperatively, Constant-Murley shoulder score and University of California-Los Angeles scores were better in Groups B and C than in Group A (P < .05). Joint swelling was more common in Group A than in Groups B and C (P < .05) but with no significant difference in the incidence of postoperative stiffness (P > .05). ERAS can relieve postoperative pain, shorten LOS, and help restore shoulder joint mobility, thereby reducing postoperative swelling. ISB + ERAS optimized pain control and allowed a shorter LOS, but had similar effects on early functional recovery and complications.

The association between anesthesia type and postoperative outcomes in patients receiving primary total shoulder arthroplasty

PURPOSE

There has been interest to investigate optimal anesthetic techniques for primary total shoulder arthroplasty (TSA). In this study, we investigate if there are differences in postoperative complications in patients receiving (1) regional alone; (2) general alone; and (3) regional plus general anesthesia for primary TSA.

METHODS

Patients undergoing primary TSA from 2014 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: general anesthesia, regional anesthesia, and general anesthesia combined with regional anesthesia. Thirty-day complications were assessed using bivariate and multivariate analyses.

RESULTS

Of 13,386 total patients undergoing TSA, 9079 patients (67.8%) had general anesthesia, 212 (1.6%) had regional anesthesia, and 4095 (30.6%) had general anesthesia combined with regional anesthesia. There were no significant differences in postoperative complications between the general anesthesia group and the regional anesthesia group. Following adjustment, an increased risk of extended length of hospital stay was seen in the combined general and regional anesthesia group compared to those who only had general anesthesia (p = 0.001).

CONCLUSION

General versus regional versus general plus regional anesthesia have no difference in postoperative complications in patients receiving primary total shoulder arthroplasty. However, addition of regional anesthesia to general anesthesia is associated with increased length of stay.

LEVEL OF EVIDENCE

III.

Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures

PURPOSE

Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs.

METHODS

A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018-these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts.

RESULTS

Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579).

CONCLUSION

With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit

INTRODUCTION

To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres.

METHODS

Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET.

RESULTS

Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance.

CONCLUSIONS

The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

Anesthesia in Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis

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For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay.

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Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty.

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There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter.

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Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty.

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Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.

Regional Anaesthesia for Lower Extremity Amputation is Associated with Reduced Post-operative Complications Compared with General Anaesthesia

OBJECTIVE

Primary and secondary lower extremity amputation, performed for patients with lower extremity arterial disease, is associated with increased post-operative morbidity. The aim of the study was to assess the impact of regional anaesthesia vs. general anaesthesia on post-operative pulmonary complications.

METHODS

A retrospective analysis of 45 492 patients undergoing lower extremity amputation between 2005 and 2018 was conducted using data from the American College of Surgeons National Safety Quality Improvement Program database. Multivariable logistic regression was carried out to assess differences in primary outcome of post-operative pulmonary complications (pneumonia or respiratory failure requiring re-intubation) within 48 hours and 30 days after surgery between patients receiving regional (RA) or general anaesthesia (GA). Secondary outcomes included post-operative blood transfusion, septic shock, re-operation, and post-operative death within 30 days.

RESULTS

Of 45 492 patients, 40 026 (88.0%) received GA and 5 466 (12.0%) RA. Patients who received GA had higher odds of developing pulmonary complications at 48 hours (2.1% vs. 1.4%; adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI] 1.09 - 1.78; p = .007) and within 30 days (6.3% vs. 5.9%; aOR 1.15, 95% CI 1.09 - 1.78; p = .039). The odds of blood transfusions (aOR 1.11, 95% CI 1.02 - 1.21; p = .017), septic shock (aOR 1.29, 95% CI 1.03 - 1.60; p = .025) and re-operation (OR 1.26, 95% CI 1.03 - 1.53; p = .023) were also higher for patients who received GA vs. patients who received RA. No difference in mortality rate was observed between patients who received GA and those who received RA (5.7% vs. 7.1%; odds ratio 0.95, 95% CI 0.84 - 1.07).

CONCLUSION

A statistically significant reduction in pulmonary complications was observed in patients who received RA for lower extremity amputation compared with GA.

Biological sex impacts perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture

Background

The purpose of this study was to determine the difference in complication rates between males and females undergoing reverse shoulder arthroplasty for proximal humerus fractures. We hypothesized that (1) females were more likely to undergo reverse shoulder arthroplasty for fracture, and (2) males were more likely to sustain a perioperative complication.

Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent reverse shoulder arthroplasty for proximal humerus fracture between 2011 and 2018. Patients were stratified based on biological sex. Patient demographics, comorbidities, and 30-day perioperative complication rates were collected. Univariate analyses and multiple variable logistic regression modeling were performed.

Results

About 905 patients were included in the analysis—175 (19.3%) were male and 730 (80.7%) were female. Males were more likely to sustain perioperative complications (26.3% vs. 14.1%; P < .001)—pneumonia (2.9% vs. 0.5%; P = .016), unplanned intubation (2.3% vs. 0.4%; P = .029), and unplanned reoperation (9.1% vs. 1.1%; P < .001). On multivariate analysis, males were at a 2.4-fold increase risk of developing any complication (OR = 2.38 [95% CI 1.55-3.65]; P < .001) and a 10-fold increase risk of returning to the operating room for an unplanned reoperation (OR = 10.59 [95% CI 4.23-27.49]; P < .001) compared with females.

Conclusion

Females were more likely to undergo reverse shoulder arthroplasty for proximal humerus fracture, but males were at increased risk of sustaining short-term complications. This study provides useful information for clinicians to consider when counseling their patients during the perioperative period.

Complications and Readmissions After Reverse and Anatomic Total Shoulder Arthroplasty With Same-day Discharge

BACKGROUND

Recent studies have demonstrated the safety of anatomic total shoulder arthroplasty (TSA) in an outpatient setting. No clinical studies, to date, have specifically analyzed complication and readmission rates after reverse total shoulder arthroplasty (RTSA) with same-day discharge. The purpose of this study was to compare the 90-day complication and readmission rates of patients undergoing TSA and RTSA with same-day discharge.

METHODS

Ninety-eight consecutive patients who underwent 104 shoulder arthroplasties with same-day discharge (52 TSA and 52 RTSA) between 2016 and 2019 were analyzed. Suitability for same-day discharge was determined preoperatively using the standardized criteria. Demographic variables, operative time, 90-day readmission, and complication rates were recorded and compared between groups. Differences between the patients undergoing TSA versus RTSA were evaluated with Student t-test, Mann-Whitney test, or Chi square tests as statistically appropriate and reported as P values.

RESULTS

Average age in the TSA cohort was significantly lower (60.1 ± 7.4 versus 67.5 ± 7.5, respectively; P < 0.001). Total operating room time was significantly shorter in the RTSA cohort (153 ± 30.1 minutes versus 171 ± 20.9). Three minor postoperative complications (5.8%) were observed in the TSA cohort (three seromas) within the 90-day postoperative period. There were four postoperative complications (7.7%) in the RTSA cohort (two postoperative seromas, one periprosthetic fracture, and one dislocation). None of the TSA patients required readmission and 1 RTSA (periprosthetic fracture) patient required readmission within 90 days.

DISCUSSION

RTSA with same-day discharge is a safe option for appropriately selected patients despite significantly increased age. 90-day readmission and complication rates between outpatient TSA and RTSA are similar.

DATA AVAILABILITY

Yes.

TRIAL REGISTRATION NUMBERS

NA.

LEVEL OF EVIDENCE

III (case-control).

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Trends in total shoulder arthroplasty from 2005 to 2018: lower complications rates and shorter lengths of stay despite patients with more comorbidities

Background

Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis.

Results

Bivariate analysis revealed significantly more comorbidities among patients in the 2015-2018 cohort compared with the 2005-2010 cohort, specifically American Society of Anesthesiologist class III or IV (57.0% vs. 44.3%, P < .001), morbid obesity (10.8% vs. 7.8%, P < .001), diabetes (17.8% vs. 12.1%, P < .001), and chronic obstructive pulmonary disease (6.7% vs. 4.1%, P = .003). The use of regional anesthesia has decreased (5.6% in 2005-2010 vs. 2.8% in 2015-2018, P < .001), as has operative time (▵: −16 minutes, P < .001) and length of stay (▵: −0.6 days, P < .001). There were also significant decreased rates of perioperative blood transfusion (OR [odds ratio], 0.46), non-home discharge (OR, 0.79), urinary tract infection (OR, 0.47), and sepsis (OR, 0.17), (P < .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts.

Conclusions

Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.

The effectiveness of additional thoracic paravertebral block in improving the anesthetic effects of regional anesthesia for proximal humeral fracture surgery in elderly patients: study protocol for a randomized controlled trial

BACKGROUND

The innervation of the shoulder-upper-extremity area is complicated and unclear. Regional anesthesia with a brachial plexus and cervical plexus block is probably inadequate for the proximal humeral surgery. Missing blockade of the T1-T2 nerves may be the reason. We conduct this prospective randomized controlled trial (RCT) to explore whether an additional T2 thoracic paravertebral block (TPVB) can improve the success rate of regional anesthesia for elderly patients in proximal humeral fracture surgery.

METHODS/DESIGN

The patients aged 65 years or older, referred for anterior-approach proximal humeral fracture surgery, will be enrolled. Each patient will be randomly assigned 1:1 to receive a combined interscalene brachial plexus with superficial cervical plexus block (IC) (combined interscalene brachial plexus with superficial cervical plexus block) or an IC block combined with thoracic paravertebral block (ICTP) block (combined thoracic paravertebral block with brachial plexus and superficial cervical plexus block). The primary outcome is the success rate of regional anesthesia without rescue analgesic methods. The secondary outcomes are as follows: sensory block at the surgical area, proportion of patients who need rescue anesthesia (intravenously administered remifentanil or conversion to general anesthesia), cumulative doses of intraoperative vasoactive medications and adverse events. The total sample size is estimated to be 80 patients.

DISCUSSION

This RCT aims to confirm whether an additional T2 TPVB can provide better anesthetic effects of regional anesthesia with brachial and cervical plexus block in elderly patients undergoing proximal humeral surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03919422. Registered on 19 April 2019.

Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review

PURPOSE OF REVIEW

Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia.

RECENT FINDINGS

Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.

Trends in Inpatient Resource Utilization and Complications Among Total Joint Arthroplasty Recipients: A Retrospective Cohort Study

INTRODUCTION

Joint arthroplasty practice is highly dynamic to adapt to economic changes and advances in medicine. This study provides updates of the current perioperative practice on healthcare resource utilization.

METHODS

The study included total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty within the healthcare cost and utilization project New York State database from 2007 to 2013 (ie, 202,100, 127,872, and 8858 cases, respectively).

RESULTS

A higher proportion of sicker patients were prevalent over time. The length of stay decreased continuously. However, total hospital charges increased after adjusting for inflation. The incidence of wound infection and transfusion decreased steadily over time, whereas acute renal failure has been on the rise. There was an increased utilization of echocardiography, while decreased among other resources.

DISCUSSION

Total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty changed toward sicker patients with shorter length of stay, fewer complications, and less resource utilization. However, overall costs increased over time.

Enhanced Recovery After Shoulder Arthroplasty

Enhanced recovery after surgery (ERAS) protocols depend on multidisciplinary care and should be peer-reviewed and data-driven. ERAS has reduced hospital length of stay and complications, simultaneously improving patient outcomes. ERAS protocol after shoulder arthroplasty features multidisciplinary collaboration among different perioperative services and multimodal analgesia with a focus on regional anesthesia. Despite success, adoption is not universal because ERAS protocols are resource intensive. They require clinicians invested in the success of these programs and patients who can take charge of their own health. Future protocols need to include quality of life and functional outcome measures to gauge success from the patient perspective.

Association between sleep apnea and perioperative outcomes among patients undergoing shoulder arthroscopy

PURPOSE

Sleep apnea is a recognized risk factor for adverse perioperative outcomes in total joint arthroplasty. Nevertheless, little is known about its impact on shoulder arthroscopy, which is a commonly performed ambulatory procedure. Our primary objective was to determine whether sleep apnea was associated with increases in complications and healthcare utilization in this setting.

METHODS

We analyzed administrative data collected from 583 U.S. hospitals between 2010-2015 and identified a cohort of 128,932 patients who underwent shoulder arthroscopy. Using a cross-sectional study design, we examined the relationship between sleep apnea and perioperative outcomes including mortality, stroke, myocardial infarction, and pulmonary complications. We also examined a variety of health utilization outcomes.

RESULTS

Among patients who underwent shoulder arthroscopy, approximately 6% (7,761 of 128,932) had the diagnosis of sleep apnea. The overall complication rate in these patients was 1.39% (95% confidence interval [CI], 1.33 to 1.45). In a crude analysis, sleep apnea was associated with increases in the majority of systemic complications. In adjusted analyses, sleep apnea was associated with a 4.95 (95% CI, 1.81 to 13.5) times greater odds of acute myocardial infarction and a 4.92 (95% CI, 2.72 to 8.9) times greater odds of pulmonary complications. Sleep apnea was also associated with increased odds of requiring postoperative ventilation, hospital admission, and intensive care unit admission.

CONCLUSION

Sleep apnea is associated with an increased risk of complications and resource utilization in patients undergoing shoulder arthroscopy.