MODERATE RECOMMENDATION The Peri-Op Injection recommendation has been downgraded one level because of inconsistent evidence.
Six high quality (Kuchalik 2017 (a), Kuchalik 2017 (b), Kuchalik 2013, Jules-Elysee 2015, Johnson 2017, Fahs 2018) total hip arthroplasty and twenty-six total knee arthroplasty (Tong 2018, Runge 2016, Zhou 2018, Kampitak 2018, Mayr 2019, Varshney 2019, Chaubey 2017, McDonald 2016, Tanikawa 2014, Fan 2016, McCarthy 2019, Safa 2014, Rizk 2017, Affas 2011, Meftah 2019, Sogbein 2017, Carli 2010, Chandy 2019, Chaumeron 2017, Tammachote 2013, Mahadevan 2012, Li 2017, Ukai 2020, Gi 2014, Uesugi 2014, Tanikawa 2017) showed no difference in patient outcomes.
Benefits/Harms of Implementation
Improved pain control can improve patient satisfaction and reduce patient morbidity by mitigating the systemic stress response. Reducing opioid use in the post-op period mitigates their well-known side-effects such as nausea/vomiting, respiratory depression, tolerance, etc. Local anesthetic systemic toxicity is always a concern when using local anesthetics. Proximal brachial plexus regional anesthesia may cause hemidiaphragm paresis which may not be tolerated in those with severe pulmonary disease.
Outcome Importance
Postoperative pain control is an important concern to patients, and when poorly managed is associated with delays in achieving functional milestones, greater opioid use, and increased morbidity. The US is in the midst of an opioid epidemic known to contribute to the development of hyperalgesia, tolerance, dependence, addiction, and abuse. Therefore, reducing opioid use is a national priority.
Cost Effectiveness/Resource Utilization
Bupivacaine and ropivacaine, the most used long-acting local anesthetics in regional anesthesia, are both inexpensive and available in generic formulations. The peri-operative use of continuous regional anesthesia requires the assistance of a qualified anesthesia provider, an infusion pump system, and close patient follow-up
Acceptability
Continuous regional anesthesia has been widely used for orthopaedic surgery patients for over 30 years.
Feasibility
Continuous regional anesthesia may not be available in smaller medical centers or ambulatory surgery centers
Future Research
Local anesthetics have a key role in treating surgical pain. Future studies should explore novel local anesthetics and adjuvant agents that prolong the duration of pain relief, as well as motor-sparing regimens. These studies should also examine the optimal combination of both local and regional anesthetics versus either technique alone.
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