Peri-op Injections Total Shoulder Arthroplasty

The Peri-Op Shoulder Injection recommendation has been upgraded one level due to the large magnitude of treatment effects for the critical outcomes of pain and opioid consumption.

One high quality study (Panchamia 2019) demonstrated that a continuous interscalene brachial plexus catheter was associated with reduced pain and less opioid use thru noon on post-operative day 1 after Total Shoulder Arthroplasty.

One moderate quality study (Bjornholdt 2015) demonstrated that a continuous interscalene brachial plexus catheter was associated with reduced pain thru 8 hours post-operatively and less opioid use in the first 24 hours after Total Shoulder Arthroplasty.

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.