Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty
A randomized, triple-masked, placebo-controlled study
Ilfeld, B. M., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Theriaque, D. W., Chmielewski, T. L., Spadoni, E. H., & Wright, T. W. (2006). Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology, 105(5), 999-1007.
BACKGROUND: A continuous interscalene nerve block (CISB) may be used to provide analgesia after shoulder arthroplasty. Therefore, inpatient stays may be shortened if CISB (1) provides adequate analgesia without intravenous opioids and (2) improves shoulder mobilization. This study investigated the relationship between ambulatory CISB and the time to reach three discharge criteria after shoulder arthroplasty.
METHODS: Preoperatively, patients received a CISB. All patients received a perineural 0.2% ropivacaine infusion from surgery until 06:00 the following morning, at which time they were randomly assigned either to continue perineural ropivacaine or to switch to normal saline. The primary endpoint was the time from the end of surgery until three discharge criteria were attained (adequate analgesia, independence from intravenous analgesics, and tolerance to 50% of shoulder motion targets). Patients were discharged home as early as the afternoon after surgery with their CISB using a portable infusion pump.
RESULTS: Patients receiving perineural ropivacaine (n = 16) attained all three discharge criteria in a median (10th-90th percentiles) of 21 (16-41) h, compared with 51 (37-90) h for those receiving perineural normal saline (n = 13, P < 0.001). Unlike patients receiving perineural ropivacaine, patients receiving perineural normal saline often required intravenous morphine, but still experienced a higher degree of pain and tolerated less external rotation.
CONCLUSIONS: An ambulatory CISB considerably decreases the time until readiness for discharge after shoulder arthroplasty, primarily by providing potent analgesia that permits greater passive shoulder movement and the avoidance of intravenous opioids. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with earlier discharge.