Continuous Interscalene Block for Same Day Discharge Following Total Shoulder Arthroplasty
Condition: Pain, Shoulder
MeSH terms: Shoulder Pain
Study type: Interventional

Summary: 
      Total shoulder surgeries are associated with considerable postoperative pain which may
      prevent rehabilitation and early discharge from the hospital. Continuous interscalene blocks
      with home infusions are commonly performed for pain relief following total shoulder
      arthroplasties. We want to evaluate the time to readiness for discharge following
      interscalene blocks in patients undergoing total shoulder arthroplasties.
    

Detailed description: 
      The number of shoulder replacement surgeries is increasing over the years and it is expected
      to continue as the population ages (1). This necessitates adequate pain control in the
      immediate and early postoperative period when pain levels are typically high. Adequate
      analgesia ensures patient comfort and the ability to perform physical therapy exercises
      associated with positive surgical outcomes (2-3). Interscalene brachial plexus block (ISB) is
      commonly performed to provide analgesia for patients undergoing surgical procedures in the
      shoulder region. Either single injection blocks or continuous perineural infusions are
      performed along with oral medications for better pain control in these patients. Compared
      with intravenous opioids, ISB is known to produce superior analgesia after major shoulder
      surgery (4,5). There are reports of outpatient TSA discharged directly from the recovery room
      following the use of continuous ISB but achievement of adequate range of motion were not
      tested in them (6). Consequently, ambulatory ISB may offer decreased hospitalization while
      ensuring adequate analgesia after TSA. Ilfeld et al (7) prospectively compared ISB and
      opioids regarding the time to readiness for discharge following TSA, which was followed by
      many other studies demonstrating the safety and efficacy of continuous ISB for TSA (8, 9).
      Ilfeld et al (6) showed that discharge criteria were 21 (16-41) h with the use of ISB as
      compared to 51 (37-90) h for those receiving perineural normal saline. In our centre, healthy
      patients requiring shoulder arthroplasty usually remain as in-patients for management of
      pain. Perineural infusions may be continued at home using a portable infusion pump after
      discharge. With the use of disposable portable infusion pump for continuous ISB, it may be
      feasible to discharge patients and reduce hospitalization time.

      Although the study by Ilfeld et al showed continuous ISB allowing earlier home discharge
      following TSA, the patients in the study were evaluated for readiness to discharge on POD1 at
      10 AM rather than the earliest times possible. Another interesting finding is that all
      patients received ropivacaine infusions till 6 AM of POD1 but the authors also claim to have
      discharged few patients on the same afternoon after the surgery. The block infusions reported
      in previous studies are higher than used at our institute.

      There is also conflicting evidence that although continuous ISB provides adequate analgesia,
      they seldom impact early functional rehabilitation (10). With this background we want to
      evaluate the earliest times for the achievement of readiness to discharge with the use of ISB
      following TSA.
    

Intervention name(s): Interscalene block
Intervention type(s): Procedure
Intervention description(s): Interscalene catheters will be placed under aseptic precautions in each patient by one of the investigators using combined peripheral nerve stimulation and ultrasound guidance to get twitch in the C5-C6 dermatomes and documented spread of injectate near C5-6 nerve roots. Twenty mL of 0.2% ropivacaine will be injected while documenting adequate drug spread under ultrasound. After 20 min of injection, the interscalene nerve block will be evaluated and considered successful with inability to abduct the shoulder and a decrease in perceived sensation to cold of the skin over the deltoid muscle.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Interscalene Block; Perineural catheter; Ropivacaine; Postoperative pain; Home regional