Bridging multimodal pain management provides 48-hour pain control in patients undergoing total shoulder replacement

Abstract

Background: We report our experience with a bridging multimodal pain management program that provides comprehensive 48-hour pain control in patients undergoing total shoulder replacement (TSR).

Methods: The study included all patients undergoing unilateral TSR by 1 surgeon between May 2015 and April 2017. There were 62 patients (23 men, 39 women) with an average age of 68 years (range 38-92 years). Of these, 31 underwent standard nonconstrained TSR and 31 underwent reverse TSR. The bridging multimodal pain management protocol included scalene block regional anesthesia using 0.25% bupivacaine enhanced with 4 mg of dexamethasone, application of 20 mg of liposomal bupivacaine diluted with 40 mL of normal saline in the periarticular soft tissues at time of closure, scheduled 24 hours of intravenous acetaminophen and ketorolac, and immediate cryotherapy. Parameters measured included hospital length of stay, postoperative use of intravenous narcotics, and 30-day hospital readmission.

Results: The median length of stay was 1 day (range, 1-6; average, 1.5 days). Overall, 41 patients (66%) were discharged on postoperative day 1. Intravenous narcotics were required postoperatively in 22 patients (35.5%). There were no 30-day readmissions.

Conclusion: This bridging multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients, even for higher-risk patients with American Society of Anesthesiologists Physical Status Classification III (63%). Of the 62 patients, 64% (n = 40) did not require postoperative intravenous narcotics. For properly selected patients, this program may be considered for performing TSR as an ambulatory procedure.

Keywords: dexamethasone; liposomal bupivacaine; multimodal pain management; opioid consumption; scalene block regional anesthesia; total shoulder replacement.