Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: Technique, efficacy, and complications

doi:10.1016/j.jse.2006.10.012

Journal of Shoulder and Elbow Surgery

Volume 16, Issue 4, July–August 2007, Pages 388-395

https://doi.org/10.1016/j.jse.2006.10.012 Get rights and content

Indwelling interscalene catheters are utilized for inpatient postoperative pain control after shoulder surgery. Improved medical equipment and advanced techniques may allow safe and efficacious outpatient use. One hundred and forty-four consecutive indwelling interscalene catheter placements were reviewed to determine adverse events, complications, and efficacy. Real-time ultrasound-guided catheter placement technique is described. Post-anesthesia care unit (PACU) narcotic consumption and last recorded pain score were reviewed to gauge efficacy. The catheter placement technique was 98% successful. There were 14 (9.7%) minor adverse events including inadequate analgesia (8), accidental catheter removal (4) of disconnection (1), and shortness of breath (1). The single complication (0.7%) was a small apical pneumothorax. The average PACU narcotic consumption in intravenous morphine equivalents was 1.7 mg. The average last recorded PACU pain score on a scale of 1 to 10 was 0.6. Catheter placement under real-time ultrasound guidance is accurate. Outpatient use of indwelling interscalene catheters is safe and efficacious.

Section snippets

Materials and methods

All procedures and surgeries were conducted in Salt Lake City, Utah, at the University of Utah Orthopedic Center, a single orthopaedic specialty hospital designed primarily for ambulatory surgery but capable of weekday, overnight inpatient care. All patients receiving indwelling interscalene catheters during a 13-month period, from November 2004 through November 2005, were identified from a review of anesthesia records. A retrospective chart review was performed for the patients who underwent

Results

During the 13-month inclusion period, 154 interscalene catheters were placed. Of these, 10 were placed for upper extremity surgery not including the shoulder and thus were excluded. Data regarding the remaining 144 surgeries are shown in Table I. There were 144 surgeries in 141 patients, consisting of 56 female and 85 male patients. Their ages ranged from 15 to 80 years, with a mean of 46 years. Arthroplasty, rotator cuff repair, and instability repair comprised slightly more than 80% of the

Discussion

The use of indwelling interscalene analgesia is supported in the literature when compared with opioid analgesia. A recent meta-analysis of the available literature compared peripheral nerve catheters with opioids.³¹ Six studies involving interscalene catheters5, 6, 7, 18, 21, 23 and one involving infraclavicular catheters¹⁷ were reviewed. There was a statistically significant increase in patient satisfaction and decrease in pain scores, nausea, vomiting, difficulty sleeping, pruritus, and

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Cited by (60)

Unanticipated costs associated with interscalene nerve catheters for shoulder surgery
2023, Journal of Shoulder and Elbow Surgery
Regional anesthesia has become a mainstay of analgesia following shoulder arthroscopic and reconstructive procedures. Local anesthetic can be injected in the perineural space of the brachial plexus by a single shot or continuously by an indwelling catheter. Although previous studies have compared efficacy and direct cost of single shot to catheters, few have evaluated unanticipated costs of ongoing care or complications. Pulmonary complications can lead to unexpected admissions and emergency department visits. The purpose of the study was to identify unplanned hospital admissions or emergency department visits related to regional anesthesia after shoulder surgery and determine the additional associated costs.
A series of 1888 shoulder surgeries were identified in 1856 unique patients at a single, large academic center. As part of an interscalene nerve catheter program, a continuous interscalene block (CIB) was given to 1728 patients, whereas 160 patients had a single-shot interscalene block (SSIB). A hospital-employed quality control nurse contacted all patients receiving a CIB at 1, 2, 7, and 14 days following surgery. All emergency department visits and readmissions were recorded, and the associated billing charges were reviewed for the inpatient and any outpatient visits immediately preceding or immediately following the readmission. The regional average Medicare fee schedule was used to determine a cost for these episodes of care.
Of the 1728 patients who had CIB, 10 patients were readmitted following open or arthroscopic surgery or presented to the emergency department in the immediate postoperative period for pulmonary compromise. No patient in the SSIB group had an emergency department visit or readmission. The average age of the 10 patients with readmission was 60 years (7 females, 3 males). The majority were diagnosed with hypoxemia on admission (R09.02). Length of stay during readmission ranged from 0 to 4 days, with 1 patient requiring admission to the intensive care unit. The average cost of admission to the hospital or visit to the emergency department was $6849 (range, $1988-$19,483). These costs were primarily related to chest radiographs and electrocardiogram (9/10), chest computed tomography (CT) with contrast (3/10), and head CT (2/10).
Although uncommon, unanticipated pulmonary complications after CIB can result in significant cost compared to SSIB. The indirect costs of pulmonary workup after readmission or emergency department workup may be overlooked if only considering direct costs, such as medication charges, medical supplies, and physician fees.
Risk factors for early returns to care following same-day discharge primary shoulder arthroplasty
2023, Seminars in Arthroplasty JSES
Citation Excerpt :
Both liposomal bupivacaine and a short-acting single-shot block associated with a lower likelihood of return within 1 day of discharge when compared to a continuous catheter. Bryan et al7 noted difficulties with catheter removal and leaky catheters leading to ED visits. Detail on reasons for returns is beyond the scope of this study and we are unable to confirm whether patients with continuous catheters returned due to issues with catheter removal.
Understanding who is most likely to return to care following same-day discharge (SDD) shoulder arthroplasty might improve our understanding of the indications for home recovery. Therefore, we sought to identify risk factors for early returns to care following same-day shoulder arthroplasty.
Patients aged ≥18 years who underwent a primary shoulder arthroplasty and were discharged on the same day as their procedure were identified using a health care system’s shoulder arthroplasty registry (2009-2020). The outcome of most interest was early returns to care, defined as an emergency department visit or readmission within 1 day and 2 days of the discharge date. Factors associated with returns in univariable logistic regression with P < .1 were included in the final multivariable model where a P < .05 was the threshold for statistical significance.
The study cohort included 3666 SDD shoulder arthroplasty. Of the final sample, 93 (2.5%) and 144 (3.9%) patients returned to care within 1 day and 2 days after discharge, respectively. Patients with a history of chronic pulmonary disease had a higher likelihood of returning to care within 1 day, while the addition of liposomal bupivacaine or single-shot regional anesthesia when compared to continuous catheter anesthesia associated with a lower likelihood of return. Patients with a history of neurological disorders had a higher likelihood of return within 2 days. Patients with a history of peptic ulcer disease/bleeding had a higher likelihood of return within 1 day and 2 days postoperative, while an operative start time of noon or later and a longer operative time were associated with a lower likelihood at both time points.
Less than 4% of patients in a large integrated health care system experienced a return to care within 2 days of SDD shoulder arthroplasty. Risk factors for returns varied depending on the window evaluated with some medical comorbidities and continuous catheters associated with a higher likelihood of early returns.
Dexamethasone added to levobupivacaine prolongs the duration of interscalene brachial plexus block and decreases rebound pain after arthroscopic rotator cuff repair
2020, Journal of Shoulder and Elbow Surgery
It has been reported that the addition of dexamethasone to interscalene brachial plexus block (ISBPB) prolongs the duration of the block effect. However, there have been no studies focusing on the effects of dexamethasone on rebound pain after the block effect has worn off. The aim of this study was to investigate the effect on postoperative pain when dexamethasone was added to ISBPB for arthroscopic rotator cuff repair (ARCR).
In this multicenter, single-blinded, and randomized controlled study, 54 patients (33 males, 21 females) who received ARCR were randomly assigned to group L (ISBPB with 20 cc of 0.25% levobupivacaine; 21 patients) or group LD (ISBPB with 20 cc of 0.25% levobupivacaine + 3.3 mg dexamethasone; 33 patients). The primary outcome was the visual analog scale (VAS) for pain after the block effect had worn off. Secondary outcomes were the duration of analgesia, the time to the first request for additional analgesic, the number of additional doses of analgesic, and complications.
The VAS scores on postoperative days 0 and 1 were significantly lower in group LD than group L (P = .005, .035). This indicated that the rebound pain was relieved in group LD. After postoperative day 1, there was no significant difference in VAS score (P = .43 and .19 for days 2 and 3, respectively). The duration of analgesia was significantly longer in group LD than group L (P < .001). The time to the first request for additional analgesic was significantly longer in group LD than group L (P < .001). The number of additional doses of analgesic was significantly lower in group LD (P < .001).
In ARCR, the addition of dexamethasone to levobupivacaine not only prolongs the duration of ISBPB but also relieves rebound pain after the block effect wears off.
Peripheral nerve catheters: A critical review of the efficacy
2019, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
Frequencies of either primary or secondary failure of cPNB were assessed as the primary outcome in 3 studies [24–26], while the remaining studies reported or treated them as secondary outcomes. The reported secondary failure ranged from 0 to 50 percent [15–57]. As an example, 21% [95%CI: 6–36] of saphenous or so-called adductor canal catheters failed after a follow-up of 39 h [95%CI: 15–62].
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
Future Frontiers in Shoulder Arthroplasty and the Management of Shoulder Osteoarthritis
2018, Clinics in Sports Medicine
Recovery after shoulder arthroscopy: In-patient versus out-patient management
2018, Revue de Chirurgie Orthopedique et Traumatologique
L’arthroscopie d’épaule est particulièrement adaptée à la prise en charge en ambulatoire grâce aux progrès des techniques anesthésiques et antalgiques. L’objectif principal de cette étude était de comparer la récupération postopératoire entre les patients pris en charge en ambulatoire et ceux en hospitalisation conventionnelle après une arthroscopie d’épaule.
Il n’y a pas de différence en termes de récupération fonctionnelle entre une prise en charge en hospitalisation conventionnelle et ambulatoire.
Il s’agissait d’une étude prospective monocentrique, mono-opérateur. Dans les 2 groupes nous avons utilisé une analgésie contrôlée par le patient à l’aide d’un cathéter interscalénique. Les critères d’inclusion étaient la réalisation d’une arthroscopie d’épaule pour tendinopathies de la coiffe des rotateurs. Le choix de la prise en charge en ambulatoire revenait au patient. Nos critères de jugement étaient l’évaluation de la récupération postopératoire par le QoR-15 à j1, j2, j3, j4, j7 et par le QuickDASH à 6 semaines.
Quarante-neuf patients ont été inclus, répartis en 2 groupes. Le groupe ambulatoire (A) et le groupe hospitalisation conventionnelle (H) étaient comparables. La chirurgie réparatrice représentait 54 % des gestes dans le groupe A contre 62 % dans le groupe H. Il n’y avait pas de différence significative dans la récupération rapide en postopératoire précoce (QoR-15), ni à 6 semaines (QuickDASH) (p > 0,05). L’évaluation de la douleur par l’EVA retrouvait de manière significative des chiffres plus élevés dans le groupe A dès le retour à domicile.
Aucune différence significative de récupération postopératoire n’a été mise en évidence entre les 2 groupes. Malgré cela l’amélioration de la prise en charge de la douleur et de l’information du patient semble nécessaire dans les prises en charge en ambulatoire.
Étude comparative niveau II.

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Original articleIndwelling interscalene catheter use in an outpatient setting for shoulder surgery: Technique, efficacy, and complications

Section snippets

Materials and methods

Results

Discussion

J Clin Anesth

Br J Anaesth

Arthroscopy

J Shoulder Elbow Surg

Reg Anesth Pain Med

Reg Anesth Pain Med

Br J Anaesth

Reg Anesth Pain Med

Reg Anesth Pain Med

Br J Anaesth

Clin Sports Med

Serious complications related to regional anesthesia: results of a prospective survey in France

Anesthesiology

Major complications of regional anesthesia in France: the SOS regional anesthesia hotline service

Anesthesiology

Interscalene regional anesthesia for shoulder surgery

J Bone Joint Surg Am

Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery

Anesthesiology

Patient-controlled analgesia after major shoulder surgery: patient-controlled interscalene analgesia versus patient-controlled analgesia

Anesthesiology

Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients

Anesthesiology

Original article
Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: Technique, efficacy, and complications