Peripheral Nerve Blocks for Ambulatory Shoulder Surgery

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mtu620

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What do you guys think (article attached)? How do these results influence your practice?

Question was do peripheral nerve blocks vs no peripheral no blocks affect post-discharge outcomes in ambulatory shoulder surgery?

Essentially what they found was:
- Peripheral nerve blocks are associated with a decrease in unplanned admissions after ambulatory shoulder surgery
- There is no associated improvement in other postoperative outcomes such as emergency department visits, readmissions, mortality, or costs
- PNB associated with increase $325 Canadian compared to no PNB in health care system costs

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Did they measure time in recovery?

Of course with variables like ED admissions, mortality. Costs. The standard will always be to do less procedures. Stick with General anesthesia.

As Obama said. “Take a pill” to control pain. Cheaper.
 
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There is a huge difference in recovery room length of stay, immediate post-op opiate use, post-op respiratory depression, PONV, and patient satisfaction between these two groups.
Unfortunately this study did not measure any of these things.
This study is similar to those that compare MD's to CRNAs and conclude they are equal since they both kill a similar number of patients!
 
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I only skimmed the article, but it appears flawed in its initial basis. It's a cohort-study, so there's no way of controlling for any confounders. Hypothetically, the anesthesiologists in Canada could be choosing their patient so perfectly that they've managed to negate the risk of PNBs.

More importantly, this is ambulatory shoulder surgery, in patients with an average age of 50 years old and mainly undergoing rotator cuff surgery, which denotes a certain degree of activity. Not exactly the most unhealthy cohort overall. And their outcomes were "unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome)". The expectation that a PNB is going to improve on any of these factors in this population sample is ludicrous. Just like plank mentioned, you have to look at relevant outcomes in order to actually come up with anything meaningful.

They also say that PNB had a decrease in unplanned admissions, but I couldn't find the reason for these unplanned admissions.

Heck, if this study was able to associate PNB with an increased/decreased risk of mortality, it would be one of the most groundbreaking studies in anesthesia history. It would behoove the authors to be more realistic during their attempt to get something published.
 
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I would think nerve blocks would lead to more er visits from the pain once it wears off.

with decadron and bupivicaine blocks, by the time the block wears off you can likely skip the narcotics most of the time
 
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I would think nerve blocks would lead to more er visits from the pain once it wears off.
We start multi-modals before surgery. Never heard of any of our patients needed to go to ER because of pain. Routinely use bupi/decadron, on occasion exparel for total shoulders and some more complex cuff repairs.
 
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This is interesting in a way. Depends if you're a regionalist or not whether you would 'like' aspects of this.

I remember many, many calls from residency about shoulder pain pumps, and at least 5-10 admits with failure to cope with pain. It was always 2am Day1 initial bolus were off and bang 10/10 pain. One guy thought he was going to die.

We often joked that the only way the outpatient pain catheter & single shot service was viable was cause of 'free' labour from the residents on call.

So do these things happen in your place and you just dont know about it cause the residents take all the calls? Or someone else?

I like doing blocks but same old story the evidence that they're worth the hassle just isn't really there. Theres 10 studies to prove yes they're great and another 10 to prove that theyre no better than an lma and multimodal
 
I personally have had an interscalene block done, and boy it was an awful experience when the block wore off. Didnt start taking pain meds because it had only been 7 or so hours. Wanted to eat dinner before opioids. I was tempted to go to er for pain meds, but gutted it out with percocet.
 
But look how sweet and happy they are in the recovery room. The PACU nurses think you are amazing.
 
I personally have had an interscalene block done, and boy it was an awful experience when the block wore off. Didnt start taking pain meds because it had only been 7 or so hours. Wanted to eat dinner before opioids. I was tempted to go to er for pain meds, but gutted it out with percocet.
No offense, but you had a crap block. 7 hours?! My dex/bupi blocks routinely last 16-20, and I've had plenty get to 30+.

Also, we start multi-modals before we even go into the OR. Patients are already on tylenol, nsaids and gabapentin before the block wears off. Helps a lot. We don't see our pts having issues when the block wears off. And our ambi center calls every patient and asks about pain and the block wearing off.
 
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The only ones who will tell you that narcotics are as good or better than a block are the sacklers and Purdue pharma. It's not even close.
 
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I remember my fem/sci wearing off at 0300 after my ACL reconstruction. That ****ing sucked. Of course, I was also an idiot and didn't take anything else before going to bed, because I felt great (and had no training to know how long it was going to last)! I now tell patients my story, counsel them to get something on board before going to sleep, and have never heard of a patient coming back to the ED for pain (did have one 30-something with a Horner's thinking he had a stroke, though). If it's happening, I would think the surgeons would bring it up, but they keep asking for blocks.
 
Read the article closely guys. Look at their obesity percentage in the study. 0.5%!!!

I knew there was a problem with the study. They basically the study on skinny people! With no severe sleep apnea to hinder narcotics usage and blur the study with hospital admissions studies.

I bet they sing a different tune with nerve blocks and hospital stays if they move the field goal post to real patients in USA like 30-40% of them are bmi more than 35 that we treat.

Idiots. Do they think the public is that dumb. I guess so.

It’s like the npo studies were done originally in the 1960s on asa 1 22 year old male medical studies 5 foot 10 weighing 150 pounds.
 
Whether you like it or not this study is in A&A and has nearly 60k ppl on it. It's not small change and is being read by a lot of people incl budget providers!
 
What do you guys think (article attached)? How do these results influence your practice?

Question was do peripheral nerve blocks vs no peripheral no blocks affect post-discharge outcomes in ambulatory shoulder surgery?

Essentially what they found was:
- Peripheral nerve blocks are associated with a decrease in unplanned admissions after ambulatory shoulder surgery
- There is no associated improvement in other postoperative outcomes such as emergency department visits, readmissions, mortality, or costs
- PNB associated with increase $325 Canadian compared to no PNB in health care system costs

There is no evidence for LESIs for the treatment of LBP exacerbations when looking at similar outcomes either, so how come so many people get them? Because they dont want to suffer while they await a resolution.

Same for the ISB for shoulder operations: you COULD do the case without the block, and 48hrs later the patient will be alive and pain will be OK. But for that 48hrs, why suffer with no block? The patient gets through the surgery with minimal other anesthetic, moves quickly and uneventfully through the ASC, and doesnt need as much post op opioid in total. And I'm sure the surgeons' offices' phone calls about pain/pain prescriptions are a lot less with blocks lasting well into POD 1 and 2. Would you rather be in agony during that time, consuming percocet, nonfunctional and miserable.. or your usual self with a numb arm and 350 dollars less in your pocket?
 
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Whether you like it or not this study is in A&A and has nearly 60k ppl on it. It's not small change and is being read by a lot of people incl budget providers!

Yeah but most don’t look at the specific details. 0.5% are considered obese.

The study is invalid cause 0.5% is not the patient population we are dealing with. It’s closer to 30% bmi over 35. Plus 68% asa 1/2. Again we in the real world deal with 30% asa 1/2 at many places.

They got a lot of selection bias. Extreme selection bias.
 
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This study is garbage.

Just like someone said above regarding LESIs, I’m doing a nerve block to improve pain control. Block or no block, whatever anesthetic technique I choose, patients will ultimately have the same outcome, but how you get there matters for the patient. Never have I thought in my mind when doing a nerve block “wow, this block is going to decease hospital unplanned admission, ER visit, or mortality”.
 
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Have you read the study showing that labor epidurals don’t decrease all cause mortality in the 72 hours after delivery, they don’t affect time to discharge, and they increase costs $632 per patient? (They didn’t look into pain or patient satisfaction.)
 
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I remember my fem/sci wearing off at 0300 after my ACL reconstruction. That ****ing sucked. Of course, I was also an idiot and didn't take anything else before going to bed, because I felt great (and had no training to know how long it was going to last)! I now tell patients my story, counsel them to get something on board before going to sleep, and have never heard of a patient coming back to the ED for pain (did have one 30-something with a Horner's thinking he had a stroke, though). If it's happening, I would think the surgeons would bring it up, but they keep asking for blocks.
That's the problem with blocks. They wear off. So you are just kicking the can down the road. Eventually you have to deal with the pain unless you keep the catheter forever. Might as well deal with it from the get go with multi modal.
 
That's the problem with blocks. They wear off. So you are just kicking the can down the road. Eventually you have to deal with the pain unless you keep the catheter forever. Might as well deal with it from the get go with multi modal.
The amount of pain, though, also decreases over time. When I had my shoulder scope, I added some adjuvants to stretch the surgical block duration out past 30+ hours, with a gradual fade. I took one percocet as it was wearing off, but it turned out to be unnecessary, as I was able to manage further discomfort with just occasional tylenol. If we can get patients past that acute phase, we can improve their recovery, and decrease the user of opioids.
 
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The amount of pain, though, also decreases over time. When I had my shoulder scope, I added some adjuvants to stretch the surgical block duration out past 30+ hours, with a gradual fade. I took one percocet as it was wearing off, but it turned out to be unnecessary, as I was able to manage further discomfort with just occasional tylenol. If we can get patients past that acute phase, we can improve their recovery, and decrease the user of opioids.


Surgeon I took care of reported a similar experience. He actually had a rotator cuff repair and require no postop opioids.
 
That's the problem with blocks. They wear off. So you are just kicking the can down the road. Eventually you have to deal with the pain unless you keep the catheter forever. Might as well deal with it from the get go with multi modal.

no, you are skipping the worst of the pain and letting them regain sensation further down the road when the pain is less intense.
 
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That's the problem with blocks. They wear off. So you are just kicking the can down the road. Eventually you have to deal with the pain unless you keep the catheter forever. Might as well deal with it from the get go with multi modal.

uh, no:prof:
 
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That's the problem with blocks. They wear off. So you are just kicking the can down the road. Eventually you have to deal with the pain unless you keep the catheter forever. Might as well deal with it from the get go with multi modal.
No. You do a block and multi-modal. And you markedly reduce your post-op pain in PACU and first 24 hrs, reduce your PONV and decrease LOS.

Not doing multi-modal with your blocks is asking for trouble. But pretending multi-modals are the equivalent of a block is stupidity.
 
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It's pretty amazing the studies that Anesthesiology will publish. They will reject a well-designed RCT asking a clinically relevant question yet publish pure garbage like this. Catheters are associated with increased unplanned readmissions/ED visits? Wow. Regionalists up North need to learn how to place/manage nerve catheters. That's all I gathered from this trash. Catheters are a hassle, but they definitely do not increase readmissions/ED visits if placed/managed correctly.
 
If blocks were included in the global anesthesia fee. Aka you wouldn’t see an extra dime. Would u do it in a true fee for service private practice?. I wouldn’t. Extra risk. Less is better when it comes to risks (hospital admissions)

At the end of Day. It’s always about the money. (In outpatient fee for service).
 
If blocks were included in the global anesthesia fee. Aka you wouldn’t see an extra dime. Would u do it in a true fee for service private practice?. I wouldn’t. Extra risk. Less is better when it comes to risks (hospital admissions)

At the end of Day. It’s always about the money. (In outpatient fee for service).


No. My friends at Kaiser, the VA, and the U do tons of blocks.
 
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No. My friends at Kaiser, the VA, and the U do tons of blocks.
Probably because they are included in some stupid non-opiate protocol, which increases the bean counters' end-of-year pay for performance. Which wouldn't even exist if medicine wouldn't play the politics du jour, currently the "war" on opiates. Why isn't there a war on stupidity EVER?
 
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Catheters are a hassle, but they definitely do not increase readmissions/ED visits if placed/managed correctly.
Catheters are a B**ch: I placed a picture perfect infra clav cath: tip right under the artery and taped the hell out of it with surgical glue etc...
Next morning I could not believe getting a call for the patient because the block had worn off.
I check with US and the tip had moved one cm lateral to the artery.
I undid the tapping and at the skin it hadn’t moved a mm!
 
If blocks were included in the global anesthesia fee. Aka you wouldn’t see an extra dime. Would u do it in a true fee for service private practice?. I wouldn’t. Extra risk. Less is better when it comes to risks (hospital admissions)

At the end of Day. It’s always about the money. (In outpatient fee for service).
No, at the end of the day, it's what kinda care I'd want for myself. And if that's not why you're doing what you're doing, then you should re-examine you're priorities. And if you know what you're doing, blocks don't increase hospital admissions.
 
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No, at the end of the day, it's what kinda care I'd want for myself. And if that's not why you're doing what you're doing, then you should re-examine you're priorities. And if you know what you're doing, blocks don't increase hospital admissions.
i used to be self-righteous.... then i snapped out of it..
 
If blocks were included in the global anesthesia fee. Aka you wouldn’t see an extra dime. Would u do it in a true fee for service private practice?. I wouldn’t. Extra risk. Less is better when it comes to risks (hospital admissions)

At the end of Day. It’s always about the money. (In outpatient fee for service).
We do most shoulders with just a block so it’s the primary anesthetic. There is a small bump in fee for using real time ultrasound and our own machine but it’s not much. So, yes, I would do that. Frankly, if I didn’t use an ISB for shoulders, I’d be replaced where I work.
We did have an ER visit from one recently who felt SOB hours after admission due to the phrenic. We are addressing that with better pre discharge teaching to our patients.
 
We do most shoulders with just a block so it’s the primary anesthetic. There is a small bump in fee for using real time ultrasound and our own machine but it’s not much. So, yes, I would do that. Frankly, if I didn’t use an ISB for shoulders, I’d be replaced where I work.
We did have an ER visit from one recently who felt SOB hours after admission due to the phrenic. We are addressing that with better pre discharge teaching to our patients.
The reason I said we wouldn’t do many blocks if money wasn’t involved is it’s human nature.

The main driving force of private practice medicine is almighty dollar especially in corporate owned/or even physician owned standalone outpatient centers.

I was 1099 contractor a few years ago in Florida and corporate owned standalone surgery center sent nasty email to head nurse about closing surgery center for the day due to pending hurricane. Let’s just say it was owned 51% by 8 billion dollar hedge fund people. Hurricane coming and they still wanted to run regular day cases to 4pm cause they thought they could finish before the storm came.
 
I always tell patients that if I was having XYZ surgery and a block was offered/available, then I would take it. Within reason, we should provide the anesthetic that we would want if we were the patient. Blocks usually help, side effects are rare, and with an appropriate multi-modal regimen started with time to kick in before the block wears off, then you can minimize or even avoid using narcotics.

The politics behind a study like this seem a bit suspicious, given the lapses in study design and outcome measures already mentioned in other posts higher up.
 
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I know many of you are skeptical but I’d pay an extra $200 for a small 10 ml bottle of Exparel if I was having an open rotator cuff repair or a total shoulder
If I was having a routine shoulder scope and rotator cuff repair via the scope I’d simply ask for Bup plus dexamethasone.

Dyspnea/SOB post ISB is related to 5 factors: intraplexus (I recommend periplexus), total volume of injectate, morbidly obesity sleep apnea and preexisting lung disease.

I am able to mitigate dyspnea by adjusting my block for those 5 factors.

Of course, there are other issues which can exacerbate dyspnea post ISB like phrenic nerve injury to the non operative side, neuromuscular diseases, etc but those are rare. The 5 main factors are the ones I see daily.
 
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“Future directions in regional anaesthesia: not just for the cognoscenti

T. Selak
First published: 05 September 2019
Cited by: 1
No external funding or competing interests declared.
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I read with interest Turbitt, Mariano and El‐Boghdadly's recent editorial 1. Regional anaesthesia has numerous potential benefits including opioid minimisation, high quality analgesia and avoidance of general anaesthesia risks. The recent proliferation of affordable ultrasound machines with improved image quality has led to the development of many ultrasound‐guided regional anaesthesia blocks. These blocks aim to further improve patient care, but the authors argue that some so‐called ‘new’ techniques are in fact previously used methods relying on ‘anatomical minutiae’ using unique nomenclature to differentiate them. This unnecessary complexity can alienate the non‐expert and can lead to block avoidance. Some patients therefore have no access to regional anaesthesia because their anaesthetist perceives modern techniques as insurmountably difficult. The authors argue that regionalists should focus on a simplification process, whereby the most effective blocks are selected from the plethora of options and these chosen few are actively moved from the bespoke into the mainstream. Turbitt et al. argue that anaesthesia as a specialty should aim to promote ‘a few blocks for the many’ rather than ‘many blocks for the few’.

The authors published a short list of high‐value basic blocks that they believe should be core for all anaesthetists and they go on to list other advanced blocks that can be used by experts. Predictably, the published list has triggered robust discussion amongst regional experts on social media 2. This commentary, while informative and entertaining, displays one of the downsides of discussions within groups of enthusiasts. In our quest to provide the best technical care for patients, have we placed sufficient emphasis on patient‐centred care? The holistic anaesthetist cares about the emotional wellbeing of the patient, as well as technical aspects of care.

A recent prospective observational study of upper limb surgery under regional or general anaesthesia assessed patient satisfaction postoperatively 3. The study was limited by a small sample size and lack of randomisation and therefore risks uncorrected confounders. However, the results are worthy of review and may be surprising to some anaesthetists. There was a statistically significant decrease in satisfaction for patients who had regional anaesthesia (32.1% not fully satisfied) compared with those who had general anaesthesia (5.5% not fully satisfied). The most common reasons for dissatisfaction were insufficient anaesthesia prior to surgery and discomfort with an insensate and uncontrollable arm postoperatively. Additionally, Droog et al. noted that lower pain scores did not necessarily lead to higher satisfaction scores.

De Andres et al. noted that patients’ experience of regional anaesthesia was the least evaluated area of anaesthetic practice 4. This seems to have remained unchanged 24 years later. A Google ScholarTM search of ‘regional anaesthesia’ retrieved 2860 results on the 8th July 2019. Adding the term ‘satisfaction’ to the title search reduced this to 23 results. An identical PubMedTM search produces a ratio of 1045:3. In practice, anaesthetists care deeply about the experience of their patients, but this is not reflected in the journals. We cannot assume to know what patients want, we need to ask them.

Whilst I applaud the insight of Turbitt et al. to propose an edit of regional anaesthesia techniques in order to simplify, be inclusive and facilitate broader use, future regional anaesthesia work should, however, include a greater emphasis on patient preferences and satisfaction to inform selection of the most appropriate anaesthetic techniques, whether regional or general.”
 
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it's hard for any joe on the street who's getting surgery done to understand or even comprehend what the experience is like to have a nerve block or even to have pain after surgery. As a result, patient experience is going to be strongly related to how well they were communicated with and how well their expectations end up matching their reality. If you had all day to explain an in-depth hour-long PARQ on anesthesia for shoulder surgery, I suspect people would go for a block and overall be very satisfied with the results.

Then again, those who opt to not have a block need to know the expectations post-op and I bet they would be *probably* satisfied as long as they knew what to expect.
 
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it's hard for any joe on the street who's getting surgery done to understand or even comprehend what the experience is like to have a nerve block or even to have pain after surgery. As a result, patient experience is going to be strongly related to how well they were communicated with and how well their expectations end up matching their reality. If you had all day to explain an in-depth hour-long PARQ on anesthesia for shoulder surgery, I suspect people would go for a block and overall be very satisfied with the results.

Then again, those who opt to not have a block need to know the expectations post-op and I bet they would be *probably* satisfied as long as they knew what to expect.

Fully agree. I think this is more about communication than anything else. Every block I do, I tell them they'll probably have some pain/soreness after surgery, but the block will take away the majority of pain they'd otherwise experience. When they wake up pain free the majority of the time, they're ecstatic. My partners who tell all their patients they will be completely numb and won't feel anything? They get more unhappy customers because not every block is perfect. Same for my epidurals for labor. Set the expectation at a reasonable level, not best case scenario, and the patient will be happy the vast majority of the time.
 
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Fully agree. I think this is more about communication than anything else. Every block I do, I tell them they'll probably have some pain/soreness after surgery, but the block will take away the majority of pain they'd otherwise experience. When they wake up pain free the majority of the time, they're ecstatic. My partners who tell all their patients they will be completely numb and won't feel anything? They get more unhappy customers because not every block is perfect. Same for my epidurals for labor. Set the expectation at a reasonable level, not best case scenario, and the patient will be happy the vast majority of the time.
Couldn’t agree more. This is a huge problem with labor epidurals. Sometimes before I even get to the patient, the nurse has told them they will be pain free from the epidural.
 
Fully agree. I think this is more about communication than anything else. Every block I do, I tell them they'll probably have some pain/soreness after surgery, but the block will take away the majority of pain they'd otherwise experience. When they wake up pain free the majority of the time, they're ecstatic. My partners who tell all their patients they will be completely numb and won't feel anything? They get more unhappy customers because not every block is perfect. Same for my epidurals for labor. Set the expectation at a reasonable level, not best case scenario, and the patient will be happy the vast majority of the time.
Totally agree with the labor epidural part. Might just be me, but disagree on the PNB part.
 
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