Single shot ISB vs continuous interscalene catheter for TSA

[excalibur]

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Anyone doing single shot ISB for their total shoulder arthroplasties? If so, and you are using decadron, how are your patients doing upon block resolution?

I ask because I have been doing blocks with decadron and patients do great. Around 30 hrs of analgesia and a tolerable 4-5/10 of pain upon block resolution per the patients that is easily controlled with oral pain meds. I was wondering if practitioners were seeing the same results if patients were having TSA or if that pain is more intense that a catheter would be warranted.

Also, if anyone is doing single shot blocks for TSA, are you trying to time the block so that the patient can participate in ROM physical therapy the following day?

Thanks

 

[BLADEMDA]

Yes. 20-25 mls of 0.5 percent Bup with decadron. I'm also adding 60-90 mics of Buprenorphine for the healthier patients. Blocks are in the 28-34 hour range and the patients seem satisfied with it.

 

[excalibur]

Thanks, Blade. I figured these patients would do well with single shot.

Any issues from the orthopods about ROM on POD 1? Not sure if there is a desired PT regimen like the TKA's

 

[Oggg]

My ortho doesn't care about motor block after TSA. We are doing catheters right now. I don't have buprenorphine yet. Our TSA get OxyContin and Percocet. They seem to hurt real bad after bupiv 0.5 wears off. Maybe decadron in the block, and a tough patient would do ok with SS. I don't think my pts are that tough

 

[excalibur]

My ortho doesn't care about motor block after TSA. We are doing catheters right now. I don't have buprenorphine yet. Our TSA get OxyContin and Percocet. They seem to hurt real bad after bupiv 0.5 wears off. Maybe decadron in the block, and a tough patient would do ok with SS. I don't think my pts are that tough

So you don't add decadron to initial bolus prior to starting infusion?

I would then say yes your TSA pts are going to hurt after Bupi wears off in 15 hrs or so. In residency the regular arthroscopy pts hurt severely when we would do plain LA blocks once the LA wore off at 15 hrs. They would sleep terribly and state the night was miserable. This is why I was so interested in trying to extend blocks past 24 hrs.

I spoke with some practitioners recently who use catheters for all shoulders. They said they just started using decadron at beginning of year for their initial bolus and starting infusion the next day. This is where I contended that from time and money perspective, SSB would be superior with still very good patient satisfaction

 

[Oggg]

I meant to say that a few of our CISB have dislocated, and when the initial bolus of 0.5 bupiv wears off, and the catheter fails, pts hurt a lot.

Your idea of bolusing with bupiv and steroid, then plugging in the pump the next day -- that sounds like a great idea. The only drawback is that it makes pain rounds longer on POD1, offset by extra day billed. I'm actually wondering if we should do that for our CACB for TKAs. And maybe even our cont sciatics for ankle fx. Granted, if your primary block wears off early, you could get called at 5am for pain.

 

[BLADEMDA]

So you don't add decadron to initial bolus prior to starting infusion?

I would then say yes your TSA pts are going to hurt after Bupi wears off in 15 hrs or so. In residency the regular arthroscopy pts hurt severely when we would do plain LA blocks once the LA wore off at 15 hrs. They would sleep terribly and state the night was miserable. This is why I was so interested in trying to extend blocks past 24 hrs.

I spoke with some practitioners recently who use catheters for all shoulders. They said they just started using decadron at beginning of year for their initial bolus and starting infusion the next day. This is where I contended that from time and money perspective, SSB would be superior with still very good patient satisfaction

I plan on using Exparel 133 mg (10 mls plus 10 mls of saline with 4mg decadron) next year once it gets approval from the FDA. This should give me 40- 48 hours without a catheter or pump. My hunch is 266 mg will give 48 hours without decadron and over 48 hours with decadron. I plan on starting with 133 mg as dosages lower than that may be less effective than my current combo of .5% Bup, decadron and Buprenorphine.

 

[BLADEMDA]

I meant to say that a few of our CISB have dislocated, and when the initial bolus of 0.5 bupiv wears off, and the catheter fails, pts hurt a lot.

Your idea of bolusing with bupiv and steroid, then plugging in the pump the next day -- that sounds like a great idea. The only drawback is that it makes pain rounds longer on POD1, offset by extra day billed. I'm actually wondering if we should do that for our CACB for TKAs. And maybe even our cont sciatics for ankle fx. Granted, if your primary block wears off early, you could get called at 5am for pain.

If you utilize 0.5% Bup with Decadron and Buprenorphine the initial block will exceed 24 hours.

 

[climbingak]

Anyone doing single shot ISB for their total shoulder arthroplasties? If so, and you are using decadron, how are your patients doing upon block resolution?

I ask because I have been doing blocks with decadron and patients do great. Around 30 hrs of analgesia and a tolerable 4-5/10 of pain upon block resolution per the patients that is easily controlled with oral pain meds. I was wondering if practitioners were seeing the same results if patients were having TSA or if that pain is more intense that a catheter would be warranted.

Also, if anyone is doing single shot blocks for TSA, are you trying to time the block so that the patient can participate in ROM physical therapy the following day?

Thanks

I do catheters for regular scopes but only do single shots for total shoulders. Our total shoulders are being started on Xarelto after 24 hours and we do them "outpatient" (spend the night in an ALF attached to the surgery center). I can get my SS to last the 24 hours so I find not much extra benefit in placing a cath only to pull it the next day once they start anticoagulation. I add decadron but have never added buprenorphine. I also would be interested in how exparel will fair for these. We are doing our first total knee tomorrow with Exparel. I am taking tips from the board here and doing half a vial in the adductor canal and half for local infiltration. These patients also go to our ALF after surgery here at the surgery center so I am looking forward to decreasing the motor block.

 

[GaseousClay]

we do a lot of catheters at our institution and have good results. we havent really started using decadron yet but I would like to see for myself how long a SS lasts with bupi/decadron

 

[excalibur]

I do catheters for regular scopes but only do single shots for total shoulders. Our total shoulders are being started on Xarelto after 24 hours and we do them "outpatient" (spend the night in an ALF attached to the surgery center). I can get my SS to last the 24 hours so I find not much extra benefit in placing a cath only to pull it the next day once they start anticoagulation. I add decadron but have never added buprenorphine. I also would be interested in how exparel will fair for these. We are doing our first total knee tomorrow with Exparel. I am taking tips from the board here and doing half a vial in the adductor canal and half for local infiltration. These patients also go to our ALF after surgery here at the surgery center so I am looking forward to decreasing the motor block.

If you are doing your TSA's with decadron Single shot blocks with good results, why on earth are you doing simple shoulder arthroscopies with catheters???

Shoulder arthroscopy (RCR, SAD, Mumford, biceps tendonesis) = Single shot ISB with decadron +/- buprenorphine = 30 hrs of 0/10 pain followed by 4/10 pain upon resolution of block at 30-32 hrs easily controlled by PO narcs.

Doing a catheter for a shoulder arthroscopy is wasting time and money and adding headaches via orders, setting pumps, possible dislodged catheters, follow up to remove catheter, etc.

I only wondered if catheters were warranted for TSA's thinking they would hurt significantly more than arthtosvopies on POD 1 when the 30+ hr block wore off. Based on Blade's info and the fact that you state your institution goes TSA's with SSB's with good results, I guess catheters aren't necessary for TSA's either

 

[climbingak]

If you are doing your TSA's with decadron Single shot blocks with good results, why on earth are you doing simple shoulder arthroscopies with catheters???

Shoulder arthroscopy (RCR, SAD, Mumford, biceps tendonesis) = Single shot ISB with decadron +/- buprenorphine = 30 hrs of 0/10 pain followed by 4/10 pain upon resolution of block at 30-32 hrs easily controlled by PO narcs.

Doing a catheter for a shoulder arthroscopy is wasting time and money and adding headaches via orders, setting pumps, possible dislodged catheters, follow up to remove catheter, etc.

I only wondered if catheters were warranted for TSA's thinking they would hurt significantly more than arthtosvopies on POD 1 when the 30+ hr block wore off. Based on Blade's info and the fact that you state your institution goes TSA's with SSB's with good results, I guess catheters aren't necessary for TSA's either

As I stated, the reason I don't do Caths for totals is because of the anticoagulation and the fact that we are sending them home after 23 hours.

Despite your disbelief, catheters for shoulder arthroscopies is a very common practice. Rotator cuff repairs hurt. My patients and the surgeons like the catheters. They get 3 days of relief after a good 24 hour full on block. It is not a waste of my time or a headache for me. I place them all myself, send them home and follow them myself. They remove them at home by themselves, no problems. After over a thousand of these placed and followed I have a good sense of how long these procedures hurt for, and for me and my patients, it is worth it.

You seem like you have it figured out for your patients, and that is great. But there are a lot of ways to skin a cat. ISB caths at my orthopedic ASC work very well. It keeps my surgeons and their patients happy which goes a long way in keeping my contract. I was only trying to share my experience to answer your question. I would have appreciated a more respectful response despite you having it all figured out.

 

[BLADEMDA]

I've had Shoulder Surgery. A Single shot block was more than adequate. The only time a Catheter is really needed for outpatient shoulder surgery is for open rotator cuff repair; surgical repair via the scope with a small incision doesn't require pumps. That said, with the right payer mix I fully understand the "need" for ISB catheters at ASCs.

 

[climbingak]

I've had Shoulder Surgery. A Single shot block was more than adequate. The only time a Catheter is really needed for outpatient shoulder surgery is for open rotator cuff repair; surgical repair via the scope with a small incision doesn't require pumps. That said, with the right payer mix I fully understand the "need" for ISB catheters at ASCs.

Ok, cool. So because someones practice differs from yours and your surgical experience they are only after money. I see. I can't wait until I reach the level of regional knowledge where I can pass judgement on others practice.

But aren't you the same guy who wants to use exparel for ISB to increase your block times to 48 hours? Why, if it isn't necessary? Why use decadron? Isn't it to extend the blocks? But it isn't necessary right? A single shot is perfectly adequate as long as it lasts 30 hours, right? Your message is confusing. Everyone would like to prolong the block because people have pretty intense pain for 2 days and finally start getting back to normal on day 3. I call these patients and follow them daily. Its not universal, but POD 2 can still be a bad day. POD3 they sound like themselves again. The caths help and are widely requested by both surgeons and patients.

I appreciate you passing judgement on my intentions though. Very professional.

 

[BLADEMDA]

For open Shoulder Repairs and Total Shoulders an ISB lasting at least 48 hours would be desirable. This means Exparel or a catheter makes sense on those subgroups.
For Shoulder Arthroscopy with a minimal incision the Exparel or Catheter is overkill.

 

[BLADEMDA]

Ok, cool. So because someones practice differs from yours and your surgical experience they are only after money. I see. I can't wait until I reach the level of regional knowledge where I can pass judgement on others practice.

But aren't you the same guy who wants to use exparel for ISB to increase your block times to 48 hours? Why, if it isn't necessary? Why use decadron? Isn't it to extend the blocks? But it isn't necessary right? A single shot is perfectly adequate as long as it lasts 30 hours, right? Your message is confusing. Everyone would like to prolong the block because people have pretty intense pain for 2 days and finally start getting back to normal on day 3. I call these patients and follow them daily. Its not universal, but POD 2 can still be a bad day. POD3 they sound like themselves again. The caths help and are widely requested by both surgeons and patients.

I appreciate you passing judgement on my intentions though. Very professional.

You are quite sensitive to comments. Nobody is passing judgment on you here. In fact, in a lot of places catheters and pain pumps are routinely placed for just about any type of Ortho operation. But, this stuff costs money and while I totally support a pain free experience the benefits of a block beyond 24-30 hours have yet to be proven. Hence, less invasive surgeries with minimal incisions most likely don't need catheters or pumps. Of course, with our current healthcare system we are paid to do more procedures even if the benefit is minimal. Hence, the better the payer mix the more likely the patient will receive a pain pump.

FYI, a single shot with Exparel should cost less than a pain pump filled with local and catheter system. Still, I'm not happy with a $280 local anesthetic as that cost needs to come down to about 1/2 that amount.

 

[sevoflurane]

I personally think that the real painful part is the distal clavicle excision. Dropping anchors and sutures can be painful, but I think removing part of your clavicle is more so. Honestly, I do believe that a catheter is probably best for those patients. You can dial in the analgesia and motor deficit. I’ve seen some amazing videos of patients having full strength and no pain after major surgery. Pretty awesome care. When I get that 36+ hour block from a single shot and the patient tells me they felt like they had a stroke for 1.5+ days, I don’t like it and nor do they... until the block wears off. If I had the resources, I’d do catheters for shoulders that require distal clavicle excision or are overly intrusive.
Now, if you are just removing some frayed fibers and just cleaning up the joint, then I'd do single shot all the way. If it's an overnight patient with significant comorbidites, I think the extra day you can get with the catheters is worth it. Day 3 can often still hurt. No doubt.
I used to send people home with pumps.
They loved it.
I'm glad to hear it's still being done, cuz that's what I would want for a full rotator cuff repair. Dial up when it hurts and take it out at my convenience. 🙄