Association of peripheral nerve blocks with postoperative outcomes in ambulatory shoulder surgery patients: a single-centre matched-cohort study

Abstract

Purpose Regional anesthesia may have immediate postoperative advantages compared with general anesthesia, but its impact on post-discharge outcomes is poorly described. Our objective was to measure the association between regional anesthesia and outcomes after ambulatory shoulder surgery. Methods We conducted a historical cohort study at The Ottawa Hospital. Adults C 18 yr old having elective ambulatory shoulder surgery from January 1, 2011 to December 31, 2016 were included. Using one-to-many coarsened exact matching (CEM) to adjust for potential confounders, we matched peripheral nerve block (PNB) patients to those without a PNB. Within the matched cohort, we assessed whether PNBs were associated with our primary composite outcomes, comprising unplanned admissions, emergency department visits, readmissions, or death within 30 days of surgery. Results There were 1,623 patients who met the inclusion criteria; PNBs were placed in 1,382 (85.2%) patients. CEM matched 211 patients who did not receive a PNB to 950 patients with similar characteristics who did receive a PNB (n = 1,161; 71.5% of total cohort). In patients who received a PNB compared with those who had no PNB, there was no difference in risk of composite outcome (relative risk, 1.58; 95% confidence interval [CI], 0.83 to 3.01), or hospital costs (ratio of means 0.73; 95% CI, 0.21 to 2.49). Conclusion Peripheral nerve blocks in ambulatory shoulder surgery were not associated with a significant difference in a composite of adverse postoperative outcomes. Nevertheless, given the lower than expected incidence and moderate effect size associating PNBs with post-discharge events, future large prospective trials are needed to assess post-discharge outcomes. Trial registration www.clinicaltrials.gov (NCT03309 644). Registered 13 October 2017.

Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery

“…Jensen et al 7 found that continuous peripheral nerve blocks are associated with increased rates of ED visits after arthroscopic rotator cuff repair (6.71% vs 4.74%, P < 0.02), and King et al 26 reported that unanticipated health care resource utilization related to continuous peripheral nerve blocks in upper extremity surgery may approach 38%. Hamilton et al, 27 however, did not find increased ED resource utilization among 2207 patients undergoing elective shoulder surgery with and without blocks at their institution, a finding corroborated by their subsequent population study of 59 644 Ontario residents. 4 Liu et al reported that among 103 476 patients undergoing outpatient arthroscopic surgery at 243 facilities in New York state, the most common reason for an unanticipated acute care encounter within 7 postoperative days (ie, inpatient or ED encounter) is musculoskeletal pain (23.8% of the 1867 acute care patient encounters).…”

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature

“…Finally, 28 studies including 27,581 patients were identified as potentially relevant and were selected for the systematic review. 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 All of the included studies were published in English. These studies covered the period from January 2000 to May 2021.…”

“…The sample size of the included studies ranged from 20 to 14,713 adults who underwent various medical procedures under general and local or regional anesthesia in an outpatient setting. General anesthesia was compared to local anesthesia in 15 studies, 10 , 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 27 , 30 , 33 to spinal anesthesia in 7 studies, 12 , 15 , 25 , 31 , 32 , 34 , 35 and to both in 5 studies. 26 , 28 , 29 , 36 , 37 Medical procedures were different and included laryngoplasty, knee arthroscopy, biopsy, hernia repair, hysteroscopy, and others.…”

“…Regional anesthetic techniques encompassed axillary brachial plexus block, 33 ilioinguinal-hypogratric 37 or paracervical 18 or peripheral 24 or sciatic-femoral 23 , 28 , 30 nerve block, and epidural 26 or spinal 15 , 25 , 28 , 29 , 31 , 32 , 34 , 35 , 36 , 37 or intravenous regional 33 anesthesia. Thirteen studies were randomized controlled trials, 12 , 22 , 23 , 25 , 26 , 28 , 29 , 30 , 31 , 32 , 34 , 36 , 37 2 of which were double-blinded, 23 , 25 and 15 were observational with a prospective 16 , 27 , 33 or a retrospective 10 , 11 , 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 , 24 , 35 design. The overall quality of the included studies was assessed with the CHEC list ( Appendix A ).…”

“…Regardless of the medical procedure, the total costs were significantly higher for general anesthesia than local 14 , 16 , 17 , 19 , 20 , 21 , 22 , 27 or regional 11 , 12 , 15 , 18 , 24 , 25 , 28 , 32 , 33 , 34 , 37 anesthetic techniques in almost all included studies, other than five studies that reported no statistically significant difference between loco-regional and general anesthesia. 13 , 23 , 30 , 31 , 35 Only one study reported higher costs in patients who received the loco-regional anesthesia. 10 Furthermore, three studies comparing all three types of anesthesia 26 , 29 , 36 confirmed the lowest costs for medical procedures under local anesthesia and similar costs between general and spinal or epidural anesthesia, 26 , 29 except one showing higher costs under general anesthesia.…”