Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

Leas, Daniel; Connor, Patrick M.; Schiffern, Shadley C.; D’Alessandro, Donald F; Roberts, Kailey E.; Hamid, Nady

doi:10.1016/j.jse.2019.01.013

Cited by 26 publications

(18 citation statements)

References 44 publications

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“…17 However, in shoulder arthroplasty, it has been demonstrated that optimizing patient pathways can allow for opioid-free postoperative recovery. 56 No specific nerve block was revealed to be superior in our study, although continuous ISB was shown to have the highest P-score at most time points. The advantage of a network meta-analysis is that it allows for comparison of all nerve blocks, with the ability to rank them based on outcomes using the P-score.…”

Section: Discussioncontrasting

confidence: 46%

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

et al. 2020

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Background: Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. Purpose: To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. Results: Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores ( P < .05). No benefit was found in any of the studies evaluating subacromial infusions. Conclusion: Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

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Section: Discussioncontrasting

confidence: 46%

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

et al. 2020

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“…In line of this assumption, Lavand'homme & Estebe [12] suggested that OFA stands as a new paradigm, which can deliver safe and stable anesthesia without intraoperative (IO) opioids to patients undergoing various surgical procedures. Also, Leas et al [20] reported that opioid-free multimodal pain management is safe and effective option in patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids and Soffin et al [21] found OFA within an ERAS pathway for lumbar spinal decompression can minimize perioperative opioid exposure without adversely affecting pain control or recovery. Moreover, Mulier [22] documented that opioid-free general anesthesia is a viable option for gynecological and breast surgeries.…”

Section: Discussionmentioning

confidence: 99%

Opioid-Free Anesthesia for Laparoscopic Hysterectomy: Is it Appropriate?

Salem

2019

JAICM

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Opioids are frequently associated with adverse events such as dizziness, drowsiness [7], high incidence of PO nausea and vomiting, which varies from 20%-60% [8] or constipation which disturbs PO recovery and extends the duration of hospital stay [7].With increased awareness of both short-and longterm problems associated with liberal perioperative opioid administration, the need for routinely and clinically feasible alternatives is greater than ever [9]. Implementation of multimodal analgesic regimen achieved equivalent and effective pain control aiming to reduce the reliance on opioid-based medications [10]. The application of enhanced recovery pathways promoted opioid-free and multimodal analgesia [11] and allowedAbstract Objective: To evaluate intraoperative (IO) and postoperative (PO) outcome of women assigned to laparoscopic hysterectomy under opioidfree anesthesia (OFA) in comparison to opioid-based anesthesia (OBA).Patient and Methods: 72 women were randomly divided into OBA and OFA groups according to the provided IO analgesic regimen. OBA patients received Fentanyl (FEN) as loading and Remifentanyl (REM) infusion as maintenance analgesia. OFA patients received preoperative parecoxib sodium for preparation, dexmedetomidine (DEX) and lidocaine (LID) as loading and maintenance analgesia. Study Outcomes included the frequency of patients developed IO deviated mean arterial pressure (MAP) measures by >20% of baseline measures, duration of surgery and time till fulfilling criteria for PACU discharge, duration of PO analgesia, time till 1st ambulation, PO complications and hospital stay.Results: Demographic data and surgical characteristics were comparable in all groups. The D group showed delay in onset for first call for analgesia (900±60.9min) while M and K groups results were (600±33.4min) and (350±17.4min) respectively, all of the group's results were statistically significant than the control group result (260±14.3min).Results: MAP measures during and 30-min after abdominal insufflations were significantly higher in patients of OFA than patients of OBA. Among 216 MAP readings, increased MAP measures by >20% of baseline measure was recorded in 10 (4.6%) versus 3 (1.4%) readings in OFA and OBA groups, respectively with a non-significant difference (p=0.091) between both groups. Duration till 1st ambulation was significantly shorter with OFA compared to OBA, while duration till 1st request of rescue analgesia was significantly longer with OFA, while the frequency of patients requested more rescue analgesia was significantly higher with OBA than OFA. PONV was reported in 53 patients and 17 patients required anti-emetic therapy with significantly higher incidence with OBA compared to OFA group. Conclusion:The applied protocol for OFA provided satisfactory IO analgesia and control of surgery-induced pressor reflexes. Also, it allowed reduction of PO analgesic consumption with early ambulation and reduced PONV that were reflected as shorter PO hospital stay.

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“…An early case-series study offers encouraging results. Leas et al (2019) [36] reported that patients undergoing elective shoulder arthroplasty and treated with non-opioid multimodal analgesia experienced overall low levels of pain at 24 h after surgery (2.5 out of 10), which remained stable at all postoperative time points. Additionally, there were low rates of reported nausea, constipation, and falls.…”

Section: Discussionmentioning

confidence: 99%

“…These steering committee members are experts in their respective fields and utilized existing literature (summarized in the background section) to inform the inclusion of various non-opioid analgesics in the protocols. Pilot testing was performed on a group of shoulder arthroplasty patients (data published previously in a case series [36]). The final protocols are presented in Table 2.…”

Section: Methods: Trial Design Patient Selection and Interventionmentioning

confidence: 99%

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Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

Shing

Leas

Michalek

et al. 2021

BMC Musculoskelet Disord

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Background The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics. Methods We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status. Discussion We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis. Trial registration The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783) on November 25, 2019, retrospectively registered

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Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

Cited by 26 publications

References 44 publications

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

Opioid-Free Anesthesia for Laparoscopic Hysterectomy: Is it Appropriate?

Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

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