Peripheral Nerve Blocks for Ambulatory Shoulder Surgery

Abstract

Background: Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery. Methods:We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators.results: We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups. conclusions:In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant. (ANESTHESIOLOGY 2019; 131:1254-63) editor'S PerSPective What We Already Know about This Topic • The use of peripheral nerve blocks after ambulatory shoulder surgery is increasing • While short-term pain control is improved by nerve blocks in this context, the relationship with postdischarge outcomes is unclear What This Article Tells Us That Is New • 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 Acute pain 302 (1.1) 434 (1.4) Surgical dressing or suture 168 (0.6) 102 (0.3) bleeding 94 (0.3) 69 (0.2) Pain in joint 50 (0.2) 68 (0.2) Urinary retention 76 (0.3) 64 (0.2) eD, emergency department; PNb, peripheral nerve block.

Managing rebound pain after regional anesthesia

“…This may be partly explained by the fact that RA patients were far less likely to have received opioid and non-opioid analgesics prior to discharge, and there was no systematic patient education plan in place regarding post-discharge management of the postoperative transition from RA to systemic analgesia. A negative impact of RA (and the associated rebound pain) on healthcare utilization was not however borne out in a much larger retrospective study of over 59,000 patients undergoing outpatient shoulder surgery [52]. Patients who received a PNB, in fact, had a significantly lower rate of unplanned admissions, readmissions, or emergency department visits (9% vs. 12%) in the first seven postoperative days.…”

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

“…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). Similar to our study, these encounters most frequently occurred within the first postoperative day.…”

“…3 These benefits have contributed to increasing use of peripheral nerve blocks over time in upper extremity surgery. 4,5 The effect of peripheral nerve blocks on perioperative resource utilization, however, is less clear. It is generally believed that peripheral nerve blocks decrease health care resource utilization by obviating the need for overnight hospital stays for pain control.…”

“…3 These benefits have contributed to increasing use of peripheral nerve blocks over time in upper extremity surgery. 4,5…”

A year in review in Minerva Anestesiologica 2022: anesthesia, analgesia, and perioperative medicine

“…86 interestingly, Hamilton et al conducted a multicenter analysis of almost 60.000 patients addressing the issue of peripheral nerve blocks (PNB) for ambulatory shoulder surgery. 87 they compared patients who received peripheral nerve blockade to those who did not about outcomes, such as readmission rates and costs in the first seven days after surgery. They found that "nerve blockade was not associated with any difference in a composite outcome measure, but was associated with a small increase in costs.…”