Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?
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Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.
Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups?
We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay.
We identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2–68.9 years] versus 69.1 years [95% CI: 68.9–69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97–1.02; p = 0.467)
Addition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
- Aguirre, J, Moral, A, Cobo, I, Borgeat, A, Blumenthal, S (2012) The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012: pp. 560879
- Austin, P, Rothwell, DM, Tu, JV (2002) A comparison of statistical modeling strategies for analyzing length of stay after CABG surgery. Health Services & Outcomes Research Methodology. 3: pp. 107-133 CrossRef
- Bhatia, A, Lai, J, Chan, VW, Brull, R (2010) Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block. Anesth Analg. 111: pp. 817-819 CrossRef
- Borgeat, A, Ekatodramis, G, Kalberer, F, Benz, C (2001) Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 95: pp. 875-880 CrossRef
- Brandl, F, Taeger, K (1991) [The combination of general anesthesia and interscalene block in shoulder surgery] [in German]. Anaesthesist. 40: pp. 537-542
- Claeys, MJ, Sinnaeve, PR, Convens, C, Dubois, P, Boland, J, Vranckx, P, Gevaert, S, Coussement, P, Beauloye, C, Renard, M, Vrints, C, Evrard, P (2013) Inter-hospital variation in length of hospital stay after ST-elevation myocardial infarction: results from the Belgian STEMI registry. Acta Cardiol. 68: pp. 235-239
- Deyo, RA, Cherkin, DC, Ciol, MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 45: pp. 613-619 CrossRef
- Gaughan, J, Kobel, C, Linhart, C, Mason, A, Street, A, Ward, P (2012) Why do patients having coronary artery bypass grafts have different costs or length of stay? An analysis across 10 European countries. Health Econ. 21: pp. 77-88 CrossRef
- Guay, J (2006) The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis. J Clin Anesth. 18: pp. 124-128 CrossRef
- Hortense, A, Perez, MV, Amaral, JL, Oshiro, AC, Rossetti, HB (2010) Interscalene brachial plexus block: effects on pulmonary function. Rev Bras Anestesiol. 60: pp. 74-78
- Hosmer, DW, Lemeshow, S (2000) Applied Logistic Regression. John Wiley & Sons Inc, New York, NY CrossRef
- Hosmer, DW, Lemeshow, SA (1980) Goodness-of-fit test for the multiple logistic regression model. Commun Stat. A10: pp. 1043-1069 CrossRef
- llfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–925.
- Ilfeld, BM, Vandenborne, K, Duncan, PW, Sessler, DI, Enneking, FK, Shuster, JJ, Theriaque, DW, Chmielewski, TL, Spadoni, EH, Wright, TW (2006) Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 105: pp. 999-1007 CrossRef
- Ilfeld, BM, Wright, TW, Enneking, FK, Morey, TE (2005) Joint range of motion after total shoulder arthroplasty with and without a continuous interscalene nerve block: a retrospective, case-control study. Reg Anesth Pain Med. 30: pp. 429-433
- Kessler, ER, Shah, M, Gruschkus, SK, Raju, A (2013) Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 33: pp. 383-391 CrossRef
- Lenart, MJ, Wong, K, Gupta, RK, Mercaldo, ND, Schildcrout, JS, Michaels, D, Malchow, RJ (2012) The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 13: pp. 828-834 CrossRef
- Lin, E, Choi, J, Hadzic, A (2013) Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol. 26: pp. 467-474
- Lindenauer, PK, Pekow, P, Wang, K, Mamidi, DK, Gutierrez, B, Benjamin, EM (2005) Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 353: pp. 349-361 CrossRef
- Liu, SS, Gordon, MA, Shaw, PM, Wilfred, S, Shetty, T, Yadeau, JT (2010) A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg. 111: pp. 617-623 CrossRef
- Memtsoudis, SG, Sun, X, Chiu, YL, Nurok, M, Stundner, O, Pastores, SM, Mazumdar, M (2012) Utilization of critical care services among patients undergoing total hip and knee arthroplasty: epidemiology and risk factors. Anesthesiology. 117: pp. 107-116 CrossRef
- Memtsoudis, SG, Sun, X, Chiu, YL, Stundner, O, Liu, SS, Banerjee, S, Mazumdar, M, Sharrock, NE (2013) Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 118: pp. 1046-1058 CrossRef
- Merkow, RP, Hall, BL, Cohen, ME, Dimick, JB, Wang, E, Chow, WB, Ko, CY, Bilimoria, KY (2012) Relevance of the c-statistic when evaluating risk-adjustment models in surgery. J Am Coll Surg. 214: pp. 822-830 CrossRef
- Pepe, MS (2003) The Statistical Evaluation of Medical Tests for Classification and Precision. Oxford University Press, Oxford, UK
- Premier Inc. Premier perspective database. Available at: www.premierinc.com/quality-safety/tools-services/prs/data/perspective.jsp. Accessed September 7, 2013.
- Rohrbaugh, M, Kentor, ML, Orebaugh, SL, Williams, B (2013) Outcomes of shoulder surgery in the sitting position with interscalene nerve block: a single-center series. Reg Anesth Pain Med. 38: pp. 28-33 CrossRef
- Shah, A, Nielsen, KC, Braga, L, Pietrobon, R, Klein, SM, Steele, SM (2007) Interscalene brachial plexus block for outpatient shoulder arthroplasty: postoperative analgesia, patient satisfaction and complications. Indian J Orthop. 41: pp. 230-236 CrossRef
- Sinha, SK, Abrams, JH, Barnett, JT, Muller, JG, Lahiri, B, Bernstein, BA, Weller, RS (2011) Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 36: pp. 17-20 CrossRef
- Stundner, O, Chiu, YL, Sun, X, Mazumdar, M, Fleischut, P, Poultsides, L, Gerner, P, Fritsch, G, Memtsoudis, SG (2012) Comparative perioperative outcomes associated with neuraxial versus general anesthesia for simultaneous bilateral total knee arthroplasty. Reg Anesth Pain Med. 37: pp. 638-644 CrossRef
- Sviggum, HP, Jacob, AK, Mantilla, CB, Schroeder, DR, Sperling, JW, Hebl, JR (2012) Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 37: pp. 490-494 CrossRef
- Tetzlaff, JE, Yoon, HJ, Brems, J (1994) Interscalene brachial plexus block for shoulder surgery. Reg Anesth. 19: pp. 339-343
- United States Department of Health and Human Services. OCR Privacy Brief: Summary of the HIPAA Privacy Rule. Washington, DC: Office for Civil Rights, HIPAA Compliance Assistance; 2003.
- Urmey, WF, Gloeggler, PJ (1993) Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume. Reg Anesth. 18: pp. 244-249
- Urmey, WF, Talts, KH, Sharrock, NE (1991) One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg. 72: pp. 498-503 CrossRef
- Verelst, P, Zundert, A (2013) Respiratory impact of analgesic strategies for shoulder surgery. Reg Anesth Pain Med. 38: pp. 50-53 CrossRef
- Wolfe, JW, Butterworth, JF (2011) Local anesthetic systemic toxicity: update on mechanisms and treatment. Curr Opin Anaesthesiol. 24: pp. 561-566 CrossRef
- Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?
Clinical Orthopaedics and Related Research®
Volume 472, Issue 5 , pp 1482-1488
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- 1. Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria
- 2. Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY, USA
- 3. Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
- 4. Department of Trauma Surgery, Paracelsus Medical University, Salzburg, Austria
- 5. Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA