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

  • Gavin M. Hamilton
  • Reva Ramlogan
  • Anne Lui
  • Colin J. L. McCartney
  • Faraj Abdallah
  • Daniel I. McIsaacEmail author
Reports of Original Investigations

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 ≥ 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 (NCT03309644). Registered 13 October 2017.

Association entre les blocs nerveux périphériques et des critères d’évaluation postopératoires chez des patients ambulatoires opérés de l’épaule: étude de cohorte appariée monocentrique

Résumé

Objectif

L’anesthésie régionale peut présenter des avantages postopératoires immédiats par rapport à une anesthésie générale, mais ses répercussions sur l’évolution après le congé sont mal connues. Notre objectif était de mesurer l’association entre l’anesthésie régionale et l’évolution des patients après une chirurgie ambulatoire de l’épaule.

Méthodes

Nous avons mené une étude de cohorte historique à l’hôpital d’Ottawa. Des adultes âgés de 18 ans et plus ayant subi une chirurgie ambulatoire de l’épaule entre le 1er janvier 2011 et le 31 décembre 2016 ont été inclus. Utilisant la technique d’appariement CEM (coarsened exact matching) « d’un-à-plusieurs » pour tenir compte des facteurs confondants éventuels, nous avons apparié des patients ayant subi un bloc nerveux périphérique (BNP) à des patients sans BNP. Au sein de la cohorte appariée, nous avons évalué si les BNP étaient associés à notre critère d’évaluation composite principal, comprenant les hospitalisations non planifiées, les visites aux urgences, les réhospitalisations ou les décès dans les 30 jours suivant la chirurgie.

Résultats

Au total, 1 623 patients satisfaisaient les critères d’inclusion; des BNP ont été réalisés chez 1 382 patients (85,2 %). Le logiciel de CEM a apparié 211 patients n’ayant pas reçu de BNP à 950 patients présentant des caractéristiques similaires et ayant reçu un BNP (n = 1 161; 71,5 % de la cohorte totale). Chez les patients ayant reçu un BNP comparés aux patients sans BNP, aucune différence n’a été observée sur le risque du critère composite (risque relatif, 1,58; intervalle de confiance [IC] à 95 % : 0,83 à 3,01) ou sur les coûts hospitaliers (rapport des moyennes 0,73; IC à 95 %, 0,21 à 2,49).

Conclusion

Les blocs nerveux périphériques n’ont pas été associés à une différence significative pour un critère d’évaluation composite d’événements indésirables postopératoires dans la chirurgie ambulatoire de l’épaule. Néanmoins, compte tenu de l’incidence plus faible que prévue et de la taille d’effet modéré associant les BNP aux événements post congé, de futurs grands essais prospectifs seront nécessaires pour évaluer les complications post congé.

Enregistrement de l’essai clinique

www.ClinicalTrials.gov (NCT03309644). Enregistré 13 octobre 2017.

Notes

Acknowledgements

The authors acknowledge the assistance of Sascha Davis, Information Specialist (Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada), for her assistance in developing and executing our literature search. The authors also acknowledge the Canadian Anesthesia Society for supporting this research.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Gavin M. Hamilton, Reva Ramlogan, and Daniel I. McIsaac contributed to all aspects of this manuscript, including study conception and design, and data acquisition, analysis, and interpretation. They also contributed to drafting the article. Anne Lui contributed to the conception and design of the study and interpretation of data. Colin J.L. McCartney and Faraj Abdallah contributed to the conception and design of the study.

Funding sources

CAS Resident Research Grant. Daniel I. McIsaac receives salary support from The Ottawa Hospital Department of Anesthesiology and Pain Medicine, is a Clinical Research Chair at the University of Ottawa, and is supported by the CAS Career Scientist Award.

Supplementary material

12630_2018_1234_MOESM1_ESM.pdf (16 kb)
Supplementary material 1 (PDF 15 kb)

References

  1. 1.
    Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Heal Stat Rep 1997; 11: 1-25.Google Scholar
  2. 2.
    Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord 2014; 15: 4.CrossRefGoogle Scholar
  3. 3.
    Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery–a prospective study. Can J Anaesth 1998; 45: 612-9.CrossRefGoogle Scholar
  4. 4.
    Memtsoudis SG, Ma Y, Swamidoss CP, Edwards AM, Mazumdar M, Liguori GA. Factors influencing unexpected disposition after orthopedic ambulatory surgery. J Clin Anesth 2012; 24: 89-95.CrossRefGoogle Scholar
  5. 5.
    Gerbershagen HJ, Aduckathil S, van Wijck A, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013; 118: 934-44.CrossRefGoogle Scholar
  6. 6.
    Wennberg J, Gittelsohn A. Small area variations in health care delivery 1973; 182: 1102-8.Google Scholar
  7. 7.
    Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am 2013; 95: 1318-24.CrossRefGoogle Scholar
  8. 8.
    von Elm E, Altman DG, Egger M, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Br Med J 2007; 335: 806-8.CrossRefGoogle Scholar
  9. 9.
    Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015; 12: e1001885.CrossRefGoogle Scholar
  10. 10.
    McIsaac DI, Bryson GL, van Walraven C. Impact of ambulatory surgery day of the week on postoperative outcomes: a population-based cohort study. Can J Anesth 2015; 62: 857-65.CrossRefGoogle Scholar
  11. 11.
    Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg 2015; 24: 24-30.CrossRefGoogle Scholar
  12. 12.
    Wodchis W, Bushmeneva K, Nikitovic M, McKillop I. Guidelines on person level cost using administrative databases in Ontario. Working Paper Series - Volume 1, May 2013. Available from URL: http://www.hsprn.ca/uploads/files/Guidelines_on_PersonLevel_Costing_May_2013.pdf (accessed August 2018).
  13. 13.
    Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130-9.CrossRefGoogle Scholar
  14. 14.
    Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Commun Stat Simul Comput 2009; 38: 1228-34.CrossRefGoogle Scholar
  15. 15.
    Blackwell M, Iacus S, King G, Porro G. CEM: coarsened exact matching in stata. Stata J 2009; 9: 524-46.CrossRefGoogle Scholar
  16. 16.
    Iacus SM, King G, Porro G. Multivariate matching methods that are monotonic imbalance bounding. J Am Stat Assoc 2011; 106: 345-61.CrossRefGoogle Scholar
  17. 17.
    King G, Nielsen R, Coberley C, Pope JE, Wells A. Comparative effectiveness of matching methods for causal inference. Unpublished Manuscript 2011. Available from URL: http://j.mp/2nydGlv (accessed August 2018).
  18. 18.
    van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 2009; 47: 626-33.CrossRefGoogle Scholar
  19. 19.
    Austin PC, Ghali WA, Tu JV. A comparison of several regression models for analysing cost of CABG surgery. Stat Med 2003; 22: 2799-815.CrossRefGoogle Scholar
  20. 20.
    Austin PC. Statistical criteria for selecting the optimal number of untreated subjects matched to each treated subject when using many-to-one matching on the propensity score. Am J Epidemiol 2010; 172: 1092-7.CrossRefGoogle Scholar
  21. 21.
    Austin PC. A tutorial and case study in propensity score analysis: an application to estimating the effect of in-hospital smoking cessation counseling on mortality. Multivariate Behav Res 2011; 46: 119-51.CrossRefGoogle Scholar
  22. 22.
    McNutt LA, Wu C, Xue X, Hafner JP. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol 2003; 157: 940-3.CrossRefGoogle Scholar
  23. 23.
    Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU. Interscalene block for shoulder arthroscop: comparison with general anesthesia. Arthroscopy 1993; 9: 295-300.CrossRefGoogle Scholar
  24. 24.
    D’Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth 1995; 20: 62-8.Google Scholar
  25. 25.
    Danninger T, Stundner O, Rasul R, et al. Factors associated with hospital admission after rotator cuff repair: the role of peripheral nerve blockade. J Clin Anesth 2015; 27: 566-73.CrossRefGoogle Scholar
  26. 26.
    Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005; 102: 1001-7.CrossRefGoogle Scholar
  27. 27.
    Atchabahian A, Schwartz G, Hall CB, Lajam CM, Andreae MH. Regional analgesia for improvement of long-term functional outcome after elective large joint replacement. Cochrane Database Syst Rev 2015; 8: CD010278.Google Scholar
  28. 28.
    Warrender WJ, Syed UA, Hammoud S, et al. Pain management after outpatient shoulder arthroscopy: a systematic review of randomized controlled trials. Am J Sports Med 2017; 45: 1676-86.CrossRefGoogle Scholar
  29. 29.
    Liu J, Flynn DN, Liu WM, Fleisher LA, Elkassabany NM. Hospital-based acute care within 7 days of discharge after outpatient arthroscopic shoulder surgery. Anesth Analg 2018; 126: 600-5.CrossRefGoogle Scholar
  30. 30.
    Ding DY, Mahure SA, Mollon B, Shamah SD, Zuckerman JD, Kwon YW. Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: a retrospective propensity-matched cohort analysis. J Orthop 2017; 14: 417-24.CrossRefGoogle Scholar
  31. 31.
    Sunderland S, Yarnold CH, Head SJ, et al. Regional versus general anesthesia and the incidence of unplanned health care resource utilization for postoperative pain after wrist fracture surgery: results from a retrospective quality improvement project. Reg Anesth Pain Med 2016; 41: 22-7.CrossRefGoogle Scholar
  32. 32.
    Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol 2015; 32: 88-105.CrossRefGoogle Scholar
  33. 33.
    Myles PS, Devereaux PJ. Pros and cons of composite endpoints in anesthesia trials. Anesthesiology 2010; 113: 776-8.CrossRefGoogle Scholar
  34. 34.
    Marhofer P, Anderl W, Heuberer P, et al. A retrospective analysis of 509 consecutive interscalene catheter insertions for ambulatory surgery. Anaesthesia 2015; 70: 41-6.CrossRefGoogle Scholar
  35. 35.
    Fredrickson MJ, Leightley P, Wong A, Chaddock M, Abeysekera A, Frampton C. An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study. Anaesthesia 2016; 71: 373-9.CrossRefGoogle Scholar
  36. 36.
    Bernatz JT, Tueting JL, Anderson PA. Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis. PLoS One 2015; 10: e0123593.CrossRefGoogle Scholar
  37. 37.
    Mahoney A, Bosco JA 3rd, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg 2014; 23: 377-81.CrossRefGoogle Scholar
  38. 38.
    Sherman SL, Lyman S, Koulouvaris P, Willis A, Marx RG. Risk factors for readmission and revision surgery following rotator cuff repair. Clin Orthop Relat Res 2008; 466: 608-13.CrossRefGoogle Scholar
  39. 39.
    Bosco L, Zhou C, Murdoch JA, et al. Pre- or postoperative interscalene block and/or general anesthesia for arthroscopic shoulder surgery: a retrospective observational study. Can J Anesth 2017; 64: 1048-58.CrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Pain MedicineUniversity of OttawaOttawaCanada
  2. 2.The Ottawa Hospital Research InstituteUniversity of OttawaOttawaCanada
  3. 3.School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada

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