Multimodal Pain Management Protocol Versus Patient Controlled Narcotic Analgesia for Postoperative Pain Control after Shoulder Arthroplasty

Document Type : RESEARCH PAPER

Authors

Department of Orthopaedic Surgery, Rothman Institute- Thomas Jefferson University, Philadelphia, PA, USA

Abstract

 
Background: Our institution’s traditional pain management strategy after shoulder arthroplasty has involved the utilization of postoperative patient-controlled narcotic analgesia. More recently, we have implemented a protocol (TLC) that utilizes a multimodal approach. The purpose of this study was to determine whether this change has improved pain control and decreased narcotic utilization.
Methods: Patients undergoing primary total shoulder or reverse arthroplasty were retrospectively studied. All patients underwent interscalene brachial plexus blockade. “Traditional” patients were provided a patient-controlled analgesic pump postoperatively. TLC patients were given preoperative and postoperative multimodal, non-narcotic analgesic medications and breakthrough narcotics. Morphine equivalent units (MEU) consumed and Visual Analog Scale (VAS) scores for pain (0, 8, 16, and 24 hours) were considered.
Results: There were 108 patients in each group. Total postoperative narcotic consumption in the first 24 postoperative hours was 38.5 +/- 81.1 MEU in the “Traditional group” compared to 59.3 +/- 59.1 MEU in the TLC group (P<0.001). Of patients in the TLC group, 88% utilized breakthrough narcotics. VAS pain was significantly higher in the “Traditional group” at 16 hours (4.1 +/- 2.9 vs 3.2 +/- 2.7, P=0.020) and 24 hours (4.8 +/- 2.7 vs 3.7 +/- 2.6, P=0.004).
Conclusion: Those treated with the TLC protocol had greater narcotic utilization but better VAS pain scores at 24 hours after surgery. Both groups experienced rebound pain. While the TLC protocol led to an improved pain experience, further modification of the currently protocol may be necessary to reduce overall narcotic utilization.
Level of evidence: III

Keywords

Main Subjects

References

1. Halawi MJ, Grant SA, Bolognesi MP. Multimodal
analgesia for total joint arthroplasty. Orthopedics.
2015; 38(7):e616-25.
2. Parvizi J, Bloomfield MR. Multimodal pain
management in orthopedics: implications for joint
arthroplasty surgery. Orthopedics. 2013; 36(2
Suppl):7-14.
3. Bohl DD, Louie PK, Shah N, Mayo BC, Ahn J, Kim TD,
et al. Multimodal versus patient-controlled analgesia
after an anterior cervical decompression and fusion.
Spine (Phila Pa 1976). 2016; 41(12):994-8.
4. Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost
D, Trost GR, et al. Comparison of perioperative oral
multimodal analgesia versus IV PCA for spine surgery.
J Spinal Disord Tech. 2010; 23(2):139-45.
5. Stempniak M. The opioid epidemic. Hosp Health Netw.
2016; 90(3):22-4.
6. Rasche S, Koch T. [Regional anaesthesia versus
general anaesthesia--pathophysiology and clinical
implications]. Anaesthesiol Reanim. 2004; 29(2):30-8.
7. Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani
LU. Interscalene block for shoulder arthroscopy:
comparison with general anesthesia. Arthroscopy.
1993; 9(3):295-300.
8. 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(1):62-8.
9. Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G,
Dermksian J, et al. For outpatient rotator cuff surgery,
nerve block anesthesia provides superior same-day
recovery over general anesthesia. Anesthesiology.
2005; 102(5):1001-7.
10. Wu CL, Rouse LM, Chen JM, Miller RJ. Comparison of
postoperative pain in patients receiving interscalene
block or general anesthesia for shoulder surgery.
Orthopedics. 2002; 25(1):45-8.
11. Conroy BP, Gray BC, Fischer RB, Del Campo LJ, Kenter
K. Interscalene block for elective shoulder surgery.
Orthopedics. 2003; 26(5):501-3.
12. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking
FK. Continuous interscalene brachial plexus block for
postoperative pain control at home: a randomized,
double-blinded, placebo-controlled study. Anesth
Analg. 2003; 96(4):1089-95.
13. Williams G Jr, Kraeutler MJ, Zmistowski B, Fenlin JM Jr.
No difference in postoperative pain after arthroscopic
versus open rotator cuff repair. Clin Orthop Relat Res.
2014; 472(9):2759-65.
14. Kane-Gill SL, Rubin EC, Smithburger PL, Buckley
MS, Dasta JF. The cost of opioid-related adverse
drug events. J Pain Palliat Care Pharmacother. 2014;
28(3):282-93.
15. McCarthy M. US needs $1.1bn to treat opioid addiction.
BMJ. 2016; 352:i694.
16. Takada M, Fukusaki M, Terao Y, Yamashita K,
Takada M, Ando Y, et al. Postoperative analgesic
effect of preoperative intravenous flurbiprofen in
arthroscopic rotator cuff repair. J Anesth. 2009;
23(4):500-3.
17. Chechik O, Dolkart O, Mozes G, Rak O, Alhajajra F,
Maman E. Timing matters: NSAIDs interfere with
the late proliferation stage of a repaired rotator cuff
tendon healing in rats. Arch Orthop Trauma Surg.
2014; 134(4):515-20.
18. Connizzo BK, Yannascoli SM, Tucker JJ, Caro AC,
Riggin CN, Mauck RL, et al. The detrimental effects
of systemic Ibuprofen delivery on tendon healing
are time-dependent. Clin Orthop Relat Res. 2014;
472(8):2433-9.
19. Ahn S, Byun SH, Park K, Ha JL, Kwon B, Kim JC. Analgesic
efficacy of preemptive pregabalin administration
in arthroscopic shoulder surgery: a randomized
controlled trial. Can J Anaesth. 2016; 63(3):283-9.
20. Cohen SM. Extended pain relief trial utilizing
infiltration of Exparel(®), a long-acting multivesicular
liposome formulation of bupivacaine: a Phase IV
health economic trial in adult patients undergoing
open colectomy. J Pain Res. 2012; 5:567-72.
21. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL,
Adams JB. Soft tissue and intra-articular injection
of bupivacaine, epinephrine, and morphine has a
beneficial effect after total knee arthroplasty. Clin
Orthop Relat Res. 2004; 428:125-30.
22. Marcet JE, Nfonsam VN, Larach S. An extended paIn
relief trial utilizing the infiltration of a long-acting
Multivesicular liPosome foRmulation Of bupiVacaine,
EXPAREL (IMPROVE): a Phase IV health economic
trial in adult patients undergoing ileostomy reversal.
J Pain Res. 2013; 6:549-55.
23. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the
real benefits of single-shot interscalene block please
stand up? A Systematic review and meta-analysis.
Anesth Analg. 2015; 120(5):1114-29.
24. Kim CW, Kim JH, Kim DG. The factors affecting pain
pattern after arthroscopic rotator cuff repair. Clin
Orthop Surg. 2014; 6(4):392-400.
25. Cuff DJ, O’Brien KC, Pupello DR, Santoni BG. Evaluation
of factors affecting acute postoperative pain levels
after arthroscopic rotator cuff repair. Arthroscopy.
2016; 32(7):1231-6.
26. Premkumar A, Samady H, Slone H, Hash R, Karas S,
Xerogeanes J. Liposomal bupivacaine for pain control
after anterior cruciate ligament reconstruction: a
prospective, double-blinded, randomized, positivecontrolled
trial. Am J Sports Med. 2016; 44(7):1680-6.
27. Surdam JW, Licini DJ, Baynes NT, Arce BR. The
use of exparel (liposomal bupivacaine) to manage
postoperative pain in unilateral total knee arthroplasty
patients. J Arthroplasty. 2015; 30(2):325-9.
28. Vendittoli PA, Makinen P, Drolet P, Lavigne M,
Fallaha M, Guertin MC, et al. A multimodal analgesia 
protocol for total knee arthroplasty. A randomized,
controlled study. J Bone Joint Surg Am. 2006;
88(2):282-9.
29. Rennick A, Atkinson T, Cimino NM, Strassels SA,
McPherson ML, Fudin J. Variability in opioid equivalence
calculations. Pain Med. 2016; 17(5):892-8.
The Archives of Bone and Joint Surgery
Volume 6, Issue 3
May 2018
Pages 196-202

Files

History

  • Receive Date: 16 June 2017
  • Revise Date: 06 November 2017
  • Accept Date: 11 November 2017

Share

How to cite

Statistics