American Society of Regional Anesthesia and Pain Medicine May 2017 - 34
nerve block typically addresses this area of discomfort if performed
preoperatively or can simply be infiltrated by the surgeon prior to
portal placement. Placement of the anterior superior portal (working
portal) is generally well tolerated.
In patients who opt to stay awake during surgery, the surgeon
evaluates the shoulder and discusses findings with the patient,
diagnoses and treats the existing abnormalities, and alludes to
postoperative expectations (rehabilitation, recovery, and use).
Patients actively participating in their surgery express higher levels
of satisfaction, report a better understanding of their procedure,
and rarely complain of discomfort.
Patients make a seamless transition from the operating room to
the PACU with minimal to no cognitive impairment often bypassing
phase I recovery. Moreover, most are ready for discharge upon
arrival into the PACU as they have already discussed the goals
of care, have adequate pain control, and have negligible residual
anesthetic or nausea, all of which are deterrents to discharge.
The overwhelming majority of patients who undergo shoulder
arthroscopy with minimal sedation and interscalene nerve block
report high levels of satisfaction and would repeat the procedure in
a similar fashion.
Two and half years ago, we instituted a multimodal perioperative pain
protocol for patients undergoing ambulatory shoulder surgery. The
main elements of the protocol (in addition to RA) are acetaminophen,
gabapentin, short course of nonsteroidal anti-inflammatory drugs,
and opioids as needed. Implementation of this protocol resulted in
overall reduction in opioid consumption over the first 3 days after
surgery, better quality of recovery, and higher patient satisfaction
with their pain management. The results of this work were presented
at the ASRA spring meeting in San Francisco, 2017.21
Continuous ambulatory perineural catheters are offered to select
patients. This portion of our practice represents only 20% of our
ambulatory surgical volume. Selection criteria include, but are
not limited to: patients with chronic pain syndromes or increased
analgesic requirements, patients scheduled for arthroscopic capsular
release for adhesive capsulitis, and patients who are very sensitive to
oral opioids. Patients who are discharged home with an ambulatory
catheters should have adequate home support, be reliable, be
accessible, and be able to understand and follow instructions.
We believe that a team approach and communication between
perioperative care management team members are the key
elements to success for implementation of any new care protocols.
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Husby T, Haugstvedt JR, Brandt M, Holm I, Steen H. Open versus arthroscopic
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Sauerbrey AM, Getz CL, Piancastelli M, Iannotti JP, Ramsey ML, Williams GR
Jr. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical
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Severud EL, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus
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Cullen DJ, Kirby RR. Beach chair position may decrease cerebral perfusion:
catastrophic outcomes have occurred. APSF Newsletter. 2007;22(2):25.
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Buess E. Open versus arthroscopic rotator cuff repair: a comparative view of 96
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Bankart repair: analysis of patient subjective outcome and cost arthroscopy.
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comparative view of 96 cases. Arthroscopy. 2005;21:597-604.
11. Sperling JW. Patient perceptions of open and arthroscopic shoulder surgery.
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12. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic
shoulder surgery. Arthroscopy. 2002;18:88-95.
13. Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright
position: a case series. J Clin Anesth. 2005;17:463-9.
14. Soeding PF. The effect of the sitting upright or "beachchair" position on cerebral
blood flow during anaesthesia for shoulder surgery. Anaesth Intensive Care.
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15. Dagal A, Lam AM. Cerebral autoregulation and anesthesia. Curr Opin
Anaesthesiol. 2009;22(5):547-52.
16. Laflam A. Shoulder surgery in the beach chair position is associated with
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18. Brown AR, Weiss R, Greenberg C, et al. Interscalene block for shoulder
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19. Gonano C, Kettner SC, Ernstbrunner M, et al. Comparison of economical
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20. Ende D, Gabriel RA, Vlassakov KV, Dutton RP, Urman RD. Epidemiologic data and
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21. Wang A, Kuntz A, Liu J, Mattera M, Elkassabany N. Improved quality of recovery
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American Society of Regional Anesthesia and Pain Medicine
2017
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