Single-shot block for elective shoulder surgery Is it enough? Mr C Watkins, Miss L Onwordi Mr J Chakravarthy, Dr A Gupta. NESRA annual meeting 2016

Transcription

1 Single-shot block for elective shoulder surgery Is it enough? Mr C Watkins, Miss L Onwordi Mr J Chakravarthy, Dr A Gupta. NESRA annual meeting 2016

2 Aim of review: Review of block practice and post-operative pain analgesic requirements. To assess the effectiveness of the current analgesia regime against the RCA standards. Pain scores (0 10) at rest, active movement, night recorded pre-op, day 1,3,7,14, 42 (6 weeks), 84 (12 weeks). Analgesia pre-op, on discharge and post op recorded on day at the same time intervals. Patient compliance.

3 Pre-operative Education. Outpatient clinic review: Awake surgery standard practice. All patients receive ISB awake. Patient leaflets. ( Pre-assessment: Clinic info reinforced by nurses and physiotherapists. Day of surgery: Final review by Consultant anaesthetist and surgeon Patient chooses RA only (Awake) or RA +GA.

4 Audit Standards. Royal College of Anaesthesia (RCA) guidance: <5% reporting severe pain on verbal pain score ( 7 on scale 0-10) in the first 48 hours after discharge.

5 Methods Prospective review of a non-consecutive cohort. Single surgeon. Period of review 29/09/14 31/12/2015. Total 87 patients recruited.

6 Results. Total 87 patients recruited. Total 32 patients (37%) had complete ISB data. Total 39 patients (44.8%) had complete post operative pain data. Total 34 patients (39%) had complete pre & post operative analgesia data.

7 Review of ISB practice. Total 32 patients. Technique: US only 8. US with NS 24. Supplementary 10mls 1% lignocaine around portal sites ISB Technique US only US +NS

8 ISB Practice. Local anaesthetic (LA) Number patients Vol LA mean (mls) Vol LA range (mls) Block duration Mean (hrs) Block duration Range (hrs) Ropivacaine 0.75% Levobupivacaine 0.375% + 2% lignocaine Levobupivacaine 0.5% Levobupivacaine 0.375% Levobupivacaine 0.5% + Prilocaine 1% All patients

9 Duration of ISB analgesia Mean average duration of block (hours) Local anesthetic agents Ropivacaine 0.75% Levobupivacaine 0.5% Levobupivacaine 0.5% + Prilocaine 1% Levobupivacaine 0.375% Levobupivacaine 0.375% + Lignocaine 2%

10 Total 11 ISB side effects Horners Phrenic nerve palsy Hoarseness Vasovagal 0 Side effects

11 Post-operative pain analysis Patient Demographics. Total 39 patients. 18 male; 21 female. Average age 50.9 years (range years). Period of review 29/09/14 31/12/ ISB + GA. 30 ISB only (awake surgery).

12 Pain score (0-10) Post-operative pain analysis mean pain score for all 39 patients pre-op 1 day 3 days 7 days 14 days 42 days 84 days rest active movement night

13 Pain score 0-10) Arthroscopic cuff repair group mean pain score 18 patients pre-op 1 day 3 days 7 days 14 days 42 days 84 days Rest Active movement Night

14 Pain score (0-10) Adhesive capsulitis group: Arthroscopic capsular release & MUA mean pain score 5 patients pre-op 1 day 3 days 7 days 14 days 42 days 84 days Rest Active movement Night

15 Pain score (0-10) Impingement group: Arthroscopy & SAD mean pain score 8 patients pre-op 1 day 3 days 7 days 14 days 42 days 84 days Rest Active movement Night

16 Pain score (0-10) Impingement & ACJ Group: Arthroscopy, SAD & ACJ excision (mean pain score) 3 patients pre-op 1 day 3 days 7 days 14 days 42 days 84 days Rest Active movement Night

17 Pain VAS (0-10) Labral & SLAP stabilisation group: mean pain score 5 patients pre-op 1 day 3 days 7 days 14 days 42 days Rest Active movement Night

18 Did we meet our audit standard? Active movement Female Male Mean age (years) GA Awake Total All Rest Active /23 Rest yes 43% no 57% Night Night RCA guidance: <5% reporting severe pain on verbal pain score ( 7 on scale 0-10) in the first 48 hours after discharge. yes 59% no 41% yes 36% All no 64% yes 38% no 62%

19 Number of patietns Number of patients reporting a severe 35 pain score ( 7) Pre op Day 1 Day 3 Day 7 Day 14 Day 42 Day 84 Total Rest Active Night

20 What factors may influence post Age & Sex? Type of surgery? Block duration? operative pain? Pre operative pain score? Pre operative analgesia? Compliance with prescribed discharge analgesia?

21 Does age or sex influence have an influence on post-operative pain? Pain score 7 post op day 1 Pain score 7 Post op day 1 Total Mean age Male Female ISB + GA ISB + Awake Total

22 Number of patients Number of patients with severe pain (score 7) on post-op day all rest active night cuff repair SAD Labral stablisation ACJ excision adhesive capsulitis

23 ISB duration (hours) Is there a correlation with ISB duration? mean block duration pain score >7 mean block duration pain score < 7 0 all rest active night

24 Duration of surgery (mins) Is a longer duration of surgery related to increased post-operative pain? duration of surgery (pain score 7) duration of surgery (pain score 7) 0 all patients Rest Active Night

25 Pain score (0-10) Does pre-operative pain have an 10 effect? all active night mean pre op pain score Mean pre op pain score

26 Does pre-operative analgesia requirements influence post operative requirements? Tramadol 0% Morphine 5% Neuropathic 5% Codeine 30% Not recorded 14% Nil 11% Simple 35% Pre-op analgesia Nil 4 Simple (paracetamol, naproxen, ibuprofen) Number of patients with pain score 7 13 Codeine 11 Tramadol 0 Neuropathic 2 Morphine 2 Not recorded 5 Total 25

27 Patient compliance with prescribed analgesic regime. All Patients total 34 Severe pain score ( 7) post op day 1 total 25 26% 74% Compliant Non-compliant 15% 18% 67% Compliant Non-compliant Not recorded

28 Analegsia prescribed on discharge - total 34 patients. Paracetamol Paracetamol & Ibuprofen Paracetamol & Codeine Paracetamol & Tramadol Paracetamol & Morphine Paracetamol & Ibuprofen & Codeine Paracetamol & Naproxen & Codeine Paracetamol & Ibuprofen & Tramadol Paracetamol & Naproxen & Tramadol Paracetamol & Codeine & Neuropathic Paracetamol & Codeine & Morphine 10% 3% 3% 3% 3% 3% 22% 3% 3% 3% 44%

29 Analgesic use for all patients. Simple codeine tramadol morphine neurpathic Pre-op 1 day 3 days 7 days 14 days 42 days 82 days

30 Limitations Small cohort and need larger numbers in order to validate results. Onset time of block was not recorded. Pain score on discharge was not recorded. Compliance with data collection was an issue.

31 Summary of findings Duration of Block is excellent with all regimes. trend towards longer duration of block with levobupivacaine. 1 patient had an adverse event requiring anaesthetic intervention (vasovagal).

32 Summary of findings Post-operative analgesia regime Post-operative analgesia regime was insufficient for the majority of patients undergoing elective shoulder arthroscopy as 64% did not meet RCA standards for post-operative pain relief In our cohort patients in all operative groups experienced severe pain on day 1 post op. (cuff repair, arthroscopic stabilisation worse pain scores.) Moderate pain seems to continue up to 2 weeks and longer in some groups (frozen shoulder, ACJ procedures). Improvements need to be made to post-op analgesia regime in terms of Increasing analgesic strength and patient compliance.

33 Evidence Post-operative analgesia regimes for shoulder arthroscopy. Single-injection v continuous infusion.

34 Post-operative analgesic regimes

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37 Suggestions for service improvement Currently in the process of developing an online audit platform Aim to improve real time data collection as 45% patients had incomplete data. Include onset time of block in data collection. Record post op nausea and vomiting (PONV) score. Record pain score on discharge. RCA guidance > 85% none to mild pain on discharge. Include patient satisfaction with analgesia regime. RCA guidance > 85% should be satisfied with analgesia regime.

38 Suggestions for service improvement e-prescribing post-operative analgesia bundle for shoulder arthroscopy to be set up. Post-operative Interscalene catheter service Audit all elective shoulder surgery at the QE To compare outcomes (pain, PONV, shoulder scores) between GA + LA, RA + GA and RA + awake surgery. Additionally, collect health status questionnaire (Euro Qual 5D) and Oxford Shoulder Score.

39 Questions