ORIGINAL ARTICLE

Postoperative analgesia in outpatient arthroscopic

shoulder surgery: Prospective and comparative
study of single-injection interscalene block versus
continuous injection by interscalene catheter
J. Deranlot MD, L. Kopel…..

___________________________________
result in good analgesia with minimal
opioid requirement, cost savings and
BACKGROUND AND OBJECTIVES possibly improvement in outcome
Arthroscopic shoulder surgery has grown measures (nielsen 2003))
significantly over the past few years at the
expense of open-air surgery for some
In this study, our aim was to compare the
shoulder surgery procedures. That trend
postoperative pain after an arthroscopic
can be explained by the many benefits
shoulder surgery between a continuous
offered by the arthroscopic
infra-scalenic block by Naropeine over 3
approach, especially in terms of early
days versus a single-injection infra-
postoperative pain reduction, sparing the
scalenic block in combination with
muscles of the shoulder gridle. The
dexamethasone (DXM) Secondary issues
management of pain is an important issue
were to determine and compare the side
as much as it conditions the functional
effects.
recovery. Our hypothesis was that there were no
Ambulatory care in arthroscopic shoulder differences between the two analgesic
surgery has experienced an important protocols.
development through the improvement of
loco-regional anesthesia and more recently METHODS
with multimodal techniques associated
We performed a prospective non-
with conventional anesthetic products and
randomized, monocentric, mono-operator,
adjuvant products (uquillas ). The benefit
comparative study between November
of continuous perineural infusions for pain
2014 and December 2015, in a private
control after shoulder procedures is not
hospital in France, including 39
well established, on the other hand the
consecutive patients undergoing surgery
safety of the procedure has been
for rotator cuff repair or subacromial
demonstrated
decompression (acromioplasty). The
(CONCLUSION:
patients with contraindication to outpatient
The use of CIBPB for 72 hr in patients
surgery were excluded. All patients
undergoing
received an interscalenic preoperative
major  ambulatory  shoulder surgery can
blockade by Naropeine (2mg/ml)
associated with dexamethasone, and a
standardized general anesthesia.
Two groups were constituted. Group 1
consisting of 19 patients, received
outpatient care through hospitalization at
home (HAH). After the surgery, a catheter
was placed with a Naropein diffuser,
2mg/ml 5ml/hr with an elastometric pump,
(BISCD) over 3 days in combination with
oral analgesia including Paracetamol +
code and non-steroidal anti-inflammatory
drugs. The catheter was placed after the
surgery. The care was carried out twice a
day by a specialized team which could be
contacted by telephone 24 hours a day.
Group 2, consisting of 20 patients, were
treated as outpatients with oral analgesics
Paracetamol + code (Klipal) and non-
steroidal anti-inflammatory drugs.
The pain was measured 4 times a day, in
the morning, at midday, in the evening and
during the night, using the visual analog
scale (VAS) during the first postoperative
week. Data concerning oral analgesic use,
side effects (nausea, vomiting, anxiety,
dizziness) and satisfaction were also
collected. The data were recorded by the
patient himself through a questionnaire and
recovered during the first postoperative
consultation with the surgeon at D15.
The primary endpoint was the average
VAS during the first postoperative week
(on a scale from 0 to 10). Secondary
endpoint was oral analgesic consumption.
Statistic analysis :
Mean and standard deviation were used to
describe continuous variables and
proportions for categorical variables. The
level of significance was set at 0.05. Data
of group 1 and 2 were compared by use of
the Wilcoxon test. All statistical analyses
were conducted with SAS software,
version 9.4 (SAS Institute, Cary, North
Carolina).
RESULTS
Of 39 patients presenting for arthroscopic
shoulder surgery during the study, no
patients were lost to sight. Group
characteristics are reported in Figure n°X.
The average age was 60,3 for group 1 and
54,2 for group. The 2 groups were
comparable on sex and age. Concerning
the average VAS during the first
postoperative week, there was no
significant difference between the two
groups (p = 0.3): it was 1,8 (1,3) in group 1
versus 2,3(1,4) in group 2 (Figure X). A
significant difference was observed on the
first day in favor of group 1: 3,1(1,4)
versus 4,2(2,3) p=0,09. There was no
significant difference in analgesic
consumption between the 2 groups: the
average cumulative number of oral
analgesic used during the first 7
postoperative days was 25,3 in group 1
versus 27,6 in group 2 for the Klipal
(p=0,9), and 8,3 versus 7,3 for the anti-
inflammatory drugs (p=0,9) (Figure X). A
single complication was observed in the
HAH group requiring the catheter to be
placed on D1. No major drug side effects
were noted in either group, and no
significant different was observed between
the 2 groups concerning the nausea,
vomiting, anxiety, dizziness occurrence.
DISCUSSION
This study’s aim was to compare 2
different pain management after outpatient
arthroscopic shoulder surgery, an
interscalene blockade with continuous
delivery with hospitalization at home
versus a single-injection blockade; both in
association with oral analgesic including
paracetamol+code and non-steroidal anti-
inflammatory drugs. No difference was
found between the two treatments neither
for the pain experienced by the patients nor
for the oral analgesic consumption along
the first postoperative week. We found a
significant different on the first day which
concorn which other studies
Some limits exist in this study: the low
number of patients included may shade the
extrapolation of its results. Others studies
on the same subject including more
patients exposed different results. This
study also did not bring data about sleep
quality, which could be an important factor
for the patient satisfactiont. We also did
not make any cost study, which could be
interesting to evaluate the justification of
either treatment, especially the continuous
blockade with catheter, which needs an
hospitalization at home which a special
team dedicated.

Previous articles on the same subject

On the first day

  HAH/BISCD BISI

Age   59.8 (10.3) 53.5 (11.8)

Surgery duration   65.0 (21.5) 58.3 (26.5)

Acromioplasty / Cuff 0 / 19 7 / 13
Type of surgery
repairment
Work accident/ No 14 12
occupational disease
Oui / Non 6 / 10 4 / 16
Smoking

1. Description des patients

Total Groupe 1 Groupe 2

Age 57.2 (11.4) 60.3 (10.3) 54.2 (11.8)

Age opération 56.6 (11.4) 59.8 (10.3) 53.5 (11.8)
Poids 77.2 (14.0) 78.2 (14.7) 76.2 (13.7)
Taille 1.7 (0.1) 1.7 (0.1) 1.7 (0.1)
IMC 26.5 (5.0) 27.5 (5.7) 25.6 (4.2)
Durée intervention 61.5 (24.2) 65.0 (21.5) 58.3 (26.5)
Sexe
Femme 11 (28.2) 6 5
Homme 28 (71.8) 13 15
Coté operé
Droite 22 (56.4) 11 11
Gauche 17 (43.6) 8 9
Type
d’intervention Acromio 7 (18.0) 0 7
Coiffe 32 (82.0) 19 13
Type d’ALR
 Bis 39 (100) 19 20
Nausées
Non 8 (66.7) 7 1
Oui 4 (33.3) 3 1
Vomissements
Non 10 (90.9) 9 1
Oui 1 (9.1) 0 1
Vertiges
Non 8 (72.7) 7 1
Oui 3 (27.3) 2 1
Anxiété
Non 10 (90.9) 8 2
Oui 1 (9.1) 1 0
Remarque
Pose ratée du KT 1 1 0
Satisfaction
Non 2 (15.4) 1 1
Oui 11 (84.6) 8 3
AT/MP
Non 26 (66.7) 14 12
Oui 13 (33.3) 5 8
Tabac
Arrêt 3 (7.7) 3 0
Non 26 (66.7) 10 16
Oui 10 (25.6) 6 4
Tendons
3T 12 (37.5) 8 4
Sub-scap 3 (9.4) 1 2
Sus +Sous Ep 10 (31.2) 6 4
Sus Ep 7 (21.9) 4 3
Retraction
1 7 (21.9) 4 3
2 20 (62.5) 12 8
3 5 (15.6) 3 2
Infiltration
1 13 (40.6) 6 7
2 18 (56.3) 12 6
3 1 (3.1) 1 0
 2. Tests de comparaison des
groupes

Age : p=0.06
Sexe : 0.6

Les 2 groupes ne sont pas différents sur l’âge

et le genre.

3. Différence de traitements dans

les 2 groupes

Calcul du nombre cumulé de médicaments

pris sur les 7 jours
Total Groupe 1
kl Klipal 26.5 (11.4) 25.3 (13.4)
AINS 7.8 (5.8) 8.3 (8.1)

Le nombre cumulé de médicaments ne différent pas dans les 2 groupes. On compare

donc le score de douleur.
 4. EVA

On calcule le score EVA moyen sur la journée. On compare J1, J7 et la moyenne de J1 à J7

Groupe 1 Groupe 2 pvalue
J1 3.1 (2.3) 4.2 (1.4) 0.09
J7 0.5 (0.7) 1.1 (1.3) 0.3
Moyenne suivi 1.8 (1.3) 2.3 (1.4) 0.3

Profil moyen du score EVA

  HAD/BISDC BISI p

J1 3.1 (2.3) 4.2 (1.4) 0.09

J7 0.5 (0.7) 1.1 (1.3) 0.3

Moyenne suivi 1.8 (1.3) 2.3 (1.4) 0.3

Conclusion.
We did not find any significant difference between the two groups in the evaluation of
postoperative pain as well as in the consumption of analgesic per os.
Outpatient surgery with the placement of a catheter to the continuous diffusion to the whole
post-operative analgesia versus techniques of multimodal anesthesia simpler and less
expensive to set up.

-description du soin de l’équipe d’HAD/ consistution de l’équipe d’HAD/

-CRITERE DE JUGEMENT PRINCIPAL ? EVA moyenne ? EVA à un Jour précis ? lien avec la consommation
d’antalgiques supplémentaires  ?
-critères de jugement secondaire

- Qui est chargé de la récolte des données  ? le chirurgien  ? un investigateur externe ?

- Analyse statistique
 39 patients presenting for
arthroscopic shoulder excluded:Contraindications
surgery to ambulatory surgery

Randomized at surgery conclusion

19 BISDC/ 20 BISI