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

Abstract

<br /> <strong><span style="font-size: xx-small;">Background: </span></strong><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">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. </span></span><br /> <span style="font-size: xx-small;"><strong>Methods: </strong></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">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. </span></span><br /> <span style="font-size: xx-small;"><strong>Results: </strong></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">There were 108 patients in each group. Total </span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">postoperative narcotic consumption in the first 24 postoperative </span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">hours was 38.5 +/- 81.1 MEU in the “Traditional group" compared to 59.3 +/- 59.1 MEU in the TLC group (</span></span><em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">P<0.001</span></span></em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">). Of patients in the TLC group, 88% utilized breakthrough narcotics. VAS pain </span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">was significantly higher in the “</span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">Traditional group" at 16 hours (4.1 +/- 2.9 vs 3.2 +/- 2.7, </span></span><em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">P=0.020</span></span></em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">) and 24 hours (4.8 +/- 2.7 vs 3.7 +/- 2.6, </span></span><em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">P=0.004</span></span></em><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">). </span></span><br /> <span style="font-size: xx-small;"><strong>Conclusion: </strong></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">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, </span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">further modification of the currently protocol </span></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">may be necessary to reduce overall narcotic utilization. </span></span><br /> <span style="font-size: xx-small;"><strong>Level of evidence: </strong></span><span style="font-family: Arial,Arial; font-size: xx-small;"><span style="font-family: Arial,Arial; font-size: xx-small;">III </span></span>