The American journal of orthopedics
-
Attention to patient satisfaction is critical in today's health care environment-satisfaction surveys inform the development of hospital performance standards and can influence an institution's rankings and reimbursement. The effectiveness of postoperative pain management can affect clinical outcomes and also influence the patient's perception of the overall surgical experience. Ample clinical- trial data now exist that demonstrate the benefits of periarticular injections as part of a multimodal regimen in patients undergoing joint arthroplasty. ⋯ The US Food and Drug Administration has approved liposomal bupivacaine for injection into the surgical site to produce postsurgical analgesia. The safety and efficacy of liposomal bupivacaine has been demonstrated in clinical studies in multiple types of surgical procedure, including double-blind, randomized, controlled clinical trials that involved over 1300 patients. In a case-control study comparing clinical and economic parameters before and after the introduction of liposomal bupivacaine as a component of the multimodal perioperative pain regimen for total joint arthroplasty, liposomal bupivacaine provided improved overall pain scores, an increase in patients reporting a pain score of 0, increased patient satisfaction, decreased length of stay, and a decrease in overall costs.
-
Case Reports
Tension Pneumothorax After Ultrasound-Guided Interscalene Block and Shoulder Arthroscopy.
Interscalene brachial plexus anesthesia is commonly used for outpatient arthroscopic shoulder procedures. Ultrasound guidance has helped to minimize the cardiac, neurologic, and pulmonary complications associated with this block. ⋯ We present a case of tension pneumothorax in a patient undergoing arthroscopic rotator cuff repair under both interscalene regional and general anesthesia. Surgeons and anesthesiologists must remain aware that ultrasound-guided interscalene blocks may be associated with pneumothorax and must initiate treatment expeditiously.
-
In the current health care environment, it is more important than ever for orthopedic surgeons to strive for optimal efficiency and effectiveness. For maximum efficiency, patients can be preselected to limit patient types that commonly require a greater investment of the practice's time and resources. Structuring surgical practices for efficiency may involve rethinking the staffing model, anticipating problems that may occur with individual patients, and enhancing internal and external communications. ⋯ Among such advances are tranexamic acid, intravenous acetaminophen, and bupivacaine liposome injectable suspension (EXPAREL®, Pacira Pharmaceuticals, Inc). Intravenous acetaminophen and liposomal bupivacaine, in particular, can significantly improve efficiency by reducing the administration of opioid medication during the postoperative period, and thereby reducing opioid-related side effects. Liposomal bupivacaine has also been shown to shorten the hospital length of stay and, in many cases, eliminate the need for costly and inefficient nerve blocks.
-
Despite advances in the understanding of postoperative pain, approximately 80% of surgical patients still experience a meaningful level of pain, which can result in unnecessary stress and suffering; compromise the patient's progress, recovery, and outcome; and lead to poor function and the development of chronic pain. In arthroplasty patients, the goals of pain management include improving comfort and satisfaction, enabling patients to ambulate and move their joints soon after surgery, and, where appropriate, reducing the hospital length of stay. ⋯ Furthermore, as-needed administration of opioids allows for the repeated return of pain after the operation as each dose wears off. A balanced multimodal approach that combines different anesthetic and analgesic modalities in a rational way to target the distinct pain pathways, rather than relying predominantly on opioid drugs, is essential for effective control of postoperative pain, avoiding the risk of opioid-related adverse events and complications, reducing length of stay, and improving longterm outcomes.
-
The efficacy of regional anesthesia and peripheral nerve blocks in the management of postoperative pain has resulted in widespread use of this approach in hip and knee arthroplasty. With extensive clinical use, however, the limitations of this approach have become apparent. ⋯ The long-acting anesthetic bupivacaine liposome injectable suspension (EXPAREL®, Pacira Pharmaceuticals, Inc), in particular, has been shown to be highly effective in managing postoperative pain and reducing opioid consumption. Consequently, a growing body of data and extensive clinical experience now support replacing nerve blocks with periarticular injections.