Continuous Interscalene Block for Same Day Discharge Following Total Shoulder Arthroplasty
Continuous Interscalene Block for Same Day Discharge Following Total Shoulder Arthroplasty
Total shoulder surgeries are associated with considerable postoperative pain which may
 prevent rehabilitation and early discharge from the hospital. Continuous interscalene blocks
 with home infusions are commonly performed for pain relief following total shoulder
 arthroplasties. We want to evaluate the time to readiness for discharge following
 interscalene blocks in patients undergoing total shoulder arthroplasties.
The number of shoulder replacement surgeries is increasing over the years and it is expected
 to continue as the population ages (1). This necessitates adequate pain control in the
 immediate and early postoperative period when pain levels are typically high. Adequate
 analgesia ensures patient comfort and the ability to perform physical therapy exercises
 associated with positive surgical outcomes (2-3). Interscalene brachial plexus block (ISB) is
 commonly performed to provide analgesia for patients undergoing surgical procedures in the
 shoulder region. Either single injection blocks or continuous perineural infusions are
 performed along with oral medications for better pain control in these patients. Compared
 with intravenous opioids, ISB is known to produce superior analgesia after major shoulder
 surgery (4,5). There are reports of outpatient TSA discharged directly from the recovery room
 following the use of continuous ISB but achievement of adequate range of motion were not
 tested in them (6). Consequently, ambulatory ISB may offer decreased hospitalization while
 ensuring adequate analgesia after TSA. Ilfeld et al (7) prospectively compared ISB and
 opioids regarding the time to readiness for discharge following TSA, which was followed by
 many other studies demonstrating the safety and efficacy of continuous ISB for TSA (8, 9).
 Ilfeld et al (6) showed that discharge criteria were 21 (16-41) h with the use of ISB as
 compared to 51 (37-90) h for those receiving perineural normal saline. In our centre, healthy
 patients requiring shoulder arthroplasty usually remain as in-patients for management of
 pain. Perineural infusions may be continued at home using a portable infusion pump after
 discharge. With the use of disposable portable infusion pump for continuous ISB, it may be
 feasible to discharge patients and reduce hospitalization time.

 Although the study by Ilfeld et al showed continuous ISB allowing earlier home discharge
 following TSA, the patients in the study were evaluated for readiness to discharge on POD1 at
 10 AM rather than the earliest times possible. Another interesting finding is that all
 patients received ropivacaine infusions till 6 AM of POD1 but the authors also claim to have
 discharged few patients on the same afternoon after the surgery. The block infusions reported
 in previous studies are higher than used at our institute.

 There is also conflicting evidence that although continuous ISB provides adequate analgesia,
 they seldom impact early functional rehabilitation (10). With this background we want to
 evaluate the earliest times for the achievement of readiness to discharge with the use of ISB
 following TSA.
Inclusion Criteria:

 1. Male and females of 18-80 years of age, scheduled to undergo elective shoulder
 arthroplasty.

 2. ASA Class I, II, III

 Exclusion Criteria:

 1. Patients with associated significant cardiac and respiratory disease.

 2. Patients who will need hospitalization due to reason other than the planned surgery.

 3. Patients with coexisting sleep apnea or morbid obesity (BMI> 35).

 4. Patients with pre-existing major organ dysfunction such as hepatic and renal failure.

 5. Psychiatric illnesses.

 6. Lack of informed consent.

 7. Allergy to any of the drugs used in the study.

 8. Contraindications to interscalene block