A U G U S T 2 0 1 7 O U T P A T I E N T S U R G E R Y . N E T 3 5
The main elements
Our multimodal perioper-
ative pain protocol for
shoulder arthroscopy —
widely considered to be
one of the most painful
outpatient procedures —
decreases the need for
opioids and improves
recoveries. Regional anes-
thesia is a key ingredient
in the multimodal protocol. Most shoulder arthroscopy patients receive a
brachial plexus nerve block with or without general anesthesia. Additional ele-
ments include pre-operative acetaminophen (1 gram every 8 hours) and
gabapentin (starting with 300 mg 3 times a day); intraoperative ketorolac; and
post-operative oral acetaminophen, gabapentin and ketorolac, with oxycodone
as needed for breakthrough pain.
The dosage regimens are standard, but we provide enough wiggle room to
accommodate significant variability. For example, an opioid-naive patient may do
fine with a single-shot regional anesthetic or a regional block plus the multi-
modal analgesia. But you'd want more prolonged pain control with a patient
who's been treated for opioid addiction, so we might opt for an ambulatory
catheter and a continuous nerve block that lasts as long as possible.
With our multimodal shoulder arthroscopy protocol, patients have significant-
ly better pain scores after 24 and 48 hours and significantly better quality of
recovery scores at 24 and 48 hours and at 1 week, compared with equivalent
patients before we instituted the protocol. Additionally, their total oxycodone
requirements for breakthrough pain were less than half of what other shoulder
patients required. Finally, their average PACU stays were reduced by about 20
• BUILDING BLOCKS Regional anesthesia is the foundation on which multimodal
protocols are built.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
