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Objectives Pain control after shoulder arthroscopy can be challenging, often relying on opioids. The study aims to measure the quality of recovery (QoR) before and after implementation of a "Multimodal Perioperative Pain Protocol" (MP3) in patients undergoing ambulatory shoulder arthroscopy. Design Prospective cohort study. Setting Free-standing ambulatory surgery facility of a tertiary care academic center. Subjects Patients undergoing ambulatory shoulder arthroscopy. Methods The primary end point of the study was the QoR-9 score at 24 hours, 48 hours, and one week after surgery. Secondary end points included 1) measuring the quality of pain management using the Revised American Pain Society Patient Oriented Questionnaire (APS-POQ-R) and 2) postoperative opioid requirements. Results Data from132 patients in the control group (pre-intervention) and 120 patients in the MP3 group were analyzed. The QoR-9 scores were significantly higher for the MP3 group at all time points, but only met the minimal clinical important difference threshold at 24 hours (13.4 vs 14.9, P  < 0.05) and 48 hours (14.0 vs 15.0, P  < 0.05) postoperatively. Patients reported better quality of pain management after implementation of the MP3 in the domains of pain intensity, pain interference with activity, and sleep, and they reported the presence of negative emotions up to two days after ambulatory shoulder surgery. In addition, this protocol significantly reduced opioid consumption up to three days after surgery. Conclusions Implementation of the MP3 improved the overall QoR and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery. [ABSTRACT FROM AUTHOR]

The subspecialty of regional anesthesiology and acute pain medicine (RAAPM) is in a position to lead changes that may impact the current opioid crisis. At the hospital level, RAAPM experts can implement evidence-based multimodal analgesic clinical pathways featuring regional anesthesia. Multimodal analgesia consists of using two or more analgesic modalities targeting pain pathways at various levels to improve pain control, while also aiming to reduce opioid utilization and related adverse effects. These types of pathways or protocols have been widely applied in the joint replacement population. This review focuses on the current state of the evidence regarding individual elements of a multimodal analgesic pathway for patients with total knee arthroplasty including new regional anesthesia techniques like the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block and suggests future research directions to improve the clinical care of this surgical population in the future. [ABSTRACT FROM AUTHOR]

Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion. [ABSTRACT FROM AUTHOR]

Objective. This study aims to assess diaphragmatic excursion and measure pulmonary functions as measures of the degree to which the phrenic nerve is blocked after ISB with two different concentrations of ropivacaine: 0.2% and 0.1%. Design. Randomized, double-blinded study. Setting and Patients. Ambulatory surgical facility. Subjects. Fifty patients undergoing shoulder arthroscopy for rotator cuff repair. Methods. Patients were randomized to receive ultrasound-guided ISB with 20mL of either 0.2% or 0.1% ropivacaine. Diaphragmatic excursion was measured using M-mode ultrasound. Pulmonary functions were assessed by portable spirometer. Additional outcome data included oxygen saturation in post-anesthesia care unit (PACU), pain scores, quality of recovery scores (QOR), and opioid consumption over 72hour period after surgery. Results. Forced vital capacity (FVC) was significantly reduced 30minutes after block placement and in PACU in the 0.2% group when compared with the 0.1% group (P=0.04, P= 0.03, respectively). Forced expiratory volume (FEV1) was also significantly decreased in the 0.2% group in PACU when compared with the 0.1% group (P=0.04). There were no significant differences in pain scores, length of stay, and total opioid consumption in PACU. Patients who received 0.2% ropivacaine had a longer block duration (18 vs 11.9hours, P=0.04) and used less opioid in the 72hours after surgery (55mg vs 102mg codeine equivalents, P=0.02), when they were compared to their counterparts who received 0.1% for their block. Conclusion. 0.1% ropivacaine may impair pulmonary function less than 0.2% ropivacaine. The clinical significance of these differences needs to be further studied. [ABSTRACT FROM AUTHOR]