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Patient-initiated mandatory boluses for ambulatory continuous interscalene analgesia: an effective strategy for optimizing analgesia and minimizing side-effects.

AbstractBACKGROUND:
This prospective, randomized study tested the hypothesis that a reduced dose continuous interscalene regimen incorporating a low background infusion with mandatory boluses would provide similar shoulder surgery analgesia compared with a dose regimen incorporating a conventional higher background infusion.
METHODS:
After rotator cuff surgery, patients received via an interscalene catheter, one of two elastomeric pumps, each having a 5 ml per 60 min bolus function and a 2 ml h⁻¹ (n=38) or 5 ml h⁻¹ (n=43) ropivacaine 2 mg ml⁻¹ infusion. Boluses commenced from the onset of pain and continued for >48 h as required (pro re nata, PRN) up to every hour for a numerical rating pain score (NRPS, 0-10) >2. Group 2 ml h⁻¹ received mandatory 6 hourly boluses irrespective of the NRPS. Rescue tramadol was available. Patients were questioned on postoperative days 1 and 2 for treatment effectiveness and side-effects.
RESULTS:
Postoperative pain was similar between the groups [Group 2 ml h⁻¹ day 2 median (IQR) (95% confidence interval of the mean) worst movement pain=4 (1-5) (2.8-4.7) vs 4 (2-5) (3.1-4.6), P=0.99], as were night awakenings and tramadol consumption. Numerically rated numbness and weakness were similar between the groups; however, nine patients (21%) in the 5 ml h⁻¹ group vs one (3%) in the 2 ml h⁻¹ group required a temporary infusion cessation due to side-effects (predominantly hand numbness) (P=0.02).
CONCLUSIONS:
Continuous interscalene ropivacaine 0.2% 2 ml h⁻¹ with mandatory 6 hourly (and PRN) boluses provides similar analgesia after rotator cuff repair but with reduced side-effects compared with 5 ml h⁻¹ with PRN only boluses.
AuthorsM J Fredrickson, A Abeysekera, D J Price, A C Wong
JournalBritish journal of anaesthesia (Br J Anaesth) Vol. 106 Issue 2 Pg. 239-45 (Feb 2011) ISSN: 1471-6771 [Electronic] England
PMID21112881 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
Chemical References
  • Amides
  • Anesthetics, Local
  • Ropivacaine
Topics
  • Adult
  • Aged
  • Ambulatory Care (methods)
  • Amides (administration & dosage)
  • Analgesia, Patient-Controlled (adverse effects, methods)
  • Anesthetics, Local (administration & dosage)
  • Arthroscopy
  • Brachial Plexus
  • Drug Administration Schedule
  • Female
  • Humans
  • Male
  • Middle Aged
  • Nerve Block (adverse effects, methods)
  • Pain Measurement (methods)
  • Pain, Postoperative (prevention & control)
  • Postoperative Care (methods)
  • Prospective Studies
  • Ropivacaine
  • Rotator Cuff (surgery)
  • Rotator Cuff Injuries
  • Shoulder Joint (surgery)

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