The edition · Anaesthesiology
Shoulder arthroplasty: single-shot interscalene plus basics, not liposomal bupivacaine
PROSPECT recommends paracetamol, an NSAID, dexamethasone and a single-shot interscalene block after total shoulder arthroplasty; a hypotension prediction index did not beat simply treating at a MAP of 73; and cannabis users needed slightly more propofol.
The edition in brief
PROSPECT recommendations from a systematic review of 30 randomised trials and seven reviews advise paracetamol, a perioperative and postoperative NSAID, intravenous dexamethasone 8–10 mg, opioid rescue and a single-injection interscalene block with plain long-acting local anaesthetic after total shoulder arthroplasty; local infiltration is the alternative, and liposomal bupivacaine and continuous catheters are not recommended on current evidence. A two-centre randomised trial of 100 adults found hypotension prediction index–guided management did not reduce hypotension compared with treating whenever MAP fell to 73 mmHg or below. A retrospective cohort of 341,199 procedures found cannabis users received modestly more propofol (+6.85 µg/kg/min for non-medical users) and marginally more volatile anaesthetic. The FDA recorded a supplement to a generic buprenorphine application, an administrative action.
Hypotension prediction index did not beat a simple MAP-73 trigger
Treating early at a higher MAP threshold may deliver much of what a hypotension prediction index offers, without the monitor.
Cannabis users needed modestly more propofol and volatile
Ask about cannabis use and anticipate modestly higher propofol needs in daily users, titrating to effect.
FDA records a supplement to a generic buprenorphine application
No change to practice from this notice.
Interscalene block means a hemidiaphragm, usually
Check respiratory reserve before an interscalene block; most patients will lose half a diaphragm for hours.
PROSPECT for total shoulder arthroplasty: basics, dexamethasone and a single-shot interscalene
After total shoulder arthroplasty, use paracetamol, an NSAID, dexamethasone and a single-shot interscalene block with plain local anaesthetic; keep opioids for rescue.
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