A procedure-specific analgesia plan for shoulder arthroplasty, and fibrinogen concentrate's case for fewer transfusions

The edition in brief

A PROSPECT systematic review of 30 randomised trials and seven reviews recommends that, absent contraindications, total shoulder arthroplasty analgesia include paracetamol, a perioperative and postoperative NSAID, intravenous dexamethasone 8 to 10 mg, rescue opioids, and a single-shot interscalene block with plain long-acting local anaesthetic rather than liposomal bupivacaine; local infiltration is the alternative where a block is unsuitable. A meta-analysis of 58 studies and 13,530 patients found adults given fibrinogen concentrate for acquired hypofibrinogenaemia received fewer red cell, plasma and platelet units, largely from cardiac surgery, with no difference in mortality or thrombosis; most included studies were not randomised. A triple-blind trial of 80 patients found IPACK and a selective tibial nerve block gave similar analgesia and function after ACL reconstruction. The FDA recorded a supplement to a generic buprenorphine application, an administrative action rather than a safety finding. The pearl covers preparing for local anaesthetic systemic toxicity before any block.