Liposomal Bupivacaine Infiltration vs Continuous Perineural Ropivacaine Infusion for Post-operative Pain After Total Shoulder Arthroplasty
| Status: | Terminated |
|---|---|
| Conditions: | Post-Surgical Pain |
| Therapuetic Areas: | Musculoskeletal |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 2/11/2018 |
| Start Date: | August 2014 |
| End Date: | May 31, 2017 |
Bupivacaine 1.3% Liposomal Suspension (Exparel) vs Continuous Perineural Ropivacaine Infusion in the Management of Post-operative Pain Following Total Shoulder Arthroplasty; An Open-label, Randomized, Controlled Study
Total shoulder replacement is associated with considerable postoperative pain. A common
method to treat and prevent this post operative pain is to place a catheter in the neck and
leave it in place for up to 48 hours. The catheter delivers a medication called ropivacaine
directly to a major nerve near your shoulder. It is very effective at stopping pain. In
addition to preventing pain, it also prevents movement of the arm because it blocks the nerve
completely.
A newer method of treating post operative pain uses only a series of small injections into
the joint, skin, and muscles of the shoulder near the end of the surgery. This medication,
liposomal bupivacaine (Exparel), potentially provides analgesia for greater than 48 hrs but
does not require a catheter to remain in place and does not prevent patients from moving
their arm after surgery because it only blocks the pain portion of the nerve. Both methods
also frequently include the addition of oral and injected pain medicines like narcotics to
effectively control the pain.
Ropivacaine and Exparel both work well for postoperative pain after total shoulder
replacement. It is not known, however, if one method is superior in its ability to
treat/prevent pain or which method may have fewer side effects. The purpose of this study is
to randomly assign patients to receive either a catheter with ropivicaine or Exparel
injections to help determine if one method is superior in pain relief and if either method
has fewer side effects.
method to treat and prevent this post operative pain is to place a catheter in the neck and
leave it in place for up to 48 hours. The catheter delivers a medication called ropivacaine
directly to a major nerve near your shoulder. It is very effective at stopping pain. In
addition to preventing pain, it also prevents movement of the arm because it blocks the nerve
completely.
A newer method of treating post operative pain uses only a series of small injections into
the joint, skin, and muscles of the shoulder near the end of the surgery. This medication,
liposomal bupivacaine (Exparel), potentially provides analgesia for greater than 48 hrs but
does not require a catheter to remain in place and does not prevent patients from moving
their arm after surgery because it only blocks the pain portion of the nerve. Both methods
also frequently include the addition of oral and injected pain medicines like narcotics to
effectively control the pain.
Ropivacaine and Exparel both work well for postoperative pain after total shoulder
replacement. It is not known, however, if one method is superior in its ability to
treat/prevent pain or which method may have fewer side effects. The purpose of this study is
to randomly assign patients to receive either a catheter with ropivicaine or Exparel
injections to help determine if one method is superior in pain relief and if either method
has fewer side effects.
Patients undergoing total shoulder arthroplasty commonly receive an interscalene block using
ropivacaine to provide analgesia. To provide analgesia for up to 48 hours postoperatively, an
indwelling catheter can be placed and a constant infusion of ropivacaine given. This is a
safe and very effective technique for managing postoperative pain in this population. This
procedure is associated with reduced need for narcotics and improved patient satisfaction.
Side effects are uncommon and include catheter displacement and failure of the block. A
consequence of this procedure is that it causes paralysis or weakness of the affected arm
until the catheter is removed and the drug wears off.
Liposomal bupivacaine (Exparel, Pacira Pharmaceuticals, Inc.) was approved by the FDA in
October 2011 and is indicated for administration into a surgical site to produce postsurgical
analgesia. The duration of analgesia from a single administration is up to 72 hours. Like the
ropivicaine constant infusion, Exparel is associated with good patient satisfaction and
reduced narcotics requirement. Its advantage over a continuous infusion is that it is
technically far less challenging to administer than a catheter insertion and it does not
cause paralysis of the affected arm.
Investigators are unaware of any studies that compare the efficacy, patient satisfaction, and
complication rates of these two different procedures. It is, therefore, the purpose of this
investigation to explore these differences. Investigators aim to randomly assign 100 subjects
in an open-labeled fashion who are scheduled to have a total shoulder arthroplasty at the
UMROI to receive either a continuous infusion of ropivicaine via an interscalene catheter or
a single administration of a single dose interscalene nerve block plus Exparel injected into
the soft tissue within and around the shoulder during surgery.
In this study, investigators plan to use an open label randomized control trial to compare
the efficacy of a one time dose of liposomal bupivacaine vs. ropivacaine infusion over 36
hours in providing analgesia. All patients will receive an interscalene block with
ropivacaine for operative anesthesia. The patients will be randomized to either receive an
indwelling interscalene catheter with a continuous infusion of 6 ml per hour of 0.2%
ropivacaine, or surgical wound infiltration of 266 mg of 1.3% liposomal bupivacaine
suspension. The patients will be given rescue pain medications as needed and will not be
subjected to suffer pain if their pain is not controlled by their local anesthetic.
Investigators plan to compare the amounts of rescue pain medications used by the individuals
in both groups and the patient reported pain scores to help determine whether local
infiltration of liposomal bupivacaine is as effective as a ropivacaine infusion for providing
analgesia. If the surgical wound infiltration of liposomal bupivacaine provides the same or
improved analgesia, this would benefit future patients and not subject them to having a
peripheral nerve catheter placed as they would get equivalent pain relief from a single shot
injection followed by wound infiltration with local anesthetic.
ropivacaine to provide analgesia. To provide analgesia for up to 48 hours postoperatively, an
indwelling catheter can be placed and a constant infusion of ropivacaine given. This is a
safe and very effective technique for managing postoperative pain in this population. This
procedure is associated with reduced need for narcotics and improved patient satisfaction.
Side effects are uncommon and include catheter displacement and failure of the block. A
consequence of this procedure is that it causes paralysis or weakness of the affected arm
until the catheter is removed and the drug wears off.
Liposomal bupivacaine (Exparel, Pacira Pharmaceuticals, Inc.) was approved by the FDA in
October 2011 and is indicated for administration into a surgical site to produce postsurgical
analgesia. The duration of analgesia from a single administration is up to 72 hours. Like the
ropivicaine constant infusion, Exparel is associated with good patient satisfaction and
reduced narcotics requirement. Its advantage over a continuous infusion is that it is
technically far less challenging to administer than a catheter insertion and it does not
cause paralysis of the affected arm.
Investigators are unaware of any studies that compare the efficacy, patient satisfaction, and
complication rates of these two different procedures. It is, therefore, the purpose of this
investigation to explore these differences. Investigators aim to randomly assign 100 subjects
in an open-labeled fashion who are scheduled to have a total shoulder arthroplasty at the
UMROI to receive either a continuous infusion of ropivicaine via an interscalene catheter or
a single administration of a single dose interscalene nerve block plus Exparel injected into
the soft tissue within and around the shoulder during surgery.
In this study, investigators plan to use an open label randomized control trial to compare
the efficacy of a one time dose of liposomal bupivacaine vs. ropivacaine infusion over 36
hours in providing analgesia. All patients will receive an interscalene block with
ropivacaine for operative anesthesia. The patients will be randomized to either receive an
indwelling interscalene catheter with a continuous infusion of 6 ml per hour of 0.2%
ropivacaine, or surgical wound infiltration of 266 mg of 1.3% liposomal bupivacaine
suspension. The patients will be given rescue pain medications as needed and will not be
subjected to suffer pain if their pain is not controlled by their local anesthetic.
Investigators plan to compare the amounts of rescue pain medications used by the individuals
in both groups and the patient reported pain scores to help determine whether local
infiltration of liposomal bupivacaine is as effective as a ropivacaine infusion for providing
analgesia. If the surgical wound infiltration of liposomal bupivacaine provides the same or
improved analgesia, this would benefit future patients and not subject them to having a
peripheral nerve catheter placed as they would get equivalent pain relief from a single shot
injection followed by wound infiltration with local anesthetic.
Inclusion Criteria:
- Presenting to University of Maryland Rehabilitation and Orthopaedic Institute for
total shoulder arthroplasty (TSA) or reverse TSA
- Primary language is English
Exclusion Criteria:
- Allergy to either ropivacaine or bupivacaine
- On chronic opioid therapy at the time of evaluation
- Pre-existing neurologic condition which precludes the use of regional anesthesia
- Unable to provide consent as determined by the operating surgeons
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