Consider administering a single-shot interscalene nerve block following shoulder surgery, which provides an excellent quality of recovery when combined with multimodal oral analgesia.
Researchers in the United Kingdom, using the recently developed Quality of Recovery-15 (QoR-15) score, found that those receiving the nerve block were functioning at or slightly above preoperative levels at 24 and 48 hours postoperatively. According to Damon Kamming, MD, consultant anesthesiologist at University College London Hospitals (UCLH), London, England, the patients continued to improve over the first postoperative week.
Dr. Kamming and Maria Chazapis, MD, a Darzi Fellow in Clinical Leadership at UCLH, presented their findings at the 2015 Regional Anesthesiology and Acute Pain Medicine annual meeting.
The QoR-15 is a “psychometrically tested and validated questionnaire,” according to the study. Used to measure outcomes after surgery and anesthesia, the QoR-15 can be completed with questioning over the telephone and takes less than two minutes. The QoR-15 has not yet been routinely used in research or clinical settings.
“We always felt anxious about sending patients home without catheters, because we were worried our patients would be in severe pain when the single-shot block wore off,” Dr. Kamming said. “However, we were also keen to continue the noncatheter route for safety reasons.”
Dr. Kamming explained that many patients at the hospital travel significant distances to get there, making it potentially challenging for the hospital to monitor how they are coping at home with the catheters.
There is also the potential for safety issues to develop with catheters, with potentially serious outcomes, including the risk for local anesthetic systemic toxicity if catheters migrate as patients go about their daily routines.
“We therefore decided to find out the quality of our patients’ experience postoperatively after a single-shot block to determine whether we actually needed to start a catheter service,” Dr. Kamming said. Drs. Kamming and Chazapis tracked the recovery of 117 shoulder surgery patients from June to November 2013.
The median age was 46.8 years, with 71 men and 46 women. The shoulder surgeries included the Latarjet procedure for anterior inferior shoulder instability, arthroscopic subacromial decompression and other arthroscopic procedures.
QoR-15 a Promising Instrument
Patients filled out a baseline QoR-15 before surgery. The QoR-15 was developed from the longer QoR-40, by a team that included Paul Myles, MD, director of the Department of Anaesthesia and Perioperative Medicine at Alfred Hospital and Monash University in Melbourne, Australia (Anesthesiology 2013;118:1332-1340). The QoR-15 asks 15 questions to assess five domains of patient-reported health status: pain, physical comfort, physical independence, psychological support and emotional state. The 11-point numerical rating scale leads to a minimum score of 0 (very poor recovery) and a maximum score of 150 (excellent recovery).
All patients received an awake ultrasound-guided single-shot interscalene nerve block with 0.5% bupivacaine and then were given a general anesthetic, Dr. Kamming said. Patients were educated and encouraged to take oral multimodal analgesia around the clock postoperatively before the block wore off.
Nurses called 24 and 48 hours and then one week after surgery to complete the QoR-15 questionnaire. Patients were asked, among other things, whether they felt rested, were able to use the toilet and attend to personal hygiene unaided, and whether they were experiencing moderate or severe pain.
On average, the patients scored 132 before surgery, 134 after 24 hours, 133 after 48 hours and 141 at seven days postoperatively, the study found. Postoperative severe pain immediately fell to minimal levels during the two days after surgery, and fell to very low levels at seven days after surgery.
However, Dr. Kamming said he was most encouraged by the success of the QoR-15 as a measurement of enhanced recovery and functional outcome in patients after surgery. He noted that 117 of a possible 132 shoulder surgery patients, or 87%, had agreed to fill out the survey, which takes roughly two minutes. “The QoR-15 is an acceptable and feasible patient-centered assessment of the quality of postoperative recovery and functional outcomes, as demonstrated by the high recruitment and response rate,” the study noted.
“For me it’s not about using catheters or not using catheters,” Dr. Kamming said. “What I think is essential for anesthesiology is deciding what we should be measuring and whether our patients agree [that] this is important and reflects their experience. The QoR-15 is a very good patient-reported outcome measure that is acceptable to our patients. Globally, there is currently no consensus for what score we should use to measure quality of recovery and functional outcomes after anesthesia.”
Dr. Kamming asked, “Could the QoR-15 score become the international gold-standard measurement of the quality of recovery after anesthesia?”
Still, more work needs to be done to back up the claims of the study that catheters are no longer needed following shoulder surgery, argued Lisa Warren, MD, co-directo r of acute pain and regional anesthesia at Massachusetts General Hospital in Boston.
Dr. Warren faulted the study for failing to use a control group, although she called the study “a good first step.”
“It would be great to have a follow-up on this,” she said, adding that the QoR-15 “does seem like a nice way to look at patient recovery post-op.”