RESUMO
Background: Interscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations. Purpose/Hypothesis: The purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Enrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints. Results: The liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all). Conclusion: The use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.
RESUMO
Pneumothorax is a known complication following breast surgery but is likely underappreciated by anesthesiologists. Iatrogenic pneumothorax can be caused by needle injury during local anesthetic injection, surgical damage to the intercostal fascia or pleura, or pulmonary injury from mechanical ventilation. We present two cases of pneumothorax following bilateral mastectomy with bilateral pectoral blocks and immediate breast reconstruction. Both cases occurred at a freestanding ambulatory surgery center in patients with no history of lung disease. One patient was found to have bilateral pneumothoraxes after complaining of shortness of breath and chest pain in the post-operative care unit. The second patient was asymptomatic but found to have a right-sided pneumothorax on a chest X-ray (CXR) that was ordered to rule-out left-sided pneumothorax due to concern of intraoperative breach of the left chest wall. Both patients were treated with chest tubes, transferred to a nearby hospital, and discharged several days later. Anesthesiologists must be aware of this potentially life-threatening complication and consider pneumothorax in the differential diagnosis of perioperative hypoxemia, shortness of breath, chest pain, and hemodynamic collapse in patients undergoing breast surgery. Though traditionally diagnosed via radiograph, pneumothorax can be rapidly diagnosed with ultrasound. Tension pneumothorax should be decompressed immediately with a needle. A clinically significant, non-tension pneumothorax is treated with chest tube placement. Equipment necessary to treat pneumothorax should be available for emergency treatment in facilities wherever breast surgery is performed.