Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis

Background: Pain control and quality of recovery (QoR) at home remains a challenge after ambulatory shoulder arthroscopy. This study aims to assess the QoR and pain relief using a sequential implementation strategy for rescue analgesic drugs.

Methods: After IRB approval, patients ( >18yrs, ASA 1-3 stable) scheduled for ambulatory surgery under general anesthesia with a single shot interscalene nerve block were enrolled. After discharge, patients received standard information regarding the postoperative recovery and care consisting of a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The first 48 postoperative hours allowed us to compare three different rescue drug regimes with a control group, in sequential order: tramadol (control group), tramadol+nefopam, immediate release oxycodone (IR), IR and extended release oxycodone (ER). The primary endpoint was to QoR 40 score at 48 hours after surgery. Secondary endpoints were pain relief and adverse events over a 7 day-period. An intention-to-treat statistical analysis was performed with sequential analysis (as an interim analysis) every 20 patients. Results were recorded as medians and interquartiles (25-75).

Results: We analyzed 109 patients with similar characteristics among groups. The QoR 40 scores were similar for the tramadol group (168 [161-172]), the tramadol+nefopam group (161[151-173], p=0.09) and the IR group (164[153-169], p=0.17), but higher for the ER group (176[167-181], p=0.03). Concerning adverse events, drugs were interrupted more frequently in the tramadol+nefopam group (36 %). In the ER group, a higher quality of postoperative relief was attained in the domains of pain and sleep.

Conclusion: The present study shows that a combination of immediate and extended release oxycodone over a short period of time (<48h) is associated with a better quality of recovery at home after ambulatory shoulder surgery.

Level of evidence: Level II; Prospective Cohort Design; Treatment Study.

Keywords: analgesia; nefopam; oxycodone; shoulder; surgery; tramadol.