Best shoulder surgery practice?

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sevoflurane

sevoflurane

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I’m curious how many of you do your TSA/Rotator cuff repairs/Reverse shoulders.
I’ve gone back and forth with different methods. Currently, I feel this is a solid anesthetic.


Admitting nurse @ 6:00 AM:
Gabapentin 600mg, Celebrex 400mg, Tylenol 1000mg all p.o. with a sip of H2O.

Pre-op:
.2mg of glyco as an antisialogogue. ISB: mild sedation including 40mcg of precedex + 25cc’s of 1:400k epi with 4mg of PF decadron.

Induction:
Propofol + 50-75 mcg of ketamine, 4mg of decadron. LMA.

Maintanence:
Propofol (or ketafol) gtt, 4gms of Mag. O2 at 50-60% with SV + APL at 5 cm H20 to provide mild peep.
Keep bps above 10-15% of pre-op/nml bps. Treat all bps under 100 systolic.
~1-1.5 liters LR

Tail/Emergence:
Zofran and 15-30mg of Toradol (if appropriate) at the end for good measure.
D/C propofol 10-15 minutes prior to leaving the OR. Pull LMA B4 leaving OR.

Benefits of the above:
Near zero N/V (narcotic/halogenated agent free anesthetic).
Preemptive analgesia via pain pathways.
Anti-inflamatory cocktail via site of operation.
Preservation of respiratory mechanics and very little, if any, atelectasis.
Smooth emergence in pacu and quick pacu discharge.
Very low nursing burden for 30ish hrs.
*This all assumes a favorable AW and good LMA fit.

I'm always looking to refine my anesthetics. Any suggestions?
(Urge... you're not allowed to say prop, sux, tube)
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That good but complicated. Mine is a lot more simple.
I'll post it soon but I wonder why Toradol when you gave Celebrex already. Do you think it adds that much?
 
Noyac said:
That good but complicated. Mine is a lot more simple.
I'll post it soon but I wonder why Toradol when you gave Celebrex already. Do you think it adds that much?
Click to expand...

Maybe. They get the celebrex @ 6:00am. I'm more inclined to give it during the complicated/tarumatic shoulders that last 3+ hours. That means that there is about 4.5+ hours btw/ celebrex and toradol. I'm not trying to control pain with it as the ISB does that part. Just want a good anti-inflamatory bump to minimize post-op swelling.
If it's an in and out shoulder, or they are old, I skip it.

Prolly sounds more complicated than it really is. Once you get things going you're kicking back for the case.
 
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Interested in hearing other peoples anesthetic plans...
 
sevoflurane said:
Interested in hearing other peoples anesthetic plans...
Click to expand...
I do the same as you except for this:
Gabapentin 600mg, Celebrex 400mg, Tylenol 1000mg
.2mg of glyco as an antisialogogue, mild sedation including 40mcg of precedex
50-75 mcg of ketamine, 4mg of decadron.
Propofol (or ketafol) gtt, 4gms of Mag.
Zofran and 15-30mg of Toradol

:p
 
dhb said:
I do the same as you except for this:
Gabapentin 600mg, Celebrex 400mg, Tylenol 1000mg
.2mg of glyco as an antisialogogue, mild sedation including 40mcg of precedex
50-75 mcg of ketamine, 4mg of decadron.
Propofol (or ketafol) gtt, 4gms of Mag.
Zofran and 15-30mg of Toradol

:p
Click to expand...

:rolleyes:

Looks awfully familiar DHB....
 
I give 2 mg versed for ISB (0.5% Ropiv 20-30cc with 2-4mg decadron). No epi! I never use epi in my blocks.
Tylenol Celebrex pre-op on occasion
LMA usually for the case
Mg 2-4 gm for the case.
Occasional IV ibuprofen but not offen.
Low dose narcs just to keep the RR slow. Usually around 100-150 mcg Fent with 50 mcg of that for the wake up. This low dose narc has not burned me with regards to PONV yet.

Why the glyco? Because you are using an LMA? Or because of the ketamine?
 
Noyac said:
I give 2 mg versed for ISB (0.5% Ropiv 20-30cc with 2-4mg decadron). No epi! I never use epi in my blocks.
Tylenol Celebrex pre-op on occasion
LMA usually for the case
Mg 2-4 gm for the case.
Occasional IV ibuprofen but not offen.
Low dose narcs just to keep the RR slow. Usually around 100-150 mcg Fent with 50 mcg of that for the wake up. This low dose narc has not burned me with regards to PONV yet.

Why the glyco? Because you are using an LMA? Or because of the ketamine?
Click to expand...

Sounds like you are adding some degree of inhaled agents in addition to the above...?

Glyco is mainly for the ketamine... although LMAs are great for picking up secretions, a lot of our population here tend to be heavy somkers and they also tend to be salivary/mucous secreting monsters... add ketamine to the mix and the secretions at the end of the case can be pretty copious. With the precedex on board they stay at good HR's.

Good to hear you're not getting any PONV. I haven't been so lucky in the past with certain subset of our populous that get a whiff of narcs + some degree of inhaled agents. I find that TIVA's without narcotics have reduced my PONV to near zero as they are getting propofol gtt throughout as their main anesthetic. A little labor intensive, but not too bad.
 
6195caf5-d80f-4575-8d6a-81499db4a3d2_zps5a436d44.jpg


Respers are spot on w/o narcs or inhaled agents. I truly believe in the synergism of prop, mag and ketamine. I do find some value here with precedex.
 
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Admitting nurse @ 6:00 AM:
Gabapentin 600mg, Celebrex 400mg, Tylenol 1000mg all p.o. with a sip of H2O.
SAME except
If on home narcotics: 10 mg oxycontin + 8 mg oral zofran

Pre-op:
.2mg of glyco as an antisialogogue. ISB: mild sedation including 40mcg of precedex + 25cc’s of 1:400k epi with 4mg of PF decadron.
No robinol. Sedation 2-5 mg versed depending on anxiety level/tolerance
ISB Catheter: Initial bolus lidocaine 2%+epi 30 cc then 0.125% bupivicaine 8 cc/hr in recovery
If just single shot ISB block: 30 cc Bupivicaine 0.25% + 4 mg Decadron+150 mcg bupernorphine

Induction:
Propofol + 50-75 mcg of ketamine, 4mg of decadron. LMA.
Same minus ketamine
If contraindication for LMA will tube with no fentanyl.

Maintanence:
Propofol (or ketafol) gtt, 4gms of Mag. O2 at 50-60% with SV + APL at 5 cm H20 to provide mild peep.
Keep bps above 10-15% of pre-op/nml bps. Treat all bps under 100 systolic.
~1-1.5 liters LR
Propofol sandwich (induction/emergence). Sevo in between.

Tail/Emergence:
Zofran and 15-30mg of Toradol (if appropriate) at the end for good measure.
D/C propofol 10-15 minutes prior to leaving the OR. Pull LMA B4 leaving OR.
Same minus toradol

We do a ton of shoulders and this is the routine I developed for our group in conjunction with our ortho department. We created it as an order set for "fast tracking" total joints. Our total knees and hips are almost the exact same except with spinal anesthesia with propofol maintenance and TKA get single shot adductor canal block in recovery.
 
^^^this is pretty similar to my approach. "Propofol sandwich" love it. That's how I get away with using gas. Only difference is that I do use some low dose narcs like I said. I also use B blockers generously. I really like to wake them up with a slow HR 40-60's. No long acting narcs tho. I use Fent because it's gone in 45 min.
 
mostwanted said:
I haven't seen magnesium used at our hospital. What are the benefits?
Click to expand...
Multimodal pain relief. Mechanism is Ca channels and NMDA receptors.


I keep meaning to have our preop RNs give acetaminophen and NSAID +/- gabapentin but I'm not sure I'm ready to engage that particular coven.
 
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I am not sure you need all the extra stuff (Gabapentin, Tylenol, Magnesium...) if you are doing a good ISB with added Decadron.
Just give some Midazolam, do a good ISB, go to the OR, induce with Propofol, insert LMA, either maintain with Sevo or Propofol, total Fentanyl 100 mcg, give Zofran.
That's it... the ISB should give you at least 24 hours of analgesia.
 
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Planktonmd said:
I am not sure you need all the extra stuff (Gabapentin, Tylenol, Magnesium...) if you are doing a good ISB with added Decadron.
Just give some Midazolam, do a good ISB, go to the OR, induce with Propofol, insert LMA, either maintain with Sevo or Propofol, total Fentanyl 100 mcg, give Zofran.
That's it... the ISB should give you at least 24 hours of analgesia.
Click to expand...

I can't say I thought of that initially, but this makes sense to me.
 
After reading all the various threads here for a few years now I think I'm gonna change my approach.
Preop :
Tylenol, gabapentin, protonix, Celebrex
ISB cath on an On-Q pump with US PLACEMENT
Dosed with 10cc Exparel in 10cc milk of mag for NMDA and some clonidine and bupanorphine for good measure
sedation with precedex

Intraoperative:
Induce with precedex, versed,
Start Remi gtts
Place pt on BiPAP at 70%
Supplement with Mg, ketamine, dextromethorphan
20mg of decadron so the block lasts
Give 10cc of exparel to surgeon to squirt down the shaft of the humerus
Lidocaine infusion started and continued at home for 24hrs.

Postop:
Ketamine and lidocaine infusion with a MG PCEA.
ROBITUSSIN for breakthrough pain
D/C home.
 
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Noyac said:
After reading all the various threads here for a few years now I think I'm gonna change my approach.
Preop :
Tylenol, gabapentin, protonix, Celebrex
ISB cath on an On-Q pump with US PLACEMENT
Dosed with 10cc Exparel in 10cc milk of mag for NMDA and some clonidine and bupanorphine for good measure
sedation with precedex

Intraoperative:
Induce with precedex, versed,
Start Remi gtts
Place pt on BiPAP at 70%
Supplement with Mg, ketamine, dextromethorphan
20mg of decadron so the block lasts
Give 10cc of exparel to surgeon to squirt down the shaft of the humerus
Lidocaine infusion started and continued at home for 24hrs.

Postop:
Ketamine and lidocaine infusion with a MG PCEA.
ROBITUSSIN for breakthrough pain
D/C home.
Click to expand...
LMAO
 
Noyac said:
After reading all the various threads here for a few years now I think I'm gonna change my approach.
Preop :
Tylenol, gabapentin, protonix, Celebrex
ISB cath on an On-Q pump with US PLACEMENT
Dosed with 10cc Exparel in 10cc milk of mag for NMDA and some clonidine and bupanorphine for good measure
sedation with precedex

Intraoperative:
Induce with precedex, versed,
Start Remi gtts
Place pt on BiPAP at 70%
Supplement with Mg, ketamine, dextromethorphan
20mg of decadron so the block lasts
Give 10cc of exparel to surgeon to squirt down the shaft of the humerus
Lidocaine infusion started and continued at home for 24hrs.

Postop:
Ketamine and lidocaine infusion with a MG PCEA.
ROBITUSSIN for breakthrough pain
D/C home.
Click to expand...


:laugh::laugh:

Where is the bis and the cerebral oximetry...?
 
Sorry but no BIS.
I will go straight to neuro monitoring. SSEPs MEPs
 
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and... ICP monitor since they are in the sitting position.
 
Sorry Sevo, it looks like I've turned your serious thread into a circus show.
 
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Noyac said:
Sorry Sevo, it looks like I've turned your serious thread into a circus show.
Click to expand...

This thread is starting to sound like the "superBOWL" texts we had a couple months back... That was epic. :artist:
 
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ISB block with ropi/lido. To OR and MAC. Back to phase II post op.
 
Pent sux tube....

I don't do those currently.

Back when I was doing them we used ISB and a propofol drip MAC. Percocets post op.
 
There are some issues here which need commenting on by me:

1. Total shoulder or Reverse Total Shoulder in the Beach chair- BP at the cuff with a systolic of 100 is likely too low. The standard of care is to maintain cerebral perfusion at the circle of willis so you must adjust the BP at the arm for a mean of at least 60-70 at the tragus (70 is better for ASA 3 and ASA 4 patients). Higher risk patients like I see routinely get arterial lines with the transducer placed at the tragus. Patients with HTN have their cerebral autonomic regulation shifted to the right. This means a systolic BP of 100 at the level of the arm is too low for most patients.

2. I utilize Cerebral Oximetry 50% of the time for ASA 3 and ASA 4 patients undergoing procedures in the Beach chair position. The Cerebral Oximeter combined with a mean BP greater than 70 at the level of the tragus is worth considering for certain patients.

3. The risk of a CVA following this surgery is remote. Still, such a complication is a devastating event and likely to result in the scrutiny of your anesthetic technique.

4. I applaud the use of low dose Ketamine, MG++ 30 mg/kg, celebrex, tylenol, etc but for this procedure my blocks are sufficient and last over 24 hours;
Some providers are using Exparel for Total Shoulders and getting 72 hours of postop analgesia. Once Exparel gets FDA approval in March/April of 2015 I will likely switch to it for this operation in healthier patientws.

5. ETCo2- Spontaneous respirations allow the ETC02 to rise to the 45-50 range; this isgood for cerebral blood flow. But, the majority of my patients are obese so I end up intubating them and using a ventilator. I do keep the CO2 in the 45 or so range.
 
The reason everybody is obsessed with a MAP over 65 in the ICU is that it has been proven that 65 is the cutoff to avoid end-organ ischemia and injury. Above 65, autoregulation kicks in, so there is not much difference between a MAP of 70 and one of 100, but you definitely don't want to play games under 65 at the level of the tragus (that's at least 20 cm higher than the middle of the arm, meaning you'll need a MAP of at least 80 mmHg if the cuff is on the arm).
 
Last edited by a moderator:
In the beachchair position, each patient
has a critical MAP, below which maximal cerebral
vasodilatation fails to augment flow and CBF
becomes pressure dependent28. As MAP continues
to decrease, CBF is also reduced, predisposing
patients to cerebral ischaemia. Intraoperatively, this
autoregulatory threshold cannot be identified unless
changes in both MAP and CBF are monitored.
With intact autoregulation the relationship between
CBF and MAP is non-linear, and without CBF
monitoring, the anaesthetist can only speculate
as to what constitutes an ideal MAP, estimating
CPP on the basis of the haemodynamic state. The
assumption is that flow is on the plateau of the static
pressure autoregulation curve. However the lower
limit of autoregulation can vary between patients28,
particularly in the elderly with hypertension,
indicating that MAP alone is inadequate to
accurately predict global cerebral oxygen delivery.
In addition, non-invasive measurement of blood
pressure, using a sphygmomanometer cuff on the
arm, will significantly underestimate blood pressure
at the patient’s head due to the hydrostatic pressure
gradient.
 
BLADEMDA said:
2. I utilize Cerebral Oximetry 50% of the time for ASA 3 and ASA 4 patients undergoing procedures in the Beach chair position. The Cerebral Oximeter combined with a mean BP greater than 70 at the level of the tragus is...
Click to expand...

Seems overkill to measure bp with a transducer at the tragus plus cerebral oximetry. People have strokes with this surgery because of cerebral hypotension. Why the belt and suspenders?

I would put a cuff and a phenylephrine drip. Much cheaper.
 
urge said:
Seems overkill to measure bp with a transducer at the tragus plus cerebral oximetry. People have strokes with this surgery because of cerebral hypotension. Why the belt and suspenders?

I would put a cuff and a phenylephrine drip. Much cheaper.
Click to expand...


Fine. Do you know how much the surgery costs itself? For high risk patients undergoing a Total Shoulder replacement SAFETY comes first; the use of Cerebral Oximetry is a marker for global cerebral perfusion; this information combined with a MAP of 70 at the level of the tragus ensures I am doing everything possible (along with a CO2 of 45 or so) to minimize the risk of a perioperative CVA.

Now, do I think you need all of this stuff to do the case? Absolutely not. Much of the APSF recommendations are without much scientific data and in fact, we have no evidence that any of these things changes outcome whatsoever.
 
http://www.apsf.org/newsletters/html/2013/spring/05_beachchairimpact.htm

Here is the APSF Newsletter from last year. It's worth reading


Furthermore, while rSO2 is a simple and easy to use surrogate for cerebral blood flow (CBF), it may underestimate malperfusion events. Jeong compared rSO2 with jugular venous bulb saturations in 56 patients undergoing general anesthesia with either propofol/remifentanil or nitrous/sevoflurane. This study found that cerebral oximetry had only a 30% sensitivity for detecting a jugular venous saturation <50% which is typically considered a critical value. Although it raises questions regarding the sensitivity of rSO2, this study clearly demonstrated cerebral malperfusion events in the BCP with 41% of patients suffering a jugular venous bulb desaturation.8
 
J Shoulder Elbow Surg. 2013 Sep;22(9):1228-35. doi: 10.1016/j.jse.2012.12.036. Epub 2013 Feb 15.
Cerebral desaturation events during shoulder arthroscopy in the beach chair position: patient risk factors and neurocognitive effects.
Salazar D1, Sears BW, Aghdasi B, Only A, Francois A, Tonino P, Marra G.
Author information

Abstract
BACKGROUND:
Patients undergoing shoulder surgery in the beach chair position may be at increased risk for serious neurocognitive complications due to cerebral ischemia. We sought to define the incidence, patient risk factors, and clinical sequelae of intraoperative cerebral desaturation events.

METHODS:
Regional cerebral tissue oxygen saturation (rSO2) was monitored intra-operatively using near-infrared spectroscopy (NIRS) on 50 consecutive patients. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was administered to each patient pre- and postoperatively. Intra-operative decreases in rSO2 of 20% or greater were defined as cerebral desaturation events (CDE). The association between intraoperative CDE and postoperative cognitive decline was assessed.

RESULTS:
The incidence of intraoperative CDE in our series was 18% (9/50). Increased body mass index (BMI) was found to have a statistically significant association with intraoperative CDE (mean BMI 37.32 vs 28.59, P < .0001). There was no statistical significance in pre- vs postoperative RBANS either in composite scores or any of the sub-indices in either group.

CONCLUSION:
The degree and duration of cerebral ischemia required to produce neurocognitive dysfunction in this patient population remains undefined; however, cerebral oximetry with NIRS allows prompt identification and treatment of decreased cerebral perfusion decreasing the risk of this event. Increased BMI was found to be a statistically significant patient risk factor for the development of intra-operative CDE. The transient intra-operative CDEs were not associated with postoperative cognitive dysfunction in our patient series. We believe protocols aimed at detecting and reversing CDE minimize the risk of neurocognitive dysfunction and improve patient safety.
 
The data doesn't support the conclusion that we need to use Cerebral Oximetry for Beach Chair Procedures at all; yet, the authors state otherwise in their conclusion.
 
BLADEMDA said:
Fine. Do you know how much the surgery costs itself?
Click to expand...

I know medicare pays you peanuts for the anesthesia on these patients and will pay you even less if costs keep going higher.
 
FFP said:
The reason everybody is obsessed with a MAP over 65 in the ICU is that it has been proven that 65 is the cutoff to avoid end-organ ischemia and injury. Above 65, autoregulation kicks in, so there is not much difference between a MAP of 70 and one of 100, but you definitely don't want to play games under 65 at the level of the tragus (that's at least 20 cm higher than the middle of the arm, meaning you'll need a MAP of at least 80 mmHg if the cuff is on the arm).
Click to expand...
Auto regulation changes with chronic HTN.
 
I'm not sure why people would prefer to monitor a problem rather than just prevent it.

Run the MAP at 90 or more and be done with it.
 
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Regional Anesthesia & Pain Medicine:
January/February 2012 - Volume 37 - Issue 1 - p 120
doi: 10.1097/AAP.0b013e31823a9934
Letters to the Editor
The Beach-Chair Position and General Anesthesia
Weiner, Menachem M. MD; Fischer, Gregory W. MD; Rosenblatt, Meg A. MD



1 which reviewed more than 4000 ambulatory shoulder surgeries performed in the beach-chair position and reported a zero incidence of stroke despite the use of intraoperative hypotension to reduce surgical bleeding. It is only through continued interest and research in this topic that patient safety will improve and we will be able to prevent the devastating complication of perioperative stroke in the beach-chair surgical population. However, we believe that the more crucial study to conduct is on patients undergoing surgery in the beach-chair position who are under general anesthesia with mechanical ventilation.

As the authors correctly acknowledge, there are no published case reports of patients with permanent neurologic deficit following shoulder surgery performed with regional anesthesia with spontaneous ventilation. All 4 patients in the case series of cerebral ischemia during shoulder surgery, reported by Pohl and Cullen,2 had received general anesthesia with mechanical ventilation. The same is true for other case reports of this catastrophic complication, including one of visual loss.3

Although no similar large-scale studies have been conducted on patients under general anesthesia, 2 smaller studies deserve mention. No strokes occurred in either study, but both studies used cerebral oxygen saturation as determined using near-infrared spectroscopy as a surrogate marker of cerebral blood flow. Murphy et al4 compared the beach-chair position to the lateral decubitus position in patients undergoing shoulder surgery under general anesthesia and found significant reductions in cerebral oxygenation in patients in the beach-chair position as opposed to the lateral decubitus position. At our institution, we performed a small study, with institutional review board approval, comparing mechanical ventilation to spontaneous ventilation (both general anesthesia and sedation) that we presented at the annual meeting of the American Society of Anesthesiologists in 2010. Unfortunately, because of surgical preference, we were able to enroll only 8 patients in the mechanical ventilation group as compared with 74 in the spontaneous ventilation one. We found that the mechanical ventilation group showed a dependency between cerebral oximetry values and systemic perfusion pressure. In other words, cerebral blood flow was no longer pressure independent within a physiologic blood pressure range as would be predicted by cerebral autoregulation, but it correlated directly with systemic perfusion pressure. In contrast, the spontaneous ventilation group showed cerebral oximetry values that were independent of systemic blood pressure.

Further large studies are needed to prove whether mechanically ventilated patients are at greater risk for stroke while in the beach-chair position. In the interim, it may be prudent to monitor this subgroup of patients with cerebral oximetry.

Menachem M. Weiner, MD

Gregory W. Fischer, MD

Meg A. Rosenblatt, MD

Department of Anesthesiology

Mount Sinai School of Medicine
 
urge said:
I know medicare pays you peanuts for the anesthesia on these patients and will pay you even less if costs keep going higher.
Click to expand...


As long as patients can sue me for a Million dollars per BAD OUTCOME then I'll cover my ass as required. CMS along with a certain community organizer can go #$#%# themselves. Notice I said "bad outcome" and not malpractice because one gets sued for the former way more often than the latter.

Costs will keep going higher and reimbursement will keep going lower until Physicians say "no mas" to the ASA 4 Medicare/Medicaid patient. I'm looking forward to the day when CMS limits procedures and Physicians stop operating on piss poor protoplasm.
 
Here's a question for you smart guys. Can you use a BIS as a cerebral oximetry monitor?
 
So according to the above paper if you keep them spontaneously breathing they will regulate cerebral perfusion and it will be independent of MAP? I guess this is related to CO2 and cerebral vasodilation?
 
risnwb said:
So according to the above paper if you keep them spontaneously breathing they will regulate cerebral perfusion and it will be independent of MAP? I guess this is related to CO2 and cerebral vasodilation?
Click to expand...

Correct. But try that technique with a BMI over 45 and let me know how it goes.
 
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