Best shoulder surgery practice?

[Noyac]

Try it on your next carotid and let me know if you notice a difference.

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[deleted171991]

Here's a question for you smart guys. Can you use a BIS as a cerebral oximetry monitor?

No. It's an EEG monitor compiled into a number. I really don't expect it to be sensitive enough to detect early ischemia. They would have advertised the hell out of that.

 

[Noyac]

No. It's an EEG monitor compiled into a number. I really don't expect it to be sensitive enough to detect early ischemia. They would have advertised the hell out of that.

It's not extremely accurate but you will notice change if ischemia begins.
Just like SSEP's change with SC ischemia.

 

[deleted171991]

I bet a real EEG would be helpful. And I bet SSEP wouldn't mean crap if reduced to some number.

 

[Noyac]

Possibly. I don't know.

 

[deleted171991]

Me neither.

 

[Noyac]

Ask Blade.

 

[deleted171991]

If it worked, the BIS guys would have made a BISSEP a long time ago.

 

[deleted9493]

As one who rarely manages patients in beach chair positioning, how often are you regulars seeing/managing Bezold-Jarisch reflex manifestations? What is your most effective management?

 

[dhb]

Preop - 2mg midaz --> block

Intraop - general

Postop - patient goes home pain free

This, no narc GA w sevo no ponv.

I don't buy the nsaid will reduce post-op swelling.

 

[risnwb]

As one who rarely manages patients in beach chair positioning, how often are you regulars seeing/managing Bezold-Jarisch reflex manifestations? What is your most effective management?

I've heard of giving zofran prior to positioning as a serotonin receptor antagonist... Not sure how effective it is but I've done lots of beach chair shoulders and never seen bezold-jarisch reflex (and never given preemptive zofran).

 

[sevoflurane]

.

I don't buy the nsaid will reduce post-op swelling.

I do:

Having Cox-2 inhibition before mechanical trauma is beneficial. Decreasing inducible prostaglandins is a good thing... decreases vascular permeability and edema.

 

[deleted171991]

Makes sense to me, too. You get the anti-inflammatory effects of COX-2, without the antiaggregant effects of COX-1.

On the other hand, we give 4-8 mg of decadron to many of our patients, to prevent PONV, so giving the COX-2 inhibitor too sounds superfluous.

 

[sevoflurane]

Makes sense to me, too. You get the anti-inflammatory effects of COX-2, without the antiaggregant effects of COX-1.

On the other hand, we give 4-8 mg of decadron to many of our patients, to prevent PONV, so giving the COX-2 inhibitor too sounds superfluous.

Different mechanisms. Decadron inhibits the synthesis of prostaglandins.

 

[sevoflurane]

Anectodal, but back in the day, when we had 20-30 post-op blocks to round on, it was pretty evident that those who recieved the pill cocktail in addition to PNB did much better than those who did not. Especially if kept on a regimen for the first 3 days.

 

[sevoflurane]

Now.. Let's talk about gabapentin.

Sounds like some people are against it, some for it, and some just don't care.
Unfortunately alot of the earlier studies about gabapentin were fabricated by Dr. Reuben....
However, for total joints, there have been a number of papers that do look at it's effectiveness.
There is no question that it has opiod sparing effects. They reduce opiod consumption beyond the effect of PNBs. Some have gone as far as saying that it may prevent chronic pain associated with these procedures. They do cause dizziness in some.
We all know we are able to achieve a good 24 hrs. of exceptional analgesia, but as anesthesiologists we need to be looking not just at POD1 analgesia, but further out... until discharge. I believe gabapentin may have a role here.

 

[sevoflurane]

 

[urge]

That's fine. But, you need to clarify where you are monitoring the BP.

Put it on the arm as usual. You know the brain is like 20 points lower.

My guess is that the 4 patients who had the infamous stroke were run at MAPs of 60 to 70 monitored on the arm. The brain was fairly hypotensive. Who knows if they were hyperventilated also?

I'm not saying that cerebral oximetry does not make sense from a scientific standpoint. My point is that the number needed to treat times the price of the device does not factor favorably against the root of the problem.

 

[urge]

Anectodal, but back in the day, when we had 20-30 post-op blocks to round on, it was pretty evident that those who recieved the pill cocktail in addition to PNB did much better than those who did not. Especially if kept on a regimen for the first 3 days.

Why is the block business drying up?

 

[sevoflurane]

Why is the block business drying up?

Different institutions. One with a busy acute pain service, one without due to staffing issues and a money loser.

 

[pgg]

That's fine. But, you need to clarify where you are monitoring the BP.

Do you?

When patients go to their doctor's clinic, or sit in the chair at Wal-Mart, where are they monitoring the BP? The arm. Are they sitting? Yes.

When they check in to day surgery, where does the baseline BP get measured? The arm. Are they sitting? Yes.

What's so special about sitting in the OR and getting the BP measured on the arm? Nothing.

I think the focus on measuring BP at the ear, or with an a-line, or adding 20 mmHg to the numbers on the monitor is a little odd. A cuff on the arm in a sitting patient is fine. Just keep them where they live, or close to it. Phenylephrine is a fine drug, a cheap drug, and a drip is 20 seconds of effort.

Dual Bis monitors? Cerebral oximetry?

I do:
Having Cox-2 inhibition before mechanical trauma is beneficial. Decreasing inducible prostaglandins is a good thing... decreases vascular permeability and edema.

I do too. I give ketorolac in preop holding more often than I give midazolam ... then 5 minutes before closing when the surgeon magnanimously leans over and says "you can give Toradol" I just smile and nod.

 

[deleted171991]

Different mechanisms. Decadron inhibits the synthesis of prostaglandins.

And what do COX-2 inhibitors do, according to your own figure?

 

[sevoflurane]

And what do COX-2 inhibitors do, according to your own figure?

Well in that case: and I raise you a ...!

 

[twoliter]

Different mechanisms. Decadron inhibits the synthesis of prostaglandins.

Umm...don't NSAIDs do that?

ETA: Someone beat me to it.

 

[twoliter]

Do you?

When patients go to their doctor's clinic, or sit in the chair at Wal-Mart, where are they monitoring the BP? The arm. Are they sitting? Yes.

When they check in to day surgery, where does the baseline BP get measured? The arm. Are they sitting? Yes.

What's so special about sitting in the OR and getting the BP measured on the arm? Nothing.

My still-a-resident thought is that the difference is due to the altered cerebral autoregulation with inhaled anesthetics and propofol making them more pressure-dependent.

 

[pgg]

My still-a-resident thought is that the difference is due to the altered cerebral autoregulation with inhaled anesthetics and propofol making them more pressure-dependent.

Volatiles reduce CMRO2 and impair autoregulation (causing cerebral vasodilationwhich would increase flow at a given pressure).

Propofol reduces CMRO2. Autoregulation remains intact.

Normal CBF is around 50 mL per 100g of brain per minute. Assuming normal blood O2 content (Hb and SpO2) ischemia starts around 22 mL/100g/min. Cell death around 10.

CMRO2 has two components, basal metabolism and activity. An isoelectric EEG gets the O2 requirement down by 50% or so. Normal GETA with volatiles and/or propofol reduces O2 demand by some amount short of that.

If anything anesthesia would be protective of hypotension effects on the brain.


Now - I'm not saying I would count on GA to protect the brain, no matter what else I did, just that GA isn't hurting you here, and probably helps.

I think a normal BP measured in the usual fashion is fine. As usual, urge's simple answer is a good one.

 

[sevoflurane]

Umm...don't NSAIDs do that?

ETA: Someone beat me to it.

And what do COX-2 inhibitors do, according to your own figure?

http://www.ncbi.nlm.nih.gov/pubmed/22103778

The combination of a COX-2 inhibitor and dexamethasone results in better pain relief 24 h after surgery in patients undergoing outpatient ACL surgery, compared to COX-2 inhibitor alone or dexamethasone alone. With a dedicated multimodal pain regime, most ACL patients may be discharged within 3 h.

You guys are going to have chase down the biochemistry yourselves. Different mechanims, yet they both decrease inducible PG.

 

[deleted171991]

Well in that case: and I raise you a ...!

 

[PianoMedic]

Did a quick google search on corticosteroid effect on prostaglandins as opposed to NSAIDS. Results:
https://medschool.vanderbilt.edu/ophthalmology/labs/kim (no time to find the original research underlying their chart here sorry)

http://www.nature.com/nature/journal/v278/n5703/abs/278456a0.html

Both inhibit prostaglandin synthesis, but it looks like sevo was correct in that they are slightly different in their method of inhibition. Corticosteroids also inhibit leukotriene synthesis.

 

[uk_anaesthesia]

Drastic overkill with oximetry monitoring in my opinion. The twin statements of "there is little evidence" AND "I'll keep using it on the off chance that I get sued" completely undermines the argument for its use.

I hope that the anaesthetic trainees are listening closely to the rationale discussed by the various seniors. It actually matters little what you use, but more that you have thought about it and made a justifiable choice based on experience, evidence and social justice (i.e. equitable distribution of health care assists).

 

[uk_anaesthesia]

Also, are you guys avoiding COX-2 inhibitors in those with a cardiac history?

 

[BLADEMDA]

Drastic overkill with oximetry monitoring in my opinion. The twin statements of "there is little evidence" AND "I'll keep using it on the off chance that I get sued" completely undermines the argument for its use.

I hope that the anaesthetic trainees are listening closely to the rationale discussed by the various seniors. It actually matters little what you use, but more that you have thought about it and made a justifiable choice based on experience, evidence and social justice (i.e. equitable distribution of health care assists).

Easy to post your response when you have NO CLUE what it is liked to be sued in the USA. I can guarantee you will LOSE the case if you run BP of 100/50 on the arm and the patient has a stroke. Again, practicing any way you want that is reasonable in the UK won't suffice in my part of the woods.

Standard of care based on the APSF and best available evidence clearly dictates higher BP at the level of the tragus for a patient undergoing a Total Shoulder Replacement in the beachchair position utilizing a GA technique with positive pressure ventilation.

I, for one, totally agree with lawsuits against flippant, cowboy providers who slap on a cuff on a mobidly obese patient in the beach chair position and run MAPs of 60. WHEN an adverse CVA/TIA occurs in this type of patient you might as well just write the check.

 

[BLADEMDA]

Put it on the arm as usual. You know the brain is like 20 points lower.

My guess is that the 4 patients who had the infamous stroke were run at MAPs of 60 to 70 monitored on the arm. The brain was fairly hypotensive. Who knows if they were hyperventilated also?

I'm not saying that cerebral oximetry does not make sense from a scientific standpoint. My point is that the number needed to treat times the price of the device does not factor favorably against the root of the problem.

It's fine to use the BP cuff at the arm for these patients but it isn't fine to run MAPs of 60-70. Second, studies have shown that periodic hypotensive episodes can an do occur in the O.R. with varying degrees of treatment intervention by providers. In a high risk patient an arterial line provides a higher margin of safety and the ability to titrate pressors more precisely for mild hypotensive events.

The use of Cerebral Oximetry is more controversial but again MAY add a margin of safety for certain subgroup of patients.

I don't have the luxury of ASA 1-2 patients; or, the Ferris Doctrine to insulate me from lawsuits.

 

[BLADEMDA]

Man died three days after routine shoulder surgery, inquest told

http://www.smh.com.au/nsw/man-died-...lder-surgery-inquest-told-20130422-2i9md.html

 

[BLADEMDA]

Quality and safetyA regularly updated list of safety alerts can be found on the ANZCA website here.Arthroscopic shoulder surgery in “beach-chair” position: NSW Coroner’s findings and recommendations
On April 26, 2013 the NSW Deputy State Coroner found that in August 2011 a 50-year-old former rugby player died as a result of a massive stroke during arthroscopic shoulder surgery in the “beach-chair” position. This was presumed to be the result of cerebral hypoperfusion as noted by the coroner: “This … was caused by a failure to estimate and maintain an appropriate level of mean arterial pressure in the blood supply of the brain”.

The coroner has recommended to the NSW Minister for Health and ANZCA that all anaesthetic departments “develop guidelines for the appropriate adjustment for the hydrostatic gradient by anaesthetists when calculating mean arterial pressure for ‘beach-chair’ surgery”.

The College does not have a specific policy relating to management of the patient in the sitting position or "beach chair" position, however this case highlights the importance of measuring (or estimating) blood pressure at the level of the Circle of Willis, for which the tragus of the ear is often used as a reference point, and maintaining an appropriate perfusion pressure. Patients with a risk of compromised cerebral perfusion, such as those with cerebrovascular or carotid disease should logically be considered a high risk for such positions. The Quality and Safety Committee will be considering this issue and any comments or submissions from Fellows regarding this would be appreciated and can be sent to the ANZCA Quality and Safety Co-ordinator, Karen Gordon-Clark.

 

[BLADEMDA]

?High-risk Outpatient Surgery? and the Benefits of Regional Anesthesia, Even in Patients on Antiplatelet Therapy
Abstract Number: A220
Abstract Type: Medically Challenging Case



Christopher Moore, M.D., Neil Hanson, M.D., David Auyong, M.D.
Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA


Introduction: Arthroscopic shoulder surgery is considered a safe outpatient procedure. However, the beach chair position in which it is performed increases risk of morbidity compared to supine positioning. Associated complications, including strokes, have been reported even in healthy patients[1]. Regional anesthesia can be beneficial by reducing opioid-related side effects postoperatively. ASRA guidelines advise withholding clopidogrel 5-7 days prior to surgery, but do not offer much guidance regarding procedures during continued antiplatelet therapy[2]. Anesthesiologists often face these situations not addressed by guidelines where they must weigh risks and benefits of performing regional anesthesia in anti-coagulated patients with multiple comorbidities. Often, this limits regional techniques to ?easily compressible? or ?less traumatic? techniques to avoid hematomas or vascular injury.
Case: A 79-year-old male presented for outpatient arthroscopic rotator cuff repair in the beach-chair position. Pertinent medical history included hypertension, GERD, diabetes, prior TIA, and acetaminophen allergy. Blood pressure was 184/86, above his baseline systolic of 160mmHg. A recent MRI showed multiple high-grade stenoses not amenable to treatment. For this he was placed on clopidogrel, which he continued for the procedure. Due to his clopidogrel use, no pre-operative brachial plexus block was performed. After detailed risk/benefit discussion with the surgeon and patient, it was decided to proceed with general anesthesia for surgery. A radial arterial-line was placed to accurately maintain blood pressure near baseline. The case was completed without immediate complications and intravenous hydromorphone was dosed for nociception.
Post-operative management: In the PACU, he complained of severe shoulder pain unresponsive to opioids and became nauseated and confused shortly after administration. Per pre-operative discussion, a ?rescue? single-shot interscalene brachial plexus block was performed. During ultrasound pre-scan, the dorsal scapular artery was noted to be directly posterior to the brachial plexus and in the path of a standard in-plane posterior needle approach. Therefore, an out-of-plane approach was used to avoid any vasculature and resulted in immediate analgesia. Despite ongoing use of clopidogrel, this interscalene block allowed the patient to be sent home with superior analgesia, preventing unexpected hospital admission for intractable pain. Upon follow-up, the patient reported good analgesia for >12 hours, but noted significant discomfort from the initial opioid side effects.
Discussion: With uncontrolled hypertension in the setting of prior TIA, our patient underwent surgery in the beach chair position, placing him at risk of repeat stroke. Management may have been improved by using regional anesthesia and multimodal analgesics. Though there is literature highlighting the opioid-reducing benefits of regional anesthesia, little addresses performance of regional anesthesia in the setting of antiplatelet agents. With the use of ultrasound-guided regional anesthesia, vascular structures can sometimes be identified and avoided, but in the absence of large studies on individual anticoagulants to guide us, clinical judgment on individual cases must be used. In this case, regional anesthesia allowed us to avoid an unplanned hospitalization, and could likely have prevented a prolonged PACU stay if placed pre-operatively.
References:

1. Pohl and Cullen. J Clin Anes 2005; 17:463-9.
2. Horlocker et al. RAPM 2010; 35:64-101.

Reg Anesth Pain Med Spring 2013

 

[BLADEMDA]

Anesth Analg. 2012 Jun;114(6):1301-4. Epub 2011 Nov 3.
Case report: focal cerebral ischemia after surgery in the "beach chair" position: the role of a congenital variation of circle of willis anatomy.

Drummond JC, Lee RR, Howell JP Jr.
Source

FRCPC, VA Medical Center-125, 3350 La Jolla Village Dr., San Diego, CA 92161. [email protected].

Abstract

A 50-year-old man underwent shoulder surgery in the beach chair position. His mean arterial blood pressure at arm level was approximately65 mm Hg. Postoperatively, there was delayed awakening and a right hemiparesis. Radiologic evaluation revealed a congenital asymmetry of the circle of Willis that resulted in limited collateral flow to the left anterior and middle cerebral artery distributions. Similar anatomical variations are relatively common in the general population and may render some patients relatively and unpredictably more vulnerable to hypotension.

 

[Noyac]

After reading some of the replies here I should clarify something. I am not proposing that we use 2 BIS monitors on these cases. That was a joke that took off as to where it could actually be done. I have never used 2 BIS monitors on a shoulder case.

Also, I wanna talk about gabapentin. When I was doing pain medicine I started many people on gabapentin. I would start them on a lower dose than 600mg because frequently they had SE's (confusion, lethargy, dizziness) all things I dont. Want postop. The issue I have with giving peolpe this medication is that we are not continuing it postop ( as far as I know) and the older the pt the more severe the SE's. It is my understanding that gabapentin takes time to work. And I have a hard time believing that 1dose or 5 doses for that matter make much difference. Personally, I don't give it.

 

[Planktonmd]

I think the benefit of Gabapentin in multimodal analgesia is equivalent to any other agent that has a CNS depressing or sedative effect.
It's not better than any other sedative and actually has more undesirable side effects.
You might be able to achieve the same or better opiate sparing result by simply giving a long acting Benzo pre-op like people did in the old days, when everyone got Dizepam before surgery.

 

[BuzzPhreed]

I think an a-line is overkill in beachchair position. Just take the BP frequently and add 15 to the MAP. Zone of cerebral autoregulation in a normal person is MAP 60-150 mmHg. That should be your goal MAP. And make sure the surgeon isn't one of those that takes 4 hours to do a shoulder.

COX-2 inhibition is also good post-operatively. I think there is little benefit to doing it immediately pre-operatively, especially with Toradol and glucocorticoid given (with the block or IV). You can make an argument for post-op augmentation in my opinion. Giving it in the holding area is just one more thing for them to potentially vomit up.

 

[urge]

I think an a-line is overkill in beachchair position. Just take the BP frequently and add 15 to the MAP.

What do you mean by adding 15 to the MAP?

 

[Noyac]

I think he means subtract.

 

[pgg]

I don't have the luxury of ASA 1-2 patients; or, the Ferris Doctrine to insulate me from lawsuits.

Surely that's directed at me.

Just to clear up a point of fact, the broad medicolegal protection afforded by Feres Doctrine only applies to patients presently on active duty. I'm not sure I've ever cared for a middle-aged to elderly chronically bad HTN patient ... still in uniform. In fact, the overwhelming majority of patients cared for at military hospitals are retirees and retirees' spouses, and the spouses and kids of active duty personnel, and they can and do sue. So that whole "can't sue" thing is a little overstated. (What I do have going for me is that they have to sue the government and not me directly, and my liability "policy" has the deepest of deep pockets. And I think that's a pretty awesome perk of my otherwise underpaying employer.)


Regardless. There's defensive medicine, and then there's arterial lines and cerebral oximetry for sitting shoulders. I am not by any means reluctant to place an a-line in anyone who has an indication, to wit, potential for harm from possible abrupt derangements in BP that would be missed by a q3min cuff, inability to obtain reliable NIBPs because of BMI-induced conical arms, etc.

But there ain't nothin' wrong or risky about using "just" a BP cuff in a chronic hypertensive patient sitting for a shoulder surgery if you keep their pressures near baseline, and obfuscating this issue with defensive statements about how you don't want to get sued doesn't change that.


Now, obviously if you let them ride with maps 40% below baseline because the orthopod asked you to make his patient bleed less and you agreed, you're asking for it and your monitor of choice makes no difference in the matter.

 

[BLADEMDA]

Surely that's directed at me.

Just to clear up a point of fact, the broad medicolegal protection afforded by Feres Doctrine only applies to patients presently on active duty. I'm not sure I've ever cared for a middle-aged to elderly chronically bad HTN patient ... still in uniform. In fact, the overwhelming majority of patients cared for at military hospitals are retirees and retirees' spouses, and the spouses and kids of active duty personnel, and they can and do sue. So that whole "can't sue" thing is a little overstated. (What I do have going for me is that they have to sue the government and not me directly, and my liability "policy" has the deepest of deep pockets. And I think that's a pretty awesome perk of my otherwise underpaying employer.)


Regardless. There's defensive medicine, and then there's arterial lines and cerebral oximetry for sitting shoulders. I am not by any means reluctant to place an a-line in anyone who has an indication, to wit, potential for harm from possible abrupt derangements in BP that would be missed by a q3min cuff, inability to obtain reliable NIBPs because of BMI-induced conical arms, etc.

But there ain't nothin' wrong or risky about using "just" a BP cuff in a chronic hypertensive patient sitting for a shoulder surgery if you keep their pressures near baseline, and obfuscating this issue with defensive statements about how you don't want to get sued doesn't change that.


Now, obviously if you let them ride with maps 40% below baseline because the orthopod asked you to make his patient bleed less and you agreed, you're asking for it and your monitor of choice makes no difference in the matter.

Another key point here is WHO is actually sitting the case? Monitors don't save lives but they do make it easier for certain groups of providers to pay close attention to details.

I don't use anything other than a BP cuff on the arm for 50% of my beach chair cases. The other 25% get arterial lines and the last group gets Arterial line plus Cerebral Oximetry. Again, monitors don't make up for lack of vigilance but they do help reinforce the issue to pay attention to the vitals and NO MATH is required or cycling of the cuff.

 

[BLADEMDA]

October 13, 2014 04:00 PM Eastern Daylight Time
PARSIPPANY, N.J.--(BUSINESS WIRE)--Pacira Pharmaceuticals, Inc. (NASDAQ: PCRX) today announced data demonstrating that EXPAREL®(bupivacaine liposome injectable suspension) used in peripheral nerve blocks has comparable safety to placebo and bupivacaine HCl. The analysis, based on a review of six Phase 1-3 clinical trials, will be presented during a podium session at the annual meeting of the American Society of Anesthesiologists in New Orleans this week.

“Building on the solid foundation of EXPAREL data that formed the basis of our sNDA for an expanded nerve block indication, we are pleased to announce that the first comprehensive review of our peripheral nerve block program reinforces the safety profile of the product”

“Our review of this peripheral nerve block clinical program found that EXPAREL administered at doses up to 266 mg as a femoral, intercostal or ankle block exhibited a similar safety profile to both placebo and bupivacaine HCl,” said Brian Ilfeld, M.D., the study’s lead investigator and chair for clinical research for the Division of Regional Anesthesia at the University of California San Diego. “This safety profile involving peripheral nerve blocks is similar to that found with wound infiltration and suggests that EXPAREL will have the same safety success with peripheral nerve blocks as it has exhibited for wound infiltration and hundreds-of-thousands of applications.”

The comparative analysis found that all groups experienced a similar rate of adverse events (AEs) — 76% for EXPAREL vs 76% for placebo vs 61% for bupivacaine HCl — and that these appeared to be related to the procedure or opioid rescue rather than the study medication itself. The most common events were in the gastrointestinal disorders class, followed by general disorders/administration site conditions and nervous system disorders.

Additionally, the EXPAREL and placebo groups experienced a similar incidence of:

• Serious AEs (8% for EXPAREL vs 10% for placebo); none of these were assessed as being related to the study drug
• Nervous system AEs (21% in both groups)
• Cardiac AEs (9% vs 12%, respectively)

Older patients and patients with more co-morbidities were more prone to experience adverse events, as expected, and this trend was true across all groups.

“Building on the solid foundation of EXPAREL data that formed the basis of our sNDA for an expanded nerve block indication, we are pleased to announce that the first comprehensive review of our peripheral nerve block program reinforces the safety profile of the product,” added Dave Stack, president, chief executive officer and chairman of Pacira. “If approved for a nerve block indication, we believe that EXPAREL could not only improve patient quality of life by providing multiple days of postsurgical analgesia while eliminating pumps and catheters, but also conserve hospital and provider resources associated with the placement and management of continuous nerve blocks.”

EXPAREL is indicated for single-dose administration into the surgical site to produce postsurgical analgesia. Pacira has submitted a supplemental New Drug Application (sNDA) to the U.S. Food and Drug Administration (FDA) for a nerve block indication for EXPAREL, with a target Prescription Drug User Fee Act (PDUFA) date of March 5, 2015.

 

[BLADEMDA]

March 5th 2015 should be the date Exparel gets FDA approval for nerve blocks and thus, shortly thereafter, I begin using 133 mg doses for my nerve blocks like ISB, SCB, Femoral, etc

 

[BuzzPhreed]

What do you mean by adding 15 to the MAP?

I think he means subtract.

Ackkk... Yeah, that wasn't clear at all. Mea culpa.

Your actual MAP at the circle of Willis is roughly 15 mmHG lower than what you measure at the arm. Therefore, your target MAP will need to be higher if you're measuring with a cuff on the arm. It needs to be within that zone of cerebral autoregulation.

For example, if your MAP is 70 mmHg with the cuff, your actual MAP at the CoW is about 55 mmHg. Therefore you need to do something to augment the BP in order to get to your target MAP. Your target is whatever you add to the MAP you're measuring in order to get into that zone.

Sorry.

Another key point here is WHO is actually sitting the case? Monitors don't save lives but they do make it easier for certain groups of providers to pay close attention to details.

I don't use anything other than a BP cuff on the arm for 50% of my beach chair cases. The other 25% get arterial lines and the last group gets Arterial line plus Cerebral Oximetry. Again, monitors don't make up for lack of vigilance but they do help reinforce the issue to pay attention to the vitals and NO MATH is required or cycling of the cuff.

Good point. I won't say I never put in an a-line for these cases. I was working with one of our CRNAs sometime back and there was the prototypical zero muscle tone "Pillsbury doughboy" patient with chronic acromial subluxation who was going in for a total shoulder. I went in the room and the CRNA had put the BP cuff on the leg. The patient had those big doughy coniform upper arms. She got an a-line. We put the transducer at the level of the tragus.

Having said that, we have three surgeons who routinely do shoulders. Two do them in beach chair. The other one does them in lateral supine with suspension. Have yet to have a catastrophic anoxic event. The majority just get the standard BP cuff.

 

[BLADEMDA]

Arterial lines simply offer reliable, fast BP measurement while the cuff is set to cycle every 3-5 minutes. The big difference is treating hypotension quickly and without delay which will occur more frequently with an arterial line.

 

[BuzzPhreed]

They are also an additional invasive medical procedure that requires additional (sometimes significant) time to perform, has a higher reported complication rate than the reported CNS injury during in this position, and more often than not doesn't change or impact clinical management.

Select patients. Not for everyone.

 

[deleted171991]

Having said that, we have three surgeons who routinely do shoulders. Two do them in beach chair. The other one does them in lateral supine with suspension. Have yet to have a catastrophic anoxic event. The majority just get the standard BP cuff.

I usually try to adapt to the surgical technique, instead of the other way round, but beach chair shoulders should go the way of cataract surgeries with GA or retrobulbar block. Seriously, this is 2014. Why put the patient at risk, just because the surgeon is incompetent, and has been doing things the same way for decades? Anything that can be done in lateral position should not be done in prone or beach chair, and this should be a hospital rule.

This is also the patients' fault, because they are a bunch of lazy uninformed people. Again, in 2014, there is no fracking excuse to have no idea about your surgical and anesthetic risks.