Best shoulder surgery practice?

[Mman]

Once Exparel gets FDA approval in March/April of 2015 I will likely switch to it for this operation in healthier patientws.

Is that after the January 2011 approval of Suggamadex that we are still waiting for?

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[Anesthdoc21]

Why GA? I just do ISB with 30 ml 0.5% ropi + epi + dex, give some versed, position patient, propofol drip at 50-100 mcg/kg/min. Surgeon given 10 cc local total for all ports (5 cc posterior port) or incision site. BP usually within 20% of preop levels.

 

[Noyac]

Why GA? I just do ISB with 30 ml 0.5% ropi + epi + dex, give some versed, position patient, propofol drip at 50-100 mcg/kg/min. Surgeon given 10 cc local total for all ports (5 cc posterior port) or incision site. BP usually within 20% of preop levels.

This doesn't make complete sense to me.
Why would the surgeon have to put local in the ports if you are able to do the case with moderate sedation (50mcg/kg/min)?
On Another note, at 100/kg/min you are now in GA range for many pts. Why not put an LMA in?

 

[urge]

This doesn't make complete sense to me.
Why would the surgeon have to put local in the ports if you are able to do the case with moderate sedation (50mcg/kg/min)?
On Another note, at 100/kg/min you are now in GA range for many pts. Why not put an LMA in?

They have to put local for a MAC. ISB doesn't cover the back of the shoulder. This is how I used to do them.

 

[Noyac]

I know that it doesn't always cover the back of the shoulder so why not add a suprascap?

 

[BuzzPhreed]

I draw up 30 mL of 0.5% ropivicaine with 4 mg of decadron mixed in. I put 23 mL, using ultrasound, of the mixture in between the ISB and the supraclavicular point where the brachial plexus looks like a snowman. I leave the twitch monitor at 0.5 mA and I circumferentially block around the brachial plexus noting the twitches as I move the needle around. I do this until I have a nice hydrodissection and the twitches ablate.

I save the last 7 mL of the mixture and do a suprascapular block. In >95% of the patients we do this for, they have 0/10 pain in the PACU and most don't require supplemental analgesia. The patients still get GA for the procedure, as this is a good analgesic but not a good anesthetic block. Before I used to routinely do suprascapular, I had a more-than-significant number of patients that complained of posterior and/or axillary pain post-op.

http://www.nysora.com/educational-tools/picture-gallery/us-images/3387-suprascapular-nerve.html

EDIT: Ninja'd by Noyac.

 

[urge]

I know that it doesn't always cover the back of the shoulder so why not add a suprascap?

That works also.

I was doing these blocks before the days of the ultrasound. I don't think a suprascapular block by anatomy would be that great vs just infiltrating the skin.

 

[BLADEMDA]

That works also.

I was doing these blocks before the days of the ultrasound. I don't think a suprascapular block by anatomy would be that great vs just infiltrating the skin.

I agree with you. 5-10 mls of local by the surgeon over the skin plus solid ISB equals zero pain in pacu.

The SCB is a good block for shoulder surgery but IMHO the IsB is slightly better at achieving 0/10 Postop pain scores.

 

[Anesthdoc21]

I ask them to inject local because a small fraction of the time the skin is not covered because it is superficial cervical plexus distribution. Most of the time it actually is. Why should I do suprascap block and waste another few mins when the surgeon can easily inject few mls of local around the incision port. Pain is always 0/10
As for placing LMA, why? The pt is comfortable and breathing on their own. 50 mcg/kg/min is far from GA in my patient population.

 

[BLADEMDA]

I ask them to inject local because a small fraction of the time the skin is not covered because it is superficial cervical plexus distribution. Most of the time it actually is. Why should I do suprascap block and waste another few mins when the surgeon can easily inject few mls of local around the incision port. Pain is always 0/10
As for placing LMA, why? The pt is comfortable and breathing on their own. 50 mcg/kg/min is far from GA in my patient population.

I've done these cases with light sedation, Propofol drip without an airway, PROPOFOL drip with an LMA, LMA with Sevo and Of course the ETT with Sevo.

The choice is up to you but the more I do (I've done thousands) the more I become conservative in my approach. I like the LMA with propofol or LMA with Sevo as it preserves spontaneous respiration and may decrease the risk of Perioperative CVA. For those with N/V issues the LMA with propofol drip is flying first class.

As usual, patient selection is key in deciding on the anesthetic choice. Your approach is sound provided the other patient variables line up. For example, sleep apnea would be a contraindication in my opinion to your approach in this type of case.

 

[BuzzPhreed]

I am invariably asked if the patient is "relaxed". Despite the block. ETT for everyone. You know, shoulder girdle muscles impairing the operation and whatnot. B.S. but a secure airway is a secure airway. They learn to expect what we give them. Oh, and they like a lower BP if the site is bleeding. Whatever.

 

[risnwb]

I am invariably asked if the patient is "relaxed". Despite the block. ETT for everyone. You know, shoulder girdle muscles impairing the operation and whatnot. B.S. but a secure airway is a secure airway. They learn to expect what we give them. Oh, and they like a lower BP if the site is bleeding. Whatever.

During residency surgeons doing total shoulders routinely request that the patients NOT be paralyzed.

 

[sevoflurane]

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

Uk... thanks for posting. Always glad to see you guys pop in these forums from across the sea.

To anwer your question, we are not concerned with giving Cox-2 inhibitors as it's a one time dose.

 

[Planktonmd]

Uk... thanks for posting. Always glad to see you guys pop in these forums from across the sea.

To anwer your question, we are not concerned with giving Cox-2 inhibitors as it's a one time dose.

You know... I think the increase in cardiac ischemic events with Cox2 inhibitors is actually a class effect of all NSAIDS... The only difference is that other NSAIDs are cheap and their makers are not claiming that their medications are the best cure to pain as the makers of COX2 inhibitors are trying to do.
So, as a result, no one is going to spend money on a study to prove that all NSAIDs increase the incidence of heart attacks.

 

[sevoflurane]

What are your thoughts on asprin? Do you see it as an outlier due to TXA2? I think some of the other NSAIDs have some degree of effect there. I'd have to look into it though.

 

[Noyac]

You know... I think the increase in cardiac ischemic events with Cox2 inhibitors is actually a class effect of all NSAIDS... The only difference is that other NSAIDs are cheap and their makers are not claiming that their medications are the best cure to pain as the makers of COX2 inhibitors are trying to do.
So, as a result, no one is going to spend money on a study to prove that all NSAIDs increase the incidence of heart attacks.

I think you are right about all NSAIDs being risky, at least that is how I understand it. But I can't answer the ASA question. Maybe that's why we recommend 81mg instead of 325mg. Don't know.

 

[BLADEMDA]

I think you are right about all NSAIDs being risky, at least that is how I understand it. But I can't answer the ASA question. Maybe that's why we recommend 81mg instead of 325mg. Don't know.

All NSAIDs carry increased cardiac risk; I should know because I take one on a daily basis. Second, Baby Aspirin is utilized because that is the dose needed to reduce cardiac risk for most patients. A full dose Aspirin is not needed and may increase the risk of bleeding, stomach ulcers, etc. Of Course, those with Cardiac stents usually take full dose aspirin.

As for doing blocks on these patients taking Nsaids, ASA, Plavix, etc I think it's a non-issue provided U/S is utilized to perform the block and a preblock scan is performed looking for blood vessels. In addition, an experienced Attending (N over 500 blocks) should be doing these "higher risk" blocks as it is important to avoid all blood vessels.

 

[BLADEMDA]

For long-term prevention of cardiovascular disease, the recommended dose of aspirin is 75 to 325 mg once daily.2 Some guidelines recommend only baby aspirin (75 to 100 mg) for long-term prevention, based on evidence that higher doses cause more gastrointestinal bleeding but do not provide additional protection against heart attack and stroke.

 

[BLADEMDA]

It appears that even after an MI or a Cardiac stent low dose aspirin is all you need; most cardiologists have been prescribing full dose aspirin but maybe that will change after recent studies:

http://www.ncbi.nlm.nih.gov/pubmed/18819961

http://www.ncbi.nlm.nih.gov/pubmed/23257371


http://www.ncbi.nlm.nih.gov/pubmed/21790788

 

[risnwb]

http://www.apsf.org/newsletters/html/2008/winter/17_problems_of_posture.htm

I know this topic has been discussed at length, but i hadn't really thought of it this way before and I happened to come across this letter to the editor regarding some case reports of ischemia following sitting shoulder cases and thought it was an interesting read.
Any thoughts on this "closed" vs. "open" cerebral circulation model, and the idea that we are actually discussing transmural pressure vs. perfusion pressure when making calculations to account for height of non-invasive cuff in beach chair position?

 

[MikeMerk-MtS]

Wtf?

LOL

 

[jetproppilot]

That's

WAYYYYYYY TOO COMPLICATED MAN.

1) Midazolam 6mg IV
2) USG interscalene block in the Pre-op Holding Area
3) Transport Dude To The Operating Room When It Is Time
4) Preoxygenate. Push 200mg Propofol IV.
5) Insert #4 LMA. Verify that it Feels Good.
6) Turn Whatever Volatile Anesthetic You Wish Counterclockwise.
7) Monitor Your Depth Of Anesthesia with BIS so you can Wake Them Up Quickly When The Time Comes.
8) Position Patient In Whatever Weird Position Surgeon Desires
9) Sit There For The Thirty Minute Case Thinking About What You Want For Dinner
10) Wake the patient up Immediately when the case is done, trying to not use the suction...if you don't use the suction, consider yourself well on the way ...(this is kinda Tongue In Cheek and kinda not)
11) Bring Dude to PACU
12) REVEL in the fact that these surgeries can be done SANS OPIOIDS and with LMAs in the Lateral Position (gasp...I know...alotta you out there are Sheltered...See The Light...)...giving No Opioids is Really Significant. Leads to less nausea and less sedation post-op and Shorter PACU Times....and LATERAL POSITIONED PATIENTS CAN BE SAFELY DONE WITH AN LMA. (trust me...I'm a doctor. LOL)
13) Happy Mardi Gras!!!!

 

[OB1🤙]

Jet's here! Awesome. Agree 99.9%, with the following comments-

1) If I gave 6mg midaz to most of my patients, they'd be obtunded for the rest of the day. Of course, that's because they don't have a Carnival season's worth of upregulated liver enzymes to metabolize it, they way yours do down there in NOLA.
7) Disagree it's necessary, but I know you love it and it works for you, so you go with your bad self.
9) I would kill for the alligator cheesecake at Jacque-Imo's right now.
12) Absofugginglutely.
13) Laissez les bon temps rouler!

 

[sevoflurane]

9) What are those bead necklaces good for?
oh... yeah... better check the reserves.

 

[psychbender]

Less midaz, switch numbers 8 with 4/5. I like letting the patient position himself before inducing (starting to get the others in my hospital to not only use an LMA while lateral, but put it in while lateral). I also don't use the BIS, and keep the gas at about 0.6-0.7 MAC, if doing a GA, and not just sedation with the ISB. They're all awake, with the LMA out before the drapes are pulled.

 

[ScaleneDoc]

How do "all NSAIDS" increase cv risk? Asa is an NSAID, proven to reduce MIs. Following logic, asa increases MIs.

 

[deleted171991]

How do "all NSAIDS" increase cv risk? Asa is an NSAID, proven to reduce MIs. Following logic, asa increases MIs.

At low doses, aspirin is an antiaggregant, by inhibiting predominantly COX-1 and thromboxane. However, at regular doses, most NSAIDs inhibit COX-2 (and prostacyclin) more, resulting in a prothrombotic effect.

 

[Dawkter]

Would you do LMA in beach chair? This is not standard practice at our institution.

 

[nimbus]

Would you do LMA in beach chair? This is not standard practice at our institution.

Yes, been doing this for 12 years with no issues. Isb, position in beach chair awake, make sure they are nice n comfy, induce, lma, go. You do need an assistant to ensure the head doesn't flop over before you get that foam mask/strap on.

I do this for arthroscopy and tsr.

 

[Mman]

Yes, been doing this for 12 years with no issues. Isb, position in beach chair awake, make sure they are nice n comfy, induce, lma, go. You do need an assistant to ensure the head doesn't flop over before you get that foam mask/strap on.

I do this for arthroscopy and tsr.

I once reviewed a case of a patient that died with LMA in beach chair. Arthroscopy fluid tracked subcu into the neck and there was a large volume of it compressing the airway before anybody realized it. By the time they figured it out they were unable to get the patient intubated (and zero chance of trach with that much fluid).

Just something to keep in the back of your mind.