Anybody do shoulder arthoscopy with block and sedation?

[ethilo]

Just wondering if people have experience doing shoulder surgery under regional with sedation in PP? I've always done it with ISB + GETA. It might not be practical if the block doesn't set up fast enough. I'm looking for ways to expedite the recovery period for our outpatient surgery center.

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[psychbender]

Just wondering if people have experience doing shoulder surgery under regional with sedation in PP? I've always done it with ISB + GETA. It might not be practical if the block doesn't set up fast enough. I'm looking for ways to expedite the recovery period for our outpatient surgery center.

I had mine done with block only, no sedation (bad PONV with previous surgeries). I did the same for an IM resident at our hospital. I used to do block plus GETA, then block plus GLMA, then at a previous hospital, started transitioning to block and sedation (low dose prop +/- a little ketamine) in select patients for our faster surgeons. When it works, it works great, and they clear out of PACU very quickly. Wrong patient, or the procedure stretches into hours on the table, and any advantage goes out the window.

 

[narcotics999]

My old place block + propofol infusion in sitting position 95% time. I was hesitating at the beginning. Worked pretty well actually.

 

[cchoukal]

Mine are SCB and half are GA, half are sedation. Depends on surgeon and patient. But yes, you can do a shoulder under sedation with ISB or even SCB.

 

[ethilo]

My old place block + propofol infusion in sitting position 95% time. I was hesitating at the beginning. Worked pretty well actually.

Do you place the block in the room or in a pre-op block bay? What generally is your rate for your propofol gtt?
I have to put the blocks in the moment they hit the room. With decadron added I think there just might be enough time but I'm nervous I will be just a few mins shy of block setup in time for incision.

 

[narcotics999]

Do you place the block in the room or in a pre-op block bay? What generally is your rate for your propofol gtt?
I have to put the blocks in the moment they hit the room. With decadron added I think there just might be enough time but I'm nervous I will be just a few mins shy of block setup in time for incision.

Most of the time in block area. Sometimes in OR. If in OR, add 5ml 1.5% Mepi. I guess lidocaine should work too. Pt in sitting position. It took a few minutes to position pt. Help the block to set up.

Pt usually not sick or old. Propofol around 75-150. Versed, fentanyl, or ketamine, your preference.

 

[nimbus]

Most of the time in block area. Sometimes in OR. If in OR, add 5ml 1.5% Mepi. I guess lidocaine should work too. Pt in sitting position. It took a few minutes to position pt. Help the block to set up.

Pt usually not sick or old. Propofol around 75-150. Versed, fentanyl, or ketamine, your preference.

Sounds like a pretty big MAC. Why not just slip in an LMA? I use 50-100mcg fentanyl preblock, then prop/LMA/sevo. Patients are usually spitting out LMA when the drapes come down and talking enroute to pacu. Some MACs end up spending more time in PACU than a minimalist GA.

 

[kmurp]

We do almost all with ISB and sedation. We work with CRNAs so setup time isn’t much of a problem. These cases can be a real challenge for the CRNAs as, even with what appears to be a good block, the patients can get antsy. I never know if it’s pain in the shoulder or something else. They almost always wake up with no pain. The airway can be an issue with heavier sedation. Sometimes an LMA is placed for airway obstruction and we do TIVA. Ketamine occasionally helps.

 

[deleted59964]

Mine are SCB and half are GA, half are sedation. Depends on surgeon and patient. But yes, you can do a shoulder under sedation with ISB or even SCB.

how much local do you use for a shoulder with a SCB?

 

[Hoya11]

Just wondering if people have experience doing shoulder surgery under regional with sedation in PP? I've always done it with ISB + GETA. It might not be practical if the block doesn't set up fast enough. I'm looking for ways to expedite the recovery period for our outpatient surgery center.

i have done it but i prefer an lma - it takes literally 5 seconds to put it in and you have a more secure airway and the ability to give sevo, if you time it right its not a delay compared to mac and often faster recovery.

 

[GravelRider]

Block + LMA. I did “sedation” a few times and didn’t see much benefit. It’s really not sedation, though, is it? I can’t imagine there is much difference in PACU times between GA from a propofol infusion and from our modern volatiles.

 

[psychbender]

If block set up time is an issue, try starting the block with the lido you're using for skin local. Inject some in skin and subQ, then under real-time ultrasound guidance, approach the plexus and deposit lido as you go. If you can visualize the needle well, you can start the block with lidocaine, and it's already setting up by the time you start the block worth bupi/rop.

 

[BLADEMDA]

Years back I did a shoulder scope under Block with minimal sedation. The patient was an Ex-marine (30+ years) who was motivated to have it performed that way. There were no issues and the case went well.

If you decide to go the "block only route" I recommend infiltration of the skin and port holes with local anesthesia by the surgeon to enhance any areas missed by your ISB. Some would add a superficial cervical plexus block to the ISB but the local injection to those areas works quite well.

These days I do them under ISB plus LMA. If N/V is a concern postop then run a propofol infusion with a little fentanyl IV (50-100 ug). Everyone is happy and the case is very easy to manage intraop.

 

[cchoukal]

how much local do you use for a shoulder with a SCB?

20 ml 0.5% bupiv. No additives.

 

[deleted59964]

20 ml 0.5% bupiv. No additives.

interesting - I've never tried SCBs for shoulders - have always done ISBs for them - if supraclavs work reliably i'd rather do that.

 

[cchoukal]

interesting - I've never tried SCBs for shoulders - have always done ISBs for them - if supraclavs work reliably i'd rather do that.

Agreed. In my hands, they’re much easier and faster, and, in theory, less likely to bag the phrenic.

 

[okayplayer]

Agreed. In my hands, they’re much easier and faster, and, in theory, less likely to bag the phrenic.

I always do some hybrid of the 2. Start with SC view and slowly scan up and take the block wherever the image looks best (I also still use stim). Usually closer to SC than classic ISB at the level of cricoid.