- Joined
- Mar 21, 2011
- Messages
- 6
- Reaction score
- 2
All,
I'm part of the quality committee at a surgery center and there is an interesting case involving an anesthesiologist and a surgeon, both of whom are quietly blaming one another for the complication. I'm a CRNA but I was not involved in the case, however, the anesthesiologist is a member of our group, and he's a friend of mine, and myself and the another anesthesiologist are on the committee and I'd like more input (I run the meetings and have been at the center for years) We're all very collegial and this has sort of rattled the center.
The patient is 2 weeks out from her shoulder surgery does not have motor abilities in her deltoid. I'm seeking input as to 1) determining the source of the injury and 2) prognosis/treatment options.
Here are the anonymized details:
38 yo female for shoulder surgery related to pain. No major cardiopulmonary disease. Has a history of tingling in the hands due to "disc issues" in her neck (per patient) which she didn't reveal in the preop eval with anesthesia or surgery. In either case, a decision was made to block presumably because of her history of pain and depression. On Wellbutrin, Seroquel, and gabapentin.
Block was without issue. Twitch monitor used, twitch gone at 0.3, Shoulder twitch present. I talked to my friend who stated he backed off the brachial plexus until the twitch was gone as everyone does. 1mg of versed only for block, 20cc of 0.5% Ropi with Dex. Classic interscalene signs after block (Horner's, mildly symptomatic one-sided diaphragmatic block)
Presumably the patient has a numb arm going into surgery, but in unusual fashion, she states she woke up with "severe cutting" pain in her shoulder immediately after surgery. Goes home after some pain medication. I'm going to review records but she didn't have a cuff repair done - seems only Subacromial decompression and distal clavicle excision.
Two weeks later the surgeon calls and complains about the block. We spoke to her.
It's an unusual presentation: Patient has full motion in her hand and elbow, and has sensory sensation though with "positional tingling" at times). She also has sensory innervation on her shoulder/deltoid area, but she has no motor. I've reviewed many mild sensory deficits after nerve blocks and shoulder surgery, all of which have resolved. I've not seen this sort of presentation previously (8 years in practice).
Obviously, everyone involved feels terrible for this woman, who is active, works as a Vet tech, and is a Mom. She is extremely nice and not accusatory at all and understands that nerve injuries happen (as she's seen in her work). But, everyone is also very concerned as well.
My questions are as follows:
It's been recommend that the patient have EMG and NCS studies in another week or two. Is there anything else that we should expect to see from the neurologist? She's already on increased amounts of OT.
It sounds to us (anesthesia) as though this is axillary nerve distribution (motor distribution to the deltoid) at the level of the divisions of the BP. If this was from the block, wouldn't we see significant motor involvement of the Medial and Radial nerve as well (coming off C7)?
Again to us (anesthesia) this sounds fairly definitive that something occurred during surgery - whether from the surgery or positioning or whatever - but we find it very unusual for the patient to be numb heading in and have "cutting pain" afterwards.
We've also advised the patient that if this doesn't heal within 3 months surgery may be necessary.
And my key question: will an EMG and NCS study be able to distinguish between an injury as a result from the inter scalene nerve block (at trunk level) vs at a lower level (i.e. divisions or cords where the axillary nerve eventually branches out)?
Thanks everyone -
I'm part of the quality committee at a surgery center and there is an interesting case involving an anesthesiologist and a surgeon, both of whom are quietly blaming one another for the complication. I'm a CRNA but I was not involved in the case, however, the anesthesiologist is a member of our group, and he's a friend of mine, and myself and the another anesthesiologist are on the committee and I'd like more input (I run the meetings and have been at the center for years) We're all very collegial and this has sort of rattled the center.
The patient is 2 weeks out from her shoulder surgery does not have motor abilities in her deltoid. I'm seeking input as to 1) determining the source of the injury and 2) prognosis/treatment options.
Here are the anonymized details:
38 yo female for shoulder surgery related to pain. No major cardiopulmonary disease. Has a history of tingling in the hands due to "disc issues" in her neck (per patient) which she didn't reveal in the preop eval with anesthesia or surgery. In either case, a decision was made to block presumably because of her history of pain and depression. On Wellbutrin, Seroquel, and gabapentin.
Block was without issue. Twitch monitor used, twitch gone at 0.3, Shoulder twitch present. I talked to my friend who stated he backed off the brachial plexus until the twitch was gone as everyone does. 1mg of versed only for block, 20cc of 0.5% Ropi with Dex. Classic interscalene signs after block (Horner's, mildly symptomatic one-sided diaphragmatic block)
Presumably the patient has a numb arm going into surgery, but in unusual fashion, she states she woke up with "severe cutting" pain in her shoulder immediately after surgery. Goes home after some pain medication. I'm going to review records but she didn't have a cuff repair done - seems only Subacromial decompression and distal clavicle excision.
Two weeks later the surgeon calls and complains about the block. We spoke to her.
It's an unusual presentation: Patient has full motion in her hand and elbow, and has sensory sensation though with "positional tingling" at times). She also has sensory innervation on her shoulder/deltoid area, but she has no motor. I've reviewed many mild sensory deficits after nerve blocks and shoulder surgery, all of which have resolved. I've not seen this sort of presentation previously (8 years in practice).
Obviously, everyone involved feels terrible for this woman, who is active, works as a Vet tech, and is a Mom. She is extremely nice and not accusatory at all and understands that nerve injuries happen (as she's seen in her work). But, everyone is also very concerned as well.
My questions are as follows:
It's been recommend that the patient have EMG and NCS studies in another week or two. Is there anything else that we should expect to see from the neurologist? She's already on increased amounts of OT.
It sounds to us (anesthesia) as though this is axillary nerve distribution (motor distribution to the deltoid) at the level of the divisions of the BP. If this was from the block, wouldn't we see significant motor involvement of the Medial and Radial nerve as well (coming off C7)?
Again to us (anesthesia) this sounds fairly definitive that something occurred during surgery - whether from the surgery or positioning or whatever - but we find it very unusual for the patient to be numb heading in and have "cutting pain" afterwards.
We've also advised the patient that if this doesn't heal within 3 months surgery may be necessary.
And my key question: will an EMG and NCS study be able to distinguish between an injury as a result from the inter scalene nerve block (at trunk level) vs at a lower level (i.e. divisions or cords where the axillary nerve eventually branches out)?
Thanks everyone -