Interscalene and COPD

[loveumms]

Thoughts - 65 yo female presents for shoulder arthroscopy. Not just a "simple arthroscopy" per surgeon. Could take up to two hours.

Pt with h/o CAD s/p 2 stents three years ago, DM II and COPD. Per OSH reports, severe obstructive defect with mild improvement post bronchodilator (2011 PFTs). No actual report from those PFTs however, Pt had PFTs at our institution in 2009 with FEV1/FVC ratio of 55% predicted. Pt not on o2 at home but, limited functional capacity and "short of breath with very little exertion". Pt not been on her prescribed inhalers because she can't afford them. We discuss with Pt regional anesthesia and she declines because she is scared (we told her it can cause worsening of her breathing by knocking out the phrenic). Surgeon comes in and pushes regional. He wants her to go home today and is worried about pain.

Would you do the block?

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[dhb]

Yes: no reason to take out the phrenic if you're using ultrasound and you limit your volume.
And if ever you get burned you put her on CPAP

 

[bostonblaz]

100% do the block. If you are worried about the phrenic do it as low as you can or use really low volume(10 to 15 cc) and add something to it like decadron so it wil last. The narcs she will need after will be much worse than and block can do.