Interscalene blocks as sole anesthetic for Rotater C repair

[Laurel123]

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Well, a lot of you guys seem very adept at regional so I was wondering on your experience with rotator cuff repairs using interscalene blocks as sole anesthetic.

Personally, I am not a fan of the interscalene block. It isn't even close to 100%, and I have used it occasionally for post-op pain control, but never as the sole anesthetic. Anyways, I was called about a patient who needed a rotator cuff repair but has 'a lot of medical problems' Unfortunately, the message giver only knew the patient had a pheochromocytoma, but no other details. (this is for a surgery in the far future) I guess someone thought this patient was 'too sick' for a general and was asking about doing it under regional only.

My philosophy is that except for the most minor of surgeries (skin biopsy, cataract), a person that is 'too sick' for a general is 'too sick' for elective surgery. General anesthesia is always the backup plan for if there is a complication. Plus, I don't think that interscalene blocks (like spinals and epidurals) are harmless riskfree techniques for anyone, let alone a sick patient.

So, I told them to set up a consult - but I just wanted to get some thoughts from people who may have done rotator cuff repairs with an interscalene only and how well it works.

 

[Planktonmd]

Well, a lot of you guys seem very adept at regional so I was wondering on your experience with rotator cuff repairs using interscalene blocks as sole anesthetic.

Personally, I am not a fan of the interscalene block. It isn't even close to 100%, and I have used it occasionally for post-op pain control, but never as the sole anesthetic. Anyways, I was called about a patient who needed a rotator cuff repair but has 'a lot of medical problems' Unfortunately, the message giver only knew the patient had a pheochromocytoma, but no other details. (this is for a surgery in the far future) I guess someone thought this patient was 'too sick' for a general and was asking about doing it under regional only.

My philosophy is that except for the most minor of surgeries (skin biopsy, cataract), a person that is 'too sick' for a general is 'too sick' for elective surgery. General anesthesia is always the backup plan for if there is a complication. Plus, I don't think that interscalene blocks (like spinals and epidurals) are harmless riskfree techniques for anyone, let alone a sick patient.

So, I told them to set up a consult - but I just wanted to get some thoughts from people who may have done rotator cuff repairs with an interscalene only and how well it works.

You are absolutely right!
A rotator cuff repair under Interscalene block is not less risky than GA, and shoulder surgery in general requires significant sedation for the patient to tolerate the position even if you have a perfect block.
I occasionally do these procedures under regional in select patients who request it (highly motivated patients) and I usually add a Suprascapular block to the interscalene to improve the quality of the block (My personal belief and I don't know if it's supported by any evidence).
In these "select" patients I have great results, but I wouldn't do it on a patient who is "too sick" to tolerate GA whatever that means.

If a patient has Pheochromocytoma I think their rotator cuff should wait 🙂

 

[jetproppilot]

Well, a lot of you guys seem very adept at regional so I was wondering on your experience with rotator cuff repairs using interscalene blocks as sole anesthetic.

Personally, I am not a fan of the interscalene block. It isn't even close to 100%, and I have used it occasionally for post-op pain control, but never as the sole anesthetic. Anyways, I was called about a patient who needed a rotator cuff repair but has 'a lot of medical problems' Unfortunately, the message giver only knew the patient had a pheochromocytoma, but no other details. (this is for a surgery in the far future) I guess someone thought this patient was 'too sick' for a general and was asking about doing it under regional only.

My philosophy is that except for the most minor of surgeries (skin biopsy, cataract), a person that is 'too sick' for a general is 'too sick' for elective surgery. General anesthesia is always the backup plan for if there is a complication. Plus, I don't think that interscalene blocks (like spinals and epidurals) are harmless riskfree techniques for anyone, let alone a sick patient.

So, I told them to set up a consult - but I just wanted to get some thoughts from people who may have done rotator cuff repairs with an interscalene only and how well it works.

There are two issues here.

1) I dont think an interscalene block can be used day in and day out as a reliable, sole-source anesthetic for shoulder surgery..... theres always a risk of incomplete penetrance independent of one's needle-driving skill, so as you accurately pointed out there is always a chance GA will be instituted.

2) Pheochromocytoma and elective surgery carries risks that exceed the benefit of the elective surgery IMHO.

You are spot on with your assessments.

 

[urge]

did every single one of them under block when i was in residency.

 

[Noyac]

I just read the title of this thread so if I am off base then I will correct it later. I have done many IS blocks for the sole anesthetic for many different shoulder cases including RTR. It is pt dependent.

 

[Laurel123]

Great! i was hoping to get some input on how you do the interscalene, with nerve stim or ultrasound, how much and what meds were used and what the surgeon and patient satisfaction is. Unfortunately, I rarely use block in private practice now, and I didnt have attendings that used blocks for anesthesia for shoulder surgery. It will just help me in assesment of patients like this.

 

[militarymd]

We block 80% to 90% of our shoulders, and although we always also put them to sleep, I would say over 90% of our blocks would be enough for surgery.

We use 30 ml of 0.5% bupivicaine with 1:200,000 epinephrine with nerve stimulation....and ultrasound VERY rarely when anatomic landmarks are insufficient.

 

[Planktonmd]

Great! i was hoping to get some input on how you do the interscalene, with nerve stim or ultrasound, how much and what meds were used and what the surgeon and patient satisfaction is. Unfortunately, I rarely use block in private practice now, and I didnt have attendings that used blocks for anesthesia for shoulder surgery. It will just help me in assesment of patients like this.

Every shoulder I do gets an interscalene block for post op pain and I do it with nerve stimulator and use 30 CC of Bupivacaine 0.25% with epi. with success rate close to 100%.
If the block is for surgical anesthesia then I use 20 cc Bupivacaine 0.5% mixed with 10cc Lidocaine 2% with epi. and a Suprascapular block (No nerve stim needed) with 10cc Lidocaine 1%.

 

[Noyac]

If pt is going to sleep I use 30cc 0.5% Ropiv

If not going night night, 15-20 cc 0.5% ropiv mixed with 15-20cc 1.5% Mepiv.

Nothing fancy.

 

[Noyac]

Every shoulder I do gets an interscalene block for post op pain and I do it with nerve stimulator and use 30 CC of Bupivacaine 0.25% with epi. with success rate close to 100%.
If the block is for surgical anesthesia then I use 20 cc Bupivacaine 0.5% mixed with 10cc Lidocaine 2% with epi. and a Suprascapular block (No nerve stim needed) with 10cc Lidocaine 1%.

plank, why the suprascapular block? Are you doing it for surgical pain or post-op pain? Are you using a nerve stim? Personally, I have not found this to be necessary, am I missing something?

 

[Planktonmd]

plank, why the suprascapular block? Are you doing it for surgical pain or post-op pain? Are you using a nerve stim? Personally, I have not found this to be necessary, am I missing something?

I add a Suprascapular block when the surgery is going to be done under straight regional because I feel that it improves the quality of the block specifically to the upper part of the plexus (C5 C6).
I don't use a nerve stimulator for this block although you could.
Most of the times you don't need this block if your local anesthetic had spread evenly and covered C5 through T1 but occasionally the superior trunk does not get a dense block because the local anesthetic migrates caudally.
This is a personal trick and I don't have any evidence to support it, but if you get an incomplete interscalene try adding a suprascapular block, it might save the day.

 

[Noyac]

I add a Suprascapular block when the surgery is going to be done under straight regional because I feel that it improves the quality of the block specifically to the upper part of the plexus (C5 C6).
I don't use a nerve stimulator for this block although you could.
Most of the times you don't need this block if your local anesthetic had spread evenly and covered C5 through T1 but occasionally the superior trunk does not get a dense block because the local anesthetic migrates caudally.
This is a personal trick and I don't have any evidence to support it, but if you get an incomplete interscalene try adding a suprascapular block, it might save the day.

Thats what I thought.