Need some Jedi Advice

[turnupthevapor]

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So Monday have a 90 yo severe COPD pt (FEV1 40%) for Total shoulder. Pulmonary recommends the case done under regional! My experience is she probably will not tolerate wacking the phrenic. May be worth a shot as if she doesn't tolerate the ISB I will just intubate (as I would have for GA anyway). Think Mepi w cath or single shot bupi for a good dense block (with the potential for 24 hour post op ventilation if she doesn't breath well)? Or ignore my thoughts nd tell me your regimen! thanks peeps

 

[Planktonmd]

So Monday have a 90 yo severe COPD pt (FEV1 40%) for Total shoulder. Pulmonary recommends the case done under regional! My experience is she probably will not tolerate wacking the phrenic. May be worth a shot as if she doesn't tolerate the ISB I will just intubate (as I would have for GA anyway). Think Mepi w cath or single shot bupi for a good dense block (with the potential for 24 hour post op ventilation if she doesn't breath well)? Or ignore my thoughts nd tell me your regimen! thanks peeps

Someone actually decided to do a total shoulder on a 90 Y/O 😱
Do a single shot supraclavicular block + LMA.

 

[ZzzPlz]

Prop sux tube. This is a perfect example of how even pulmonologists have no idea what we do.

Don't touch her with a block or you may regret it

 

[caligas]

Inpatient case. Frank discussion with family and patient. Pre op steroid and neb. Low dose block and ETT.

 

[deleted162650]

Someone actually decided to do a total shoulder on a 90 Y/O

She needs the total shoulder because her OA is so bad it's making it hard for her to get the cigarette to her lips.

 

[deleted162650]

Narcs aren't going to be her friend either (either peri or post-op). The best option is a come to Jesus talk outlining why there really isn't a great anesthetic option for her. Any reasonable volume of local for an SS ISB or SCB is going to reliably bag the phrenic. I might be tempted to place a catheter and sloooooowly trickle in local while keeping my fingers crossed and rubbing my rabbits foot that I don't knock out the diaphragm (all the while prepared that I still might). I'd probably go with the shortest acting local I could find too just in case.

But seriously - what's her 1 yr mortality rate?? This orthopod needs a .

 

[BLADEMDA]

I've done about a dozen of these cases at my hospital (85-90 years old). Yes, I agree they shouldn't be done but I don't cancel them.

Discussion with family and patient about risks, postop ventilation, etc.

Steroids preop and probably for 24 hours

Plan: Suprascapular nerve block with 15 mls plus infraclavicular block (posterior cord) with 10 mls. Complete phrenic nerve sparing technique. Excellent postop pain relief with all patients reporting 0-1 out of 10 VAS.

http://www.epostersonline.com/asra_RA16/node/1104

 

[Scotty_G]

You know what's funny I was going to ask about a similar case I have coming up which is basically the same scenario except the patient is 70 with ****ty lungs. I was going to do lma +/- supraclav with dilute local. Has anyone tried using < .25% of bupi for a PNB? Or would you guys do LMA place catheter preop and bolus with mepi or lido intraop to see how she does?

 

[Scotty_G]

SC plus IC blade? I think SC with 15cc on an avg/skinny person should be adequate

 

[BLADEMDA]

SC plus IC blade? I think SC with 15cc on an avg/skinny person should be adequate

Probably, but since it's a total shoulder I will add the block of the posterior cord using 10 mls to get the Axillary nerve.

 

[BLADEMDA]

SC plus IC blade? I think SC with 15cc on an avg/skinny person should be adequate

SUPRASCAPULAR not Supraclavicular just to be clear here

 

[deleted162650]

You know what's funny I was going to ask about a similar case I have coming up which is basically the same scenario except the patient is 70 with ****ty lungs. I was going to do lma +/- supraclav with dilute local. Has anyone tried using < .25% of bupi for a PNB? Or would you guys do LMA place catheter preop and bolus with mepi or lido intraop to see how she does?

I would imagine higher concentration local but lower volume would be the way the go. Hopefully still a dense block with less collateral damage??

 

[BLADEMDA]

You know what's funny I was going to ask about a similar case I have coming up which is basically the same scenario except the patient is 70 with ****ty lungs. I was going to do lma +/- supraclav with dilute local. Has anyone tried using < .25% of bupi for a PNB? Or would you guys do LMA place catheter preop and bolus with mepi or lido intraop to see how she does?

Well if you do a suprascapular nerve block there is ZERO phrenic nerve paresis postop.

 

[Planktonmd]

You know what's funny I was going to ask about a similar case I have coming up which is basically the same scenario except the patient is 70 with ****ty lungs. I was going to do lma +/- supraclav with dilute local. Has anyone tried using < .25% of bupi for a PNB? Or would you guys do LMA place catheter preop and bolus with mepi or lido intraop to see how she does?

I use 0.25% Bupivacaine frequently and it works great, the duration is shorter though.

 

[Scotty_G]

Where are you blocking suprascapular? I know you have mentioned this before but I have never tried it.

 

[Scotty_G]

I use .25% bupi with dex and patient's do fine, but I have never tried going lower on a crappy lung patient.

 

[Planktonmd]

Where are you blocking suprascapular? I know you have mentioned this before but I have never tried it.

It's an inadequate block and you will still need opiates.

 

[dhb]

5ml ISB w 0.5÷ bupivacaine, try to spot out the phrenic and stay away from it. If she needs a little vent i don't think it's a big deal, she will benefit more from good pain control than phrenic nerve preservation.
Although blade's technique looks sexy.
How do you reliably block the suprascap?

 

[narcusprince]

How do you position your shoulders? Lateral? Beach chair?

 

[Scotty_G]

We do them in mod beach chair but my surg are good so I usually just do LMA.

 

[OB1🤙]

Blade is correct, suprascapular is the way to go here.

 

[amyl]

supraclav and lma. did these all the time in fluffy smokers in bfe flyover state

 

[caligas]

So you LMA folks don't stress about lack of access to the airway for intubation if needed?(admittedly not likely but possible).

 

[nap$ter]

So Monday have a 90 yo severe COPD pt (FEV1 40%) for Total shoulder. Pulmonary recommends the case done under regional! My experience is she probably will not tolerate wacking the phrenic. May be worth a shot as if she doesn't tolerate the ISB I will just intubate (as I would have for GA anyway). Think Mepi w cath or single shot bupi for a good dense block (with the potential for 24 hour post op ventilation if she doesn't breath well)? Or ignore my thoughts nd tell me your regimen! thanks peeps

did this case a month ago. 10mL 0.375% bupi supraclavicular block/catheter, dexmed sedation. zero opiate. worked good. lengthy pessimistic preop conversation c family/pt/surgeon.

 

[narcusprince]

Your surgeons I would do an LMA and single shot infraclavicular and the periarterial superscapular nerve block. With my surgeons total shoulders may take 4+ hours arthroscpies 3-4 hours LMA out of the picture.

 

[Mman]

I hate these cases as there is no good answer. It's a bunch of bad options. Personally I'd do a preop supraclavicular block with about 10 mls of 0.5% Ropivicaine. I'd also do preop IV steroids and albuterol neb. Do case under GA with whatever airway device you want and try to give no narcotics. Probably won't take out phrenic nerve enough with that small volume to make clinical difference, but if you do you can try extubating to CPAP.

Pt obviously needs overnight admission and can maybe go home in 24-48 hours if they are lucky. But I'd have a long discussion about potential need for postop ventilation and I'd explain why the pulmonologist is wrong about doing case under regional. I mean you can do it under regional, but you will have a 100% chance of taking out the phrenic nerve if you do.

edit: I'd also place an arterial line intraop for monitoring blood gases postop.

 

[Robotic Wis-Hipple]

15ml for suprascapular? That seems like a ton. I'm used to seeing 5-10ml.

And Blade, you obviously are far far far more experienced than I, but have you ever had anyone with even a 2 VAS?

 

[Planktonmd]

So you LMA folks don't stress about lack of access to the airway for intubation if needed?(admittedly not likely but possible).

I almost never use ETT with shoulders.

 

[Mman]

I almost never use ETT with shoulders.

my enthusiasm for LMAs with shoulder arthroscopy dwindled when I saw a patient have massive swelling of their neck from arthroscopy fluid tracking subcutaneously from what I think was a malfunctioning port, though I don't personally want to criticize those that do use them

 

[Ronin786]

my enthusiasm for LMAs with shoulder arthroscopy dwindled when I saw a patient have massive swelling of their neck from arthroscopy fluid tracking subcutaneously from what I think was a malfunctioning port, though I don't personally want to criticize those that do use them

Bingo. Seen this complication as well and thankfully the patient had a ETT in place. Nightmare airway otherwise. On the other hand, LMAs sit extremely nicely in the beach chair position.

 

[deleted162650]

And Blade, you obviously are far far far more experienced than I, but have you ever had anyone with even a 2 VAS?

Never. Not once in the >200,000 shoulder cases he has personally provided the anesthetic for. 😉

Seriously though, I just google taught myself how to do a suprascapular block and now I'm anxiously awaiting a good case to use it. Thanks Blade.

 

[deleted171991]

I've done about a dozen of these cases at my hospital (85-90 years old). Yes, I agree they shouldn't be done but I don't cancel them.

Discussion with family and patient about risks, postop ventilation, etc.

Steroids preop and probably for 24 hours

Plan: Suprascapular nerve block with 15 mls plus infraclavicular block (posterior cord) with 10 mls. Complete phrenic nerve sparing technique. Excellent postop pain relief with all patients reporting 0-1 out of 10 VAS.

http://www.epostersonline.com/asra_RA16/node/1104

Combined Suprascapular and Axillary (Circumflex) Nerve Block: The Shoulder Block

 

[BLADEMDA]

It's an inadequate block and you will still need opiates.

No. On an 80-90 year old a suprascapular block plus posterior cord provides excellent analgesia post op.


http://journals.lww.com/em-news/fulltext/2014/09000/The_Speed_of_Sound__Ultrasound_Guided.13.aspx

 

[BLADEMDA]

Never. Not once in the >200,000 shoulder cases he has personally provided the anesthetic for. 😉

Seriously though, I just google taught myself how to do a suprascapular block and now I'm anxiously awaiting a good case to use it. Thanks Blade.

Yes. an adductor canal block without a posterior capsule injection plus LIA will result in pain scores over 6. I would guess about 150 total knee patients got this for their total knees until I realized that it wasn't adequate.

Now, I do adductor plus ipack with LIA by surgeon or Femoral plus ipack with LiA by surgeon. VAS are 2-3 for the former and 1-2 for the latter most of the time.

 

[BLADEMDA]

did this case a month ago. 10mL 0.375% bupi supraclavicular block/catheter, dexmed sedation. zero opiate. worked good. lengthy pessimistic preop conversation c family/pt/surgeon.

A few years ago I did these cases with supraclavicular block 10-12 mls with excellent results. I didn't have a single case which required postop ventilation in patients with COPD.

But, I am risk averse and my new combo is safer and very effective in the highest risk patients. Most 80-90 year olds only need this "shoulder block" to be quite comfy postop as their pain tolerance is much better than younger patients.

 

[BLADEMDA]

 

[BLADEMDA]

David Auyong out of Seattle (Virginia Mason) is doing a lot of suprascapular blocks in the neck. It's easy and a modified SCB approach.

https://www.researchgate.net/public...scription_of_a_Novel_Supraclavicular_Approach

 

[BLADEMDA]

 

[BLADEMDA]

Since I trained with the dinosaurs I had to adapt my practice and skills as the new techniques evolved. I know it's easy to stay in your current "safe mode" and not venture out to try new things. But, regional is moving forward and I'm going along for the ride.

I would say that after just 400-500 blocks your skill level should be to the point that you can try new techniques. Certainly once you reach 1,000-1500 u/s guided blocks the concept of learning a new block should be quite simple.

 

[BLADEMDA]

http://www.scitechnol.com/combined-...ed-nerve-blocks-shoulder-arthroscopy-TzeC.pdf

David Auyong has been doing a lot of SSN blocks in the neck. One could place 5-7 mls near the SSN then advance the needle near the divisions/subclavian artery and place another 5-7 mls. Essentially you are doing two nerve blocks but the volume for the SCB is extremely low which should avoid phrenic nerve palsy.

 

[BLADEMDA]

just as some experts like the QL1 or QL2 block over the TAP as described by Hebbard the actual evidence over the superiority of one technique over the other has yet to be proven.

This is probably true for the low volume SCB vs the SSN/ICB or SSN/very low dose SCB for shoulder surgery.

What I can tell you is that using volumes over 15 mls will likely result in phrenic nerve palsy when performing an ISB. If the ISB is chosen the volume will likely need to be 5 mls or less to avoid the phrenic nerve. For SCB volumes less than 15 mls are pretty safe but not guaranteed to avoid phrenic nerve palsy. I've been fortunate to do quite a few low dose SCBs without any issues.

That said, the SSN plus ICB or SSN plus very low dose SCB should be the safest approach in patients with severe lung disease, oxygen dependent etc

 

[pastafan]

90 y.o. for total shoulder?? Skip surgery, send for suprascapular RFA instead. If that fails to provide relief then surgery.

 

[BLADEMDA]

90 y.o. for total shoulder?? Skip surgery, send for suprascapular RFA instead. If that fails to provide relief then surgery.

In my neck of the woods we do total joint replacements for 85-90 year olds at least 5-6 times per week. Most of them are ASA3 with the rest ASA4.

 

[sigrhoillusion]

As someone else mentioned, what are these 90yo ASA 4 patients using their new shoulders for and for how long...? I completely understand the lively 90yo ASA 2, but ASA 4 implies that there's a lot more going wrong with the patient then some OA in their shoulder joint.

 

[nap$ter]

A few years ago I did these cases with supraclavicular block 10-12 mls with excellent results. I didn't have a single case which required postop ventilation in patients with COPD.

But, I am risk averse and my new combo is safer and very effective in the highest risk patients. Most 80-90 year olds only need this "shoulder block" to be quite comfy postop as their pain tolerance is much better than younger patients.

ok, i'll bite - why do you say you new combo is safer? is it as effective? same time to place?

 

[BLADEMDA]

ok, i'll bite - why do you say you new combo is safer? is it as effective? same time to place?

It is theoretically safer to do a SSN/ICB vs a low dose SCB because there is zero risk of phrenic nerve palsy. My best guess is that risk of phrenic nerve palsy with s low dose SCB (10-12 mls) is around 5 percent. The SSN eliminates that risk entirely. In my experience both approaches are safe but one is just a bit safer if you do a high volume of blocks.

Second, it does take about 10 minutes longer to do the classic SSN plus ICB vs a low dose SCB. That said, David Auyong has reduced the total time to do a SSN to less than 5 minutes by performing a modified SCB approach to block the SSN.
I'm still too new at his technique to comment on success vs the traditional SSN at the Suprscapular notch but Auyong reports a very high success rate.

Third, in the elderly population (over 75 at my shop) the SSN plus ICB has worked great. Their pain scores are very low but part of that is due to the fact that elderly patients have a higher pain threshold than younger patients. I do not think that a SSN with ICB is as good as a SCB for young patients. That said, Combining a SSN with a very low dose SCB (both in the neck) should be as good as the low dose SCB I was doing just a few years ago.

 

[BLADEMDA]

https://forums.studentdoctor.net/th...-infraclavicular-block.1121807/#post-16202561

 

[dhb]

I'm not sure their pain tolerance is higher, maybe it's just their schrunken periostium which is less painfull...

 

[deleted171991]

Btw, this is the kind of case healthcare waste is about. What's her expected survival, 5 years? It would almost be ethical to call Medicare and report the surgeon.

 

[BLADEMDA]