Need some Jedi Advice

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FFP said:
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.
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Total shoulder arthroplasty can be performed in patients 80 years and older with rates of perioperative complications and mortalities comparable to those of younger patients, although these older patients may require a longer period of institutional care before return to home and may be more likely to require a blood transfusion.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048261/
 
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BLADEMDA said:
Total shoulder arthroplasty can be performed in patients 80 years and older with rates of perioperative complications and mortalities comparable to those of younger patients, although these older patients may require a longer period of institutional care before return to home and may be more likely to require a blood transfusion.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048261/
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The mean age of the above 80 Y/O group was 82! Which means they most likely did not have anyone over 90 Y/O getting shoulder replacement.
A 95 Y/O patient with terminal lung disease is not comparable to an 82-83 Y/O who is fully functional and a professional ballroom dancer in my humble simple logic.
We need to take these studies with a a grain of salt.
 
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BLADEMDA said:
Total shoulder arthroplasty can be performed in patients 80 years and older with rates of perioperative complications and mortalities comparable to those of younger patients, although these older patients may require a longer period of institutional care before return to home and may be more likely to require a blood transfusion.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048261/
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We are not talking about 80. We are talking about 90, which is way above the expiration date. If you take the probability of surviving 5 years at that age, it's probably far less than 50% (more like 20% in this patient). I don't care how functional somebody is, elective surgeries on 85-90 year-olds should be mostly out-of-pocket fun, not Medicare. "The needs of the many outweigh the needs of the few."
 
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FFP said:
We are not talking about 80. We are talking about 90, which is way above the expiration date. If you take the probability of surviving 5 years at that age, it's probably far less than 50% (more like 20% in this patient). I don't care how functional somebody is, elective surgeries on 85-90 year-olds should be mostly out-of-pocket fun, not Medicare. "The needs of the many outweigh the needs of the few."
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And again a 90yo who is an ASA4 has more going on than just a sore shoulder... CAD, CKD, PVD, CVA, HTN, DM? 90 yo marathon runner or Jack Lalane(sp?) wants a new shoulder? Sure.

Then again if someone classified as an ASA4 can live until 90 with all those morbidities, then perhaps they can take a little banging on their shoulder ender anesthesia...
 
My record for a patient having a total joint replacement at my shop is 101. Yes, 101 years old! I seriously doubt the surgeons at my place are going to stop doing total joints on 85-90 year olds anytime soon. The only way that happens is if Medicare stops paying them.
 
BLADEMDA said:
My record for a patient having a total joint replacement at my shop is 101. Yes, 101 years old! I seriously doubt the surgeons at my place are going to stop doing total joints on 85-90 year olds anytime soon. The only way that happens is if Medicare stops paying them.
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Wow. Nothing else. Just wow.


Sent from my iPad using SDN mobile app
 
BLADEMDA said:
My record for a patient having a total joint replacement at my shop is 101. Yes, 101 years old! I seriously doubt the surgeons at my place are going to stop doing total joints on 85-90 year olds anytime soon. The only way that happens is if Medicare stops paying them.
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Man, I am always on the fence about orthos in so many ways. I try to give them the benefit of the doubt, greatly respect their skills and knowledge, etc. And I personally know some of them who are great human beings and ethical doctors. But then there is stuff like this. Many of them really seem to not actually care about their patients at times. It's amazing. Think about it, do other surgical sub specialties do crap like this?!?!? No. And why are they sooooo douchy in the OR often to anes, when they know less physical/pharm than basically any other type of surgeon? Again, often compromising patient care with 0/4 twitches post tetanic and BPs in the toilet please and rush rush rush etc etc. What is the deal with these guys...can anyone enlighten me????? I don't think it's all about the cash. What amount of cash is worth the post op hastles associated with 90+ yo pt joint replacements. It's something else but I can't put my finger on it. Like a culture in ortho of just being alpha and bull headed and sort of ignorant?
 
Timeoutofmind said:
Man, I am always on the fence about orthos in so many ways. I try to give them the benefit of the doubt, greatly respect their skills and knowledge, etc. And I personally know some of them who are great human beings and ethical doctors. But then there is stuff like this. Many of them really seem to not actually care about their patients at times. It's amazing. Think about it, do other surgical sub specialties do crap like this?!?!? No. And why are they sooooo douchy in the OR often to anes, when they know less physical/pharm than basically any other type of surgeon? Again, often compromising patient care with 0/4 twitches post tetanic and BPs in the toilet please and rush rush rush etc etc. What is the deal with these guys...can anyone enlighten me????? I don't think it's all about the cash. What amount of cash is worth the post op hastles associated with 90+ yo pt joint replacements. It's something else but I can't put my finger on it. Like a culture in ortho of just being alpha and bull headed and sort of ignorant?
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I dont think its the culture of ortho, its the way our system is set up that ortho/neuro/cardiac surgeons are king. They make millions per year, they lose sight of reality, they think they are kings and they act like it. Everyone caters to their ridiculous requests for fears of them complaining to hospital CEO who is medically untrained. Then CEO fears big total joint guy will leave. The surgeon who does big lucrative cases right now is king of the suits at the hospital and all other medical staff because they have such power due to the revenue they bring in.

I dont think this trend will last forever. These guys salary will float down to the 500-600k range within the next 10 years (hopefully) as people slowly realize what is going on. Then they wont be so scary to take on with patient concerns like hypotension, anesthetic technique.... These guys are technicians, they are not caring for the whole patient, which is what they are billing for... What other service can admit a guy for a complex total joint and then be a consultant on the guy while medicine does everything due to his prior history of HTN? I think everyone is sick of ortho docs acting this way..
 
^^ This reminds me of a time in residency when I watched ortho and medicine attendings fighting over who would be the primary vs consult service on a mostly healthy old woman with a hip fracture. The ortho attending won when he busted out, "Come on, would you really want me taking care of your grandmother?"
 
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Timeoutofmind said:
Man, I am always on the fence about orthos in so many ways. I try to give them the benefit of the doubt, greatly respect their skills and knowledge, etc. And I personally know some of them who are great human beings and ethical doctors. But then there is stuff like this. Many of them really seem to not actually care about their patients at times. It's amazing. Think about it, do other surgical sub specialties do crap like this?!?!? No. And why are they sooooo douchy in the OR often to anes, when they know less physical/pharm than basically any other type of surgeon? Again, often compromising patient care with 0/4 twitches post tetanic and BPs in the toilet please and rush rush rush etc etc. What is the deal with these guys...can anyone enlighten me????? I don't think it's all about the cash. What amount of cash is worth the post op hastles associated with 90+ yo pt joint replacements. It's something else but I can't put my finger on it. Like a culture in ortho of just being alpha and bull headed and sort of ignorant?
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Yes ... it's all about cash, and nothing else!
If you make a lot of money for yourself and for the hospital, then the hospital will bend backward to accommodate you, and that includes forcing other specialties to tolerate your abuse and clean up your mess.
 
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So the other similar case I see in this demographic is prox humerus fx's. I'm thinking the suprascap+ax/posterior cord combo wouldn't be adequate for this but what does the SDN brain trust think.
 
SaltyDog said:
So the other similar case I see in this demographic is prox humerus fx's. I'm thinking the suprascap+ax/posterior cord combo wouldn't be adequate for this but what does the SDN brain trust think.
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Good old fashion inter-scalene block is the answer in 99.9% of these cases, and in the 0.1% where you really feel strongly that the ISB is going to be so bad just do prop/sux/tube and tell the surgeon to put some local around the repair site at the end.
 
Planktonmd said:
Good old fashion inter-scalene block is the answer in 99.9% of these cases, and in the 0.1% where you really feel strongly that the ISB is going to be so bad just do prop/sux/tube and tell the surgeon to put some local around the repair site at the end.
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Personally agree with this. There is also some evidence that you can significantly reduce your diaphragm paralysis incidence by staying lateral to the sheath. Been doing it this way for a long time (mainly to avoid parasthesias) and blocks work great. I'm not checking for diaphgram paralysis obviously, but personally, unless the patient is on home oxygen and really in bad shape from a pulm perspective, I'll do a ISB in COPD patients without really thinking about it.

Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial
N Palhais, R Brull, C Kern, A Jacot-Guillarmod, A Charmoy, A Farron, E Albrecht
British Journal of Anaesthesia 2016, 116 (4): 531-7

BACKGROUND: Hemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We tested the hypothesis that an injection lateral to the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with a conventional intrafascial injection, while providing similar analgesia.

METHODS: Forty ASA I-III patients undergoing elective shoulder and clavicle surgery under general anaesthesia were randomized to receive an ultrasound-guided interscalene brachial plexus block for analgesia, using 20 ml bupivacaine 0.5% with epinephrine 1:200 000 injected either between C5 and C6 within the interscalene groove (conventional intrafascial injection), or 4 mm lateral to the brachial plexus sheath (extrafascial injection). The primary outcome was incidence of hemidiaphragmatic paresis (diaphragmatic excursion reduction >75%), measured by M-mode ultrasonography, before and 30 min after the procedure. Secondary outcomes were forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow. Additional outcomes included time to first opioid request and pain scores at 24 h postoperatively (numeric rating scale, 0-10).

RESULTS: The incidences of hemidiaphragmatic paresis were 90% (95% CI: 68-99%) and 21% (95% CI: 6-46%) in the conventional and extrafascial injection groups, respectively (P<0.0001). Other respiratory outcomes were significantly better preserved in the extrafascial injection group. The mean time to first opioid request was similar between groups (conventional: 802 min [95% CI: 620-984 min]; extrafascial: 973 min [95% CI: 791-1155 min]; P=0.19) as were pain scores at 24 h postoperatively (conventional: 1.6 [95% CI: 0.9-2.2]; extrafascial: 1.6 [95% CI: 0.8-2.4]; P=0.97).

CONCLUSIONS: Ultrasound-guided interscalene brachial plexus block with an extrafascial injection reduces the incidence of hemidiaphragmatic paresis and impact on respiratory function while providing similar analgesia, when compared with a conventional injection.

CLINICAL TRIAL REGISTRATION: NCT02074397.
 
Planktonmd said:
Good old fashion inter-scalene block is the answer in 99.9% of these cases, and in the 0.1% where you really feel strongly that the ISB is going to be so bad just do prop/sux/tube and tell the surgeon to put some local around the repair site at the end.
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Look, I'm not asking for advice on how to do the case. I'm really just looking for an excuse to do a suprascap + posterior cord/ax block, so I want to know if this will cover the prox Hunerus. I figure I'm much more likely to see a severe COPDer with a fx than I am to see one for a total shoulder (my orthopods aren't that greedy/stupid I don't think). @facted , you're a regional dude, will these blocks cover that area?
 
SaltyDog said:
Look, I'm not asking for advice on how to do the case. I'm really just looking for an excuse to do a suprascap + posterior cord/ax block, so I want to know if this will cover the prox Hunerus. I figure I'm much more likely to see a severe COPDer with a fx than I am to see one for a total shoulder (my orthopods aren't that greedy/stupid I don't think). @facted , you're a regional dude, will these blocks cover that area?
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I haven't tried this personally, so I can't say. However, reading over the literature for this (mainly the NYSORA article), I would highly doubt this would work for a prox humerus as the suprascap is really only helping the shoulder and the axillary wouldn't be enough for the humeral shaft or even an inferior incision from the shoulder (if it wasn't a humeral nail). I would personally do a low volume supraclav and I think you'd be totally fine. I would have to defer to @BLADEMDA. Any thoughts?
 
SaltyDog said:
Look, I'm not asking for advice on how to do the case. I'm really just looking for an excuse to do a suprascap + posterior cord/ax block, so I want to know if this will cover the prox Hunerus. I figure I'm much more likely to see a severe COPDer with a fx than I am to see one for a total shoulder (my orthopods aren't that greedy/stupid I don't think). @facted , you're a regional dude, will these blocks cover that area?
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It won't cover the proximal humerus.
I have done suprascapular blocks for years as either rescue blocks after a crappy ISB or for chronic pain, even before ultrasound, and the analgesia is mainly confined to the joint and the muscles of the rotator cuff.
 
Guess what slim? If you combine a Suprascapular nerve block with an Infraclavicular block the postop analgesia is very good to excellent for patients having an ORIF of the proximal humerus.
 
The subscapular nerve(s) are a terminal branch of posterior cord, supplying the fourth rotator cuff muscle, the subscapularis, upon which the posterior cord lies. The nerve also provides sensation to the anterior joint capsule, and the anterior glenoid and the anterior surface of the scapula.

The lateral pectoral and the musculocutaneous nerves are both branches of the lateral cord. They both assist the suprascapular nerve in supplying sensation the anterior joint capsule. The lateral pectoral nerve also supplies the pectoralis major and minor, while the musculocutaneous nerve's motor supply within the shoulder joint is to the long head of biceps.
 
The Axillary nerve (not an axillary block) is a branch of the posterior cord. The great coverage one gets with an ICB is why I add it to my SSN most of the time.

chart2_re.jpg
 
BLADEMDA said:
An ICB done properly will easily block all 3 cords with 20 mls of local (multiple injection technique):

brachial-plexus-injuries-by-krr-6-638.jpg
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I'm well versed in the ways of the ICB (trained by one of the guys that developed it) and it's a block I really like. Typically though I see the numbness begin more at the mid-humeral level hence my question re: prox hunerus fx's right around the numeral neck area. Next one of theses that shows up in my preop area I'll give it a try though I'll stick with ISB or SCB in the healthy lung crowd.
 
SaltyDog said:
I'm well versed in the ways of the ICB (trained by one of the guys that developed it).
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When did the guy develop it?
I saw a impressive French guy 20 sec flat to do the block w NS.
Supra-clavicular entry aiming at the axilla old school style.
 
SaltyDog said:
I'm well versed in the ways of the ICB (trained by one of the guys that developed it) and it's a block I really like. Typically though I see the numbness begin more at the mid-humeral level hence my question re: prox hunerus fx's right around the numeral neck area. Next one of theses that shows up in my preop area I'll give it a try though I'll stick with ISB or SCB in the healthy lung crowd.
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Ok. Let's review the anatomy here for a minute. I'm sure we agree that a SCB would work fine for postop analgesia in patients having an ORIF of the Proximal humerus.

If we block the SSN and perform an ICB what nerve are we missing vs a traditional SCB?

Answer: only the nerve to the subclavius
 
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Effective control of post-surgical shoulder pain generally requires local anaesthetic blockade of the nerve supply to the synovium, capsule, articular surfaces, periosteum, ligaments and muscles of the shoulder joint 1. These structures receive sensory innervation from the nerves that supply the muscles working across the glenohumeral articulation. As mentioned above, five nerves are responsible.

suprascapular_nerve.jpg

Figure 1
 
Not arguing with you @BLADEMDA. Just relaying what I see with regards to the areas of numbness after ICB. You have me convinced though Obi Wan. I'm eager to try it.

The problem with this last diagram is that it showes the cutaneous innervation. I'm much more interested in the nerve supply to the deep and bony structures which I don't think I've ever seen. Anyone have a good source that shows an "osteotome" map??
 
Look at the diagram above. As you can see the skin isn't anesthetized around the shoulder or inner arm (upper 1/2 of medial side of humerus) with a ICB.

But, a SSN plus ICB provides very good postop pain relief for the proximal humerus (review the anatomy again)
 
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Hoya11 said:
. These guys salary will float down to the 500-600k range within the next 10 years (hopefully) as people slowly realize what is going on. ..
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No it won't. You are really, really wrong about this.
 
dhb said:
When did the guy develop it?
I saw a impressive French guy 20 sec flat to do the block w NS.
Supra-clavicular entry aiming at the axilla old school style.
Click to expand...

Shoulda been more specific: He was an Indian guy that claimed to have developed the U/S approach to the ICB. Woulda been back in the early 2000's. He did have a rather inflated view of himself, so I wouldn't be surprised to learn that he exaggerated his involvement a bit.
 
SaltyDog said:
Shoulda been more specific: He was an Indian guy that claimed to have developed the U/S approach to the ICB. Woulda been back in the early 2000's. He did have a rather inflated view of himself, so I wouldn't be surprised to learn that he exaggerated his involvement a bit.
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Was his name Sandhu? Capan is the other guy and he's not indian...

http://neuraxiom.com/bja-us-ic-bpblock.pdf
 
SaltyDog said:
Shoulda been more specific: He was an Indian guy that claimed to have developed the U/S approach to the ICB. Woulda been back in the early 2000's. He did have a rather inflated view of himself, so I wouldn't be surprised to learn that he exaggerated his involvement a bit.
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This guy?

http://bja.oxfordjournals.org/content/89/2/254.full

P.S. The research was done at the same time but, because of earlier publication, the Nobel goes to @facted. 😀
 
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BLADEMDA said:
Guess what slim? If you combine a Suprascapular nerve block with an Infraclavicular block the postop analgesia is very good to excellent for patients having an ORIF of the proximal humerus.
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I would prefer that a crazy half demented POS like you who takes his pills only occasionally not call me "slim", can you do that for me?
 
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By the way none of these copy and paste irrelevant posts that lunatic who calls himself Blade has again inflicted on us, proves any point remotely relevant to the subject we are discussing!
The guy does not even understand the difference between skin and bone innervation, has never tried the block he is advocating for proximal humerus surgery, and as usual keeps googling crap and posting it!
 
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Planktonmd said:
By the way none of these copy and paste irrelevant posts that lunatic who calls himself Blade has again inflicted on us, proves any point remotely relevant to the subject we are discussing!
The guy does not even understand the difference between skin and bone innervation, has never tried the block he is advocating for proximal humerus surgery, and as usual keeps googling crap and posting it!
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Is the anatomy to hard for you to understand? FYI, I've performed these blocks on real live patients and they work great.
 
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BLADEMDA said:
Effective control of post-surgical shoulder pain generally requires local anaesthetic blockade of the nerve supply to the synovium, capsule, articular surfaces, periosteum, ligaments and muscles of the shoulder joint 1. These structures receive sensory innervation from the nerves that supply the muscles working across the glenohumeral articulation. As mentioned above, five nerves are responsible.

suprascapular_nerve.jpg

Figure 1
Click to expand...

As you can see from the diagram a SSN plus ICB blocks all 5 nerves responsible for post-surgical shoulder pain.
 
Planktonmd said:
I would prefer that a crazy half demented POS like you who takes his pills only occasionally not call me "slim", can you do that for me?
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Serious bro...what's your prob?
This is just mean spirited.
Blade never has taken it to a personal level, posts clinical stuff all the time for the betterment of the forum, and cares about his work more than most in anes.
U need to introspect...
 
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