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[USAnesthesiaDoc]

Have a slightly interesting case. Any thoughts about regional anesthesia versus GA versus both?

50 year old female for repeat right shoulder arthroscopy. History significant for diagnosis of myasthenia gravis in 1979 (ptosis, no respiratory compromise), never needed treatment with ACHE inhibitors, had thymectomy 4 months after diagnosis and was treated with prednisone for 1 -2 years afterwards. No other meds since for MG. No other signs or symptoms of MG since then either. Has had several GA's over the years after her thymectomy without problems except for her first shoulder arthroscopy last year; she said "the anesthesia took a long time to wear off" but she can't be any clearer about the details. She was able to be discharged home the same day according to her. She also has a history of sleep apnea diagnosed by sleep study but not bad enough to warrant CPAP. She is about 5'3" and 185 lbs.

Any thoughts on the management?

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[Noyac]

I don't really see any problems. There are so many variables that may have caused her delayed emergence but narrowing them down would be next to impossible. Probably just a heavy handed provider.

 

[Planktonmd]

Have a slightly interesting case. Any thoughts about regional anesthesia versus GA versus both?

50 year old female for repeat right shoulder arthroscopy. History significant for diagnosis of myasthenia gravis in 1979 (ptosis, no respiratory compromise), never needed treatment with ACHE inhibitors, had thymectomy 4 months after diagnosis and was treated with prednisone for 1 -2 years afterwards. No other meds since for MG. No other signs or symptoms of MG since then either. Has had several GA's over the years after her thymectomy without problems except for her first shoulder arthroscopy last year; she said "the anesthesia took a long time to wear off" but she can't be any clearer about the details. She was able to be discharged home the same day according to her. She also has a history of sleep apnea diagnosed by sleep study but not bad enough to warrant CPAP. She is about 5'3" and 185 lbs.

Any thoughts on the management?

She seems to be asymptomatic for Myasthenia Gravis.
And the fact that she is not requiring treatment is a good sign too.
Sure you could do it with straight interscalene block but the fact that she has sleep apnea and on the heavy side might limit your ability to sedate her intraop especially that your access to the airway is going to be limited and she will be in a very uncomfortable position.
So, here is what I would do:

1- Interscalene in Holding and use a mixture of Lido 2 % and Bupivacaine 0.5 % .
2- Go to OR, induce with Propofol + Lidocaine + Fentanyl and intubate without muscle relaxant, and no muscle relaxant during the case either.
3- Next case.

 

[BLADEMDA]

Have a slightly interesting case. Any thoughts about regional anesthesia versus GA versus both?

50 year old female for repeat right shoulder arthroscopy. History significant for diagnosis of myasthenia gravis in 1979 (ptosis, no respiratory compromise), never needed treatment with ACHE inhibitors, had thymectomy 4 months after diagnosis and was treated with prednisone for 1 -2 years afterwards. No other meds since for MG. No other signs or symptoms of MG since then either. Has had several GA's over the years after her thymectomy without problems except for her first shoulder arthroscopy last year; she said "the anesthesia took a long time to wear off" but she can't be any clearer about the details. She was able to be discharged home the same day according to her. She also has a history of sleep apnea diagnosed by sleep study but not bad enough to warrant CPAP. She is about 5'3" and 185 lbs.

Any thoughts on the management?

If she can handle the loss of the diaphragm on one side I would strongly consider an Interscalene Block plus LMA with Propofol Infusion for the case (Beach Chair Position).

Pre-treatment with my Voodoo cocktail of Reglan and Zantac to ward off any evil aspiration spirits. Perhaps, consider doing the block with an assistant and 60 mg propofol instead of any midazolam. Patients are wide awake a few minutes after the block and no residual hang-over.
I like straight Ropivicaine 0.5% with 1:400,000 Epi for her. The Ropivicaine gives you an equal or greater safety profile to the Lido/Bupi mixture with a longer reliable duration.

Of Course, nothing consistently beats the duration of action of undiluted 0.5% bupivicaine for this block except the placement of catheter (which I would not do in this case).

Blade

The block plus propofol should provide excellent anesthesia and analgesia with MINIMAL narcotic use.

 

[milrisome]

I think block too. Excellent analgesia and you get to avoid giving muscle relaxants. It does seem like her MG is history but you won't have any problems with them if you don't use them.
Next you need to consider the surgeon. Is he the type who will be cranking on their arm every which way and swearing up a storm? Maybe better asleep. If not, sounds like her airway isn't that bad, and she will be in a beach chair position, you could probably get by with a little sedation. If you have to go to sleep, I like plank's idea of propofol with no muscle relaxant and use remi 1 mcg/kg for intubation.

Next question: Do you send her home the same day with diagnosed sleep apnea? You know the surgeon will be pushing for it.

 

[Noyac]

I think block too. Excellent analgesia and you get to avoid giving muscle relaxants. It does seem like her MG is history but you won't have any problems with them if you don't use them.
Next you need to consider the surgeon. Is he the type who will be cranking on their arm every which way and swearing up a storm? Maybe better asleep. If not, sounds like her airway isn't that bad, and she will be in a beach chair position, you could probably get by with a little sedation. If you have to go to sleep, I like plank's idea of propofol with no muscle relaxant and use remi 1 mcg/kg for intubation.

Next question: Do you send her home the same day with diagnosed sleep apnea? You know the surgeon will be pushing for it.

If you did the block and didn't need to use any narc's then she goes home. If you used narc's well then she goes home as well. Unless she has severe OSA , an abd procedure, or needed large amounts of narc's, I wouldn't worry.

 

[jetproppilot]

If she can handle the loss of the diaphragm on one side I would strongly consider an Interscalene Block plus LMA with Propofol Infusion for the case (Beach Chair Position).

Pre-treatment with my Voodoo cocktail of Reglan and Zantac to ward off any evil aspiration spirits. Perhaps, consider doing the block with an assistant and 60 mg propofol instead of any midazolam. Patients are wide awake a few minutes after the block and no residual hang-over.
I like straight Ropivicaine 0.5% with 1:400,000 Epi for her. The Ropivicaine gives you an equal or greater safety profile to the Lido/Bupi mixture with a longer reliable duration.

Of Course, nothing consistently beats the duration of action of undiluted 0.5% bupivicaine for this block except the placement of catheter (which I would not do in this case).

Blade

The block plus propofol should provide excellent anesthesia and analgesia with MINIMAL narcotic use.

For the residents, do you know the incidence of unilateral phrenic nerve paralysis from an interscalene block?

 

[Laurel123]

Have a slightly interesting case. Any thoughts about regional anesthesia versus GA versus both?

50 year old female for repeat right shoulder arthroscopy. History significant for diagnosis of myasthenia gravis in 1979 (ptosis, no respiratory compromise), never needed treatment with ACHE inhibitors, had thymectomy 4 months after diagnosis and was treated with prednisone for 1 -2 years afterwards. No other meds since for MG. No other signs or symptoms of MG since then either. Has had several GA's over the years after her thymectomy without problems except for her first shoulder arthroscopy last year; she said "the anesthesia took a long time to wear off" but she can't be any clearer about the details. She was able to be discharged home the same day according to her. She also has a history of sleep apnea diagnosed by sleep study but not bad enough to warrant CPAP. She is about 5'3" and 185 lbs.

Any thoughts on the management?

Propofol, LMA, toradol and a little fentanyl. If I am not happy with the LMA fit, then intubate with remi.

 

[Planktonmd]

Propofol, LMA, toradol and a little fentanyl. If I am not happy with the LMA fit, then intubate with remi.

I am curious, why no block?
Do you think that "little Fentanyl" and Toradol is going to be enough?

 

[Laurel123]

Is fentanyl and toradol enough for a shoulder scope? Sometimes. I suppose it depends on the surgeon and the patient and the shoulder. I usually do shoulder scopes without the block and I use toradol, fentanyl and some dilaudid and the results are good. I think a block is good choice too, though for me, since this woman has a history of neurological disorder I would probably choose to just avoid the block and avoid any issues. Granted I dont think a block is that much riskier for her than any other patient, but I would still avoid it.

 

[Noyac]

Is fentanyl and toradol enough for a shoulder scope? Sometimes. I suppose it depends on the surgeon and the patient and the shoulder. I usually do shoulder scopes without the block and I use toradol, fentanyl and some dilaudid and the results are good. I think a block is good choice too, though for me, since this woman has a history of neurological disorder I would probably choose to just avoid the block and avoid any issues. Granted I dont think a block is that much riskier for her than any other patient, but I would still avoid it.

I'm a big fan of blocks but I don't block shoulder scopes usually. They just don't seem to hurt that much. If they are doing a "rotary cup" repair or something like that I will. But most of the surgeons I work with still do a mini open for the RCR.

 

[dhb]

For the residents, do you know the incidence of unilateral phrenic nerve paralysis from an interscalene block?

I would say 10-20%.

 

[Planktonmd]

I would say 10-20%.

Think again!

 

[Planktonmd]

I'm a big fan of blocks but I don't block shoulder scopes usually. They just don't seem to hurt that much. If they are doing a "rotary cup" repair or something like that I will. But most of the surgeons I work with still do a mini open for the RCR.

I block every shoulder unless I find a good reason not to.

 

[hokie]

For the residents, do you know the incidence of unilateral phrenic nerve paralysis from an interscalene block?

Here's another way to ask the question: What happens when you do an interscalene block for a right RCR when the patient has a previous left phrenic nerve injury s/p CABG?

 

[VentdependenT]

For the residents, do you know the incidence of unilateral phrenic nerve paralysis from an interscalene block?

I'd say its gotta be almost 100%. Its one of the characteristics of the block.

 

[VentdependenT]

For your supraclavicular I'd guess unilat phrenic nerve paralysis is somewhere around 50-75%.

 

[Planktonmd]

I'd say its gotta be almost 100%. Its one of the characteristics of the block.

 

[Noyac]

I block every shoulder unless I find a good reason not to.

 

[Jeff05]

midaz 2 + fent 100 before the block

depending on surgeon
if fast...interscalene with 40ml mepiv 1.5%/bicarb.
if avg....with 20 ml mepiv +bicarb/20 0.5% bupiv
if ******ed...40 ml bupiv with epi

propofol infusion.

phase II.

 

[nchhabra]

For the residents, do you know the incidence of unilateral phrenic nerve paralysis from an interscalene block?

per some book i read its close too 100%

 

[dhb]

I'd say its gotta be almost 100%. Its one of the characteristics of the block.

Right C3-5, i was thinking recurent nerve which once source says it's between 5 and 25% of cases.