R Shoulder Arthroscopy in patient with Inspire Device

[DocVapor]

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I've got the above case coming up. It will be my first time dealing with the inspire device perioperatively at all. The manufacturer website is unhelpful on what to expect and the only article I've found is this one, which isn't super helpful. Patient's generator is located in the right subclavicular region.

We generally do these cases with an ISB for POPC, which after reviewing the R shoulder x-ray I should be able to complete just fine. This surgeon is -meticulous- (if you catch my drift), so the patient will get intubated, but he does them in the lateral position at least.

Obviously I'll leave the device off and hopefully the patient will bring the remote as instructed. Has anyone seen any complications from electrocautery? Damage to the device? Any decreased effectiveness post-op if my block manages to bag the phrenic nerve on that side?

Anything else I'm missing?

Thanks in advance.

 

[TheLoneWolf]

To draw parallels to SCS, make sure device is off and that you had discussed potential electrosurgical interference or device damage is always possible though not likely. Document both of these. Do block, restart device in PACU. Done.

 

[D4C]

It's a hypoglossal nerve stim that is turned on by the patient when they sleep, the device itself is not "on" all the time. No reason to suspect bovie will interfere / harm it. Doubt you will encounter the lead while doing an ISB. The device has nothing to do with the phrenic nerve.

 

[DocVapor]

It's a hypoglossal nerve stim that is turned on by the patient when they sleep, the device itself is not "on" all the time. No reason to suspect bovie will interfere / harm it. Doubt you will encounter the lead while doing an ISB. The device has nothing to do with the phrenic nerve.

Yes, I was aware of the patient on/off, just trying to cover my bases here. I admittedly haven't kept up with the devices as I haven't been seeing them, but when I talked with an ENT a few years ago he explained to me they had to implant sensors to detect the diaphragm contraction, and my worry was if there was phrenic weakness due to my block afterwards, would the device pick it up.

I now see the newest units have integrated respiratory sensors so it shouldn't be an issue.

Thanks for the reassurance from both of you.

 

[cchoukal]

Could always do a supraclav instead, and stay out of the neck altogether. Years ago, Blade posted some article showing equivalent POPC outcomes compared to ISB. It's what I do unless I'm dumb enough to try doing the case under block+MAC.

 

[Beeftenderloin]

To draw parallels to SCS, make sure device is off and that you had discussed potential electrosurgical interference or device damage is always possible though not likely. Document both of these. Do block, restart device in PACU. Done.

I don’t understand how it’s somehow incumbent upon us to assume responsibility for something the surgeon is doing. I get us being involved in periop PPM/ICD management since it has serious hemodynamic consequences. But SCS, inspire, etc. that’s between the patient and the surgeon. I’m not personally doing anything that’s going to be a problem for their device.

 

[Anestheezee]

I just did ACE questions a few weeks ago and there's a new block the costoclavicular block (CCB) that was noninferior to ISB in arthroscopic shoulder surgery and essentially eliminated phrenic nerve palsy. It seems fairly easy to do, might be worth looking into it.

 

[TheLoneWolf]

I don’t understand how it’s somehow incumbent upon us to assume responsibility for something the surgeon is doing. I get us being involved in periop PPM/ICD management since it has serious hemodynamic consequences. But SCS, inspire, etc. that’s between the patient and the surgeon. I’m not personally doing anything that’s going to be a problem for their device.

Senior partner in large group was called to a closed door meeting for some bad outcome. On his recounting, the one line that stuck with him was an administrator stating

"Doctor, you assumed full liability the moment you accepted to proceed with the case"

 

[Beeftenderloin]

Senior partner in large group was called to a closed door meeting for some bad outcome. On his recounting, the one line that stuck with him was an administrator stating

"Doctor, you assumed full liability the moment you accepted to proceed with the case"

Sounds like less of a legal issue and more of a hospital policy issue.

 

[cittykat]

Senior partner in large group was called to a closed door meeting for some bad outcome. On his recounting, the one line that stuck with him was an administrator stating

"Doctor, you assumed full liability the moment you accepted to proceed with the case"

The appropriate response is for the large group not to proceed with any high risk cases.

 

[BLADEMDA]

 

[BLADEMDA]

Anesthetic Implications for Patients With Implanted Hypoglossal Nerve Stimulators: A Case Report - PMC

Obstructive sleep apnea is a serious health issue affecting more than one billion people worldwide. Although continuous positive airway pressure is the mainstay for the treatment of obstructive sleep apnea, hypoglossal nerve stimulation is a ...

pmc.ncbi.nlm.nih.gov

1. Make sure the device is turned off prior to surgery

2. Intubate the patient (ETT) in the OR (device off)

3. Consider turning on the device in the PACU to assist with the Sleep Apnea until the patient is fully awake

4. The ISB on the Right side may interfere with phrenic nerve function affecting the device's ability to sense the movement of the diaghram; this could significantly increase the risk of severe Sleep Apnea postoperatively for the next 24-30 hours. (single shot ISB).

I would request that the patient bring the remote control with him/her. If the shoulder surgery was on the right side then an ISB may be contraindicated for outpatient surgery.

 

[BLADEMDA]

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial - PubMed

The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

This is a fairly easy block to do. I have performed it.

 

[Simba1711]

I have done costoclavicular block for 1 patient getting shoulder surgery. Patient was a pulmonary cripple that I couldn’t risk phrenic nerve paralysis. It was only one patient but it wasn’t that great for shoulder coverage. Patient needed narcotics in comparison to isb which they get none. Your experience may vary.

 

[BLADEMDA]

I have done costoclavicular block for 1 patient getting shoulder surgery. Patient was a pulmonary cripple that I couldn’t risk phrenic nerve paralysis. It was only one patient but it wasn’t that great for shoulder coverage. Patient needed narcotics in comparison to isb which they get none. Your experience may vary.

I agree that interscalene block works best for shoulder surgery, the other blocks are all inferior imho.

 

[UscGhost]

I agree that interscalene block works best for shoulder surgery, the other blocks are all inferior imho.

What about a tap block.... 😉

 

[cittykat]

What about a tap block.... 😉

My best friend did a TAP block for an inguinal hernia repair on an anesthesia tech at his hospital. The guy couldn’t move his leg for a day 😂

 

[cchoukal]

My best friend did a TAP block for an inguinal hernia repair on an anesthesia tech at his hospital. The guy couldn’t move his leg for a day 😂

Was it really a TAP block, then?

 

[UscGhost]

My best friend did a TAP block for an inguinal hernia repair on an anesthesia tech at his hospital. The guy couldn’t move his leg for a day 😂

Haha.

Sounds like the surgeon made the error not anes

 

[cittykat]

Was it really a TAP block, then?

Spread to lumbar plexus so coulda been TFP/QLB

 

[markneil]

Anesthetic Implications for Patients With Implanted Hypoglossal Nerve Stimulators: A Case Report - PMC

Obstructive sleep apnea is a serious health issue affecting more than one billion people worldwide. Although continuous positive airway pressure is the mainstay for the treatment of obstructive sleep apnea, hypoglossal nerve stimulation is a ...

pmc.ncbi.nlm.nih.gov

1. Make sure the device is turned off prior to surgery

2. Intubate the patient (ETT) in the OR (device off)

3. Consider turning on the device in the PACU to assist with the Sleep Apnea until the patient is fully awake

4. The ISB on the Right side may interfere with phrenic nerve function affecting the device's ability to sense the movement of the diaghram; this could significantly increase the risk of severe Sleep Apnea postoperatively for the next 24-30 hours. (single shot ISB).

I would request that the patient bring the remote control with him/her. If the shoulder surgery was on the right side then an ISB may be contraindicated for outpatient surgery.

This.

 

[Gaseous Clay]

Spread to lumbar plexus so coulda been TFP/QLB

Is that truly possible?

 

[UscGhost]

Is that truly possible?

Much more likely to be the local injection by the surgeon, or traction.

 

[BLADEMDA]

Is that truly possible?

I've had one after a successful Tap block.

A Rare Complication of a TAP Block Performed after Caesarean Delivery - PMC

The transversus abdominis plane block is a regional anesthesia technique that has become popular. Being a relatively simple procedure, the TAP block has an excellent safety profile and major complications are rare. We present a case of transient ...

pmc.ncbi.nlm.nih.gov

We present a case of transient femoral nerve palsy occurring after a TAP block with involvement of the sacral plexus for a patient who had undergone a caesarean section.

 

[Orin]

Have y'all done some shoulder articular branch blocks for these? I enjoy doing them as ultrasound guided blocks in the office with 1 mL of bupi 0.5% as a diagnostic prior to RFA. They won't cover the the skin incision, but 2-4 mL on the lateral pectoral, suprascapular, and axillary nerve's articular branches should get good post-operative analgesia without the phrenic issues.