Reverse total shoulders and total shoulders

[chmd]

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A orthopod at my hospital who is coming from the east coast doesn't seem particularly pro regional (no fnb for acls etc) and that's fine. This surgeon does want ISBs for his total and reverse total shoulders, however he wants them in pacu after a neuro assessment. There are a number of reasons I might be against this including:

1) seems bad for pt to endure discomfort for no benefit to patient potentially
2) dangerous to add block to narc'ed pt esp if OSA/copd etc
3) thorough neuro exam prob hard to get immediately post op in distressed and confused pt. could this be a legal maneuver just to position anesthesiologist as at fault in case of palsy?

I might advocate no block at all in these pts unless placed preop but don't want to anger surgeons and or administration. Thoughts? Is this a normal practice elsewhere?

There's no reason to suspect this surgeon isn't acting in the patients best interest and I want to do what's best for patient as well so I might just go along w surgeon's requests until a problem arises.

 

[nap$ter]

A orthopod at my hospital who is coming from the east coast doesn't seem particularly pro regional (no fnb for acls etc) and that's fine. This surgeon does want ISBs for his total and reverse total shoulders, however he wants them in pacu after a neuro assessment. There are a number of reasons I might be against this including:

1) seems bad for pt to endure discomfort for no benefit to patient potentially
2) dangerous to add block to narc'ed pt esp if OSA/copd etc
3) thorough neuro exam prob hard to get immediately post op in distressed and confused pt. could this be a legal maneuver just to position anesthesiologist as at fault in case of palsy?

I might advocate no block at all in these pts unless placed preop but don't want to anger surgeons and or administration. Thoughts? Is this a normal practice elsewhere?

There's no reason to suspect this surgeon isn't acting in the patients best interest and I want to do what's best for patient as well so I might just go along w surgeon's requests until a problem arises.

i agree with you - postop blocks for joints are pretty senseless. i did 3 of these yesterday - all preop isb's.

if it were me, i would bring it to my group and appoint a representative to bring the group's consensus to the surgeon outlining all of the reasons blocks should be done preop, as you did above. your surgeon's desire to do a postop neuro check and get a block postop is something i've never encountered for shoulder replacements and way outside the norm.

 

[bostonblaz]

Let he/she do their exam. If you look to do pre op and then have an issue he/she will hang you out to dry. Give some fentnyl for the case, do the block post-op when you are ready to. Don't let the pacu nurses give narcs before the block and the patient will be happy. Blaz

 

[nap$ter]

Let he/she do their exam. If you look to do pre op and then have an issue he/she will hang you out to dry. Give some fentnyl for the case, do the block post-op when you are ready to. Don't let the pacu nurses give narcs before the block and the patient will be happy. Blaz

if the surgeon would hang you out to dry for a preop block complication they will certainly hang you out to dry for a postop block complication as well.

there's nothing a surgeon could hang me out to dry with because i document a thorough informed consent and never sell a block to a patient that doesn't want it.

no offense, blaz, but the above approach is buckling like a belt. man up and act like the consultant you are.

if attempts to educate/persuade the surgeon fail and he/she rejects the recommendation from the group/you, then accept it and do the postop block. you've given your recommendation - not everyone can be reasoned with and it isn't worth it to deny the patient the block altogether.

 

[deleted126335]

Our arthropods approached us on this issue. More from a point of view of trying to minimize the 1% chance that they could be held up for the preop block.We refused. If you don't feel strong enough to do so, you could say that blocks are optional and need to be done the way that you feel comfortable- Preop or no block at all. You could also place a dry catheter preop and dose in PACU after evaluation. Not perfect, Doesn't skirt all the issues.

 

[sevoflurane]

Our arthropods approached us on this issue. More from a point of view of trying to minimize the 1% chance that they could be held up for the preop block.We refused. If you don't feel strong enough to do so, you could say that blocks are optional and need to be done the way that you feel comfortable- Preop or no block at all. You could also place a dry catheter preop and dose in PACU after evaluation. Not perfect, Doesn't skirt all the issues.

Yep.
Catheter->chloroprocaine bolus for the case->neruo exam in pacu>local dujour.

 

[GaseousClay]

we have only 1 orthopod who insists on doing silly post-op neuro checks on lower extremity surgery (even tho patient is usually wrapped pretty good after). We will usually put in a catheter and bolus after her "exam" or else not do a block.

 

[Wiscoblue]

I would just not do a block for the patients. This ortho guy will lose business. Word will spread that his patients are in pain after surgery as compard to other ortho guys. He will come and ask for pre op blocks.

 

[Jay K]

Preop block.

Postop blocks are a bad precedent. They should be reserved for rare individual cases with extenuating circumstances, that satisfy informed consent criteria and are lucid enough to participate appropriately with verbal responses during the procedure.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/21792494
http://www.ncbi.nlm.nih.gov/pubmed/8919443

In the 1990's we used to block all total shoulders in the PACU. It was a fairly common practice in the mid 1990s due to brachial plexus injury from the surgery. I abandoned the practice about 14 years ago because a complete Neurological examination isn't possible or likely in the PACU. Yes, you will detect a major neuropathy but the minor injuries go undetected. Hence, I believe there is more medico-legal risk in doing the block in the PACU rather than in holding/preop under U/S.

Review the published evidence on brachial plexus injuries. Ultimately, the Ortho guy and you need to discuss the medical facts, peer reviewed evidence and decide on the best approach.

Here is study worth looking at: http://www.ncbi.nlm.nih.gov/pubmed/22705952


I'd get a copy of that study and explain the use of U/S combined with a nerve stimulator reduces the chance of a severe brachial plexus injury due to a NERVE BLOCK to a very rare event.

 

[chmd]

Thanks for all the helpful responses. I don't look forward to this discussion.

If brachial plexopathies occur 2% of the time I wonder how many are discovered on the post op neuro exams. Maybe it's wise to avoid risking a double crush phenomen, ie block not causing injury but worsening effect of injury?

Obviously it's wise to avoid getting blamed for a surgical complication that occurs with regularity.

 

[Apollyon]

Our arthropods approached us on this issue.

Was that autocorrect, or intentional?

 

[Mman]

Thanks for all the helpful responses. I don't look forward to this discussion.

If brachial plexopathies occur 2% of the time I wonder how many are discovered on the post op neuro exams. Maybe it's wise to avoid risking a double crush phenomen, ie block not causing injury but worsening effect of injury?

Obviously it's wise to avoid getting blamed for a surgical complication that occurs with regularity.

The "double crush" injury would happen regardless of whether you did your block pre or post op. The nerve compression and local toxicity is one hit and the surgical manipulation is a 2nd hit. It's quite unlikely the order would make any difference.

 

[chmd]

The "double crush" injury would happen regardless of whether you did your block pre or post op. The nerve compression and local toxicity is one hit and the surgical manipulation is a 2nd hit. It's quite unlikely the order would make any difference.

Right. I was saying perhaps blocks should be avoided. The reasoning may be a justifiable way to refuse to do block if we decide to go that way.

 

[loveumms]

It may be a moot point - there was some discussion on here about changes in reimbursement for regional. It has not hit us on the east coast yet but in talking with some of our coders, several parts of the country are dealing with hassles for regional billing. Block preop = no payment. Block postop = no payment unless documented it is warranted. Silly and its a disservice for our patients.

If you are doing a single shot, postop may give the patient longer comfort. We do dry catheters preop for all our shoulder surgeries. I would assume if you are doing it postop with ultrasound, enough skin infiltration will make the pt comfy enough to tolerate it (without nerve stimulation). I would imaging nerve stimulation after surgery would be pretty painful. Lido at start, wears off for postop exam, then bolus with rope. Most patients do well.