Shoulder Arthroscopy with an LMA

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I used to do this, and had my own scope with labral repair under ISB with no sedation. The key was patient selection, and actually doing just moderate sedation. Some of our CRNAs (this was military, so they were "independent") jumped on the bandwagon, but were doing prop 100-150 plus a bunch of midaz, plus fent, maybe plus ketamine. I had to be called by the surgeon to bail out my "colleagues" a few times too many, then the main surgeon that asked for this retired from the service, and it went by the wayside.
 
kidthor said:
Where I was a resident they did shoulders with a block and “sedation” (really TIVA GA + unprotected airway). This practice made no sense and led to frequent problems.
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It is essentially GA without an airway given the doses of propofol/precedex we are running.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
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LMA. As said above, sticking an LMA doesn't delay discharg or slow down the room. It's about safety not public relations.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
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tenor.gif
 
Dawkter said:
It is essentially GA without an airway given the doses of propofol/precedex we are running.
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oh and your TIVA GA is running through an IV below the BP cuff that keeps going off


giant pain in ass and not worth anything. Ask the surgeon how many extra cases per day they think this will let them do. Answer is none so please stop caring.
 
I get that you know whether you have a good LMA as soon as you place it and you can always place an ETT if it doesn’t seat upon insertion…but still, I don’t understand the risk for LMA in beach chair. You’re seriously going to drop the head, risk contaminating the field, and then have a challenging intubation with the head in that foam strap contraption/brace in order to rescue a failing LMA?

Maybe I’m looking at it wrong, but ETT for me.
 
In the time it takes me to jackazz around with a Propofol pump, I could put an ETT in.

In the time it takes to get drapes down/turn the bed/get the shoulder immobilizer on, I can get the pt breathing and ready for extubation.

In the time it takes me to tell an orthopedic surgeon to “eff off”, and mind their business on THEIR side of the drape, even a few HUNDRED times, well...., that’s STILL less time and stress than dealing with depositions/hearings involving a “lost airway”.

Our PACU nurses couldn’t get their documentation done fast enough, to justify any time savings in the recovery room.
 
As a resident and now academic attending, I’ve always done my shoulder scopes half GA, half sedation, all with blocks. OSA or big BMI? GA all the way. I’m surprised at the resistance here to doing them under sedation. Usually you guys are so hip…
 
I used to do shoulders with a block and sedation at my old private practice. Lateral position. However my partners were also spineless and did what the surgeons wanted with no good explanation.
 
Simba1711 said:
did what the surgeons wanted with no good explanation.
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This kinda thing is so bizarre to me when it involves techniques without a lot of evidence. In reality, the ortho knows about as much about the nuances of performing a block/deep sedation vs GA as I do about which instruments to use for a hemiarthroplasty, so he definitely has no business making demands about the technique.

The only time when I think this is even remotely appropriate is when an anesthetic technique has so much effect upon a surgical outcome that even the surgical journals are publishing about it (i.e. blocks for AVF, ERAS protocols in colorectal or gyn etc). And even in those cases, it's still a discussion, not a demand.
 
Simba1711 said:
I used to do shoulders with a block and sedation at my old private practice. Lateral position. However my partners were also spineless and did what the surgeons wanted with no good explanation.
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I’m confused. Are you saying that you also just followed suit blindly…thereby making you spineless as well..???
 
cchoukal said:
As a resident and now academic attending, I’ve always done my shoulder scopes half GA, half sedation, all with blocks. OSA or big BMI? GA all the way. I’m surprised at the resistance here to doing them under sedation. Usually you guys are so hip…
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just because it can be done under a block and sedation most of the time doesn't necessarily mean it should. And since I am not personally sitting in the room the entire case, I prefer an endotracheal tube to minimize chances of a problem.
 
We all know important factors are a) patient selection b) skill and personality of the surgeon and c) skill of the anesthesiologist involved. I include personality of the surgeon because in my humble opinion, for block w/ sedation techniques to work well you have to have a surgeon that really understands the fact that the patient isn't fully asleep and not only communicates with the anesthesiologist but also with the patient. It's the ones who want "sedation" but also don't want to communicate what's going on or have the patient talking during the procedure is where you may as well just do a general. And let's be honest here, what some people on here are calling "sedation", if you look at the charts, may as well be a general just without a secure airway. Again, this whole MAC vs sedation/twilight vs GA stuff is all just PR marketing the long run. If patients really actually cared about their own safety during a procedure they would all ask us to sleep them and at very minimum LMA them.
 
Twiggidy said:
We all know important factors are a) patient selection b) skill and personality of the surgeon and c) skill of the anesthesiologist involved. I include personality of the surgeon because in my humble opinion, for block w/ sedation techniques to work well you have to have a surgeon that really understands the fact that the patient isn't fully asleep and not only communicates with the anesthesiologist but also with the patient. It's the ones who want "sedation" but also don't want to communicate what's going on or have the patient talking during the procedure is where you may as well just do a general. And let's be honest here, what some people on here are calling "sedation", if you look at the charts, may as well be a general just without a secure airway. Again, this whole MAC vs sedation/twilight vs GA stuff is all just PR marketing the long run. If patients really actually cared about their own safety during a procedure they would all ask us to sleep them and at very minimum LMA them.
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I had an interventional cardiologist that kept telling patients they were getting "conscious sedation" then would yell at everyone how "unacceptable" it was when the patient was moving or talking. Then they'd yell at us when the patient got an LMA for the actual desired depth of anesthesia because per him it was an "unnecessary escalation of care".

Luckily I don't work with them anymore. But it's all to say the skill and professionalism of the surgeon matters a lot in the choice of anesthetic.
 
Sedation with “field avoidance” should only be done in eye surgery and some plastics cases. Doing otherwise is risky, stupid, and a lot more work and stress then what you’re getting paid for. Honestly if it’s me or my mom having the surgery it’s ETT all day.
 
I can’t believe this many of you guys intubate for shoulders, rather than placing an LMA.

Not right or wrong, just surprising; kind of like the sitting or standing to wipe thing.
 
I would say the analogy is more like fully wiping your ass multiple times and checking to see if the toilet paper is clean (ETT) vs wiping once and hoping its streak free (LMA).
 
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JoelJoel84 said:
I can’t believe this many of you guys intubate for shoulders, rather than placing an LMA.

Not right or wrong, just surprising; kind of like the sitting or standing to wipe thing.
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I have to believe that the difference here mainly lies in the patient positioning that the surgeon asks for. All but one of my surgeons require the most jacked up positions I've ever seen. My colleagues tell me of a case before I got here where a patient nearly fell off the table - the only two things preventing him from hitting the floor was the weight strap and the cuffed ETT. I would consider it malpractice to attempt utilizing an LMA for any of those surgeons.

The other surgeon does them lateral and is quite smooth. I would consider an LMA for his cases, but I know that once the others heard he got special treatment they'd start demanding equal treatment despite their vastly inferior skills.
 
DocVapor said:
I have to believe that the difference here mainly lies in the patient positioning that the surgeon asks for. All but one of my surgeons require the most jacked up positions I've ever seen. My colleagues tell me of a case before I got here where a patient nearly fell off the table - the only two things preventing him from hitting the floor was the weight strap and the cuffed ETT. I would consider it malpractice to attempt utilizing an LMA for any of those surgeons.

The other surgeon does them lateral and is quite smooth. I would consider an LMA for his cases, but I know that once the others heard he got special treatment they'd start demanding equal treatment despite their vastly inferior skills.
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a cuffed ett doesn't hold anything your story is bs
 
Mman said:
if you can hold a patient up off the floor by your cuffed ETT you might have overinflated the cuff just a bit 🤣
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Oh I agree! Cuff overinflation is a battle I've been fighting since I've been here. Before I got to this place I would have said the same thing @GassYous said. I have since seen things happen that made the story told to me more believable.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
Click to expand...
Even with a a great block for pain free surgical anesthesia rotator cuff surgery would be annoying for patients. The recovery from propofol and enough sevo to tolerate a tube/LMA is so complete when post op narcotics aren't needed.

Unlike written exams our goal should be to score 100 percent and make the day uneventful and drama free.
 
Dantrolene FC said:
Current resident. I’ve done a few shoulders in Beach chair with a block and sedation. The longest case, not sat by me, went 7 hours.
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Got good and bad news for you. The bad news is you are likely to run into surgery times like this in PP. The good news......productivity time based pay.
 
I do lots of blocks and have 5 different surgeons requesting shoulders in all kinds of positions: beach chair, supine, lateral decub, and one that does almost all of his shoulders lateral decubitus with bed turned 180 degrees. Not sure why it must be that way but that's what he wants. I have tried every anesthetic for these and I'd say I'm a younger anesthesiologist willing to try all kinds of creative approaches.

I have concluded on performing a block and ETT for my standard for essentially every shoulder regardless of situation. I LTA spray cords every time. I just don't see what you gain by doing an LMA that makes it worth it.

The pieces of realization that I go back to each time is that
- There once was a time where no LMAs existed and all of these procedures were either hand-masked or intubated.
- I'm very good at intubating safely without trauma or harmful stimulation (as we all should be at this point).
- You can absolutely get sore throat and other oropharyngeal trauma from an LMA, as well as laryngospasm.
- I don't see a way to smoothly transition from a failed LMA to an ETT intraoperatively without being a high inconvenience for everyone. So high of an inconvenience that I stress myself out to unacceptable levels arguing internally about whether or not I halt surgery to clean up my mess.
 
ethilo said:
I do lots of blocks and have 5 different surgeons requesting shoulders in all kinds of positions: beach chair, supine, lateral decub, and one that does almost all of his shoulders lateral decubitus with bed turned 180 degrees. Not sure why it must be that way but that's what he wants. I have tried every anesthetic for these and I'd say I'm a younger anesthesiologist willing to try all kinds of creative approaches.

I have concluded on performing a block and ETT for my standard for essentially every shoulder regardless of situation. I LTA spray cords every time. I just don't see what you gain by doing an LMA that makes it worth it.

The pieces of realization that I go back to each time is that
- There once was a time where no LMAs existed and all of these procedures were either hand-masked or intubated.
- I'm very good at intubating safely without trauma or harmful stimulation (as we all should be at this point).
- You can absolutely get sore throat and other oropharyngeal trauma from an LMA, as well as laryngospasm.
- I don't see a way to smoothly transition from a failed LMA to an ETT intraoperatively without being a high inconvenience for everyone. So high of an inconvenience that I stress myself out to unacceptable levels arguing internally about whether or not I halt surgery to clean up my mess.
Click to expand...

I've done these cases many times and only converted from lma to ett 3 times. Only once was after draping in a smoker with a ton of secretions who laryngospasmed. Extubation sucked
 
ethilo said:
I do lots of blocks and have 5 different surgeons requesting shoulders in all kinds of positions: beach chair, supine, lateral decub, and one that does almost all of his shoulders lateral decubitus with bed turned 180 degrees. Not sure why it must be that way but that's what he wants. I have tried every anesthetic for these and I'd say I'm a younger anesthesiologist willing to try all kinds of creative approaches.

I have concluded on performing a block and ETT for my standard for essentially every shoulder regardless of situation. I LTA spray cords every time. I just don't see what you gain by doing an LMA that makes it worth it.

The pieces of realization that I go back to each time is that
- There once was a time where no LMAs existed and all of these procedures were either hand-masked or intubated.
- I'm very good at intubating safely without trauma or harmful stimulation (as we all should be at this point).
- You can absolutely get sore throat and other oropharyngeal trauma from an LMA, as well as laryngospasm.
- I don't see a way to smoothly transition from a failed LMA to an ETT intraoperatively without being a high inconvenience for everyone. So high of an inconvenience that I stress myself out to unacceptable levels arguing internally about whether or not I halt surgery to clean up my mess.
Click to expand...

Just based on your tolerance level. Also the surgeon. I certainly don’t want to do a shoulder with block and sedation for 7 hours. That would stress me the **** out. On the other hand, LMA with good seal, for 7 hours? Possibly, especially if I get them spontaneously breathing early on. Usually I will give LMA two good attempts, if it’s ****ty, I will just tube them.
I will tube for any surgeons I’ve never worked with before…. Or basically anyone I am not familiar with.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
Click to expand...
Some orthopedists want to think they're HSS, in the same way internists back in the day wanted to think they're like Mayo. It's branding and self promotion.

Hands-free techniques. Nobody got time to jaw thrust and suction for the duration of the case, much less the added risk to the patient.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
Click to expand...

No. Our orthopedists are too smart to ask.
 
Dawkter said:
We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?
Click to expand...
I can't see any advantage other than surgeons who want to say that they are so slick that their patients don't really need general anesthesia! Not a good enough reason in my opinion.
 
DocVapor said:
Oh I agree! Cuff overinflation is a battle I've been fighting since I've been here. Before I got to this place I would have said the same thing @GassYous said. I have since seen things happen that made the story told to me more believable.
Click to expand...
I've been in the habit of only pulling my balloon syringe up with 8cc of air, but the nurses will take it off and pull the plunger back all the way then inject it all into the balloon when I intubate. lol Like I appreciate the help, but that's not really helping.
 
MirrorTodd said:
I've been in the habit of only pulling my balloon syringe up with 8cc of air, but the nurses will take it off and pull the plunger back all the way then inject it all into the balloon when I intubate. lol Like I appreciate the help, but that's not really helping.
Click to expand...

I've started attaching a 5 cc syringe to my ETT for that very reason. If they pull the plunger all the way back and inject all, its 6-7 cc's of air.
 
We like it better in beach chair than lateral for for sure. That said it’s better access to the airway and (for me anyway), less stressful than propofol MAC EGDs. You are correct though that we would be on edge with a guy this size.
 
These damn beach-chair shoulder positioning devices make these cases some of the most potentially dangerous things we do. Really. There's a lot of patient mass resting on a piece of plastic about 8 inches wide.

And oh yeah - ETT all the way. Every time. I don't do anything lateral, sitting, or prone with anything but an ETT. I'm too old for anything less.
 
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