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What blocks are you doing for this case? Interscalene or IS + Intercostal brachial+ superficial cerv plexus. Most breakthrough pain with interscalene is usually not hitting the adjunct blocks.
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.
LMA. As said above, sticking an LMA doesn't delay discharg or slow down the room. It's about safety not public relations.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?
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?
It is essentially GA without an airway given the doses of propofol/precedex we are running.
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.
It is essentially GA without an airway given the doses of propofol/precedex we are running.
did what the surgeons wanted with no good explanation.
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.
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 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".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.
If this thread is moving in that direction I'm just going to say "bidet" and drop the micI 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).
That's what they do in Europe after all.If this thread is moving in that direction I'm just going to say "bidet" and drop the mic
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.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 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.
They most certainly do, or do you not deflate the cuff when you extubate?a cuffed ett doesn't hold anything your story is bs
They most certainly do, or do you not deflate the cuff when you extubate?
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.if you can hold a patient up off the floor by your cuffed ETT you might have overinflated the cuff just a bit 🤣
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.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?
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.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.
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.
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.
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.
On the other hand, LMA with good seal, for 7 hours?
Agreed, time isn’t an absolute contraindication to an LMA, but I greatly agree with above. I personally would never do an LMA for a case 3hour plus, ETT is much less traumatic and more reliable for longer case. Plus I like muscle relaxant and less deep plane of anesthesia, especially for linger case.I imagine an LMA for 7 hours might be the worst sore throat ever
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.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?
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?
I imagine an LMA for 7 hours might be the worst sore throat ever
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.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?
We do these with just an ISB and sedation.
What do you typically give for sedation?
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.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.
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.
Propofol infusion. Dose is highly variable. Kinda like GI.What do you typically give for sedation?
Propofol infusion. Dose is highly variable. Kinda like GI.