Shoulder Surgery

[Noyac]

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What position are your surgeons using, beachchair or lateral?

Do they pester you about BP?

Whats your limit?

Where do you measure BP?

What are the risks?

Thought this was a good topic we haven't discussed. Pretty basic for many but we'll see.

 

[militarymd]

lateral...

we lower the BP until they can see...no point going to the OR if surgery can't be performed.

we monitor bp in the non-operative arm

we consent ALL the patients for possible death and/or severe disability...

 

[coprolalia]

Great article a few months ago in the APSF newsletter about monitoring the BP via a-line at the level of the eardrum, especially if in beach chair position. There have been cases of catastrophic neurologic injury secondary to inadequate brain perfusion because of lowered BP and subsequent CBF. Probably putting patients at risk more often than we realize...

http://www.apsf.org/resource_center/newsletter/2007/summer/01_beach_chair.htm

-copro

 

[VentdependenT]

What position are your surgeons using, beachchair or lateral?

Do they pester you about BP?

Whats your limit?

Where do you measure BP?

What are the risks?

Thought this was a good topic we haven't discussed. Pretty basic for many but we'll see.

1)Chair.
2)yes for scope cases.
3) 20% less than map if BP well controlled pre-op. Try to minimize bp lower than that (a couple of min's at a time), but the surgery has gotta happen.
4) We use the old BP cuff. I know you gotta measure the level of the noggin. But that just don't happen w/o the a-line. I can subtract, mentally, some sort of semi-ambiguous amount of pressure from the systolic with the cuff to approximate cerebral systolic pressure.
4) Rarely discuss much more than nerve damage/airway issues.

 

[Planktonmd]

lateral...

we lower the BP until they can see...no point going to the OR if surgery can't be performed.

we monitor bp in the non-operative arm

we consent ALL the patients for possible death and/or severe disability...

Don't tell me that you actually think that this type of consent has any value.

 

[militarymd]

The BIBLE on bp management and treatment is JNCVII....no where in this 50+page document does it say anything about measuring the BP at the "noggin".

 

[Fastrach]

Do all you guys give your shoulder scopes an interscalene block as well? We do them for every single shoulder, and at times I wonder if it's more for max resident benefit than anything else.

 

[militarymd]

Don't tell me that you actually think that this type of consent has any value.

I'm not telling you this....My HIGH-PRICED (ie make more $$ than you or me) lawyer is telling you this.

 

[VentdependenT]

Do all you guys give your shoulder scopes an interscalene block as well? We do them for every single shoulder, and at times I wonder if it's more for max resident benefit than anything else.

Yes

 

[militarymd]

Do all you guys give your shoulder scopes an interscalene block as well? We do them for every single shoulder, and at times I wonder if it's more for max resident benefit than anything else.

Everyone gets a needle in the neck unless they're too afraid.

 

[VentdependenT]

The BIBLE on bp management and treatment is JNCVII....no where in this 50+page document does it say anything about measuring the BP at the "noggin".

Where do you measure BP for sitting crani?

 

[Planktonmd]

I'm not telling you this....My HIGH-PRICED (ie make more $$ than you or me) lawyer is telling you this.

He is misleading you.
This type of consent is worthless when you are doing something like induced hypotension and you cause some type of disaster.
Ask any lawyer who is not "highly priced your lawyer".

 

[militarymd]

Where do you measure BP for sitting crani?

the same place where it says to do so in JNCVII.


Anesthesioloigsts...in general...has no clue about bp management.

 

[VentdependenT]

The BIBLE on bp management and treatment is JNCVII....no where in this 50+page document does it say anything about measuring the BP at the "noggin".

They discuss cerebral perfusion autoregulation in hypertensive patients with PVD who need shoulder surgery in the sitting position under GA?

 

[Planktonmd]

the same place where it says to do so in JNCVII.


Anesthesioloigsts...in general...has no clue about bp management.

You mean Anesthesiologists who are not MMD?

 

[militarymd]

He is misleading you.
This type of consent is worthless when you are doing something like induced hypotension and you cause some type of disaster.
Ask any lawyer who is not "highly priced your lawyer".

OK...you stick with your "walmart" type lawyers....I'll stick with mine who make more money than god.

 

[Planktonmd]

They discuss cerebral perfusion autoregulation in hypertensive patients with PVD who need shoulder surgery in the sitting position?

No they don't.
He is just trying to make everybody know that he reads this stuff.

 

[militarymd]

You mean Anesthesiologists who are not MMD?

I don't consider myself an "anesthesiologist"

 

[VentdependenT]

No they don't.
He is just trying to make everybody know that he reads this stuff.

I know they don't.

 

[Fastrach]

...and just like that, another potentially interesting thread gets flushed down the flame-war toilet... thanks, guys.

 

[militarymd]

They discuss cerebral perfusion autoregulation in hypertensive patients with PVD who need shoulder surgery in the sitting position under GA?

When you read these articles....and as you track the refereces...which I know you all do....

it all leads back to bp managment...which ultimately all comes from the Framingham Study....

I won't say more....the library is free to everyone.

 

[Planktonmd]

I don't consider myself an "anesthesiologist"

No, you are Napoleon.

 

[VentdependenT]

Is there any benefit for measuring BP at the head in an old guy with PVD under GA?

How low do you run the BP? Do you have a cut off? Does it depend on the patient? A time length for maintaining relative hypotension (a quite ambiguous term in itself).

 

[militarymd]

I wish that all the ALL KNOWING anesthesiologists that I know of.....would spend some time ACTUALLY IN the LIBRARY and looking at the so called literature that is out there....track down the references.....see where it comes from....etc. etc...

rather than spewing forth the BS/dogma that everyone has heard of a billion times during residencies.......dumped upon you by junior attendings who barely know where the library. is.

 

[militarymd]

No, you are Napoleon.

let it be known who started with name-calling FIRST in this thread.

 

[Fastrach]

When you read these articles....and as you track the refereces...which I know you all do....

it all leads back to bp managment...which ultimately all comes from the Framingham Study....

I won't say more....the library is free to everyone.

Wait, you're using Framingham-based studies to guide how you routinely do BP monitoring in the OR? I'm not sure you can compare monitoring Framingham's patient population, studied over a 30 year stretch, to monitoring patients with hyper-acute BP changes in the OR... or am I missing something in your logic? 😕

 

[militarymd]

Wait, you're using Framingham-based studies to guide how you routinely do BP monitoring in the OR? I'm not sure you can compare monitoring Framingham's patient population, studied over a 30 year stretch, to monitoring patients with hyper-acute BP changes in the OR... or am I missing something in your logic? 😕

I have only one thing to say.....

read the articles....track the references......see where they lead.....it's a long trail....

Once you do your homework...you may be quite surprised.

 

[VentdependenT]

I have only one thing to say.....

read the articles....track the references......see where they lead.....it's a long trail....

Once you do your homework...you may be quite surprised.

Point noted home boy

BTW, I'm not trying to be antagonistic. I think this stuff could very well be asked on orals and I'm just trying to follow their line of questioning on this board. Its helped before, can't see how it could hurt now.

 

[militarymd]

Is there any benefit for measuring BP at the head in an old guy with PVD under GA?

How low do you run the BP? Do you have a cut off? Does it depend on the patient? A time length for maintaining relative hypotension (a quite ambiguous term in itself).

I don't know if there is any value to measuring BP at the head.

All I know is that the BP that you get from looking in a patients outpatient medical record is that of a guy sitting and the bp taken from the arm.

How does that translate into what we do in the OR...I don't know...there are many articles that make a lot of assumptions about this...but what's right...I don't know.

 

[Planktonmd]

let it be known who started with name-calling FIRST in this thread.

Calling you Napoleon is not "name calling", he was a great Military leader like yourself he just had a slightly over inflated ego.

 

[militarymd]

Point noted home boy

BTW, I'm not trying to be antagonistic. I think this stuff could very well be asked on orals and I'm just trying to follow their line of questioning on this board. Its helped before, can't see how it could hurt now.

I think I would fail the oral boards if I answered things there the way I discuss things here.

 

[Planktonmd]

I think I would fail the oral boards if I answered things there the way I discuss things here.

I have to agree with you on this one.
You will fail.

 

[ear-ache]

My understanding of how we can get into trouble is relying on lower extremity cuff pressure in beach chair position (Ex - s/p mastectomy in the non operative arm with a BP cuff on the ankle).

The BP cuff on the dependant extremity will read HIGHER than a simultaneous pressure on the arm at the phebostatic axis. So, if you have an ankle cuff reading of 80/40 the patient is probably not perfusing their pumpkin.

This should be differentiated from an A-line where the level of the catheter is irrelevant (radial, femoral, pedal) as long at the transducer is at the phlebostatic axis.

 

[Planktonmd]

I don't consider myself an "anesthesiologist"

I can't believe that you feel so ashamed of your training that you are trying to deny it.
To my knowledge you make your living from the practice of anesthesia not from being a genius in intensive care.
A year of fellowship where all you do is repetitive stuff that can be learned by any chimpanzee in a week does not make you someone else.

 

[VentdependenT]

Can we return to Noyac's original post?

 

[jwk]

What position are your surgeons using, beachchair or lateral?

Do they pester you about BP?

Whats your limit?

Where do you measure BP?

What are the risks?

Thought this was a good topic we haven't discussed. Pretty basic for many but we'll see.

Great article a few months ago in the APSF newsletter about monitoring the BP via a-line at the level of the eardrum, especially if in beach chair position. There have been cases of catastrophic neurologic injury secondary to inadequate brain perfusion because of lowered BP and subsequent CBF. Probably putting patients at risk more often than we realize...

http://www.apsf.org/resource_center/newsletter/2007/summer/01_beach_chair.htm

-copro

Most of ours use the beachchair arrangement of some sort - IMHO, the absolute most dangerous of any position we use - totally unstable, high center of gravity, restricted chest movement from the damn straps, surgeons pulling so hard they actually pull the patients head out of the headrest they have been secured to, and just a royal pain in the *** overall. I'm just waiting for one of the larger patients to hit the floor someday. I love the few talented ortho surgeons we have left that can very easily do all these types of cases in a lateral position.

Due to ongoing concerns about hypotensive anesthesia in general, and particularly after the recent APSF article, we have pretty much abandoned hypotensive techniques. Too much potential risks on spines (POVL in particular), ditto for the shoulders, and not really that much benefit to the surgeons. I'm really surprised most of you don't seem to be concerned about the APSF article - it put the fear of God in many of us as well as our surgeons. We seem to see a lot of older patients having shoulder surgery, so our tolerance for hypotension is already pretty low.

I know I've started calculating a correction (not on the anesthesia record) to give me a better idea of where my BP truly is. The correction is 0.77mmHg for each CM of gradient, or about 2mmHg per inch.

 

[Planktonmd]

Can we return to Noyac's original post?

OK,
Sorry Noyac, you know I respect you.
I am just tired of every thread becoming about MMD's views and unique opinions.
His intellectual bullying is funny sometimes but the fun stops when he insults our profession.
Again, I apologize and will not respond anymore if that is what you guys want.

 

[Planktonmd]

Most of ours use the beachchair arrangement of some sort - IMHO, the absolute most dangerous of any position we use - totally unstable, high center of gravity, restricted chest movement from the damn straps, surgeons pulling so hard they actually pull the patients head out of the headrest they have been secured to, and just a royal pain in the *** overall. I'm just waiting for one of the larger patients to hit the floor someday. I love the few talented ortho surgeons we have left that can very easily do all these types of cases in a lateral position.

Due to ongoing concerns about hypotensive anesthesia in general, and particularly after the recent APSF article, we have pretty much abandoned hypotensive techniques. Too much potential risks on spines (POVL in particular), ditto for the shoulders, and not really that much benefit to the surgeons. I'm really surprised most of you don't seem to be concerned about the APSF article - it put the fear of God in many of us as well as our surgeons. We seem to see a lot of older patients having shoulder surgery, so our tolerance for hypotension is already pretty low.

I know I've started calculating a correction (not on the anesthesia record) to give me a better idea of where my BP truly is. The correction is 0.77mmHg for each CM of gradient, or about 2mmHg per inch.

We stopped doing induced hypotension for any surgery several years ago and I can say that we are lucky that our surgeons undrstand and don't insist on it.

 

[Noyac]

Again, I apologize and will not respond anymore if that is what you guys want.

That would be nice.

I gotta say Military, you are getting old. And now you are criticizing the very profession that makes up this forum, that all of us are a part of. If you have someplace better to be with people who understand these principles better than we do then do us all a favor and go there. Personally, I doubt many others understand this stuff as well as we do and that is probably why you are here. But your incessant badgering is so f*cking predictable its not even worth reading your posts. You are ruining good threads daily.

Could you do us all a favor participate in a cordial manner? If not then take a hike.

You can attempt to insult me now like everyone else that disagrees with your pov but I will not respond. Good day.

 

[cfdavid]

Gentlemen,

Can you explain why it's necessary to induce hypotension for shoulder surgery?? I hope this isn't too dumb a question....
Also, pharmacologically, how do you do it? Which drugs?

 

[dhb]

What position are your surgeons using, beachchair or lateral?

Do they pester you about BP? Not too much for scopes

Whats your limit?

Where do you measure BP?
What are the risks?

Thought this was a good topic we haven't discussed. Pretty basic for many but we'll see.

Beach chair sort of they are actually sat up on a regular table
Not too much for scopes
Limits depends on pre-op BP hx of htn +-30%
Regular arm cuff
Bloc for everyone

 

[BlackSails]

My father had shoulder surgery a few years back, and requested regional so he could watch. It was converted to general after pain control was inadequate.

Based on the comments above ("Do you do interscalene blocks for post op pain) I would guess that regional shoulders are not commonly done. Have any of you ever done one?

 

[militarymd]

That would be nice.

I gotta say Military, you are getting old. And now you are criticizing the very profession that makes up this forum, that all of us are a part of. If you have someplace better to be with people who understand these principles better than we do then do us all a favor and go there. Personally, I doubt many others understand this stuff as well as we do and that is probably why you are here. But your incessant badgering is so f*cking predictable its not even worth reading your posts. You are ruining good threads daily.

Could you do us all a favor participate in a cordial manner? If not then take a hike.

You can attempt to insult me now like everyone else that disagrees with your pov but I will not respond. Good day.

Noy,

Let's start with the last highlighted item.....go back from the top of this thread, and follow it....take a look at just WHO started the INCESSANT and F UCKING badgering.....oh and while you're at it....take a look at ALL the other threads...and see WHO starts the F UCKING badgering....you may be surprised.

As for criticizing....who better than your OWN colleagues....OUR specialty will only get better with we LOOK at our faults.....Critizing CRNAs and other specialties (who have their own literature, and standards) is inappropriate...Self criticism, self awareness, and self improvement is my motto.....

Why does a different POV get people upset....


As for my POV.....I spent five years as chairmen of an education committee....I invest myself 110% at all the things that I do....I have literally spent hundreds of hours in the library reading this BP crap...tracking the references that I'm referring to.....that's why I say what I say...you don't have to believe, but you don't have to act like Plank..

 

[militarymd]

Noy,

look at HOW many threads that plank was "badgering" me while I simply replied....

have you looked?

 

[militarymd]

are you going to look?

 

[militarymd]

1)Chair.
2)yes for scope cases.
3) 20% less than map if BP well controlled pre-op. Try to minimize bp lower than that (a couple of min's at a time), but the surgery has gotta happen.
4) We use the old BP cuff. I know you gotta measure the level of the noggin. But that just don't happen w/o the a-line. I can subtract, mentally, some sort of semi-ambiguous amount of pressure from the systolic with the cuff to approximate cerebral systolic pressure.
4) Rarely discuss much more than nerve damage/airway issues.

Do you know where that number came from? Where's the reference?

I can't find it.

That's certainly not what we do in the CV rooms.

 

[goodoc]

Shoulders are done lateraly with ISB 30 cc of .5% bupivicaine, with LMA and agent, 1.6% or so sevo or about 3-4%des, or .6-.7% iso. Will drop bp to 80-90 systolic, (or when the surgeon does not complain, as long as pressure is safe) for bene shaving if needed with propofol or esmolol if needed, otherwise manage bp as a normal case.
CF david hypotension is requested to prevent or minimize bleeding fron the surgical site as bleeding is related to BP. Can be managed with agent or iv meds.

 

[VentdependenT]

Do you know where that number came from? Where's the reference?

I can't find it.

That's certainly not what we do in the CV rooms.

I spoke to Dr. Ken Tuman directly about that issue. Something about staying safely on the autoregulation curve.

 

[militarymd]

I spoke to Dr. Ken Tuman directly about that issue. Something about staying safely on the autoregulation curve.

right, that's what everyone I ever asked, tells me....

but where's the data....or at least where did that number come from?

No one has been able to tell me...

And HOW many times have we had patients who are hypotensive no matter what we do....and wind up with BP's that is really not acceptable...and nothing happens....

and what about in the CV room...where the BP is almost always low coming off pump?

 

[militarymd]

My father had shoulder surgery a few years back, and requested regional so he could watch. It was converted to general after pain control was inadequate.

Based on the comments above ("Do you do interscalene blocks for post op pain) I would guess that regional shoulders are not commonly done. Have any of you ever done one?

excellent "analgesia" does not always equate adequate "anesthesia"