TSA and ISB increased nerve damage risk?

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ethilo

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Hi folks,
We got a new orthopod who refuses ISB before all TSAs. He worries the paralysis from the block will relax the shoulder muscles so much intraop that it will stretch the brachial plexus after the shoulder is disarticulated and result in increased nerve injury. I've looked up papers and there are indeed increased risk of nerve injuries with TSA however nothing mentions association with pre op PNB. Anyone know anything about this? All of us in anesthesia cringe when we hear his request and feel bad for the patients but I want to know if this is a legit request or just speculation.

He does NOT request intraop paralysis.
 
NoodleIncident said:
Is he at least ok with a block post-op?
Click to expand...
Yes, he's even ok with it if still under GA. None of us will do that though. We all get post op exams before blocking.

These post op ISBs are much more difficult and occasionally impossible esp if the patient is intermittently obstructing from all the narcs
 
SaltyDog said:
Does he specifically request NO intra-op paralysis?
Click to expand...
He does not explicitly announce that, maybe I should tell him he needs to state that in timeout or something.
 
There are certain hypermobility syndromes that predispose patients to stretch injury (Ehlers-Danlos, even RA, etc), but those injuries are usually thought to be due to positioning. I avoid blocking these patients preoperatively to not muddy the water if they do indeed have a stretch injury. I had an RA patient once have 0/5 strength for 2 months in a C5-6 distribution and of course I had blocked her preop. The surgeon wasn’t your typical orthopod (i.e: was really academic and actually researched the topic rather than just pointing the finger at me) and agreed that it was likely due to positioning, given the fact that studies show that even intraneural injections don’t cause long term damage like what we observed. Luckily her strength recovered in 2 months, but you better believe we were both &$@?ing bricks during that time.

In a normal patient there is no way a preop block predisposes to stretch injury. He’s probably been careless with positioning the head/neck in the past and was looking for something to blame his complications on.
 
ethilo said:
Yes, he's even ok with it if still under GA. None of us will do that though. We all get post op exams before blocking.

These post op ISBs are much more difficult and occasionally impossible esp if the patient is intermittently obstructing from all the narcs
Click to expand...
In my reaidency we do the majority of our blocks post op, it is indeed harder for all the upper extremity blocks. Especially a shoulder the anatomy is sometimes distorted after surgery and the patient is all hunched up in pain. Have to give a bolus if fentanyl before the block often. I think it makes it harder for us, but on the other end I think the patients’ satisfaction with the block is much greater.
 
ethilo said:
Yes, he's even ok with it if still under GA. None of us will do that though. We all get post op exams before blocking.

These post op ISBs are much more difficult and occasionally impossible esp if the patient is intermittently obstructing from all the narcs
Click to expand...

Why won’t you place nerve blocks under GA?
 
dipriMAN said:
In my reaidency we do the majority of our blocks post op, it is indeed harder for all the upper extremity blocks. Especially a shoulder the anatomy is sometimes distorted after surgery and the patient is all hunched up in pain. Have to give a bolus if fentanyl before the block often. I think it makes it harder for us, but on the other end I think the patients’ satisfaction with the block is much greater.
Click to expand...

Yeah! I bet the satisfaction is much greater when they’ve felt that excruciating pain first and then having their shoulder go numb. The patients getting blocks pre-op don’t experience the degree of pain that they’re avoiding.
 
NoodleIncident said:
Why won’t you place nerve blocks under GA?
Click to expand...
The issue of placing a block under GA is mainly legal rather than scientific.
19 years ago Dr. Benumof published a small series of case reports (4 cases) where performing an interscalene block under GA resulted in major neurological injuries. Since that time it has become one of those dogmatic things and almost the standard of care to avoid blocks under GA.
Most people avoid it because they know that there will be many "expert witnesses" who will crucify them if they have a complication.
Here is the link to that article from the year 2000:
anesthesiology.pubs.asahq.org

Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene Block Performed under General Anesthesia

PERFORMING an interscalene block (ISB) during general anesthesia (GA) for postoperative shoulder surgery analgesia is a common procedure. Although epidural, 1–3subarachnoid, 4–6and motor nerve root 7injections have been reported during the performance of ISB, there have been no cases reported in...
anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
 
In the early 90s (pre ultrasound) there was an editorial in Anesthesiology that specifically condemned the practice of placing nerve blocks under GA.
 
NoodleIncident said:
Yeah! I bet the satisfaction is much greater when they’ve felt that excruciating pain first and then having their shoulder go numb. The patients getting blocks pre-op don’t experience the degree of pain that they’re avoiding.
Click to expand...
Yes. I know it seems ridiculous, it is not the optimal timing for the block. But think about patient satisfaction on the OB floor. Satisfaction isn’t just about how much pain relief you can achieve, people are dissatisfied for many reasons. Maybe if a patient experiences a small amount of time with post surgical pain in the PACU, they are less likely to be dissatisfied with a completely numb and limp r for 24 hours.
 
NoodleIncident said:
Yeah! I bet the satisfaction is much greater when they’ve felt that excruciating pain first and then having their shoulder go numb. The patients getting blocks pre-op don’t experience the degree of pain that they’re avoiding.
Click to expand...

For me, more than anything else, in a solo MD practice placing blocks postoperatively is inconvenient and doesn’t work from a workflow perspective. All bets are off as to when you are able to perform a postoperative block, and having a patient sit in PACU until you become available is not practical.

Preop blocks placed in between cases during turnover FTW. Oh yeah, and the whole needing less anesthesia, not making your patient suffer needlessly, etc etc is also nice...
 
Planktonmd said:
The issue of placing a block under GA is mainly legal rather than scientific.
19 years ago Dr. Benumof published a small series of case reports (4 cases) where performing an interscalene block under GA resulted in major neurological injuries. Since that time it has become one of those dogmatic things and almost the standard of care to avoid blocks under GA.
Most people avoid it because they know that there will be many "expert witnesses" who will crucify them if they have a complication.
Here is the link to that article from the year 2000:
anesthesiology.pubs.asahq.org

Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene Block Performed under General Anesthesia

PERFORMING an interscalene block (ISB) during general anesthesia (GA) for postoperative shoulder surgery analgesia is a common procedure. Although epidural, 1–3subarachnoid, 4–6and motor nerve root 7injections have been reported during the performance of ISB, there have been no cases reported in...
anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
Click to expand...

But it's ok to maim pediatric patients who have a long life of nerve damage to look forward to? It doesn't make any sense.

I think you'll find plenty of expert witnesses who perform all their blocks under GA who would testify that it's safer to do the blocks under GA because the patient won't be moving. Sudden movement can push the needle into unintended spaces.


And who's having all these complications? People transecting nerves? Injecting into a nerve with high pressure? Arterial administration?


Ultrasound makes it so much safer, but ultrasound is hard if the patient is jumpy.
 
This was 19 years ago. If you sample the literature from the last 5-10 years, you will find several articles that advocate that the risk of complications is no higher under GA than not.
 
20 years ago it was common practice to place ISB post surgery after a brief neuro exam in the PACU. There were case reports of brachial plexus injuries from the surgery and the surgeons blamed the block. With the routine use of U/s this practice gradually fell away to the point we almost always do the block preop now.

www.ncbi.nlm.nih.gov

Complete brachial plexus palsy after total shoulder arthroplasty done with interscalene block anesthesia - PubMed

Proper diagnosis and treatment of postprocedure brachial plexus palsy may improve recovery of function. Several precautions may reduce the likelihood of brachial plexus palsy following interscalene block for total shoulder arthroplasty.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Traction injury of the brachial plexus confused with nerve injury due to interscalene brachial block: A case report - PMC

The confusing factor of regional block in shoulder surgery when neurologic damage appears after surgery. The importance of intraoperative head and neck position checking in long procedures. The beach-chair position as a possible factor that ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
dr doze said:
Waiting for the position statement of ASA or ASRA or editorial in Anesthesiology saying that this practice gets a 👍
Click to expand...
Don't even need a position statement, I just want one of their editorials to at least bring it up in a major way.
 
Brachial plexus injury after total shoulder arthroplasty has been estimated at 2.8%.


Lynch NM, Cofield RH, Silbert PL, Hermann RC: Neurologic complications after total shoulder arthroplasty. J Shoulder Elbow Surg 1996; 5:53–61Lynch, NM Cofield, RH Silbert, PL Hermann, RC

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
 
Neurological complications have been reported to occur in 3% of hemiarthroplasties, 0.1% to 4% of anatomic total shoulder arthroplasties, and 2% to 4% of reverse total shoulder arthroplasties. The brachial plexus is most commonly involved. Observations in cadaver studies have suggested that the most likely etiology of these neuropathies is stretch of the brachial plexus secondary to patient arm positioning. Although the majority of these injuries resolve spontaneously, permanent and debilitating injuries do occur, but rarely. Cadaver and intraoperative nerve monitoring studies have identified shoulder abduction of >90 degrees; combinations of abduction, external rotation, and either flexion or extension; and combinations of adduction, extension, and either internal or external rotation as positions which cause nerve dysfunction.

journals.lww.com

Brachial Plexus Injuries During Shoulder Arthroplasty:... : Techniques in Shoulder & Elbow Surgery

ost likely etiology of these neuropathies is stretch of the brachial plexus secondary to patient arm positioning. Although the majority of these injuries resolve spontaneously, permanent and debilitating injuries do occur, but rarely. Cadaver and intraoperative nerve monitoring studies have...
journals.lww.com journals.lww.com
 
OUTCOME: The mechanism of injury of the median nerve can be isolated to traction injury. Demonstrated on an in vitro cadaver brachial plexus computerized 3D model that successfully calculated the strain and measured nerve displacement before and after placement of reverse shoulder prosthesis (Van Hoof et al). Results showed that the medial (19.3[percnt]) and lateral (15.3[percnt]) root of the median nerve are far more strained than any other parts of the brachial plexus. CONCLUSIONS: To the authors’ best knowledge, this case is the first report of a proximal median mononeuropathy arising from reverse shoulder arthroplasty. Future design modifications should consider reducing the strain on the brachial plexus.
 
FYI, this is my Anecdotal experience with Exparel (133 mg) mixed with 55-60 mg of 0.5% Bup for ISB:

academic.oup.com

Brachial Plexus Block with Liposomal Bupivacaine for Shoulder Surgery Improves Analgesia and Reduces Opioid Consumption: Results from a Multicenter, Randomized, Double-Blind, Controlled Trial

AbstractObjective. The utility of single-injection and continuous peripheral nerve blocks is limited by short duration of analgesia and catheter-related co
academic.oup.com academic.oup.com

I have personally followed up with the patients and the duration of analgesia was in the 40-48 hour range. I stress ANALGESIA as the duration of the block exceeded 24 hours the quality of both motor and sensory block begin to decline with most of the motor component gone by 24-28 hours.

I must add that the phrenic nerve paresis will likely persist beyond 24 hours with some data (including my own) showing phrenic paresis in the 36 hour range (for the majority of patients). Hence, be careful when adding in the Exparel 133 mg because of this increased duration of phrenic nerve palsy.

www.morressier.com

EVALUATION OF PHRENIC NERVE PARALYSIS AFTER AN INTERSCALENE BLOCK WITH AND WITHOUT LIPOSOMAL BUPIVACAINE

Introduction: Interscalene blocks have been used as a effective way to minimize post op pain in may different shoulder surgeries. A well known co |
www.morressier.com www.morressier.com
 
Last edited:
Mikkel said:
Don't even need a position statement, I just want one of their editorials to at least bring it up in a major way.
Click to expand...


Waiting for the self serving cockroaches to do something useful to those of us actually providing the lion's share of the care. They utterly failed us awhile back when hyperbaric bupiviacaine was not available and we used isobaric stuff- The bottles that were labeled "NOT FOR SPINAL ANESTHESIA" in big red letters. We all had ZERO medical issues with using these drugs. Lots of medicolegal concerns about using them. But these cowardly academic, administrative, cockroaches failed to step up and give us some cover. Same thing with placing blocks under GA with ultrasound.

For those members of ASA leadership reading this- This is one of the many reasons, (e.g., timidity on the CRNA issue, failing to oppose ABA on MOCA) why many of us hate you and more of us are failing to renew our membership.
 
Mikkel said:
He relies on the patient to tell him that he's jabbing a nerve, which he'll ignore anyway and quietly order "give another 100 fentanyl, please".
Click to expand...

Had an attending in residency that did all the blocks with 150mcg of fent and 5 mg of midazolam. It took me about a month to realize the drugs are not there to treat the patient's anxiety about the needle. they were there to mask her own lack of ultrasound skills. It doesn't look good when the patient is jumping because that cutting needle has gone through the nerve.

A 22g echogenic blunt needle doesn't hurt. I maintain that if you can't do a block without sedation, you're not doing the block correctly. Because that needle going through connective tissue and muscle does not hurt.

On doing blocks under GA. I think people need to realize it's an ultimate trust in your own US skills. If you can't visualize the needle tip 100% of the times you're moving it. Then you probably shouldn't be doing them under GA. I am now realizing how hard this is to do for some people. Heck, some of the regional fellows here has to be constantly reminded that they need the needle in view.....
 
dchz said:
On doing blocks under GA. I think people need to realize it's an ultimate trust in your own US skills. If you can't visualize the needle tip 100% of the times you're moving it. Then you probably shouldn't be doing them under GA. I am now realizing how hard this is to do for some people. Heck, some of the regional fellows here has to be constantly reminded that they need the needle in view.....
Click to expand...

Anatomy is 3-dimensional, an ultrasound picture is 2-dimensional until you start moving it.

You don't need the needle in view 100% of the time if you actually understand where the needle is.

I use out of plane ultrasound information to know where to direct my needle, and only keep my needle in view about 33% of the time, which is mostly when my needle is next to or inside the nerve.

You can also understand where your local is going if you can see it in 3d.
 
Why do people want to do blocks under GA? Even if the US makes it safe, having the patient awake to be able to state pain is the ultimate safety.
 
dchz said:
Had an attending in residency that did all the blocks with 150mcg of fent and 5 mg of midazolam. It took me about a month to realize the drugs are not there to treat the patient's anxiety about the needle. they were there to mask her own lack of ultrasound skills. It doesn't look good when the patient is jumping because that cutting needle has gone through the nerve.

A 22g echogenic blunt needle doesn't hurt. I maintain that if you can't do a block without sedation, you're not doing the block correctly. Because that needle going through connective tissue and muscle does not hurt.

On doing blocks under GA. I think people need to realize it's an ultimate trust in your own US skills. If you can't visualize the needle tip 100% of the times you're moving it. Then you probably shouldn't be doing them under GA. I am now realizing how hard this is to do for some people. Heck, some of the regional fellows here has to be constantly reminded that they need the needle in view.....
Click to expand...


Yep. Giving that much versed and fentanyl defeats half the benefit of doing a block. Most patients can be blocked with little or no sedation.
 
MirrorTodd said:
And yet, peds blocks are almost universally under GA. What's the difference between peds blocks under ga vs adult blocks under ga?
Click to expand...
dipriMAN said:
Why do people want to do blocks under GA? Even if the US makes it safe, having the patient awake to be able to state pain is the ultimate safety.
Click to expand...

Patient won't move, patient won't feel discomfort from needle, you don't need separate block area, patient already fully monitored, room staff very well prepared to help, block time billed as anesthesia time.

Pain is nonspecific and subjective. Ultrasound w/wo stim is the ultimate truth teller.
 
dipriMAN said:
Why do people want to do blocks under GA? Even if the US makes it safe, having the patient awake to be able to state pain is the ultimate safety.
Click to expand...

Have you considered that it’s been shown that patients’ complaints of pain do not correlate with neural injury?
 
The more blocks you do the more opportunity for complications. As the number of blocks start to exceed 1,000 then 3,000 etc the chance that 1 or 2 patients will have some nerve injury post op is fairly high. Most “injuries” resolve on their own over 6-8 months. Still, what If the injury persists beyond 1 year as I have read in many case reports? Do you want to defend that block performed under GA while their expert claims you deviated from the University level standard of care?

The choice to do a block under GA vs mild sedation or no sedation (like in pacu ) is yours to make but the medicolegal risk while small should not be ignored.
 
BLADEMDA said:
The more blocks you do the more opportunity for complications. As the number of blocks start to exceed 1,000 then 3,000 etc the chance that 1 or 2 patients will have some nerve injury post op is fairly high. Most “injuries” resolve on their own over 6-8 months. Still, what If the injury persists beyond 1 year as I have read in many case reports? Do you want to defend that block performed under GA while their expert claims you deviated from the University level standard of care?

The choice to do a block under GA vs mild sedation or no sedation (like in pacu ) is yours to make but the medicolegal risk while small should not be ignored.
Click to expand...

You're explaining statistics, of course it's possible to see a complication after 1,000-10,000 blocks.


Practice safety, and you won't have problems. Don't inject into the nerve under high pressure, don't use cutting needle when going into the nerve, use multiple small pokes in the sheath to relieve pressure, use sterile prep and sterile gel.

It's debatable whether GA blocks are unsafe. There is no standard of care, despite what some academics say. All you need is an expert witness who does blocks routinely under GA, and you have one expert's word against another.
 
Mikkel said:
You don't need the needle in view 100% of the time if you actually understand where the needle is.
Click to expand...

dchz said:
If you can't visualize the needle tip 100% of the times you're moving it. Then you probably shouldn't be doing them under GA.
Click to expand...

100% of the time while you're moving it.

okayplayer said:

Is this a "cutting needle"?
Click to expand...

The pajunk needles are very blunt, even if they are touhy tip, they are very blunt and you kinda have to force it through the skin.

BD precisionglide needle are cutting. 22g 1.5in.

examples are here but the needle cuts, because you don't need to force it to go through skin.
 
ethilo said:
Yes, he's even ok with it if still under GA. None of us will do that though. We all get post op exams before blocking.

These post op ISBs are much more difficult and occasionally impossible esp if the patient is intermittently obstructing from all the narcs
Click to expand...
We do all the peds blocks under anesthesia and the literature supports that it is safe, however I can understand not wanting the surgeon to blame his nerve injury on your block.
 
I believe nerve blocks under GA by an experienced Anesthesiologist (N over 1,000) is safe. That said, I typically do my blocks preop or postop the vast majority of time.

There are many Case reports of post op neuropathy where the technique seemed excellent IMHO. So, I simply don’t believe in giving the plaintiff’s lawyer any more ammunition to attack us with than absolutely necessary.
 
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