1. Sharon Acheson
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  3. Tuesday, 02 March 2021
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Hi, I have a patient who would like awake shoulder surgery and I was wondering if anyone had any tips! We have not done awake shoulder surgery before at our trust. Should an interscalene block be sufficient? I've often struggled to give IV Dexamethasone to prolong the block in awake patients due to it's undesirable side effect. Do you use in in the LA mix? Any advice would be greatly appreciated. Thanks!
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Hi Sharon,

I do this sometimes, but I know Ash Gupta and some others on the board are big fans.
Simple arthroscopic stuff is pretty straightforward with just an interscalene block, very occasionally you'll need a bit of supplementation for the posterior port if the surgeon places this low. If the surgery is prolonged, or high volumes of fluid used, then you sometimes get axillary pain from distension.
Giving the patient a screen to watch is important, i.e. see their surgery, as once they get over the initial anxiety, they'll get engrossed in the operation. Sedation can be problematic if they get fidgety.
Dexamethasone is good for prolongation of block, but not necessary for the actual surgery. Just give it really slowly. Personally dont mix drugs for my blocks, but know plenty that do.
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Hi Sharon

Thanks for your question. I concur with Sim.

We do awake shoulders as a routine in our Trust.

Inter scalene block with 20 mls of 0.75% Ropivacaine and 2-3 mls for superficial cervical plexus block to cover supraclavicular nerve (skin of the shoulder and AC joint). The posterior port is not covered by the block so I ask the surgeon to infiltrate the posterior port site with plane Lignocaine 1% (no adrenaline) after the block and positioning in the anaesthetic room.

There is high incidence of Bezold Jarish reflex (upto 30% reported in literature) (vaso vagal) which is most commonly related to anxiety. I run TCI propofol (normally 0.5 to 0.8 mcg/ml) with an aim to calm rather than sedate. Always keep IV atropine and ephedrine handy. There is a separate screen for the patients to watch and a transparent drape which avoids the claustrophobia and keeps the communication open with the team. I have unbroken alfentanil 1 mg ampule ready for breakthrough pain which can sometimes happen (1 in 5 patients) while working on anterior capsule. (generally aliquot of 0.25 mg is good enough; I have never needed more than 1mg).

We use a helmet headrest in case the patient becomes a bit sleepy (to prevent the head wobbling).

IV dexamethasone (6.6mg) prolonged our Ropivacaine block on average 9 hrs. I give it slowly over a few minutes regularly without any reported untoward side effects.

Make sure the whole team is on board for the awake surgery. Surgical time over 2 hrs could make it tricky for the reasons mentioned by Sim.

Always have a plan B. For me, I make sure the airway bowl with appropriate I-gel is kept near you and the anaesthetic nurse stays in the theatre / anaesthetic room (immediately available). If needed increase propofol and bolus alfentanil and push the i-gel without changing the position of the patient. (i have not needed to do it for last few years now)

I hope this is helpful and happy to answer any more questions.

Please let me know how you got on.
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Hi Simeon and Ashwani,

Thank you both for your replies and helpful tips, they are very much appreciated. We don't have Ropivacaine, just Levobupivacaine. I will let you know how we get on!

Best wishes,

Sharon
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