American Society of Regional Anesthesia and Pain Medicine May 2017 - 33

GA; nevertheless, there was little to no evidence of causation
of neurologic injury.13,15-17 Despite the fact that the transient
intraoperative cerebral desaturation events (CDE) have not been
shown to be associated with either postoperative cognitive
dysfunction or levels of biomarkers of neuronal injury, and the
degree and duration of cerebral ischemia required to produce
neurocognitive dysfunction in this patient population remain
undefined; there is a need for strict hemodynamic management
with higher blood pressure in the upright position during general
anesthesia.16
Although GA with or without regional anesthesia (RA) has been
the popular practice for shoulder arthroscopy, well-placed RA
alone might be sufficient to provide surgical anesthesia. RA has
numerous advantages to GA for arthroscopic procedures, including
intraoperative analgesia and muscle relaxation without systemic
paralysis, avoiding airway manipulation, less hemodynamic
variation, preservation of cerebral autoregulation, decreased
postoperative nausea and vomiting by reducing systemic opioid
administration, superior pain control in the postanethesia care unit
(PACU), shorter operating room times, expedited time to discharge,
reduced admission rates, and reduction of overall cost.18,19
Recently, Ende et al analyzed 169,878 shoulder arthroscopy
records from January 2010 to December 2014 documented in
National Anesthesia Clinical Outcomes Registry and discovered
that 105,666 cases (62%) were performed under GA, 60,765 (36
%) with GA+RA, and only 3447 (2.0 %) under RA alone.20 This
suggests that RA alone is still underutilized despite the advantages
mentioned above.
APPLICATION OF RA AT OUR INSTITUTION
In our institution, we hypothesized that the frequency of CDE can
be significantly reduced by risk stratification and implementation
of an anesthesia protocol based on patients' risk category. In
2014, we tested the rate of the CDE in patients undergoing
shoulder arthroscopy in the sitting position in 100 consecutive
patients. CDE were more frequent in patients who received GA
when compared with those who received RA only despite strict
hemodynamic control in the GA group. However, this difference was
not statistically significant. The result of this quality improvement
project was a proposal that patients with the highest risk for
cerebral desaturation events (Framingham criteria >10 or previous
cerebrovascular accident) should be offered RA with or without
sedation for shoulder surgery in the beach chair position as the first
option. If GA is chosen, invasive monitors and a strict hemodynamic
management protocol should be deployed.
We believe the underutilization of RA for shoulder arthroscopy
procedure is likely due to concerns over sufficient intraoperative
sensory coverage and airway management. We worked closely with
our shoulder surgeons to implement a pilot project aiming to use
RA as an alternative to GA in select high-risk patients.

Figure 1: Setup for the awake shoulder arthroscopy.

Initially, RA was reserved for patients who were at risk for
stroke or compromised cerebral perfusion. As our group
(anesthesiologists and surgeons) became more comfortable with
RA for intraoperative anesthesia, we started to offer this technique
to healthy patients.
We created patient educational material to teach patients about
RA options for shoulder surgery. These educational brochures were
made available at the surgeon's office and were part of the surgery
packet when the patient is scheduled for surgery. An online version
of the education material was made available to patients in the
waiting room during their clinic visits as well.
During the preoperative visit, surgeons would address expectations
of the surgery, provide an overview of the anesthetic options, and
direct patients to the Penn Medicine website, which outlines the two
techniques: general as well as RA for orthopedic surgery. On the day
of surgery, the anesthesia team approaches well-informed patients
to confirm their choice and answer any last-minute questions.
All patients scheduled for a arthroscopic shoulder surgery expect
to have RA but are also given the choice between being "awake"
or "sleepy with sedation" for their surgery. An ultrasound-guided
interscalene nerve block is performed in the holding area, 20 to
30 minutes before the scheduled surgery. Intraoperatively, the
awake and cooperative patient is easily seated in the beach chair
position, absolving problems such as postural hypotension and
improperly padded pressure points. A separate monitor is placed
under the drape for the patient to view the surgery (Figure 1). Once
the surgical field is draped, the surgeon assesses the adequacy
of the block. In our practice, placement of the posterior (viewing)
portal between the inferior edge of the infraspinatus and teres
minor may be spared after interscalene block. A separate axillary

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2017

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