P063: COMPLETE REGIONAL ANESTHETIC TECHNIQUE FOR POSTERIOR SHOULDER LABRAL REPAIR AND CUBITAL TUNNEL RELEASE IN A PATIENT WITH HIGH-RISK BILATERAL PULMONARY BLEBS
Andrey Suprun, MD; Keyana Vyas, MD; Adrian J Maurer, MD; University of Florida Department of Anesthesiology
Introduction/Background: Pulmonary blebs are weak-walled, air-filled subpleural pouches which are at risk of rupture and resultant pneumothorax. The risk increases with positive pressure ventilation (PPV), and chest tube placement for treatment of the pneumothorax is complicated if the patient has undergone pleurodesis or other thoracic surgical procedures. Here we describe the use of regional anesthesia techniques to provide an anesthetic for a shoulder labral repair and cubital tunnel release in a patient at high risk of pulmonary bleb rupture.
A 41-year-old male presented with right shoulder labral tear and ulnar nerve impingement at the cubital tunnel, and was scheduled for arthroscopic labral repair and cubital tunnel release. His PMH was most notable for multiple bilateral pulmonary blebs with prior rupture, treated with chest tubes, right thorascopic bleb resection, and left pleurodesis. CT demonstrated numerous bilateral blebs in the lung apices and several medial blebs next to the heart and great vessels. He was laid off due to inability to work and required the surgery on a specific day to ensure insurance coverage.
Methods: A full regional anesthetic technique was selected to minimize the need for PPV. All blocks were single-shots under ultrasound guidance, with echogenic nerve block needles and 0.5% ropivacaine. First, a T2 paravertebral block was performed in the sitting position, with ultrasound visualization of pleural depression on injection. Then, targeted C5 and C6 nerve root blocks were performed at the interscalene groove. A superficial cervical plexus block was also performed along the fascia deep/posterior to the sternocleidomastoid muscle. Finally, to address the cubital tunnel release portion of the case, we performed middle and lower trunk blocks at the supraclavicular fossa.
Results: The patient subsequently had complete anesthesia of the entire right forequarter from posterior midline to the right sternal border, and from the mandibular angle to approximately T4 on the chest/back. In the OR, ASA monitors and a nasal cannula with CO2 monitoring were applied; he was positioned lateral, prepped/draped, and surgery commenced. The surgical sites were completely insensate throughout; he was quite inquisitive and talkative to the anesthesia and surgical teams intraoperatively and a low-dose propofol infusion was initiated to aid surgical focus. The surgery was completed successfully, and he was recovered and discharged home from PACU uneventfully with no pain.
Discussion/Conclusion: Our main consideration in this case was risk reduction of bleb rupture. Due to bleb location, history of thorascopic procedures, and prior pleurodesis, there was concern for technical challenges of chest tube placement and possible non-communication of the pleural space, as well as cardiac/hemodynamic compromise due to compression from medial bleb rupture. The regional techniques chosen provided coverage for the procedures as booked, but also hedged against conversion to open labral repair (due to insurance, aborting the arthroscopic repair to perform an open procedure later was untenable to the patient). In conclusion, there is feasibility of performing a full regional technique to provide complete anesthesia of the forequarter and avoid PPV in patients at high risk of complications from that ventilatory modality.