New trends in regional anesthesia for shoulder surgery: Avoiding devastating complications

Abstract

Surgeons and patients are often reluctant to support regional anesthesia (RA) for shoulder and other orthopedic surgeries. This is because of the sometimes true but usually incorrectly perceived “slowing down” of operating room turnover time and the perceived potential for added morbidity. Recently, severe devastating and permanent nerve injury complications have surfaced, and this article attempts to clarify the modern place of RA for shoulder surgery and the prevention of these complications. A philosophical approach to anesthesiology and regional anesthesiology is offered, while a fresh appreciation for the well-described and often forgotten microanatomy of the brachial plexus is revisited to explain and avoid some of the devastating complications of RA for shoulder surgery.

Current Concepts in Anaesthesia for Shoulder Surgery

“…Particular risk factors include medial angulation of needle with depth >2.0 cm [65] and catheter advancement of >5 cm [66] beyond the needle tip which brings with it the risk of catheter knotting leading to brachial plexus avulsion injuries on removal [66] as well as catastrophic catheter misplacement [67]. …”

Tfe3 and Tfeb Transcriptionally Regulate Peroxisome Proliferator-Activated Receptor γ2 Expression in Adipocytes and Mediate Adiponectin and Glucose Levels in Mice

“…Given prior evidence that Tfe3 participates in metabolic regulation of various tissues (9,15,16,18) and the structural/functional overlap among members of the MiT transcription factor family (4,14,33), we decided to investigate their expression levels in several organs after a 16-h fasting and 12-h refeeding of C57BL/6J (B6) mice. As shown in Fig.…”

Recovery after orthopedic surgery

“…Any indication of high injection pressure at the peripheral nerve level would suggest subperineural (intrafascicular) injection, which should cause discontinuation of the injection, repositioning of the needle and reconfirmation of its placement [53][54][55]. Lack of cerebrospinal fluid back-flow should be confirmed by opening the needle to ambient pressure prior to local anesthetic injection.…”

“…It is imperative to understand that intraneural injection during any root level block (inclusive of blocks performed at or proximal to the interscalene level) and any paravertebral block in the cervical, thoracic, lumbar or sacral region, is especially dangerous and will likely result in significant adverse effect or injury[53,54]. It is imperative to understand that intraneural injection during any root level block (inclusive of blocks performed at or proximal to the interscalene level) and any paravertebral block in the cervical, thoracic, lumbar or sacral region, is especially dangerous and will likely result in significant adverse effect or injury[53,54].…”