Blocks for Shoulders

80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.

Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. International Journal of Surgery, Volume 45, September 2017, Pages 85-91.

  • Supraclavicular block could provide similar analgesic efficacy compared with interscalene block.
  • Ultrasound-guided supraclavicular block was associated with a low incidence of hoarseness and Horner syndrome.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. European Journal of Anaesthesiology 36(6):p 427-435, June 2019

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology July 2018, Vol. 129, 47–57.

From Anesthesiology July 2018, Vol. 129, 47–57.

A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery. Regional Anesthesia & Pain Medicine 2018;43:590-595.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand. 2021; 65: 674– 680.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research volume 16, Article number: 376 (2021).

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review. Osteology 20222(1), 52-61.

YouTube: Anterior suprascapular nerve block and literature 11:43 for procedure

YouTube: Suprascapular and axillary nerve block

Epidural blood patch

I was asked to consult on a 30-something year old patient who had a recent subdural hemorrhage. It was a spontaneous event without trauma. After a week of stabilization of the SDH, the patient started developing positional headaches. CT scan showed a CSF leak from C4-T5 ventrally and another one from T6-T10 dorsally.

CT head: Small evolving right greater than left bilateral subdural hematomas, not significantly changed compared to prior. No evidence of new hemorrhage. Trace right to left midline shift is unchanged.

Cspine/T-spine/L-spine with contrast: Extensive CSF leak. The dominant component of this process is a ventral epidural contrast collection extending from C6-T4 levels, but there is also abnormal dorsal epidural contrast extending from T5-T10. The contrast is densest in the cervicothoracic ventral epidural space, also suggesting that this is the primary leakage site.

MRA neck without acute abnormalities. MRI cervical/thoracic/lumbar spine which incidentally revealed multifocal demyelinating lesions in the cervical cord with a focal lesion at T7 and MRI brain showed multiple foci of T2 flair hyperintensity in the supratentorial white matter of the brain, suspicious for undiagnosed demyelinating disease.

What is a CSF leak?

What is an epidural blood patch?

Recent update on epidural blood patch: Review. Anesth Pain Med 2022;17:12-23.

Typically, anesthesia gets consulted for lumbar epidural blood patches after lumbar CSF leaks. However, in this case, the CSF leak occurs quite high in the cervicothoracic spine. Oftentimes, it’s very difficult to inject a greater volume of blood in the lumbar epidural space due to back pain to reach the higher cervical and thoracic areas.

From Post Dural Puncture Headache – We Can Prevent It. July 2014.

Why not do a lumbar epidural blood patch to reach the cervical or thoracic space?

One question that is often asked is whether CEBPs are necessary, or would lumbar EBPs suffice, even for dural leaks at the cervical levels. There are several reports indicating that lumbar EBP can permanently alleviate the headache regardless of whether or not the site of leakage is identified . However, other reports demonstrate that lumbar EBP does not always result in permanent relief [36–38]. A study by Diaz suggests that the site of leakage should be identified by radioisotope cisternography and treated with EBP targeted to CSF leak site levels . Cousins et al suggested that placement of the EBP close to the site of CSF leakage is important . Studies have shown that blood injected at the lumbar level does reach the cervical levels. Ferrante et al., for instance, performed epidural blood patch at L3-4 and placed in the patient in trendelenburg for 22 hours . He was able to show presence of blood in the epidural space at the cervical levels on postprocedure MRIs. The mean spread of the blood patch in the epidural space has been found to be 4.6 ± 0.9 vertebral levels . Most of the blood spread in the cephalad direction . However, the amount of blood that reaches the higher cervical levels in comparison to the amount of blood needed to form a stable clot is unclear. Despite spread of blood to cervical levels, Beards did note that after an epidural blood patch, the majority of the clot and mass effect appears to be concentrated in the area around the injection site .

Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Efficacy of epidural blood patches for spontaneous low-pressure headaches: a case series. J R Coll Physicians Edinb 2016; 46: 234–7.

Sagittal postmyelogram CT of the cervical and upper thoracic spine showing a ventral epidural contrast collection. VES indicates ventral epidural space; VSS, ventral subarachnoid space; C, cord. From Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86

How does one reach a cervical or thoracic epidural space?

Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension. American Journal of Neuroradiology November 2005, 26 (10) 2663-2666.

Thoracic epidural blood patch with high volume blood for cerebrospinal fluid leakage of cervical spine (C2–3) complicated with spontaneous intracranial hypotension. Acta Anaesthesiologica Taiwanica. Volume 53, Issue 3, September 2015, Pages 112-113.

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series. Pain Physician 2015; 18:343-348.

A, Postmyelogram CT at the level of the T7–8 disc interspace demonstrates a ventral CSF leak (white arrow) containing contrast with an attenuation slightly less than that of intrathecal contrast. A small spiculated osteophyte (white arrowhead) is the presumed cause for the leak. B, Lateral projection dynamic myelogram of the midthoracic spine confirms the origin of the CSF leak at T7–8. Note the split of the contrast column at this level consistent with a ventral CSF leak (white arrow). From CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Utilizing this information, I thought this patient would be better suited for a CT-guided targeted (cervicothoracic) ventral epidural blood patch performed by the IR team. Additionally, I recommended conservative therapy: hydration, caffeine, Fioricet, lying flat, and an abdominal binder.

CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86.

Abdominal Compartment Syndrome

A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients. Crit Care 24, 97 (2020).

From Crit Care 24, 97 (2020).

Abdominal compartment syndrome among surgical patients. World J Gastrointest Surg. 2021 Apr 27; 13(4): 330–339.

Patients with ACS will usually be critically ill and unable to provide history and symptoms. On physical exam, patients present with a distended abdomen. However, palpation and abdominal circumference are not reliable for the diagnosis of ACS[25].

A prospective study in postoperative ICU patients showed physicians have less than a 50% chance to identify IAH by clinical examination[25]. The clinical abdominal exam as IAP assessment has an estimated sensitivity of 56%-60% and specificity of 80%-87%[25,26].

Signs of ACS will present as the end-organ effect from the physiologic changes (Table ​(Table2).2). The most notorious signs are usually abdominal distention, oliguria, high ventilatory pressures, diminished cardiac output, and metabolic acidosis[26].

Abdominal Compartment Syndrome. StatPearls, Nov 2021.

The more commonly used method is an indirect measurement such as intravesicular catheter pressures (e.g., Foley catheter), which has become the gold standard due to its widespread availability and limited invasiveness. The trans-bladder technique involves using aseptic clamping the drainage tubing of the Foley then connecting the Foley to a three-way stop tap adjusted to the level of the mid-axillary line at the iliac crest to zero transducers follow by injecting 25 cc of sterile saline into the bladder.  Measurements should be taken at end-expiration and complete supine position and expressed in mmHg.  Bladder pressures below 5 mm Hg are expected in healthy patients. Pressures between 10 to 15 mm Hg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mm Hg are highly suspicious of abdominal compartment syndrome and should be correlated clinically. It is recommended that pressure measurements be trended to show and recognize the worsening of intra-abdominal hypertension.

Contraindications to using bladder pressures include bladder trauma, neurogenic bladder, BPH, and pelvic hematoma. Bladder pressures may be inaccurate if the patient is not sedated or lying flat.[9][10]

How to Measure Intrabdominal Pressure

From London Health Science Centre

The primary treatment for ACS is surgical decompression. However, the early use of non-surgical interventions may prevent the progression of IAH to ACS. Early recognition involves supportive care to include keeping patients comfortable with pain well-controlled.  Decompressive procedures such as NG tube placement for gastric decompression, rectal tube placement for colonic decompression, and percutaneous drainage of abscesses, ascites, or fluid from the abdominal compartment. The neuromuscular blockade has been described to be used as a brief trial in an attempt to relax the abdominal musculature, leading to a significant decrease in abdominal compartment pressures in the ventilated ICU patient. If conservative and medical management does not resolve the IAH and further organ damage is noted, surgical decompression using emergent laparotomy may be considered. [11][2]

After surgical laparotomy for compartment syndrome, the abdominal fascia may be closed using temporary closure devices such as (vacs, meshes, and zippers). The fascia can be appropriately closed after 5 to 7 days after the compartment pressures and swelling have decreased.

Methylene Blue

Case: 65 yo male with septic endocarditis and septic emboli with + valve vegetations. Severe MR, mod AI, mod TR, no PFO, EF 60-70%. Mild pericardial effusion. Large bilateral pleural effusions.

Vasoplegic syndrome—the role of methylene blue. European Journal of Cardio-Thoracic Surgery, Volume 28, Issue 5, 1 November 2005, Pages 705–710.

OpenAnesthesia: Methylene Blue

2 mg/kg bolus –> 0.5 mg/kg/hr x 12 hours
Worked wonderfully for vasoplegia unresponsive to levophed or vasopressin.

Antithrombin III

The other day we had a patient come in for a CABG. Aside for some coronary artery disease, hypertension, and chronic kidney disease, the patient was pretty healthy. They were not on anticoagulation prior to the procedure.

After I gave full dose heparin for going on bypass (41,000U in this case), the ACT only came up to 422. An additional 10,000U of heparin was given with a repeat ACT of 457. Still, our surgeon was not quite comfortable with that number and requested an additional 10,000U heparin. The ACT came to 477.

If the ACT stayed in the low 400s, would you go on bypass? What if the ACT had not responded to the repeated heparin dosings?

Management of coagulation during cardiopulmonary bypass. Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 6, 1 December 2007, Pages 195–198,

Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2002 Feb;123(2):213-7.

Would you give antithrombin III or plasma?

Treating Heparin Resistance With Antithrombin or Fresh Frozen Plasma. The Annals of Thoracic Surgery. June 2008Volume 85, Issue 6, Pages 2153–2160.

Is there evidence that fresh frozen plasma is superior to antithrombin administration to treat heparin resistance in cardiac surgery? Interact Cardiovasc Thorac Surg. 2014 Jan; 18(1): 117–120.

We ultimately decided to go on bypass. Repeat ACTs on bypass were in the 500s. No antithrombin was given. After separation from cardiopulmonary bypass and administration of protamine, repeat ACT was 111. Protamine was dosed accordingly to heparin administration and ACTs while on bypass.

Recommendations for the use of antithrombin concentrates and prothrombin complex concentrates. Blood Transfus. 2009 Oct; 7(4): 325–334.

Thrombate (antithrombin III) package insert

Updated August 2022

Had a patient who was on a heparin drip for CAD with recent NSTEMI. Heparin gtt was discontinued upon entry to OR. Pt weight: 138kg. Heparin 36,000U given. First ACT 500. then 5000U given and then again x2 for total additional heparin 15,000U. ACT 460-480. Went on CPB, 10,000U heparin given on pump and ACT 483. AT3 500U given and repeat ACT 15 minutes later was 520.

Guidelines on Use of AT3 in Cardiac Surgical Patients

AT3 to Treat Heparin Resistance in Cardiac Surgery Patients

Protecting patient safety

Check out @ASAGrassroots’s Tweet:

#NewYork budget excluded provision that would have undermined physician-led anesthesia care, opposed by @ASALifeline & @NYSSApga. #THANKYOU to New York lawmakers for protecting patient safety. #SafeAnesthesia4NY

Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers.  That’s socialized medicine.  You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare.  But in a way, it’s empowering patients to take responsibility for their own health.  Smoking, for sure — I agree 100% that surgery should be banned for this population.  Obesity is a bit trickier — there’s genetics and environmental factors at play in this one.  I don’t think anyone chooses to be obese.  But, people do have the power to change their eating and exercise habits.  Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

From SlideShare

From SlideShare


Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

From HealthStats

I think the NHS is on to something here.  They’re opening doors to moving the liability and responsibility away from physicians and towards patients.  This is a plus.  Outsiders may see it as separatism and elitist to only provide care for people who are healthy.  But look at the facts and the data…. obesity has a lot of co-morbidities associated.  Smoking has a lot of co-morbidities associated as well.  Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough?  In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness.  With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health.  I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation.  It’s not easy, but my health is 100% my responsibility.  I refuse to pass the buck to my husband, my family, my physician, etc.  I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health.  It is not your spouse’s responsibility to track your meds.  It is your responsibility to know your medical conditions and surgical history.  The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery.  This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care.  Please do not forget recreational drugs, smoking habit, and drinking habit in this list.  It is very important to know all of these things.  Also, your emotional history is very important.  Depression, anxiety, failure to cope, etc.  This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:


Emergency Checklists

It seems like in today’s day and age, emergencies are occurring everywhere.  From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do.  Here are some fabulous checklists I’ve found for getting through those emergencies.  These are not substitutions for knowledge and training.  Clinical judgement warranted.

Emergency Manual from Stanford — Printable PDF

Ariadne Labs OR Crisis Checklist

Ariadne Labs Safe Surgery Checklist Template

Ariadne Labs Ambulatory Safe Surgery Checklist Template

Project Check

Newton-Wellesley’s L&D Checklists

WHO Safe Childbirth Checklist

Checklist for Trauma Anesthesia

ASRA checklist for Local Anesthetic Systemic Toxicity

WHO Surgical Safety Checklist

WHO H1N1 Checklist

Johns Hopkins Central Line Checklist

STS Adult Cardiac Surgery Checklist

Ariadne Labs Cardiac Surgery Checklist

STS General Thoracic Surgery Checklist

STS Congenital Heart Surgery Checklist

University of Kansas Daily ICU Quality Checklist


Deep Hypothermic Circulatory Arrest

Case Cerebral ischemia: deep hypothermia

SCA 2013 PBLD: Anesthetic Management for Deep Hypothermic Circulatory Arrest

BJA: Deep hypothermic circulatory arrest. July 2010

JCVA: Perioperative management of deep hypothermic circulatory arrest. Aug 2010.

Anaesthesia, Pain, and Intensive Care: Deep hypothermic circulatory arrest – anesthetic considerations. Aug 2016.

Annals of Thoracic and Cardiovascular Surgery:  REVIEW: The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion for aortic arch surgery. 2008.

Cardiac Surgery in a Jehovah’s Witness Patient


Brief case summary

Habler_Fig1 v2_1
From Nata Online

Literature Search

Habler_Fig2 v2
From Nata Online

Antifibrinolytic Debate