Background and Aims Shoulder arthroscopic surgery is associated with significant postoperative pain and opioid consumption. Regional anesthesia is a valuable part of anesthetic management either combined with general anesthesia or as a sole anesthetic technique. However, surgery in beach chair position in an awake state increases patient anxiety and discomfort.
Methods We report a case of a 74-year-old male, ASA III, admitted for arthroscopic rotator cuff repair in an ambulatory setting. He had a history of chronic obstructive pulmonary disease (important bullous emphysema), smoking and past pulmonary tuberculosis.
Results Given the high risk of iatrogenic pneumothorax and postoperative pulmonary complications, we decided to avoid mechanical ventilation. We proceeded with a locoregional technique associated with dexmedetomidine sedation. An interscalene brachial plexus block (BPB) was performed under ultrasonography guidance (in-plane technique) with nerve stimulation. 20 ml of 1% mepivacaine were used. Dexmedetomidine infusion was started at 0.6 ug/kg/h while performing the nerve block, and titrated up to 1 ug/kg/h. Intravenous analgesia with single ketamine bolus (0,3 mg/kg), acetaminophen (1gr), tramadol (100 mg) and ketorolac (30 mg) were also administered. The patient remained comfortable and under spontaneous ventilation during the procedure (90min). No bradycardia or other adverse events were registered. No additional analgesia was needed in the post-anesthesia care unit.
Conclusions BPB provides surgical anesthesia and postoperative analgesia while avoiding many side effects of general anesthesia. Dexmedetomidine allows sedation and analgesia with minimal respiratory depression and can significantly prolong the duration of BPB1. Our case suggests that BPB under dexmedetomidine sedation can be safe and effective for shoulder arthroscopy in ambulatory settings.
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