Anesthesiology

Repair of Ruptured Biceps Tendon

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What the Anesthesiologist Should Know before the Operative Procedure

A biceps tendon rupture can occur either proximally or distally. A variety of degenerative, hypovascular and mechanical factors can contribute to tendon compromise: these include excessive strain, rheumatoid arthritis, ankylosing spondylitis, end-stage renal disease, gout, malignancy, systemic lupus erythematosus, syphilis, tuberculosis, abuse of anabolic steroids and nicotine.

Proximal ruptures account for the vast majority and mostly involves the biceps long head which originates from the supraglenoid tubercle and courses over the humeral head within the capsule of the glenohumeral joint. Since the biceps short head can compensate quite well for the ruptured long head, symptoms are usually minimal. The typical patient is an older individual with preceding degenerative changes, such as a rotator cuff tear. This type of rupture can also occur, albeit very rarely, in a younger patient involved in throwing sports or weight-lifting. Surgical treatment is offered to active, younger patients, those who suffer from intolerable pain, and patients who have cosmetic concerns ("Popeye Muscle").

A distal rupture only occurs approximately 3% of all biceps tendon ruptures. These are found near the elbow joint where the tendon typically avulses from the radial tuberosity. The prevailing population is middle-aged (fourth to sixth decade) men taking part in heavy lifting or sports. Acute (within 2 weeks) surgical intervention is provided to active individuals of all ages, whether or not they are athletes.

Anesthetic concerns should be guided by the history and physical with the aforementioned contributing factors in mind.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

There is NO emergency or urgency for this surgery for proximal ruptures,

However, an early anatomical repair, meaning within 2 weeks, of an acute and complete distal biceps tendon rupture is preferable. This is secondary to findings of decreased elbow flexion and supination strength as well as decreased supination endurance in those who underwent conservative, non-surgical treatment. Moreover, a chronic presentation (greater than 4 weeks) following injury presents a greater operative challenge to the surgeon and has a higher probability of complications. This challenge to the surgeon occurs in the form of a retracted tendon as well as a more involved dissection as the previous natural 'sheath' to the bone may have deteriorated.

  1. Emergent- Surgery should never be considered emergent

  2. Urgent- Repair of a proximal rupture is not urgent, especially given that surgery is commonly only offered if three months of conservative measures fail. For a distal rupture, depending on one's timeframe, surgical intervention may be considered urgent- surgery within two to three weeks from date of injury.

  3. Elective- Surgery is most likely elective. Surgical treatment for a proximal rupture is restricted to a few groups of people: athletes and laborers who may not tolerate a decrease in strength, young and active people, sufferers of intractable pain and those with concerns of cosmesis. Distal rupture repair is offered to all active individuals.

2. Preoperative evaluation

Patients undergoing a repair of a ruptured biceps tendon are usually more or less healthy. Proximal ruptures are either the result of degenerative changes (eg, osteoarthritis, rheumatoid arthritis) or high-impact activity. Patients with significant degenerative conditions are not likely offered surgery as this modality of therapy is more or less restricted to more active people. In contrast, those who rupture their proximal biceps tendon from a high-impact activity, such as sports or manual labor, are more likely to be healthy individuals. Moreover, a proximal rupture of the biceps long head muscle is quite well compensated by the biceps short head muscle; thereby, further diminishing the need for surgery. Usually, there is only a resultant minor loss of strength in forearm flexion and supination.

Distal biceps tendon ruptures are surgically repaired for active individuals resulting in a selection for healthier candidates. Loss of strength in forearm flexion and supination following conservative therapy may be quite extensive.

ANY medically unstable conditions warrant further evaluation and surgery should be delayed as it is elective in nature.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

  1. Acute/unstable conditions: These include acute or recent MI, unstable or severe angina, and significant arrhythmias.

    1. Perioperative evaluation: Following a history and physical exam, if patient is suspected to have any of the above conditions, evaluate with respect to ABC's; stabilize and monitor the patient - ACLS, 12-lead EKG, troponins, TEE, consider cardiology consult, etc. In the setting of less acute changes, follow the AHA/ACC Guidelines for cardiac evaluation.

    2. Perioperative risk reduction strategies: Surgery should be cancelled until the patient is stabilized and optimized.

  2. Baseline coronary artery disease or cardiac dysfunction:

    1. Perioperative evaluation: In the setting of elective surgery that is usually offered to active individuals, a concerning cardiovascular comorbidity is not likely to be encountered. If patient has been active, the minimal METS requirement for surgery is probably met.

    2. Perioperative risk reduction strategies: Most medications may be continued until the day of surgery depending on the comfort of the Anesthesiologist and the surgeon - eg aspirin, ACE inhibitors. With regard to patients who have coronary stents and must continue their antiplatelet medications, surgery should be cancelled until they are able to cease the antiplatelet therapy. An intraoperative strategy of decreasing cardiac demand and increasing its supply should be adopted. For example, decreasing demand by minimizing heart rate and contractility by attenuating sympathetic response to surgery and by increasing Fi02

c. Pulmonary

  1. COPD- Surgical candidates are generally active so a significant COPD component is unlikely. Patients with mild COPD may be encountered.

    1. Perioperative evaluation- A history and physical assessing the patient's recent functional status should be performed. Within this active population, probing for any recent exacerbations is the goal (ie, any increased frequency of medication use, abnormal findings on lung auscultation).

    2. Perioperative risk reduction strategies- A less-than-optimal status should prompt a cancellation of surgery. Otherwise, their medical regimen should be continued until the day of surgery. The regimen may include corticosteroids so a stress dose of steroids should be readily available or even be administered to the patient who is likely to be adrenally suppressed. Also, consideration can be given to encourage the patient to use their inhaler(~s) prior to induction; a nebulizer treatment can likewise be provided. Intraoperatively, airway manipulation should be minimized. Regional anesthesia with sedation is a great option. If GA is to be used, placement and removal of an LMA while the patient is deeply anesthetized is another option to attenuate airway stimulation relative to intubation.

  2. OSA - As above, patients for this type of surgery are active and healthy. Significant OSA is not likely encountered.

    1. Perioperative evaluation - Severity of disease should be evaluated via history and physical. Patients should be instructed to bring their CPAP machine with them on the day of surgery if they use one.

    2. Perioperative risk reduction strategies- For proximal surgeries, this healthy population is likely able to tolerate a 25-32% reduction in pulmonary function so an interscalene catheter should not be problematic. Mild dyspnea or altered respiratory sensation may be treated with reassurance under observation/monitors. Patients who will possibly be compromised would not be good surgical candidates. However, if someone with moderate to severe sleep apnea were to undergo surgery, some options are: no regional technique, an interscalene catheter with no initial bolus, a suprascapular nerve block, or an axillary plus a suprascapular block. Of note, it appears that a decrease in diaphragmatic and pulmonary function is similar in patients having continuous interscalene analgesia with 0.2% Ropivacaine and in patients receiving patient-controlled intravenous opioids. For distal surgeries, an infraclavicular catheter would be preferable to avoid any respiratory compromise from brachial blockade.

    3. Issues- A possible exacerbation of OSA can occur with brachial plexus blockade. This is secondary to the proximity of the phrenic nerve to the plexus. A brachial plexus blockade may result in phrenic nerve blockade and thus hemidiaphragmatic paresis (HDP). The chosen brachial plexus block site results in variations in the frequency and clinical relevance of hemidiaphragmatic paresis: HDP occurrence is 100% after an interscalene block with 25-32% reduction in pulmonary function, 50% after a supraclavicular block with no or mild pulmonary function changes, and 0% after a lateral infraclavicular block with no pulmonary function changes. Of note, diaphragmatic and pulmonary functions appear similar between a technique of continuous interscalene analgesia with 0.2% Ropivacaine and a treatment of patient-controlled intravenous opioid.

    1. Reactive airway disease (Asthma)- Patients who are offered surgical treatment of a ruptured biceps tendon are active individuals so a diagnosis of asthma is most probably mild and/or well-controlled.

    2. Perioperative evaluation- The possibility that the patient is suboptimal must be assessed with respect to changes in frequency of medication usage, ER visits, and hospitalizations as well as steroid use.

    3. Perioperative risk reduction strategies- Similar to a patient with COPD. Please see above.

d. Renal-GI:

Similar to concerns with respect to other organ systems, significant issues are not likely to be encountered as patients are mostly healthy and active.

Renal-

Perioperative evaluation- As this type of surgery is elective, any acute conditions or exacerbations of a chronic disease is cause for delay/cancellation of surgery. Any existing chronic condition is unlikely to compromise the patient as more active individuals are usual surgical candidates.

Perioperative risk reduction strategies- For patients who are otherwise good surgical candidates that have a chronic renal condition, avoidance of things that may impair the renal system would be prudent: for example, the avoidance of nephrotoxic drugs (NSAIDs, aminoglycoside antibiotics).

GI-

Perioperative evaluation- NPO violations and significant GERD are common issues to be found.

Perioperative risk reduction strategies- For NPO violations, surgery should be delayed to adhere to guidelines. To decrease the chance of GERD with aspiration, a variety of medications may be given: antacids, histamine antagonists, proton pump inhibitors, promobility agents. For more severe GERD, a consideration can be made for a rapid sequence intubation.

e. Neurologic:

  1. Acute issues: Any acute issue, such as a stroke, should be further evaluated (focused history and physical exam, neurology consult, etc.) and is a cause for surgery cancellation.

  2. Chronic disease: A compromising, chronic condition is not likely to be present as this type of surgery is usually restricted to people whose activity will be jeopardized by a tendon rupture. However, when a chronic condition is elicited by the history and exam, evaluation should assess for evidence of good control. Otherwise, surgery should be cancelled for medical optimization. For instance, a patient with a history of seizures should report a good seizure-free period of time.

f. Endocrine:

Patients with endocrine comorbidities are likely stable with a very well-controlled disease in order to lead an active life. Diabetes Mellitus and thyroid issues would be the most common and, as above, probably well-controlled.

Perioperative evaluation- The history and physical exam should investigate for physiologic effects related to DM, such as cardiovascular, neurologic, renal, musculoskeletal and ophthalmologic. The degree of glucose control should also be ascertained. For thyroid issues, symptoms of hyper and hypo thyroidism should be sought.

Perioperative risk reduction strategies-For DM, determine medication regimen. Hypoglycemics may be discontinued the day prior to surgery - metformin should not be taken on the day of surgery. A reduced dose of insulin may be taken on the morning of surgery. Furthermore, a blood glucose level should be obtained preoperatively as well as postoperatively to determine if intervention is required. Thyroid medications should be continued.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Patients undergoing proximal biceps tendon ruptures may have degenerative disorders such as osteoarthritis or rheumatoid arthritis. However, since there is usually only a minor loss in strength, surgery is most often offered to those whose comorbidities do not significantly affect their ability to be active. With respect to rheumatoid arthritis, even though it is likely that a more mild form is to be encountered in this surgical population, nevertheless it would be prudent to assess for things that may impact the management of the patient. For instance, involvement of the temporomandibular joint may impair mouth opening and prompt an alternative airway management plan to a regular direct laryngoscopy (eg, fiberoptic or nasal intubation). Likewise, patients with findings of hoarseness or an inspiratory stridor may require a smaller endotracheal tube. Another consideration is for cervical spine involvement; there may be atlantoaxial subluxation and/or odontoid protrusion into the foramen magnum. As stated before, surgical candidates for this surgery are healthy, active individuals who are unlikely to have compromising comorbidities; however, if there is suspicion of significant cervical spine involvement, a lateral C-spine film may be obtained to evaluate for a greater than 5mm posterior atlanto-odontoid distance. This would be an indication for minimizing cervical spine displacement as excessive movement, such as during intubation, could impair cerebral blood flow and injure the brainstem or spinal cord.

4. What are the patient's medications and how should they be managed in the perioperative period?

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

  1. There are no specific diseases requiring specific medications in this otherwise healthy and active population.

  2. These active patients are not likely to be on medications and, if they are on medications, there is no typical disease associated with this surgery to predict commonly seen prescriptions. Generally, all medications should be continued unless their cessation would not compromise the patient and their cessation may aid with anesthetic care and/or surgical care.

A common disease, however, that may be encountered is rheumatoid arthritis, especially for proximal tendon ruptures. As such, long-term corticosteroid may be encountered. Consideration for giving the patient a stress dose of steroids should be made. One strategy is to have the patient continue their routine medication and to have a stress dose readily available to administer if signs of adrenal insufficiency appear (ie, intraoperative or postoperative hypotension).

i. What should be recommended with regard to continuation of medications taken chronically?

  1. Cardiac - Most cardiac medications may be continued. Of note, some may prefer to hold ACE Inhibitors and diuretics to minimize the hypotensive effects of anesthesia.

  2. Pulmonary - Medications to treat this family of diseases can and should be continued. With regard to steroids, although the surgery is quite minor, the patient may require a stress dose secondary to adrenal suppression.

  3. Renal - It is usually unnecessary to cease these medications. Some medications may be held to facilitate anesthesia management. For example, ACE Inhibitors may exacerbate hypotension promoted by anesthetics.

  4. Neurologic - Medications here may generally be continued. However, if patient is on an anti-platelet medication (eg, for a previous stroke), please see be below.

  5. Anti-platelet - Should be discontinued for appropriate time period depending on the medication. Cessation of this type of medication should have been cleared by the prescribing doctor to be certain patient is not assuming a high risk of morbidity/mortality especially in the case of intracoronary stents.

  6. Psychiatric - In order to decrease the chance of an exacerbation of the underlying disease, these drugs should be continued with consideration given to their anesthetic implications: no meperidine or ephedrine in the presence of an MAOI; no ketamine or epinephrine with TCA.

j. How To modify care for patients with known allergies -

Avoid drugs to which the patient is allergic.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

The OR team needs to be made aware of the condition, and all latex containing products avoided.

l. Does the patient have any antibiotic allergies?

The most common challenge is an allergy to the penicillin family, in which case vancomycin or clindamycin are acceptable alternatives.

m. Does the patient have a history of allergy to anesthesia?

  1. Malignant hyperthermia:

    1. Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

      1. Regional Anesthesia with sedation: All triggers are avoided.

      2. Proposed general anesthetic plan: Avoid triggers with use of TIVA. If muscle relaxation is required, regional anesthesia may be combined with a general anesthetic or a non-depolarizing neuromuscular blocker may be utilized.

      3. Insure MH cart available:

        1. MH protocol

    2. Family history or risk factors for MH: To minimize risk, the patient may be conservatively managed as if they have a history of MH. See i for Documented MH.

  2. Local anesthetics/ muscle relaxants:

    1. An allergy to local anesthetics is quite rare. If the patient does indeed have a local anesthetic allergy, it is more likely toward esters as opposed to amides. Esters are metabolized by pseudocholinesterase to para-aminobenzoic acid (PABA), which has been widely used in sunscreen and is a known allergen. There is no cross reactivity from esters to amides, so any patients allergic to an ester can readily tolerate an amide and vice versa. For patients who are allergic to all local anesthetics, regional anesthesia is contraindicated. General anesthesia becomes the only option.

    2. Allergy to muscle relaxants: Neuromuscular blocking drugs that cause an allergic reaction should be avoided. Alternatives to provide muscle relaxation include regional anesthesia as well as general anesthesia with increased levels of inhalational agents.

5. What laboratory tests should be obtained and has everything been reviewed?

There are no laboratory tests that are absolutely necessary. However, situations may arise for a consideration to obtain tests that help to assess the status of a disease process or therapy. For instance, if a patient has recently discontinued Coumadin, an INR may be obtained. The result may prompt the surgeon to delay/cancel the surgery.

  1. Hemoglobin levels: Unnecessary.

  2. Electrolytes: Unnecessary.

  3. Coagulation panel: Usually unnecessary but may be obtained if patient has recently discontinued coagulation medications, especially in the setting where a longer period of abstinence is the standard.

  4. Imaging: Unnecessary.

  5. Other tests: Unnecessary.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

a. Regional anesthesia - Interscalene, supraclavicular (with possible supplementation of C3-4 blockade for cape area), suprascapular nerve block, combination of axillary and suprascapular nerve blocks can be employed.

  1. Neuraxial --Inappropriate as spinal anesthesia at this level of the spinal cord is undesired.

  2. Peripheral Nerve Block: May be performed for both proximal and distal tendon rupture repairs. For proximal surgeries (ie, shoulder), various approaches may be used: interscalene, supraclavicular (with possible supplementation of C3-4 blockade for cape area), suprascapular nerve block, combination of axillary and suprascapular nerve blocks. Similarly, a variety of alternatives exists for management of distal surgeries; interscalene, supraclavicular, infraclavicular and axillary. Single shot nerve blocks or perineural catheters may be used for both proximal as well as distal surgeries. Regional anesthesia may be used as the primary anesthetic (preferably with sedation) or combined with general anesthesia.

    1. Benefits:

      1. § Avoid potential GA complications: such as trauma to lips, teeth, pharynx or vocal cords; bronchospasm; aspiration; prolonged somnolence; prolonged paralysis from atypical response to NMB; malignant hyperthermia

      2. § Superior analgesia, higher patient satisfaction

      3. § reduces opioid requirements and, thus, potential opioid complications (eg, nausea/vomiting, somnolence)

      4. § earlier mobilization and functional recovery

      5. § earlier hospital discharge (by decreasing incidence of nausea/vomiting, perioperative pain, and prolonged somnolence)

      6. § possible improvement of rehabilitation

      7. § No immunosuppression as that associated with opioids and GA

    2. Drawbacks: RA is more time consuming as time is required for the performance of the regional technique as well as for the onset of the local anesthetic. Surgical anesthesia may not be realized secondary to nerve sparing or inadequate time for procedure/onset of local anesthetic. Extra equipment is necessary which may serve as a deterrent from a standpoint of initial costs and space availability. Moreover, the intraoperative management of an awake or sedated patient may be more difficult than one that is under GA.

    3. Issues: Anticoagulation is not a contraindication for upper extremity nerve blocks, including the placement of perineural catheters. Since nerves may be damaged during surgery, a neuro exam may be indicated postoperatively; however, in the setting of a single injection nerve block, such an examination may not be possible until the elapse of many hours. Absolute contraindications to RA include patient refusal, infection at site for regional technique and allergy to local anesthetics.

b. General Anesthesia

  1. Benefits: A GA is easy to perform and requires less time to achieve good surgical conditions. It is also always successful in preparing patients for surgery. The airway is secured (especially beneficial in surgeries for proximal tendon repairs). Full muscle relaxation can be provided with the added benefit that patient will not move during surgery. A patient under GA is usually easier to manage than one that is awake or sedated. It is the only option in the setting of absolute contraindications to RA.

  2. Drawbacks: Possible trauma to airway (lips, teeth, pharynx or vocal cords). GA can potentiate bronchospasm, especially in those with pulmonary pathology such as asthma. Aspiration is more of a concern as the patient's airway reflexes are obtunded. Prolonged somnolence may result increasing the time to discharge from the OR or PACU. Pain control with narcotics is less optimal and may elicit undesirable side effects (ie, nausea/vomiting, sedation).

  3. Other issues: Anticoagulation is not a contraindication to GA. A postoperative neuro exam can be easily accomplished.

  4. Airway concerns: Usually not an issue beyond the norm is this more active population. However, in patients who are suspected of having rheumatoid arthritis that involves the temporomandibular joint, the larynx or the cervical vertebra, measures should be undertaken to minimize damage and to maximize the chance to secure the airway; for example, the use of a fiberoptic for intubation or the use of a smaller endotracheal tube.

c. Monitored Anesthesia Care

  1. Not a viable option for intraoperative care.

6. What is the author's preferred method of anesthesia technique and why?

My preferred method of anesthesia is a combination of RA and GA. In considering proximal biceps ruptures, I like to reap the benefits of RA such as superior analgesia, decreased nausea/vomiting, earlier discharge and better rehabilitation while minimizing the RA potential drawbacks with GA. With the addition of GA, concentrations of local anesthetics may be decreased to analgesic levels from those required for surgical anesthesia. Accordingly, decreased local anesthetic concentrations may decrease the potential for neurotoxicity, myotoxicity and systemic toxicity. As a corollary, the presence of RA may diminish medication levels otherwise required to achieve GA. A catheter also provides flexibility; the nerve block may be allowed to wear off should a neuro exam become desirable (assuming a shorter local anesthetic or saline was used initially). Since the patient will receive GA intraoperatively, onset time for a nerve block is no longer a concern.

Likewise in the rare instance of a patchy or failed block, if there is insufficient time for a rescue procedure prior to the commencement of surgery, the patient may still proceed without a delay with an understanding that a postoperative nerve block can be performed. Further, the management of an anesthetized patient may be easier than a sedated one in terms of preventing patient movement without simultaneously producing oversedation. Another consideration is that the surgical team is working quite close to the patient's head; a secured airway may be of greater comfort to the anesthesia team and a greater guarantee of being "out" may be of more comfort to the patient. Finally, an interscalene perineural catheter is preferred over a single shot block as evidence has shown superior benefits of a continuous technique; decrease in pain in rest and movement, decrease in opioid requirements and opioid-related side effects and sleep disturbance The interscalene catheter not only provides neural blockade to the shoulder and cape area but is also easily placed such that it does not interfere with the surgical field.

For a distal biceps rupture, RA alone is the preference. This would ensure the maximal benefits of RA while also avoiding the pitfalls of GA. With a motivated surgical team and patient, pure RA without sedation facilitates intraoperative management. However, sedation should be available to those who desire to be unaware during surgery. An interscalene catheter is preferred here as well. Since the nerve roots are relatively superficial, catheter placement is generally fast, easy and well tolerated.

Of note, a prior discussion with the surgeon is often beneficial. Various information may be gathered, such as the area required for the surgical field. This would be invaluable especially for proximal repairs so that steps can be made to ensure the catheter site is safe from surgical compromise (eg, more posterior approach or tunneling of interscalene catheter). Moreover, the extent of the surgical field may lead to a decision to perform an intercostobrachial (T2) nerve block.

Postoperatively, the patient may be discharged with the interscalene catheter (and a pump with local anesthetic) with a daily follow-up phone call until catheter removal in approximately 2-3 days. The catheter may be safely removed by the patient, a care-giver or by a member of the surgical team if an office visit is scheduled 2-3 days from surgery.

  1. What prophylactic antibiotics should be administered?

    • Per 2009 publication, Cefazolin is the first choice with Clindamycin or Vancomycin as valid alternatives in the presence of an anaphylactic reaction to penicillins or cephalosporins.

  2. What do I need to know about the surgical technique to optimize my anesthetic care?

    • Surgery may be performed by a laparoscopic or open technique, around the shoulder or elbow, or for an acute or chronic injury. Most repairs are performed laparoscopically for esthetic purposes, to minimize patient discomfort, and to minimize hospital stay (ie, outpatient surgery). An open technique is most often used for a chronic injury. In these cases, a greater amount of dissection and tissue manipulation will be necessary. Furthermore, in those cases where a graft is indicated, a hamstring autograft is a possibility.

  3. What can I do intraoperatively to assist the surgeon and optimize patient care?

    • For an arthroscopic repair, relative hypotension may be requested to decrease the amount of bleeding and to accordingly optimize visualization. Cerebral blood flow is likely maintained when mean arterial pressure exceeds 70mmHg in healthier patients undergoing shoulder surgery in the beach chair position after undergoing an interscalene block.

  4. What are the most common intraoperative complications and how can they be avoided/treated? Complications of this surgery are, with minimal blood loss and manageable post-operative pain.

  1. Cardiac complications- Severe and sudden hypotensive, bradycardic or a combination of hypotensive/bradycardic events can occur in awake patients in the sitting position undergoing shoulder arthroscopy with interscalene anesthesia. The incidence of such events may be decreased with a prophylactic dose of metoprolol given after the nerve block is performed. Metoprolol may be administered in 2.5mg increments until either a heart rate of less than 60 beats is achieved or 10mg have been injected.

  2. Pulmonary- Awake patients may experience a shortness of breath related to phrenic nerve paralysis ipsilateral to an interscalene block. Reassurance is usually adequate; conversion to GA is an option. For patients with a history of pulmonary disease (eg, asthma) laryngospasm may appear secondary to direct airway stimulation or the presence of a light plane of anesthesia. Prophylactic use of inhalational medications just prior to induction and inhalational agents for bronchodilation should be considered as well as keeping the patient deep throughout induction, surgery and extubation.

  3. Neurologic: Nerve damage during surgery is uncommon. For proximal tendon repairs, the suprascapular, axillary and musculocutaneous may be compromised due to their proximity to the surgical site. The most frequent complication of a distal biceps repair is a lateral antebrachial cutaneous nerve paresthesia, mostly the consequence of aggressive retraction. Most nerve complications are temporary in nature and resolve within 6 weeks. For those that acutely worsen or persist beyond the usual time period for resolution, a neurology consult with nerve testing is in order.

a. Neurologic

see above

b. If the patient is intubated, are there any special criteria for extubation?

No special criteria over and beyond the usual precautions.

c. Postoperative management

  1. What analgesic modalities can I implement?

    • Regional anesthesia and opioids are commonly provided to patients. With respect to NSAIDs, a discussion with the surgeon prior to implementing is prudent as some surgeons are concerned about a negative impact on bone healing and bleeding.

  2. What level bed acuity is appropriate? (Example: floor, telemetry, step-down, or ICU and justification):

    • Admission to the floor is quite appropriate for this healthy, active population. Higher acuity is guided by comorbidities and perioperative complications.

  3. What are common postoperative complications, and ways to prevent and treat them? (Example: postop delirium, postop DVT/PE, reoperation for bleeding, functional decline, increased mortality)

    • Nausea, drowsiness and pain are the most common. For nausea and vomiting, the avoidance of triggers (eg, GA and narcotics) with the provision of anti-emetics and good pain control helps to decrease the incidence. To decrease prolonged somnolence, a strategy to minimize anesthetics and other sedating medications (eg, narcotics) should be used. To decrease pain, a multimodal regimen can be provided. Regional anesthesia is beneficial in preventing these complications, which are the common barriers to timely discharge for ambulatory patients.

What's the Evidence?

Awad, IT, Chung, F. "Factors affecting recovery and discharge following ambulatory surgery". Can J Anesth. vol. 53. 2006. pp. 858-872.

Busconi, BB, DeAngelis, N, Guerrero, PE. "The Proximal Biceps Tendon: Tricks and Pearls". Sports Med Arthrosc Rev. vol. 16. 2008. pp. 187-194.

Candido, KD, Sukhani, R, Doty, R, Nader, A, Kendall, MC, Yaghmour, E, Kataria, TC. "Neurologic Sequelae After Interscalene Brachial Plexus Block for Shoulder/Upper Arm Surgery: The Association of Patient, Anesthetic, and Surgical Factors to the Incidence and Clinical Course". Anesth Analg. vol. 100. 2005. pp. 1489-95.

Chelly, JE, Ghisi, D, Fanelli, A. "Continuous peripheral nerve blocks in acute pain management". Br J Anaesth. vol. 105. 2010. pp. i86-i96.

Hadzic, A, Williams, BA, Karaca, PE, Hobeika, P, Unis, G, Demksian, J, Yufa, M, Thys, DM, Santos, AC. "For Outpatient Rotator Cuff surgery, nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia". Anesthesiology. vol. 102. 2005. pp. 1001-7.

Hines, RL, Marschall, KE. Stoelting's Anesthesia and Co-Existing Disease. Churchill Livingstone. 2008.

Klein, SM, Nielsen, KC, Greengrass, RA, Warner, DS, Martin, A, Steele, SM. "Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine". Anesth Analg. vol. 94. 2002. pp. 65-70.

Neal, JM, Hebl, JR, Gerancher, JC, Hogan, QH. "Upper Extremity Regional Anesthesia: Essentials of Our Current Understanding". Reg Anesth Pain Med.. vol. 3. 2009. pp. 134-170.

Soeding, PF, Wang, J, Hoy, G, Jarman, P, Phillips, H, Marks, P, Royse, C. "The effect of the sitting upright or 'beachchair' position on cerebral blood flow during anaesthesia for shoulder surgery". Anaesth Intensive Care. vol. 39. 2011. pp. 440-8.

Sutton, KM, Seth, DD, Ahmad, CS, Sethi, PM. "Surgical Treatment of Distal Biceps Rupture". J Am Acad Orthop Surg. vol. 18. 2010. pp. 139-148.

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