Problem-Based Learning Discussion: Postoperative Pain Management in Patients Undergoing Shoulder Arthroscopy


The November 2017 issue of ASRA News will feature a case discussion regarding options for postoperative analgesia in a patient undergoing should arthroscopy for rotator cuff repair. The article will include a summary of the case and some expert opinions.

We also want to know what you would do in this scenario. We will feature anecdotal feedback and discussion from Twitter in the article as well.

Click here to contribute to the poll and discussion.

And, be sure to retweet to get more people involved. We learn best when we all contribute!

The stem case was provided by Dr Melanie Donnelly who also solicited responses from our contributors. Dr Amit Pawa is running the Twitter poll.

Case Discussion

A 74-year-old woman presents for left shoulder arthroscopy. She suffers from chronic shoulder pain, obesity (BMI 45), coronary artery disease (drug-eluting stent placed 18 months ago), and previous deep venous thrombosis.  She is also using 2L oxygen continuously due to chronic obstructive pulmonary disease. Medications include gabapentin 600 mg every 8 hours, oxycodone 20 mg every four hours as needed, metoprolol, simvastatin, aspirin, and clopidogrel, which has been held for four days.  Her cardiologist deemed her to be at a low risk from a cardiac standpoint and stated that no further cardiac testing is needed before surgery.

The patient discusses with your her fear that her pain has been incredibly poorly controlled with previous surgical interventions and that this frightens her more than other potential complications.  The surgeon approaches you and would very much prefer a catheter technique.  

Following placement insertion of an interscalene catheter, negative test dose, and catheter dosing with 10 ml 0.5% bupivacaine, the patient is brought to the operating theater.  The patient assumes a fully supine position while transferring to the operating room table and describes significant chest heaviness.  

An electrocardiogram and chest x-ray fail to demonstrate any significant abnormalities other than an elevated left hemi-diaphragm. The patient is more comfortable with the head of the bed elevated and with the provision of supplemental oxygen.

The surgical procedure is uncomplicated, and no additional intraoperative opioids are required. At the conclusion of the case, the patient is extubated and transferred to the PACU where her oxygen saturation is noted to be 88% on 2L nasal cannula. The patient is asymptomatic, but her oxygen saturation fails to improve over the course of three hours.

The procedure was planned to be performed on an ambulatory basis.  With the removal of supplemental oxygen, the patient's oxygen saturation falls to 86%.  

The remainder of the case scenario will be published in full at the November 2017 issue of the ASRA News.

Dr. Amit Pawa, BSc(Hons) MBBS(Hons) FRCA EDRA, is a consultant anaesthetist, Specialty & Educational Lead for Regional Anaesthesia, at Guy's & St Thomas' NHS Foundation Trust, Department of Anaesthesia, St Thomas' Hospital, in London. He is also an Academic Lead for the London Society of Regional Anaesthesia (LSORA) and president-elect of Regional Anaesthesia - UK (RA-UK). @amit_pawa

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