PBLD #1

A 74-year-old woman presents for left should arthroscopy. She suffers from chronic shoulder pain, obesity (body mass index [BMI] of 45), coronary artery disease (drug-eluting stent placed 18 months ago), and previous deep venous thrombosis (DVT). SHe is also using 2L of oxygen continuously because of chronic obstructive pulmonary disease (COPD). Medications include gabapentin 600 mg every eight 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 low risk from a cardiac standpoint and stated that no further cardiac testing is needed before surgery.

Questions:

• Would you prescribe oral meds prior to this procedure?

• Would you offer a regional anesthesia technique? Which block? Catheter?

• How does the presence of an elevated BMI and chronic pain influence your decision?

• PT described terrible fear of post op pain as he has had with prior surgeries. The surgeon has requested a catheter technique. Would this impact your Willingness to perform this technique and if so, how?

• PT has chest heaviness while transferring to the OR table. What is your DD?

• Anything you could have changed to reduce the probability of this complication?

• Would you proceed with GA?

• PT has decreased sats into the mid 80’s in the RR on RA. Would you be comfortable dc’ing the PT home?

• Would you be comfortable initiating an infusion of LA thru the Cath?

• Do you have any concerns dc’ing the PT home with the Cath with sleep apnea potential and blood thinners?