Background: Shoulder surgery often requires the patient to be in the sitting position (beach chair) and this can cause dramatic haemodynamic instability.[1][2] We present the case of a high-risk 80 year old male patient who underwent shoulder surgery carried out in the beach chair position. He was deemed to be high risk for a general anaesthetic so a regional technique with sedation was used. The surgical incision was up to seven centimetres from the acromion edge (figure1); therefore, to provide complete anaesthesia of the shoulder a low approach interscalene and superficial cervical plexus block was carried out.
Case report: An ultrasound guided interscalene with a superficial cervical plexus block was used with 1% prilocaine 10mls and 0.375% levobupivacaine 20mls administered. The block was checked by confirming numbness over the anterior and posterior aspects and inability to actively flex and abduct the shoulder. Intraoperatively the patient remained stable with no drop in blood pressure, and the surgery went successfully. At the end of surgery the patient woke up quickly despite a long operating time. Within fifteen minutes of arrival in recovery he was comfortable, oriented and pain free. And he was extremely satisfied with the outcome and completed a patient satisfaction survey which confirmed this (figure 2).
Discussion: Because the patient had a previous history of stroke and myocardial infarction, maintaining a mean arterial pressure of more than 80mmHg was our target, along with maintaining a heart rate of around 60-65bpm. Tachycardia is very deleterious in a failing heart and is the most detrimental factor in managing Bezold-Jarisch reflex.[3] Keeping the patient awake during surgery helped us to adequately assess cerebral perfusion considering his pervious history of stroke.
References: 
1. Beecroft CL, Coventry DM. Anaesthesia for shoulder surgery. Contin Edu Anaesth Crit Care Pain 2008;8(6):193-8.
2. Gardner BM. The beach chair position S Afr Fam Pract 2015;57(2)(Suppl 1):S6-S9. 
3. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal

Is awake the answer in high-risk patients needing shoulder surgery?