Interscalene block without decadron

Sounds like you used ropiv.

excalibur said:

My patient for rotator cuff repair reported an allergy to decadron and steroids. I informed her that I would do the block without any steroid but be prepared that it would likely resolve in the middle of the night. I told her to just take oral pain meds as prescribed while numb, which she did.

USG block at 9 am.

I call her next day.

She says the block wore off at midnight. From 1-10 she stated the pain was "Oh my God!"

Geez. 15 hrs.

Decadron additive is averaging me 28 hrs for ISB. No comparison.

Maybe I should have tried clonidine or something.

Click to expand...

Ropivacaine 0.5% will last 12-16 hours on average (single shot)
Bupivacaine 0.5% will last 15-20 hours on average ( I have gotten over 24 hours though).

On a younger patient who needs a 24 hour block I would agree with adding the clonidine to the mixture with perhaps some fentanyl. I would also consider doing an ISB with Exparel in this situation as the expected block duration should be 48 hours with 133 mg.

The Regional Team at the VA in Pittsburgh has used Clonidine and Buprenorphine in their cocktail. So, you could have tried Bupivacaine 0.5% 20 mls mixed with 100 mics of Clonidine and 30 mics of Buprenorphine.

Please take a look at this article: http://jvsmedicscorner.com/Anaesth-...as an Adjuvant to Local Anesthetic review.pdf

So, next time add the clonidine if the patient is healthy; I would also add some Fentanyl or Sufenta as well.

Since I'm conservative when adding adjuvants to local anesthetics I would go with Clonidine 100 ug and Fentanyl 25 ug combined with 20 mls of 0.5% Bup.

http://www.ejgm.org/upload/sayi/18/EJGM-555.pdf

I would like to add that if you want 35-40 hour blocks from a single shot technique the guys at Pittsburg have quite a nice cocktail:

1. Decadron PF 1-2 mg
2. Clonidine 100 ug
3. Buprenoprhine 300 ug

My patients are very satisfied with just the Decadron adjuvant (Diabetics get 2 mg while non diabetics get 4 mg) so I skip items 2 and 3. Average block duration with just the decadron (as you know) is greater than 24 hours when Bup 0.5% is used as the local anesthetic.

excalibur said:

My patient for rotator cuff repair reported an allergy to decadron and steroids. I informed her that I would do the block without any steroid but be prepared that it would likely resolve in the middle of the night. I told her to just take oral pain meds as prescribed while numb, which she did.

USG block at 9 am.

I call her next day.

She says the block wore off at midnight. From 1-10 she stated the pain was "Oh my God!"

Geez. 15 hrs.

Decadron additive is averaging me 28 hrs for ISB. No comparison.

Maybe I should have tried clonidine or something.

Click to expand...

I routinely get 22-24 hrs out of a mepivicaine 60%, ropiviciane 40%, and 300mcg buprenorphine.

By the way, decadron systemic probably works just as well as mixing it with the block.

I wonder if precedex in the block would be better than clonidine.

epidural man said:

I routinely get 22-24 hrs out of a mepivicaine 60%, ropiviciane 40%, and 300mcg buprenorphine.

By the way, decadron systemic probably works just as well as mixing it with the block.

I wonder if precedex in the block would be better than clonidine.

Click to expand...

I routinely get 22 hours out of 0.5% Rop and 4 mg of decadron. No need to add the other stuff.

Have you seen the cost of Precedex? I bet after that eye-opening fact you will stick with the clonidine.

I totally disagree that adding IV Decadron right before the block does anything in terms of duration. I've been giving decadron IV before my blocks for over a decade with NO CHANGE in block duration. One must mix the decadron with the local to get any prolongation of the block.

I'm aware of that B.S. study recently showing IV decadron prolongs the nerve block. I'm also aware of another study showing that adding decadron to the local does NOT prolong the bock. Both are wrong. My "N" is now well over 1,000 blocks with Decadron (Mixed with local) and another 5,000 blocks where decadron IV is given before the block (with no prolongation of block).

There is a lot of garbage out there in academics and on SDN. You need to sift through the trash and find the treasure. I'll bet you money that once you switch to Rop or Bup plus decadron the results will impress you. In addition, the cost is extremely low in terms of local (30 mls of 0.5% bup is under $2.00)
and the adjuvant (PF decadron is under $2.50 a single dose vial).

I will get the exact cost of the clonidine and the Buprenorphine. Stay tuned.

+1 to dexamethasone IV doing nothing for a block.
+1 to dexamethasone absolutely making a block last longer and more dense

The new article in RAPM by Fredriksen seems to say that dexamethasone works but it doesn't make a difference at 48h, and because of that, he says its not useful. I think we can all say BS to that.

When I tried clonidine I got inconsitent results that were no better than my partners who used 20cc 2%lido and 20cc 0.5%bupiv NS. Maybe it was cuz I wasn't as good with the ultrasound then.

Haven't tried buprenorphine.

I thought fentanyl was pretty much found to be useless for PNB.

epidural man said:

By the way, decadron systemic probably works just as well as mixing it with the block.

Click to expand...

I don't believe that at all.

I give IV dexamethasone to nearly all of my patients for its antiemetic effect, and have since I was a resident. It does have some analgesic enhancing effects, but my block durations greatly increased after I started adding it to my LA.

pgg said:

I don't believe that at all.

I give IV dexamethasone to nearly all of my patients for its antiemetic effect, and have since I was a resident. It does have some analgesic enhancing effects, but my block durations greatly increased after I started adding it to my LA.

Click to expand...

+1

The theory is a controlled release mechanism. Decadron absorbs some of the local and then slowly releases it back. Sounds like that other drug... what's the name??? Exparel.

pgg said:

I don't believe that at all.

I give IV dexamethasone to nearly all of my patients for its antiemetic effect, and have since I was a resident. It does have some analgesic enhancing effects, but my block durations greatly increased after I started adding it to my LA.

Click to expand...

You are right, there is also data to show that IV decadron perioperatively helps with post op pain.


Anyway, maybe it is true that IV decadron doesn't work.

The problem with adjunct studies, in maybe 2 out of the 3 billion studies, the investigators have used a systemic control.

When that was done, buprenorphine clearly worked adding to the block - better than the systemic control.

When the only study we have available to us with decadron that used a systemic control, it didn't show a difference over the systemic control (but did over placebo) or no additive.

I think anecdotal evidence is great. I use it all the time.

But....

If you all are such strong believers, prove it. Make it a multi-center trial. It helps us all when people prove stuff like that.

Anecdotal experience is probably less useful - but certainly has a place....not saying that.

Obviously steroid on a nerve does something. We have been doing steroid on peripheral nerves in the pain clinic for years - but that is usually with particulate steroid.

I've got an N of 1,000 as proof. I've performed these decadron with Bup blocks of nurses, administrators, friends, family, etc. I've never had one Bup with decadron last less than 24 hours. Not one. Most get 26-28 hours with some close to 30 hours. My N is greater than any published study and I would bet anyone of you to do claim differently.

I'm not arguing that decadron at doses of 0.1 mg/kg or more does not decrease pain scores. It probably does. But, the block itself isn't prolonged by utilizing IV decadron.

Cost of Clonidine about $14 for a single dose vial of 1,000 micrograms.

Cost Of Buprenorphine is about $3.50 for a single dose vial. (300 ug/ml and the vial is 1 ml)

So, I guess the Pittsburgh cocktail of Bup, Clonidine, Buprenorphine and decadron will run about
$22 per patient.

The cocktail is reported to last 35- 40 hours. Exparel is 48-72 hours with a cost of $280

Reg Anesth Pain Med. 2002 Mar-Apr;27(2):162-7.
Buprenorphine added to the local anesthetic for axillary brachial plexus block prolongs postoperative analgesia.
Candido KD, Winnie AP, Ghaleb AH, Fattouh MW, Franco CD.
Source
Department of Anesthesiology and Pain Management, Cook County Hospital, Chicago, IL 60611, USA. [email protected]
Abstract
BACKGROUND AND OBJECTIVES:
Buprenorphine added to local anesthetic solutions for supraclavicular block was found to triple postoperative analgesia duration in a previous study when compared with local anesthetic block alone. That study, however, did not control for potentially confounding factors, such as the possibility that buprenorphine was affecting analgesia through intramuscular absorption or via a spinal mechanism. To specifically delineate the role of buprenorphine in peripherally mediated opioid analgesia, the present study controlled for these 2 factors.
METHODS:
Sixty American Society of Anesthesiologists (ASA) P.S. I and II, consenting adults for upper extremity surgery, were prospectively assigned randomly in double-blind fashion to 1 of 3 groups. Group I received local anesthetic (1% mepivacaine, 0.2% tetracaine, epinephrine 1:200,000), 40 mL, plus buprenorphine, 0.3 mg, for axillary block, and intramuscular (IM) saline. Group II received local anesthetic-only axillary block, and IM buprenorphine 0.3 mg. Group III received local anesthetic-only axillary block and IM saline. Postoperative pain onset and intensity were compared, as was analgesic medication use.
RESULTS:
The mean duration of postoperative analgesia was 22.3 hours in Group I; 12.5 hours in group II, and 6.6 hours in group III. Differences between groups I and II were statistically significant (P =.0012). Differences both between groups I and III and II and III were also statistically significant (P <.001).
CONCLUSIONS:
Buprenorphine-local anesthetic axillary perivascular brachial plexus block provided postoperative analgesia lasting 3 times longer than local anesthetic block alone and twice as long as buprenorphine given by IM injection plus local anesthetic-only block. This supports the concept of peripherally mediated opioid analgesia by buprenorphine.

Buprenorphine hydrochloride injection is a parenteral opioid analgesic with 0.3 mg buprenorphine being approximately equivalent to 10 mg morphine sulfate in analgesic and respiratory depressant effects in adults. Pharmacological effects occur as soon as 15 minutes after intramuscular injection and persist for 6 hours or longer. Peak pharmacologic effects usually are observed at 1 hour. When used intravenously, the times to onset and peak effect are shortened.

The limits of sensitivity of available analytical methodology precluded demonstration of bioequivalence between intramuscular and intravenous routes of administration. In postoperative adults, pharmacokinetic studies have shown elimination half-lives ranging from 1.2 to 7.2 hours (mean 2.2 hours) after intravenous administration of 0.3 mg of buprenorphine. A single, ten-patient, pharmacokinetic study of doses of 3 mcg/kg in children (age 5 to 7 years) showed a high inter-patient variability, but suggests that the clearance of the drug may be higher in children than in adults. This is supported by at least one repeat-dose study in postoperative pain that showed an optimal inter-dose interval of 4 to 5 hours in pediatric patients as opposed to the recommended 6 to 8 hours in adults.

Display Settings:AbstractSend to:
Anesthesiology. 2010 Dec;113(6):1419-26. doi: 10.1097/ALN.0b013e3181f90ce8.
Buprenorphine enhances and prolongs the postoperative analgesic effect of bupivacaine in patients receiving infragluteal sciatic nerve block.
Candido KD, Hennes J, Gonzalez S, Mikat-Stevens M, Pinzur M, Vasic V, Knezevic NN.
Source
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois 60657, USA. [email protected]
Abstract
BACKGROUND:
Results from previous studies have shown favorable effects from the addition of buprenorphine to local anesthetics used for interscalene or axillary perivascular brachial plexus blocks. The main objective of the current study was to determine whether addition of buprenorphine could enhance bupivacaine analgesia after infragluteal sciatic nerve block.
METHODS:
One hundred and three consenting adult patients for elective foot and ankle outpatient surgeries were prospectively assigned randomly, in double-blind fashion, to one of three groups. Group 1 received 0.5% bupivacaine with epinephrine 1:200,000 for infragluteal sciatic block plus 1 ml normal saline intramuscularly. Group 2 received bupivacaine sciatic block along with intramuscular buprenorphine (0.3 mg). Group 3 received bupivacaine plus buprenorphine for infragluteal sciatic block and 1 ml normal saline intramuscularly.
RESULTS:
Although patients receiving buprenorphine either for sciatic block or intramuscularly had less pain in the postanesthesia care unit compared with patients receiving only bupivacaine, the individual pair-wise comparison of the analysis of variance model showed no statistical difference. However, only buprenorphine added to bupivacaine for sciatic block prolonged postoperative analgesia. Patients receiving a combination of buprenorphine and bupivacaine for sciatic block had lower numeric rating pain scores and received less opioid medication at home than patients in the other two groups.
CONCLUSIONS:
The results show that buprenorphine may enhance and prolong the analgesic effect of bupivacaine when used for sciatic nerve blocks in patients undergoing foot and ankle surgery under general anesthesia but does not do so to the extent shown in previous studies using brachial plexus models with mepivacaine and tetracaine.
PMID: 21042200

excalibur said:

My patient for rotator cuff repair reported an allergy to decadron and steroids. I informed her that I would do the block without any steroid but be prepared that it would likely resolve in the middle of the night. I told her to just take oral pain meds as prescribed while numb, which she did.

USG block at 9 am.

I call her next day.

She says the block wore off at midnight. From 1-10 she stated the pain was "Oh my God!"

Geez. 15 hrs.

Decadron additive is averaging me 28 hrs for ISB. No comparison.

Maybe I should have tried clonidine or something.

Click to expand...

Next time go with 0.5 percent Bup 20 mls with 300 ug of Buprenorphine. If healthy consider adding 50 mics of clonidine as well ( I'm hesitant to add clonidine for outpatients due to the risk of hypotension and bradycardia).

I appreciate this thread as I have an answer the next time my patient is allergic to steroids

BLADEMDA said:

I've got an N of 1,000 as proof. I've performed these decadron with Bup blocks of nurses, administrators, friends, family, etc. I've never had one Bup with decadron last less than 24 hours. Not one. Most get 26-28 hours with some close to 30 hours.

Click to expand...

I'm not getting consistently more than 24h i would say for me it's more like 20-25h when i use 20ml 0.5% bupi +5mg decadron...

Note that clonidine prolongs motor block but not sensitive block and buprnorphine does enhace block duration at the cost of more PONV

Lot's of patients don't like the motor block lasting more than 24-28hrs. They get concerned. I let them know how and what to expect and then ask them how long they wish to have it for. I tailor the block length to their desires that way everybody is on board. It's not a perfect science, but I can dial it in pretty close.

25cc's of .5% Bupi with 1:400 epi and 5mg of decadron placed on the medial and lateral sids of the plexus sheath (12.5 cc's on ea side) goes a long way for those who want a 30 hour block.

Did one for a friend 2 days ago with the above cocktail. Placed @ 12:05 pm in pre-op. Resolved @9pm last night.

I will b adding Buprenorphine to my blocks because the MOTOR block is not prolonged like it is with Decadron and Clonidine. Hence, you pick up additional postop analgesia without the motor block. I think you will likely get a 26-28 hour motor block (and sensory) with the Bup 0.5% and decadron plus an additional 6-8 hours of analgesia with the Buprenorphine (no enhancement of the motor block) for a Total of 32-34 hours So, I will not be adding the Clonidine to my mixture.

I also plan on adding the Buprenorphine and Decadron to my Exparel; this should extend the postop analgesia for my TAP blocks into the 48 hour range.

I appreciate the discussion.

excalibur said:

Hmmmm....

The Pittsburgh cocktail has interested me.

When I tell my shoulder patients about block lasting 24-30 hrs with most being 27 or 28 hrs, thy get excited. Some jokingly ask if they can come back the next day for another injection. Perhaps if I could consistently get over 30 hrs and maybe get into the 36 hr range, this would be optimal, particularly if the motor block doesn't last that long. Right now with my 28 hr blocks, I find that the patients have a motor block pretty much the whole time. They tell me motor function begins to return 2 hrs before the pain sets in and the block wears off.

Ok. Blade, that Pitt data...was that all on one particular nerve block? I am thinking of making some changes to my ISB. It is what I do most a my small county hospital, and it is what I reliably see at 28 hrs pretty much all the time. (My sciatics have had some tendency to go extra long like 36-40 hrs already just with decadron). Blade, I looked online, but I am not sure if I see the Pitt data that u have referenced before on SDN. Can you repost please? On a previous thread your link required some subscription password also.

I am wondering about adding maybe buprenorphine to decadron for additional analgesia. By not adding clonidine I could avoid that hypotension. Must continue this discussion.

Click to expand...

http://journals.lww.com/rapm/Citati...etics_in_Diabetic_Rats__and_Patients__.4.aspx

The Cocktail is found in this article/commentary.

Please review a previous thread on this subject:

http://forums.studentdoctor.net/showthread.php?t=973311&highlight=buprenorphine

Buprenorphine is definitely sounding interesting. It must be a controlled substance though. If it really doesn't prolong motor block the. I have to get it. Bilateral wrist fractures with bilateral infraclavicular blocks with 0.2% ropiv plus buprenorphine!!

excalibur said:

That was my plan too Blade. Unfortunately, my pharmacy doesn't carry buprenorphine. Let me know how it goes, and I might request te med

Click to expand...

Simply ask to get Buprenorphine at $3.50 a vial. Take a look at the following and show it to your Pharmacy Director:

1. Bupivacaine 0.5% 30 ml ($2.00) plus Decadron PF ($2.50) plus Buprenorphine ($3.50)
Total: $8.00

2. Ropivacaine 0.5% 30 ml= $15.00


Why wouldn't your Pharmacy go along with getting you Buprenorphine? It is a controlled substance with huge abuse potential (FYI).

excalibur said:

That was my plan too Blade. Unfortunately, my pharmacy doesn't carry buprenorphine. Let me know how it goes, and I might request te med

Click to expand...

If I didn't have Buprenorphine to add to my Local and the patient was allergic to Steroids then I would go with Clonidine (up to 100 mics) or Exparel for a single shot block.

You guys need to press Pharmacy hard to get the right drugs available at your institution.
There simply is no reason not to carry Buprenorphine at $3.50 a vial or even Exparel for that matter.

Anesth Analg. 2001 Jan;92(1):199-204.
Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes.
Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z.
Source
Division of Anesthesiology, Geneva University Hospitals, Geneva 14, Switzerland. [email protected]
Abstract
Clonidine in brachial plexus block prolongs analgesia of local anesthetics of short and intermediate duration. We performed a prospective randomized double-blinded study to determine the efficacy and adverse effects of clonidine mixed with a long-acting local anesthetic on postoperative analgesia. Sixty adult patients underwent elective rotator cuff repair using interscalene brachial plexus block combined with general anesthesia and were randomly divided into one of the following three groups. Placebo (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine (1/200000) and 1 mL of 0.9% saline, completed by 1 mL of 0.9% saline IM in the controlateral shoulder; Control (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 1 mL of 0. 9% saline, completed by 150 microg (=1 mL) of clonidine IM; Clonidine (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 150 microg (=1 mL) of clonidine, completed by 1 mL of 0.9% saline IM. During anesthesia hemodynamic variables and fractional expired isoflurane concentration (FeISO) were recorded. The following postoperative variables were assessed: duration of interscalene block, quality of pain relief on a visual analog scale, side effects, and consumption of morphine with a patient-controlled analgesia device over 48 h. Patient characteristics were comparable. During anesthesia mean arterial pressure, heart rate, and FeISO were significantly decreased in Clonidine and Control groups compared with Placebo group. Duration of analgesia, defined as the time elapsed from interscalene injection to the first morphine request, was 983 +/- 489 min in the Placebo, 909 +/- 160 min in the Control, and 829 +/- 159 min in the Clonidine groups. Pain scores and consumption of morphine at 24 h and 48 h showed no differences among the three groups. We conclude that adding 150 microg of clonidine in interscalene block does not prolong analgesia induced by 40 mL of bupivacaine 0.5% with epinephrine, but decreases mean arterial blood pressure and heart rate. Implications: Clonidine in brachial plexus block does not improve postoperative analgesia when mixed with a long-lasting anesthetic. Nevertheless, with or without clonidine, bupivacaine in interscalene block provides a long-lasting analgesia of approximately 15 h.

V. Discussion:
We observed that clonidine 150 &#956;g added to a 0.25% bupivacaine in brachial block as an adjuvant leads to no significant prolongation of duration of analgesia .It however does decrease analgesic consumption, prolonged the time for first rescue analgesic and lower VAS scores indicating that clonidine modified pain mechanics to some extent. No significant side effects were observed.
On the other hand addition of Buprenorphine(0.3mg) to bupivacaine(0.25% buprenorphine,40ml) in brachial plexus block produced effective analgesia which lasted longer than the two other groups (more than twice as long as that produced by local anesthetic alone) with no difference in sensory or motor onset time ,reduced pain scores (VAS) and less supplemental analgesics. Some usual side effects of opioids are observed, but are mild.
5.1 Duration of analgesia In studies with clonidine, difference in opinion exists with regard to prolongation of postoperative analgesia when clonidine was added to local anesthetic for brachial plexus block [5-8, 10-11]. Some trials have showed benefit from the use of clonidine[10,15,16] with [6] or without [5,7,8] control group. Also includes brachial plexus block studies with 0.25%bupivacaine [10, 17] and 0.5%bupivacaine [18, 19]. Others observed [19-21] no significant difference in duration with the use of clonidine both in studies with [22] or without [10, 11] control group. Our results correlate with later studies.

http://www.iosrjournals.org/iosr-jdms/papers/Vol4-issue3/G0433039.pdf

Buprenorphine Added to the Local Anesthetic for Brachial Plexus Block to Provide Postoperative Analgesia in Outpatients
Kenneth D. Candido, M.D., Carlo D. Franco, M.D., Mohammad A. Khan, M.D., Alon P. Winnie, M.D., and Durre S. Raja, M.D.
Background and Objectives: Over the past 10 years, several studies have suggested that the addition of certain opiates to the local anesthetic used for brachial block may provide effective, long-lasting postoperative analgesia. One of these studies indicated that the agonist-antagonist, buprenorphine, added to bupivacaine provided a longer period of postoperative analgesia than the traditional opiates, but in this study, it is impossible to determine the relative contributions of the local anesthetic and the opiate to the postoperative analgesia because of the extremely long duration of the anesthesia provided by the local anesthetic, bupivacaine. By repeating the study using a local anesthetic of a shorter duration, the present study delineates more clearly the contribution of the buprenorphine to postoperative analgesia when added to a shorter-acting local anesthetic.
Methods: Forty, healthy, consenting adult patients scheduled for upper extremity surgery were enrolled in the study. Premedication was provided by intravenous midazolam 2 mg/70 kg and anesthesia by a subclavian perivascular brachial plexus block. The patients were assigned randomly to 1 of 2 equal groups based on the agents used for the blocks. The patients in group I received 40 mL of a local anesthetic alone, while those in group II received the same local anesthetic plus buprenorphine 0.3 mg. The study was kept double-blind by having 1 anesthesiologist prepare the solutions, a second anesthesiologist perform the blocks, and a third anesthesiologist monitor the anesthesia and analgesia thereafter, up to and including the time of the first request for an analgesic medication. The data were reported as means (&#56319;&#56320; SEM), and differences between groups were determined using repeated measures of analysis of variance (ANOVA) and &#56319;&#56322;2, followed by the Fisher exact test for post hoc comparison. A P value of less than .05 was considered to be statistically significant.
Results: The mean duration of postoperative pain relief following the injection of the local anesthetic alone was 5.3 (&#56319;&#56320; 0.15) hours as compared with 17.4 (&#56319;&#56320; 1.26) hours when buprenorphine was added, a difference that was statistically (and clinically) significant (P &#56319;&#56321; .0001).
Conclusions: The addition of buprenorphine to the local anesthetic used for brachial plexus block in the present study provided a 3-fold increase in the duration of postoperative analgesia, with complete analgesia persisting 30 hours beyond the duration provided by the local anesthetic alone in 75% of the patients. This practice can be of particular benefit to patients undergoing ambulatory upper extremity surgery by providing prolonged analgesia after discharge from the hospital. Reg Anesth Pain Med 2001;26:352-356.
Key Words: Brachial plexus block, Buprenorphine, Postoperative analgesia.

I posted the link to the Regional and Pain medicine journal. November/December 2012. The on,y way to get that artice in full is via e mail from a subscriber or log in.

I plan on doing Tap blocks with local plus decadron plus Buprenorphine. On the rare occasion I want a 35 hour ISB or popliteal nerve block I will use both adjuvants as well.

I don't see a need for clonidine at this point. So, I'm not going to add it.

For my open belly cases, major exploratory laps, etc, I plan on utilizing Exparel with decadron plus Buprenorphine via bilateral Subcostal tap blocks. This should provide solid, long lasting analgesia.

For the less invasive laparoscopic procedures perhaps Bupivacaine/Ropivacaine with decadron and Buprenorphine will be sufficient.

I noticed an increased incidence in nausea when I addedbuprenorphine to brachial plexus blocks and find dexameth + bupivacaine works well enough

excalibur said:

Thanks for that input.

Was your buprenorphine added to just local or local with decadron? How much buprenorphine were you adding? How long were your blocks lasting with buprenorphine?

If we want to explore more, one could wonder, well maybe a lower dose of buprenorphine (150 mcg?) could prolong analgesia and avoid the nausea. Just thinking out loud

Click to expand...

That's my plan for outpatients. 150 ug of Buprenorphine which will reduce or even eliminate the nausea issue.

For the Open Belly Cases Im planning on using 150 ug per side for a total of 300 ug. I will question the patients thoroughly about any history of nausea with P.O. narcotics prior to exceeding the 150 ug dosage. I suspect quite a few women will get low dose Buprenorphine or no Buprenorphine at all.

I did an interscalene under us at the ASC last month with 30ml of 0.25% bupi, 300 Mcg buprenex, and 5mg dexamethasone preservative free. 36 hour motor and 60 hour analgesic block. Pt received a general and got 250 Mcg fentanyl and 1.5mg dilaudid intraop. Block was performed post op. Had significant respiratory depression due to synergism between the dilaudid and buprenex I assume. Long day at the ASC or we would have had to admit him. Have continued with buprenex but usually just 100-150mcg as surgeon won't less us preop block and CRNAs have a hard time not giving a lot of narcs. Still with 5mg dexamethasone. Solid consistent 30 hour interscalene blocks with that cocktail.

BobBarker said:

I did an interscalene under us at the ASC last month with 30ml of 0.25% bupi, 300 Mcg buprenex, and 5mg dexamethasone preservative free. 36 hour motor and 60 hour analgesic block. Pt received a general and got 250 Mcg fentanyl and 1.5mg dilaudid intraop. Block was performed post op. Had significant respiratory depression due to synergism between the dilaudid and buprenex I assume. Long day at the ASC or we would have had to admit him. Have continued with buprenex but usually just 100-150mcg as surgeon won't less us preop block and CRNAs have a hard time not giving a lot of narcs. Still with 5mg dexamethasone. Solid consistent 30 hour interscalene blocks with that cocktail.

Click to expand...

My plan is 20 mls of 0.5% Bup with Decadron 4-6 mg plus Buprenorphine 150 ugs. I recommend NO LONG ACTING NARCOTICS until you assess the patient in pacu. This means Fentanyl only in the operating room. The Buprenorphine is one bad-arse narcotic (look it up).

I suspect this cocktail will provide 30-35 hours of reliable postop pain relief with minimal N/V.

excalibur said:

Great plan, Blade. This is what I was thinking as well. I use 30 mL just cuz that is whole vial, but I am willing to reduce. If I had to do one tomorrow with Buprenorpine, I would go preop USG ISB with 30 mL Bupi 0.5% + 4 mg decadron + 150 mcg Buprenorphine and see what happens.

My patients get ISB immediately preinduction in the OR, and we have no trouble with CRNA or PACU nurses giving narcs once they have had a block.

Click to expand...

No need for 30 mls. I'm getting 26-28 hours with 20 mls. I am seeing a slight reduction in block duration with 15 mls and even a bigger reduction in duration with 10 mls. 20 seems to be the sweet spot with 0.5% Bup under u/s guidance where the provider is skilled. Of course, if you aren't going to inject around the C5-C7 plexus in close proximity to the nerve roots then stick with 30 mls.

You're right and it is a time issue for the most part. Some residents and attendings ARE slow and clumsy with US. But the bigger issue at the ASC where there are only upper level residents is the surgeon just being difficult. Stroll in at 7:09 for a 7AM start, talk to patient, mark. "No preop block, why are we so late to the OR??" He would probably say he wants to do a neuro exam in PACU also but the reality is this never happens.

It was before the dexameth was suggested. I used bup 0.5% 30ml + buprenorph 0.3mg, most patients did well with prolonged analgesia but a few had significant nausea in step down requiring multiple mess and never really completely resolved before they went home. Annoying enough that I stopped using it. It seemed to be the only convenient medicine that significantly prolonged pnb analgesia. Now I. Am a dexameth fan. Haven't got exparel on the formulary yet.

stonemd said:

It was before the dexameth was suggested. I used bup 0.5% 30ml + buprenorph 0.3mg, most patients did well with prolonged analgesia but a few had significant nausea in step down requiring multiple mess and never really completely resolved before they went home. Annoying enough that I stopped using it. It seemed to be the only convenient medicine that significantly prolonged pnb analgesia. Now I. Am a dexameth fan. Haven't got exparel on the formulary yet.

Click to expand...

Candido has published several articles about adjunctive buprenex and the PONV rate was always significant in the buprenex arm of the study. But most of these patient's had a surgical block and did not receive preemptive antiemetics. Thanks for a little more info on the associated PONV as I assume your patients also got a GA and routine PONV prophylaxis.

It is also important to note that none of the
patients in either group reported opioid-related side
effects, such as nausea, vomiting, pruritus, or
showed any evidence of respiratory depression.

Candido 2001 Study in Regional Anesthesia and Pain



The
incidence of nausea, vomiting, and headache was
comparable in the 3 groups and is represented in
Table 5.

Candido 2002 Study in Regional Anesthesia and Pain. (one group was a control with ZERO Buprenorphine added and had the same incidence of N/V).

BobBarker said:

Candido has published several articles about adjunctive buprenex and the PONV rate was always significant in the buprenex arm of the study. But most of these patient's had a surgical block and did not receive preemptive antiemetics. Thanks for a little more info on the associated PONV as I assume your patients also got a GA and routine PONV prophylaxis.

Click to expand...

Sorry Slim. I looked up the Candido studies and the Buprenorphine did NOT increase the nausea and Vomiting. Candido used the 300 ug dose.

That said, just to be on the safe side I'll be using 150 ug of Buprenorphine for the outpatients.

Candido's work did show that IM Buprenorphine increased the risk of Vomiting in one study but it did not reach statistical significance. My hunch is that it most likely does cause more N/V IM and I'd be cautious with the full 300 ug dose mixed with the local for outpatients ( particularly women).

BLADEMDA said:

V. Discussion:
We observed that clonidine 150 &#956;g added to a 0.25% bupivacaine in brachial block as an adjuvant leads to no significant prolongation of duration of analgesia .It however does decrease analgesic consumption, prolonged the time for first rescue analgesic and lower VAS scores indicating that clonidine modified pain mechanics to some extent. No significant side effects were observed.
On the other hand addition of Buprenorphine(0.3mg) to bupivacaine(0.25% buprenorphine,40ml) in brachial plexus block produced effective analgesia which lasted longer than the two other groups (more than twice as long as that produced by local anesthetic alone) with no difference in sensory or motor onset time ,reduced pain scores (VAS) and less supplemental analgesics. Some usual side effects of opioids are observed, but are mild.
5.1 Duration of analgesia In studies with clonidine, difference in opinion exists with regard to prolongation of postoperative analgesia when clonidine was added to local anesthetic for brachial plexus block [5-8, 10-11]. Some trials have showed benefit from the use of clonidine[10,15,16] with [6] or without [5,7,8] control group. Also includes brachial plexus block studies with 0.25%bupivacaine [10, 17] and 0.5%bupivacaine [18, 19]. Others observed [19-21] no significant difference in duration with the use of clonidine both in studies with [22] or without [10, 11] control group. Our results correlate with later studies.

http://www.iosrjournals.org/iosr-jdms/papers/Vol4-issue3/G0433039.pdf

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No serious side-effects are reported in buprenorphine group study. Of those observed (sedation, nausea,
vomiting, pruritis, dryness of mouth) (fig.5), their incidence was similar to that reported previously [1, 4, 32, 36-37].
The most common side-effect observed in our study is sedation. None showed any respiratory depression. The
systemic effects indicate partial systemic resorption. This absorption could explain the longer duration of
analgesia in the buprenorphine group


In the study above using 300 ug of Buprenorphine the incidence of N/V was higher than the Control but did not reach statistical significance. I suspect that reducing the dose of Buprenorphine to 150 ug would likely reduce the N/V as well.