asking surgeon about blocks

[GaseousClay]

how do you guys go about asking a new ortho surgeon if they are okay with blocks? Do you ask if its ok or do you suggest that its the right thing to do or do you just say "hey im planning to block this patient what do you think?" Some surgeons seem like they say no most of the time when you are like hesitant and ask "can I block or are you ok with blocks?"

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[Hoya11]

how do you guys go about asking a new ortho surgeon if they are okay with blocks? Do you ask if its ok or do you suggest that its the right thing to do or do you just say "hey im planning to block this patient what do you think?" Some surgeons seem like they say no most of the time when you are like hesitant and ask "can I block or are you ok with blocks?"

Hi Dr. Surgeon Im Dr. Anesthesiologist, nice to meet you, I saw Mrs. Smith for the shoulder, seems like shed be a good candidate for a block... await response.. then run the schedule for the rest of the day during that same interaction so you dont have to keep bothering them. Then confirm: Ok so block, block, no block, block, got it- thx.

 

[ranvier]

A nice if ambitious goal is to have the surgeon at least mention it to the patient well ahead of time in clinic. That way, preop isnt the first time they have ever heard of a possible nerve block. Here, the younger orthopods insist on blocks for shoulders as they trained with the practice. Of course the actual consent and decision is up to us.

 

[Precedex]

A nice if ambitious goal is to have the surgeon at least mention it to the patient well ahead of time in clinic. That way, preop isnt the first time they have ever heard of a possible nerve block. Here, the younger orthopods insist on blocks for shoulders as they trained with the practice. Of course the actual consent and decision is up to us.

If you block a patient that the surgeon does not want you to you are asking for a massive headache.

 

[cchoukal]

"Hey, Fred, I'm cchoukal, the anesthesiologist doing cases with you today. I saw Ms. Jones and am planning to do a block and spinal for her TKA unless you've got a really good reason not to."

It's assertive enough, but gives them an out so they don't feel trapped (which can lead to hostility). Then, of course, what constitutes a "really good reason" can lead to some discussion.

 

[deleted162650]

I'll usually just say "Hey, how do you feel about a block for pt. so-and-so?" If they say no and give me a good reason I'll just go with it. If it's a soft call/indication for a block and they say no I'll just go with it. If they say no without a good reason and it's a pt I feel would really benefit from a block then I'll push em on it and reassure them I can do it in <5min.

 

[Ignatius J]

Hey _______, you cool with a ______ block? Sounds good.

 

[PainDrain]

My convo goes something thing like this: "Hey Bone Dork MD, I feel a block would be far better for this 85 yo patient compared to the alternative of loading them up on narcotics and contributing to post-op delirium, nausea, and constipation. But hey, if you want to field calls at home all night from the patient's nurse that's kewl with me. Also, I won't do a spinal for your 95 yo hip fracture with critical AS and CHF. "

I kid...I kid.

Seriously, I typically just run through the list with them in the AM and see how they feel about it. Younger surgeons around me tend to be very "pro block" while the older guys don't like them.

 

[pjl]

Hi new guy,
I like to do blocks for postop pain control for ____ so they are comfy all night, unless you are planning to inject or have concerns. When you list your cases, please list them as "no block" if you dont want one, otherwise I will use my judgement.
Our orthos have grown to expect blocks, and their office staff who I have blocked for their own surgeries talk them up like crazy. I think those staff are the biggest drivers of the block decisions. When I have a reason not to do one most patients are disappointed. Almost nobody comes without hearing about them. We dont block knees anymore though (exparel). Mostly upper extremity stuff or major foot/ankle.

 

[BobBarker]

Worst part about block rotation as a resident.
"Daddy, please please please can I block your next patient. I promise I will do a good job. I really promise!"

 

[aneftp]

Hi new guy,
I like to do blocks for postop pain control for ____ so they are comfy all night, unless you are planning to inject or have concerns. When you list your cases, please list them as "no block" if you dont want one, otherwise I will use my judgement.
Our orthos have grown to expect blocks, and their office staff who I have blocked for their own surgeries talk them up like crazy. I think those staff are the biggest drivers of the block decisions. When I have a reason not to do one most patients are disappointed. Almost nobody comes without hearing about them. We dont block knees anymore though (exparel). Mostly upper extremity stuff or major foot/ankle.

Knee blocks are becoming less and less preferred by surgeons unless it's a revision.

Surgeons see $$$ to manage "post op pain" with exparel injection.

 

[pjl]

Knee blocks are becoming less and less preferred by surgeons unless it's a revision.

Surgeons see $$$ to manage "post op pain" with exparel injection.

Yes, from what I have been seeing and patient discharge at our hospital, once our surgeons got better at doing their injections I would rather have the exparel for a total knee if I needed that procedure. Who knows what the future will bring.

I still think our blocks have an advantage for upper extremity, and larger ankle work.

 

[Mman]

I have discussions about generalities with surgeons. Such as for TKAs here's what we do, rotator cuffs get this, etc. Make sure they are OK with that generic plan going forward. Then if a particular patient comes up that will be a deviation from that plan for one reason or another we talk to each other. I might say, hey we usually don't block this elbow or hand or whatever but this particular patient has a real benefit so I'm going to do it. You OK with that? Then they say sure. Or they might find me and explain why they are particularly worried about monitoring a nerve injury and want to avoid a block on a particular patient.

So I lay out broad ground rules going forward and then communicate deviations from that plan for a particular patient.

 

[nimbus]

Yesterday I did a rescue block on a total knee patient in PACU. He had bupiv 0.25%x60ml, toradol 60mg, and morphine 10mg LIA by surgeon but still had 8/10 pain. Adductor canal block with ropiv 0.5%x30ml brought pain score to 0/10. This particular surgeon believes LIA is the s***.

 

[BobBarker]

Too much combined local!

 

[nimbus]

Too much combined local!

Nah he was 93kg

 

[fakin' the funk]

Nah he was 93kg

So the compressions might be a tad tricky

 

[Arch Guillotti]

Yesterday I did a rescue block on a total knee patient in PACU. He had bupiv 0.25%x60ml, toradol 60mg, and morphine 10mg LIA by surgeon but still had 8/10 pain. Adductor canal block with ropiv 0.5%x30ml brought pain score to 0/10. This particular surgeon believes LIA is the s***.

Do you always use this much local for an adductor block?

 

[lobelsteve]

Do you start Intralipid before the block?

 

[nimbus]

Do you always use this much local for an adductor block?

Yes

 

[nimbus]

Do you start Intralipid before the block?

No

 

[jwk]

Our absolute slowest orthopedic surgeon (private practice, 3-4hr ACLs and shoulder scopes) doesn't want blocks because "I don't want anything that would delay my procedures".

 

[Arch Guillotti]

Yes

wow

 

[ZzzPlz]

What? You guys think 30ml of 0.5% is too much under normal circumstances? Or just because he already received local in surgery?

 

[BobBarker]

Both. I look at it like this guy got 120mls of 0.25% marcaine.
Adductor canal you are not trying to back door a femoral or fascia iliaca compartment block. You are trying to preserve motor by blocking the femoral branches that go south and provide the sensory innervation to the knee.

 

[sleepallday]

What? You guys think 30ml of 0.5% is too much under normal circumstances? Or just because he already received local in surgery?

i use 10cc of 0.5% bupi

 

[pgg]

What? You guys think 30ml of 0.5% is too much under normal circumstances?

Probably more than you need (or want) for an adductor canal.

Or just because he already received local in surgery?

Yes.

93 kg at 2.5-3.0 mg/kg would be 232 - 279 mg of bupiv. This guy got 300 mg.

Moreover, the max safe dose of local should be calculated based on ideal body weight. What you're worried about, after either accidental intravascular injection or unexpectedly rapid uptake, is a high concentration of local in vessel-rich organs like the brain (seizures) and heart (dysrhythmias). It doesn't matter if he's got an extra 50 or 100 kg of fat, because there isn't (much) blood going there.

If he was a 6' male IBW would be closer to 75-80 kg, which puts his textbook safe range at 190 - 240 mg.

 

[ZzzPlz]

Hmm. Interesting points, thanks.

What amount of local do you guys use for your supraclavs and interscalenes?

What about your popliteal blocks?
Thanks.

 

[pgg]

For me, 20-25 mL for interscalene or supraclavicular blocks, assuming I have a satisfying view of normal anatomy with the u/s. If I'm not totally confident in my local placement (it happens ... I don't do as many blocks as I used to, I'll cheat toward 30.

If I had a compelling reason to do a supraclavicular block in someone with bad COPD and I wanted to improve my odds of missing the phrenic, I'd go as low as 10-15 mL. Data seems to show that's usually enough.

I'd go 15-20 for popliteal.

 

[nimbus]

The injections were approx 90 min apart. I thought about the total dose. It was safe to proceed.

 

[PMPMD]

Hey _______, you cool with a ______ block? Sounds good.

This is the extent of the conversation in PP. Only comes up with new surgeons.

 

[PMPMD]

Knee blocks are becoming less and less preferred by surgeons unless it's a revision.

Surgeons see $$$ to manage "post op pain" with exparel injection.

We're seeing this trend too

 

[Ignatius J]

This is the extent of the conversation in PP. Only comes up with new surgeons.

Yep. Don't know too many PP orthopods who are against blocks these days. And don't know any who really care to make a staunch stance either way. Almost always defer to me and whatever I want to do.

 

[fakin' the funk]

Yes

Dude, forget the high dose of local this patient got.

You can barely even fit 20ml into the adductor canal in normal patients. Where is the extra 10 going?

Have you seen the papers on the ED95s for volume for effective interscalenes and supraclavs (for postop pain)? We're talking about the range of like 10-15ml for a super long, super dense block.

For interscalenes, supraclavs, infraclavs, adductors, if there's great spread with 15ml or so, maybe 20, I'm done.

Popliteals I like a bit more because of the big surface area of the nerve and the slow onset. But that's probably voodoo too.

In my opinion the single most important factor in terms of block efficacy AND block safety is seeing the local spread on your realtime ultrasound image. Shows you that the local's getting where you want it to -- "halo sign" for a popliteal, e.g. -- and shows you it's not intravascular. This allows you to minimize your dose, which is the single best way to avoid LAST.

 

[nimbus]

Dude, forget the high dose of local this patient got.

You can barely even fit 20ml into the adductor canal in normal patients. Where is the extra 10 going?

Have you seen the papers on the ED95s for volume for effective interscalenes and supraclavs (for postop pain)? We're talking about the range of like 10-15ml for a super long, super dense block.

For interscalenes, supraclavs, infraclavs, adductors, if there's great spread with 15ml or so, maybe 20, I'm done.

Popliteals I like a bit more because of the big surface area of the nerve and the slow onset. But that's probably voodoo too.

In my opinion the single most important factor in terms of block efficacy AND block safety is seeing the local spread on your realtime ultrasound image. Shows you that the local's getting where you want it to -- "halo sign" for a popliteal, e.g. -- and shows you it's not intravascular. This allows you to minimize your dose, which is the single best way to avoid LAST.

That's great. And I do 30ml for the above mentioned blocks, have the highest success rate I know of, been told by numerous surgeons that my blocks always work, and haven't encountered any problems. I won't convince you to change your practice and you won't be changing mine. And 30ml fits easily in the adductor canal. And I think most cases of LAST comes from unintentional, unrecognized intravascular injection which can be prevented with real time ultrasound visualization during injection.

 

[Hoya11]

I also use 30ml 0.5% for the above blocks. Still way under the toxic dose, and maybe a longer, denser block? Probably no research either way but if it was me having the block id take the extra local volume.

 

[deleted162650]

Put me in the 25-30mL camp

 

[fakin' the funk]

And I do 30ml for the above mentioned blocks, have the highest success rate I know of, been told by numerous surgeons that my blocks always work, and haven't encountered any problems.

Oh boy.

 

[GA8314]

It's

That's great. And I do 30ml for the above mentioned blocks, have the highest success rate I know of, been told by numerous surgeons that my blocks always work, and haven't encountered any problems. I won't convince you to change your practice and you won't be changing mine. And 30ml fits easily in the adductor canal. And I think most cases of LAST comes from unintentional, unrecognized intravascular injection which can be prevented with real time ultrasound visualization during injection.

Yes, 30 ml does fit nicely in the AC. But, 30 ml for brachial plexus blocks under US guidance seems highly excessive. You've stated we won't change your mind, but I will submit to perhaps those in training that if you "suggest" to any attending of yours with lots of regional experience that you plan on putting 30 ml in for an interscalene, he/she just may puke in your face......

 

[GA8314]

As a general rule, know your surgeons. I personally respect their nauances and quirks. It is what it is.... Bigger fish to fry.

If I think the patient would benefit from a certain block, I'll talk to them. It does help to get to know them, as in if you practice with them for a while. Also, we have a pretty colleagial relationship with our ortho guys and they are open to suggestions. I try to see things from their perspective. But, our guys are also pretty reasonable, so it helps...

 

[epidural man]

That's great. And I do 30ml for the above mentioned blocks, have the highest success rate I know of, been told by numerous surgeons that my blocks always work, and haven't encountered any problems. I won't convince you to change your practice and you won't be changing mine. And 30ml fits easily in the adductor canal. And I think most cases of LAST comes from unintentional, unrecognized intravascular injection which can be prevented with real time ultrasound visualization during injection.

Nimbus - 30 cc's is fine for an sub sartorial block (I refuse to use adductor canal anymore....), but the point is, a lot of that will spread north and no doubt your blocks work great - but I'm not sure you are getting good motor sparing which is the whole reason people moved DOWN the leg in the first place. You might as well do a femoral nerve block.

Although a nice academic discussion is how often you get the obturator - which one will miss with a femoral nerve block, but will often catch sub sartorial.

 

[epidural man]

I did two pop/fem blocks last week for primary anesthetics for lower extremity surgery (one amputation). They worked great even with a thigh tourniquet (propofol - ketamine is your friend with this). I didn't ask permission and I think the surgeon loved it.

 

[nimbus]

Nimbus - 30 cc's is fine for an sub sartorial block (I refuse to use adductor canal anymore....), but the point is, a lot of that will spread north and no doubt your blocks work great - but I'm not sure you are getting good motor sparing which is the whole reason people moved DOWN the leg in the first place. You might as well do a femoral nerve block.

Although a nice academic discussion is how often you get the obturator - which one will miss with a femoral nerve block, but will often catch sub sartorial.

You may be correct. I haven't really been checking for motor sparing or degree of motor sparing.

 

[Mman]

It's



Yes, 30 ml does fit nicely in the AC. But, 30 ml for brachial plexus blocks under US guidance seems highly excessive. You've stated we won't change your mind, but I will submit to perhaps those in training that if you "suggest" to any attending of yours with lots of regional experience that you plan on putting 30 ml in for an interscalene, he/she just may puke in your face......

meh

After my N of thousands I still put in 30 ms of 0.5% ropivicaine for a single shot brachial plexus unless a patient is drastically smaller than average. Works every time and not causing systemic toxicity.

 

[ZzzPlz]

For TAPs I'll always put 30 ml per side. 0.5% if unilateral, 0.25% if bilateral.

Anyone use more/less?

TAPs have been frustrating for me. Sometimes you see great anatomy with textbook spread of local with crappy results and other times I spray and pray and the patient gets excellent results.

 

[deleted162650]

For TAPs I'll always put 30 ml per side. 0.5% if unilateral, 0.25% if bilateral.

Anyone use more/less?

TAPs have been frustrating for me. Sometimes you see great anatomy with textbook spread of local with crappy results and other times I spray and pray and the patient gets excellent results.

That's my recipe for TAPS too. I think volume is key since the local really needs to spread throughout the plane to have the best chance of success.

I think TAP blocks are the epitome of "50% of the time, they work every time"

 

[RxBoy]

I did two pop/fem blocks last week for primary anesthetics for lower extremity surgery (one amputation). They worked great even with a thigh tourniquet (propofol - ketamine is your friend with this). I didn't ask permission and I think the surgeon loved it.

Bad for billing. Just saying.

 

[deleted162650]

Bad for billing. Just saying.

Not if you do you blocks with bupi and bump the Ketofol up to "GA" levels

 

[epidural man]

Bad for billing. Just saying.

Bad for billing...amazing for the patient.

Hmmm.....

But to be fair - if I worked in private practice and had to block my own patients before they went to sleep, I think less than 1% of my patients would get blocks.

It's easy for me to talk up the regional game when I work in a system with an Acute Pain Service.

 

[epidural man]

For TAPs I'll always put 30 ml per side. 0.5% if unilateral, 0.25% if bilateral.

Anyone use more/less?

TAPs have been frustrating for me. Sometimes you see great anatomy with textbook spread of local with crappy results and other times I spray and pray and the patient gets excellent results.

They are super frustrating.

But....hard to hurt the patient, so easy to swallow the frustration pill.