Block in Pre-op vs block in OR after induction

[neutro]

Hi,

Is there any evidence that blocks in OR after induction do not cause an increased chance of worse outcome compared to doing the block in pre-op bay?

Advantage of doing a block in OR (U/S guided) are more sterile environment, patient comfort (already under sedation/general anesthesia). Disadvantage is obviously unable to assess the response from block.

In my hospital there is a preference to continue to do blocks in pre-op bay. In other hospitals I go to, it is felt that its more efficient to do it in OR as it avoids a double set up and giving sedation in pre-op.

What is everyone's preference here, and why?

Also, are there any studies done on this issue outlining risks/benefits and outcomes?

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[Mman]

i'm too lazy to dig up the literature on relative increase in nerve injury when doing blocks on adults under GA. safe in kids, probably slightly less safe in adults.

 

[Urzuz]

I’m less concerned about the actual risk of nerve injury vs the line of experts that will be more than willing to testify that performing a block on an adult patient under GA is not standard of care (even if the nerve injury is from retraction, patient positioning etc).

Advantage of doing a block in OR (U/S guided) are more sterile environment, patient comfort (already under sedation/general anesthesia). Disadvantage is obviously unable to assess the response from block.

Sterile environment is a nonissue since the rate of infection after a single shot block is pretty much zero. Patient comfort - the vast majority of adult patients should be able to tolerate a block fine without anything. If you throw a little sedation on top nearly everyone will be fine except for the biggest of *****es…and for those patients I don’t even want to give them a block since they’ll be a huge pain in my ass later.

IMO the Biggest advantage to doing it in preop is that it will be fully set up by the time incision is being made, so it helps reduce your anesthetic requirement. Additionally it saves time since we usually will do the block while the room is getting ready, so when they finally get the patient back you just induce and go.

 

[nimbus]

A lot of the literature came out pre ultrasound. Benumof who did a lot of expert witness testimony published this which put a quash on asleep blocks. Now that we use ultrasound, I think the issue should be revisited.

Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene Block Performed under General Anesthesia

PERFORMING an interscalene block (ISB) during general anesthesia (GA) for postoperative shoulder surgery analgesia is a common procedure. Although epidural, 1–3subarachnoid, 4–6and motor nerve root 7injections have been reported during the performance of ISB, there have been no cases reported in...

pubs.asahq.org

That said, at our place, it’s much more efficient to block in preop while the room is being turned over.

 

[spike7585]

Care team model it is definitely more efficient to block in preop once surgeon sees the patient.

At my old MD only gig, I would have the anesthesia tech have all the block stuff set up in the next OR.

Finish previous case, see patient and consent, have circulator bring patient back. Then move to OR bed, sedate as much as your heart desires with monitors on and an anesthesia machine readily available. Block and go to sleep. That allows you to get a couple of the "advantages" you mentioned, and you can be fairly aggressive with sedation if you prefer. Also makes the OR turnover time look amazing when you roll out and roll in within a 10 minute period.

 

[neutro]

Thank you for your responses.

Actually the reason I brought this up is because at our practice it is becoming more and more impossible to do blocks pre-op because there is no free person, nor anyone available to assist. Its just labor shortage. There is no dedicated block nurse, and anesthesia techs are already too busy. Pre-op nurses expect the block performer to gather all medications and sedation, ultrasound, and place the patient on monitors. These things are all in different parts of the pre-op suite. Cart and machine in one which only has syringes and labels and towels, intra-lipid only in PACU pyxis that must be taken out for individual patient and be bedside (cannot use one for the whole day); needles in anesthesia supply room, etc. I know this is a big part of the problem.

Secondly what is scaring me is that in our medical supervision practice both MDs and CRNAs perform their own cases independently (opt out state). Some of them are doing the blocks in the OR to avoid a second set up in pre-op. Not only that, the CRNAs are not readily calling anesthesiologists for complications or difficult anatomy (they prefer to call another CRNA first).

Thats why this whole conversation started in the first place to gauge if this is ok. We need to figure out a solution here keeping evidence and best practices in mind while not compromising efficiency.

I understand the risk esp. with inability to assess the patient under GA. I did read the article with case reports above - its very interesting, all poor outcomes appear to be due to ISBs. However, this is before US and 22 years ago.

Another point, what is the evidence that one will be able to avoid complications even with fentanyl and versed pre-op? Patient may not be appropriately responsive or arousable even with versed and fentanyl.
Relying on 'pain on injection or parasthesia' as a warning that you are directly on the nerve to withdraw the needle is not always consistently reported by patients, esp. under sedation - be it mild or moderate.

I contend that if U/S is used even by a reasonable operator and needle tip is kept in view, it will be almost impossible to enter the cervical spinal cord. There is a higher risk of entering a vessel than that for sure. Entering vertebral artery is also a remote possibility...but you'd have to be extremely posterio-medial from the entry point. if you keep the tip in view, I just dont see entering spinal cord being common place - you'd have to be extremely incompetent with U/S views to cause that.

Also, if there IS a complication and you get a high spinal from interscalene block, or LAST - isn't it better to deal with those complications in the OR anyways? Imagine intubating in pre-op bay all of a sudden and bolusing intralipid.

I dont know...i can see a point for both sides but I havent come across anything concrete that will convince me one way or ther other.

I am tending to think that truncal and lower extremity blocks in OR ideally before induction vs after are OK. Avoid UE blocks in OR. ISB ideally pre-op..

 

[CHARLESTONMMM]

Thank you for your responses.

Actually the reason I brought this up is because at our practice it is becoming more and more impossible to do blocks pre-op because there is no free person, nor anyone available to assist. Its just labor shortage. There is no dedicated block nurse, and anesthesia techs are already too busy. Pre-op nurses expect the block performer to gather all medications and sedation, ultrasound, and place the patient on monitors. These things are all in different parts of the pre-op suite. Cart and machine in one which only has syringes and labels and towels, intra-lipid only in PACU pyxis that must be taken out for individual patient and be bedside (cannot use one for the whole day); needles in anesthesia supply room, etc. I know this is a big part of the problem.

Secondly what is scaring me is that in our medical supervision practice both MDs and CRNAs perform their own cases independently (opt out state). Some of them are doing the blocks in the OR to avoid a second set up in pre-op. Not only that, the CRNAs are not readily calling anesthesiologists for complications or difficult anatomy (they prefer to call another CRNA first).

Thats why this whole conversation started in the first place to gauge if this is ok. We need to figure out a solution here keeping evidence and best practices in mind while not compromising efficiency.

I understand the risk esp. with inability to assess the patient under GA. I did read the article with case reports above - its very interesting, all poor outcomes appear to be due to ISBs. However, this is before US and 22 years ago.

Another point, what is the evidence that one will be able to avoid complications even with fentanyl and versed pre-op? Patient may not be appropriately responsive or arousable even with versed and fentanyl.
Relying on 'pain on injection or parasthesia' as a warning that you are directly on the nerve to withdraw the needle is not always consistently reported by patients, esp. under sedation - be it mild or moderate.

I contend that if U/S is used even by a reasonable operator and needle tip is kept in view, it will be almost impossible to enter the cervical spinal cord. There is a higher risk of entering a vessel than that for sure. Entering vertebral artery is also a remote possibility...but you'd have to be extremely posterio-medial from the entry point. if you keep the tip in view, I just dont see entering spinal cord being common place - you'd have to be extremely incompetent with U/S views to cause that.

Also, if there IS a complication and you get a high spinal from interscalene block, or LAST - isn't it better to deal with those complications in the OR anyways? Imagine intubating in pre-op bay all of a sudden and bolusing intralipid.

I dont know...i can see a point for both sides but I havent come across anything concrete that will convince me one way or ther other.

I am tending to think that truncal and lower extremity blocks in OR ideally before induction vs after are OK. Avoid UE blocks in OR. ISB ideally pre-op..

This sounds like a miserable place to work. I would actually be glad that a solo CRNA isn’t calling me to fix their problems. Sucks for the patient but that’s a CRNA problem now. Everytime one of my CRNAs want me to teach them ultrasound regional blocks I say no. The end.

 

[nimbus]

I’m less concerned about the actual risk of nerve injury vs the line of experts that will be more than willing to testify that performing a block on an adult patient under GA is not standard of care

This is the issue. Our practice which is self insured forbids asleep nerve blocks. Asleep fascial plane blocks are okay. My personal opinion is that asleep ultrasound guided nerve block is safe but nobody cares what I think.

 

[AnesRunner]

A lot of the literature came out pre ultrasound. Benumof who did a lot of expert witness testimony published this which put a quash on asleep blocks. Now that we use ultrasound, I think the issue should be revisited.

Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene Block Performed under General Anesthesia

PERFORMING an interscalene block (ISB) during general anesthesia (GA) for postoperative shoulder surgery analgesia is a common procedure. Although epidural, 1–3subarachnoid, 4–6and motor nerve root 7injections have been reported during the performance of ISB, there have been no cases reported in...

pubs.asahq.org

That said, at our place, it’s much more efficient to block in preop while the room is being turned over.

It's rather ironic. Benumof never did a block in his entire life. That being said, it just takes one "expert" witness to say that you did not follow the standard of care. Standard of care is still an awake patient (for adults).

 

[fittipaldi1of1]

At my place, all blocks, including Intrathecal morphine spinals are done under general. I personally do the Spinals while awake, but have become accustomed to doing the blocks asleep now.. my partners claim to have never had a complication.. I don’t love doing it the way we do it, but in all honesty is it any different than an overly sedated preop block?

 

[spike7585]

At my place, all blocks, including Intrathecal morphine spinals are done under general. I personally do the Spinals while awake, but have become accustomed to doing the blocks asleep now.. my partners claim to have never had a complication.. I don’t love doing it the way we do it, but in all honesty is it any different than an overly sedated preop block?

It will be in court.

Is 7 hours really much different than 8 hours for NPO? Probably not, but I'd be paying up for aspiration after 7 hours ha

 

[fittipaldi1of1]

It will be in court.

Is 7 hours really much different than 8 hours for NPO? Probably not, but I'd be paying up for aspiration after 7 hours ha

Funny you say that, the academic place I trained at (one of the top places in south) has an NPO timeline of 7 hours is fully fasted because NPO since midnight and 7am starts is convenient.. zero problems lol

Not saying it’s right, but it’s what’s done

 

[USCTrojan11]

Some consider HSS to be a regional anesthesia leader. HSS blocks many/most of their outpatient elective ankles after LMA. I mention ankles since that is a consequential block if the nerve if transected. Adductor probably doesn't matter since it's mostly sensory. I believe they do all interscalene caths awake before going to the room. No blocks on athletes - ever.

 

[fittipaldi1of1]

Some consider HSS to be a regional anesthesia leader. HSS blocks many/most of their outpatient elective ankles after LMA. I mention ankles since that is a consequential block if the nerve if transected. Adductor probably doesn't matter since it's mostly sensory. I believe they do all interscalene caths awake before going to the room. No blocks on athletes - ever.

Also, my place only does single shots.. in residency most of the patients that had a parenthesia experienced it with catheter placement.

Regional blocks carried out during general anesthesia or deep sedation: myths and facts - PubMed

With the use of ultrasound guidance in skilled hands, it is a reasonable option to perform neuraxial and peripheral regional blocks in sedated or anesthetized patients. Performing the procedure safely and effectively requires an adequate level of experience with the specific block technique in...

pubmed.ncbi.nlm.nih.gov

 

[Gas you down]

It depends.
Preop is fine for many but not for all. I love preop interscalenes, adductor canals, just about all of them…
As long as my target isn’t too close to lung or bowel-adjacent. PECS 1/2, yes. Serratus on top of ribs, not so much. TAP’s on a spont breathing pt in preop, no thanks.
And to be honest, some of my colleague give more sedation than you’d really like the patient to get in a long drawn out placement, multiple blocks or bilateral.
Do what’s right for the patient. Not the schedule.

 

[ambiturner]

It's rather ironic. Benumof never did a block in his entire life. That being said, it just takes one "expert" witness to say that you did not follow the standard of care. Standard of care is still an awake patient (for adults).

The more of the ‘experts’ I have met in this field, the more I am convinced that their true ‘expertise’ is in self-promotion and almost never in clinical care. How in touch can you be after years of getting 4 admin days a week, never taking call, and never soloing cases?

That said I rarely do asleep extremity or neuraxial blocks in patients over 16.

 

[USCTrojan11]

It depends.
Preop is fine for many but not for all. I love preop interscalenes, adductor canals, just about all of them…
As long as my target isn’t too close to lung or bowel-adjacent. PECS 1/2, yes. Serratus on top of ribs, not so much. TAP’s on a spont breathing pt in preop, no thanks.
And to be honest, some of my colleague give more sedation than you’d really like the patient to get in a long drawn out placement, multiple blocks or bilateral.
Do what’s right for the patient. Not the schedule.

I sincerely hope NOBODY is doing a TAP block awake or preop. #1 it likely is going to be an extended surgery so a lot of duration and benefit won't be realized. #2 WTF, why would you attempt to stick a muscle layer that is actively moving with each respiration (these are some of the accessory muscles of respiration, engaged especially when sedated). You better hope the needle moves with the IO and TA when administering the local because I can only imagine someone trying to hold the needle still, the patient contracts and RIP bowel.

As an aside, had a bad co-resident who was haphazard and stuck the bowel on a tap since he didn't care to find the tip of his needle. He was so confident that he facetiously said "aspirate there" thinking he was showing his chops with his knowledge that there are minimal vessels near this block site (block plane really). Welp, attending aspirated and lo and behold brown fluid/debris came back through the needle...

 

[USCTrojan11]

The more of the ‘experts’ I have met in this field, the more I am convinced that their true ‘expertise’ is in self-promotion and almost never in clinical care. How in touch can you be after years of getting 4 admin days a week, never taking call, and never soloing cases?

That said I rarely do asleep extremity or neuraxial blocks in patients over 16.

Some seem to really care and genuinely want to advance the field. Some purely want to get their name out there and are willing to endorse or say something novel or even controversial in order to do so. Wait - are we talking about politics or regional anesthesia?

This is very evident at ASRA every year.

 

[Volatile]

We do fascial plane blocks after the patient is asleep (TAPs, pecs, rectus sheath, QL’s etc). Everything else is awake in pre-op. I think you’re taking on unnecessary risk, especially if there’s a significant motor component to the block.

 

[MirrorTodd]

I sincerely hope NOBODY is doing a TAP block awake or preop. #1 it likely is going to be an extended surgery so a lot of duration and benefit won't be realized. #2 WTF, why would you attempt to stick a muscle layer that is actively moving with each respiration (these are some of the accessory muscles of respiration, engaged especially when sedated). You better hope the needle moves with the IO and TA when administering the local because I can only imagine someone trying to hold the needle still, the patient contracts and RIP bowel.

As an aside, had a bad co-resident who was haphazard and stuck the bowel on a tap since he didn't care to find the tip of his needle. He was so confident that he facetiously said "aspirate there" thinking he was showing his chops with his knowledge that there are minimal vessels near this block site (block plane really). Welp, attending aspirated and lo and behold brown fluid/debris came back through the needle...

Not trying to sound cocky or anything, but TAP blocks are like super easy and QL's are just as easy. Like I haven't been worried about poking the bowel since CA1 year while doing TAP blocks on a preop awake pt. I feel like you are kind of overblowing the movement/associated risks.

 

[nimbus]

It's rather ironic. Benumof never did a block in his entire life.

You are probably correct. He is still a nice guy and very smart

 

[NitroS]

We do it in preop because 1) it’s more efficient and 2) allows the block to set before incision. Our turnover time is 30 min so plenty of time after we drop off pt in pacu to see the next pt and do block.

 

[Gas you down]

Not trying to sound cocky or anything, but TAP blocks are like super easy and QL's are just as easy. Like I haven't been worried about poking the bowel since CA1 year while doing TAP blocks on a preop awake pt. I feel like you are kind of overblowing the movement/associated risks.

Unless the patient hasn’t moved in years resulting in paper-thin anatomy.
Even then, you could do it. But is it smart?

 

[teacher2md]

If you do the block with ultrasound and nerve stimulation (stim at 0.5mA), is there an actual risk of intraneural injection?

Or is the risk just being blamed for a positioning/surgical neuropathy?

 

[Mman]

If you do the block with ultrasound and nerve stimulation (stim at 0.5mA), is there an actual risk of intraneural injection?

Or is the risk just being blamed for a positioning/surgical neuropathy?

I would think that yes there is still a risk, and when people talk about intraneural need to be a little more clear in defining epineurium, perinerium, and endoneurium and what exactly we are trying to avoid. Also I think there is no real benefit to the nerve stimulator if using ultrasound. We already know it doesn't reliably indicate distance to nerve.

 

[teacher2md]

Complications and Prevention of Neurologic Injury with Peripheral Nerve Blocks - NYSORA

This chapter reviews various factors that may contribute to neurologic complications after peripheral nerve blocks (PNBs) and suggests principles of practice and implications of monitoring modalities to mitigate the risk of neurologic complications.

www.nysora.com

Hmm, after reading this, seems like pain in injection is a specific but not sensitive (35%) indicator.

I would argue that anyone who feels that they should be doing awake blocks for this reason should also feel the need to use nerve stim.

 

[DrOwnage]

We do our TKA adductor canal blocks in PACU, large majority of the time while the spinal is still working. You guys have any issues with that? Where I trained it was all preop besides plane blocks.

 

[jwk]

Some consider HSS to be a regional anesthesia leader. HSS blocks many/most of their outpatient elective ankles after LMA. I mention ankles since that is a consequential block if the nerve if transected. Adductor probably doesn't matter since it's mostly sensory. I believe they do all interscalene caths awake before going to the room. No blocks on athletes - ever.

We do zero ankle blocks. We just let the podiatrists do them, and they're always done with sedation in the OR.

 

[jwk]

Thank you for your responses.

Actually the reason I brought this up is because at our practice it is becoming more and more impossible to do blocks pre-op because there is no free person, nor anyone available to assist. Its just labor shortage. There is no dedicated block nurse, and anesthesia techs are already too busy. Pre-op nurses expect the block performer to gather all medications and sedation, ultrasound, and place the patient on monitors. These things are all in different parts of the pre-op suite. Cart and machine in one which only has syringes and labels and towels, intra-lipid only in PACU pyxis that must be taken out for individual patient and be bedside (cannot use one for the whole day); needles in anesthesia supply room, etc. I know this is a big part of the problem.

Secondly what is scaring me is that in our medical supervision practice both MDs and CRNAs perform their own cases independently (opt out state). Some of them are doing the blocks in the OR to avoid a second set up in pre-op. Not only that, the CRNAs are not readily calling anesthesiologists for complications or difficult anatomy (they prefer to call another CRNA first).

Thats why this whole conversation started in the first place to gauge if this is ok. We need to figure out a solution here keeping evidence and best practices in mind while not compromising efficiency.

I understand the risk esp. with inability to assess the patient under GA. I did read the article with case reports above - its very interesting, all poor outcomes appear to be due to ISBs. However, this is before US and 22 years ago.

Another point, what is the evidence that one will be able to avoid complications even with fentanyl and versed pre-op? Patient may not be appropriately responsive or arousable even with versed and fentanyl.
Relying on 'pain on injection or parasthesia' as a warning that you are directly on the nerve to withdraw the needle is not always consistently reported by patients, esp. under sedation - be it mild or moderate.

I contend that if U/S is used even by a reasonable operator and needle tip is kept in view, it will be almost impossible to enter the cervical spinal cord. There is a higher risk of entering a vessel than that for sure. Entering vertebral artery is also a remote possibility...but you'd have to be extremely posterio-medial from the entry point. if you keep the tip in view, I just dont see entering spinal cord being common place - you'd have to be extremely incompetent with U/S views to cause that.

Also, if there IS a complication and you get a high spinal from interscalene block, or LAST - isn't it better to deal with those complications in the OR anyways? Imagine intubating in pre-op bay all of a sudden and bolusing intralipid.

I dont know...i can see a point for both sides but I havent come across anything concrete that will convince me one way or ther other.

I am tending to think that truncal and lower extremity blocks in OR ideally before induction vs after are OK. Avoid UE blocks in OR. ISB ideally pre-op..

Sounds like your group needs to exert some influence if they have any, which sorry, it kinda sounds like you don't. (never mind the opt-out which is a crap excuse and a whole different topic!). It really sounds like the tail is wagging the dog.

We are a very busy private practice. We to a ton of blocks, especially for total knees and shoulder cases. ALL of them are done in pre-op. We don't do intra-op blocks except for TAPS. MDs do ALL of the blocks while the anesthetists are in the OR doing cases. We have block nurses in our hospitals as well as our outpatient centers. We simply told the hospital this is what we need. It doesn't require any additional personnel costs on their part. They are all pre-op nurses, and they all cross-train for a few hours (it's not rocket science) to be "block nurses". All they need to know is what drugs to draw up, how to aspirate the syringe to check for blood, and to inject how and when we tell them while we're looking at the US. BTW - drugs do not have to be labeled if they are drawn up and immediately administered (there's more time saved for ya)

Don't you have a block cart? All the drugs you need, block needles, probe covers, or whatever else you think you need? Put it all in one place, not scattered. Ours is in a secure area, no controlled substances, and locked, so it keeps pharmacy happy. One drawer has a security tag on it and has ambu, LMAs, intubation goodies, and other resuscitation equipment, as well as a bottle of intralipid. If the emergency drawer is accessed, we just tell pharmacy, who will restock it and reseal it. So all we need to have is the block cart and US. It's not difficult.

If we're doing spinals for THR or TKR, an anesthetist signs on with that patient in pre-op, patient is monitored and sedated, the spinal is done, block nurse comes in and helps with blocks if it's a TKR, and by that time the OR nurses are ready to take the patient to the OR. The anesthesia time with those actually starts in pre-op. If the block is done simply for postop pain relief, the doc does it with the block nurse. Surely you know that blocks for post-op pain are a separately chargeable procedure. A couple of blocks for a total knee often pays more than the anesthetic for the procedure. They're money-makers. If you're doing those in the OR, you're simply wasting OR time, which potentially means fewer cases per OR per day. In a high-volume quick turnover practice like ours, we simply couldn't manage the volume if we had to push it all to the OR.

 

[nimbus]

We do zero ankle blocks. We just let the podiatrists do them, and they're always done with sedation in the OR.

I think they’re talking about blocks for ankle surgery, not ankle blocks.

 

[jwk]

I think they’re talking about blocks for ankle surgery, not ankle blocks.

My bad - we do ACBs, etc. for ankle fractures, scopes, etc., but always awake/sedated in pre-op, never in the OR.

 

[MirrorTodd]

Unless the patient hasn’t moved in years resulting in paper-thin anatomy.
Even then, you could do it. But is it smart?

Well admittedly, I am a young(ish) attending, but (n=1) I have seen more cases of LAST during a TAP block than I have of bowel puncture and the reason we identified the LAST so quickly is because of the signs and symptoms the pt expressed while awake, so from my perspective, it's safer for the pt to be awake/mildly sedated.

 

[neutro]

Sounds like your group needs to exert some influence if they have any, which sorry, it kinda sounds like you don't. (never mind the opt-out which is a crap excuse and a whole different topic!). It really sounds like the tail is wagging the dog.

We are a very busy private practice. We to a ton of blocks, especially for total knees and shoulder cases. ALL of them are done in pre-op. We don't do intra-op blocks except for TAPS. MDs do ALL of the blocks while the anesthetists are in the OR doing cases. We have block nurses in our hospitals as well as our outpatient centers. We simply told the hospital this is what we need. It doesn't require any additional personnel costs on their part. They are all pre-op nurses, and they all cross-train for a few hours (it's not rocket science) to be "block nurses". All they need to know is what drugs to draw up, how to aspirate the syringe to check for blood, and to inject how and when we tell them while we're looking at the US. BTW - drugs do not have to be labeled if they are drawn up and immediately administered (there's more time saved for ya)

Don't you have a block cart? All the drugs you need, block needles, probe covers, or whatever else you think you need? Put it all in one place, not scattered. Ours is in a secure area, no controlled substances, and locked, so it keeps pharmacy happy. One drawer has a security tag on it and has ambu, LMAs, intubation goodies, and other resuscitation equipment, as well as a bottle of intralipid. If the emergency drawer is accessed, we just tell pharmacy, who will restock it and reseal it. So all we need to have is the block cart and US. It's not difficult.

If we're doing spinals for THR or TKR, an anesthetist signs on with that patient in pre-op, patient is monitored and sedated, the spinal is done, block nurse comes in and helps with blocks if it's a TKR, and by that time the OR nurses are ready to take the patient to the OR. The anesthesia time with those actually starts in pre-op. If the block is done simply for postop pain relief, the doc does it with the block nurse. Surely you know that blocks for post-op pain are a separately chargeable procedure. A couple of blocks for a total knee often pays more than the anesthetic for the procedure. They're money-makers. If you're doing those in the OR, you're simply wasting OR time, which potentially means fewer cases per OR per day. In a high-volume quick turnover practice like ours, we simply couldn't manage the volume if we had to push it all to the OR.

Thank you for your feedback. We have a very different set up and practice, and both MDs and CRNAs perform their own cases.
Once we get to medical direction model, we can consider the usual practice.

This is about systems based practice and labor shortage, efficiency vs. patient safety.

 

[GassYous]

Well admittedly, I am a young(ish) attending, but (n=1) I have seen more cases of LAST during a TAP block than I have of bowel puncture and the reason we identified the LAST so quickly is because of the signs and symptoms the pt expressed while awake, so from my perspective, it's safer for the pt to be awake/mildly sedated.

How did you get last from a tap

 

[Urzuz]

I sincerely hope NOBODY is doing a TAP block awake or preop. #1 it likely is going to be an extended surgery so a lot of duration and benefit won't be realized. #2 WTF, why would you attempt to stick a muscle layer that is actively moving with each respiration (these are some of the accessory muscles of respiration, engaged especially when sedated). You better hope the needle moves with the IO and TA when administering the local because I can only imagine someone trying to hold the needle still, the patient contracts and RIP bowel.

As an aside, had a bad co-resident who was haphazard and stuck the bowel on a tap since he didn't care to find the tip of his needle. He was so confident that he facetiously said "aspirate there" thinking he was showing his chops with his knowledge that there are minimal vessels near this block site (block plane really). Welp, attending aspirated and lo and behold brown fluid/debris came back through the needle...

I had surgery a couple years back and my anesthesiologist (one of my partners) gave me a TAP in preop. He asked me if I wanted it asleep and I told him to do whatever he normally does because I didn’t want to dictate to him how to do his job. The only request I had is I didn’t want any midazolam because I didn’t want to say anything stupid/embarrassing that I didn’t remember to the nurses and techs I work with.

He gave me 50mcg of fentanyl and did the block. It was slightly uncomfortable but not bad at all (the IV hurt more)…hence my conclusion that only complete *****es can’t sit still for a block with sedation.

 

[MirrorTodd]

How did you get last from a tap

No idea, probably hit one of the vessels between the muscles layers. No blood on aspiration (although I wasn't the one aspirating so I can't guarantee how it was done).

 

[USCTrojan11]

I mean you can do a TAP block awake....but why would you when you can guarantee 100% the patient won't move/grab the needle. Also you get more realized benefit doing it at the end of the case since they'll be awake for a larger portion of the time the block is effective. Also it is way faster for us to do it in the OR than pre-op since we don't have to go through a pre-op nurse asking "how do you spell tRaVeRzus pLaNned bLock? Or is it tRaPeZiUs? tRaPeZoIdAl? Which side are you doing? Is it ok if I unplug your ultrasound? etc..."

I'm sure 199/200 times a TAP block with light or even no sedation would be fine. But I've performed plenty of blocks where the patient either wiggled, tried to grab the needle or started giggling which leads to movement. Imagine giggling on a tap block - you can literally see those muscles contract and relax. Sure, there's extremely low risk for bowel injury but to stay in the plane if you're the type that applies pressure to the needle....you're just probably giving a decent amount intramuscular.

 

[AnesRunner]

We do all of our blocks awake since we have/are a block team and sometimes do upwards of 30 blocks per day. It's a waste of everyone's time to do blocks in the OR under these circumstances (post-induction or pre-emergence). However, most places obviously don't have this set-up. If there is any chance of your needle getting remotely close to the peritoneum, you should not be doing a TAP block. There is a zero percent chance of bowel injury if you know what you are doing (asleep or awake, makes no difference). If the patient is grabbing the needle or moving while awake, you are doing something wrong (poor or non-existent local anesthestic infiltration with lidocaine prior to entering with the block needle, inappropriate sedation, or poor patient selection). From a technical perspective, it's actually much easier to do TAPs in the lateral position on awake patients. I've done both and heavily prefer an awake, lightly sedated, cooperative patient in pre-op.

That being said, there is nothing wrong with doing fascial plane blocks asleep depending on your set-up. When you are targeting an actual nerve, standard of care is awake.

 

[GassYous]

We do all of our blocks awake since we have/are a block team and sometimes do upwards of 30 blocks per day. It's a waste of everyone's time to do blocks in the OR under these circumstances (post-induction or pre-emergence). However, most places obviously don't have this set-up. If there is any chance of your needle getting remotely close to the peritoneum, you should not be doing a TAP block. There is a zero percent chance of bowel injury if you know what you are doing (asleep or awake, makes no difference). If the patient is grabbing the needle or moving while awake, you are doing something wrong (poor or non-existent local anesthestic infiltration with lidocaine prior to entering with the block needle, inappropriate sedation, or poor patient selection). From a technical perspective, it's actually much easier to do TAPs in the lateral position on awake patients. I've done both and heavily prefer an awake, lightly sedated, cooperative patient in pre-op.

That being said, there is nothing wrong with doing fascial plane blocks asleep depending on your set-up. When you are targeting an actual nerve, standard of care is awake.

I do all my upper extremities awake. I have no problem doing lower extremity blocks under spinal or general. Haven't had any issues as it's a nonissue with ipack/fi and it's pretty tough to mess up the popliteal nerve. I think most of the problems occured with interscalene blocks before ultrasound was widely used.

 

[OptionOffense]

Thank you for your responses.

Actually the reason I brought this up is because at our practice it is becoming more and more impossible to do blocks pre-op because there is no free person, nor anyone available to assist. Its just labor shortage. There is no dedicated block nurse, and anesthesia techs are already too busy. Pre-op nurses expect the block performer to gather all medications and sedation, ultrasound, and place the patient on monitors. These things are all in different parts of the pre-op suite. Cart and machine in one which only has syringes and labels and towels, intra-lipid only in PACU pyxis that must be taken out for individual patient and be bedside (cannot use one for the whole day); needles in anesthesia supply room, etc. I know this is a big part of the problem.

Secondly what is scaring me is that in our medical supervision practice both MDs and CRNAs perform their own cases independently (opt out state). Some of them are doing the blocks in the OR to avoid a second set up in pre-op. Not only that, the CRNAs are not readily calling anesthesiologists for complications or difficult anatomy (they prefer to call another CRNA first).

Thats why this whole conversation started in the first place to gauge if this is ok. We need to figure out a solution here keeping evidence and best practices in mind while not compromising efficiency.

I understand the risk esp. with inability to assess the patient under GA. I did read the article with case reports above - its very interesting, all poor outcomes appear to be due to ISBs. However, this is before US and 22 years ago.

Another point, what is the evidence that one will be able to avoid complications even with fentanyl and versed pre-op? Patient may not be appropriately responsive or arousable even with versed and fentanyl.
Relying on 'pain on injection or parasthesia' as a warning that you are directly on the nerve to withdraw the needle is not always consistently reported by patients, esp. under sedation - be it mild or moderate.

I contend that if U/S is used even by a reasonable operator and needle tip is kept in view, it will be almost impossible to enter the cervical spinal cord. There is a higher risk of entering a vessel than that for sure. Entering vertebral artery is also a remote possibility...but you'd have to be extremely posterio-medial from the entry point. if you keep the tip in view, I just dont see entering spinal cord being common place - you'd have to be extremely incompetent with U/S views to cause that.

Also, if there IS a complication and you get a high spinal from interscalene block, or LAST - isn't it better to deal with those complications in the OR anyways? Imagine intubating in pre-op bay all of a sudden and bolusing intralipid.

I dont know...i can see a point for both sides but I havent come across anything concrete that will convince me one way or ther other.

I am tending to think that truncal and lower extremity blocks in OR ideally before induction vs after are OK. Avoid UE blocks in OR. ISB ideally pre-op..

Just do it in the O.R. before induction. What is wrong with that and have the circulating nurse help you. If crnas are doing their own cases and MDs are doing their own what is the need for medical supervision?

 

[neutro]

Just do it in the O.R. before induction. What is wrong with that and have the circulating nurse help you. If crnas are doing their own cases and MDs are doing their own what is the need for medical supervision?

Yes we often do it in the OR pre-induction.

Hospital bylaws are the answer to your last part of question - they dictate that. We will be going to medical direction model pending more hiring of MDs and firing of some malignant ‘independent’ CRNAs.

 

[MirrorTodd]

Coincidentally, our block team just did a QL post induction to start our case. It took a lot longer than it should have considering the pt had been sitting in the preop area for about 2 hours prior to rolling back to the OR.

 

[patriot6]

I mean you can do a TAP block awake....but why would you when you can guarantee 100% the patient won't move/grab the needle. Also you get more realized benefit doing it at the end of the case since they'll be awake for a larger portion of the time the block is effective. Also it is way faster for us to do it in the OR than pre-op since we don't have to go through a pre-op nurse asking "how do you spell tRaVeRzus pLaNned bLock? Or is it tRaPeZiUs? tRaPeZoIdAl? Which side are you doing? Is it ok if I unplug your ultrasound? etc..."

I'm sure 199/200 times a TAP block with light or even no sedation would be fine. But I've performed plenty of blocks where the patient either wiggled, tried to grab the needle or started giggling which leads to movement. Imagine giggling on a tap block - you can literally see those muscles contract and relax. Sure, there's extremely low risk for bowel injury but to stay in the plane if you're the type that applies pressure to the needle....you're just probably giving a decent amount intramuscular.

Lol, it’s so easy. TAP in preop everytime. It’s a fine alternative. I like that we have dedicated preop nurses who draw up my local, prep, get my gloves, and hand me the needle and US. The circulator in the OR would be much less helpful. I have zero concerns about entering the bowel and can visualize my needle tip just fine despite those pesky spontaneous respirations and giggles.

 

[Modoc]

I like preforming preop (opiod reduction)/postop blocks (longer block duration) mainly because you get a live response from the patient if the needle is in the nerve via instant neuropathy. Peds I perform intraoperatively for obvious reasons (patient compliance, patient fears/trauma etc )

 

[Mehd School]

No blocks on athletes - ever.

Is this true? We have a hot shot orthopod that had led me to block MLB pitchers (two were all stars), NFL defensive linemen, big time Division 1 QB's (think SEC) etc and I was sweating bullets doing otherwise straightforward blocks on this population. That surgeon tends to get a lot of other surgeons as his patients and I don't like doing them either.

 

[NitroS]

Is this true? We have a hot shot orthopod that had led me to block MLB pitchers (two were all stars), NFL defensive linemen, big time Division 1 QB's (think SEC) etc and I was sweating bullets doing otherwise straightforward blocks on this population. That surgeon tends to get a lot of other surgeons as his patients and I don't like doing them either.

Not worth the risk. I remember reading article on Vikings football player who claimed adductor canal block that he got causing nerve damage/muscle weakness and ended his career. The doctors were sued for $180mil

 

[GassYous]

Is this true? We have a hot shot orthopod that had led me to block MLB pitchers (two were all stars), NFL defensive linemen, big time Division 1 QB's (think SEC) etc and I was sweating bullets doing otherwise straightforward blocks on this population. That surgeon tends to get a lot of other surgeons as his patients and I don't like doing them either.

I would never block someone who could blame me for the loss of $100 million

 

[USCTrojan11]

Is this true? We have a hot shot orthopod that had led me to block MLB pitchers (two were all stars), NFL defensive linemen, big time Division 1 QB's (think SEC) etc and I was sweating bullets doing otherwise straightforward blocks on this population. That surgeon tends to get a lot of other surgeons as his patients and I don't like doing them either.

It's definitely true for HSS for ACTIVE athletes - retired is a different story. Basically always weigh the R&Bs - unfortunately in this population, risk of opioid addiction and pain is minimal compared to neuropraxia or any other injury leading to alterations in performance and the liability for loss of career earnings.

 

[nimbus]

What’s the latest on prolonged quad weakness after femoral nerve blocks? The folks at our peds hospital stopped doing them on high school athletes a few years ago because they were concerned it could delay their return to the field by months and cause them to miss a season and scholarship opportunities.

 

[Urzuz]

Is this true? We have a hot shot orthopod that had led me to block MLB pitchers (two were all stars), NFL defensive linemen, big time Division 1 QB's (think SEC) etc and I was sweating bullets doing otherwise straightforward blocks on this population. That surgeon tends to get a lot of other surgeons as his patients and I don't like doing them either.

How did he “lead you” to block them? You should never be forced to do something you aren’t comfortable with.

And if you want to appease the surgeon but you still feel uncomfortable with doing it, just give the patient informed consent which will sway them towards not accepting it (ie: a block will lead to a temporary reduction in pain but your arm may never work again…conveniently leaving out the fact that permanent nerve injury is extraordinarily uncommon ). I’m sure most professional athletes would refuse it at that point…