Help with Blockjocks

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
excalibur

excalibur

Member
Verified Member
15+ Year Member
Joined
Oct 15, 2005
Messages
655
Reaction score
9
Hi guys,

Trying to get my dept to start CISB catheters for TSA's.

We just got the new Contiplex C catheters. Have a good idea on how to put them in from a few videos.

Tips on these particular catheters?

Also, anyone have access to blockjocks that they could PM me the full videos of the links I posted. I am not a member and am too lazy to register, plus I don't want to pay a fee.

Thanks

http://www.blockjocks.com/8kKy/vip-lecture-series-the-contiplex-c-catheter-over-needle-system

http://www.blockjocks.com/RBB7/contiplex-c-femoral-catheter
Members don't see this ad.
 
The name of the website and the cartoon crack me up, considering they want to be taken seriously.

PS: Pay up, bum.
 
Members don't see this ad :)
I don't think there are videos on nysora that demonstrate using the Contiplex C catheter over needle system from B Braun. I am aware how to do the block and how to use the catheters. I was just hoping for some video instruction on tips on using this specific system. I have already seen the videos with B Braun.

I was just posting because I noticed Blockjocks has some videos of guys demonstrating how to use the Contiplex C system. I was hoping someone here on SDN had access to blockjocks and could just send me a pm of the two full length videos from the links I posted above.

If not I will either just learn from trial and error or just pay for a month subscription to check out two videos.
 
I'm trying to figure out why you would put a catheter in this case. Our TSA pts are home the next day.
 
urge said:
The name of the website and the cartoon crack me up, considering they want to be taken seriously.

PS: Pay up, bum.
Click to expand...

As an almost "old guy" who picked up U/S regional on his own by self study, going to CME courses, and shadowing a guy for a a few days, I find the website a useful resource. Not sure that I will keep it for more than two years, as I suspect that its usefulness for me will end by then. It is a little cheesy with shameless self promotion, but that doesn't bother me. As far as "Pay up, bum" There aren't many communists on SDN anesthesia. Feel free to not subscribe or change the channel. :)
 
  • Like
Reactions: 1 user
Well I just paid the fee and got to see the videos. I don't know how long I will keep the subscription

Our TSA patients go home on POD 2. They also state that when our Bupi w Decadron blocks wear off at 30 hrs, that the pain is 8/10 or more. Since they will be in house and they are in considerable pain after a single shot, I felt a catheter would help

Also in residency Rotator cuff repairs would go home same day with a catheter and get it removed on post op day 2 by ortho doc in his clinic with excellent results.
 
excalibur said:
Well I just paid the fee and got to see the videos. I don't know how long I will keep the subscription

Our TSA patients go home on POD 2. They also state that when our Bupi w Decadron blocks wear off at 30 hrs, that the pain is 8/10 or more. Since they will be in house and they are in considerable pain after a single shot, I felt a catheter would help

Also in residency Rotator cuff repairs would go home same day with a catheter and get it removed on post op day 2 by ortho doc in his clinic with excellent results.
Click to expand...
So when you pull the catheter they aren't in pain?
 
dr doze said:
They pull it at home when the On-Q pump runs out. Filled with 550ml. Run @6-8 ml/hr. 3-4 days.
Click to expand...
Yes I understand this. I'm just making the alternative point here. It is my experience that these catheters can be more trouble than they are worth since TSA are not all that uncomfortable in my practice. At least not enough to place a catheter that runs for 3-4 days. But everyone is free to do as they wish I guess.

And everyone is gonna have some discomfort at some point. Where it's POD 1 or 2 or 3 is pretty much irrelative 6 weeks post-op.
 
excalibur said:
We just got the new Contiplex C catheters. Have a good idea on how to put them in from a few videos.
Click to expand...


Those catheter suck. They bend way too much. Extremely flimsy and don't allow good skin penetration. You have to hold the movable hub as close to the tip as possible when puncturing skin, then move hub back 2 cm and advance, Repeat 2 cm until youre in the right spot. Make sure your initial trajectory is spot on because once the needle enters muscle you'll never be able to redirect because of the flimsiness. Another huge problem is the catheter often slips over the needle tip while your trying to puncture the skin. Check it often if its really tough to puncture the skin, otherwise you'll damage the catheter.

I do a ton of catheters. We used to use those catheters. Do yourself a favor, get rid of them and get the pajunk catheter over needle. Its stiffer and literally like doing a single shot block. Plus they make a couple sizes.

As for the catheter placement... aim for the side of the snowman further away from you. I do an anterior approach and put the catheter more lateral and deep. Otherwise it will dislodge very very easy. Unlike the catheter through tuohy, there is no slack buried in the subcutaneous tissue. Throw a couple stereostips, a dash of dermabond on the insertion site, and a couple small tegaderms. We have a kit that has everything in it except the needle (Braun support block tray). The whole process takes me 5-10 minutes.
 
  • Like
Reactions: 1 user
RxBoy said:
Those catheter suck. They bend way too much. Extremely flimsy and don't allow good skin penetration. You have to hold the movable hub as close to the tip as possible when puncturing skin, then move hub back 2 cm and advance, Repeat 2 cm until youre in the right spot. Make sure your initial trajectory is spot on because once the needle enters muscle you'll never be able to redirect because of the flimsiness. Another huge problem is the catheter often slips over the needle tip while your trying to puncture the skin. Check it often if its really tough to puncture the skin, otherwise you'll damage the catheter.

I do a ton of catheters. We used to use those catheters. Do yourself a favor, get rid of them and get the pajunk catheter over needle. Its stiffer and literally like doing a single shot block. Plus they make a couple sizes.

As for the catheter placement... aim for the side of the snowman further away from you. I do an anterior approach and put the catheter more lateral and deep. Otherwise it will dislodge very very easy. Unlike the catheter through tuohy, there is no slack buried in the subcutaneous tissue. Throw a couple stereostips, a dash of dermabond on the insertion site, and a couple small tegaderms. We have a kit that has everything in it except the needle (Braun support block tray). The whole process takes me 5-10 minutes.
Click to expand...

What great info. Thanks, RxBoy. Yes, I initially wanted the Pajunk catheter over needle system as I heard same complaints about this B Braun system.

Our small hospital has some contract with B Braun so it looked like this was the best system to get. I wanted to at least try it out. I know it is possible to just do the catheter with the B Braun epidural kits, which we own, but I just don't know the tips and tricks of correctly placing the catheter tip by the plexus through the 17 g Tuohy. Felt like trying this catheter out as it seems simple enough. Will take your tips to heart RxBoy. Hopefully it goes well. Might consider getting the nerve block support tray as I was thinking of extra materials I might need and that tray would help.

I am aware there are better catheters out tere, but right now we do zero PNB catheters and I am trying to get our dept into it, and this system is what I was able to get, so I will try and make it work.

Thanks
 
Members don't see this ad :)
RxBoy said:
Those catheter suck. They bend way too much. Extremely flimsy and don't allow good skin penetration. You have to hold the movable hub as close to the tip as possible when puncturing skin, then move hub back 2 cm and advance, Repeat 2 cm until youre in the right spot. Make sure your initial trajectory is spot on because once the needle enters muscle you'll never be able to redirect because of the flimsiness. Another huge problem is the catheter often slips over the needle tip while your trying to puncture the skin. Check it often if its really tough to puncture the skin, otherwise you'll damage the catheter.

I do a ton of catheters. We used to use those catheters. Do yourself a favor, get rid of them and get the pajunk catheter over needle. Its stiffer and literally like doing a single shot block. Plus they make a couple sizes.

As for the catheter placement... aim for the side of the snowman further away from you. I do an anterior approach and put the catheter more lateral and deep. Otherwise it will dislodge very very easy. Unlike the catheter through tuohy, there is no slack buried in the subcutaneous tissue. Throw a couple stereostips, a dash of dermabond on the insertion site, and a couple small tegaderms. We have a kit that has everything in it except the needle (Braun support block tray). The whole process takes me 5-10 minutes.
Click to expand...


Are you out of plane? Since I am an old guy out of plane doesn't bother me much. I do single shots in plane but it seems placing the catheter out of plane when performing a ISB is simple.
 
hqdefault.jpg
 
I was planning on putting the ISB catheter in plane just like I do a single shot. I would go through the middle scalene and advance the needle from a posterior to anterior direction.

I talked to the reps at Pajunk at the ASA and other regional anesthesia presenters and several do the same in plane technique for single shot and continuous catheters
 
Based on my decades of experience I believe the technique described in the next post is the safest way to place a catheter. ISBs have the highest complication rate of any block we do based on published literature. Eventually, you will get a complication and remember this thread.
 
We read with interest the recent editorial by Fredrickson and Harrop-Griffiths [1], and agree with the points made regarding techniques to improve the safety of interscalene catheter placement. We propose a novel technique to improve safety further, involving placement of the catheter just within the scalenus medius muscle.

The brachial plexus is imaged in the conventional way and the medial border of scalenus medius is identified at a point where the nerve roots are most closely related. The needle can then be placed just lateral to this border using an out-of-plane technique until the tip lies just lateral to the plexus but just within the body of the scalenus medius muscle (Fig. 1). The catheter can then be inserted and threaded 3–4 cm beyond the needle, in an inferior direction away from the neuraxis, thus providing a degree of protection from misplacement. Scalenus muscle tissue and fascia therefore provide another physical barrier, increasing the safety of the catheter and reducing the likelihood of intravascular placement. Catheter position can be confirmed by observing local anaesthetic spread, and it can be used to administer the first bolus and subsequent infusion of local anaesthetic.


Figure 1. Ultrasound image of the interscalene groove with arrow showing the ideal position of the needle tip or interscalene catheter, using an out-of-plane (OOP) technique, just lateral to the medial border of scalenus medius. N = nerve root.

Combining two recent one-year retrospective surveys at Wrightington Hospital, we found a 100% success rate for interscalene nerve blocks or catheter insertions performed within the scalenus medius border (49 cases). This compares with a 91% success rate for conventional single-shot ultrasound-guided injections into the interscalene groove (171 cases; chi-squared p = 0.0271). Success was measured by lack of opioid use in recovery. In all cases, a low dose of 6–10 ml ropivacaine 0.75% was used, reducing the risk of muscle necrosis; there were no serious complications.


http://onlinelibrary.wiley.com/doi/10.1111/anae.12124/full
 
Last edited:
RxBoy said:
get the pajunk catheter over needle
Click to expand...

Pajunk >> BBraun on single shot catheters, too - except that you need to make sure the little tube to the needle is locked down before using it.

Anyone else here deal with BBraun's reps? The reps for my place are friendly but don't seem to know their products. We asked for anti-backflow valves (for IVs on shoulder cases, where they're ipsilateral to the BP cuff) and they sent samples of 2 or 3 totally unrelated products before concluding that they don't sell what I want in the US market. I guess it's possible, but seemed unlikely to me. I mean, it's an anti-backflow valve, not a target-controlled infusion pump or something that needs (and presumably won't soon get) FDA's blessing. I know I've seen them stateside - though admittedly I don't know who made the ones I had seen. Our rep also told us you can only get 50mm and 100mm stimulating needles, and I wanted 80mm, so we went with Pajunk. Then the rep called to try and sell us a new nerve stimulator for some reason, before asking what I thought of the needles. And when I told her, she said, oh, we have 80mm needles and sent me some. Odd. Again, maybe they just now started making them, but ... ??
 
Planktonmd said:
You have done "thousands" interscalene blocks with an anterior approach???
The picture you posted is not an anterior approach!
I guess you meant classic approach?
Click to expand...


The classic approach of Winnie, which is considered the anterior approach, is still commonly performed, especially for single-injection blockade [9]. The technique is performed by palpating the interscalene groove at the level of the cricoid cartilage (C6 vertebra). The needle is directed medially, slightly caudal, and slightly posterior (toward the contralateral elbow) while seeking to elicit a paresthesia in the C5-C6 nerve distribution as the endpoint for injection. The nerve stimulation technique is more commonly used with this approach today, with a relevant motor twitch being the endpoint for injection
 
BLADEMDA said:
Are you out of plane? Since I am an old guy out of plane doesn't bother me much. I do single shots in plane but it seems placing the catheter out of plane when performing a ISB is simple.
Click to expand...

In plane... I dislike out of plane because Im never too certain where the needle tip is located. Its not that I can't get it into position easily, but I never know if im puncturing nerve roots. We have the new xport sonosite u/s which is remarkably clear. You can almost always see the individual nerve roots... I keep the needle in view the whole time as I guide myself around the nerve roots. I go between upper and middle nerve root and place the catheter on the other side of the sheath. If I can't see individual nerve roots, I avoid puncturing the sheath altogether and place the catheter along the outside. If you're a novice, you should always avoid puncturing the sheath even if it results in a less than stellar block.

Couple tips... Never bolus medication through the needle. If you want to hydrodissect (I never do) use normal saline. I never stimulate either. Once your catheter is in position, bolus through the catheter and watch the spread. If you are really good with the ultrasound, you can even see catheter positioning. The reason i never bolus through the needle is because I want to know if the catheter works or not. Plus you never need to drop the hand holding the ultrasound.
 
Last edited:
excalibur said:
I was planning on putting the ISB catheter in plane just like I do a single shot. I would go through the middle scalene and advance the needle from a posterior to anterior direction.

I talked to the reps at Pajunk at the ASA and other regional anesthesia presenters and several do the same in plane technique for single shot and continuous catheters
Click to expand...

Try the anterior to posterior approach. Its much easier in my opinion and the catheter is very far from the surgical field. If you do post to anter approach... A good way to do it is to have the pt hug a pillow in the lateral position. Once your done, wrap the catheter around the posterior neck to the other side. Use tape/tegaderms to secure it along the course. One of our regional gurus used to do it that way and it worked well. I just like anterior cause its fast and easy. You do have to watch for the EJ and its slightly more painful because you often have to go through the belly of the SCM. But a lot of skin local fixes that problem.

Another tip is to tape a 4x4 over the tegaderm/insertion site. This way the catheter doesnt accidently get ripped out when the drapes gets pulled off at the end of surgery.
 
excalibur said:
I am aware there are better catheters out tere, but right now we do zero PNB catheters and I am trying to get our dept into it, and this system is what I was able to get, so I will try and make it work.

Thanks
Click to expand...

Before I joined the group, no one did catheters. I started the whole regional program there and like you I initially used epidural kits. Its possible to use but it takes me about 15-20 minutes to do, plus i have to look and open a ton of extra crap. The sterile us shealth, small tegaderms, masitisol, dermabond, sterostrips, ect. Positioning the catheter through the tuohy can become time consuming specially if you are doing it alone. With the nerve block support tray and needle over catheter, it literally takes me 5-10 minutes.

Also know the braun catheter over needle is not made for structures >5 cm. The rep will actually tell you this so they are useless for adductor canal or most popliteal blocks. The pajunk ones do it easily with the longer needle.

Here is a great video on how to use them:
http://www.pajunkadvantage.com/ecatheter.php
 
RxBoy said:
Try the anterior to posterior approach. Its much easier in my opinion and the catheter is very far from the surgical field. If you do post to anter approach... A good way to do Tis to have the pt hug a pillow in the lateral position. Once your done, wrap the catheter around the posterior neck to the other side. Use tape/tegaderms to secure it along the course. One of our regional gurus used to do it that way and it worked well. I just like anterior cause its fast and easy. You do have to watch for the EJ and its slightly more painful because you often have to go through the belly of the SCM. But a lot of skin local fixes that problem.

Another tip is to tape a 4x4 over the tegaderm/insertion site. This way the catheter doesnt accidently get ripped out when the drapes gets pulled off at the end of surgery.
Click to expand...


Good luck with puncturing the sheath. While you may think that you have seen it all I guarantee you the more you do the more you will back off. The complications for the surgery and/or anesthesia are real and our literature shows ISBs to have the greatest incidence of these complications. Even if you just brush by the C5 and/or C6 nerve root as you pass through the sheath there is a risk of injury to the nerve. These blocks aren't worth that small but real increased risk so I avoid penetration of the sheath altogether and just get close to the nerve roots. The quality of the block is EXCELLENT with local NEAR the roots so touching C5, C6 or C7 isn't required. A common mistake is thinking you need to contact the roots or penetrate the sheath to make this block work.

The technique for placing a catheter is not without its own risks like damaging the small nerves on the way to the roots or local anesthetic for 48-72 hours increasing myotoxicity.


http://bja.oxfordjournals.org/content/111/5/840.extract


http://bja.oxfordjournals.org/content/111/5/840.full.pdf
 
Last edited:
We read with great interest Drs. Hanson and Auyong’s article1regarding the identification of the dorsal scapular and long thoracic nerves during ultrasound-guided interscalene nerve block. As a busy orthopedic ambulatory surgery center, we perform a large number of interscalene perineural catheters for shoulder surgery (to see a demonstration of our technique, see the Supplementary Video athttp://www.blockjocks.com/ka8K). To minimize the possibility of phrenic nerve blockade, we, too, use a posterior approach for placing these catheters.2

In combination with a low-volume technique (typically < 15 mL of local anesthetic), we have subjectively observed a significant decrease in the incidence of postoperative respiratory complications while maintaining a nearly 100% success rate for postoperative analgesia. We also feel that traversing the middle scalene muscle provides a relatively unobstructed path to the posterior aspect of the cervical roots within the interscalene groove and avoids many of the vital structures encountered with an anterior approach including the phrenic nerve itself, the carotid artery, and the internal jugular vein.

Drs. Hanson and Auyong mention that they are unaware of any outcome data that support injury to the dorsal scapular and long thoracic nerves related to an interscalene block. We found this article to be timely as we were recently made aware of a patient who appears to have suffered long thoracic nerve injury following shoulder surgery, presumably as a result of interscalene perineural catheter placement.

Like the authors, we were unable to identify any other confirmed cases of nerve block–related long thoracic or dorsal scapular nerve injuries in the regional anesthesia literature (although we suspect that underreporting may play a role). Nevertheless, our recent experience demonstrates the importance of the findings in this article. It remains unclear to us whether the addition of nerve stimulation to the use of ultrasound would effectively reduce the likelihood of injury to these nerves by allowing safe needle redirection if long thoracic or dorsal scapular nerve twitch is elicited absent ultrasound visualization during needle passage. One could argue that systematic ultrasonographic with or without nerve stimulator–assisted identification of these nerves, or at the very least awareness of their presence, could help avoid adverse outcomes such as this one. We appreciate the hard work of Drs. Hanson and Auyong and look forward to any future studies related to this subject.

Scott E Thomas, MD

J. Brandon Winchester, MD

Gregory Hickman, MD

The Andrews Institute Ambulatory

Surgery Center
 
BLADEMDA said:
The classic approach of Winnie, which is considered the anterior approach, is still commonly performed, especially for single-injection blockade [9]. The technique is performed by palpating the interscalene groove at the level of the cricoid cartilage (C6 vertebra). The needle is directed medially, slightly caudal, and slightly posterior (toward the contralateral elbow) while seeking to elicit a paresthesia in the C5-C6 nerve distribution as the endpoint for injection. The nerve stimulation technique is more commonly used with this approach today, with a relevant motor twitch being the endpoint for injection
Click to expand...
I thought you said that you did thousands of anterior to posterior insertion!!!
My bad.
As for your advice to people to not puncture the sheath, it really depends on what the block is for and how much time you can wait for the block to be fully functional.
If the block is your main anesthetic you have to go through the sheath or your block is going to be slow and patchy.
If you only use these blocks for post op analgesia then staying out of the sheath might be OK.
 
Planktonmd said:
I thought you said that you did thousands of anterior to posterior insertion!!!
My bad.
As for your advice to people to not puncture the sheath, it really depends on what the block is for and how much time you can wait for the block to be fully functional.
If the block is your main anesthetic you have to go through the sheath or your block is going to be slow and patchy.
If you only use these blocks for post op analgesia then staying out of the sheath might be OK.
Click to expand...


The ISB involves blocking the Cervical roots. For this type of block entering the sheath isn't required for a solid block. This is very different than the Sciatic/Popliteal block. And yes, I have done thousands of the Classic ISB with a NS only. FYI, I have performed hundreds of SURGICAL ISB blocks without entering the sheath as our single shot, Classic ISB almost NEVER punctured the sheath.
 
BLADEMDA said:
The ISB involves blocking the Cervical roots. For this type of block entering the sheath isn't required for a solid block. This is very different than the Sciatic/Popliteal block. And yes, I have done thousands of the Classic ISB with a NS only. FYI, I have performed hundreds of SURGICAL ISB blocks without entering the sheath as our single shot, Classic ISB almost NEVER punctured the sheath.
Click to expand...
How do you know that your classic single shot ISB done without US never punctured the sheath???
 
Last edited:
Planktonmd said:
How do you know that your classic single shot ISB done without US never punctured the sheath???
Click to expand...
I remember doing a popiteal with an old school attending. He was doing the block but wanted my help with US imaging. Under US I got him to put the needle in my favorite spot... the Y spot in between the peroneal and tibial right where they branch off sciatic. Pop the sheath but no needle in the roots. Anyways he turns on NS and is like there is no twitches... im gonna readjust. I tell him not to, but he does of course. He pops the needle right into the nerve and is like see thats a good spot with twitches now at 0.8ish... he turns it down to 0.2 and it stops. He injects... Painful to watch the nerve getting injected but makes you wonder... How often were the nerves being pierced with the NS? Thats why I don't combine NS and US. I only do in that very rare situation i have a very questionable nerve bundle.

So Blade... Whats your approach for supraclaviculars? Do you avoid the sheath there too? I mean theyre trunks of the brachial plexus so a lot of nerve tissue risk like the roots for ISB. And yes like plankton said... Non sheath punctured blocks are very patchy. Even if local makes a complete circumference around the sheath. I know this because Ive seen it so many times. Sometimes theyre stellar, sometimes they suck. Its a lot like an epidural vs a spinal.
 
To make a blanket statement about needing to puncture the sheath for ALL nerve blocks is ill-advised. Some nerve blocks like the Femoral, ISB, ICB, etc. don't require a puncture of the sheath. Other blocks like the Sciatic/Popliteal do seem to require that we enter the sheath. I think the SCB is another example when puncturing the sheath is a good idea.

The roots of the brachial plexus seems particularly vulnerable to injury. These nerves don't really like to be touched much less irritated with a needle passing between 2 nerve roots. I expect you will revisit this thread after a thousand more blocks when you have a big enough "N" to see the adverse events associated with the technique. In the mean time do your best to avoid even the slightest injury to the cervical nerve roots with your technique.
 
Neurological complications after interscalene brachial plexus block
The main fear related to regional anaesthetic techniques is the risk of permanent neurological damage. In many papers about ultrasound
guidance the authors mention that ultrasound has the potential to lower neurological complications; however, the studies available
to date are too small to prove statistical significance. In a prospective data collection of 200 ultrasound guided ISB Davis et al found
temporary neurological deficit in two patients (1%) but no permanent neurological damage [11]. In another prospective data collection of
1010 ultrasound guided peripheral nerve blocks Fredrickson et al [12] found that the presence of paraesthesia during the procedure increased
the incidence of neurological abnormalities (odds ratio 1.7). The rates of new neurological deficits were: 8.2% at day 10, 3.7% at
1 month and 0.6% after 6 months. These rates are comparable with those reported previously following nerve stimulator techniques [13].
Liu et al, in their randomized controlled trial (total 219 blocks) reported a rate of 11% of neurological abnormalities in the nerve stimulator
group after 1 week vs 8% in the ultrasound group, and 7% after 4-6 weeks with nerve stimulator vs 6% with ultrasound guidance [2].
 
Anaesthesia. 2011 Jun;66(6):509-14. doi: 10.1111/j.1365-2044.2011.06712.x.
Ultrasound-guided interscalene blocks: understanding where to inject the local anaesthetic.
Spence BC1, Beach ML, Gallagher JD, Sites BD.
Author information

Abstract
Although ultrasound-guided regional anaesthesia has gained in popularity, few data exist describing the optimal location(s) to inject local anaesthetic. Our objective was to compare, for interscalene blocks, the effectiveness of an injection between the middle scalene muscle and brachial plexus sheath (peri-plexus) with an injection within the brachial plexus sheath (intra-plexus). We enrolled 170 patients undergoing shoulder surgery with general anaesthesia and interscalene block in this randomised, controlled trial. Our primary outcome variable was loss of shoulder abduction. Block quality was also measured and defined by an evaluation of onset time, sensory and motor loss and duration. There was no difference between the two groups in block onset times or block quality. After adjusting for sex, age and volume injected, intra-plexus blocks lasted a mean of 2.6 h (16%) longer (95% CI 0.25-5.01, p=0.03) than peri-plexus blocks.
 
Given that mechanical needle-nerve trauma is an important mechanism of peripheral nerve injury, providers are cautioned to avoid intentional intraneural injection 13 or needle-nerve contact during US-guided PNB. 8,14,15 Potentially hazardous needle-to-nerve proximity may be especially relevant during US-guided ISB, where inadvertent injection beneath the epineurium may be as high as 50%. 16Subepineural, and particularly intrafascicular, injection of local anesthetic may increase the risk of nerve injury. 17 Neural elements of the interscalene brachial plexus are predominantly comprised of axonal tissue 18 and may be especially susceptible to traumatic injury. The optimal needle-tip position relative to the target nerve that balances success and safety during US-guided PNB is elusive and has recently been described as the Holy Grail of regional anesthesia.14 Therefore, in this up-and-down study, we sought to explore the question “How close is close enough?” by determining the maximum distance that the needle tip can be placed from the nerve roots to achieve a successful ISB for analgesia after shoulder surgery.
 
Our study indicates that needle-nerve contact is not a requirement for an effective ISB and a distance of about 8 mm between the needle tip and brachial plexus sheath produces effective and long-lasting analgesia in 50% of patients. Further, although a distance of 1.6 mm can achieve a successful block in 95% of patients, the upper limit of our CI suggests that this distance may actually be far greater. In fact, despite the large distance between the needle tip and roots of the brachial plexus in the present study, the intraoperative and postoperative opioid requirements among patients with a successful block were equivalent to recently published trials that evaluated analgesic efficacy of US-guided ISB. 29,30 Similarly, the durations of sensory blockade and motor blockade among patients with a successful block fell within previously reported ranges using similar doses of local anesthetic.


http://www.ncbi.nlm.nih.gov/pubmed/24310046
 
I am still not sure how you came up with the blanket statement that your "thousands" of ISBs done before ultrasound were not in the sheath???
Are you the only one who can make blanket statements?
 
Last edited:
Planktonmd said:
I am still not sure how you came up with the blanket statement that your "thousands" of ISBs done before ultrasound were not in the sheath???
Are the only one who can make blanket statements?
Click to expand...


My ISB pre-ultrasound were Not intended to be inside the sheath. I routinely got a twitch at 0.5 then backed off the needle to around 0.80-1.0. Success rate was still 99% and complications very low. I tried to AVOID the sheath then as I do now. Maybe a few times the needle entered the sheath but my goal was and is to AVOID the sheath for an ISB.

I have provided peer review evidence for my opinions.
 
BLADEMDA said:
My ISB pre-ultrasound were Not intended to be inside the sheath. I routinely got a twitch at 0.5 then backed off the needle to around 0.80-1.0. Success rate was still 99% and complications very low. I tried to AVOID the sheath then as I do now. Maybe a few times the needle entered the sheath but my goal was and is to AVOID the sheath for an ISB.

I have provided peer review evidence for my opinions.
Click to expand...
The twitch response to a certain stimulation is a very poor predictor of needle position so your good intention or illusion to stay out of the sheath does not really translate into reality and you can't make a blanket statement to that effect.
Your blocks like everyone's blocks penetrated the sheath probably around 30% of the time and these were the best and quickest blocks you had. the rest were OK but a bit slower and patchy.

 
BLADEMDA said:
We read with great interest Drs. Hanson and Auyong’s article1regarding the identification of the dorsal scapular and long thoracic nerves during ultrasound-guided interscalene nerve block. As a busy orthopedic ambulatory surgery center, we perform a large number of interscalene perineural catheters for shoulder surgery (to see a demonstration of our technique, see the Supplementary Video athttp://www.blockjocks.com/ka8K). To minimize the possibility of phrenic nerve blockade, we, too, use a posterior approach for placing these catheters.
Click to expand...

I disagree that this should be the reason to do posterior approaches.

For me there are only 2 options:
1) Respiratory function adequate - Do the block and expect to block the phrenic.
2) Respiratory cripple - Do not do the block.

If they are a respiratory cripple, Im not doing a posterior approach because even a 2% chance is too much. If they have normal respiratory function I do the block knowing it wont matter if I block the phrenic. I wont create a grey category because the posterior approach supposably has less phrenic involvement. I'll just assume I block the phrenic regardless of the approach.
 
  • Like
Reactions: 1 user
point of clarification, people always talk about the nerve roots. When you are doing an interscalene block, you are blocking the brachial at the level of the trunks, not the individual nerve roots. You can see this under ultrasound because as you follow the trunks distally, they split into divisions. At least under ultrasound that is what you are doing. It's almost impossible in many patients to actually visualize the C5, C6, and C7 nerve roots as they quickly join together with C8 and T1 to form the superior, middle, and inferior trunks.

I suppose under a landmark based (nerve stimulator) technique you might actually be putting the local on the nerve roots in some patients, but I doubt it unless you are taking a really weird approach.
 
RxBoy said:
I disagree that this should be the reason to do posterior approaches.

For me there are only 2 options:
1) Respiratory function adequate - Do the block and expect to block the phrenic.
2) Respiratory cripple - Do not do the block.

If they are a respiratory cripple, Im not doing a posterior approach because even a 2% chance is too much. If they have normal respiratory function I do the block knowing it wont matter if I block the phrenic. I wont create a grey category because the posterior approach supposably has less phrenic involvement. I'll just assume I block the phrenic regardless of the approach.
Click to expand...


Fair Enough and a reasonable thought process. I have had good success with COPD patients with a SCB low Volume technique. I place up to 15 mls of Local below C7 and above the artery. But again, I certainly would agree that even a reduced risk (10% or so chance of blocking the phrenic nerve) may still be too high when there are alternatives available.
 
  • Like
Reactions: 1 user
Mman said:
point of clarification, people always talk about the nerve roots. When you are doing an interscalene block, you are blocking the brachial at the level of the trunks, not the individual nerve roots. You can see this under ultrasound because as you follow the trunks distally, they split into divisions. At least under ultrasound that is what you are doing. It's almost impossible in many patients to actually visualize the C5, C6, and C7 nerve roots as they quickly join together with C8 and T1 to form the superior, middle, and inferior trunks.

I suppose under a landmark based (nerve stimulator) technique you might actually be putting the local on the nerve roots in some patients, but I doubt it unless you are taking a really weird approach.
Click to expand...
I think you are right!
I think with Ultrasound we almost always go low in the neck very close to the supraclavicular approach and as a result we always get trunks not roots.
 
Last edited:
BLADEMDA said:
cp17.jpg
Click to expand...

I'm saying those pictures are labeled incorrectly. Because if from that spot you follow distally, C5 and C6 don't come together to form a single superior trunk. They split into divisions.

I don't know why everybody always says that. If they were truly the individual roots, you'd see them come together as you go distally, not spread apart. They spread apart. Every time.
 
  • Like
Reactions: 1 user
Planktonmd said:
The twitch response to a certain stimulation is a very poor predictor of needle position so your good intention or illusion to stay out of the sheath does not really translate into reality and you can't make a blanket statement to that effect.
Your blocks like everyone's blocks penetrated the sheath probably around 30% of the time and these were the best and quickest blocks you had. the rest were OK but a bit slower and patchy.
Click to expand...



American Society of Regional Anesthesia and Pain Medicine's 2015 annual meeting (abstract 282).

http://www.anesthesiologynews.com/V...a&d_id=540&i=August+2015&i_id=1212&a_id=33159

FYI, my injections are now all 0.5-1 mm away from the nerve roots/trunks when performing an ISB. My efficacy still remains at 99% and I firmly believe the evidence now supports this as the BEST technique in terms of risk/benefit.
 
Last edited:
BLADEMDA said:
American Society of Regional Anesthesia and Pain Medicine's 2015 annual meeting (abstract 282).

http://www.anesthesiologynews.com/V...a&d_id=540&i=August+2015&i_id=1212&a_id=33159

FYI, my injections are now all 1-2 mm away from the nerve roots/trunks when performing an ISB. My efficacy still remains at 99% and I firmly believe the evidence now supports this as the BEST technique in terms of risk/benefit.
Click to expand...


The researchers concluded that there is an 11.5% chance that the needle-tip position may be subepineurial with an intraplexus approach. The absence of ink spread for the periplexus approach suggests that it “may be less likely to result in mechanical trauma to nerves from direct needle injury.”

“It behooves us all to find the safest techniques to be able to do these blocks, and it suggests that maybe we should be considering abandoning these intraplexus techniques if there isn't any clinical benefit,” said Dr. Kwofie.
 
You must log in or register to reply here.
Next unread thread

Similar threads

BeatriZZ
blockjocks regional anesthesia preceptorship
Replies
1
Views
1K
turnupthevapor
T
Top