Lower Extremity PNBs

[DreamLover]

Out of curiosity...

Is there anyone out there still routinely performing high sciatic blocks (in combo with femoral for example) for post op analgesia? (I'm specifically excluding Pop blocks and any need to perform these blocks for surgical anesthesia for appropriate reasons)

More and more of my orthopods are of course wanting less and less regional with desires for adductor canal blocks of the saphenous Vs Common femoral N and not wanting any sciatic block for knees etc.

Is this what others are coming across too? Are people still routinely placing FN caths for knees? These Exparel injections are becoming very common in my hospital.

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[somedumbDO]

Adductor canal catheters plus surgeon local walking and pain free, pod 0. We don't have exaprel.

 

[BLADEMDA]

Out of curiosity...

Is there anyone out there still routinely performing high sciatic blocks (in combo with femoral for example) for post op analgesia? (I'm specifically excluding Pop blocks and any need to perform these blocks for surgical anesthesia for appropriate reasons)

More and more of my orthopods are of course wanting less and less regional with desires for adductor canal blocks of the saphenous Vs Common femoral N and not wanting any sciatic block for knees etc.

Is this what others are coming across too? Are people still routinely placing FN caths for knees? These Exparel injections are becoming very common in my hospital.

Local injection by surgeon with adductor canal blocks.

A few of the old guys still prefer Femoral blocks but I avoid high sciatic blocks. Instead, selective tibial blocks or no sciatic/popliteal block at all.

Patients do fine with local injection plus adductor canal blocks. The few patients who complain of severe pain postoperatively (less than 5 percent) get rescue blocks in pacu.

 

[DreamLover]

Local injection by surgeon with adductor canal blocks.

A few of the old guys still prefer Femoral blocks but I avoid high sciatic blocks. Instead, selective tibial blocks or no sciatic/popliteal block at all.

Patients do fine with local injection plus adductor canal blocks. The few patients who complain of severe pain postoperatively (less than 5 percent) get rescue blocks in pacu.

I don't do any high sciatic blocks for post op analgesia myself, but I do still perform popliteal/saphenous blocks. Are most people shying away from those too?

 

[Noyac]

My orthopods are not having their pts walk POD #0. But they want them ready to walk the next morning for sure and we are getting the pts out of the hospital on POD 2 frequently but not every time. I don't know the actual numbers that are leaving POD 2. So I do a FNB and an Anterior Sciatic because it is virtually in the same area for needle insertion. I can prep for both blocks at the same time with the same chloraprep. The two blocks take less than 5-10 min from start to finish. The time to complete the block doesn't really after if you have time but we do our own cases and we do these blocks btw cases during turnover. The FNB gets 0.5% Ropiv and the Ant SNB gets 1.5% Mepivicaine. The SNB lasts about 8 hrs and is gone by the evening so it isn't impairing their ability to ambulate the next day. That is the key in my institution. Do what you want but have the pt ready to walk the next morning, is what our orthopods say.

If they wanted their pts walking POD 0 then we would change.

 

[DreamLover]

My orthopods are not having their pts walk POD #0. But they want them ready to walk the next morning for sure and we are getting the pts out of the hospital on POD 2 frequently but not every time. I don't know the actual numbers that are leaving POD 2. So I do a FNB and an Anterior Sciatic because it is virtually in the same area for needle insertion. I can prep for both blocks at the same time with the same chloraprep. The two blocks take less than 5-10 min from start to finish. The time to complete the block doesn't really after if you have time but we do our own cases and we do these blocks btw cases during turnover. The FNB gets 0.5% Ropiv and the Ant SNB gets 1.5% Mepivicaine. The SNB lasts about 8 hrs and is gone by the evening so it isn't impairing their ability to ambulate the next day. That is the key in my institution. Do what you want but have the pt ready to walk the next morning, is what our orthopods say.

If they wanted their pts walking POD 0 then we would change.

Ours are OOB POD#0 unless the case ends after 7pm essentially

 

[Planktonmd]

Local injection by surgeon with adductor canal blocks.

A few of the old guys still prefer Femoral blocks but I avoid high sciatic blocks. Instead, selective tibial blocks or no sciatic/popliteal block at all.

Patients do fine with local injection plus adductor canal blocks. The few patients who complain of severe pain postoperatively (less than 5 percent) get rescue blocks in pacu.

By the way ... patients do as well with local injections without the adductor canal block...

 

[DreamLover]

By the way ... patients do as well with local injections without the adductor canal block...

So you don't do any block for knees? Just the surgeon's local concoction?

What about for ankles and feet? Surgical local only?

 

[BLADEMDA]

https://ccme.osu.edu/RSSeriesBrochure/26169 - Continuous Adductor Canal Blocks Are Superior to C.pdf

 

[BLADEMDA]

So you don't do any block for knees? Just the surgeon's local concoction?

What about for ankles and feet? Surgical local only?

We had a surgeon who refused to allow his patients to get blocks for a TKA. I talked him into allowing me to do Adductor canal blocks plus his local injection. The surgeon informs me that he wants adductor canal blocks on all his patients. The pain scores are lower with the adductor canal plus local injection vs local injection alone and ambulation isn't impaired.

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/femoral-nerve-block-and-quadriceps-weakness.1004519/

We have discussed this topic many times over the past few years

 

[DreamLover]

We had a surgeon who refused to allow his patients to get blocks for a TKA. I talked him into allowing me to do Adductor canal blocks plus his local injection. The surgeon informs me that he wants adductor canal blocks on all his patients. The pain scores are lower with the adductor canal plus local injection vs local injection alone and ambulation isn't impaired.

This is almost identical to our surgeons as well. They really do like adductor canal blocks but I've not placed a continuous catheter. The continuous FN caths went out the window over the last year.

 

[Planktonmd]

So you don't do any block for knees? Just the surgeon's local concoction?

What about for ankles and feet? Surgical local only?

Our surgeons are injecting Exparel around the knee and most of the times a block is not needed.
The results are impressive although it took us a while to actually accept it.
As for other joints "ankles and feet" we are only doing blocks for rescue.
We used to do blocks on all these patients but times are changing.

 

[Planktonmd]

https://ccme.osu.edu/RSSeriesBrochure/26169 - Continuous Adductor Canal Blocks Are Superior to C.pdf

I am saying that no block at all with a surgeon who does a good exparel injection is as good as either Femoral or adductor canal block.

 

[DreamLover]

I am saying that no block at all with a surgeon who does a good exparel injection is as good as either Femoral or adductor canal block.

I find that Adductor Canal block with surgical infiltration of joint and incision etc by the surgeon is better than no PNB-granted that's just subjective for me.

 

[BLADEMDA]

Regional Anesthesia & Pain Medicine:
July/August 2013 - Volume 38 - Issue 4 - p 334–339
doi: 10.1097/AAP.0b013e318296b6a0
Original Articles
The Impact of Analgesic Modality on Early Ambulation Following Total Knee Arthroplasty
Perlas, Anahi MD, FRCPC*†; Kirkham, Kyle R. MD, FRCPC,*†; Billing, Rajeev MD,*†; Tse, Cyrus BSc,*; Brull, Richard MD, FRCPC,*; Gandhi, Rajeev MD, FRCSC,‡; Chan, Vincent W. S. MD, FRCPC*†



Introduction: Total knee arthroplasty is associated with moderate to severe pain, and effective analgesia is essential to facilitate postoperative recovery. This retrospective cohort study examined the analgesic and rehabilitation outcomes associated with 48-hour continuous femoral nerve block, local infiltration analgesia, or local infiltration analgesia plus adductor canal nerve block.

Methods: Patients undergoing total knee arthroplasty under spinal anesthesia, during an 8-month period, were retrospectively assessed with a targeted review of 100 patients per group. Records of eligible patients were reviewed to identify the analgesic technique used and the primary outcome of distance walked on postoperative day 1. Secondary outcomes included ambulation on days 2 and 3, numeric rating scale pain scores, opioid consumption, and adverse effects and discharge disposition.

Results: Two hundred ninety-eight eligible patients were reviewed. Local infiltration analgesia and local infiltration plus adductor canal block were associated with longer distances walked on postoperative day 1 than continuous femoral nerve block (median values of 20, 30, and 0 m, respectively; P < 0.0001). The addition of adductor canal block was associated with further improvement in early ambulation benchmarks and a higher rate of home discharge compared with only local infiltration (88.2% vs 73.2%, P = 0.018). Local infiltration with or without adductor canal block was associated with lower pain scores at rest and during movement for the first 24 hours and lower opioid consumption than continuous femoral nerve infusion.

Conclusions: Local infiltration analgesia was associated with improved early analgesia and ambulation. The addition of adductor canal nerve block was associated with further improvements in early ambulation and a higher incidence of home discharge.

 

[DreamLover]

Yeah-that's basically my practice but I still have friends around the country doing fem single shots or caths or a combo fem/sci for their knees.

Several friends have their surgeons injecting Exparel as well.

 

[OB1🤙]

No need for adductor canal catheters. A single shot block with decadron lasts more than a day without the hassle of the catheter.

 

[DreamLover]

No need for adductor canal catheters. A single shot block with decadron lasts more than a day without the hassle of the catheter.

What's your combo? 10cc 0.5% Ropi with how much decadron?

I'm leary of decadron because I have a huge portion of my patients that are poorly controlled, diabetic vasculopaths and I don't know how I feel about decadron that close to their nerves.

 

[OB1🤙]

I use 20cc 0.5% PF bupi, from the same vial I would have used for the spinal, plus 2.5mg (a quarter cc) PF decadron.

In a raging diabetic you could use just 1mg decadron, or just skip it.

I do my ACB at the end of the case after the dressing is on. Takes less than three minutes. I feel this has a few advantages:

1) No dealing with the logistics of getting the block done preop, no nursing hoops to jump through
2) A couple extra hours of analgesia ( block done a couple hours later)
3) No tourniquet on the pool of local, wish is probably no biggie but some worry about spread.

 

[BLADEMDA]

What's your combo? 10cc 0.5% Ropi with how much decadron?

I'm leary of decadron because I have a huge portion of my patients that are poorly controlled, diabetic vasculopaths and I don't know how I feel about decadron that close to their nerves.

20 mls of 0.5% PF Bupivacaine with 1 mg of decadron for diabetics or 2 mg of decadron for patients without diabetes. The block typically lasts for 24 hours or more.

 

[DreamLover]

Does anyone who is placing Adductor Canal catheters preop have problems with it's location and the tourniquet placement?

It seems like it'd be directly under the tourniquet and I don't know how I'd feel about having the catheter squeezed near the nerve for X hrs.

 

[Colba55o]

Also are those who are doing single shot Adductor Canal blocks post op able to get to mid thigh after the dressing is applied? Our surgeons wrap the ACE bandage at least halfway up the thigh.

 

[FootAndAnkle]

Our surgeons are injecting Exparel around the knee and most of the times a block is not needed.
The results are impressive although it took us a while to actually accept it.
As for other joints "ankles and feet" we are only doing blocks for rescue.
We used to do blocks on all these patients but times are changing.

I was just perusing this post and was wondering if this means that for foot and ankle procedures you do find utilizing Exparel useful to help with post-op analgesia or do you consider it overkill/unnecessary? I wasn't sure if the special bupivicaine formulation distinguishes this from the normal blocking with lidocaine or bupivicaine that you only do for rescue. Just a student that is curious - sorry if there's an obvious answer I missed already on here .

 

[OB1🤙]

Also are those who are doing single shot Adductor Canal blocks post op able to get to mid thigh after the dressing is applied? Our surgeons wrap the ACE bandage at least halfway up the thigh.

I do it mid thigh usually, right around where the ACE wrap ends. Occasionally I'll fold a small part of it down if the target looks better more distal. When I first started doing it this way I'd do it before they put the wrap on, but found that I didn't really have to to get to my target. Better to let the ortho go on his/her merry way.

 

[Planktonmd]

I was just perusing this post and was wondering if this means that for foot and ankle procedures you do find utilizing Exparel useful to help with post-op analgesia or do you consider it overkill/unnecessary? I wasn't sure if the special bupivicaine formulation distinguishes this from the normal blocking with lidocaine or bupivicaine that you only do for rescue. Just a student that is curious - sorry if there's an obvious answer I missed already on here .

Exparel is long acting and it could give you up to 72 hours of analgesia compared to 12-24 hours with regular Bupivacaine.
But sometimes 72 hours of neural blockade is not desirable especially if a motor nerve is involved.
Infiltration at the surgical site by the surgeon usually targets the sensory nerve endings and rarely involves any motor nerves which makes Exparel ideal.

 

[FootAndAnkle]

Exparel is long acting and it could give you up to 72 hours of analgesia compared to 12-24 hours with regular Bupivacaine.
But sometimes 72 hours of neural blockade is not desirable especially if a motor nerve is involved.
Infiltration at the surgical site by the surgeon usually targets the sensory nerve endings and rarely involves any motor nerves which makes Exparel ideal.

Wow, that's pretty cool! I can see how targeting sensory without influencing motor function is a nice benefit, and thank you for the response (for some reason I hadn't learned about that formulation yet, even in pharmacology - I'll be interested to see if it's currently being applied by pods when I start clinical work).

 

[epidural man]

We have done some femoral nerve blocks with exparel. It doesn't work nearly as well as a catheter for TKA. It works okay in the adductor canal space for other surgeries.

I think it is a question of concentration. let's say you run 0.125% bupviciane at 8cc's an hour for 3 days. That is 720mg of bupivicaine on the nerve.

If you do a single shot - full dose exparel injection, the is only 266mg on the nerve. That is a huge difference - and probably explains why exparel on the femoral nerve doesn't make them weak generally - but also is sub par for a very painful procedure - TKA.

I would like to see a study compare knee infiltration with liposomal bupivicaine, vs adductor canal and popliteal with exparel - to see which lasts longer. I think it needs to be in a less painful surgery for reasons I just explained.

Exparel works PHENOMENAL in TAP blocks.