Sciatic block approaches

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Triple AAA

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How many of you guys still do sciatic blocks with the transgluteal approach? Do you find it better/more effective than the popliteal approach?

I ask because transgluteal sciatic blocks are pretty much the only peripheral blocks that I was not trained to do under ultrasound guidance. We always did it w/ PNS due to the depth of the nerve and gluteal contours. If I had to do it by myself, I wouldn't necessarily feel comfortable. But the way I see it, popliteal blocks cover most of the area that a transgluteal would cover anyway, and if the area in between were affected, the patient would probably be better off with neuraxial in the first place. Thoughts?

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I was trained to do both anterior and classic Labat approach. In PP land, I roll them on their side and do a Labat 99/100. It's fast once you get good at it, less painful, and works well.
 
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I do the anterior approach mostly because I'm doing it in conjunction with a FNB for something like a TKA or ACL. The anterior just makes sense to me since its insertion site is only a few cm below the FNB.
 
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I was trained to do both anterior and classic Labat approach. In PP land, I roll them on their side and do a Labat 99/100. It's fast once you get good at it, less painful, and works well.

Do you find it to be more effective/utile than a popliteal block? Both essentially give the same coverate to the area below the knee. The only difference I see is extra block of the posterior thigh, for which I question the necessity.
 
Better for tourniquet pain if you are doing pure regional but i doubt a lot of people do this. I don't do FNB anymore and i was never good at the anterior sciatic approach. Popliteal or infra-gluteal if the anatomy dictates.
 
Depends on the procedure: Parasacral for hips. High pop for knees. If I'm going for speed in conjunction with a fem block, then ant sciatic.
 
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Roll em to the side and Labat. (I'm in PP). Can hit it in less time than it takes the ultrasound to boot up.
 
AKA would be benefit from suglut or higher block rather than popliteal.

On revision there would be no popliteal. Mod labat by pns would be difficult as there are no muscles to twitch.
 
Depends on the procedure: Parasacral for hips. High pop for knees. If I'm going for speed in conjunction with a fem block, then ant sciatic.
Are you doing sciatics for hip regularly? and femorals? i thought you switched to adductor canal blocks
 
Are you doing sciatics for hip regularly? and femorals? i thought you switched to adductor canal blocks

Correct. I do ACB for most TKA patients as we ambulate on POD "0".

If not, or there is a good medical reason, or the patient requests them, I'll do fem pops or fem ant. sciatics.

For hips, it again depends on the patient. FIB, parasacral + LP or LP alone. Usually FIB as it's the fastest and I can do them under GA. Parasacrals and LP take slightly longer and the patients are awake. I don't do LP on the elderly anymore.
 
Do you see an advantage with FIB alone? i didn't so i stopped...
Don't hips ambulate on POD 1 also?
 
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Don't hips ambulate on POD 1 also?

We have one ortho who likes them to be OOB and ambulating on Day 0. He injects some Toradol, bupivicaine, and morphine into the joint. I just do a tetracaine spinal for those patients. He also puts a scop patch on everyone.

I think he's a *****. And he's among the last surgeon I'd refer someone to for a THA. But his patient's love him. So, who am I to judge? He brings the patients to me. Not the other way around.
 
Do you see an advantage with FIB alone? i didn't so i stopped...
Don't hips ambulate on POD 1 also?

Sorry about the late reply. Been recovering from the hardest enduro I've ever done.

DSC_1640.jpg


Man... what a ball buster.

Anywho...

We ambulate everyone on POD 0. FIB is helpful if you are lucky enough to get some of the lumbosacral plexus via cephalad spread. Lateral femoral should be easy to get, but you really don't want to get the femoral if you are up and walking after surgery. So you need to really look at your spread as you are injecting- unless it's late in the day as PT won't work with many people after 4pmish. If you point the needle up towards the hip, you can get some pretty decent analgesia in some patients. I believe it is capable of getting 2/3 or the hip joint.
 
That's some serious mud. Not fun. I'm sure the rest of the course was tho.

I frequently do as Sevo describes but I also put a good bit of pressure just distal to the needle insertion site to push the local cephalad. It works very well.
 
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I frequently do as Sevo describes but I also put a good bit of pressure just distal to the needle insertion site to push the local cephalad. It works very well.
I guess i'll get back at it. Do you give them a morphien pca? how much do they use on average?
 
Sevo, are one of the guys in the photo?

The moto on the far left of the picture might as well have been me. But no. Not in that pic.
Had a dude wipe out in front of me in one of the mud pits. I lost momentum and got stuck.... badly. Some spectators were nice enough to help me out of the pit. Lost some time there, but more importantly I spent a lot of energy. The rest of the course was single track/woods, moto track with jumps, creek crossings and some nasty steep hill climbs with ledges and roots. Thankfully, the Colorado mountains (and my moto friends out there ;)) have taught me how to climb those decently well, so I made up some time there.

That enduro is as much physical as it is mental. Banged up and bruised up today, but feeling good. :hungover:
 
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Sciatic blocks. I still love 'em. For about 5-10% of patients status post total knee a Popliteal/Sciatic block is needed. For about 5% of Classic, Posterior approach total hip replacements a sciatic block is needed. For AKAs I am able to do a HIGH POLITEAL (mid thigh) under U/S which completely blocks the area causing the pain (with a Femoral block of course). A SubGluteal or Gluteal sciatic is rarely needed.

I like U/S for all my blocks but for the BIG PEOPLE I use just a nerve stimulator when blocking the sciatic nerve in the gluteal region. My approach is Labat but as the BMI exceeds 40 the Franco approach starts looking like the way to go. No matter how fat the patient the Franco approach plus a 6" needle gets the job done.


 
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