any private docs out there using lumbar plexus blocks?

hotsaucewilliam · Dec 12, 2009

jus curious.
you folks get many complications?
I was thinking of starting some single shots for our post op hips.
all our pts get GA plus dilaudid.

sevoflurane · Dec 12, 2009

I do them regularly for my hips. Most of our surgeons are requesting them because they do not like indwelling epidural catheters for hips. Our patients are up and walking on POD 0. I tried using lumbar plexus catheters, but I find them to not be very reliable and time consuming since you don't always get a twitch. Single shot works well for me for the first day + orthopod injects rop with epi into the capsule before closing. For lumbar plexus, I use combined LOR/Twitch... which ever comes first. Drop 35 cc's of .5% marcaine with clonidine/epi.

sevoflurane · Dec 12, 2009

I'ver never personally seen a complication, but one of our attendings during residency had an epidural spread from one and the patient ended up with low BP's.

Arch Guillotti · Dec 12, 2009

sevoflurane said:
For lumbar plexus, I use combined LOR/Twitch... which ever comes first. Drop 35 cc's of .5% marcaine with clonidine/epi.

Could you explain a little more about the LOR w/a LPB? I use a stim needle only. The only time I use LOR is finding the epidural space.

I have seen epidural spread from LPB a handful of times, and sometimes it can be very dramatic.

Planktonmd · Dec 12, 2009

There was a study not too long ago that showed I think that there is epidural spread in about 20% or so.

I found that I can achieve the same post-op analgesia with a fascia iliaca block with almost no risk at all.

Noyac · Dec 12, 2009

Planktonmd said:
There was a study not too long ago that showed I think that there is epidural spread in about 20% or so.

I found that I can achieve the same post-op analgesia with a fascia iliaca block with almost no risk at all.

Exactly. High rate of epidural spread and the block can be achieved with almost identical results with a fascia iliaca. I don't do LPB's any longer. Hips don't hurt like knees do and the IT MS seems to be plenty.

Another downside to the LPB is inadvertent renal vessel injury. Anyone seen this?

sevoflurane · Dec 12, 2009

Arch Guillotti said:
Could you explain a little more about the LOR w/a LPB? I use a stim needle only. The only time I use LOR is finding the epidural space.

It is essentially the same technique. The difference is that you use a stimulating 4 3/4 - 6" tuohy neelde depending on patient size. You will need more local and a bit more sedation. There are a couple of different tweaks you can use to your approach with a combined lor/stimulating technique.

You don't want to create false tracts with your tuohy (will make your LOR more difficult to feel). Once you've created 3-4 passes you may have to rely on twitch alone. To overcome this, I first use a spinal needle to find my way to the transverse process (it will not form appreciable tracts). I leave it in place and use it as a guide to hit the TP with the Tuohy. Once there, I remove the spinal needle and walk off this point 1cm cauad, cephalad or lateral. When you start to walk off apply LOR technique. This is the only block I use the plastic 5cc syringes and I only use air. Advancement is slower than when looking for epidural space as the LOR is not nearly as distinct. As you pop through the fascia of the psoas compartment you will get your LOR or twitch or both. Again, you only want to make one or two passes as you will loose your ability to feel LOR with many passes. Additionally, you increase your chances-substantially- of clogging your tuohy needle with fat/muscle- you will never get a LOR in this case. The process should take about 5 minutes or less from prep to drug administration. Success rate with LOR is just as good as stimulation.

Injection should have 0 resistance. If you have any you are not in the right space, likely injecting into muscle. It should go in like butter. More easily than an epidural bolus with a 10cc syringe.

Hope this helps.

sevoflurane · Dec 12, 2009

Combined with a parasacral approach to the sciatic, the lumbar plexus block is a useful tool, especailly if your incision is higher than you wanted it to be.

sevoflurane · Dec 12, 2009

I am not convinced that a Fascia Iliaca is as good for acetabular pain as a LP. Acetabulum is dualy innervated as it is, which is why a hihgh sciatic/parasacral apporach is good for hips- at least this is what I was taught in residency. I wish I could find some info on this matter, but I do remember some great lectures that stated that lumbar plexus was more predictable at achieving acetabular analgesia. I can't back this up though.

Planktonmd · Dec 12, 2009

sevoflurane said:
I am not convinced that a Fascia Iliaca is as good for acetabular pain as a LP. Acetabulum is dualy innervated as it is, which is why a hihgh sciatic/parasacral apporach is good for hips- at least this is what I was taught in residency. I wish I could find some info on this matter, but I do remember some great lectures that stated that lumbar plexus was more predictable at achieving acetabular analgesia. I can't back this up though.

You are right that the LP block is probably more predictable but we do these blocks for post op analgesia and narcotic sparing not to be used as the only analgesic.
The risk and benefit balance is really not in favor of LP blocks.

Arch Guillotti · Dec 12, 2009

sevoflurane said:
It is essentially the same technique. The difference is that you use a stimulating 4 3/4 - 6" tuohy neelde depending on patient size. You will need more local and a bit more sedation. There are a couple of different tweaks you can use to your approach with a combined lor/stimulating technique.

You don't want to create false tracts with your tuohy (will make your LOR more difficult to feel). Once you've created 3-4 passes you may have to rely on twitch alone. To overcome this, I first use a spinal needle to find my way to the transverse process (it will not form appreciable tracts). I leave it in place and use it as a guide to hit the TP with the Tuohy. Once there, I remove the spinal needle and walk off this point 1cm cauad, cephalad or lateral. When you start to walk off apply LOR technique. This is the only block I use the plastic 5cc syringes and I only use air. Advancement is slower than when looking for epidural space as the LOR is not nearly as distinct. As you pop through the fascia of the psoas compartment you will get your LOR or twitch or both. Again, you only want to make one or two passes as you will loose your ability to feel LOR with many passes. Additionally, you increase your chances-substantially- of clogging your tuohy needle with fat/muscle- you will never get a LOR in this case. The process should take about 5 minutes or less from prep to drug administration. Success rate with LOR is just as good as stimulation.

Injection should have 0 resistance. If you have any you are not in the right space, likely injecting into muscle. It should go in like butter. More easily than an epidural bolus with a 10cc syringe.

Hope this helps.

That is an approach I had not heard of before. I have always just used the stimulating needle. It sounds kinda complicated though. I am not a big fan of the LPB in general.

sevoflurane · Dec 12, 2009

Arch Guillotti said:
That is an approach I had not heard of before. I have always just used the stimulating needle. It sounds kinda complicated though. I am not a big fan of the LPB in general.

"Regional Anesthesia, An atlas of Anatomy and techniques" which is one of the first great books of regional anesthesia was co-authored by Dr. Patrick McQuillan. It is well described in his book which was published in the early 90's. He personally tought me this technique on many, many oaccasions. It works well, is actaully not complicated at all, but does have the risks of the associated block. Just my 2 cents.

seinfeld · Dec 12, 2009

Doing LPB on all our hips and knee along with high sciatic and spinal. Knock on wood no major complications. We do over 1100 a year, and as far as i am aware only 2 cases of prolonged foot drop over 3 years. 0.4% ropivicaine with epi for LPB and 0.2% ropiv without epi for sciatic. Best thing to do to prevent complications dont insert needle too deep. 10cm is about as deep as i go before i am really nervous. MOst of the time i get results between 7-9cm

Do only nerve stimulation for LPB. I have to say it still makes me more nervous than say a femoral under US but a few practical things that make a LPB a better block.

1. No need for US guidance as with femoral block (my senior partner switched to LPB after a patient required vascular surgery to repair inadvertant femoral puncture, now all femoral blocks are done under US, i know its backwords from what most would generally think)
2. Easy technical block in obese patients with a large panus compared to femoral
3. More reliable to capture Lateral Femoral cutaneous and obturator
4. Although epidural spread is a concern, in patients where i know it happened to some degree, they still received good pain relief for hours after surgery
5. I do the block with the patient sitting up, so its easy to go right from LBP to spinal.

Generally all 3 procedure take me around 10 minutes.

sevoflurane · Dec 12, 2009

seinfeld said:
Doing LPB on all our hips and knee along with high sciatic and spinal. Knock on wood no major complications. We do over 1100 a year, and as far as i am aware only 2 cases of prolonged foot drop over 3 years. 0.4% ropivicaine with epi for LPB and 0.2% ropiv without epi for sciatic. Best thing to do to prevent complications dont insert needle too deep. 10cm is about as deep as i go before i am really nervous. MOst of the time i get results between 7-9cm

Do only nerve stimulation for LPB. I have to say it still makes me more nervous than say a femoral under US but a few practical things that make a LPB a better block.

1. No need for US guidance as with femoral block (my senior partner switched to LPB after a patient required vascular surgery to repair inadvertant femoral puncture, now all femoral blocks are done under US, i know its backwords from what most would generally think)
2. Easy technical block in obese patients with a large panus compared to femoral
3. More reliable to capture Lateral Femoral cutaneous and obturator
4. Although epidural spread is a concern, in patients where i know it happened to some degree, they still received good pain relief for hours after surgery
5. I do the block with the patient sitting up, so its easy to go right from LBP to spinal.

Generally all 3 procedure take me around 10 minutes.

I have a friend who's group does the exact same thing. If you take into account the fact that you don't induce or wake up... You are probably saving time by doing it this way while giving great analgesia and good reimbursement. Nice system.

SleepIsGood · Dec 12, 2009

seinfeld said:
Doing LPB on all our hips and knee along with high sciatic and spinal. Knock on wood no major complications. We do over 1100 a year, and as far as i am aware only 2 cases of prolonged foot drop over 3 years. 0.4% ropivicaine with epi for LPB and 0.2% ropiv without epi for sciatic. Best thing to do to prevent complications dont insert needle too deep. 10cm is about as deep as i go before i am really nervous. MOst of the time i get results between 7-9cm

Do only nerve stimulation for LPB. I have to say it still makes me more nervous than say a femoral under US but a few practical things that make a LPB a better block.

1. No need for US guidance as with femoral block (my senior partner switched to LPB after a patient required vascular surgery to repair inadvertant femoral puncture, now all femoral blocks are done under US, i know its backwords from what most would generally think)
2. Easy technical block in obese patients with a large panus compared to femoral
3. More reliable to capture Lateral Femoral cutaneous and obturator
4. Although epidural spread is a concern, in patients where i know it happened to some degree, they still received good pain relief for hours after surgery
5. I do the block with the patient sitting up, so its easy to go right from LBP to spinal.

Generally all 3 procedure take me around 10 minutes.

you have hte pt sit up? How does the pt tolerate the brisk patellar snap while sitting up? I would think the pt would move so much your needle is moved.

pgg · Dec 12, 2009

Planktonmd said:
I found that I can achieve the same post-op analgesia with a fascia iliaca block with almost no risk at all.

That's what I do also. So fast, so easy, so low risk. You miss the posterior acetabulum but I find postop analgesia is still very good.

Do you ever do FIBs after patients are asleep? I have a few times in hip fx patients who couldn't move supine without agonizing pain ... induced them lateral, turn supine, tube or LMA, then block. I think it's safe to do a compartment block like this in a sleeping patient but I've gotten a few odd looks.

An old peds attending of mine did asleep FIBs for 100% of his pediatric (mostly teenage) ACL repairs. He used a nerve stimulator to prove to himself he was nowhere near a nerve but that seemed overkill to me.

Planktonmd · Dec 12, 2009

pgg said:
That's what I do also. So fast, so easy, so low risk. You miss the posterior acetabulum but I find postop analgesia is still very good.

Do you ever do FIBs after patients are asleep? I have a few times in hip fx patients who couldn't move supine without agonizing pain ... induced them lateral, turn supine, tube or LMA, then block. I think it's safe to do a compartment block like this in a sleeping patient but I've gotten a few odd looks.

An old peds attending of mine did asleep FIBs for 100% of his pediatric (mostly teenage) ACL repairs. He used a nerve stimulator to prove to himself he was nowhere near a nerve but that seemed overkill to me.

I do many lower extremity blocks under GA or after spinal including lateral popliteal, sciatic and femoral.
Fascia iliaca blocks are the ones I do the most under anesthesia.
I know all the arguments against it but I never had a problem.

dhb · Dec 12, 2009

seinfeld said:
5. I do the block with the patient sitting up, so its easy to go right from LBP to spinal.

Generally all 3 procedure take me around 10 minutes.

Are you doing the sciatic block before? in what position?

IN2B8R · Dec 12, 2009

Alain: I know for a fact that neither Eric, David or Mcq have ever injected 35mL for a LPB. So, I ask: why are you begging for epidural spread when all you need is no more than 15-20mL (max) to get complete coverage of the whole lumbar plexus (and even potentially cover some caudad sacral fibers)? Where have thy concocted the volume you are injecting? It is rather excessive and will, someday, allow you to experience the results--and excitement!--of epidural clonidine spread 😉. I assume you are including 100mcg of clonidine in your mix as you were doing in residency, or are you reducing the clonidine dose?

sevoflurane said:
I do them regularly for my hips. Most of our surgeons are requesting them because they do not like indwelling epidural catheters for hips. Our patients are up and walking on POD 0. I tried using lumbar plexus catheters, but I find them to not be very reliable and time consuming since you don't always get a twitch. Single shot works well for me for the first day + orthopod injects rop with epi into the capsule before closing. For lumbar plexus, I use combined LOR/Twitch... which ever comes first. Drop 35 cc's of .5% marcaine with clonidine/epi.

sevoflurane · Dec 12, 2009

IN2B8R said:
Alain: I know for a fact that neither Eric, David or Mcq have ever injected 35mL for a LPB. So, I ask: why are you begging for epidural spread when all you need is no more than 15-20mL (max) to get complete coverage of the whole lumbar plexus (and even potentially cover some caudad sacral fibers)? Where have thy concocted the volume you are injecting? It is rather excessive and will, someday, allow you to experience the results--and excitement!--of epidural clonidine spread 😉. I assume you are including 100mcg of clonidine in your mix as you were doing in residency, or are you reducing the clonidine dose?

My dear south african or german friend. The LPB is a "compartment block" as such it in needs a bigger volume. 15cc's is a wimpy dose for such a big space. 30-35 works great. That is my opinion and I have noticed good analgesia with my dosages. Of course it's always patient dependant. "15-20mls max" is not even recommended by Nysora: they recommend 25-35cc's. Here is the link:

http://nysora.com/peripheral_nerve_blocks/3145-technique_of_the_week.html

As a secomd reference: MCQ's book states "30-40ml of local anesthetic is injected in divided doses"

Sorry to disappoint but, my technique is perfectly sound and anesthesia is an evolving art. Each one of us have a different stroke with the paint brush.😀

sevoflurane · Dec 12, 2009

My dose of clonidine is weight based as I feel it is safer do administer weight based medications. .75 mcg per kilogram is what I use.

IN2B8R · Dec 12, 2009

Five things:

1) 15-20 mLs will give you plenty of unilateral coverage, dramatically lessening the chances of epidural spread and bilateral coverage. Trust me, I have done it long enough. More importantly and like I said in my initial post: the very people who trained you have never injected that much volume into one side--and for good reasons, inspite of what NYSORA tells you.

2) 0.75 mcg/kg will roughly give you about 50mcg of Clonidine for the average 70kg patient (I do not know of too many people who suffer from osteoarthritis who weigh that little). Nonetheless, try injecting 50-60mcg of clonidine with your next epidural and let me know how that goes 😉 It won't kill you, but it sure will produce enough bradycardia, hypotension and enough phone calls to bother the living $hit out of you and your partners.

3) I am not disappointed at all. I am indeed glad, proud and happy that you are doing what you have learned. Anesthesia is indeed an art--but be mindful that there are plenty of on-lookers here who are entitled to knowing that your recipe does carry risk of epidural spread; specifically, with Clonidine on board, things may get dicey--agreed?

4) Never--ever!--call me either German or South African. I have nothing against either nationality, but I (perhaps more than what others can say?) am proud to be U.S. graduated and U.S. trained.

5) Do not let this thread degenrate into a flame war: we both are correct in our assertions. It just so happens that I am more correct than you! :laugh:

I will gladly buy your drink if I see you at an ASA function. Stay warm and happy holidays 🙂

sevoflurane · Dec 12, 2009

Flame war? 😱 C'mmon, man... who said anything about war?😍 You should know me better than that. If you have something to teach me then I'm all ears. "To be sure is to be blind sided" You remember who use to say that????? Just a couple points then:😛

-Epidural clonidine was something I tried as a kindergarden anesthesia resident. I tried it many, many times with Eric. Didin't you? To think I don't know what could happen is presumptive on your part 😡

-By you stating that you are more correct than I means that you are more correct than the newly released 1200 page "textbook of regional anesthesia" :bullcrap:

OK.

-I'm glad you are proud and happy for me. So am I. I am actually living my dream. And if you feel that the audience should be informed of the risks of my practice. Great. That is exactly what this forum is about.😳

-Now... most importantly: I will take anejo petron with grand manier with a splash of OJ on the rocks. :soexcited:

Seriously though... I've met some incredible people during residency, and I am sure you are one of them. I wish you the very best in your corner of anesthesia. On monday I will try 15cc of LA and see how it goes.

All the best. 🙂

Planktonmd · Dec 13, 2009

3 blocks for one procedure is a little bit too much work in my opinion.

seinfeld said:
Doing LPB on all our hips and knee along with high sciatic and spinal. Knock on wood no major complications. We do over 1100 a year, and as far as i am aware only 2 cases of prolonged foot drop over 3 years. 0.4% ropivicaine with epi for LPB and 0.2% ropiv without epi for sciatic. Best thing to do to prevent complications dont insert needle too deep. 10cm is about as deep as i go before i am really nervous. MOst of the time i get results between 7-9cm

Do only nerve stimulation for LPB. I have to say it still makes me more nervous than say a femoral under US but a few practical things that make a LPB a better block.

1. No need for US guidance as with femoral block (my senior partner switched to LPB after a patient required vascular surgery to repair inadvertant femoral puncture, now all femoral blocks are done under US, i know its backwords from what most would generally think)
2. Easy technical block in obese patients with a large panus compared to femoral
3. More reliable to capture Lateral Femoral cutaneous and obturator
4. Although epidural spread is a concern, in patients where i know it happened to some degree, they still received good pain relief for hours after surgery
5. I do the block with the patient sitting up, so its easy to go right from LBP to spinal.

Generally all 3 procedure take me around 10 minutes.

seinfeld · Dec 13, 2009

SleepIsGood said:
you have hte pt sit up? How does the pt tolerate the brisk patellar snap while sitting up? I would think the pt would move so much your needle is moved.

With sedation pts seem to tolerate without a problem. Tend to turn down the mA rather quickly so they stop moving so much. Another thing we do a bit differently than what NYSORA recommends, is after finding tuffier's line, is to go over 4cm from midline and then DOWN 4 cm, trying to slip over the PSIS

As far as my system. We generally run 2 othro rooms with the surgeon alternating. crna for each room. do sciatic in lateral position. then i sit them up for the lpb and spinal. generally can get 10 cases (combo of hips/knees) done per day this way. In the younger, more slender pt i will do all 3 lateral, but i tend to be less successful with spinal in the lateral position especially in the older patients.

IN2B8R · Dec 13, 2009

If I spot you out there, your favorite drink is on me👍. Give 20mL for your next block and tell me how it went--hopefully it'll be just as good as 35mL. All the best🙂

sevoflurane said:
Flame war? 😱 C'mmon, man... who said anything about war?😍 You should know me better than that. If you have something to teach me then I'm all ears. "To be sure is to be blind sided" You remember who use to say that????? Just a couple points then:😛

-Epidural clonidine was something I tried as a kindergarden anesthesia resident. I tried it many, many times with Eric. Didin't you? To think I don't know what could happen is presumptive on your part 😡

-By you stating that you are more correct than I means that you are more correct than the newly released 1200 page "textbook of regional anesthesia" OK.

-I'm glad you are proud and happy for me. So am I. I am actually living my dream. And if you feel that the audience should be informed of the risks of my practice. Great. That is exactly what this forum is about.😳

-Now... most importantly: I will take anejo petron with grand manier with a splash of OJ on the rocks.

Seriously though... I've met some incredible people during residency, and I am sure you are one of them. I wish you the very best in your corner of anesthesia. On monday I will try 15cc of LA and see how it goes.

All the best. 🙂

BLADEMDA · Dec 13, 2009

Smaller volumes and concentrations can be used successfully for analgesia (e.g., 20 mL); however, for surgical anesthesia - 30 mL is necessary to achieve a dense blockade of the entire lumbar plexus.

From NYSORA website.

So, if you using a spinal on top of the LPB then 15-20 mls is fine. However, if you are doing the case under LBP plus Sciatic I use 25-30mls for each block. Good Surgical Anesthesia

Arch Guillotti · Dec 13, 2009

Planktonmd said:
I do many lower extremity blocks under GA or after spinal including lateral popliteal, sciatic and femoral.
Fascia iliaca blocks are the ones I do the most under anesthesia.
I know all the arguments against it but I never had a problem.

What kind of a twitch response do you get after a spinal on the above blocks? Or are you using ultrasound for each of them?

BLADEMDA · Dec 13, 2009

IN2B8R said:
Five things:

1) 15-20 mLs will give you plenty of unilateral coverage, dramatically lessening the chances of epidural spread and bilateral coverage. Trust me, I have done it long enough. More importantly and like I said in my initial post: the very people who trained you have never injected that much volume into one side--and for good reasons, inspite of what NYSORA tells you.

2) 0.75 mcg/kg will roughly give you about 50mcg of Clonidine for the average 70kg patient (I do not know of too many people who suffer from osteoarthritis who weigh that little). Nonetheless, try injecting 50-60mcg of clonidine with your next epidural and let me know how that goes 😉 It won't kill you, but it sure will produce enough bradycardia, hypotension and enough phone calls to bother the living $hit out of you and your partners.

3) I am not disappointed at all. I am indeed glad, proud and happy that you are doing what you have learned. Anesthesia is indeed an art--but be mindful that there are plenty of on-lookers here who are entitled to knowing that your recipe does carry risk of epidural spread; specifically, with Clonidine on board, things may get dicey--agreed?

4) Never--ever!--call me either German or South African. I have nothing against either nationality, but I (perhaps more than what others can say?) am proud to be U.S. graduated and U.S. trained.

5) Do not let this thread degenrate into a flame war: we both are correct in our assertions. It just so happens that I am more correct than you! I will gladly buy your drink if I see you at an ASA function. Stay warm and happy holidays 🙂

Reg Anesth Pain Med. 2006 Sep-Oct;31(5):417-21.

Links

Combined lumbar-plexus and sciatic-nerve blocks: an analysis of plasma ropivacaine concentrations.

Vanterpool S, Steele SM, Nielsen KC, Tucker M, Klein SM.
School of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
BACKGROUND AND OBJECTIVES: Lumbar-plexus and sciatic-nerve blocks are commonly combined for lower-extremity anesthesia using large doses of ropivacaine. Limited information is available about the pharmacokinetics of this practice. We analyzed plasma ropivacaine concentrations after single-injection lumbar-plexus blocks with and without sciatic-nerve blocks. METHODS: Twenty patients having lower-extremity surgery using a lumbar-plexus block with 0.5% ropivacaine with 1:400,000 epinephrine (35 mL, n = 10) or the same lumbar-plexus block with the addition of a sciatic-nerve block (25 mL, n = 10, 60 mL total) using the same solution were enrolled. Venous blood samples were collected at 5, 15, 30, 45, 60, 120, and 240 minutes after block placement and analyzed for total ropivacaine concentration by use of gas chromatography. Individual timepoints, maximum concentrations (C(max)), and time to C(max) (T(max)) were compared. Values are mean +/- SD. RESULTS: Both groups demonstrated a rapid increase in plasma concentration over the first 30 to 45 minutes. Concentrations were greater for those who received both blocks (P = .0005) at all timepoints. The lumbar-plexus block C(max) was less (986 +/- 221 ng/mL) than for the combined blocks (1,560 +/- 351 ng/mL, P = .0004). The T(max) was greater for the lumbar plexus (80 +/- 49 min) than for the combined blocks (38 +/- 22 min, P = .03). There was no relationship between the C(max) and patient age, weight, or body mass index. CONCLUSIONS: The results of this study demonstrate that the plasma ropivacaine concentrations increase quicker when a sciatic-nerve block is added to a lumbar-plexus block, but C(max) remains below the toxicity threshold.

Planktonmd · Dec 13, 2009

Arch Guillotti said:
What kind of a twitch response do you get after a spinal on the above blocks? Or are you using ultrasound for each of them?

A spinal does not affect the twitches you get Arch.

BLADEMDA · Dec 13, 2009

Planktonmd said:
3 blocks for one procedure is a little bit too much work in my opinion.

http://forums.studentdoctor.net/showthread.php?t=604398&highlight=fascia

Review this thread and see Plankton's posts. Good pictures as well.

seinfeld · Dec 13, 2009

Planktonmd said:
3 blocks for one procedure is a little bit too much work in my opinion.

it is hard work, but seeing our surgeons are discharging pts home on avg in 2.5 days (believe the DRG is 5 days) it seems worth it.

Would love to start eliminating the sciatic block as a routine, currently trying to eliminate the ON-Q devices first, and i dont know if i would have time to do sciatic block in PACU.

How often are those that are not doing sciatic as routine having patients who need it postop? Currently i dont write for any pain meds in PACU.

IN2B8R · Dec 13, 2009

Would be interesting if they had looked to see if there was epidural spread in any of those patients (it's a small sample size, but would have been a good end-point to look at). Thanks for posting.

BLADEMDA said:
Reg Anesth Pain Med. 2006 Sep-Oct;31(5):417-21. Links

Combined lumbar-plexus and sciatic-nerve blocks: an analysis of plasma ropivacaine concentrations.

Vanterpool S, Steele SM, Nielsen KC, Tucker M, Klein SM.
School of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
BACKGROUND AND OBJECTIVES: Lumbar-plexus and sciatic-nerve blocks are commonly combined for lower-extremity anesthesia using large doses of ropivacaine. Limited information is available about the pharmacokinetics of this practice. We analyzed plasma ropivacaine concentrations after single-injection lumbar-plexus blocks with and without sciatic-nerve blocks. METHODS: Twenty patients having lower-extremity surgery using a lumbar-plexus block with 0.5% ropivacaine with 1:400,000 epinephrine (35 mL, n = 10) or the same lumbar-plexus block with the addition of a sciatic-nerve block (25 mL, n = 10, 60 mL total) using the same solution were enrolled. Venous blood samples were collected at 5, 15, 30, 45, 60, 120, and 240 minutes after block placement and analyzed for total ropivacaine concentration by use of gas chromatography. Individual timepoints, maximum concentrations (C(max)), and time to C(max) (T(max)) were compared. Values are mean +/- SD. RESULTS: Both groups demonstrated a rapid increase in plasma concentration over the first 30 to 45 minutes. Concentrations were greater for those who received both blocks (P = .0005) at all timepoints. The lumbar-plexus block C(max) was less (986 +/- 221 ng/mL) than for the combined blocks (1,560 +/- 351 ng/mL, P = .0004). The T(max) was greater for the lumbar plexus (80 +/- 49 min) than for the combined blocks (38 +/- 22 min, P = .03). There was no relationship between the C(max) and patient age, weight, or body mass index. CONCLUSIONS: The results of this study demonstrate that the plasma ropivacaine concentrations increase quicker when a sciatic-nerve block is added to a lumbar-plexus block, but C(max) remains below the toxicity threshold.

Arch Guillotti · Dec 13, 2009

Planktonmd said:
A spinal does not affect the twitches you get Arch.

Does anybody else do lower extremity PNB's under spinal or GA? Is this an old school thing or are other folks out there doing this?

Plank would you do a lumbar plexus block after SAB?

Planktonmd · Dec 13, 2009

Arch Guillotti said:
Does anybody else do lower extremity PNB's under spinal or GA? Is this an old school thing or are other folks out there doing this?

Plank would you do a lumbar plexus block after SAB?

No I wouldn't.

BLADEMDA · Dec 13, 2009

seinfeld said:
it is hard work, but seeing our surgeons are discharging pts home on avg in 2.5 days (believe the DRG is 5 days) it seems worth it.

Would love to start eliminating the sciatic block as a routine, currently trying to eliminate the ON-Q devices first, and i dont know if i would have time to do sciatic block in PACU.

How often are those that are not doing sciatic as routine having patients who need it postop? Currently i dont write for any pain meds in PACU.

Me. I don't always do a Sciatic block for a total knee or ACL. Usually just a femoral. But, you will need PCA supplementation as on average 30% of the post op pain comes from the sciatic. That said, a few (about 10%) can have very significant pain from the sciatic innervation (posterior pain).
Those individuals rarely get good pain relief from Femoral plus PCA.

Arch Guillotti · Dec 13, 2009

Planktonmd said:
No I wouldn't.

me neither, but I have never placed a block on an adult under GA or post SAB that I can remember.

pgg · Dec 14, 2009

BLADEMDA said:
Me. I don't always do a Sciatic block for a total knee or ACL. Usually just a femoral. But, you will need PCA supplementation as on average 30% of the post op pain comes from the sciatic. That said, a few (about 10%) can have very significant pain from the sciatic innervation (posterior pain).
Those individuals rarely get good pain relief from Femoral plus PCA.

We're responsible for all the ortho postop PCAs (long story) and I'd rather take an extra 5 minutes to do a sciatic than deal with a PCA. So the only time my ACLs don't get femoral & sciatics is when the patient declines a block.

Most of our ACLs get done with hamstring grafts anyway and a femoral isn't enough for those guys.

sevoflurane · Dec 14, 2009

BLADEMDA said:
Me. I don't always do a Sciatic block for a total knee or ACL. Usually just a femoral. But, you will need PCA supplementation as on average 30% of the post op pain comes from the sciatic. That said, a few (about 10%) can have very significant pain from the sciatic innervation (posterior pain).
Those individuals rarely get good pain relief from Femoral plus PCA.

All my patients get femoral + sciatic for TKA. Prep for femoral and sciatic at the same time. Do the femoral with a 4 3/4"-6" stimulating cath under USD. Watch my hydrodissection move over to the femoral artery. Then drop my USD and move 4 inches down the leg for an anterior approach to the sciatic with the same needle. All in all it just takes an extra 30 seconds to draw up drugs for the sciatic and they wake up without need for any narcs.

sevoflurane · Dec 14, 2009

Traditionally I have used only femorals for ACLs... but I've noticed a little better post-op pain results with both. Maybe it's placebo, but either way, it carries little risk and is easily done. If they are big/fat and I think the sciatic may take more than 2-3 passes I will just do a femoral.

BLADEMDA · Dec 14, 2009

sevoflurane said:
All my patients get femoral + sciatic for TKA. Prep for femoral and sciatic at the same time. Do the femoral with a 4 3/4"-6" stimulating cath under USD. Watch my hydrodissection move over to the femoral artery. Then drop my USD and move 4 inches down the leg for an anterior approach to the sciatic with the same needle. All in all it just takes an extra 30 seconds to draw up drugs for the sciatic and they wake up without need for any narcs.

No U/S here. Feel the Femoral Artery or use Doppler. One finger lateral is the nerve. Stimulator with patella snap. inject local. Turn on side and do Labat Sciatic block. If Morbidly Obese may decide to do LPB with Sciatic while patient on his/her side (operative side up of course). Don't enjoy Femoral blocks on EXTREMELY MORBIDLY OBESE as they usually have skin breakdown in the femoral crease.

But, there have been many times I use U/S in the morbidly obese; when they weigh 3 X their normal body weight or more I use doppler or U/S. Still , hate that skin breakdown and panniculus.

BLADEMDA · Dec 14, 2009

U/S may not be as safe as advertised. The jury is still out if U/S is actually safer than nerve stimulation alone. In fact, U/S without visualizing the tip of the needle is more dangerous in my opinion.

http://journals.lww.com/anesthesiol..._Regarding_Ultrasound_guided_Regional.49.aspx

sevoflurane · Dec 14, 2009

BLADEMDA said:
No U/S here. Feel the Femoral Artery or use Doppler. One finger lateral is the nerve. Stimulator with patella snap. inject local. Turn on side and do Labat Sciatic block. If Morbidly Obese may decide to do LPB with Sciatic while patient on his/her side (operative side up of course). Don't enjoy Femoral blocks on EXTREMELY MORBIDLY OBESE as they usually have skin breakdown in the femoral crease.

But, there have been many times I use U/S in the morbidly obese; when they weigh 3 X their normal body weight or more I use doppler or U/S. Still , hate that skin breakdown and panniculus.

Morbidly Obese = LPB + Sciatic = very good choice for the reasons you mentioned. Again... You can prep both at the same time and knock them out one after the other.👍

sevoflurane · Dec 14, 2009

BLADEMDA said:
U/S may not be as safe as advertised. The jury is still out if U/S is actually safer than nerve stimulation alone. In fact, U/S without visualizing the tip of the needle is more dangerous in my opinion.

http://journals.lww.com/anesthesiol..._Regarding_Ultrasound_guided_Regional.49.aspx

I feel that it is user dependent. Like anything, the more you use it, the better you get at it.

I personally find USD guided block just adds to the safety of a landmark based approach. Just like throwing in a MAC catheter. I always use ultrasound and hit IJ on the first pass without question. One pass. The fact that I can SEE big red pulsating when doing an upper extremity block is a clear advantage (no pun intended). When used together (landmark and USD), I feel it's a win-win situation.

Similarly, when you use USD + Aspiration before you inject I think it adds an extra margin of safety. You are using more of your god given senses to react to anything out of the ordinary.

As far as intraneuronal injection... If you get the needle in the sheath and see a doughnut form around the nerve bundle, to me... it brings a tear to my eye as I know the patient will wake up comfy. Also... Brachial plexus has many permutations as to it's divisions, terminal branches, etc... In my opinion, these relationships are much easier to see under ultrasound.

Again... my opinion and as always it is subject to debate.

BLADEMDA · Dec 14, 2009

sevoflurane said:
I feel that it is user dependent. Like anything, the more you use it, the better you get at it.

I personally find USD guided block just adds to the safety of a landmark based approach. Just like throwing in a MAC catheter. I always use ultrasound and hit IJ on the first pass without question. One pass. The fact that I can SEE big red pulsating when doing an upper extremity block is a clear advantage (no pun intended). When used together (landmark and USD), I feel it's a win-win situation.

Similarly, when you use USD + Aspiration before you inject I think it adds an extra margin of safety. You are using more of your god given senses to react to anything out of the ordinary.

As far as intraneuronal injection... If you get the needle in the sheath and see a doughnut form around the nerve bundle, to me... it brings a tear to my eye as I know the patient will wake up comfy. Also... Brachial plexus has many permutations as to it's divisions, terminal branches, etc... In my opinion, these relationships are much easier to see under ultrasound.

Again... my opinion and as always it is subject to debate.

Not knocking the usefulness of U/S as it is a wonderful tool. But, is it really better or safer than traditional nerve stimulation in experienced hands?

Any comments on that article? Perhaps, you should LIMIT your U/S exposure when possible?

sevoflurane · Dec 14, 2009

BLADEMDA said:
Not knocking the usefulness of U/S as it is a wonderful tool. But, is it really better or safer than traditional nerve stimulation in experienced hands?

Any comments on that article? Perhaps, you should LIMIT your U/S exposure when possible?

Is it better than experienced hands? I'm not sure. I certainly see a tremendous advantage with the fat/fleshy 5'0'' 150 kg patient. But then... maybe I'm not as good as others at traditional regional anestheia. I've definately had difficulties on these early on (before USD). USD + same patient = same time I spend with a 60 kg 6"0" patient = <5 minutes from start to finish. For me, efficiency is a big part of my practice as I don't have CRNA's to get me out so I can do my blocks. USD in this type of patient is an amazing tool that has it's rightful place in my practice.

Now here is my dilema. I practice in a hospital setting with tons of resources. I do a CABG: I use USD, CCO/SVO2, 3D TEE, SWAN, Cerebral OX, etc. We need something. We ask for it. We get it. GLidescopses, McGraths, Apollo machines... etc. So... what happens when I decide to move up in the mountains... in a smaller community? I go to a hospital that does not have these resources. Then what? A great reason to keep up those traditional skills- NO DOUBT.

Additionally, traditional landmark techniques is clearly more of an art than USD. If your diaphram is contracting what do you do? How about the subscapularis? Which way do you redirect your needle? How do you do a posterior approach to the brachial plexus? More technical for sure. If you know what you are doing with USD, it is TOO EASY.

For these reasons I will always employ a traditional approach to regional anesthesia in my practice. I don't want to forget it. Still, I find myself using both approaches. Along with efficiency, safety is at the top of my list of good practice and I am a firm advocate for USD.

As for the article... Good points man. I've always thought to myself that USD is like pissing in the wind with regards to exposure and effects. I still think this way, but we live in a world based on evidence. What I do know is that I'm not causing nearly as much harm as a C-ARM or Fluoro. USD is used on developing fetuses. (Feti?... dang how do you say that?) Does the lack of evidence make it right? No. Do I admire my doughnut? Hell yeah... if only for a moment.

Thanks for the article Blade. I missed that one.

sevoflurane · Dec 14, 2009

Mmmm... one of last weeks yummy doughnuts. What do you see (Obviously this is a question to whoever is reading this post) ?

SleepIsGood · Dec 14, 2009

sevoflurane said:
All my patients get femoral + sciatic for TKA. Prep for femoral and sciatic at the same time. Do the femoral with a 4 3/4"-6" stimulating cath under USD. Watch my hydrodissection move over to the femoral artery. Then drop my USD and move 4 inches down the leg for an anterior approach to the sciatic with the same needle. All in all it just takes an extra 30 seconds to draw up drugs for the sciatic and they wake up without need for any narcs.

Do you use the same entry point that you used for the femoral block for your anterior sciatic block? I've gone to workshops where they show us how to do these....never have done it in a real person....attendings all say since you are going through more muscles to get to the sciatic this way, it's more painful.

what do you do ?

sevoflurane · Dec 15, 2009

SleepIsGood said:
Do you use the same entry point that you used for the femoral block for your anterior sciatic block? I've gone to workshops where they show us how to do these....never have done it in a real person....attendings all say since you are going through more muscles to get to the sciatic this way, it's more painful.

what do you do ?

I would say the same thing. Plus, I don't know how easy it would be to find the sciatic through femoral NB puncture. I go a hands breaths down/ 4" down (I look to see where big blue and big red are before I drop the probe). Feel for the femur, hit it with my stimulating cath, externally rotate the leg and walk off the femur to hit the sciatic. Easy block and I don't have to reposition.

periopdoc · Dec 17, 2009

Arch Guillotti said:
Does anybody else do lower extremity PNB's under spinal or GA? Is this an old school thing or are other folks out there doing this?

Plank would you do a lumbar plexus block after SAB?

At Harborview Med Center in Seattle we do a lot of femoral and pop sci blocks and we do them all under GA at the conclusion of the case. We used to do them exclusively with nerve stim and over the last 5 years have made the transition to predominantly u/s guided.

I stopped counting when I had personally performed over 100 of them as a CA-2, so you can do the math and figure how many thousands of these blocks we have performed under GA over the years.

We are unaware of any permanent nerve injury in our institution that was attributable to this technique.

- pod

any private docs out there using lumbar plexus blocks?

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