A JET CASE DONE SEPT 26th

[jetproppilot]

Advertisement - Members don't see this ad

91 year old (for real!), 110 lb, fully alert lady with a right olecrenon elbow fx requiring ORIF.

History of emphysema albeit non-02 dependent; speaks in full sentences while laying flat in bed (read: no dyspnea).

On PRN albuterol but otherwise no other meds/ health issues.

Had to speak REALLY LOUD so she could hear me:

"Whats your name, son?"

"Bill. I'm your anesthesia doctor."

"Huh?"

"BILL."

"You're a doctor?"

"Yes ma'am."

"Hello Bill." (she gives me a big toothless smile.)

Our conversation ensued and I told her and her family my plan.

Labs, EKG with no surprises.

CXR shows flattened diaphragm bilat but otherwise pretty unremarkable.

Family is full of doctors requesting a "nerve block".

Orthopedic surgeon is requesting an axillary block. Nice ortho dude who doesnt try and do your job for you....his requests are just that: requests.

How do you proceed?

Do you do an axillary block? If so, what are your thoughts? If not, how do you do a GA on a 91 year old tiny lady?

 

[The_Sensei]

Ax block with 15 cc 2% lidocaine/15 cc 0.5% bupivicaine. Inadequate? Toss in an LMA.

 

[The_Sensei]

Sorry.....Thoughts:

Ortho guys request, family full o' docs request sway me to perform an axillary block.....I try to be accomodating as long as I feel it's in the patients best interest.

 

[Noyac]

With surgery in the area of the elbow I like infraclavicular blocks. 2cm down form the coracoid process and 2cm midline. Piece of cake. use the local of choice.

1 or 2 mg versed and she sleeps through the whole case.

 

[TIVA]

Ortho wanting a nerve block for elbow fracture?

Wow. That's pretty impressive. At our institution, anything that has to do with elbows, the orthopods prefer not to have blocks so that they can assess nerve function post-op. I'd say your orthopods are pretty progressive.

The most challenging task in this lady would be the axillary block. Not because the axillary block is technically difficult or anything like that. But the axillary block is a volume block. You need at least 40 cc's of volume in that nerve sheath to get adequate blockade, preferably 45 to 50 cc's.

So, how to get 40 cc's of anesthetic volume in a less than 50 kg lady? I'd say go with 0.5% Mepivicaine. The toxic dose is among the most liberal -- something like lidocaine, on the order of 5 mg/kg. Which means you could give her 40 cc's of mepivicaine with the ax block plus 5-7 cc's of 0.5% bupivicaine for the intercostal nerve block (to prevent tourniquet pain if the surgeons are planning on putting on a tourniquet). And unlike lidocaine which'll only last a couple of hours tops, the mepivicaine will provide both surgical anesthesia and post-op analgesia.

And for those who are so inclined, if you add a little epi to your regional cocktail, you can increase your toxic threshold to 6-7 mg/kg. And if speed of onset is necessary, add a little HCO3 to the cocktail as well.

And I agree with the Sensei, try to accomodate the patient's wishes, the family's wishes, and the surgeon's wishes if possible. Not just cuz they're our customers, but because it makes for good medicine as well. After all, no need to subject an otherwise functioning 91 y.o. to mind altering substances and then wonder if the post GA delirium/agitation is residual anesthetic vs. pain vs. metabolic/electrolyte disturbances vs. oversedation vs. neuro insult vs. whatever.

So at the end of the day, I vote for ax block plus intercostal block.

 

[TIVA]

oops, I meant ropivicaine, not mepivicaine.

 

[Laryngospasm]

Stay away from an interscalene block😱 Ax block should be fine, but will likely provide inadequate pain relief depending on how far up the surgeon mutilates.

 

[Noyac]

Infraclavicular!

Only need 15-20 cc and it covers the tourniquet as well.

 

[Laryngospasm]

Infraclavicular!


Yes!

 

[jetproppilot]

I took The Sensei's/TIVA's route. Try and please everyone if possible; if it doesnt work toss in an lma.

My thoughts were that with an axillary block, the elbow is kinda no mans land......one can see incomplete analgesia at the elbow even with a perfectly performed block. Told the family/patient/surgeon the plan....I'll do the block, if it doesnt work I'll do a "light" general...whatever "light" means but seems to pacify concerned family members/patients.

I use a 21" 1.5 inch needle and transarterial approach...used 40 mL 2% lido with epi....15 mL on either side of the artery, 5 mL for a weal (about 3" long) on either side of the needle insertion site for tourniquet pain, 5mL a few inches proximal to the elbow between the biceps and coracobrachialis muscles for musculocutaneous coverage.

1 mg midazolam before the block smoked the little lady...I put the block in early so it was a little over an hour from block-time-to-incision...a little background propofol during the case and she snoozed the whole time and was awake shortly after reaching the PACU.

Better lucky than good.

Oh, and I have a confession to make. I've never done an infraclavicular block so didnt have that option.

 

[Worldtraveler]

We mainly do infraclavicular under u/s guidance with 20-30cc of 2% lido with a little epi and bicarb. very high rate of success with epidural cath left in place.

 

[Noyac]

Oh, and I have a confession to make. I've never done an infraclavicular block so didnt have that option.

Jet, its simple, easier than a axillary and safer IMHO.

My approach is to find the coracoid process which is just below the distal end of the clavicle. Once you have found it you measure 2 cm inferior and 2 cm midline. Small skin wheel and insert a block needle directly perpendicular to the skin. You will need to go 2-4 cm in before you get a twitch. Don't be satisfied until you get a twitch in the fingers at 0.4 or less mAmps. It only takes about 15-20 cc and the elbow is always covered.

Try it sometime and I'll bet you you almost completely abandon the axillary block.

 

[militarymd]

Oh, and I have a confession to make. I've never done an infraclavicular block so didnt have that option.

try it...you'll like it.

President
S.A.R.A.

 

[jetproppilot]

Jet, its simple, easier than a axillary and safer IMHO.

My approach is to find the coracoid process which is just below the distal end of the clavicle. Once you have found it you measure 2 cm inferior and 2 cm midline. Small skin wheel and insert a block needle directly perpendicular to the skin. You will need to go 2-4 cm in before you get a twitch. Don't be satisfied until you get a twitch in the fingers at 0.4 or less mAmps. It only takes about 15-20 cc and the elbow is always covered.

Try it sometime and I'll bet you you almost completely abandon the axillary block.

Thanks Noy and Dr. S.A.R.A......I'm gonna take a look at the Regional Atlas and then find a guinea pig...😱

"No, Ms. Jones, I've never done this block before. But I DID stay at a Holiday Inn Express last night."