any private docs out there using lumbar plexus blocks?

[Gaseous Clay]

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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.

Great timing on this thread. I was on call last night and we actually had a light day and finished up all the cases by around 7 PM. 2 blocks came out, my friend did a LP on a chronic pain lady s/p hip while I went to do a popliteal/saphenous on an ankle fusion.

Sure enough, we go to eat dinner when we get a call that the LP lady is hypotensive and short of breath. He took care of her for probably 30 mins, supporting her with fluids and ephedrine. We all went to see how he was going and her MAPs were in the 50's. I checked a level and she was around T1/2 on the block side and T3 on the other side. He used 30 mL 0.5% ropi. We looked up more info and one source cited a 15% rate of "significant hypotension," (sounds like many of you don't see this). Also, rate and force of injection were two main contributing factors.

 

[Planktonmd]

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.

In my hands externally rotating the leg puts the femur between your needle and the sciatic nerve, did you mean internally rotating the leg?

 

[sevoflurane]

In my hands externally rotating the leg puts the femur between your needle and the sciatic nerve, did you mean internally rotating the leg?

Good point Plank. I have tried it both ways. Some of my old collegues swear by internally rotating the leg, some swear by externally rotating the leg. I find externally rotating the leg works. You are pretty deep with your stim cath, so once I hit the femur I pull back then change my approach angle slightly to end up skimming right past the femur after it has been externally rotated. I don't truly walk off the femur as I would only be bending my catheter. The sciatic is a medial structure. In my mind, externally rotating the leg puts the sciatic in a place where you can't miss it. If you could see through the skin and muscle you would see the femur and the sciatic kissing each other. Doing this block under ultrasound is time comsuming. I have confirmed these relationships however. There are plenty of exeptions as not everyone is built the same.

 

[Arch Guillotti]

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

Interesting, anybody else doing this?

The only blocks I placed under GA were kids, and that wasn't many.