Anyone doing ISBs asleep?

[ssmallz]

Up until now the only blocks I've ever done with an asleep pt were pedi fem blocks and infiltration saphenous blocks. Yesterday I had a pt who wanted a block for his shoulder but he was so nervous he couldn't stop shaking. Gave him 6 of versed, minimal effect. It was so bad that I couldn't even lift his are without him shaking. He was not in pain, just so scared of having pain post op that he couldn't control himself. I tried to do an USG ISB but couldn't get much volume because the shaking was throwing off the picture and I couldn't see where I was injecting. I couldn't do nerve stim for obvious reasons.

Are any of you guys doing ISBs under USG asleep for these types of pts? I know some of the other guys in the group have given propofol to these types of pts but I hate the idea of managing an airway and doing a block at the same time. Thoughts

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[metalephrine]

with ultrasound I would do it after he was asleep without they gotta be awake.

 

[periopdoc]

I truly believe that with U/S guidance, you do not gain any increase in safety from having an awake patient as long as you are honest with yourself about exactly what you do and do not see. If it is safe enough for pedi patients it is safe enough for adults.

However, I still don't do them awake asleep because I have no defense if something (completely unrelated to the block) goes wrong. I just wouldn't have a leg to stand on to deflect blame.

That being said, I am fairly comfortable doing a quick propofol based sedation for them. More predictable than versed/ fent and wears off more quickly. 50-80 mg is usually sufficient for young healthy patients to keep them sedated but responsive for the block, and that is exactly what I document on the record "sedated but responsive".

- pod

 

[Gern Blansten]

http://journals.lww.com/anesthesiology/Fulltext/2000/12000/Permanent_Loss_of_Cervical_Spinal_Cord_Function.33.aspx

For your review as you decide. I would personally choose not to do it under general, although in rare circumstances, the potential benefit may out weigh the risk (ie; in kids provided US guidance is used). As a rule of thumb, I avoid it, although I will admit we did many asleep during my training using nerve stim only and never had an adverse event.

 

[Gern Blansten]

However, I still don't do them awake because I have no defense if something (completely unrelated to the block) goes wrong. I just wouldn't have a leg to stand on to deflect blame.

I assume you meant "asleep."

 

[PMPMD]

http://journals.lww.com/anesthesiol...Loss_of_Cervical_Spinal_Cord_Function.33.aspx

For your review as you decide. I would personally choose not to do it under general, although in rare circumstances, the potential benefit may out weigh the risk (ie; in kids provided US guidance is used). As a rule of thumb, I avoid it, although I will admit we did many asleep during my training using nerve stim only and never had an adverse event.

The cases in this series were done by landmark/stimulation not U/S.

 

[proman]

Like POD I'd use low dose propofol. There's nothing inherently wrong with doing an invasive procedure asleep. I've started doing a lot of my spinal drains asleep, I've found it's easier to position and faster especially in the old patient who has trouble keeping still. I just document that the benefit outweighs the risk.

 

[Multifidus]

Holy crap! The cases in that article scare the hell out of me. I was all ready to post that you should be okay doing the block under GA as long as you documented that the patient was so anxious that it prohibited you doing the block. After reading those cases, I would say you either do the block awake or you don't do it (maybe an ultrasound guided supraclavicular under GA, in such a case, would be more appropriate?).

I, personally, do all me blocks awake, except for the saphenous block that someone else mentioned.

This job never ceases to freak me out with the vast number of ways we can do harm...

 

[Patron]

I do them awake. I dont see any advantage of doing asleep. Also it might be used against you in case of injury.

 

[Gern Blansten]

The cases in this series were done by landmark/stimulation not U/S.

True, I never meant to imply otherwise. Still heightens my concern.

 

[PMPMD]

True, I never meant to imply otherwise. Still heightens my concern.

Yeah those studies scared the $#!+ out of me as a resident.

 

[BLADEMDA]

I truly believe that with U/S guidance, you do not gain any increase in safety from having an awake patient as long as you are honest with yourself about exactly what you do and do not see. If it is safe enough for pedi patients it is safe enough for adults.

However, I still don't do them awake asleep because I have no defense if something (completely unrelated to the block) goes wrong. I just wouldn't have a leg to stand on to deflect blame.

That being said, I am fairly comfortable doing a quick propofol based sedation for them. More predictable than versed/ fent and wears off more quickly. 50-80 mg is usually sufficient for young healthy patients to keep them sedated but responsive for the block, and that is exactly what I document on the record "sedated but responsive".

- pod

Agree. I like propofol and routinely use it in low doses for blocks. I once saw a block by my partner under u/s where the patient still reacted to the injection of the local even under propofol. Fortunately, the needle was repositioned and the patent did fine (no complications). Low dose propofol isn't quite "GA" but much nicer than midazolam and fentanyl. That said, I've done hundreds if not thousands of blocks on the elderly with nothing more than midazolam 2mg iv. If you aren't slick with blocks go with the propofol.

 

[bostonblaz]

I do afair amount of pedi and i do all of them asleep for blocks. I only do adults asleep if the are mentally retarted and could not understand what i am doing. If they are unable to do it with 4 mg or less of verced i wont do it. Not worth the $$ you would have to make a check out for cause any anesthesiologist would say that doing it asleep in a copus mentus adult is not the standard of care. If you are smooth and use ultrasound alone these blocks dont hurt. Having had some done to me completly awake you do feel a lot of pressure upon injection but it does not hurt. Blaz

 

[deleted126335]

There was an editorial in Anesthesiology about a dozen years ago specifically condemning the practice of placing blocks asleep. I think that it referenced the cases in post #4. Might have even been the same issue. For the OP. I would have given my squirmer labor epidural speech: "If you can't cooperate and sit nearly still, for your own safety I will abandon the procedure" Have said it a dozen times. Worked every time.

 

[ssmallz]

There was an editorial in Anesthesiology about a dozen years ago specifically condemning the practice of placing blocks asleep. I think that it referenced the cases in post #4. Might have even been the same issue. For the OP. I would have given my squirmer labor epidural speech: "If you can't cooperate and sit nearly still, for your own safety I will abandon the procedure" Have said it a dozen times. Worked every time.

Thats pretty much what I did. I gave him the speech as I was doing the block. Got about 10cc in before I just aborted b/c it was too hard. He got descent pain relief post op but it was a major pain for both us so I wondering if doing it asleep with ultrasound would be acceptable

 

[pgg]

I just sat through an RCA for a sentinel event, a common peroneal nerve injury in a patient who'd received a sciatic block. I posted about the complication in another thread not too long ago.

Despite an EMG study all but proving that the injury was at the fibular head, and solid documentation of the block done in a standard way in an awake patient, plantar flexion twitch suggesting needle position near the tibial 1/2, etc etc, a member of the committee still insisted that direct needle trauma or intraneural injection couldn't be ruled out as THE cause of he injury. At times I wanted to snap that we couldn't rule out aliens either.

One thing this experience has really highlighted for me is that when complications occur, even if they're nobody's fault, having nothing weird in the chart really helps deflect undue blame attempts. SOMEONE is going to want to pin it on you.

Absent a compelling and documented reason, I would not do an asleep block. If they can't sit still, they can go home with some Percocet. Easy.

 

[thegasman]

propofol sedation. "sedation" being the key word and documented on the chart. All of this is cya. Personally I think asleep would be safe, but defensive medicine as lame as it is could save your butt with a complication

 

[Mman]

Up until now the only blocks I've ever done with an asleep pt were pedi fem blocks and infiltration saphenous blocks. Yesterday I had a pt who wanted a block for his shoulder but he was so nervous he couldn't stop shaking. Gave him 6 of versed, minimal effect. It was so bad that I couldn't even lift his are without him shaking. He was not in pain, just so scared of having pain post op that he couldn't control himself. I tried to do an USG ISB but couldn't get much volume because the shaking was throwing off the picture and I couldn't see where I was injecting. I couldn't do nerve stim for obvious reasons.

Are any of you guys doing ISBs under USG asleep for these types of pts? I know some of the other guys in the group have given propofol to these types of pts but I hate the idea of managing an airway and doing a block at the same time. Thoughts

I'd have done it in the PACU as he was waking up. He'd be awake enough to be responsive, but still not totally coherent and likely far less nervous about the situation.

 

[Lee123]

It is all about risk vs benefit:

benefit - you get a block and don't know about the needle because you are asleep
risk - horrific, disabling pain from an intraneural injection for the rest of your life

I see no reason to do it asleep. If they can't stay still they get no block. If something goes wrong they will come after you.

 

[ssmallz]

I'd have done it in the PACU as he was waking up. He'd be awake enough to be responsive, but still not totally coherent and likely far less nervous about the situation.

Thought about that but he wanted to do it preop. I was going to supplement post op if woke up w/pain and could stop shaking. He woke up comfortable so I must have gotten some local in the right spot and it wasn't an issue

 

[ssmallz]

It is all about risk vs benefit:

benefit - you get a block and don't know about the needle because you are asleep
risk - horrific, disabling pain from an intraneural injection for the rest of your life

I see no reason to do it asleep. If they can't stay still they get no block. If something goes wrong they will come after you.

I was mainly referring to USG ISBs where you can easily visualize the anatomy and the needle. My thinking, you can visualize the needle and spread of local. Pain on injection is very unreliable IMO b/c so many pts c/o some pain on injection which turns out to just be pressure from the local rather than an intraneural injection. Even when the pt is alseep you've still got resistance upon injection and needle visualization to tell you whether or not you are intraneural. We do them on kids w/fem nerve blocks and don't even use US and they do fine.

I agree that the risk:reward is likely skewed toward risk so I'm just playing devils advocate here.

 

[secoy]

Like everyone else, I've done blocks: awake, w/ versed, w prop, and under general. I find that mot blocks that I do under general are because we didnt have preop surgical consent and marking preop. Therefore, in order to prevent any delays we just kept patient asleep for an additional couple of minutes post op to do the block.

More important to me than level of patient sedation is a quiet cooperative pt. In other words, I'll do a block with no sedation if a patient can tolerate it. But have given heavy doses of propofol to young teenagers or patients who are freaked out/panicking despite versed & fentanyl. I feel that I am more likely to either injur or have an unsuccessful block with a patient that moving and not sitting still,

 

[Oggg]

The Benumof article refers to the anterior, direct approach to the interscalene groove. If you go too medial, you are headed for the cervical spinal cord. If you use US and go Out of Plane from the anterior position, you could go too deep and end up in spinal cord if you somehow lost your needle tip and advanced too far (unlikely). But if you go with a posterolateral in plane approach you are pretty safe. If you advance too far, you end up in the anterior scalene or maybe the IJ/carotid (if you overshoot by sev cm). There is something called the cervical paravertebral block, which of I understand it correctly, is basically a non-ultrasound, posterior approach where you start in the levator scapulae, blindly hit the transverse process then walk lateral to that, and you enter the interscalene groove - if you overshoot you're likely to exit the skin of the anterior neck.

My sedation pathway is versed 2, then versed 2, then fentanyl 25-100, then propofol 20 increments. I would do an In plane US ISB under general for special cases (tremor, dementia/MRCP)

 

[DrN2O]

My sedation pathway is versed 2, then versed 2, then fentanyl 25-100, then propofol 20 increments. I would do an In plane US ISB under general for special cases (tremor, dementia/MRCP)

That's a lot of sedation for US. Usually 0-2 mg of versed is enough for IS. I only use fentanyl if it's NS or a LE block like sciatic or lumbar plexus. I guess if you need more after 4 of versed, 100 of fentanyl, you might as well push propofol to induce.

 

[BlockJock79]

It has been my experience that most patients require little to no sedation for ISB's (single shots) if the proper reassurance and hand patting is applied beforehand, but that assumes the use of ultrasound and a single pass of the needle. For selfish reasons, I also like that they remember the procedure and remember that I was the one who did it for them....

 

[BLADEMDA]

It has been my experience that most patients require little to no sedation for ISB's (single shots) if the proper reassurance and hand patting is applied beforehand, but that assumes the use of ultrasound and a single pass of the needle. For selfish reasons, I also like that they remember the procedure and remember that I was the one who did it for them....

My average ISB gets versed 2 mg IV. But, my average patient is over 75.
The more I do (I've done thousands) and the older I get the less sedation I give to adults over 30. But, blocking anxiety prone woman under 30 and kids are a whole different ball of wax.

 

[Magoun]

My average ISB gets versed 2 mg IV. But, my average patient is over 75.
The more I do (I've done thousands) and the older I get the less sedation I give to adults over 30. But, blocking anxiety prone woman under 30 and kids are a whole different ball of wax.

One of the coolest experiences of rotating through HSS was seeing an old-school ISB.

No ultrasound. No NS. No sedation. Perfect block, everytime I saw him try.

I wasn't with the one attending who still does it enough for him to let me try it, but old-school regional really is an art.

 

[BLADEMDA]

One of the coolest experiences of rotating through HSS was seeing an old-school ISB.

No ultrasound. No NS. No sedation. Perfect block, everytime I saw him try.

I wasn't with the one attending who still does it enough for him to let me try it, but old-school regional really is an art.

Indeed. The ISB is a 2-3 minute block in the right hands. Literally, a 1/4-1/2 inch under the Interscalene groove and the volume does the rest.

 

[Planktonmd]

I give Propofol and do ISBs on crazy people everyday.

 

[ssmallz]

I give 2mg of versed to everyone except the oldest and sickest. My thinking is that on top of the sedation it provides, if I do get some LA tox versed will raise the seizure threshold a bit and help me out. It might be pissing in the wind given the volume of local we give and adjustment in seizure threshold from 2mg of versed but it helps me sleep better at night

 

[Oggg]

Sorry my post was poorly worded. I start with versed 2mg, and most people are calm enough to do the block. If they are nervous still, I proceed with more versed, and if they're still freaking out I give fentanyl. Finally I start going to propofol. But most just get versed 2mg.