Asleep Blocks?

[amyl]

one of the guys at my hospital does all his blocks asleep... something i was obviously taught not to do. what do most of you guys in private practice think?

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[pgg]

one of the guys at my hospital does all his blocks asleep... something i was obviously taught not to do. what do most of you guys in private practice think?

I wouldn't do it here, except maybe in some cases for kids or other patients who wouldn't cooperate for a safe awake block. I don't see any up side to pushing that envelope.


However, I'm getting ready to go to Afghanistan, and one of the guys I'm relieving says nearly every fresh casualty with an extremity injury will get blocked under GA. Preop blocks aren't really an option there, it helps get them extubated earlier, and of course the risk of getting sued is zero.

 

[Laryngophed]

I wouldn't do it here, except maybe in some cases for kids or other patients who wouldn't cooperate for a safe awake block. I don't see any up side to pushing that envelope.


However, I'm getting ready to go to Afghanistan, and one of the guys I'm relieving says nearly every fresh casualty with an extremity injury will get blocked under GA. Preop blocks aren't really an option there, it helps get them extubated earlier, and of course the risk of getting sued is zero.

You going to mod from the other side of the world?

 

[Arch Guillotti]

You going to mod from the other side of the world?

he has mad skillz

 

[IlDestriero]

We do them every day, many times a day on kids under GA. Spinals, thoracic epidurals, caudals, single shots, catheters, everything. Thousands and thousands of kids in the database over the last 8 years or so with no problems.
Having said that, if you're very uncomfortable with them, don't do them that way. Just be aware that it's done in Children's hospitals every day all over the country.

 

[amyl]

I know its done in kids all the time... just wondering about in adults?

 

[okayplayer]

At my program at the county/trauma hospital we do sciatic/saphenous PNCs to the tune of 10-12/day probably. 100% on intubated pts on propofol gtts in PACU. Not aware of any complications but that doesn't mean there haven't been any.

 

[pgg]

You going to mod from the other side of the world?

Probably, plywood hut internet connectivity has gotten pretty good 10 years into this party.

 

[BLADEMDA]

I know its done in kids all the time... just wondering about in adults?

The norm in the USA is sedated but not asleep or SAB for adults. Most of us prefer to stay within established practice parameters. That said, I'd be willing to do a nerve block under GA or SAB provided the patient has no preexisting neurological disorders and I use ultrasound combined with a nerve stimulator. I'd want to use all available safety precautions including low pressure during injection. I'd try to get my twitch above 0.5 but less than 1 while also visualizing the tip of the needle during injection.

 

[psychbender]

Have only done them under GA in children, but I'm in a similar boat as PGG, and will be doing them in anesthetised adults in a few months, as I have also been told that it is a common practice for our soldiers when they get to Germany.

 

[Gern Blansten]

http://www.ncbi.nlm.nih.gov/pubmed/11149455

(Sorry, I can't access the full text from home, but it is basically 4 patients who awakened with quadriplegia or paraplegia after interscalene blocks done under general.)

This case series report by Benumof is what caused our place to stop doing blocks under general unless it was kids or if the benefits far outweigh the risks. Of course, now we do most with ultra sound, which I think improves the safety margin. We still have not gone back to blocks under general though.
A small amount of sedation makes most patients amenable to the block, so it has not been an issue in 99% of adult cases.
There was an article recently that was also advocating for no sedation for chronic pain procedures such as LESI's. That is also pretty standard at my place. Patients do great with it. The only ones that have issues are the ones that come from outside who have had it done under room air general and are leery of having it with no sedation. They eventually warm up to the idea.

 

[Gern Blansten]

Have only done them under GA in children, but I'm in a similar boat as PGG, and will be doing them in anesthetised adults in a few months, as I have also been told that it is a common practice for our soldiers when they get to Germany.

Thanks to you and pgg for your service and for taking care of our soldiers. That has to be a tough job.

 

[BLADEMDA]

Have only done them under GA in children, but I'm in a similar boat as PGG, and will be doing them in anesthetised adults in a few months, as I have also been told that it is a common practice for our soldiers when they get to Germany.

It's perfectly safe under U/S. That is my opinion and the opinion of many in this field.
Under Nerve Stimulator only I'm not as ceratin about that "pefectly safe" comment concerning blocks under GA.

If you have U/S and a NS combination then PNBs are perfectly safe in my opinion.

 

[BLADEMDA]

http://www.biomedsearch.com/article/Long-term-neurological-complications-associated/188796748.html

44% of the blocks were placed under GA. U/S was NOT utilized which should make the BLOCK even safer in 2012.

 

[BLADEMDA]

http://www.usra.ca/isura2012/syllabus/SAPPro.pdf

Take a look. I'd do a Block under GA using U/S and a NS.

 

[periopdoc]

My take on it.

There is no increased risk from doing a proper U/S guided nerve block under GA vs awake.

However, the risk of any nerve block is not zero and when a complication occurs, you made your defense significantly harder when you chose to do it asleep.


- pod

 

[Oggg]

As i understand it, in peds hospitals, they'll do asleep blocks in a 17yo "peds" pt.

With ultrasound, I feel pretty confident doing all nerve blocks except posterior lumbar plexus (little experience) under GA, provided I have a good view. I'll throw on the nerve stim if its handy. In a similar vein, I'll reblock patients if their preop block failed or is only partially effective.

 

[bostonblaz]

Take away the fact that it is safe and done a lot all over the country. It only matters if it is the standard of care and I don't think it is. I also think if down the line you had to put on a tie and stand in front of a jury of your peers a lawyer on the other side would parade a lot of anesthesiologists in front of said jury and each would say that it is "probably" safe but not the standard of care unless it is a kid or a mentally challenged adult. Blaz

 

[BLADEMDA]

Take away the fact that it is safe and done a lot all over the country. It only matters if it is the standard of care and I don't think it is. I also think if down the line you had to put on a tie and stand in front of a jury of your peers a lawyer on the other side would parade a lot of anesthesiologists in front of said jury and each would say that it is "probably" safe but not the standard of care unless it is a kid or a mentally challenged adult. Blaz

Sounds like we need a study on adults under GA getting nerve blocks with u/s. A study of 2,000 patients should help convince "a jury of your peers" that blocks under GA with u/s are safe.

 

[periopdoc]

The data already exists at Harborview in Seattle (at least for pop-sci). Unfortunately, IRB wouldn't let us prospectively gather data and I believe they gave us problems with the retrospective stuff too. A real shame given how useful the data would be. This may have changed with the new chair who has since left for greener pastures.

If I was a prosecuting malpractice attorney, I would find a panel of experts to claim that it is patently unsafe and I would have a load of literature that supports that contention. As the defense, I would have a panel of experts claiming that, although the literature doesn't clearly show that it is safe, the pediatric literature supports the idea that it is. Which one do you think that your 12 "peers" is going to believe? If I knew that I was going to be judged by a jury of 12 of my actual peers, I could change a lot of the way that I practice.

- pod

 

[Mman]

It's perfectly safe under U/S. That is my opinion and the opinion of many in this field.
Under Nerve Stimulator only I'm not as ceratin about that "pefectly safe" comment concerning blocks under GA.

If you have U/S and a NS combination then PNBs are perfectly safe in my opinion.

While I like to think U/S increases the margin of safety, I'm not aware of any evidence that ultrasound definitively decreases your chances of a nerve injury. There has even been suggestion by some that U/S in and of itself increases the risk although I think that's a complete load (but it's out there in the literature).

 

[Planktonmd]

There are some anesthesia "experts" out there who make tons of money testifying against other anesthesiologists.
These same so called "experts" are the ones who do these so called "studies" showing how horrible it is to do a block under general anesthesia.
I am not going to name any particular "expert" but they are well known!

 

[HollywdAnesth]

I do mine after the dressing has been placed, and the patient is still asleep.
I use an ultrasound and nerve stim to 0.5 mA. I've done a couple hundred and haven't had a complication.
I know several anesthesiologists that perform asleep blocks as well. Its not in practice guidelines. I feel with an ultrasound and a clear picture of the needle tip it is safe, and the surgeon isn't breathing down your neck while you do the block.

 

[Gern Blansten]

There are some anesthesia "experts" out there who make tons of money testifying against other anesthesiologists.
These same so called "experts" are the ones who do these so called "studies" showing how horrible it is to do a block under general anesthesia.
I am not going to name any particular "expert" but they are well known!

Did I reference one of those "experts?"

 

[Planktonmd]

Did I reference one of those "experts?"

 

[Jay K]

My past and current practice, is to perform adult PNB's and neuraxial blocks with a verbally responsive and lucid patient.

 

[BLADEMDA]

My past and current practice, is to perform adult PNB's and neuraxial blocks with a verbally responsive and lucid patient.

That's fine. At times I prefer patients "heavily sedated" for Nerve Blocks. However, other times 2 mg of Midazolam is all that is needed. IMHO, safety isn't compromised by sedating a patient with our drugs and may, in fact, be enhanced.

 

[cchoukal]

That's fine. At times I prefer patients "heavily sedated" for Nerve Blocks. However, other times 2 mg of Midazolam is all that is needed. IMHO, safety isn't compromised by sedating a patient with our drugs and may, in fact, be enhanced.

I had an attg while in residency who always liked to "deeply" sedate patients with fentanyl and propofol before blocks. Inevitably, they'd go apenic and decide to take a HUGE breath just as I'd get the needle in the right place, thereby obscuring the whole view/twitch/angle. I loved that.

 

[Mman]

I find 2 mg of versed and a small skin wheal with a 25g or 27g needle and some lidocaine tends to allow >95% of patients to easily tolerate a single shot block with a 22 g needle and ultrasound guidance (no stimulation). It causes less discomfort than the 18 g IV that they just had started and they've got the versed on board.

I personally use high injection pressure and/or pain on injection as my 2 most reliable indicators of impending nerve injury if I continue, so their being awake enough to tell me if it hurts is a big safety issue for me. It's hard to cause a nerve injury if it's easy to inject and the patient doesn't even notice it going in.