Axillary Blocks

[MAC10]

Ive had some pretty crappy blocks with the stimulator that looked great got down to .4 with good hand twithes. Then I tried transarterial, no fuss, done in 5 min in holding room and worked great. What technique are you guys using in private pratice? Nerve stimulator, transarterial, ultrasound?

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[The_Sensei]

Transarterial - 1/2 volume anterior, 1/2 volume posterior

 

[fval28]

Ive had some pretty crappy blocks with the stimulator that looked great got down to .4 with good hand twithes. Then I tried transarterial, no fuss, done in 5 min in holding room and worked great. What technique are you guys using in private pratice? Nerve stimulator, transarterial, ultrasound?

transarterial with a 25 ga needle- 1/2 volume posterior, 1/2 volume anterior- usually use a mix of mepivicaine 1.5%, NaHCO3, and tetracaine 1%- get about 4-6 hours of pain relief.

 

[Noyac]

I never go transarterial unless I do it on accident (once and I went with it). I use the stimulator. I aim for the nerve distribution that the surgery is going to take place at. Just for review. Median n is above the artery, radial n is behind the artery and the ulnar is below the artery. I lok for a twitch down to 0.4 or less in the distribution of the surgical area and give 1/2 of my dose there. Then I move to the other nerves giving a 1/4 dose on each. I usually use 40-60 cc of local. My mixture is usually 30cc 0.5% ropiv and 30 cc 1.5% mepiv. I don't add anything to the mixture. This sets up in 15 minutes or less. I also add 10cc of local to the musculocutaneous n. in the coracobrachialis belly and do a ring block around the insertion (needle) site.

But I rarely do ax. blocks any more unless it is a hand case only. I prefer the infraclavicular blocks for the elbow down. It nearly 100% of the time covers the whole hand. I use less local and I don't have to find different nerves.

 

[Lizard1]

i've found that sometimes even if you get a good muscle response on the stimulator at a low amperage; when you start to inject, just the shear volume of the local will actually push the needle tip away from where you're trying to inject the local.

i'd had a few blocks fail where i knew i was dead on the nerve so i watched a couple under u/s and sure enough - saw it happen. so now i've gotten in the habit of advancing the needle just a tad once i start to inject(with neg aspirations of course!)

 

[Noyac]

i've found that sometimes even if you get a good muscle response on the stimulator at a low amperage; when you start to inject, just the shear volume of the local will actually push the needle tip away from where you're trying to inject the local.
i'd had a few blocks fail where i knew i was dead on the nerve so i watched a couple under u/s and sure enough - saw it happen. so now i've gotten in the habit of advancing the needle just a tad once i start to inject(with neg aspirations of course!)

I would argue that you were not within the sheath if this occurs. Its more of a matter of pushing the nerve away from the needle tip. In doing this, you are not moving the needle tip. Therefore, if you are in the sheath in the first place, then you will remain in the sheath w/c is necessary for an effective block. This is why the pt has a brief moment of pain when you first start to inject. If you think about it as the nerve moves away so does the sheath but when the sheath moves, it moves up the shaft of the needle. The local then fills the perineural space.

 

[InGasWeTrust]

I was told by one our regional attending's that the use of a nerve stimulator is now the standard of care and that not using one you are practicing below that standard. He states that if/when a complication occurs, you will be undone if a nerve stimulator was not used.

 

[jetproppilot]

I was told by one our regional attending's that the use of a nerve stimulator is now the standard of care and that not using one you are practicing below that standard. He states that if/when a complication occurs, you will be undone if a nerve stimulator was not used.

WHOA.....

Thats a lofty statement.

There are alotta standard-of care things in anesthesia.

Routine monitors, sterile technique for epidural placement, putting the tube in the correct hole, etc.

As of June 27th, 2006, nerve-stimulator-technique for axillary blockade has NOT been established as standard of care.

 

[DrDre']

I can HEAR the tone of voice this was said in, the holier-than-thou ivory tower you-know-what-I-am-talkin-about-kinda-thing.

Ah, academics, love the search for knowledge but not some of the baggage.

Of course, in a few years, this may be SOC, who knows...


Howdy Cracka Jet, how things settlin' down for you in the house?

I was told by one our regional attending's that the use of a nerve stimulator is now the standard of care and that not using one you are practicing below that standard. He states that if/when a complication occurs, you will be undone if a nerve stimulator was not used.

 

[jetproppilot]

I can HEAR the tone of voice this was said in, the holier-than-thou ivory tower you-know-what-I-am-talkin-about-kinda-thing.

Ah, academics, love the search for knowledge but not some of the baggage.

Of course, in a few years, this may be SOC, who knows...


Howdy Cracka Jet, how things settlin' down for you in the house?

BOW WOW WOW YIPPY YO YIPPY YAY JET PROP IN THE MUTHA *&*KIN HOUSSSEE

WHADUP DRE???!!!

My crib is almost done.

I could bitch about the last 10 months but I'll save you the agony of listening to me.

Back to the post....

WHOA.....

an academic attending HAS PROCLAIMED THE NERVE STIMULATOR TECHNIQUE IS THE STANDARD OF CARE....



We have alotta standard of cares in anesthesia.

Routine monitors, sterile technique when jabbing a baby-momma with a Tuohy, etc.

As of June 27th, 2006, said academic attending has made a lofty comment that simply isnt true.

To date, literature has not shown the NS technique to be safer than other techniques...nor have malpractice cases isolated a specific technique as safer than others.

Do I agree with him?

Maybe.

But thats not the point.

Professing NS technique as standard of care for axillary blocks when....

1) textbooks continue to describe other techniques....transarterial, "quadrant technique", etc

2) clinicians use non-nerve-stimulator techniques for axillary blockade every day, very safely

3) The ASA hasnt established the nerve stim tech as standard of care

is a disgrace to academia....i.e. propegation of something that is untrue.

 

[jetproppilot]

Ive had some pretty crappy blocks with the stimulator that looked great got down to .4 with good hand twithes. Then I tried transarterial, no fuss, done in 5 min in holding room and worked great. What technique are you guys using in private pratice? Nerve stimulator, transarterial, ultrasound?

Thats why I use transarterial.

 

[DrDre']

It takes experience to be able to weed through statements like this when you are a student or resident, I think.

However, it helps a lot to have been a cab driver- my BS meter is pretty high-powered.

Glad your house is almost done. Is your wife still supportive of your 4x4 addiction s/p flood?

BOW WOW WOW YIPPY YO YIPPY YAY JET PROP IN THE MUTHA *&*KIN HOUSSSEE

WHADUP DRE???!!!

My crib is almost done.

I could bitch about the last 10 months but I'll save you the agony of listening to me.

Back to the post....

WHOA.....

an academic attending HAS PROCLAIMED THE NERVE STIMULATOR TECHNIQUE IS THE STANDARD OF CARE....



We have alotta standard of cares in anesthesia.

Routine monitors, sterile technique when jabbing a baby-momma with a Tuohy, etc.

As of June 27th, 2006, said academic attending has made a lofty comment that simply isnt true.

To date, literature has not shown the NS technique to be safer than other techniques...nor have malpractice cases isolated a specific technique as safer than others.

Do I agree with him?

Maybe.

But thats not the point.

Professing NS technique as standard of care for axillary blocks when....

1) textbooks continue to describe other techniques....transarterial, "quadrant technique", etc

2) clinicians use non-nerve-stimulator techniques for axillary blockade every day, very safely

3) The ASA hasnt established the nerve stim tech as standard of care

is a disgrace to academia....i.e. propegation of something that is untrue.

 

[jetproppilot]

Glad your house is almost done. Is your wife still supportive of your 4x4 addiction s/p flood?

Thanks, bro.

As far as my boss and my Git-Er-Done truck addiction....

HAHAHAHHAHAHAHAHAHAHHAHAHA

Shannon evacuated in my truck to her parent's camp in Mississippi for the storm.

Shannon couldnt've left the camp after the storm, because of all the surrounding flooding/loose ground etc had it not been for my ligted Yukon XL 4WD.

After our reunion, here's her exact words, her eyes meeting mine like she's telling me about an epiphany:

"Honey, I'll never make fun of your truck again. Ever."

 

[jetproppilot]

Thanks, bro.

As far as my boss and my Git-Er-Done truck addiction....

HAHAHAHHAHAHAHAHAHAHHAHAHA

Shannon evacuated in my truck to her parent's camp in Mississippi for the storm.

Shannon couldnt've left the camp after the storm, because of all the surrounding flooding/loose ground etc had it not been for my ligted Yukon XL 4WD.

After our reunion, here's her exact words, her eyes meeting mine like she's telling me about an epiphany:

"Honey, I'll never make fun of your truck again. Ever."

spelling correction...

LIFTED Yukon XL 4WD...

 

[militarymd]

I was told by one our regional attending's that the use of a nerve stimulator is now the standard of care and that not using one you are practicing below that standard. He states that if/when a complication occurs, you will be undone if a nerve stimulator was not used.

Just to spite this guy, I may have to start doing trans-arterial approaches again.

 

[InGasWeTrust]

Yup you guys are awesome!


I knew this was not right, because before this dude arrived, all axillary blocks were done with transarterial technique with minimal complications.