Bka

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Depends on whether they are chronic ischemia with pre-op severe pain vs those diabetics who have severe neuropathy. For those with a lot of pre op pain I like to do femoral and popliteal catheters and then an LMA. Run the caths for a couple days until discharge. For the diabetics patients just do an LMA and no blocks; pain typically isn’t an issue in these patients.
 
Often these are sick patients, so pop plus fem/saph plus sedation. If not too unhealthy, blocks plus GA
 
DocMcCoy said:
Assuming no contraindications and relatively straight forward patient, I do fem pop blocks and ga with lma. Can be pretty smooth and almost never require anything else.
Click to expand...

For a BKA a Saphenous nerve block with a Popliteal block is all you need for excellent intraop and postop analgesia. A Femoral block is unnecessary but will of course work. A popliteal block is a better choice because if any injury to the nerve occurs it will much more distal than a gluteal or subgluteal approach to the sciatic nerve. The bottom line is the risk/benefit curve favors saphenous/popliteal or no block at all in this high risk population.


Ultrasound-guided popliteal sciatic and adductor canal block for below-knee surgeries in high-risk patients - PMC

Central neuraxial block and general anaesthesia in patients with significant comorbidities are associated with considerable peri-operative morbidity and mortality. This study aims to delineate peripheral nerve block as a suitable alternative ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
BLADEMDA said:
For a BKA a Saphenous nerve block with a Popliteal block is all you need for excellent intraop and postop analgesia. A Femoral block is unnecessary but will of course work. A popliteal block is a better choice because if any injury to the nerve occurs it will much more distal than a gluteal or subgluteal approach to the sciatic nerve. The bottom line is the risk/benefit curve favors saphenous/popliteal or no block at all in this high risk population.


Ultrasound-guided popliteal sciatic and adductor canal block for below-knee surgeries in high-risk patients - PMC

Central neuraxial block and general anaesthesia in patients with significant comorbidities are associated with considerable peri-operative morbidity and mortality. This study aims to delineate peripheral nerve block as a suitable alternative ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...


Very true! Thanks for the article Blade. and if they are high risk my strategy changes and I’m less concerned about any awareness during the procedure, then no GA.

the GA with LMA is for cruise control in the right patient. Plus I have to do my blocks in the OR with an eager surgeon ready to go and get a lot of funny looks waiting for a block to set up.

One could argue blocks w/ sedation with prop gtt or versed or what ever is superior. A lot of times it’s just easier for me to run .5MAC of Sevo and toss in an LMA. Im sure that is a contentious issue...

Spinal isn’t off the table either. Again with no contraindications.

Do you use stim for block placement?
 
DocMcCoy said:
Very true! Thanks for the article Blade. and if they are high risk my strategy changes and I’m less concerned about any awareness during the procedure, then no GA.

the GA with LMA is for cruise control in the right patient. Plus I have to do my blocks in the OR with an eager surgeon ready to go and get a lot of funny looks waiting for a block to set up.

One could argue blocks w/ sedation with prop gtt or versed or what ever is superior. A lot of times it’s just easier for me to run .5MAC of Sevo and toss in an LMA. Im sure that is a contentious issue...

Spinal isn’t off the table either. Again with no contraindications.

Do you use stim for block placement?
Click to expand...

When I use the nerve stimulator it is for additional safety purposes only. That is, I am more concerned about injecting local into the nerve than I am in obtaining a successful block. Hence, I use the nerve stimulator (at times) to back the needle off of the nerve so I am not injecting any local with a twitch less than 0.5/0.6. The combination of the nerve stimulator with U/S can increase safety IMHO when used properly. For example, my last 200 hundred ISB all have been Periplexus with no twitch whatsoever. If I see a twitch I back up or back away from the nerve prior to injecting any local.
 
Block + LMA unless they are really on death’s doorstep, in which case they would get a block and lie there.

No nerve stimulator - all you need is an ultrasound.
 
DocMcCoy said:
Who is comfortable placing blocks in these patients after induction?
(Sheepishly raises own hand)
Click to expand...
How is this any different from placing blocks before spinal wears off? At my shop, we never do nerve blocks after induction unless it is a field block, yet we do post-op blocks before spinal wears off all the time.
 
JiPo said:
How is this any different from placing blocks before spinal wears off? At my shop, we never do nerve blocks after induction unless it is a field block, yet we do post-op blocks before spinal wears off all the time.
Click to expand...

I know it’s been talked about before, more of a discussion question. That’s also part of my argument. With US and stim I’m personally comfortable with most lower extremity blocks under GA or before spinal wears off. Common practice to do lower extremity blocks in my shop under GA. Some increases medico legal risk though.

The few I’ve seen that say never under general are also the ones that flog a patient with 4 of versed and 100 fentanyl before they put one in which kinda defeats the purpose.


 
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DocMcCoy said:
I know it’s been talked about before, more of a discussion question. That’s also part of my argument. With US and stim I’m personally comfortable with most lower extremity blocks under GA or before spinal wears off. Common practice to do lower extremity blocks in my shop under GA. Some increases medico legal risk though.

The few I’ve seen that say never under general are also the ones that flog a patient with 4 of versed and 100 fentanyl before they put one in which kinda defeats the purpose.


Click to expand...

Rather than asking can it be done, the better question is, what are you trying to accomplish by placing it asleep? In my opinion, unless there is an indication for placing it asleep, eg: developmental delay, pediatrics, dementia, etc, the vast majority of patients should be able to tolerate a block with minimal to no sedation (and I say this after having had a block myself under pretty much nothing). Why unnecessarily increase your medicolegal risk? You better believe that if there is any sort of nerve injury, even if it is clearly from positioning, retraction during surgery, etc, you will get completely lit up on the stand if you blocked them while they were under GA. Keep in mind that peripheral nerve injuries are not all that uncommon following surgery.

On a separate note, if someone finds the need to snow a patient to place a block (like you said, 4 of Versed and 100 of fentanyl), I feel like they probably just suck at placing them and their techniques need refinement.
 
With regards to some comments above:
Like Blade, I too use a nerve stimulator on my blocks to try to avoid injection into the nerve for safety and medicolegal reasons.
I never do blocks (other than TAP type), under GA for safety and medicolegal reasons. Most patients get 2 of versed only.
 
You can tell where the site of injury is with ncs. That will let you know if it is positioning, surgical, pressure point or block. I think that as long as you aren't placing 30 cc within the nerve sheath at high pressure, there is no problem with blocks under ga.

Patients are less likely to move, the image quality can be better, patients aren't uncomfortable during needle placement, blocks can be performed faster, you don't have to carve out time. Same reasons for why I do lines after induction most of the time.
 
Same here, all blocks are placed as patient is waking up from GA, needle tip visualized under U/S. Doesn't slow anything down, patient comfortable, everyone's happy, you look slick, schedule not delayed, everyone goes home early. Not sure what the concern is exactly if you are able to clearly visualize your needle tip on U/S?
 
PainDrain said:
Depends on whether they are chronic ischemia with pre-op severe pain vs those diabetics who have severe neuropathy. For those with a lot of pre op pain I like to do femoral and popliteal catheters and then an LMA. Run the caths for a couple days until discharge. For the diabetics patients just do an LMA and no blocks; pain typically isn’t an issue in these patients.
Click to expand...

I'll do single adductor canal vs fem & pop blocks and LMA (unless cannot tolerate GA), but I'm interested in your catheter use.

What do you run for local and infusion rates? Any PCCA?
 
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Velefunt said:
I'll do single adductor canal vs fem & pop blocks and LMA (unless cannot tolerate GA), but I'm interested in your catheter use.

What do you run for local and infusion rates? Any PCCA?
Click to expand...

Just give em ropi 0.2 10cc/h and titrate it up or down until you get it right
or around 0.15-0.2 per kilo per hour
 
Velefunt said:
I'll do single adductor canal vs fem & pop blocks and LMA (unless cannot tolerate GA), but I'm interested in your catheter use.

What do you run for local and infusion rates? Any PCCA?
Click to expand...

We do 0.2% ropi and run each cath at 4ml/hr. We keep them in on average 2-4 days. Surgeons seem happy.
 
PainDrain said:
We do 0.2% ropi and run each cath at 4ml/hr. We keep them in on average 2-4 days. Surgeons seem happy.
Click to expand...

Looks like I'll have to talk to pharmacy about obtaining 100ml bags of 0.2% ropi; Unfortunately things like that may have to pass system-wide approval before we can obtain it.
 
Velefunt said:
Looks like I'll have to talk to pharmacy about obtaining 100ml bags of 0.2% ropi; Unfortunately things like that may have to pass system-wide approval before we can obtain it.
Click to expand...

Worth it. If you mix your own bags, are you gonna come in at 2 am to replace one that runs out? F that.

On-q pumps are nice since patients are able to be discharged home with them. They can last for 3 days and if they go home with the catheter you can have a nurse come by to take it out and educate them.
Pain Pump Information | Local Anesthetic Pump | On-Q
 
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