Blocks and Additives??

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facted said:
I usually do 0.5% bupi (30ml) with decadron. Usually getting 24-30 hours. I wonder also about the bupi vs ropi difference. There is some literature out there suggesting bupi lasts longer than ropi but it depends on the study.
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Bupivacaine with Dexamethasone has a duration of analgesia which exceeds Ropivacaine with dexamethasone by about 4 hours. The price you pay is a much more pronounced motor block with Bupivacaine.
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BLADEMDA said:
That's why you need to be cautious with using Precedex in your blocks for the elderly having outpatient procedures. They could experience a drop in BP leading to dizziness with an increased risk of falling.
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Agreed. This month's RAPM addressed some of this with their meta-analysis regarding the addition of precedex to brachial plexus blocks. At doses less than 50mcg, the incidence of bradycardia and hypotension was not significantly different than controls. In the elderly, though, I would probably just avoid it, unless I REALLY needed those extra few hours in the right patient.

facted said:
I usually do 0.5% bupi (30ml) with decadron. Usually getting 24-30 hours. I wonder also about the bupi vs ropi difference. There is some literature out there suggesting bupi lasts longer than ropi but it depends on the study.
Click to expand...

We used 0.5% bupivacaine often in residency, and I noticed the same thing regarding longer duration with decadron compared to ropivacaine. We only had ropivacaine at the time I had my block, and that's our default local for random local custom reasons.
 
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I'm a bupi guy myself. Longer block duration and far less expensive. I don't really see the draw for ropi. We didn't have it in residency so I just didn't train with it really. The improved safety profile is great in theory and all but I've done many countless blocks, and knock on wood, the closest I've come to LAST is writing a chapter on it... :)

As for longer motor block than ropi, I'm not 100% sure if that's even true. But even if it were, not sure it matters too much. Most of our patients aren't doing active rehab within block time anyway. Any rehab they get is passive ROM which a nice dense block works great for ;)
 
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The use of dexmedetomidine decreases inflammation around peripheral nerves, thereby decreasing the potential for peripheral nerve injury.[12] In human beings, the beneficial effects of adding dexmedetomidine to local anesthetics during regional anesthesia and some peripheral nerve blockade procedures have proved to be efficacious for the surgical patients.[6,7,11]

In a study on sciatic nerve block in rats, addition of dexmedetomidine to ropivacaine resulted in increased duration of sensory and motor block and showed no evidence of neurotoxicity.[5] In addition, use of dexmedetomidine decreases inflammation around peripheral nerves, thereby decreasing the potential for peripheral nerve injury.[12] Thus, use of dexmedetomidine is safe in peripheral nerve blocks. Supporting the animal study data no neurological deficit was observed in any of our patients. No neurological deficit was reported in the study by Swami et al.[11] and Esmaoglu et al.[10] also.


Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block
 
IMHO, Precedex is safer than Dexamethasone as an adjuvant added to local anesthetics for peripheral nerve blocks.


There is a theoretical risk of dexamethasone-induced peripheral neurotoxicity based on in vitro studies [2, 82, 83], and this must be weighed against the apparent efficacy of systemic administration. Further high-quality preclinical and clinical study is merited before it can be recommended for routine use.

Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review
 
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BLADEMDA said:
The use of dexmedetomidine decreases inflammation around peripheral nerves, thereby decreasing the potential for peripheral nerve injury.[12]

Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block
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This statement is false. Perineural inflammation is not thought to cause nerve injury, intrafasicular pressure / compartment syndrome is more likely.

Not arguing precedex doesn't decrease inflammation though, as does perineural decadron.
 
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BLADEMDA said:
IMHO, Precedex is safer than Dexamethasone as an adjuvant added to local anesthetics for peripheral nerve blocks.
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And this is based on...? Not aware of any studies showing issues from perineural dexamethasone.

As for the topic and motor block, I'm just not sure what that gets you. What's the difference if the person just had surgery? Surgeons aren't making patients test their repairs the day after surgery...
 
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facted said:
And this is based on...? Not aware of any studies showing issues from perineural dexamethasone.

As for the topic and motor block, I'm just not sure what that gets you. What's the difference if the person just had surgery? Surgeons aren't making patients test their repairs the day after surgery...
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There are issues with perineural dexamethasone; it's potentially neurotoxic at the dosages many are using in clinical practice.
 
BLADEMDA said:
There are issues with perineural dexamethasone; it's potentially neurotoxic at the dosages many are using in clinical practice.
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So is local anesthetic. In fact, the only animal study I know of that looked at this showed ropi was far more neurotoxic then dexamethasone. Regardless, I'm not aware of any study in humans showing increased nerve injury from dexamethasone. Are you?
 
BLADEMDA said:
Unusually Prolonged Motor and Sensory Block Following Single Injection Ultrasound-Guided Infraclavicular Block With Bupivacaine and Dexamethasone

More than a few Anesthesiologists across the USA have seen this unusually prolonged effect; I've spoken to BlockJocks and they have had it as well. It's not common but if you do enough you may encounter it.
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42 hours is certainly outside the norm, but it's not that crazy either. I've had blocks last this long, and I always tell my patients block could last up to 2-3 days and not to be alarmed.
 
facted said:
I usually do 0.5% bupi (30ml) with decadron. Usually getting 24-30 hours. I wonder also about the bupi vs ropi difference. There is some literature out there suggesting bupi lasts longer than ropi but it depends on the sty.
Click to expand...
I use ropiv because I "don't" want the motor block to last much more than 24 hours.

I believe that the Holy Grail of regional blocks is one that lasts long enough to get the pt through the acute phase of surgical pain and that carries as little or as short of motor blockade as possible. When pts are asked what they liked and disliked about regional blocks, a large portion of them will state that they didn't like the paralysis. They all like the pain control. It is quite annoying to have a paralysized limb even if it is painless.
 
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Noyac said:
I use ropiv because I "don't" want the motor block to last much more than 24 hours.
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I see plenty of studies showing ropivacaine sparing motor in epidurals.

I also see plenty of studies looking at bupi vs ropivacaine for PNB that show absolutely no difference for motor vs sensory time for ropivacaine. I can link then if interested.

Can anyone provide studies showing motor vs sensory ropivacaine differential in PNB?
 
facted said:
I see plenty of studies showing ropivacaine sparing motor in epidurals.

I also see plenty of studies looking at bupi vs ropivacaine for PNB that show absolutely no difference for motor vs sensory time for ropivacaine. I can link then if interested.

Can anyone provide studies showing motor vs sensory ropivacaine differential in PNB?
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Hello! Are you new here? Let me introduce myself. I'm Noy. I've been doing this gig for a long time. I am no smarter than any other person here but I do have a ton of experience. I am more than aware of your studies. If you don't agree with me then fine, your choice. But I don't need you to lecture me on studies that prove your point. I'm sure you are aware that I could produce just as many studies refuting your stance. But that's not what I do here. We have Blade for that. Thanks Blade.
 
Noyac said:
Hello! Are you new here? Let me introduce myself. I'm Noy. I've been doing this gig for a long time. I am no smarter than any other person here but I do have a ton of experience. I am more than aware of your studies. If you don't agree with me then fine, your choice. But I don't need you to lecture me on studies that prove your point. I'm sure you are aware that I could produce just as many studies refuting your stance. But that's not what I do here. We have Blade for that. Thanks Blade.
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I'm not lecturing anyone on studies. I'm simply asking for evidence. I've heard a lot of people talk about ropivacaine giving better sensory vs motor profile, but I've seen no evidence for it in PNB.

It's nice you have experience. So do I and a lot of other people on here. That doesn't mean I try to lecture people based on it without providing evidence... I leave that to surgeons

As for saying you could provide studies to refute my point, that's exactly what I asked for in my post. I'd like to see some evidence for it because the countless studies I've read don't show the sensory motor difference in PNB.
 
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Noyac said:
Hello! Are you new here? Let me introduce myself. I'm Noy. I've been doing this gig for a long time. I am no smarter than any other person here but I do have a ton of experience. I am more than aware of your studies. If you don't agree with me then fine, your choice. But I don't need you to lecture me on studies that prove your point. I'm sure you are aware that I could produce just as many studies refuting your stance. But that's not what I do here. We have Blade for that. Thanks Blade.
Click to expand...

My entire group knows that Bupivacaine when used for a PNB produces substantially more motor block than Ropivacaine. That's a clinical fact. Whether you care that the motor block is prolonged is your decision. I've had a PNB and I disliked the intense motor block from Bupivacaine. That said, I use both locals frequently in my practice.

For some PNBs of the lower extremity the prolonged motor block/weakness may be an issue postop. I'll leave that decision up to you.

Noy, I appreciate your post (as usual you add to the discussion).
 
facted said:
42 hours is certainly outside the norm, but it's not that crazy either. I've had blocks last this long, and I always tell my patients block could last up to 2-3 days and not to be alarmed.
Click to expand...

I've had blocks last 40-70 hours with the use of dexamethasone in the 4-8 mg range. IMHO, that duration of block is too long and the risk of neurotoxicity too great to use that clinical dosage. Many have drastically reduced the dosage of dexamethasone used as an adjuvant with local for PNBs. IMHO, Precedex is a safer alternative to Dexamethasone as an adjuvant. That said, low dose dexamethasone combined with Precedex may offer the 24++ hours of post op analgesia we are seeking with a good safety factor.
 
These days I utilize low dose dexamethasone (if at all) for my PNBs (1-2 mg mixed with 20 mls of local) and give the dexamethasone primarily IV at 0.1 mg/kg up to 12 mg IV.
I do add Precedex for healthy outpatients and some inpatients like a total shoulder.

For my TAP and QL blocks I'll add Buprenorphine to the mixture as well.

I encourage SDN members to lower the dosage of dexamethasone (if added at all) used as adjuvant with local anesthetic for PNBs; instead, give the remainder of the dexamethasone IV to meet or exceed 0.1 mg/kg.

Additives to Local Anesthetics for Peripheral Nerve Blockade

http://www.jcafulltextonline.com/article/S0952-8180(14)00416-4/abstract

Conclusion
Low-dose dexamethasone (1-2 mg) prolongs analgesia duration and motor blockade to the similar extent as 4-mg dexamethasone when added to 0.25% bupivacaine for supraclavicular brachial plexus nerve block.
 
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Low-dose Dexamethasone Prolongs Analgesia for Brachial Plexus Block
Researchers at University of Pennsylvania’s Perelman School of Medicine found that the addition of a low dose (1-2 mg) of dexamethasone to 0.25% bupivacaine for brachial plexus nerve block prolonged the duration of analgesia and motor blockade to a similar extent as a higher dose (4 mg).

The randomized double-blind study examined the analgesic effect of 3 doses of dexamethasone in combination with low-concentration local anesthetics to determine the lowest effective dose to use an adjuvant in supraclavicular brachial plexus block.

Eighty-nine patients scheduled for shoulder arthroscopy received a single-shot supraclavicular brachial plexus nerve block with 30 mL of 0.25% bupivacaine. In addition to the bupivacaine, patients were randomized to receive:

  • No dexamethasone (control group; n=23)
  • 1-mg dose of preservative-free dexamethasone (n=20)
  • 2-mg dose of preservative-free dexamethasone (n=22)
  • 4-mg dose of preservative-free dexamethasone (n=24
Duration of analgesia and motor block were measured.

The median duration analgesia without dexamethasone was 12.1 hours. The addition of 1-, 2-, or 4-mg dexamethasone significantly prolonged the analgesia duration to 22.3, 23.3, and 21.2 hours, respectively (P=0.0105). The duration of motor nerve block was also extended with dexamethasone in a similar trend (P=0.0247).

There was 1 episode of clinically significant paresthesia, which resolved on POD3, with no other complications noted in the study.

Source

Liu J, Richman KA, Grodofsky SR, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical stu
 
BLADEMDA said:
Low-dose Dexamethasone Prolongs Analgesia for Brachial Plexus Block
Researchers at University of Pennsylvania’s Perelman School of Medicine found that the addition of a low dose (1-2 mg) of dexamethasone to 0.25% bupivacaine for brachial plexus nerve block prolonged the duration of analgesia and motor blockade to a similar extent as a higher dose (4 mg).

The randomized double-blind study examined the analgesic effect of 3 doses of dexamethasone in combination with low-concentration local anesthetics to determine the lowest effective dose to use an adjuvant in supraclavicular brachial plexus block.

Eighty-nine patients scheduled for shoulder arthroscopy received a single-shot supraclavicular brachial plexus nerve block with 30 mL of 0.25% bupivacaine. In addition to the bupivacaine, patients were randomized to receive:

  • No dexamethasone (control group; n=23)
  • 1-mg dose of preservative-free dexamethasone (n=20)
  • 2-mg dose of preservative-free dexamethasone (n=22)
  • 4-mg dose of preservative-free dexamethasone (n=24
Duration of analgesia and motor block were measured.

The median duration analgesia without dexamethasone was 12.1 hours. The addition of 1-, 2-, or 4-mg dexamethasone significantly prolonged the analgesia duration to 22.3, 23.3, and 21.2 hours, respectively (P=0.0105). The duration of motor nerve block was also extended with dexamethasone in a similar trend (P=0.0247).

There was 1 episode of clinically significant paresthesia, which resolved on POD3, with no other complications noted in the study.

Source

Liu J, Richman KA, Grodofsky SR, et al. Is there a dose response of dexamethasone as adjuvant for supraclavicular brachial plexus nerve block? A prospective randomized double-blinded clinical stu
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I'm not questioning the prolongation of block with decadron but a couple things about this study seem off. Why are they doing supraclavicular blocks for shoulder scopes? I understand that a supraclav block can block up to the shoulder but typically an interscalene block is the preferred choice for a shoulder scope. Also, with that volume of LA used for this study, the 12 hrs of analgesia attained in the no decadron group seems quite low. Even as a resident learning these blocks, I'd get longer analgesia than that with half the volume of LA they used
 
Ezekiel2517 said:
Why are they doing supraclavicular blocks for shoulder scopes? I understand that a supraclav block can block up to the shoulder but typically an interscalene block is the preferred choice for a shoulder scope.
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Both blocks work for an average shoulder scope.
 
Arch Guillotti said:
Both blocks work for an average shoulder scope.
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as I just posted, I understand that. However, as most would probably attest, an interscalene is done for this procedure the vast majority of the time. What's the point of blocking the arm all the way down to the fingers when all you have are a couple tiny incisions way up on top of the shoulder?
 
facted said:
I'm not lecturing anyone on studies. I'm simply asking for evidence. I've heard a lot of people talk about ropivacaine giving better sensory vs motor profile, but I've seen no evidence for it in PNB.
Do your research. You obviously haven't paid attention.

It's nice you have experience. So do I and a lot of other people on here. That doesn't mean I try to lecture people based on it without providing evidence... I leave that to surgeons
You leave this to surgeon? They don't care. Not as long as you get your pt in the OR on time. They don't see the pt for 2 weeks post op. They never ask about their block experience. You are green my man. Very green.

As for saying you could provide studies to refute my point, that's exactly what I asked for in my post. I'd like to see some evidence for it because the countless studies I've read don't show the sensory motor difference in PNB.
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Do your research. You obviously haven't paid attention.

You leave this to surgeon? They don't care. Not as long as you get your pt in the OR on time. They don't see the pt for 2 weeks post op. They never ask about their block experience. You are green my man. Very green

"Countless"? One study is my guess. You need more time in the trenches.
Btw, as I stated, Blade is much better at the studies thing. Read the following posts.

Disclaimer, the difference btw bupiv and ropiv is minimal. We are splitting hairs. But for my practice, I like ropiv so let's leave it at that rookie.
 
BLADEMDA said:
My entire group knows that Bupivacaine when used for a PNB produces substantially more motor block than Ropivacaine. That's a clinical fact.
Click to expand...

I appreciate your posts blade. I know you love your studies. Can you post or PM me studies showing me this for PNB. I can't find any. Thanks.
 
facted said:
I appreciate your posts blade. I know you love your studies. Can you post or PM me studies showing me this for PNB. I can't find any. Thanks.
Click to expand...


Following upper limb surgery
There was similar pain relief with ropivacaine and bupivacaine,[40] although hand strength returned more quickly and there was less paraesthesia of the fingers in patients receiving ropivacaine than in those receiving bupivacaine.[40] At 24 hours after the block, hand strength (primary endpoint) reduced by 48% in ropivacaine recipients and 66% in bupivacaine recipients (P<0.05). Further, 6 hours after discontinuation of the infusion, hand strength was fully restored in the ropivacaine group but still decreased by 25% in the bupivacaine group (P<0.05).[40]

In a trial involving lower limb surgeries the duration of sensory block with ropivacaine 15 mg was found to be similar with bupivacaine 10 mg, and the motor block was significantly shorter, it was also suggested that on a milligram for milligram basis, the potency of ropivacaine relative to bupivacaine is two-thirds with regard to sensory block and half with regard to motor block.[28]
 
BLADEMDA said:
Following upper limb surgery
There was similar pain relief with ropivacaine and bupivacaine,[40] although hand strength returned more quickly and there was less paraesthesia of the fingers in patients receiving ropivacaine than in those receiving bupivacaine.[40] At 24 hours after the block, hand strength (primary endpoint) reduced by 48% in ropivacaine recipients and 66% in bupivacaine recipients (P<0.05). Further, 6 hours after discontinuation of the infusion, hand strength was fully restored in the ropivacaine group but still decreased by 25% in the bupivacaine group (P<0.05).[40]

In a trial involving lower limb surgeries the duration of sensory block with ropivacaine 15 mg was found to be similar with bupivacaine 10 mg, and the motor block was significantly shorter, it was also suggested that on a milligram for milligram basis, the potency of ropivacaine relative to bupivacaine is two-thirds with regard to sensory block and half with regard to motor block.[28]
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That makes sense for sensory. I've always felt like 0.5% ropiv provides a similar block to 0.375% bupiv in peripheral blocks. Same with 0.2% ropiv compared to 0.125% bupiv for epidurals.

I thought ropiv was thought to provide less of a motor blockade due to the reduced lipophilicity.


Sent from my iPhone using Tapatalk
 
All that said, I am not sure we really know the equipotent concentration of Ropivacaine compared to Bupivacaine, which makes it challenging to compare their effects.
In other words who said that 0.2% Ropivacaine is equipotent to 0.125% Bupiva? Maybe all the differences we are seeing are simply caused by Ropivacaine being less potent than we assume.
 
polar403 said:
That makes sense for sensory. I've always felt like 0.5% ropiv provides a similar block to 0.375% bupiv in peripheral blocks. Same with 0.2% ropiv compared to 0.125% bupiv for epidurals.

I thought ropiv was thought to provide less of a motor blockade due to the reduced lipophilicity.


Sent from my iPhone using Tapatalk
Click to expand...

Good point. My hunch based on a study or two is that 0.75% Ropivacaine is probably equivalent to 0.5% Bupivacaine in terms of duration of block, both sensory and motor.

My posts are primarily about 0.5% Ropivacaine vs 0.5% Bupivacaine which is what we PP people us all the time.
 
I use .5% bupi wth epi and decadron almost exclusively for TAPs, ACBs and PECs. No motor block with these.
FNBs: .25% rop plain.
For RCR: .5% rop with decadron.
For TSA: Low volume .5% rop with .2% rop onQ catheter the patient goes home with x 3days.
Total Ankles and other painful foot stuff: .5% bupi with epi and decadron +/- onQ catheter
Other non-weight bearing surgeries: .5% bupi with decadron.

At equivalent volume and concentration, bupivicaine outlasts ropivicaine in both motor block and analgesia.
For the longest duration blocks: .5% Bupi with fresh epi and decadron is my goto.
If they need to be up and moving I switch to ropivicaine at various concentrations.

I have little experience with precedex in blocks (lots of experience with clonidine). Personally, I don't see much value in it especially once you have to start giving glyco or ephedrine.

I also have one partner that ended up getting a neuropathy with precedex when he first started using it. Not sure if it was related to it or not, but I just don't need much more than decadron if I want to extend duration- at least at this point. Just my 2 cents.
 
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Also .2% ropivicaine with 2mcg/ml of fentanyl is diesel for the OB floor.
Def. my favorite mixture with the least amount of calls.
 
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I've been using dexamethasone in my blocks for 10 years now and what i really like about it is that you don't get the on/off effect of a block with pure local. It smoothes out the tail end of the block and patient will often need only tramadol instead of more potent opioids post op.
Imho it make a huge difference in hallux valgus corrections or hemorroidal surgery for example.
 
I also don't believe IV decadron is equivilant to decadron mixed with local at the site of the PNB.
Never have.
 
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dhb said:
I've been using dexamethasone in my blocks for 10 years now and what i really like about it is that you don't get the on/off effect of a block with pure local. It smoothes out the tail end of the block and patient will often need only tramadol instead of more potent opioids post op.
Imho it make a huge difference in hallux valgus corrections or hemorroidal surgery for example.
Click to expand...

What block are you doing for hemorroidal surgery !?!
 
Pudendal block
If you've not done this block you cannot call yourself a master jedi.
One eyed wink ftw :pompous:
 
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So you load them up on oxy?
I had a patient for a repeat procedure who had stayed 5 nights in house for pain control. With the block she only needed some tramadol the next day and left the hospital...
 
BLADEMDA said:
Good point. My hunch based on a study or two is that 0.75% Ropivacaine is probably equivalent to 0.5% Bupivacaine in terms of duration of block, both sensory and motor.

My posts are primarily about 0.5% Ropivacaine vs 0.5% Bupivacaine which is what we PP people us all the time.
Click to expand...

Fair enough. I've switched from 0.375% bupiv to 0.5% ropiv in my practice, as the group and hospital prefer ropiv. Seem to be equivalent when following up on block duration and density. Can't say I've used 0.5% bupiv very often.

I don't know about anything that has determined equipotent doses. It was just a guess from switching between bupiv and ropiv in practice.
 
dhb said:
So you load them up on oxy?
I had a patient for a repeat procedure who had stayed 5 nights in house for pain control. With the block she only needed some tramadol the next day and left the hospital...
Click to expand...

For a G'dam hemmroid? No silly...
Our surgeons love exparel for hemmroids.
That's a same day surgery case.
5 nights? What a pain in the butt.
 
dhb said:
So you load them up on oxy?
I had a patient for a repeat procedure who had stayed 5 nights in house for pain control. With the block she only needed some tramadol the next day and left the hospital...
Click to expand...

Surgeons infiltrate area with Exparel and patients all seem to do just fine that first night at home.
 
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