Blocks...discharge instructions....

[s204367]

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Just a few quick questions. Now in a relatively busy 16 or hospital doing a fair amount of regional. Interscalene/ coracoid/ fem/sciatic is about it. One of the old school surgeons was very reluctant to have blocks, and now continually complains about the block wearing off and him getting a call at 2am for pain. I wrote up a brief discharge intstruction sheet for the patients letting them know what to expect and when to get some oral opioids on board, but he still bitches. Personally I think he'd like to have some do everything for him including wiping his own ass. He's mediocre DO orthopod with i think a little bit of a chip on his shoulder, and I seem to be one of the ony gas passers that can tolerate him. Anyway, any of you attendings or resident departments have a good discharge intsruction sheet for your regional patients???

Also, I've played with lots of different locals. I initially used ropivicaine sec to its proposed decreased cardio toxicity, but went back to the racemic bupivicaine a few months ago. I call every pt I block 2 days after to see how the block worked for them. Consistently the bupivicaine gives 6-8 hours more analgesia. I use .5% 30cc, for both anasthesia during the procedure, and analgesia post-op, and often MAC the patients with nasal cannula or a face mask. Ocassionally an LMA if I am worried about their airway and the positioning of the pt(shoulder on a fattie).

Thanks..

 

[Noyac]

I do the same except that I use ropiv. almost exclusively. I have seen two seizures from ropiv and I was glad that they used ropiv instead of Bupiv in both cases. I also had a block for knee surgery a few months back and I was really ready for it to wear off by the time it did. I think it is extremely annoying to have a totally numb limb, therefore I don't usually care if bupiv lasts longer (total shoulders are an exception). This way the pt's block will wear off b/4 bedtime and they can get the pain under control earlier, if that makes sense. I tell them to start taking pain meds when the limb starts to tingle like the block is wearing off. If it is still numb when they go to bed then take 1-2 pain pills b/4 bedtime.
Also, if the block needs to last longer (say 2 days) we use a the continuous ON-Q pump with the block mostly for shoulders.

 

[militarymd]

I use 0.5 % ropivacaine 30 cc on my interscalene, coracoid, axillary, and femoral nerve blocks.

I do them in the recovery room after emergence from GA.

> 90% last until the next am...lunch time.

 

[jetproppilot]

I use 0.5 % ropivacaine 30 cc on my interscalene, coracoid, axillary, and femoral nerve blocks.

I do them in the recovery room after emergence from GA.

> 90% last until the next am...lunch time.

Hmmm...thats kinda cool, Mil.

I swear though, and yeah, I know, theres no literature supporting that adjunctive regional (interscalene, fem/sci, etc) instituted before the operation makes any difference after the first 24 hours, but that first 24 hours is pretty important...

and anecdotally, the patients with these blocks done before the surgery require less volatile agent/opiods intraop...and they look better and feel better in the PACU in comparison to a straight GA pt...and they are discharged quicker...

why not do the blocks pre-op so you can exploit their anesthesia-lowering benefits? An ACL/shoulder only takes a cuppla hours, so doing them in the recovery room may add a few hours of post op relief, but at the expense of requiring more "stuff" intraop, which leads to more potential PACU issues....

just my opinion.

 

[militarymd]

Hmmm...thats kinda cool, Mil.

I swear though, and yeah, I know, theres no literature supporting that adjunctive regional (interscalene, fem/sci, etc) instituted before the operation makes any difference after the first 24 hours, but that first 24 hours is pretty important...

and anecdotally, the patients with these blocks done before the surgery require less volatile agent/opiods intraop...and they look better and feel better in the PACU in comparison to a straight GA pt...and they are discharged quicker...

why not do the blocks pre-op so you can exploit their anesthesia-lowering benefits? An ACL/shoulder only takes a cuppla hours, so doing them in the recovery room may add a few hours of post op relief, but at the expense of requiring more "stuff" intraop, which leads to more potential PACU issues....

just my opinion.

You're right. I would rather do them pre-op (if I was doing a block anyways), but the way my gig is set up, it is next to impossible to do them pre-op.

Pre-op area does not have monitors, a/w stuff, and is physically very small......It would mean moving to PACU to do the block...then to the OR....logistically a pain in the neck....

Maybe, this will be my next project, after I get some good anesthesiologists on board....

 

[jetproppilot]

You're right. I would rather do them pre-op (if I was doing a block anyways), but the way my gig is set up, it is next to impossible to do them pre-op.

Pre-op area does not have monitors, a/w stuff, and is physically very small......It would mean moving to PACU to do the block...then to the OR....logistically a pain in the neck....

Maybe, this will be my next project, after I get some good anesthesiologists on board....

please save me a spot starting after Hurricane Season 2006, since I'm outta here if we flood again, wifey or no wifey!

 

[militarymd]

please save me a spot starting after Hurricane Season 2006, since I'm outta here if we flood again, wifey or no wifey!

You're on big guy!!!

 

[Noyac]

You're right. I would rather do them pre-op (if I was doing a block anyways), but the way my gig is set up, it is next to impossible to do them pre-op.

Pre-op area does not have monitors, a/w stuff, and is physically very small......It would mean moving to PACU to do the block...then to the OR....logistically a pain in the neck....

Maybe, this will be my next project, after I get some good anesthesiologists on board....

Sort of in the same boat. My previous gig did the blocks post-op b/c of logistics (I think) and current gig we do them pre-op. Let me tell you, there is a big difference as Jet touched on. But we had to train the pre-op nurses and post-op nurses to look out for these cases and get the pts to the PACU b/4 the case. I even take the schedule for the upcoming day and write the blocks that are going to be done in on the schedule. This almost idiot proofs it for them.
Also, 30cc 0.5% Ropiv is my standard dose for almost all blocks as well. On occassion I will push the volume up on femoral and axillary blocks or I will add 2% mepivicaine if I really am short on time and need it to set up fast. No bicarb, no epi, ever. I will add Clonidine if pharmacy can get it, however.

 

[jetproppilot]

Sort of in the same boat. My previous gig did the blocks post-op b/c of logistics (I think) and current gig we do them pre-op. Let me tell you, there is a big difference as Jet touched on. But we had to train the pre-op nurses and post-op nurses to look out for these cases and get the pts to the PACU b/4 the case. I even take the schedule for the upcoming day and write the blocks that are going to be done in on the schedule. This almost idiot proofs it for them.
Also, 30cc 0.5% Ropiv is my standard dose for almost all blocks as well. On occassion I will push the volume up on femoral and axillary blocks or I will add 2% mepivicaine if I really am short on time and need it to set up fast. No bicarb, no epi, ever. I will add Clonidine if pharmacy can get it, however.

Tell me about the clonidine thing, Noy...you just add it in the syringe with the local anesthetic? How much?

I remember reading literature on epidural clonidine quite a while ago....have never done it...

 

[militarymd]

I attended a session at the ASA where the presenter stated that only clonidine and epinephrine adds anything to local anesthetic in a regional block....at least based on solid data.


I think the dose for clonidine was 1/5 mcg per kilo, but I 'm not 100% sure.

 

[Noyac]

Jet, I had to make sure of the dose cause we haven't been using it lately due to pharmacy issues. We would add 50mcg to the block solution and could expect about 30-40 hrs of block time.
For spinals we would use 30-50mcg but you can see some decrease in BP with this use.

 

[jetproppilot]

Jet, I had to make sure of the dose cause we haven't been using it lately due to pharmacy issues. We would add 50mcg to the block solution and could expect about 30-40 hrs of block time.
For spinals we would use 30-50mcg but you can see some decrease in BP with this use.

Geez, thats a huge benefit.

Thanks!