Buying a nerve stimulator for regional blocks

[appcan]

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I was planning on buying a nerve stimulator to help out with nerve blocks to avoid any accidental nerve injuries. Is there any cheaper way to purchase for example a Braun nerve stimulator without paying that $1400-1600 price tag?

 

[GassYous]

Is this 1999?

 

[appcan]

There's reports of vastus medialis atrophy because of injuries to the nerve during ACBs. Gadsden even demonstrated in a workshop how usual needling for an ACB often lands the needle very close and even skewering the nerve to vastus medialis. It also helps identify the dorsal scapular n. and long thoracic n. during interscalene blocks which are very commonly encountered if your needle trajectory goes through the middle scalene muscle. And in general, it helps confirm that it's safe to advance the needle in e.g. obese patients where visualization isn't great. Not sure how any of those are poor reasons? I use ultrasound for all of my blocks, but at least I'm acknowledging that it isn't perfect.

 

[deleted87051]

There's reports of vastus medialis atrophy because of injuries to the nerve during ACBs.

I looked and couldn’t find any case reports.

Do you have a reference?

 

[woopedazz]

I agree there is a material risk of injury to these tricky nerves. However, you can usually see each of those nerves, or at least tissue density changes in the muscle bellies where they could be, hence areas to avoid.

They are also so far away from the needle-tip destination that normally I'm moving through those "danger zones" at pace. If I were to use a nerve stimulator, and it was to stimulate said nerves, and a muscle was too twitch... I've probably already driven straight through the thing and what's done is done.

 

[appcan]

I looked and couldn’t find any case reports.

Do you have a reference?

There's two things for that, both of which are from Duke's anesthesiology department. From presumably Dr Jeff Gadsden's experience or that of others, they have seen isolated vastus medialis atrophy after adductor canal blocks based on his recent video ( ) starting at 7:41. They've also presented an abstract of their cadaveric study (Use of Nerve Stimulation During Adductor Canal Block Could Help Identify and Avoid Injury to Nerve to Vastus Medialis) showing how these injuries can happen (abstract link: Search | 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting 2023). I understand that none of this is anywhere near equivalent to a peer-reviewed publication, but it is coming from a well-respected source and has some weight in my opinion.

 

[PpfSuxTube]

I was planning on buying a nerve stimulator to help out with nerve blocks to avoid any accidental nerve injuries. Is there any cheaper way to purchase for example a Braun nerve stimulator without paying that $1400-1600 price tag?

You could send me $1000 and I'll send you something even better... regional is nonsense and doesn't work...

Let your surgeon infiltrate the knee with a tonne of their lia and don't worry about any of that

 

[UscGhost]

You could send me $1000 and I'll send you something even better... regional is nonsense and doesn't work...

Let your surgeon infiltrate the knee with a tonne of their lia and don't worry about any of that

Huh?

Comparison of Adductor Canal Block Versus Local Infiltration Analgesia on Postoperative Pain and Functional Outcome after Total Knee Arthroplasty: A Randomized Controlled Trial - PMC

Introduction: Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have ...

www.ncbi.nlm.nih.gov

A quick Google search produced many articles which would disagree

 

[Simba1711]

I don’t use a nerve stimulator as I was trained with ultrasound and don’t know how to use one but a lot of my older colleagues use both ultrasound and nerve stimulator for their blocks. I think it makes sense. For instance , one of my colleague uses it for Peng blocks. Although the femoral nerve block is far away I think there was a case report of an injury to the femoral nerve during block. May add protection in case of injury and reassurance during injection.

I’m surprised your hospital isn’t willing to pay for one.

 

[appcan]

I don’t use a nerve stimulator as I was trained with ultrasound and don’t know how to use one but a lot of my older colleagues use both ultrasound and nerve stimulator for their blocks. I think it makes sense. For instance , one of my colleague uses it for Peng blocks. Although the femoral nerve block is far away I think there was a case report of an injury to the femoral nerve during block. May add protection in case of injury and reassurance during injection.

I’m surprised your hospital isn’t willing to pay for one.

I looked into it, turns out they already have a bunch of stimulators. The group never uses them so I never saw them out.

 

[medicine2wallstreet]

You could send me $1000 and I'll send you something even better... regional is nonsense and doesn't work...

Let your surgeon infiltrate the knee with a tonne of their lia and don't worry about any of that

Spoken like a true cardiac doc that isn't agile with regional!

 

[PpfSuxTube]

Spoken like a true cardiac doc that doesn't care to be agile with regional!

Ha. Absolutely.
All nonsense

 

[PpfSuxTube]

Huh?

Comparison of Adductor Canal Block Versus Local Infiltration Analgesia on Postoperative Pain and Functional Outcome after Total Knee Arthroplasty: A Randomized Controlled Trial - PMC

Introduction: Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have ...

www.ncbi.nlm.nih.gov

A quick Google search produced many articles which would disagree

Did you just quote an article from the Malaysian orthopedic journal?

 

[DrN2O]

Is this 1999?

Isn't a couple of grand well worth it to avoid such common complications with US blocks? Why even use a US machine that cost 100x or more? Big Ultrasound doesn't want any trial comparing stim vs. US.

 

[pgg]

Spoken like a true cardiac doc that isn't agile with regional!

I'm a cardiac doc who can do regional but I'd rather not.

 

[deleted87051]

I'm a cardiac doc who can do regional but I'd rather not.

You’re obviously not paid by unit production.

 

[UscGhost]

You’re obviously not paid by unit production.

And he probably doesn't work with orthopedic surgeons.

Our surgeons tend to prefer docs who can do regional well

 

[gunnershow]

ASA4E with host of cardiopulmonary comorbidities and lower extremity NSTI with early sepsis comes in for guillotine AKA to control the infection. I've done this exact case over 2 dozen times with regional alone and spared many of them ICU stays. 4 pre-op blocks in 5min (10 max) and your anesthetic is done, less time than it would take to intubate and line up. Fail to see what's nonsense about that.

 

[pgg]

You’re obviously not paid by unit production.

I am not.

But I do the blocks anyway, because it's the norm here, and I want my group to bill for them.

I just conceal my bad attitude about it, except when I'm whining about it here. 🙂

 

[deleted87051]

And he probably doesn't work with orthopedic surgeons.

Our surgeons tend to prefer docs who can do regional well

Almost all our sternotomies get some type of block….transversus thoracic plane, pecs or parasternal. Thoracic gets PVB or ESPB.

 

[abolt18]

Almost all our sternotomies get some type of block….transversus thoracic plane, pecs or parasternal. Thoracic gets PVB or ESPB.

I already do so many things "different" from my partners (TEE for every cardiac case, pre-induction art line, ultrasound for my art line every time, only place swan occasionally) that I think the nurses would lose their minds if I started doing blocks for these cases too.

 

[teacher2md]

I can’t wait for the inevitable argument about PP blocks that don’t work vs. “real” blocks at academic centers

 

[pgg]

I already do so many things "different" from my partners (TEE for every cardiac case, pre-induction art line, ultrasound for my art line every time, only place swan occasionally) that I think the nurses would lose their minds if I started doing blocks for these cases too.

Sounds like a good reason to do them!

 

[PpfSuxTube]

ASA4E with host of cardiopulmonary comorbidities and lower extremity NSTI with early sepsis comes in for guillotine AKA to control the infection. I've done this exact case over 2 dozen times with regional alone and spared many of them ICU stays. 4 pre-op blocks in 5min (10 max) and your anesthetic is done, less time than it would take to intubate and line up. Fail to see what's nonsense about that.

Well I'm convinced anyways. You saved them from a GA...

 

[GassYous]

ASA4E with host of cardiopulmonary comorbidities and lower extremity NSTI with early sepsis comes in for guillotine AKA to control the infection. I've done this exact case over 2 dozen times with regional alone and spared many of them ICU stays. 4 pre-op blocks in 5min (10 max) and your anesthetic is done, less time than it would take to intubate and line up. Fail to see what's nonsense about that.

Which blocks do you do?

 

[Maverikk]

ASA4E with host of cardiopulmonary comorbidities and lower extremity NSTI with early sepsis comes in for guillotine AKA to control the infection. I've done this exact case over 2 dozen times with regional alone and spared many of them ICU stays. 4 pre-op blocks in 5min (10 max) and your anesthetic is done, less time than it would take to intubate and line up. Fail to see what's nonsense about that.

Yeah which four? I could see femoral, lfcn, and sciatic. I’ve had good success with this, and a low dose prop gtt…the only thing I’ve found is that even doing the sciatic as high in the thigh as I can I think there are still a few early branches that make it down. I do anterior sciatic bc I don’t do many subgluteal and looking at the positioning for subgluteal sciatic just seems like a pain in butt, all puns intended. Usually do the anterior sciatic at the proximal 1/3 of the thigh as soon as I get a view after the femoral.

Also, I support someone wanting to get a stim…if you work in a high volume block place it can be very useful for blocks where the anatomy is not clear, mostly interscslenes/popliteal in the obese with no muscles, renal failure with multiple collateral veins. I rarely use one but I’m glad it’s there when I need it

 

[gunnershow]

Which blocks do you do?

Subgluteal sciatic (with posterior cutaneous nerve), obturator, LFCN, femoral.

Positioning for sciatic is really not that bad.. just have to turn them on their side. I've even done it supine before with knee bent and it was fine. I find the positioning for ESP and QL to be much more annoying.