Case #10 How to improve my next QL block?

[DrAmir0078]

Hi SDN Anesthesiologists,
It is me again, and presenting this case :

71 years old, 65 kg male presenting with incarcerated Right inguinal hernia, with a past medical history of Depression, increased renal indices, elevated Coags, with Bigeminy ECG on monitoring with a PR 47 - 50 bpm.

Plan A : Regional Anesthesia with Quadratus Lumborum Block QL3
Patient was difficult to stay even - continuous hiccup.

QL3 done with 36 ml of plane Bupivacaine (20 ml - 0.375 % and 15 ml. 0.5%)
20 minutes later and with skin test, unfortunately was positive for pain response.

Plan B proceeded, GA with opioid 100 mcg Fentanyl, Pentothal 250 mg double diluted, Ketamine 30 mg, Atracurium 30 mg, ETT size 7.5 with Lido with prior good preoxygenation.

Operation was faced spiked Hypertension episodes and his pulse oximeter PR kept with 50s - irregular with Bigiminy on ECG monitor, but frank PR was 70s.

During extubation Hypertension episode were treated with GTN boluses 10mcg / bolus, and then when the patient was ready to extubate after obeying command, reversal given and extubated.

Bp was controlled post extubation. 140s/90s

Patient was free of pain postoperatively and advised to stay on O2 for the next 48 hours at least.

Patient followed up after 6 hours and he is free of pain, clear urine, soft abdomen.

The question is how I can predict the onset of action of Bupivacaine?

The other day a very hard lower arm fracture and 20 minutes after SC block it works like a charm.

The other day BKA with both popliteal sciatic and Adductor canal, it didn't work, but worked well the other day!

I was furious, separation well, but onset of action was questionable!
Switch to Lido+Epi next time?

Do you like QL block?

Cheers!

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[Mman]

The question is how I can predict the onset of action of Bupivacaine?

The other day a very hard lower arm fracture and 20 minutes after SC block it works like a charm.

The other day BKA with both popliteal sciatic and Adductor canal, it didn't work, but worked well the other day!

I was furious, separation well, but onset of action was questionable!
Switch to Lido+Epi next time?

Do you like QL block?

Cheers!

I don't think it is the bupivacaine impacting the onset of duration, it's the type of block. Supraclavicular blocks set up very fast. Popliteal sciatic blocks can take a really long time to work. QL probably also takes a while to work.

 

[deleted875186]

Abdominal blocks don’t provide surgical anesthesia, not reliable, I wouldn’t even have tried it.

the popliteal block should have worked, perhaps delayed onset if you weren’t inside the fascia to the nerve sheath. The characteristic pop of needle getting past this facial in my opinion is the most reliable sign the block will work. Yes, can try half lido half bupi next time.

 

[DrZzZz]

Abdominal blocks don’t provide surgical anesthesia, not reliable, I wouldn’t even have tried it.

the popliteal block should have worked, perhaps delayed onset if you weren’t inside the fascia to the nerve sheath. The characteristic pop of needle getting past this facial in my opinion is the most reliable sign the block will work. Yes, can try half lido half bupi next time.

Hasn't several studies disproven the mix of local as beneficial? You end up with an onset time on par with the bupivacaine. Adding lido just shortens the duration, but has little effect on the onset.

 

[Blockit]

Hasn't several studies disproven the mix of local as beneficial? You end up with an onset time on par with the bupivacaine. Adding lido just shortens the duration, but has little effect on the onset.

That “early onset with lidocaine and long duration with bupivacaine” explanation that people used to give is largely crap. You just end up with some sort of unknown mixture that has intermediate characteristics of both drugs.
my guess on the popliteal block is that you were not fully within the sheath.
If you used 2% lidocaine in your popliteal block and you were in the sheath you’ll probably get three or four hours out of it.
Longer with dexamethasone.

 

[PainDrain]

Abdominal blocks don’t provide surgical anesthesia, not reliable, I wouldn’t even have tried it.

the popliteal block should have worked, perhaps delayed onset if you weren’t inside the fascia to the nerve sheath. The characteristic pop of needle getting past this facial in my opinion is the most reliable sign the block will work. Yes, can try half lido half bupi next time.

I get decent to good surgical anesthesia with a well placed ilioinguinal/iliohypogastric block for hernias. I have also used this for radical orchioectomy (plus genitofemoral) and inguinal hernia repair for excellent post op pain relief.

 

[Gnarvin]

I agree with whoever said it above, these fascial plane blocks are not supposed to be surgical level blocks. They have been described for analgesia, not surgical level anesthesia, at least to my knowledge.

Also, if I am doing a block for surgical level anesthesia, I wouldn’t use anything less than all 0.5% bupi. For analgesia your mix of 0.375% with 0.5% bupi would be fine.

 

[deleted697535]

Hi SDN Anesthesiologists,
It is me again, and presenting this case :

71 years old, 65 kg male presenting with incarcerated Right inguinal hernia, with a past medical history of Depression, increased renal indices, elevated Coags, with Bigeminy ECG on monitoring with a PR 47 - 50 bpm.

Plan A : Regional Anesthesia with Quadratus Lumborum Block QL3
Patient was difficult to stay even - continuous hiccup.

QL3 done with 36 ml of plane Bupivacaine (20 ml - 0.375 % and 15 ml. 0.5%)
20 minutes later and with skin test, unfortunately was positive for pain response.

Plan B proceeded, GA with opioid 100 mcg Fentanyl, Pentothal 250 mg double diluted, Ketamine 30 mg, Atracurium 30 mg, ETT size 7.5 with Lido with prior good preoxygenation.

Operation was faced spiked Hypertension episodes and his pulse oximeter PR kept with 50s - irregular with Bigiminy on ECG monitor, but frank PR was 70s.

During extubation Hypertension episode were treated with GTN boluses 10mcg / bolus, and then when the patient was ready to extubate after obeying command, reversal given and extubated.

Bp was controlled post extubation. 140s/90s

Patient was free of pain postoperatively and advised to stay on O2 for the next 48 hours at least.

Patient followed up after 6 hours and he is free of pain, clear urine, soft abdomen.

The question is how I can predict the onset of action of Bupivacaine?

The other day a very hard lower arm fracture and 20 minutes after SC block it works like a charm.

The other day BKA with both popliteal sciatic and Adductor canal, it didn't work, but worked well the other day!

I was furious, separation well, but onset of action was questionable!
Switch to Lido+Epi next time?

Do you like QL block?

Cheers!

I think the others addressed the regional issues but what is going on with the extubation strategy?

You wait until patient obeys commands before giving reversal then extubate soon after? Giving nitro for htn while a pt may be paralysed doesn't make.much sense to me but dont listen to me, what do i know?

What dose reversal, titrated to what repsonse?
I understand you dont have tof monitor so would just give the reversal early, like as soon as theyre closed fascia. Reversal like neostig isnt great reversal. Its not a switch. There is a dose. And if they have less than 2 twitches it can paradoxically delay reversal in some studies... Sooo... Maybe look at that...


As for regional.. Whatever. It doesnt really work or need to be done for these cases but fine it floats your boat...

 

[anbuitachi]

Hi SDN Anesthesiologists,
It is me again, and presenting this case :

71 years old, 65 kg male presenting with incarcerated Right inguinal hernia, with a past medical history of Depression, increased renal indices, elevated Coags, with Bigeminy ECG on monitoring with a PR 47 - 50 bpm.

Plan A : Regional Anesthesia with Quadratus Lumborum Block QL3
Patient was difficult to stay even - continuous hiccup.

QL3 done with 36 ml of plane Bupivacaine (20 ml - 0.375 % and 15 ml. 0.5%)
20 minutes later and with skin test, unfortunately was positive for pain response.

Plan B proceeded, GA with opioid 100 mcg Fentanyl, Pentothal 250 mg double diluted, Ketamine 30 mg, Atracurium 30 mg, ETT size 7.5 with Lido with prior good preoxygenation.

Operation was faced spiked Hypertension episodes and his pulse oximeter PR kept with 50s - irregular with Bigiminy on ECG monitor, but frank PR was 70s.

During extubation Hypertension episode were treated with GTN boluses 10mcg / bolus, and then when the patient was ready to extubate after obeying command, reversal given and extubated.

Bp was controlled post extubation. 140s/90s

Patient was free of pain postoperatively and advised to stay on O2 for the next 48 hours at least.

Patient followed up after 6 hours and he is free of pain, clear urine, soft abdomen.

The question is how I can predict the onset of action of Bupivacaine?

The other day a very hard lower arm fracture and 20 minutes after SC block it works like a charm.

The other day BKA with both popliteal sciatic and Adductor canal, it didn't work, but worked well the other day!

I was furious, separation well, but onset of action was questionable!
Switch to Lido+Epi next time?

Do you like QL block?

Cheers!

abdominal blocks definitely not reliable. including TAP/QL for surgery alone. if you need to do regional, can do epidural.

if you do sciatic and adductor , and it doesnt work, can test dermatome to see if its pop or adductor that failed you.

 

[Gnarvin]

Also, if you are doing regional for a BKA, I would do a true femoral instead of an adductor canal block. That could be part of your less than optimal outcome for your BKA case.

 

[deleted697535]

Also, if you are doing regional for a BKA, I would do a true femoral instead of an adductor canal block. That could be part of your less than optimal outcome for your BKA case.

What about the fall risk?

 

[ethilo]

completely agree with QLs being analgesic, NOT surgical blocks. Studies generally show a couple points decrease in pain scores with QLs, not meant for surgical anesthesia.

My usual mix for bilateral QL is 40-50mL bupi 0.25% with 1:400k epi, 0.2 mg/mL decadron, and a total of 1 mcg/kg precedex. Total volume split evenly between the 2 sides (20-25mL per side).

Usually the second side is harder to ultrasound than the first side because of dependent edema when they lie in lateral decubitus for the first block. It always makes the imaging harder when they roll to the other side.

These blocks can be annoying because you never know if you did it successfully since the exam post block is inconsistent and the effect is not dramatic.

 

[Mman]

Usually the second side is harder to ultrasound than the first side because of dependent edema when they lie in lateral decubitus for the first block. It always makes the imaging harder when they roll to the other side.

are you leaving them in the lateral position for 12 hours to do one side and then flipping them? How much edema are you seeing in 5 minutes?

 

[DrAmir0078]

Very interesting insights from all of you - that was my first QL block in my residency; but as far as the outcome of postoperative analgesia, the patient was very happy !
Such a world the RA !

 

[Justice4all]

i rather do the ql blocks pre incision than post. The post surgical changes just distort the anatomy.

 

[DrAmir0078]

i rather do the ql blocks pre incision than post. The post surgical changes just distort the anatomy.

That what I did!
I thought it will work for surgical anesthesia, but appears not!

 

[ethilo]

are you leaving them in the lateral position for 12 hours to do one side and then flipping them? How much edema are you seeing in 5 minutes?

5 mins per side. See for yourself, I notice it consistently: the second block ALWAYS has worse imaging. Maybe it's not edema? Not sure, but no matter which side you start with I see this pattern.

 

[deleted875186]

5 mins per side. See for yourself, I notice it consistently: the second block ALWAYS has worse imaging. Maybe it's not edema? Not sure, but no matter which side you start with I see this pattern.

Interesting

 

[Justice4all]

Never noticed it

 

[ethilo]

Never noticed it

I very well could just not be good at them, I had to teach myself as I learned them after residency :-/

 

[Mman]

5 mins per side. See for yourself, I notice it consistently: the second block ALWAYS has worse imaging. Maybe it's not edema? Not sure, but no matter which side you start with I see this pattern.

I often find the second block to be easier, probably because patients are usually symmetric for the most part and I have familiarized myself with their muscle anatomy on the first block.

I'd guess second block faster than first block about 80% of the time or so.

 

[GassYous]

Do it supine and bump em

 

[MirrorTodd]

Do it supine and bump em

Agreed, that's how I did mine my last year of residency if the attending would allow. You don't need that much of a bump.

 

[anbuitachi]

i rather do the ql blocks pre incision than post. The post surgical changes just distort the anatomy.

id rather do any block pre incision. even the taps can be challenging post op. too much distortion. really need to get it in the layers to work and when teh layers are the opposite of obvious... high fail rate

 

[Urzuz]

My collection of random thoughts:

Mixing local anesthetics leads to unpredictable results. I recommend avoiding this practice.

If you want to do a case under regional anesthesia alone and choose to use bupivacaine since you want some postoperative pain relief as well (or the case is expected to be long), try mixing 0.5-1 ml of 8.4% sodium bicarbonate into your local anesthetic. It'll lead to a faster onset due to the altered acid-base status of the mixture.

Don't do a regional anesthetic as your sole anesthetic for an incarcerated hernia. Do a GA with an RSI. Secure your airway from the get-go.

Don't do fascial plane blocks expecting surgical anesthesia. You may have success here and there, but you will have cases where you end up with a pissed off patient, a pissed off surgeon, and a pissed off anesthesia attending.