Case#9 below knee amputation - any further advice?

[DrAmir0078]

Hi SDN Anesthesiologists,
I hope you are doing well, I am bringing a unique case for me as a newbie in RA

Old age female with history of IHD, HT, DM, dilated CMP and global hypokinesia + moderate TR and mild MR (EF 42%), very edematus, presented for below knee amputation. With covid +ve.

Regional Anesthesia done by me and Dr. Ali Raad in supine position. Can't lay prone. Because of the edema, the print of the probe stays (pitting edema)

Adductor canal block done by me
Popliteal sciatic block done by Ali

With Bupivacaine 0.375% total volume divided : 28 ml and with extra 40 mg 5 ml lidocaine 1%
With Dexamethasone cover.

13 ml Adductor block
20 ml Popliteal block

Operation done without complications and free of pain.

This is the video of Adductor canal block using my USGNAD device!

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[ethilo]

Fem pop chop chop! :-D

 

[dabears505]

Solid work.

 

[DrAmir0078]

Solid work.

I am using my device that I created to improve the visualization of the needle path - commercially available, but mine I made it by my hand and now it is 3D printed simple plastic device to guide the needle, I am very happy with the result !

 

[coffeebythelake]

Hi SDN Anesthesiologists,
I hope you are doing well, I am bringing a unique case for me as a newbie in RA

Old age female with history of IHD, HT, DM, dilated CMP and global hypokinesia + moderate TR and mild MR (EF 42%), very edematus, presented for below knee amputation. With covid +ve.

Regional Anesthesia done by me and Dr. Ali Raad in supine position. Can't lay prone. Because of the edema, the print of the probe stays (pitting edema)

Adductor canal block done by me
Popliteal sciatic block done by Ali

With Bupivacaine 0.375% total volume divided : 28 ml and with extra 40 mg 5 ml lidocaine 1%
With Dexamethasone cover.

13 ml Adductor block
20 ml Popliteal block

Operation done without complications and free of pain.

This is the video of Adductor canal block using my USGNAD device!

Nice job. Also your hospital seems to have pretty decent facilities and equipment. Would you be up for giving us a video tour of your hospital some day?

 

[DrAmir0078]

Nice job. Also your hospital seems to have pretty decent facilities and equipment. Would you be up for giving us a video tour of your hospital some day?

I would love for sure, if you meant the OR, I would do it, if you meant the whole Hospital, I will try to.
This Ultrasound machine is always on broken edge, if we lost it, we lose the training.

 

[Beeftenderloin]

Personally I prefer popliteal/sciatic and femoral for BKAs. I can’t reliably visualize the saphenous nerve in every patient and in the rare case where either the nerve or the needle aren’t where they’re supposed to be, you can end up with a failed block. Femoral is usually very easy to visualize and if there’s any doubt in my mind, I can get absolute confirmation with nerve stimulation. If I’ve made the decision to do regional as my primary anesthetic because patient is too sick to go to sleep, I don’t want there to be any doubt that my block is going to work. But if you’re that confident in your adductor canal block, more power to you.

 

[GassYous]

Personally I prefer popliteal/sciatic and femoral for BKAs. I can’t reliably visualize the saphenous nerve in every patient and in the rare case where either the nerve or the needle aren’t where they’re supposed to be, you can end up with a failed block. Femoral is usually very easy to visualize and if there’s any doubt in my mind, I can get absolute confirmation with nerve stimulation. If I’ve made the decision to do regional as my primary anesthetic because patient is too sick to go to sleep, I don’t want there to be any doubt that my block is going to work. But if you’re that confident in your adductor canal block, more power to you.

Wtf is the point of the adductor block? To avoid motor block so that they can ambulate postop?

 

[Beeftenderloin]

Wtf is the point of the adductor block? To avoid motor block so that they can ambulate postop?

The orthos I worked with in residency preferred it for TKAs for that reason. Doesn’t quite apply to this patient though.

 

[DrAmir0078]

Personally I prefer popliteal/sciatic and femoral for BKAs. I can’t reliably visualize the saphenous nerve in every patient and in the rare case where either the nerve or the needle aren’t where they’re supposed to be, you can end up with a failed block. Femoral is usually very easy to visualize and if there’s any doubt in my mind, I can get absolute confirmation with nerve stimulation. If I’ve made the decision to do regional as my primary anesthetic because patient is too sick to go to sleep, I don’t want there to be any doubt that my block is going to work. But if you’re that confident in your adductor canal block, more power to you.

Try Civco needle guide, it works to find the needle path, same as mine I created 🙂

 

[Beeftenderloin]

Try Civco needle guide, it works to find the needle path, same as mine I created 🙂 View attachment 341545

It looks like your device does a great job of keeping the needle centered under the probe. But that doesn’t fix the problems of being unable to reliably recognize the nerve in every patient, or in morbidly obese patients when your target is 8+cm deep and it doesn’t matter how well aligned you are, it’s still difficult to visualize your needle tip through all that tissue. For those reasons, I would still pick femoral in this case.

 

[DrAmir0078]

It looks like your device does a great job of keeping the needle centered under the probe. But that doesn’t fix the problems of being unable to reliably recognize the nerve in every patient, or in morbidly obese patients when your target is 8+cm deep and it doesn’t matter how well aligned you are, it’s still difficult to visualize your needle tip through all that tissue. For those reasons, I would still pick femoral in this case.

I understand what you are saying, yesterday we had one of the most TAP on very obese one with lots of fat, and due to shortage of needle, I have used 80 mm... Barely could reach!

This is humble video :

 

[dabears505]

Man. You are doing better anesthesia than me, and I work in one of the most posh hospitals in America. So cool how you made that device. Keep up the strong work

 

[DrAmir0078]

Man. You are doing better anesthesia than me, and I work in one of the most posh hospitals in America. So cool how you made that device. Keep up the strong work

Thanks for your encouragement, I had started it with syringes and now 3d printed, also started Beta marketing. (a turtle speed) and our Iraqi Board Chairman is proud too and he said "it helps the beginners to master the technique till they master it without it". I have been posting the progress on the private forum...

I'll be more than happy to send you the device as a gift, it won't cost 25 USD, but shipping cost is expensive, I truly feel sorry. Although it is designed for Ezono machines, you know even Civco or Innofine request which probe on which device you are using to give you the exact model.

This is my video explaining how I used my USGNAD device for a TAP block...

It is another video.

Attached some photos too...

 

[GassYous]

Now that I think of it, the device is really good for amateurs who can't needle and us at the same time.

 

[DrAmir0078]

Now that I think of it, the device is really good for amateurs who can't needle and us at the same time.

Yes indeed, I prefer to stay amateur - it is a piece of mind. Although I was a preceptor of Ultrasound Guided IVs at the George Washington University Hospital ER for 5 years and mastered out of plane, and can do an IV in most difficult small veins in the forearm not even the arm with less than 1 minute. You may ask about me at GWUHER. But honestly found in plane difficult sometime with RA ... I am amateur.

 

[Gnarvin]

I understand what you are saying, yesterday we had one of the most TAP on very obese one with lots of fat, and due to shortage of needle, I have used 80 mm... Barely could reach!

This is humble video :

Haha it must be a very different patient population there. In my residency there were many times I had to use the 120mm needles and push down so hard with the probe that my arm was almost elbow deep in fat for TAP blocks.

 

[DrAmir0078]

Haha it must be a very different patient population there. In my residency there were many times I had to use the 120mm needles and push down so hard with the probe that my arm was almost elbow deep in fat for TAP blocks.

Yes probably hahaha, I wish if I had 120 mm needle yesterday. Glad my device helped me to navigate the needle in such fat!