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kmurp

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I have a guy tomorrow for a wrist fx. He is morbidly obese >300lbs with OSA. MI 2 months ago with DES on plavix which is not being stopped. Haven't seen him to eval. the airway.
Would any of you risk a supraclavicular block in this guy? Not just thinking of pnuemo but also of bleeding with the plavix. Likely to be a short thick neck so my U/S view may be suboptimal...
 
Take a good look with the probe and see how easy (or not) it would be. Define the anatomy and then decide risk vs benefit. If you do decide to persue this, take only one pass, if you encounter any difficulty, then abort.

I wouldn't do sciatics, lumbar plexus, paravertebrals or other noncompressable areas. I wouldn't hesitate to do femoral n. blocks with usd with the right body habbitus. Your patient I would likely pass, but I would still take a look. Bad AW?

The question is how often have you hit big red when doing a supraclavicular under USD guidence? I would bet most here have not. Still, your goal is to minimize risk.
 
Agree with above. If neck anatomy looks sketchy, I'd consider doing an u/s guided axillary block, which would give you the advantage of definitely not boxing the phrenic for this behemoth, but weighed against the con of having to supplement the musculocutaneous (or just the lateral cutaneous n of the forearm, probably at the level of the elbow).

Tourniquet placement becomes a consideration.
 
Ultrasound-guided ax + musculocutaneous (for the tourniquet). This is a great block for a wrist and the artery is easy to see and avoid. Of course, it's important to point out that the wrist fracture better be urgent tonoperate so soon after a stent, and you alway need to consider the possibility of a failed block, excessive sedation, and other reasons to convert to GA, but you'll have the airway near you.
 
pgg said:
What'd you end up doing?


In addition to the above posts, another possible option is a Bier block.

I'd be reluctant to do a block more proximal than an axillary in a patient on Plavix.
Click to expand...

Yep... so long as the surgeon can guarantee (if there is such a thing) he is gonna take about an hour. Nothing worse than dealing with tourniquet pain 1.5 hours into the case with hardware still on the mayo stand. 🙄

Retrospectively, USG axillary is the safer approach if the plexus and MC appear to be an easier target . I think that in the right patient with a bulging honeycomb plexus 1.5cm under the skin, a supraclavicular is a nice one pass, one shot spinal of the arm.

Risk vs. Benefit. Just need to check your options, IMHO.

But yeah... I'd definitely be reluctant and would likely pass on regional with an easy airway. LMA or ETT.
 
kmurp said:
I have a guy tomorrow for a wrist fx. He is morbidly obese >300lbs with OSA. MI 2 months ago with DES on plavix which is not being stopped. Haven't seen him to eval. the airway.
Would any of you risk a supraclavicular block in this guy? Not just thinking of pnuemo but also of bleeding with the plavix. Likely to be a short thick neck so my U/S view may be suboptimal...
Click to expand...

I'd put the dude to sleep.

Plavix + Needle In The Neck = Bad or Potentially Bad stuff

in my book.
 
jetproppilot said:
I'd put the dude to sleep.

Plavix + Needle In The Neck = Bad or Potentially Bad stuff

in my book.
Click to expand...

I'ld have no qualms putting the dude to sleep...
or putting a needle in the neck....
US guided supraclavicular or infraclavicular is safe, in the right hands... I'm no guru of regional anesthesia but feel very comfortable using US to avoid vascular puncture and safely perform a brachial plexus block....

Blind block? I would do an ax block...

Would you put a central line in this guy?

drccw
 
Embarrassed to say I did the supraclavicular. Thought I got good spread and even put some next to the artery but...... Poor distal anesthesia so he bought an LMA which worked OK. Just OK. No harm, no foul, I guess.
Anyway, thanks for the discussion. As we all know, it's often real judgement call in cases like this.
 
kmurp said:
Embarrassed to say I did the supraclavicular. Thought I got good spread and even put some next to the artery but...... Poor distal anesthesia so he bought an LMA which worked OK. Just OK. No harm, no foul, I guess.
Anyway, thanks for the discussion. As we all know, it's often real judgement call in cases like this.
Click to expand...

Don't be embarrassed. That's a reasonable plan; as long as you have an appropriate plan B.

I'm not totally sold on the ability of the supraclavicular to provide distal anesthesia. It seems wheneer I do a supraclavicular for shoulder surgery I get a numb numb hand.... However, it's hit or miss for when I want distal anesthesia so I typically do an infraclavicular (which I find to be more difficult; at least in my hands)

drccw
 
drccw said:
Would you put a central line in this guy?

drccw
Click to expand...

Thats a really good question.

A question that will make me contradict myself.

Kinda.

All the attendings on here, and alotta the residents, have done emergency CABGs on patients on Plavix.

And yeah, all these patients get central lines, a triple lumen at least; some get the dreaded 9.0 French gorilla central line.😱

On Plavix.

So my statements about Needle in the neck + Plavix = Bad

contradicts, right?

Yeah, kinda, but we're dealing with apples and oranges here:

1) EMERGENCY CABG, dude may die without the surgery which explains why we're in the operating room at 1am while the mutual fund managers are fast asleep and we're wide awake. Like I stated, bad s h i t can happen when you stick a needle in the neck of a dude taking Plavix. Theres always risk/benefit. This dude is here because not being here means he's probably gonna die. In order to provide him with the hemodynamic support he needs to survive this operation and potentially the CVP/SWAN monitoring he "needs", I need access to his central circulation. So I stick a needle in his neck to make it happen. DO I WANT TO? Absolutely not. I'd rather endure a vasectomy with no local than stick a needle in this mo foe's neck.

DO I HAVE TO?

ok ok ok..look at those last four words I typed folks...

Do I Have To?

Yes.

I HAVE TO.

Emergency heart. Needs a central line. Period.

Lets move on to the other case:



Elective wrist fracture repair. Patient on Plavix.

I dunno how much experience all of you out there have with doing surgery on patients that have therapeutic Plavix levels.

I can speak from experience about me and a plethora of homies I have in this biz that I'm in frequent contact with.

We all have the same opinion about patients on Plavix:

Patients on Plavix ALWAYS bleed like STUCK PIGS.

Always.

Some things are written in stone, agreed? Like Death, Taxes, and Bleeding On Plavix.

Which brings me to another point:

Why are you doing wrist fracture surgery on a patient on Plavix?

Please tell me something that makes sense...it's open. Vascular compromise. Neurologic deficit. Something.

OK, assuming say, it's an open fracture that needs repair.

Dudes on Plavix. Therapeutic levels.

As an aside, I'm a huge regional anesthesia advocate.

You dudes out there wanting to do regional, to put a needle in this dude's neck, are

F %#&ING CRAZY.

This is not an emergency CABG. This is WRIST surgery.

On a patient on Plavix.

HAVE YOU LOST YOUR MIND??
😱

I can get this dude thru a surgery with general anesthesia. I can control his hemodynamics. I can anticipate.

I CANNOT do anything about clandestine bleeding caused by my block needle, in his...uhhhh...NECK (this isn't a femoral block, dudes...neck bleeding and/or injury is taken VERY SERIOUSLY...review the trauma surgery literature...it's such a serious area when injured, they divide it into ZONES...and you wanna put a block needle there??? With Plavix on board? For someone's WRIST? Not their heart....their....WRIST.) something thats gonna be real hard to explain on a wrist fracture surgery. Not an emergency heart....no....a WRIST.

Save the heroics, colleagues.

Push the white stuff.

Stay away from doing regional on patients taking Plavix.
 
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Gotta agree with you on this one, partna'. I'd push the white stuff, surgeon can do a field block.... If a gun was placed to my head and I'm "forced" to do a block, I'd go with an axillary block(i.e., this patient may die if I induced GA--that kinda gun to the head...). And for what it is worth, this is coming from a fuggin' US guided regional rock star 😉




jetproppilot said:
Thats a really good question.

A question that will make me contradict myself.

Kinda.

All the attendings on here, and alotta the residents, have done emergency CABGs on patients on Plavix.

And yeah, all these patients get central lines, a triple lumen at least; some get the dreaded 9.0 French gorilla central line.😱

On Plavix.

So my statements about Needle in the neck + Plavix = Bad

contradicts, right?

Yeah, kinda, but we're dealing with apples and oranges here:

1) EMERGENCY CABG, dude may die without the surgery which explains why we're in the operating room at 1am while the mutual fund managers are fast asleep and we're wide awake. Like I stated, bad s h i t can happen when you stick a needle in the neck of a dude taking Plavix. Theres always risk/benefit. This dude is here because not being here means he's probably gonna die. In order to provide him with the hemodynamic support he needs to survive this operation and potentially the CVP/SWAN monitoring he "needs", I need access to his central circulation. So I stick a needle in his neck to make it happen. DO I WANT TO? Absolutely not. I'd rather endure a vasectomy with no local than stick a needle in this mo foe's neck.

DO I HAVE TO?

ok ok ok..look at those last four words I typed folks...

Do I Have To?

Yes.

I HAVE TO.

Emergency heart. Needs a central line. Period.

Lets move on to the other case:



Elective wrist fracture repair. Patient on Plavix.

I dunno how much experience all of you out there have with doing surgery on patients that have therapeutic Plavix levels.

I can speak from experience about me and a plethora of homies I have in this biz that I'm in frequent contact with.

We all have the same opinion about patients on Plavix:

Patients on Plavix ALWAYS bleed like STUCK PIGS.

Always.

Some things are written in stone, agreed? Like Death, Taxes, and Bleeding On Plavix.

Which brings me to another point:

Why are you doing wrist fracture surgery on a patient on Plavix?

Please tell me something that makes sense...it's open. Vascular compromise. Neurologic deficit. Something.

OK, assuming say, it's an open fracture that needs repair.

Dudes on Plavix. Therapeutic levels.

As an aside, I'm a huge regional anesthesia advocate.

You dudes out there wanting to do regional, to put a needle in this dude's neck, are

F %#&ING CRAZY.

This is not an emergency CABG. This is WRIST surgery.

On a patient on Plavix.

HAVE YOU LOST YOUR MIND??
😱

I can get this dude thru a surgery with general anesthesia. I can control his hemodynamics. I can anticipate.

I CANNOT do anything about clandestine bleeding caused by my block needle, something thats gonna be real hard to explain on a wrist fracture surgery. Not an emergency heart....no....a WRIST.

Save the heroics, colleagues.

Push the white stuff.

Stay away from doing regional on patients taking Plavix.
Click to expand...
 
i block this guy without a second thought probably, but he gets an ax block for this. show me where outcomes are worse and you get uncontrollable bleeding with regional anesthesia and plavix?

i would not do PVB or lumbar plexus, every other regional block is on the table for me in this patient
 
pgg said:
What'd you end up doing?


In addition to the above posts, another possible option is a Bier block.

I'd be reluctant to do a block more proximal than an axillary in a patient on Plavix.
Click to expand...

id like to hear how smoothly your wrist fractures are going with IV regional anesthesia? id bet not very.

any of the UE blocks are safe on plavix, id avoid an IC for the same reasons i would avoid a subclavian line.
 
Idiopathic said:
id like to hear how smoothly your wrist fractures are going with IV regional anesthesia? id bet not very.

any of the UE blocks are safe on plavix,
Click to expand...

Dude put the water bong down.

You are literally ASKING FOR TROUBLE

doing what you suggest.
 
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IN2B8R said:
Gotta agree with you on this one, partna'. I'd push the white stuff, surgeon can do a field block.... If a gun was placed to my head and I'm "forced" to do a block, I'd go with an axillary block(i.e., this patient may die if I induced GA--that kinda gun to the head...). And for what it is worth, this is coming from a fuggin' US guided regional rock star 😉
Click to expand...

I feel YA!
 
pgg said:
Never done one.
Click to expand...

I have works fine.

In this case i would check the anatomy: a supraclavicular can be less vascularized than an axillary with multiple veins. My preference would be axillar but if the SC is 2cm under the skin with no vessels then why not? It is in a compressible area for those wondering...
 
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I still disagree.

I understand the consequences of bleeding and Plavix.

But, using an ultrasound makes UE blocks safer. I haven't done a ton (maybe 400) but I have yet to have a vascular puncture. I only place the needle when I have a clear view of the anatomy.

We are also talking about a blunt 22 g needle.

I don't know if regional anesthesia was the right choice but I do not think it was contra indicted. But the ASRA guidelines probably disagree.

I would not do a LPB for sure though.

Drccw.
 
drccw said:
I still disagree.

I understand the consequences of bleeding and Plavix.

But, using an ultrasound makes UE blocks safer. I haven't done a ton (maybe 400) but I have yet to have a vascular puncture. I only place the needle when I have a clear view of the anatomy.

We are also talking about a blunt 22 g needle.

I don't know if regional anesthesia was the right choice but I do not think it was contra indicted. But the ASRA guidelines probably disagree.

I would not do a LPB for sure though.

Drccw.
Click to expand...

Yes....You can see the pulsating artery... (but lets face it, if you have done enough regional blocks (i.e., >5000 u/s guided blocks), there are times when you don't have the best of view, especially with the morbidly obese..). Moreover, if you are close enough to the artery, your patient whom you have not oversedated due to his morbid obesity, may accidently turn his head the wrong way (hell, I've had a patient sneeze once 🙂)during your block placement....Gotta remember the simple adage in our business: if there is an easier, similarly beneficial route, then take it! If ASRA is recommending that you don't do something, then, God forbid if something does go wrong, do you think someone will be there by your side to defend you when you are on the stand? Better yet, how will you manage the hematoma and potentially complicated AW thereafter? Gonna infuse platelets and plug up his stent? What's your move in the worst case senario and have you prepared for it--that, in a nut shell, is what we all are supposed to be prepared for.... That is why the board examiners do not hesitate to tell you that, in spite of your stellar u/s guided efforts, "your block failed, what are you going to do next...."
 
pgg said:
In addition to the above posts, another possible option is a Bier block.
Click to expand...

Earlier I thought about offering this option to the OP as well (given the time constraints as mentioned by sevo), but then I thought exsanguinating the limb with that nitrile wrap-around would be a bitch (for the patient) with a fractured wrist.
 
Again: good points by all:
Jet: as to why we were doing him at all, he needed a repair that wouldn't heal without surgery. I figured with DES, he would be on plavix forever so the situation wouldn't change if we waited. Interestingly, he was scheduled originally at the surgicenter: due to his OSA and no note at that time from cardiology indicating they knew he was having surgery, I refused the case for that facility, opting for the hospital (where he bounced back to me).
This probably would be a good oral board question. In cases like this on the boards, what's most important is not necessarily what you do but rather, that you have adequate justification for your choice including knowledge of the risks as well as having a backup.
 
dhb said:
I have works fine.

In this case i would check the anatomy: a supraclavicular can be less vascularized than an axillary with multiple veins. My preference would be axillar but if the SC is 2cm under the skin with no vessels then why not? It is in a compressible area for those wondering...
Click to expand...

wait you have done a Bier block for an open repair of a wrist fracture?
 
kmurp said:
Again: good points by all:
Jet: as to why we were doing him at all, he needed a repair that wouldn't heal without surgery. I figured with DES, he would be on plavix forever so the situation wouldn't change if we waited. Interestingly, he was scheduled originally at the surgicenter: due to his OSA and no note at that time from cardiology indicating they knew he was having surgery, I refused the case for that facility, opting for the hospital (where he bounced back to me).
This probably would be a good oral board question. In cases like this on the boards, what's most important is not necessarily what you do but rather, that you have adequate justification for your choice including knowledge of the risks as well as having a backup.
Click to expand...

You betcha.... classic board scenerio. 👍

Just out of curiosity... how long did you wait after you did to SC block? Although an Ax block tends to set up faster, I'm still a SC block guy as i think a needle in the axilla is more painful than one in the neck + when I do an ax block I try and hit it on both sides of the artery + MC = more passes with my stimuplex.

When I get incomplete anesthesia coverage or the block is taking longer to set up, I'll supplement the block by picking off the the ulnar, median and radial individually. They are super easy with USD and they work like a charm! :luck:

Thanks for sharing your case with us.
 
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Someone mentioned 22g needle... we tried them out and found that they tend to bend easily when going through tough skin. 21g never bend. My .02 cents.
 
sevoflurane said:
You betcha.... classic board scenerio. 👍

Just out of curiosity... how long did you wait after you did to SC block? Although an Ax block tends to set up faster, I'm still a SC block guy as i think a needle in the axilla is more painful than one in the neck + when I do an ax block I try and hit it on both sides of the artery + MC = more passes with my stimuplex.

When I get incomplete anesthesia coverage or the block is taking longer to set up, I'll supplement the block by picking off the the ulnar, median and radial individually. They are super easy with USD and they work like a charm! :luck:

Thanks for sharing your case with us.
Click to expand...


Yes I concur...thanks dude for sharing. Great case, great conversation. This is how we all learn...by sharing experiences and hearing opposing points of view.

Thanks again.👍
 
Idiopathic said:
wait you have done a Bier block for an open repair of a wrist fracture?
Click to expand...

What's the problem - duration of the case or quality of the block?

Honestly asking, I've only done maybe 10 Bier blocks in my life, and none for fractures. I'm not even sure if I could find a double tourniquet for one at my current hospitals if you put a gun to my head. But I've done fractures that were quick enough that I can't see why a Bier block wouldn't work.
 
Late to the conversation, but still wanted to add my $0.02

I totally agree with Jet.

On a morbidly obese patient on Plavix, not worth it to try a regional technique that can turn ugly. Even if the regional technique works, good luck sedating this dude with the OSA business.

Jets point about the central line in the emergency CABG is well taken. The wrist is an elective procedure - doesn't need a needle close to vascular structures to get the job done like a CABG needs a central line.

LMA's on morbidly obese? Asking for trouble. The only reason one of my morbidly obese patients gets an LMA is if I'm temporizing things before trying another intubation attempt. We had a malpractice attorney come speak to us and she named four factors in high payout cases (not necessarily occurring all at the same time) #1 Obesity, #2 Use of LMA, #3 NPO violation, #4 Prone position. You can see how a combination of these factors can leave someone writing a check.

Early in CA-1 year, one of my resident colleagues had a case where they blocked a morbidly obese patient for a wrist. Details are a bit hazy, but as I remember it, block wore off, general anesthesia induced, LMA placed, airway temporarily lost, prolonged ICU stay, compartment syndrome in buttocks, pure nastiness.

There are many things those in private practice do more efficiently and better than those in academics. However, I think you are rolling the dice big time when you block patients on plavix or use LMA's as plan A for morbidly obese patients.
 
gaspasser2004 said:
Late to the conversation, but still wanted to add my $0.02

I totally agree with Jet.

On a morbidly obese patient on Plavix, not worth it to try a regional technique that can turn ugly. Even if the regional technique works, good luck sedating this dude with the OSA business.

Jets point about the central line in the emergency CABG is well taken. The wrist is an elective procedure - doesn't need a needle close to vascular structures to get the job done like a CABG needs a central line.

LMA's on morbidly obese? Asking for trouble. The only reason one of my morbidly obese patients gets an LMA is if I'm temporizing things before trying another intubation attempt. We had a malpractice attorney come speak to us and she named four factors in high payout cases (not necessarily occurring all at the same time) #1 Obesity, #2 Use of LMA, #3 NPO violation, #4 Prone position. You can see how a combination of these factors can leave someone writing a check.

Early in CA-1 year, one of my resident colleagues had a case where they blocked a morbidly obese patient for a wrist. Details are a bit hazy, but as I remember it, block wore off, general anesthesia induced, LMA placed, airway temporarily lost, prolonged ICU stay, compartment syndrome in buttocks, pure nastiness.

There are many things those in private practice do more efficiently and better than those in academics. However, I think you are rolling the dice big time when you block patients on plavix or use LMA's as plan A for morbidly obese patients.
Click to expand...

As usual, gaspasser has something good and thought provoking.👍

I agree.

Morbid Obesity = ETT
Obese = patient selection.

I must say that I have done quick cases with an LMA + reverse tburg in seleted patients with morbid obesity. I don't like paralyzing these people if I can avoid it. But they pose a unique risk :barf:.

99% of the time they get a tube.
 
Idiopathic said:
wait you have done a Bier block for an open repair of a wrist fracture?
Click to expand...

No closed repair. I would hit him with some K to exsanguinate.


gaspasser2004 said:
Even if the regional technique works, good luck sedating this dude with the OSA business.
Click to expand...

This is one of the problems you have in the US: you want to sedate everyone, this guy doesn't need sedation he needs a good regional anesthesia and a pat on the shoulder (maybe some headphones with soothing music)
 
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dhb said:
This is one of the problems you have in the US: you want to sedate everyone this guy doesn't need sedation he needs a good regional anesthesia and a pat on the shoulder (maybe some headphones with soothing music)
Click to expand...

DHB is right - a perfectly (or even reasonably) functioning regional block can be the sole anesthetic. For a small number of patients, this will be acceptable to them. Here's the problem, most patients don't want to hear or remember anything from the OR. I ask med students and starting residents, what are the goals of anesthesia? Not feeling anything (analgesia), not remembering anything (amnesia) and being still enough so the surgeon can get their job done. With only a regional block, you are taking care of the analgesia part, not addressing the amnesia part and taking a chance on whether or not the patient will lie still when the surgeon starts operating. I'm not saying it can't be done, I'm just saying that the majority of the patients in the United States have an expectation of anxiolysis and amnesia when undergoing even minor procedures - thats why anesthesiologists make cash money here and not so much in other countries.

Not too long ago I was sent to the dungeon of MRI to provide anesthesia for a 400 lb gentleman with a beard that resembled that dude from Harry Potter. He needed an MRI because the internist wanted an image of a lower extremity that had cellulitis.

Gaspasser: Sir, you really can't just lie still while we scan your leg in our OPEN MRI scanner?

Patient: I've been shot at, I've been in buildings on fire, I've done it all. But what scares me the most is being stuck in that tube. (His head would be out of the scanner, but most of his body would be in it)

We eventually, painfully, did the MRI under GA with an ETT. We did actually try a "dry run" without any sedation and true to his word, the patient flipped out. The patient had an expectation, however dangerous, of being sedated in the MRI scanner. The internist, however invaluable or worthless the study would be, had an expectation of getting the study done. Me, as a consultant, had a duty to provide the anesthesia.
 
pgg said:
What's the problem - duration of the case or quality of the block?

Honestly asking, I've only done maybe 10 Bier blocks in my life, and none for fractures. I'm not even sure if I could find a double tourniquet for one at my current hospitals if you put a gun to my head. But I've done fractures that were quick enough that I can't see why a Bier block wouldn't work.
Click to expand...

Duration. I dont think we could do an open repair in an hour.
 
sevoflurane said:
You betcha.... classic board scenerio. 👍

Just out of curiosity... how long did you wait after you did to SC block? Although an Ax block tends to set up faster, I'm still a SC block guy as i think a needle in the axilla is more painful than one in the neck + when I do an ax block I try and hit it on both sides of the artery + MC = more passes with my stimuplex.

When I get incomplete anesthesia coverage or the block is taking longer to set up, I'll supplement the block by picking off the the ulnar, median and radial individually. They are super easy with USD and they work like a charm! :luck:

Thanks for sharing your case with us.
Click to expand...
Sevo:To answer you question; I think I waited around 1/2 hour before giving up and going with GA. As the patient had a fair amount of pain in PACU, I think my decision to go to GA ended up correct.
As for the distal nerve blocks as a rescue: I have no experience with them, sadly. I have been out for many years and am self taught on these blocks. I was considering a median nerve block at the elbow postop to control his PACU pain but didn't try it. One of the reasons was, I wasn't sure which nerve supplied the bone to the distal radius. The NYSORA textbook has an osteotome (bone innervation) diagram which seemed to indicate the median was the correct nerve, but it might also show some radial nerve innervation at that spot so I wasn't sure.
If you were doing a rescue block: which nerves would you have gone for?
 
You'll prolly have to pick off the medial and lateral antibrachial as well... athough asking the surgeon to use local at the incisional site usually takes care of this.
 
I hear and appreciate those saying to absolutely avoid the supraclavicular on plavix. But I would submit the following:

1) You're basing your recommendation against on theory, not evidence.

2) The danger you're concerned about must be in poor technique, i.e. "losing" the needle tip and getting into the artery.

3) This block used to be avoided because doing it blind resulting in an unacceptably high rate of pneumothorax. We've all now decided that since u/s affords us the ability to avoid the lung by seeing the needle tip, it's a block with an acceptable safety margin.

4) But what you're now saying is that the block is OK to do in an ordinary patient because we can visualize and control the needletip and avoid the potentially damaging complication of PTX, but not OK to do in a pt on plavix because heaven forbid you lose your needletip and puncture the artery with your 22g needle?

It just seems to me that the argument "it's just wrist surgery, why risk a hemothorax," isn't outrageously different from "it's just shoulder surgery in a healthy 20 yo, why risk a pneumothorax?"

Just stirring the pot for discussion's sake.
 
Hawaiian Bruin said:
I hear and appreciate those saying to absolutely avoid the supraclavicular on plavix. But I would submit the following:

1) You're basing your recommendation against on theory, not evidence.

2) The danger you're concerned about must be in poor technique, i.e. "losing" the needle tip and getting into the artery.

3) This block used to be avoided because doing it blind resulting in an unacceptably high rate of pneumothorax. We've all now decided that since u/s affords us the ability to avoid the lung by seeing the needle tip, it's a block with an acceptable safety margin.

4) But what you're now saying is that the block is OK to do in an ordinary patient because we can visualize and control the needletip and avoid the potentially damaging complication of PTX, but not OK to do in a pt on plavix because heaven forbid you lose your needletip and puncture the artery with your 22g needle?

It just seems to me that the argument "it's just wrist surgery, why risk a hemothorax," isn't outrageously different from "it's just shoulder surgery in a healthy 20 yo, why risk a pneumothorax?"

Just stirring the pot for discussion's sake.
Click to expand...

I hear you about avoiding the large vascular structures with Ultrasound.

As you know, dude, the human body is not a robot where every body is identical. I've seen small aberrant arteries with US that weren't described in any anatomy textbook in places they shouldn'tve been. God only knows what very small non-described arteries we miss as we probe because we aren't looking for them and don't expect them.

My point is that Plavix dramatically increases your chances of unexpected bleeding, bleeding that once it starts, if you have no mechanism of stopping it will just keep bleeding, and the neck is not an area that a clinician wants this scenario to begin.

There are many pitfalls awaiting you besides the large vascular structures. Some you will be able to identify. Some you will miss.

Stay away from regional on a patient on Plavix.
 
Hawaiian Bruin said:
I hear and appreciate those saying to absolutely avoid the supraclavicular on plavix. But I would submit the following:

[...]
Click to expand...

Unfortunately we now have the 2010 ASRA guidelines which may make complications stemming from elective regional in patients on Plavix harder to defend.

Blade was griping about this in his 'ASRA Screwed Me' thread.
 
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