Chronic pain patients and regional anesthesia

[Planktonmd]

I feel that regional anesthesia/ analgesia is rather disapointing in the chronic pain population.
Anyone else shares that feeling?

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[pd4emergence]

I can usually avoid it by telling them that they will need much less pain medicine if they get the block. After I tell them this quite a few refuse the block and ask if they can get their dilaudid now because just the thought of surgery makes them hurt. I do know what you mean, I 'm sure there is a great explanation but when talk of overactive afferent and underactive inhibitory pathways gets mixed into talk of types of opoid receptors and their relationship to chronic pain my eyes glaze over and I start thinking of when I should schedule my next root canal.

 

[ucsfgaspain]

This comes from a pain guy. When I'm in the OR, I really only like to do one type of block. The one that works 100% of the time. It's the fastest block and takes no time to set up. The cortical block. This blocks every pain receptor from the periphery to the center. Takes care of all types of pain: neuropathic, nociceptive and most importantly...supratentorial.

Now post op...that's another question. I've got no magic bullets there. Regional buys you time...but all blocks wear off. I figure better to bite the bullet early on and deal with the pain than later. When you show a patient the heaven of no pain, then hell becomes any experience of even a little pain.

Sorry not the PC answer from a pain guy...but my experience so far.

 

[militarymd]

Postopertive pain seems the worst in the first 24 hours....

I insist on blocks in my chronic pain patients....

they continue all their regular pain meds...+ block...after 24 hours...it goes to the pain guys like you.

This comes from a pain guy. When I'm in the OR, I really only like to do one type of block. The one that works 100% of the time. It's the fastest block and takes no time to set up. The cortical block. This blocks every pain receptor from the periphery to the center. Takes care of all types of pain: neuropathic, nociceptive and most importantly...supratentorial.

Now post op...that's another question. I've got no magic bullets there. Regional buys you time...but all blocks wear off. I figure better to bite the bullet early on and deal with the pain than later. When you show a patient the heaven of no pain, then hell becomes any experience of even a little pain.

Sorry not the PC answer from a pain guy...but my experience so far.

 

[urge]

I feel that regional anesthesia/ analgesia is rather disapointing in the chronic pain population.
Anyone else shares that feeling?

Regional anesthesia is disappointing by itself.

 

[ucsfgaspain]

Postopertive pain seems the worst in the first 24 hours....

I insist on blocks in my chronic pain patients....

they continue all their regular pain meds...+ block...after 24 hours...it goes to the pain guys like you.

Military,

I know, and that's probably why I have the philosophy that I do

 

[Planktonmd]

Regional anesthesia is disappointing by itself.

You really think so?
I actually like regional anesthesia because I feel that I can improve the patient's post op experience considerably and possibly improve the outcome (although many might disagree).
For example the hospital course after knee replacement has been transformed from a horrible experience into a very positive one since we started using continuous femoral nerve blocks.
One population that remains challenging is the chronic pain people and I feel sometimes that it's not even worth it to offer them regional since they will never admit that they have good pain relief because that might mean less narcotics.

 

[deleted126335]

.

 

[urge]

There are few things in anesthesia more satisfying than a well conducted and well tolerated and successful regional anesthetic.

There are few things more miserable than a regional anesthetic that is lacking one of the above.

I think you have a personality that likes gambling. Do you enjoy spending time at casinos? I bet you do. My buddy from residency loved regional(did a fellowship) and loved to gamble. I think doing a block is taking a gamble. You commit "all in" when you stick the needle. Then the tension grows in anticipation of a failed block until that magical moment when incission occurs. Either you lose or you win. You think you enjoy "blocking" but you just really enjoy gambling.

I couldn't care less for gambling. I like dependability.



Plank,

A fem block for TKR is the only block I would allow on myself if, and only if, I have been miserable on a PCA.

 

[ucsfgaspain]

I think you have a personality that likes gambling. Do you enjoy spending time at casinos? I bet you do. My buddy from residency loved regional(did a fellowship) and loved to gamble. I think doing a block is taking a gamble. You commit "all in" when you stick the needle. Then the tension grows in anticipation of a failed block until that magical moment when incission occurs. Either you lose or you win. You think you enjoy "blocking" but you just really enjoy gambling.

I couldn't care less for gambling. I like dependability.



Urge, That is the most beautiful thing I've ever seen written. I'm going all in too...but not with a needle...but with my trusty 8.0 tube and a stick of whatever relaxant you want

 

[jetproppilot]

Postopertive pain seems the worst in the first 24 hours....

I INSIST ON BLOCKS in my chronic pain patients....

they continue all their regular pain meds...+ block...after 24 hours...it goes to the pain guys like you.

This quote is from the president of S.A.R.A.

(society against regional anesthesia)

WHATS UP, PROFESSOR? ARE YA FEELIN OK?

 

[jetproppilot]

Do you enjoy spending time at casinos?

.

ABSOLUTELY!

Made the 2 final tables at a World Series of Poker event in 2007.

Regularly prey on drunk tourists who show up at high-stakes cash games thinking they are Johhny Chan.

Headed out to Vegas in June for another WSOP tourney.

First place will be around six hundred large.

Top 10% will finish in the money.

Wish me luck.

I'm gonna need it.

All the guys you see on TV will be there.

 

[Noyac]

ucsfgaspain, I am surprised at your approach. Personally, I find that folks that don't like regional typically are not that good at it. Maybe b/c they suck at it and maybe b/c they halfass it since they are jaded. But as a pain guy I would expect that you would feel as though getting the pt to their homeostatic state proves to be much easier to manage than to add some pain on top of an already unstable (chronic pain) situation. Performing a good block in a pain pt and then as Mil stated giving them their maintenance dose of narc's proves to be much easier to manage then to try to increase their narc dosage.

I perform blocks in these pts as often as possible. I tell them that they will receive their usual pain meds as well.

 

[militarymd]

Remember a few years ago when we met here?

when I didn't think blocks made a difference.....well....I was wrong....because when I started the service (for more revenue)...it was obvious how well the patients are doing....

The come off the street now asking for it...

The nurses around the hospital TELL the patients to ask for it....

I HATE being wrong...especially seeing how I"m the presdient of SARA.

This quote is from the president of S.A.R.A.

(society against regional anesthesia)

WHATS UP, PROFESSOR? ARE YA FEELIN OK?

 

[jetproppilot]

Remember a few years ago when we met here?

when I didn't think blocks made a difference.....well....I was wrong....because when I started the service (for more revenue)...it was obvious how well the patients are doing....

The come off the street now asking for it...

The nurses around the hospital TELL the patients to ask for it....

I HATE being wrong...especially seeing how I"m the presdient of SARA.

Well said, Hung.

You've always been DA MAN in my book.

And you just increased your street cred by a thousand percent. although your cred didnt need increasing...so lets see...you were already credible but just increased by 1000%...what number is that? Whos that black hole genius dude in the wheel chair? Ya got his cell phone number by any chance? I gotta give him a ring.....he'll know the answer...

 

[jetproppilot]

I think you have a personality that likes gambling. Do you enjoy spending time at casinos? I bet you do. My buddy from residency loved regional(did a fellowship) and loved to gamble. I think doing a block is taking a gamble. You commit "all in" when you stick the needle. Then the tension grows in anticipation of a failed block until that magical moment when incission occurs. Either you lose or you win. You think you enjoy "blocking" but you just really enjoy gambling.

I couldn't care less for gambling. I like dependability.

Jet looks at the flop. THERES A KING THERE! OMFG. I now have a set of KINGS!! I'll CHECK and trap these mo-fos....even the pro on the button....HUH? Pro-on-the-button puts out a POT SIZED BET?? HAHAHAHHAA.....OK....composure.....okokok.....

"I raise."

I push in alotta chips, tripling his bet.


Pro-on-the-button is bewildered. He sits there for a lifetime (OK, it was probably 2 minutes....THEN PUSHES ALL HIS CHIPS IN....and says those magical words:

"I'M ALL IN."

"I CALL," I said, joyously.

I turn over my pocket kings, revealing the set.

The table reacts in awe at my set of kings.

Pro-on-the-button turns over Ace-rag suited...clubs.....

HE WENT ALL IN ON A CLUB FLUSH DRAW???? A ONE IN FIVE CHANCE OF HITTING AND HE GOES ALL IN, ONE HOUR INTO THE TOURNEY???

I lick my chops.

Blue Oakley Scars come off.

I'm readying myself to garner his chips.

The next card is permanently etched in my retinas. I can still see it being turned...

QUEEN OF CLUBS.

Pro-on-the-button gambled. One in five. Hit it.

Nut flush.

Sent me back to my hotel room.

excerpt from Jets trip to the WSOP last year

 

[dhb]

I HATE being wrong...especially seeing how I"m the presdient of SARA.

WAWAWEWA the SARA is losing it's founding member!!

Indeed the moment when the surg cuts the patient and you see no hemodynamic change is pretty satisfying

 

[epidural man]

Regional anesthesia is disappointing by itself.

If I need a knee scope, inguinal hernia repair, etc, give me a damn spinal. No sedation either....I'm going to watch a movie on my iphone during the case.

 

[VentdependenT]

Remember a few years ago when we met here?

when I didn't think blocks made a difference.....well....I was wrong....because when I started the service (for more revenue)...it was obvious how well the patients are doing....

The come off the street now asking for it...

The nurses around the hospital TELL the patients to ask for it....

I HATE being wrong...especially seeing how I"m the presdient of SARA.

There is a first time for everything eh MMD?

Now if you could just lose your virginity then you'd be all out of "first times."

 

[Arch Guillotti]

well....I was wrong....

Sticky this pronto.

 

[coprolalia]

ucsfgaspain, I am surprised at your approach. Personally, I find that folks that don't like regional typically are not that good at it. Maybe b/c they suck at it and maybe b/c they halfass it since they are jaded. But as a pain guy I would expect that you would feel as though getting the pt to their homeostatic state proves to be much easier to manage than to add some pain on top of an already unstable (chronic pain) situation. Performing a good block in a pain pt and then as Mil stated giving them their maintenance dose of narc's proves to be much easier to manage then to try to increase their narc dosage.

I perform blocks in these pts as often as possible. I tell them that they will receive their usual pain meds as well.

I agree 100%, Noy. I've been watching this "ucsfgaspain" character, and I smell a troll.

A "cortical" block is not the be-all, end-all block. As many have pointed out here, the spinal and subcortical responses to pain are present and still quite important even during a general anesthetic. The fact that an "attending" would not appear to know or understand this, and then even go so far as to under-emphasize this fact in a post, has my "trolldar" pinging.

A great regional block is great, but it has to be in the right patient for the right procedure. In other words, you can't fix crazy with a regional block. In an academic program, residents take care of the blocks on the floor. If you stick a catheter into someone who is nuts, you're basically buddy-f*cking the guy who is on call. At the very least, tuck them well when you do sign-out rounds (that means Dilaudid PCA 0.5mg q6min).

-copro

 

[Planktonmd]

I agree 100%, If you stick a catheter into someone who is nuts, you're basically buddy-f*cking the guy who is on call. At the very least, tuck them well when you do sign-out rounds (that means Dilaudid PCA 0.5mg q6min).

-copro

Copro,
Congratulations! You are ready for private practice.

 

[pmichaelmd]

ucsfgaspain, I am surprised at your approach. Personally, I find that folks that don't like regional typically are not that good at it. Maybe b/c they suck at it and maybe b/c they halfass it since they are jaded. But as a pain guy I would expect that you would feel as though getting the pt to their homeostatic state proves to be much easier to manage than to add some pain on top of an already unstable (chronic pain) situation. Performing a good block in a pain pt and then as Mil stated giving them their maintenance dose of narc's proves to be much easier to manage then to try to increase their narc dosage.

I perform blocks in these pts as often as possible. I tell them that they will receive their usual pain meds as well.

I do the same, although I also agree that you can't cure crazy, particularly with a catheter. I give my patients the spiel that blocks usually decrease pain, but that they may not necessarily be "pain-free." After all, the surgeon is going to be attacking them with a knife...can they really expect that to not hurt at all?

Our results with PNBs has been excellent, although the chronic pain, fibromyalgia types are always gonna hurt more, be it via upregulation of receptors or the usual supratentorial BS. Either way, I like to get a block in 'em and keep 'em on their home doping regimen.

-PMMD

 

[Planktonmd]

I do the same, although I also agree that you can't cure crazy, particularly with a catheter. I give my patients the spiel that blocks usually decrease pain, but that they may not necessarily be "pain-free." After all, the surgeon is going to be attacking them with a knife...can they really expect that to not hurt at all?

Our results with PNBs has been excellent, although the chronic pain, fibromyalgia types are always gonna hurt more, be it via upregulation of receptors or the usual supratentorial BS. Either way, I like to get a block in 'em and keep 'em on their home doping regimen.

-PMMD

So, Here is a theoretical situation:
A patient who claims his current chronic pain and disability was the result of steroid epidural that went wrong and might be in the process of suing the pain specialist who did the procedure.
He is here to get a knee replacement.
Would you offer him any form a regional anesthesia?

 

[pmichaelmd]

So, Here is a theoretical situation:
A patient who claims his current chronic pain and disability was the result of steroid epidural that went wrong and might be in the process of suing the pain specialist who did the procedure.
He is here to get a knee replacement.
Would you offer him any form a regional anesthesia?

That certainly is the question. I have to admit that I'd balk at a patient who is hell-bent on litigation. That is the supratentorial and secondary gain part of the equation I'd prefer to avoid. I guess it really is on a case-by-case basis. Since the pain they'd likely sue for is subjective, and we can't "measure" it, it'd be more of a pain in the *** than it's worth. Then again, that same patient may be just as likely to claim that he/she has persistent hoarseness or throat pain from intubation, etc. I'm not sure where that mentality ends. Thoughts?

 

[coprolalia]

Thoughts?

I wouldn't block him.

-copro

 

[Noyac]

So, Here is a theoretical situation:
A patient who claims his current chronic pain and disability was the result of steroid epidural that went wrong and might be in the process of suing the pain specialist who did the procedure.
He is here to get a knee replacement.
Would you offer him any form a regional anesthesia?

This pt probably wouldn't want a block.

I'd say fine, you go to sleep now.

 

[VentdependenT]

ZYPREXA 10mg DEEP IM injection STAT

 

[Planktonmd]

ZYPREXA 10mg DEEP IM injection STAT