Deep peripheral blocks

[Justice4all]

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Would you consider femoral/pop sciatic/ adductor a deep PNB? Asking in regards to anticoagulants and ASRA guidelines?

 

[facted]

Would you consider femoral/pop sciatic/ adductor a deep PNB? Asking in regards to anticoagulants and ASRA guidelines?

None of those. Only ones I consider deep are paravertebral, neuraxials or lumbar plexus blocks.

 

[deleted59964]

From a practical view point, the key issues for me are

If I get a hematoma, is it potentially catastrophic
If I cause bleeding, can I stop it with compression

Therefore, none of those blocks concern me

 

[Arch Guillotti]

Would you consider femoral/pop sciatic/ adductor a deep PNB?

No.

 

[sleepallday]

Would you consider femoral/pop sciatic/ adductor a deep PNB? Asking in regards to anticoagulants and ASRA guidelines?

I wouldn't worry about any of those blocks. But I might worry about doing the actual surgery while they are anticoagulated.

 

[Psai]

I wouldn't worry about any of those blocks. But I might worry about doing the actual surgery while they are anticoagulated.

That's what the tourniquet is for 😀

 

[AdmiralChz]

Wasn’t this just asked? If you can compress it there aren’t any restrictions.

 

[Lecithin5]

Wasn’t this just asked? If you can compress it there aren’t any restrictions.

I agree with you. But devil’s advocate- a bleed after an interscalene (compressible, but let’s say you can’t get control) can cause airway compromise, spinal hematoma, etc. Rare but devastating

 

[deleted87051]

I agree with you. But devil’s advocate- a bleed after an interscalene (compressible, but let’s say you can’t get control) can cause airway compromise, spinal hematoma, etc. Rare but devastating

If someone’s needle path is anywhere near a vessel for an ISB they are doing something very wrong. And we stick bigger needles in coagulopathic patients all the time for IV access and monitoring. Regional anesthesia is not so special.

 

[facted]

I agree with you. But devil’s advocate- a bleed after an interscalene (compressible, but let’s say you can’t get control) can cause airway compromise, spinal hematoma, etc. Rare but devastating

No, not really.

I agree with you. But devil’s advocate- a bleed after an interscalene (compressible, but let’s say you can’t get control) can cause airway compromise, spinal hematoma, etc. Rare but devastating

I rarely put Central lines anymore, but I've done plenty in coagulopathy patients. Much more risk there, no?

 

[Lecithin5]

I am comfortable and will do these blocks in anticoagulated patients. But I know several large academic centers (and thus assume lots of physicians out there wouldn’t block these patients) that won’t touch these patients because they are elective procedures at the end of the day, unlike central lines. I am specifically referring to interscalenes- adductors, axillary etc are no problem. Again, rare, but hematomas have been known to happen, even without skewering a large vessel.

 

[facted]

Deleted.

 

[Arch Guillotti]

I agree with you. But devil’s advocate- a bleed after an interscalene (compressible, but let’s say you can’t get control) can cause airway compromise, spinal hematoma, etc. Rare but devastating

Can you explain how it causes a apinal hematoma if you can see the target and the needle the whole time?

 

[cleansocks]

I actually think the interscalene block is one of the scariest blocks out there. For a busy, high volume service with trainees or careless people doing the blocks, complications are really plausible with this one

Hitting a major vessel is easier than you might think.
http://accessanesthesiology.mhmedical.com/data/books/hadzpnb2/hadzpnb2_c029f004.png
https://www.e-sciencecentral.org/upload/kjpain/thumb/kjpain-29-179-g001.jpg

Case series of permanent phrenic nerve damage, albeit there's more than meets the eye on that one:
Permanent Diaphragm Paralysis after Shoulder Rotator Cuff Repair: Interscalene Block Is Not the Only Factor | Anesthesiology | ASA Publications

the fact that within a few cm, you reach the cervical nerve roots:
https://i.ytimg.com/vi/SKGA1LGi9_Y/maxresdefault.jpg
(good pic of a root lying within the anterior and posterior tubercle in the bottom middle of the screen)




That said, if one stays shallow and doesn't try to be a hero with multiple passes to make sure to get every little nook and cranny of the plexus at this level, anticoagulation shouldn't be a real concern.

 

[Lecithin5]

And as Arch stated, if you see the target the needle and target the entire time, shouldn’t be a problem. But as cleansocks stated, esp in thinner pts, you can be close the tubercles. Also, just like how you can get epidural or subdural spread of local, that is also a location where a bleed could occur (again, highly unlikely). A few months ago one of my colleagues had a hematoma compressing the plexus that needed surgical eval, which would be a more likely (still rare) complication.

 

[kidthor]

if you see the target the needle and target the entire time, shouldn’t be a problem.

I bet a lot of people (not you) don't see the target and needle the entire time... especially when going out of plane. Bad ultrasound, suboptimal needles, or lackluster/developing/rusty skills likely all contribute.

 

[dhb]

I bet a lot of people (not you) don't see the target and needle the entire time... especially when going out of plane. Bad ultrasound, suboptimal needles, or lackluster/developing/rusty skills likely all contribute.

You can see the needle and the target but by focusing on those things you can also miss the vessel that's in between...