Elbow and wrist block duration

[Oggg]

I did an ORIF of a thumb distal phalanx, and I wanted to do a block, but the surgeon wanted to just do a digital block. I assume his bupivacaine will last 6h, but does anyone have experience with this?

I told him the main benefit of my blocks (supraclav) would be longer duration (avoidance of GA is a weak reason). Downside is the whole arm paralysis. I thought about doing blocks at the elbow or wrist (median,radial), but I don't know how long these blocks last -- if it's just 6h then I wouldnt bother.

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[BLADEMDA]

Anaesth Intensive Care. 1998 Oct;26(5):515-20.
A comparison of 0.5% ropivacaine and 0.5% bupivacaine for axillary brachial plexus anaesthesia.

McGlade DP, Kalpokas MV, Mooney PH, Chamley D, Mark AH, Torda TA.
Source

Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria.

Abstract

The purpose of this study was to compare the use of 0.5% ropivacaine with 0.5% bupivacaine for axillary brachial plexus anaesthesia. Sixty-six patients undergoing upper limb surgery were enrolled in a double-blind, randomized, multicentre trial. Five patients were subsequently excluded for various reasons. Of the remaining patients, 30 received 40 ml of 0.5% ropivacaine and 31 received 40 ml of 0.5% bupivacaine. Brachial plexus block was performed by the axillary approach using a standardized technique with a peripheral nerve stimulator. Parameters investigated included the frequency, onset and duration of sensory and motor block, the quality of anaesthesia and the occurrence of any adverse events. The six principal nerves of the brachial plexus were studied individually. The frequency for achieving anaesthesia per nerve ranged from 70 to 90% in the ropivacaine group and 81 to 87% in the bupivacaine group. The median onset time for anaesthesia was 10 to 20 minutes with ropivacaine and 10 to 30 minutes with bupivacaine, and the median duration was 5.3 to 8.7h with ropivacaine and 6.9 to 20.3h with bupivacaine. Motor block was evaluated at the elbow, wrist and hand, and was completely achieved at a rate of 60 to 73% in the ropivacaine group and 55 to 71% in the bupivacaine group. The median duration of motor block was 6.5 to 7.5h with ropivacaine and 6.0 to 9.0h with bupivacaine. These parameters were not statistically different. The duration of partial motor block at the wrist (6.8 v 16.4h) and hand (6.7 v 12.3h) was significantly longer with bupivacaine. Ropivacaine 0.5% and bupivacaine 0.5% appeared equally efficacious as long-acting local anaesthetics for axillary brachial plexus block.

 

[BLADEMDA]

I did an ORIF of a thumb distal phalanx, and I wanted to do a block, but the surgeon wanted to just do a digital block. I assume his bupivacaine will last 6h, but does anyone have experience with this?

I told him the main benefit of my blocks (supraclav) would be longer duration (avoidance of GA is a weak reason). Downside is the whole arm paralysis. I thought about doing blocks at the elbow or wrist (median,radial), but I don't know how long these blocks last -- if it's just 6h then I wouldnt bother.

6-8 hours for most patients even with Bupivacaine or Ropivacaine. If you add Decadron then 12 hours (reliably) is likely but I'm not adding it yet for distal nerve block rescue.

 

[BLADEMDA]

I did an ORIF of a thumb distal phalanx, and I wanted to do a block, but the surgeon wanted to just do a digital block. I assume his bupivacaine will last 6h, but does anyone have experience with this?

I told him the main benefit of my blocks (supraclav) would be longer duration (avoidance of GA is a weak reason). Downside is the whole arm paralysis. I thought about doing blocks at the elbow or wrist (median,radial), but I don't know how long these blocks last -- if it's just 6h then I wouldnt bother.

I just had 2 last week. Hand Surgeon did his field block and post op the patient was pain free.
The next case I did a SCB with Decadron.

When I saw the surgeon again he said "my block wore off after 8 hours and the patient called me for more pain meds but your block lasted for 26 hours." I now have his permission to block any and all of his ORIF patients.

 

[dhb]

I
When I saw the surgeon again he said "my block wore off after 8 hours and the patient called me for more pain meds but your block lasted for 26 hours." I now have his permission to block any and all of his ORIF patients.

 

[IlDestriero]

I just had 2 last week. Hand Surgeon did his field block and post op the patient was pain free.
The next case I did a SCB with Decadron.

When I saw the surgeon again he said "my block wore off after 8 hours and the patient called me for more pain meds but your block lasted for 26 hours." I now have his permission to block any and all of his ORIF patients.

Our ortho guys won't allow blocks for fractures. I assume it's fear of unrecognized compartment syndrome, cast problems, etc.

Cheers!

 

[pgg]

Our ortho guys won't allow blocks for fractures. I assume it's fear of unrecognized compartment syndrome, cast problems, etc.

I think some of our orthopods think pain is good for bone healing, or maybe it builds character, or something.

There's no other way to explain some of the anti-regional bias.

 

[RussianJoo]

I think some of our orthopods think pain is good for bone healing, or maybe it builds character, or something.

There's no other way to explain some of the anti-regional bias.

that could be a great study in the making! lol just kidding.

 

[Noyac]

Ask the stupid f*cking orthopod to show you a study describing compartment syndrome with delayed recognition because of regional. If they can't then tell them to step aside.

 

[Oggg]

RAPM actually has a case report about a pt who was diagnosed with compartment syndrome after having breakthrough pain while on a continuous perineural infusion. Nice