Failed sciatic (popliteal) block

[deleted131481]

I am looking for some tips on popliteal sciatic blocks.

I graduated from residency a bit over a year ago and I'm doing my first blocks in about 18 months so a bit rusty. I remember having trouble with popliteal block failures in residency as well despite the anatomy appearing so simple. Upper extremity is fine but I had several issues with popliteal (sciatic) blocks including failed surgical block and some poor post-op pain control on others.

I realize it would have been useful if I had taken some ultrasound images. I am able to identify the anatomy easily. All of the blocked patients had onset of skin numbness within minutes using 20cc of 2/3 bupivacaine . 5% and 1/3 lidocaine 2. Post-op two patients had motor strength with only minor weakness but still with skin numbness.

I am targeting proximal to the popliteal crease about 5-10 centimeter before sciatic bifurcation into the tibial and common peroneal nerves. I wonder if I'm not piercing the nerve sheath as I should and I'm simply surrounding it as I get skin numbness throughout but lack motor block and adequate pain control for ankle surgery.

Do you guys go proximal or distal to the bifurcation? Should I consider targeting the tibial and common peroneal separately?

Thanks

---

Members don't see this ad.

 

[deleted131481]

Well, I should have searched before posting as there is a good thread called popliteal block with some good tips. I may try piercing the sheath and aim for separation and circumferential spread of both nerves.

 

[Dexmetaketapropofol]

I am looking for some tips on popliteal sciatic blocks.

I graduated from residency a bit over a year ago and I'm doing my first blocks in about 18 months so a bit rusty. I remember having trouble with popliteal block failures in residency as well despite the anatomy appearing so simple. Upper extremity is fine but I had several issues with popliteal (sciatic) blocks including failed surgical block and some poor post-op pain control on others.

I realize it would have been useful if I had taken some ultrasound images. I am able to identify the anatomy easily. All of the blocked patients had onset of skin numbness within minutes using 20cc of 2/3 bupivacaine . 5% and 1/3 lidocaine 2. Post-op two patients had motor strength with only minor weakness but still with skin numbness.

I am targeting proximal to the popliteal crease about 5-10 centimeter before sciatic bifurcation into the tibial and common peroneal nerves. I wonder if I'm not piercing the nerve sheath as I should and I'm simply surrounding it as I get skin numbness throughout but lack motor block and adequate pain control for ankle surgery.

Do you guys go proximal or distal to the bifurcation? Should I consider targeting the tibial and common peroneal separately?

Thanks

This is the one block I don't mind injecting Ropivicaine (without additives) with a small amount of intraneural deposit. If you do a pubmed or search you'll see studies showing that the outcomes of EMG or peripheral nerve disturbances are not clinically significant. The studies I know about are admittedly not the most robust, but we do a lot of ankle/foot work and i do a single shot vs catheter sciatic (proximal to bifurcation) and a single shot adductor canal if there is pain in that distribution.

 

[Noyac]

Well I’ve never had a block fail so it’s hard for me to comment

But seriously, I think the popliteal is the most common of the five or six top blocks ( ISB, Supraclav, axillary, FNB SCIATIC and popliteal) to fail. I know the popliteal is a sciatic for you smartasses out there. With that being said I found it to be one of the easiest non US blocks we do. And it works well. I am at least 9cm above the crease when I inject. But with US I find the nerve to be somewhat ill defined. So this is the only. US Block that i still use a twitch monitor with. I do pierce the sheath I guess. I try to get the two branches to separate.

I found my pop blocks were better quality when I wasn’t using US too. But now they are pretty much equal. I don’t think it is your local solution that matters either. But I just use 0.5% ropiv with decadron. If I want to do the case under block lanky then I mix in 1.5% mepiv at 50/50.

Be sure to cover the saphenous though. Either the field block or by ACB.

I know this is nothing new to you or enlightening but maybe there is something in this that helps.

 

[facted]

If you're good with ultrasound and needle technique, I recommend going out of plane right where the two branches come together.

I also highly recommend prone position to make your life as easy as possible.

A great resource: https://www.nysora.com/ultrasound-guided-popliteal-sciatic-block-2

 

[Hoya11]

I am looking for some tips on popliteal sciatic blocks.

I graduated from residency a bit over a year ago and I'm doing my first blocks in about 18 months so a bit rusty. I remember having trouble with popliteal block failures in residency as well despite the anatomy appearing so simple. Upper extremity is fine but I had several issues with popliteal (sciatic) blocks including failed surgical block and some poor post-op pain control on others.

I realize it would have been useful if I had taken some ultrasound images. I am able to identify the anatomy easily. All of the blocked patients had onset of skin numbness within minutes using 20cc of 2/3 bupivacaine . 5% and 1/3 lidocaine 2. Post-op two patients had motor strength with only minor weakness but still with skin numbness.

I am targeting proximal to the popliteal crease about 5-10 centimeter before sciatic bifurcation into the tibial and common peroneal nerves. I wonder if I'm not piercing the nerve sheath as I should and I'm simply surrounding it as I get skin numbness throughout but lack motor block and adequate pain control for ankle surgery.

Do you guys go proximal or distal to the bifurcation? Should I consider targeting the tibial and common peroneal separately?

Thanks

Do it lateral.

See the nerves come together and then keep going up a cm or two.

Enter the skin in the back of the leg NOT the side. Lateral to medial. Straight down and in the middle of the probe.

Locate your needle IN PLANE upon entrance into the leg. Pick your angle towards the nerve.

Surround the nerve with local AND pierce the sheath and inject. Surround it first. 20ml around and 10ml inside.

And change your volume to 30ml 0.5% bupi. Lido buys you nothing. The block sets up by the time you prep and drape if your in the sheath.

The set up in the beginning is the key. Dont settle for a suboptimal view. Identify nerve. Hold view. Identify needle, match the two. Make sure there is no doubt about it. Good luck

 

[anbuitachi]

i inject a few cm (not 10) above where they split, make sure the two branches split from the local, scan up and down and see the local separate and surround both branches from where i injected

 

[ZzzPlz]

Agree the popliteal nerve can be hard to identify on US. I find that very subtle pronation and supination of your hand holding the probe can make it really “pop” on the ultrasound usually when It’s tough to find

Also look for the artery as a landmark

 

[okayplayer]

Stim very helpful when in doubt.

 

[deleted131481]

Thanks for the replies. The NYSORA link spells out the sheath pretty clearly. I had seen their landmark technique page but not US.

I'l going to add back nerve stimulator at least until I'm getting good success and confident I can do without.

Also was doing these supine to get adductor easier but will try lateral or possibly prone.

Enter the skin in the back of the leg NOT the side. Lateral to medial. Straight down and in the middle of the probe.

Locate your needle IN PLANE upon entrance into the leg. Pick your angle towards the nerve.

I don't quite understand the description here. Is it similar to to figure 12 on the left of the NYSORA link? Sorry won't let me post direct link.

Is the reasoning for this to come right center on top (posterior) rather than lateral, similar to the comment stating out of plane?

 

[Mman]

Upper extremity is fine but I had several issues with popliteal (sciatic) blocks including failed surgical block and some poor post-op pain control on others.

Don't use it for surgical anesthesia. It can take a LONG time to set up in some patients even with perfect U/S anatomy. IMHO if you need a surgical block of the sciatic nerve, move on up to a more classic approach and it has a far better chance of success. Popliteal approach is strictly for postop pain control.

 

[Psai]

We use popliteal all the time for surgical anesthesia.

 

[facted]

Don't use it for surgical anesthesia. It can take a LONG time to set up in some patients even with perfect U/S anatomy. IMHO if you need a surgical block of the sciatic nerve, move on up to a more classic approach and it has a far better chance of success. Popliteal approach is strictly for postop pain control.

Disagree. We routinely use pop block for foot and ankle surgery with some prop sedation (at most 75ish). The key is to let block set, maybe 15 minutes?

If you want faster onset, can use half 0.5 bupi and half 1.5% mepiv (with 1 ml of bicarb per 10ml mepiv) and don't mix the syringes. But I haven't done this in a long time and if you wait 15ish minutes, you'll be fine.

As for the OP, gotta make sure you're in the sheath... Look for the kissing sign where the nerves come together and just pop in out of plane right between them.

 

[facted]

Thanks for the replies. The NYSORA link spells out the sheath pretty clearly. I had seen their landmark technique page but not US.

I'l going to add back nerve stimulator at least until I'm getting good success and confident I can do without.

Also was doing these supine to get adductor easier but will try lateral or possibly prone.



I don't quite understand the description here. Is it similar to to figure 12 on the left of the NYSORA link? Sorry won't let me post direct link.

Is the reasoning for this to come right center on top (posterior) rather than lateral, similar to the comment stating out of plane?

As for Hoya's suggestion, he's just saying make sure you start with your needle right next to the probe as opposed to coming from the side of the leg, which some proppe often use for a pop. The advantage stayings right next to the probe like you would for a supra, is that you see the needle from the get go. I would really advocate learning this block out of plane which makes it a pretty simple block and it's much easier to get into the sheath between the two branches without piercing right between the nerves.

Do this block prone and don't mess around, especially if you're having trouble. Flipping the patient back and forth takes maybe 30 seconds for each turn, which is well worth it.

I've maybe done 500 pop blocks, can't remember the last failed one, and still do them prone unless the pt is truly immobile and then I go lateral. Resting the probe on the leg as opposed to pushing it upwards is infinitely easier and will let you focus on the block instead of how much force you're applying on the probe. Believe it or not, ergonomics has a role to play in how easy or hard the block is.

 

[BLADEMDA]

Popliteal block

 

[Hoya11]

Thanks for the replies. The NYSORA link spells out the sheath pretty clearly. I had seen their landmark technique page but not US.

I'l going to add back nerve stimulator at least until I'm getting good success and confident I can do without.

Also was doing these supine to get adductor easier but will try lateral or possibly prone.



I don't quite understand the description here. Is it similar to to figure 12 on the left of the NYSORA link? Sorry won't let me post direct link.

Is the reasoning for this to come right center on top (posterior) rather than lateral, similar to the comment stating out of plane?

In the lateral position, entering posteriorly on the leg, instead of lateral, allows you to insert into fleshier tissue. The lateral side of the leg is very muscular and "locks" you into one trajectory and IME is more difficult to maneuver the needle around the plexus. The flesh of the back of the leg offers no such resistance/tightness.

 

[Urzuz]

Agree the popliteal nerve can be hard to identify on US. I find that very subtle pronation and supination of your hand holding the probe can make it really “pop” on the ultrasound usually when It’s tough to find

Also look for the artery as a landmark

This.

Especially in obese patients, fat can look remarkably like nerve bundles. In these patients, you should scan up and down the thigh around the popliteal fossa. The sciatic nerve is the only structure that splits in the popliteal fossa. Remember this, as it has helped me out tremendously. In training we were always taught to take the nerve(s) a little distal to where the tibial and common peroneal are separating from one another, because in theory your local anesthetic is covering a larger surface area of the nerve bundles. As others have indicated, if there is any doubt, don't be afraid to throw a nerve stimulator on!

I always do them supine with the patient's leg on something, probe posterior, my needle entering laterally and slightly anterior to the nerves (needle approach on ultrasound is diagonal). As you approach, you can inject a bit to start dissecting out the smaller common peroneal nerve which you will see approach first (lateral to the tibial). Then use the needle to bisect the two nerves, and proceed to inject around tibial. After you have them separated with local, it's just a matter of creating your local anesthetic "donuts" around both of them.

Don't be afraid to ask your partners to watch you, or you watch them, as nothing can replace doing and seeing it live. Good luck!

 

[DM27]

Did it outright fail? I haven't had one 100% fail yet, but I have had a few where the images weren't great and the block took longer to set in than I had hoped, so if we hadn't waited 10 more minutes it would have been deemed a fail for surgery.

In regards to where to inject. I do them with the patient supine, I identify the nerves, move more proximal to where it just merges in like a sideways figure-8 to become "sciatic" and inject at this point. If I am curious, about halfway through I will scan distal and proximal and observe the spread within the sheath. If I do not see spread I will usually be a little more aggressive about making sure I pierced the sheath and then observe for spread.

The cases where I did not observe any real spread are the ones that come to mind where the block took about 2-3x longer than expected to set in.

 

[Noyac]

Disagree. We routinely use pop block for foot and ankle surgery with some prop sedation (at most 75ish). The key is to let block set, maybe 15 minutes?

If you want faster onset, can use half 0.5 bupi and half 1.5% mepiv (with 1 ml of bicarb per 10ml mepiv) and don't mix the syringes. But I haven't done this in a long time and if you wait 15ish minutes, you'll be fine.

As for the OP, gotta make sure you're in the sheath... Look for the kissing sign where the nerves come together and just pop in out of plane right between them.

We rarely have 15 min to let the block set up.
Why do you say “don’t mix th syringes”? I’ve done it both ways and the results are the same.

 

[Psai]

We rarely have 15 min to let the block set up.
Why do you say “don’t mix th syringes”? I’ve done it both ways and the results are the same.

Do it in preop?

If you mix them they become half concentration

 

[facted]

We rarely have 15 min to let the block set up.
Why do you say “don’t mix th syringes”? I’ve done it both ways and the results are the same.

Bicarb will precipitate in bupi. Snow globe. If I do a mepiv/bicarb and bupi half/half block, I keep them on a stopcock but don't mix the two syringes.

 

[Noyac]

Bicarb will precipitate in bupi. Snow globe. If I do a mepiv/bicarb and bupi half/half block, I keep them on a stopcock but don't mix the two syringes.

Wouldn’t they mix at the site?

 

[Noyac]

Do it in preop?

If you mix them they become half concentration

Where else would you do the block? Not in the OR!

 

[facted]

Wouldn’t they mix at the site?

Yes they do, presumably, although the precipitation probably occurs because of pH changes, I believe, and pH in solution in the syringe is different than in tissue.

Furthermore, if you let it get to snow-globe, you'll also have a doozy of a time injecting through the block needle

 

[Noyac]

Yes they do, presumably, although the precipitation probably occurs because of pH changes, I believe, and pH in solution in the syringe is different than in tissue.

Furthermore, if you let it get to snow-globe, you'll also have a doozy of a time injecting through the block needle

Are you mixing bicarb in your blocks? What precipitation are you talking about?

 

[Arch Guillotti]

Don't use it for surgical anesthesia. It can take a LONG time to set up in some patients even with perfect U/S anatomy. IMHO if you need a surgical block of the sciatic nerve, move on up to a more classic approach and it has a far better chance of success. Popliteal approach is strictly for postop pain control.

Disagree. Popliteal is fine for surgical anesthesia the vast majority of the time.

 

[Arch Guillotti]

Are you mixing bicarb in your blocks? What precipitation are you talking about?

Also would like to know if you are mixing bicarb in. Never heard of this.

 

[facted]

Are you mixing bicarb in your blocks? What precipitation are you talking about?

I don't do it anymore, but routinely did in residency for use with mepiv for faster onset. Mepiv comes as an acid (mepivicaine hydrochloride). Adding bicarb increases ph to closer to physiologic ph, which results in increased non-ionized fraction. Increased non-ionized fraction = faster block onset.

I know people that add bicarb to lidocaine for section epidurals all the time, with the same idea. It speeds onset as well.

With that being said, I haven't done this in a quite a while now, and like I said, if you mix bupi and bicarb you'll precipitate and it can be difficult to inject.

Here's one study, but there are others that have looked at this:

[Addition of sodium bicarbonate and/or clonidine to mepivacaine: influence on axillary brachial plexus block characteristics]. - PubMed - NCBI

 

[ZzzPlz]

I don't do it anymore, but routinely did in residency for use with mepiv for faster onset. Mepiv comes as an acid (mepivicaine hydrochloride). Adding bicarb increases ph to closer to physiologic ph, which results in increased non-ionized fraction. Increased non-ionized fraction = faster block onset.

I know people that add bicarb to lidocaine for section epidurals all the time, with the same idea. It speeds onset as well.

With that being said, I haven't done this in a quite a while now, and like I said, if you mix bupi and bicarb you'll precipitate and it can be difficult to inject.

Here's one study, but there are others that have looked at this:

[Addition of sodium bicarbonate and/or clonidine to mepivacaine: influence on axillary brachial plexus block characteristics]. - PubMed - NCBI

Luckily we have 3% chloroprocaine at my shop. **** is scary fast acting for crash c sections with pre existing epidural

 

[Mman]

Disagree. Popliteal is fine for surgical anesthesia the vast majority of the time.

IMHO it's probably fine if you have 30+ minutes from doing the block until incision is made. This is in contrast to something like a supraclavicular block where you can generally make incision within 5-10 minutes depending on the local you choose.

If you only have 15 minutes or so, it's hit or miss as to whether a popliteal block will set up fast enough. It's certainly slower in onset than a classic sciatic that works much more quickly.

 

[Noyac]

I don't do it anymore, but routinely did in residency for use with mepiv for faster onset. Mepiv comes as an acid (mepivicaine hydrochloride). Adding bicarb increases ph to closer to physiologic ph, which results in increased non-ionized fraction. Increased non-ionized fraction = faster block onset.

I know people that add bicarb to lidocaine for section epidurals all the time, with the same idea. It speeds onset as well.

With that being said, I haven't done this in a quite a while now, and like I said, if you mix bupi and bicarb you'll precipitate and it can be difficult to inject.

Here's one study, but there are others that have looked at this:

[Addition of sodium bicarbonate and/or clonidine to mepivacaine: influence on axillary brachial plexus block characteristics]. - PubMed - NCBI

You are confusing the crap out of me. Can we talk like we are practicing at least in the current state of care. Cesarean epidurals occasionally have bicarb added, I agree. But this is a completely different situation. Don’t confuse the two. If your regional block for ankle surgery isn’t fully set up by the time they are prepp’d and draped even without bicarb then it isn’t gonna cut it.

So what I am gathering is that you are making statement about things that nobody does. And if they do then they need to reassess. I haven’t seen bicarb added to a regional block ever.

I would caution you and everyone here not to make statements that are irrelevant. And I would caution some young buck/buckettes as to taking what you read here as acceptable practice. Use sound reasoning.

Sorry to be so harsh but “come on man”.

 

[Noyac]

IMHO it's probably fine if you have 30+ minutes from doing the block until incision is made. This is in contrast to something like a supraclavicular block where you can generally make incision within 5-10 minutes depending on the local you choose.

If you only have 15 minutes or so, it's hit or miss as to whether a popliteal block will set up fast enough. It's certainly slower in onset than a classic sciatic that works much more quickly.

I do it all the time.
I use 1.5% mepiv mixed with 0.5% ropiv with decadron.
No f’n bicarb.
Mixed in the syringe
No issues.
Next Case !!!

And this will come across once again as Noy bragging but my orthopods like when I’m in their room for hand and foot/ankle cases because I don’t usually put those pts to sleep. They could care less what I do usually but when their pts go home and tell their friends that they didn’t even have to go to sleep for the surgery, well then the surgeon gets more referrals. It makes “them” look good. Don’t think what you do doesn’t matter.

 

[fakin' the funk]

- I feel like this is a very reliable block
- I do it right at or just below the bifurcation, US only
- in plane short axis entering from side of leg
- for me supine is usually easiest (no repositioning, do need a stack of blankets or the candy cane)
- more volume is good though I usually do 20ml, if surgical would do 30ml

 

[ZzzPlz]

My favorite popliteal block for surgical anesthesia is a spinal

 

[Mman]

I do it all the time.
I use 1.5% mepiv mixed with 0.5% ropiv with decadron.
No f’n bicarb.
Mixed in the syringe
No issues.
Next Case !!!

And this will come across once again as Noy bragging but my orthopods like when I’m in their room for hand and foot/ankle cases because I don’t usually put those pts to sleep. They could care less what I do usually but when their pts go home and tell their friends that they didn’t even have to go to sleep for the surgery, well then the surgeon gets more referrals. It makes “them” look good. Don’t think what you do doesn’t matter.

Do those patients also tell their patients about how short their block lasted postop and how soon they started hurting? Because that's what happens when you start mixing locals. I didn't even have to go to sleep! And then that night I couldn't sleep because I was in so much pain!

 

[Noyac]

Do those patients also tell their patients about how short their block lasted postop and how soon they started hurting? Because that's what happens when you start mixing locals. I didn't even have to go to sleep! And then that night I couldn't sleep because I was in so much pain!

It gets them through the night just fine. I do not understand why anyone would want a block to last more than a day.
My usual block is straight 0.5% Ropiv with decadron. The Mepivicane is added about 10% of the time when I need it to set up faster.

 

[deleted162650]

They could care less what I do usually but when their pts go home and tell their friends that they didn’t even have to go to sleep for the surgery, well then the surgeon gets more referrals.

You and I have a very different patient population. 99.7% of patients tell me they want to be completely asleep and not aware of anything even for minor cases that could easily be done under a block. The only notable exception was the lady a couple months ago that was adamant we do her knee scope under local (worked remarkably well).


How often are you guys doing surgical blocks?? It's been a good 3+ years since I've done a block as my primary anesthetic. Generally I could care less how long the block takes to set up 'cuz the prop/LMA/sevo sets up pretty damn quick. As long as they're numb by the time the drapes come down everyone's happy.

 

[Mman]

You and I have a very different patient population. 99.7% of patients tell me they want to be completely asleep and not aware of anything even for minor cases that could easily be done under a block. The only notable exception was the lady a couple months ago that was adamant we do her knee scope under local (worked remarkably well).


How often are you guys doing surgical blocks?? It's been a good 3+ years since I've done a block as my primary anesthetic. Generally I could care less how long the block takes to set up 'cuz the prop/LMA/sevo sets up pretty damn quick. As long as they're numb by the time the drapes come down everyone's happy.

Our patients also overwhelmingly want to be "asleep". When I'm trying to explain the benefits of a regional technique for a procedure, I still have to assure them they we will give them lots of sedation like with a colonoscopy we just won't have to stick a breathing tube down their throat. Because while they also want to be "asleep", they also don't want a "breathing tube".

We do the overwhelming majority of our dialysis access procedures under a surgical block as well as some other hand/arm stuff.

 

[Southpaw]

Beyond the misinformation regarding anesthesia presented here, could you grown men with your MD degrees please start using the phrase correctly. You could not care less about x. Therefore, you COULDN’T care less [this is key in the saying]....

If, as you say, you COULD care less, then please go right ahead and CARE LESS!!!!

 

[Southpaw]

I do the block like @fakin' the funk. I do it for post-op pain. My patients almost universally want to be asleep.

Also, my experience w ropi blocks is that they don’t last through the night into POD1. For that reason I like bupi + decadron.

 

[facted]

You are confusing the crap out of me. Can we talk like we are practicing at least in the current state of care. Cesarean epidurals occasionally have bicarb added, I agree. But this is a completely different situation. Don’t confuse the two. If your regional block for ankle surgery isn’t fully set up by the time they are prepp’d and draped even without bicarb then it isn’t gonna cut it.

So what I am gathering is that you are making statement about things that nobody does. And if they do then they need to reassess. I haven’t seen bicarb added to a regional block ever.

I would caution you and everyone here not to make statements that are irrelevant. And I would caution some young buck/buckettes as to taking what you read here as acceptable practice. Use sound reasoning.

Sorry to be so harsh but “come on man”.

Don't talk to me like I'm some sort of cowboy who has no idea what I'm doing. I've done north of a thousand blocks and have been out of training for quite a while now. I'm just telling you that in my residency program, we routinely added bicarb to mepiv in PNB to speed onset. I'm talking a BUSY place where we where we routinely used it, many different attendings, including a highly respected figure in the regional anesthesia world.

What exactly about this is irrelevant? It's actually based on evidence. There's also a section specifically talking about bicarb in blocks on NYSORA (basically the encyclopedia of regional anesthesia). https://www.nysora.com/local-anesthetics-clinical-pharmacology-and-rational-selection . There are also a few studies looking at this on pubmed.

Just because you've never done it or seen it means jack ****. There are lots of ways to do anesthesia, and this is just another technique.

My answer stands. If you want to speed up onset of your block, then try adding 1ml of bicarb per 10ml of mepiv. Or just do the block in holding and wait for it to set, or just put an LMA in. Lots of ways to get it done.

 

[psychbender]

I'm actually going to second Facted here. While I no longer do it, several attendings at my old residency program would regularly add bicarb to mepi for peripheral blocks that were intended as the primary anesthetic, and performed close to rolling back. Several of them also added it to rop, but it didn't seem to lead to significantly shorter onset of the block. I can only get bicarb in large bottles or amps, so cannot justify using a miniscule amount with a handful of blocks a day, and throwing the rest away. I don't think I even have mepivicaine on formulary at my new hospital, so it's a moot point for me now,

 

[Arch Guillotti]

My favorite popliteal block for surgical anesthesia is a spinal

Even if they are going home?

 

[ZzzPlz]

Even if they are going home?

3% nesicain spinal would work for that. I miss spinal lidocaine for these patients though.
In all reality though, I’d be more inclined to LMA + politeal block them if they’re looking to get home soon

My point was, if I’m trying to avoid GA on a patient, I’d rather go neuraxial and go from there


Edit: sp, 3% Nesacaine

 

[Mman]

I add Bicarb to every Mepi supraclav block I do for dialysis access. The block is usually starting to work before I am done documenting the block. We immediately roll back and they usually have a strong motor block before we are in the room. Works like a charm.

 

[dhb]

I'll go out on a limb and say there is no clinically relevant difference in block onset between local anesthetics if you do the block correctly.

 

[Mman]

I'll go out on a limb and say there is no clinically relevant difference in block onset between local anesthetics if you do the block correctly.

I will 100% disagree in my experience. Converting an epidural to a stat c-section? You have a much quicker time to comfort for incision with chloroprocaine or lidocaine + bicarb compared to something like Ropivacaine or Bupivacaine.

Now if you are referring to some place that moves at a slow pace and 10 or 15 minutes doesn't matter to anybody, well then it might not be clinically relevant to you, but the effect is clear.

 

[dhb]

I will 100% disagree in my experience. Converting an epidural to a stat c-section? You have a much quicker time to comfort for incision with chloroprocaine or lidocaine + bicarb compared to something like Ropivacaine or Bupivacaine.

Now if you are referring to some place that moves at a slow pace and 10 or 15 minutes doesn't matter to anybody, well then it might not be clinically relevant to you, but the effect is clear.

I was talking about PNBs

 

[Mman]

I was talking about PNBs

is there reason to believe there is a difference between an epidural and a PNB in terms of different local anesthetics setting up more quickly than others? If so, what mechanism do you propose?

 

[dhb]

is there reason to believe there is a difference between an epidural and a PNB in terms of different local anesthetics setting up more quickly than others? If so, what mechanism do you propose?

Well in OB 2min makes a difference while it doesn't for other cases.