Failed sciatic (popliteal) block

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dhb said:
Well in OB 2min makes a difference while it doesn't for other cases.
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depends on how fast your ORs move. In a big academic medical center with 45 minute room turnovers, no it doesn't make a difference. In the real world where you can have 15 minute room turnovers it can make a difference. And the difference is > 2 minutes.
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Mman said:
depends on how fast your ORs move. In a big academic medical center with 45 minute room turnovers, no it doesn't make a difference. In the real world where you can have 15 minute room turnovers it can make a difference. And the difference is > 2 minutes.
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I figured he was talking about block setup time for a stat section
 
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Mman said:
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?
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Yes. In the PNB you are injecting right in the sheath. In the epidural its a large area and the medicine has to "seep" to the target area.. How long does it take a bupivicaine spinal to start acting?

There is no reason to use anything other than bupi in a a PNB even if you are immediately prepping and draping
 
Hoya11 said:
There is no reason to use anything other than bupi in a a PNB even if you are immediately prepping and draping
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Do people still use bupivacaine for PNBs routinely? I haven't seen that in a while.
 
facted said:
I do. What do you use?
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Ropivacaine. It's what we used 12 years ago in residency. The people we've hired recently have barely ever used Bupivacaine. I mean I've used it, just like <10% of the time. I assumed it was going away.
 
Mman said:
Ropivacaine. It's what we used 12 years ago in residency. The people we've hired recently have barely ever used Bupivacaine. I mean I've used it, just like <10% of the time. I assumed it was going away.
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Yea, we really never used ropi in residency so I continue with bupi. There are some studies that show it doesn't last as long as bupi as well, plus last time I checked there was quite a price difference. Also, with ultrasound blocks, I'm not really worried about LAST though of course anything can happen....
 
Noyac said:
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.
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Don’t you feel this shortens the duration of analgesia? The mixing I mean. I’m thinking with straight ropivacaine it’s closer to 30min to setup though.
 
Hoya11 said:
Yes. In the PNB you are injecting right in the sheath. In the epidural its a large area and the medicine has to "seep" to the target area.. How long does it take a bupivicaine spinal to start acting?

There is no reason to use anything other than bupi in a a PNB even if you are immediately prepping and draping
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Not so if you are using the block as a primary anesthetic.
 
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kmurp said:
Don’t you feel this shortens the duration of analgesia? The mixing I mean. I’m thinking with straight ropivacaine it’s closer to 30min to setup though.
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Funny you ask this now. I don’t usually follow up with pts to ask how long the block lasted. But I will tell you that the surgeons and PA’s say that my blocks work extremely well.
I have stated that all I really want from a block is to get the pt through the first night. I am not interested in much more than 24 hrs.
But I say that it is funny you ask this today because just yesterday one of my staff for which I have done many anesthetics on her and her family asked if I could tell my partner how I do my blocks since I am out of town for her up coming foot surgery. So,I started questioning her about the length of the blocks and she said it lasted an easy 30 hrs. Plus I did her daughters wrist surgery a month ago where I mixed mepiv and ropiv. She remained awake for the entire case only getting 2mg verses for the block. That one lasted at least 30 hrs as well. So no I don’t think it is shortening the block. Actually I wouldn’t mind if it did.
 
Noyac said:
Funny you ask this now. I don’t usually follow up with pts to ask how long the block lasted. But I will tell you that the surgeons and PA’s say that my blocks work extremely well.
I have stated that all I really want from a block is to get the pt through the first night. I am not interested in much more than 24 hrs.
But I say that it is funny you ask this today because just yesterday one of my staff for which I have done many anesthetics on her and her family asked if I could tell my partner how I do my blocks since I am out of town for her up coming foot surgery. So,I started questioning her about the length of the blocks and she said it lasted an easy 30 hrs. Plus I did her daughters wrist surgery a month ago where I mixed mepiv and ropiv. She remained awake for the entire case only getting 2mg verses for the block. That one lasted at least 30 hrs as well. So no I don’t think it is shortening the block. Actually I wouldn’t mind if it did.
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That’s an interesting story. I too ,don’t really know how long my blocks last and have the same goal as you. I had read that there was no advantage in onset time and a shorter duration The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene bl... - PubMed - NCBI
But this study was ISB which sets up quicker that popliteal at least for me.
 
Noyac said:
Funny you ask this now. I don’t usually follow up with pts to ask how long the block lasted. But I will tell you that the surgeons and PA’s say that my blocks work extremely well.
I have stated that all I really want from a block is to get the pt through the first night. I am not interested in much more than 24 hrs.
But I say that it is funny you ask this today because just yesterday one of my staff for which I have done many anesthetics on her and her family asked if I could tell my partner how I do my blocks since I am out of town for her up coming foot surgery. So,I started questioning her about the length of the blocks and she said it lasted an easy 30 hrs. Plus I did her daughters wrist surgery a month ago where I mixed mepiv and ropiv. She remained awake for the entire case only getting 2mg verses for the block. That one lasted at least 30 hrs as well. So no I don’t think it is shortening the block. Actually I wouldn’t mind if it did.
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Very surprised you are getting 30h for an upper extremity block with 0.25% bupivacaine.
 
dhb said:
Very surprised you are getting 30h for an upper extremity block with 0.25% bupivacaine.
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He said ropi/mepi which makes it even more surprising he’s getting 30h. I’ve done a lot of blocks (not Blade numbers of course...) and plenty with Ropi and Mepi and I’ve never gotten 30h. Not one single time. In fact I’d be concerned my injection was intraneural if I was at 30h w ropi or mepi. In my experience the only block that lasts consistently up to and occasionally past 24h is bupi + dex (upper extrem). I do not put dex in lower extremity blocks however due to concerns of prolonged block/neuropraxia.
 
Southpaw said:
He said ropi/mepi which makes it even more surprising he’s getting 30h. I’ve done a lot of blocks (not Blade numbers of course...) and plenty with Ropi and Mepi and I’ve never gotten 30h. Not one single time. In fact I’d be concerned my injection was intraneural if I was at 30h w ropi or mepi. In my experience the only block that lasts consistently up to and occasionally past 24h is bupi + dex. I do not put dex in lower extremity blocks however due to concerns of prolonged block/neuropraxia
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Agree.
 
Southpaw said:
He said ropi/mepi which makes it even more surprising he’s getting 30h. I’ve done a lot of blocks (not Blade numbers of course...) and plenty with Ropi and Mepi and I’ve never gotten 30h. Not one single time. In fact I’d be concerned my injection was intraneural if I was at 30h w ropi or mepi. In my experience the only block that lasts consistently up to and occasionally past 24h is bupi + dex (upper extrem). I do not put dex in lower extremity blocks however due to concerns of prolonged block/neuropraxia.
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What about iv dex? That's all the rage from what i hear, although i think the last time someone brought it up the consensus was that its not that great
 
Psai said:
What about iv dex? That's all the rage from what i hear, although i think the last time someone brought it up the consensus was that its not that great
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I don’t think it works. Doesn’t prolong a bupi block like perineural dex, that’s for sure.

P.S. you’re still a resident right? I don’t mean to be cynical but never once did any of my attendings actually pick up the phone and call a patient POD1. It’s only by doing that you learn what does and doesn’t work. And it’s also good PR.
 
kmurp said:
Not so if you are using the block as a primary anesthetic.
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Disagree. I do it a lot. From the time my needle is out to the time prepping and draping and surgery starting is 10 mins, plenty of cases done under light mac with just bupi, youve just got to inject in the sheath
 
Southpaw said:
I don’t think it works. Doesn’t prolong a bupi block like perineural dex, that’s for sure.

P.S. you’re still a resident right? I don’t mean to be cynical but never once did any of my attendings actually pick up the phone and call a patient POD1. It’s only by doing that you learn what does and doesn’t work. And it’s also good PR.
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The trick for me to learn what works best is rounding on inpatients the next day. At big academic places this can be tough since there is often a separate acute pain team and you have to go above and beyond to check on things. I don’t hear how outpatients’ blocks worked out unless it was no bueno. or if they come back for another procedure later.

The block duration seems to get a little (lot) inflated on anonymous online forums
 
ZzzPlz said:
The trick for me to learn what works best is rounding on inpatients the next day. At big academic places this can be tough since there is often a separate acute pain team and you have to go above and beyond to check on things. I don’t hear how outpatients’ blocks worked out unless it was no bueno. or if they come back for another procedure later.

The block duration seems to get a little (lot) inflated on anonymous online forums
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Lots of things get wildly inflated on this forum. But yes, definitely block duration (especially exparel) is one of them.
 
I’ve had patients (a nurse and a surgeon) tell me they didn’t need pain meds until noon on pod1 after a 7am rotator cuff repair. I use bupiv .25%x30ml for ISBs and give IV dex to just about everyone. I wonder if it could be a volume effect or maybe these particular patients are just tough.
 
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Psai said:
What about iv dex?
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I don't think it works - at least not near anywhere as good as perineural dex. That being said, I'm gonna give it anyways for nausea so I just go ahead give it along with the Midaz when I do the block (in addition to the perineurial dex). I figure it can't hurt.
 
Southpaw said:
He said ropi/mepi which makes it even more surprising he’s getting 30h. I’ve done a lot of blocks (not Blade numbers of course...) and plenty with Ropi and Mepi and I’ve never gotten 30h. Not one single time. In fact I’d be concerned my injection was intraneural if I was at 30h w ropi or mepi. In my experience the only block that lasts consistently up to and occasionally past 24h is bupi + dex (upper extrem). I do not put dex in lower extremity blocks however due to concerns of prolonged block/neuropraxia.
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Well he said he mixed 0.5% bupi so that's why i said 0.25% bupi 😉
 
Noyac said:
Ok just be sure I wasn’t crazy I mixed mepiv with ropiv today and it lasted two days from now.
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I'm pretty agressive with the needle (not so much on volume) but i've never had a 48 block.
How much volume are you using?
48h for 0.25% bupivacaine is clearly unusual, how much dex?
 
dhb said:
I'm pretty agressive with the needle (not so much on volume) but i've never had a 48 block.
How much volume are you using?
48h for 0.25% bupivacaine is clearly unusual, how much dex?
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You’re more impressed by his block duration than his ability to see into the future???
 
So I've had two popliteal blocks fail recently for ankle surgeries. I was at the bifurcation and injected between the nerves. I didn't feel a pop though, maybe I was just outside the sheath? The patient had some numbness lateral and dorsal but not plantar. It's not the local because the expiration date is a few years away and the adductor seemed work fine. Any suggestions? I've been doing them supine and haven't had issues before but now I'm considering turning them prone for the block.
 
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GassYous said:
So I've had two popliteal blocks fail recently for ankle surgeries. I was at the bifurcation and injected between the nerves. I didn't feel a pop though, maybe I was just outside the sheath? The patient had some numbness lateral and dorsal but not plantar. It's not the local because the expiration date is a few years away and the adductor seemed work fine. Any suggestions? I've been doing them supine and haven't had issues before but now I'm considering turning them prone for the block.
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Prone is amateur hour. You need to "pop" into the sheath.
 
GassYous said:
So I've had two popliteal blocks fail recently for ankle surgeries. I was at the bifurcation and injected between the nerves. I didn't feel a pop though, maybe I was just outside the sheath? The patient had some numbness lateral and dorsal but not plantar. It's not the local because the expiration date is a few years away and the adductor seemed work fine. Any suggestions? I've been doing them supine and haven't had issues before but now I'm considering turning them prone for the block.
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Only Blade's blocks never fail. The rest of us mere mortals have a failure every now and then.
 
GassYous said:
So I've had two popliteal blocks fail recently for ankle surgeries. I was at the bifurcation and injected between the nerves. I didn't feel a pop though, maybe I was just outside the sheath? The patient had some numbness lateral and dorsal but not plantar. It's not the local because the expiration date is a few years away and the adductor seemed work fine. Any suggestions? I've been doing them supine and haven't had issues before but now I'm considering turning them prone for the block.
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you got any pictures?
 
GassYous said:
So I've had two popliteal blocks fail recently for ankle surgeries. I was at the bifurcation and injected between the nerves. I didn't feel a pop though, maybe I was just outside the sheath? The patient had some numbness lateral and dorsal but not plantar. It's not the local because the expiration date is a few years away and the adductor seemed work fine. Any suggestions? I've been doing them supine and haven't had issues before but now I'm considering turning them prone for the block.
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Go higher than the bifurcation, way higher.

I do mine lateral. No one has to hold the leg.

Use a nerve stimulator.

Pop into the sheath. Get Twitch. Inject.

Before you inject all of it, buzz around the area with the stimulator to make sure nothing is still active.

This can be a tricky block between the sheath and the bifurcation, lots of opportunities to end up with patchiness

I have found that going higher and using the stim drastically improves success
 
I second going higher than the bifurcation, I inject usually just above the bifurcation, maybe 1-2 cm. Have to feel a pop into the stealth, it is the biggest indicator of success for a block in my opinion. After injecting, scan down the nerve to see local spread at the bifurcation to confirm its in the sheath and around the nerve.
 
any reason why go above bifurcation should be better? the local should spread above and below anyway after block and you scan it..

it would theoretically make sense if below bifurcation works better/faster due to more surface area
 
anbuitachi said:
any reason why go above bifurcation should be better? the local should spread above and below anyway after block and you scan it..

it would theoretically make sense if below bifurcation works better/faster due to more surface area
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Less needle redirects to cover the whole thing.
 
SaltyDog said:
Training wheels.
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Yeah that sounds like a good plan for someone who is humble enough to admit they are having failed blocks and is trying to improve consistency and technique... otherwise what exactly is being proposed as a new technique change for this person asking for help?

I do lots of pops for complex outpatient knee procedures, so they are done very high at the mid thigh, depth is 4.9cm, when the BMI is 45 I am not ashamed to use the stimulator to get it done quickly and effectively in combo with the US.

Pop is the only block where I will use it due to the sheath and bifurcation inconsistencies I have found after doing many many with US alone.
 
Go at bifurcation where there is like <0.5cm between the nerves. Start so that the needle is anterior to the common peroneal (since probe is sitting on posterior thigh, on the US image it’ll appear below the nerve) and push the CP down posteriorly, bisect the two branches, and end up posterior to (on US, on top of) tibial. Inject while retracting the needle and see the nerves start to get donuted out with local. The rest is just injecting around them.
 
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