Femoral block in ambulatory cases

[Dinkyconductor]

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Does anyone do femoral blocks in patients who are going home the same day? It would be nice to do them for, say, ACL repairs, or in some instances for arthroscopic knee cases.

But, I've never done it, since I've been worried about sending them home with a blocked leg...they could try to stand on it and fall. In fact, I never do lower extremity blocks at all on patients going home the same day.

Of course, I send people home after IS/axillary blocks all the time, but falling is the issue I'm worried about.

 

[BISof60]

I'm in residency. We have a surgical center where femoral nerve blocks are done routinely for knee ligament repairs and then pt sent home same day.

The pt's are released with their knees in the big orthocare postop braces so they're not walking around much. Phone call from nurse the next day to follow-up on block. Runs like clockwork.

I don't know the implications for the PP world, but no issues with this system in academia....

 

[Planktonmd]

Does anyone do femoral blocks in patients who are going home the same day? It would be nice to do them for, say, ACL repairs, or in some instances for arthroscopic knee cases.

But, I've never done it, since I've been worried about sending them home with a blocked leg...they could try to stand on it and fall. In fact, I never do lower extremity blocks at all on patients going home the same day.

Of course, I send people home after IS/axillary blocks all the time, but falling is the issue I'm worried about.

I do femoral blocks for out patients but I only use Bupivacaine 0.25% and I inform them to be careful if they need to ambulate.
No problems so far.

 

[pmichaelmd]

Does anyone do femoral blocks in patients who are going home the same day? It would be nice to do them for, say, ACL repairs, or in some instances for arthroscopic knee cases.

But, I've never done it, since I've been worried about sending them home with a blocked leg...they could try to stand on it and fall. In fact, I never do lower extremity blocks at all on patients going home the same day.

Of course, I send people home after IS/axillary blocks all the time, but falling is the issue I'm worried about.

We do single shot femorals with 0.5% ropivacaine and inform them that they'll have difficulty walking for 12-18 hours, so keep the brace on and don't try to ambulate without assistance before then. Follow up by phone is a great idea, just to make sure.

 

[urge]

I agree with following up on pts is a good idea. But, will it make a difference? "Hey buddy, it's your friendly anesthesiologist. I'm calling to find out if you tried to walk on a weak knee, fell, and broke your neck. Did you? No, good- bye. Yes, well I guess I should let my lawyer know." Someone somewhere sometime is going to fall and the anesthesiologist will be sued. That's the way the cookie crumbles.

 

[Dejavu]

We do a bunch of ACL repairs (by scope) with a home-going femoral catheter and a disposable pump full of bupivacaine 0.1% at 10cc/hour. After two days, the pt removes it themselves. They have the number of our Acute Pain Service to call if they have questions. Also given teaching by PACU nursing staff before discharge. Been doing this for about 3 years now. Works great, very satisfied patients.

 

[BobBarker]

I had a femoral block for my ACL. The patient is just going to sit in a recliner with his ice machine for the first day home anyways..

 

[Gator05]

Are you all also sending folks home with catheters for shoulders? Anything else?

 

[Arch Guillotti]

We do shoulders, subgluteals, rarely an inraclavicular. No femorals.

 

[psychbender]

I had a femoral block (.25% bupivicaine...I was curious and asked) for my ACL reconstruction and was sent home that day. I'm a stuborn fool and tried to walk on it, rather successfully I might add, but managed not to break myself or anyone else in the process.

 

[Noyac]

I vaguely remember the title of an article that described how common it was for people with LE blocks to fall and hurt themselves when they were place for outpatient surgery. I didn't read it.
I do a fem/sciatic block for ACL's and send them home. They seem to be pretty aware that their leg won't support them when both blocks are in place.

 

[drccw]

The Virgina Mason apparently has an outpatient catheter service where they will place either femoral or interscalene blocks, keep them overnight and send the patient home the next day with a Stryker pump. These are all cases in which the patient would be going home the next day anyway (with narcs). Every day the resident assigned to the rotation will telephone the patient and see how they are doing. Around day 3 they walk them through removal of the catheter. In my mind i'm not so keen to place these outpatient catheters because that means you own the patient. Anything screws up and you're responsible as well. Too much liability in my mind and not enough benefit.

Oh and they are using 17G tuohy needles with ultrasounds guidnace to place epidural catheters. i much prefer smaller, blunt tipped needles for catheter placement but that's my opinion

 

[Salt Creep]

Dejavu 07:56 AM 04-03-2008
We do a bunch of ACL repairs (by scope) with a home-going femoral catheter and a disposable pump full of bupivacaine 0.1% at 10cc/hour. After two days, the pt removes it themselves. They have the number of our Acute Pain Service to call if they have questions. Also given teaching by PACU nursing staff before discharge. Been doing this for about 3 years now. Works great, very satisfied patients.

I had ACL and meniscus repair in '05 and had a femoral block, went home a few hours postop with catheter in the joint, instructed to remove it in 2 days or at orthopod f/u visit in 3 days.

Worked extremely well, and I saw just how well when the block wore off. I had the big ELS splint & was supposed to be non-weight bearing for the meniscus anyway.

 

[Gator05]

The Virgina Mason apparently has an outpatient catheter service where they will place either femoral or interscalene blocks, keep them overnight and send the patient home the next day with a Stryker pump. These are all cases in which the patient would be going home the next day anyway (with narcs). Every day the resident assigned to the rotation will telephone the patient and see how they are doing. Around day 3 they walk them through removal of the catheter. In my mind i'm not so keen to place these outpatient catheters because that means you own the patient. Anything screws up and you're responsible as well. Too much liability in my mind and not enough benefit.

We do something similiar. We'll put a catheter in at our ASC, and follow the patient via telephone. If the pump runs out, they come back for refill. Most patients are returning next door anyway for PT, so if questions we ask them to pop over and take a look for ourselves. Might be less than ideal for residents, but the patients love the catheters.

By the way, Boezaart et al did a study in Iowa looking at the economics of having home health nurses manage these catheters vs keeping the patients in house for pain mgmt. Savings >1000 dollars per day per patient. Still can't get folks to pay for home health nurses to manage this. Nuts. Seems like an obvious move: better pain control, less money, possibly less hospital-acquired complications (my opinion), and happier patient. I'd look for these for THA/TKA/TSA in the next 5 years at an ASC. For reference, see Ilfeld et al.