Femoral nerve block and quadriceps weakness

[deleted126335]

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There are so many questions about the ADC block that the current state of literature hasn't even begun to address.

First off - please tell me where the ADC is. No ultrasound paper clearly defines this. Under dissection I can find it but how do I know where it is under ultrasound? And also, is the adductor canal 10cm long? Is it only 2cm long? Do you have to actually be under the adductor canal aponeurosis or just under the sartorius somewhere or just next to the artery? If the canal is 10cm long - does it make a difference if I am near the entrance or near the distal end? A block 10cm above the knee is different than mid leg, or 2/3s up the leg from the knee. Those could all potentially be called "adductor canal" blocks because the artery and nerve is under the sartorious muscle for most of that distance.

How about volume? There are studies to show that dye can spread all the way up the inguinal region with a certain amount of volume. Won't that affect outcome studies?

I prefer the the term perifemoral approach to saphenous rather than adductor canal as a name for the block.

Excellent Post! You have crystallized some of my own thoughts and doubts on the "adductor canal/low femoral/saphenous nerve" block.

 

[epidural man]

Looks solid. But again, there is no evidence that your "technique" is superior to my single shot ACB which lasts for 30 hours and costs $3.00.

Ditto for my Exparel ($280) vs. your catheter technique ($70).

A catheter technique with a disposable pump is way more than $280. Exparel will put the pump sales out of business.

I'm very surprised stryker or a similar company hasn't purchased Pacira yet.

I don't own stock either, but if I had a ton of money, I would have day-traded the SH&T out of that stock. It has significant resistance at 30 and support around 28.80 and it has bounced between these numbers for months! I could have scalped many-a-dollar. I suspect it will continue but I would be careful on the short side as I think the potential for the stock to break resistance and head much higher is there. I'm not sure of any catalyst coming up - perhaps buyout rumors - but it could go up higher. As far as falling, they DO loose money with each sell. It costs them more to produce each vial then they get in reimbursement - there is that to consider.

 

[deleted126335]

A catheter technique with a disposable pump is way more than $280. Exparel will put the pump sales out of business.

I'm very surprised stryker or a similar company hasn't purchased Pacira yet.

I don't own stock either, but if I had a ton of money, I would have day-traded the SH&T out of that stock. It has significant resistance at 30 and support around 28.80 and it has bounced between these numbers for months! I could have scalped many-a-dollar. I suspect it will continue but I would be careful on the short side as I think the potential for the stock to break resistance and head much higher is there. I'm not sure of any catalyst coming up - perhaps buyout rumors - but it could go up higher. As far as falling, they DO loose money with each sell. It costs them more to produce each vial then they get in reimbursement - there is that to consider.

1. Exparel has yet to be approved for blocks that involve motor nerves
2. It ain't cheap. Cost of production is high as you mentioned.
3. No studies yet showing superiority or parity for that matter to catheter based techniques.
4. in a world of ever more cost control, it might have to prove itself from a cost/benefit perspective against generic bupivicaine plus decadron single shot as opposed to continuous infusion.

 

[Mman]

Why would you care about FDA indication? You use a ton of drugs every day in the operating room that is not FDA approved. The FDA doesn't dictate physician practice.



Experal is FDA indicated for soft tissue infiltration. TAP is not a nerve block, it is a soft tissue infiltration. Just because ultrasound identifies the exact place for the soft tissue infiltration doesn't make it a nerve block. The reps are 100% within the bounds of the law on this.

FDA indication and using drugs off label...that's nice. I'm sure you have a long list of distinguished experts willing to back you up on it's common use in nerve blocks. I am just not aware of those people to defend me.

As for "TAP is not a nerve block", surely you jest. You'll find descriptions of the technique listed as a nerve block in text books. You won't find any source that states it is not a "nerve block". If you want to state it's just "soft tissue infiltration" then you can use that description for any nerve block. I mean that's all a femoral or supraclavicular block is, just infiltrating local in the soft tissues near the nerve.

 

[Mman]

I don't own stock either, but if I had a ton of money, I would have day-traded the SH&T out of that stock. It has significant resistance at 30 and support around 28.80 and it has bounced between these numbers for months!

Day trading sounds like solid financial advice. Of course it's always in hindsight that people mention how awesome that idea was.

 

[BLADEMDA]

FDA indication and using drugs off label...that's nice. I'm sure you have a long list of distinguished experts willing to back you up on it's common use in nerve blocks. I am just not aware of those people to defend me.

As for "TAP is not a nerve block", surely you jest. You'll find descriptions of the technique listed as a nerve block in text books. You won't find any source that states it is not a "nerve block". If you want to state it's just "soft tissue infiltration" then you can use that description for any nerve block. I mean that's all a femoral or supraclavicular block is, just infiltrating local in the soft tissues near the nerve.

The reps are still pushing me hard to use Exparel for all my TAP blocks. The regional/district sales guy is now pushing me as well. I guess the company feels pretty good about Exparel for tap blocks.

 

[BLADEMDA]

There are so many questions about the ADC block that the current state of literature hasn't even begun to address.

First off - please tell me where the ADC is. No ultrasound paper clearly defines this. Under dissection I can find it but how do I know where it is under ultrasound? And also, is the adductor canal 10cm long? Is it only 2cm long? Do you have to actually be under the adductor canal aponeurosis or just under the sartorius somewhere or just next to the artery? If the canal is 10cm long - does it make a difference if I am near the entrance or near the distal end? A block 10cm above the knee is different than mid leg, or 2/3s up the leg from the knee. Those could all potentially be called "adductor canal" blocks because the artery and nerve is under the sartorious muscle for most of that distance.

How about volume? There are studies to show that dye can spread all the way up the inguinal region with a certain amount of volume. Won't that affect outcome studies?

I prefer the the term perifemoral approach to saphenous rather than adductor canal as a name for the block.

Great questions. All I can tell you is that 15-20 mls works quite well for blocking the saphenous nerve and likely the posterior branch of the obturator nerve. As currently performed the Femoral nerve is spared completely and there is no significant quadriceps weakness.

The total knee patients seems to be satisfied with an adductor canal plus or minus a selective tibial block.

 

[epidural man]

FDA indication and using drugs off label...that's nice. I'm sure you have a long list of distinguished experts willing to back you up on it's common use in nerve blocks. I am just not aware of those people to defend me.

As for "TAP is not a nerve block", surely you jest. You'll find descriptions of the technique listed as a nerve block in text books. You won't find any source that states it is not a "nerve block". If you want to state it's just "soft tissue infiltration" then you can use that description for any nerve block. I mean that's all a femoral or supraclavicular block is, just infiltrating local in the soft tissues near the nerve.

Seriously you are defending the FDA? Wow....

And by the way, what nerve is blocked with that plane block?

 

[Mman]

Seriously you are defending the FDA? Wow....

And by the way, what nerve is blocked with that plane block?

Who is defending the FDA? Merely stating a fact.

As to "what nerve is blocked"...surely you don't think that a TAP block works by soft tissue diffusion like a skin wheal. It works by placing local around actual nerves such as the iliohypogastric that traverse the plane between the transversus abdominus and internal oblique.

 

[etudiante04]

Wow, I like this discussion thread. I guess all that gross anatomy lab tutoring was useful after all.

 

[Mofeen]

We have been placing AC catheters routinely at our main site for almost 16 months now after TKA. Anywhere from 2-6 per day. Usually pulled POD 2.

Most (90%) of the operative anesthetic is SAB. They then go to PACU and a catheter is placed post op, most of the time with residual motor and some sensory block post SAB. I have mixed feelings about performing them like this, but our surgeons want them out of the PACU ASAP and up to the floor with PT right after lunch. Due to multiple issues, mostly logistical, we cannot place the catheters pre op.

Just curious what your thoughts are?

Patients and surgeons alike love the catheters, as they have a high success rate and effective pain relief. The orthopods also use the peri articular cocktail or morphine/toradol/ropivacaine which covers posteriuor knee pain quite well.

 

[epidural man]

FDA indication and using drugs off label...that's nice.

Doing a THA (redo) tomorrow - gonna use tranexamic acid bolus and infusion. This is so far off FDA label, I hope I don't get in trouble!

I'll probably put fentanly in the epidural space as well - again SO FAR off FDA approval. I might go to jail.

A large percentage of the anesthesiologists will be using Sevo on some kiddos - again, way off FDA use. They better watch themselves!

 

[Mman]

Doing a THA (redo) tomorrow - gonna use tranexamic acid bolus and infusion. This is so far off FDA label, I hope I don't get in trouble!

I'll probably put fentanly in the epidural space as well - again SO FAR off FDA approval. I might go to jail.

A large percentage of the anesthesiologists will be using Sevo on some kiddos - again, way off FDA use. They better watch themselves!

Guess what, things like epidural fentanyl and sevoflurane for children have millions of safe uses documented. Exparel for a nerve block doesn't. Do whatever you want. I'm just pointing out that if you have a complication it's going to be hard to defend in a court. I'm not praising the FDA. I'm pointing out the thin limb you go out on with new drugs and using them for non approved indications. I'm still waiting to hear what you think you are doing with a TAP block that doesn't involve a nerve.


Do whatever the hell you want. You are a doctor so use your judgment. I trust you don't make any clinical decisions off posts in an anonymous internet forum because that would be wildly inappropriate.

 

[BLADEMDA]

Guess what, things like epidural fentanyl and sevoflurane for children have millions of safe uses documented. Exparel for a nerve block doesn't. Do whatever you want. I'm just pointing out that if you have a complication it's going to be hard to defend in a court. I'm not praising the FDA. I'm pointing out the thin limb you go out on with new drugs and using them for non approved indications. I'm still waiting to hear what you think you are doing with a TAP block that doesn't involve a nerve.


Do whatever the hell you want. You are a doctor so use your judgment. I trust you don't make any clinical decisions off posts in an anonymous internet forum because that would be wildly inappropriate.

Exparel is perfectly safe to use for sensory blocks. I've performed about 100 so far with Exparel and have had no complications.

The company Is promoting its use for TAP blocks so I'm not concerned about going out on a limb by using it.

 

[BLADEMDA]

We have been placing AC catheters routinely at our main site for almost 16 months now after TKA. Anywhere from 2-6 per day. Usually pulled POD 2.

Most (90%) of the operative anesthetic is SAB. They then go to PACU and a catheter is placed post op, most of the time with residual motor and some sensory block post SAB. I have mixed feelings about performing them like this, but our surgeons want them out of the PACU ASAP and up to the floor with PT right after lunch. Due to multiple issues, mostly logistical, we cannot place the catheters pre op.

Just curious what your thoughts are?

Patients and surgeons alike love the catheters, as they have a high success rate and effective pain relief. The orthopods also use the peri articular cocktail or morphine/toradol/ropivacaine which covers posteriuor knee pain quite well.

Nice technique and I congratulate your entire team on that approach. As long as your postop placement of catheters are technically feasible to perform I would continue placing them under SAB in the PACU.

Again, nice work in rendering state of the art care to your patients.

 

[Mman]

Exparel is perfectly safe to use for sensory blocks. I've performed about 100 so far with Exparel and have had no complications.

The company Is promoting its use for TAP blocks so I'm not concerned about going out on a limb by using it.

That's fine and dandy. In most of the US they are legally prohibited from promoting it for that purpose. If/when a complication arises, there will be a lawsuit and somebody will be defending themselves. Not a lot of expert witnesses lining up to defend you at this point.

 

[epidural man]

I'm still waiting to hear what you think you are doing with a TAP block that doesn't involve a nerve.

You first...I'm still waiting for the name of the nerve(s) that are blocked with a TAP for let's say a midline incision just above the umbilicus.

And when did I say it didn't involve a nerve? What local anesthetic placed anywhere in the body (except IV) doesn't block a nerve? The whole function of sodium channel blockers are on nerves, big or small, some named, some unnamed. I'm not sure what that has to do with anything.

 

[sevoflurane]

Ant. rami of spinal nerves T7-L1. L1 being ilioinguinal and iliohypogastric.

If you look closely, you can sometimes see these nerves.

 

[Mman]

You first...I'm still waiting for the name of the nerve(s) that are blocked with a TAP for let's say a midline incision just above the umbilicus.

And when did I say it didn't involve a nerve? What local anesthetic placed anywhere in the body (except IV) doesn't block a nerve? The whole function of sodium channel blockers are on nerves, big or small, some named, some unnamed. I'm not sure what that has to do with anything.

 

[BLADEMDA]

That's fine and dandy. In most of the US they are legally prohibited from promoting it for that purpose. If/when a complication arises, there will be a lawsuit and somebody will be defending themselves. Not a lot of expert witnesses lining up to defend you at this point.

2 more Exparel Tap blocks today and counting. Still no reported complications from the Exparel by me or anyone else for that matter.