Femoral nerve block right after spinal placement

[pencan]

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If you gave a peron a spinal anesthetic (standard Bupivacaine) and say about 30 minutes later attempted to place a femoral nerve block with ultrsound guidance and a nerve stimulator. would you see a positive muscle twitch from the nerve stimulation? I believe you would since you are directly stimulating the nerve verses stimulation that has to access the CNS. My fellow classmate believes you would not since the spinal anesthetic is blocking any electrical signal. Who is right?

 

[dhb]

Yes you would see a twitch but the patient will not be able to indicate pain upon injection.

 

[dfk]

Yes you would see a twitch but the patient will not be able to indicate pain upon injection.

i'm gonna play dumb here for a minute, but if you block sodium channels and propagation (generalized), would there really be stimulation along a branch? what i think is funny is that when blocks are placed (via stim +/- US), we rarely if ever check deep stim well after 'SAB' has been placed. we go for sensory level. good thread/inquiry for sure.

 

[Noyac]

i'm gonna play dumb here for a minute, but if you block sodium channels and propagation (generalized), would there really be stimulation along a branch? what i think is funny is that when blocks are placed (via stim +/- US), we rarely if ever check deep stim well after 'SAB' has been placed. we go for sensory level. good thread/inquiry for sure.

I don't think you are playing.

Let me ask you, what Na channels are blocked after SAB? Where are they? Then think about where you are stimulating when doing a FNB.

 

[dhb]

if you block sodium channels and propagation (generalized)

Then you're probably dead.

 

[pgg]

i'm gonna play dumb here for a minute, but if you block sodium channels and propagation (generalized), would there really be stimulation along a branch? what i think is funny is that when blocks are placed (via stim +/- US), we rarely if ever check deep stim well after 'SAB' has been placed. we go for sensory level. good thread/inquiry for sure.

What?

Are you routinely doing PNBs after spinals?

What is "check deep stim" and why would you do it after a spinal?

And what do you mean by "block sodium channels and propagation (generalized)"? You realize that the local anesthetic administered for a spinal goes in the spine, right?

 

[BLADEMDA]

No indication for femoral block "right" after spinal. Either place the block prior to SAB or after sensory function has returned to the leg.

However, it can be done this way and I have seen it. If there is a complication (even using U/S guidance) that technique is open for criticism.

By the way the nerve stimulator will work properly with GA, Epidural or Spinal.

 

[ChrisA]

If you are looking for additional block post op for pain either do before spinal, wait till spinal is gone or do a Fascia Iliaca Block which can be done safely without a Nerve stim or US...

 

[pgg]

If you are looking for additional block post op for pain either do before spinal, wait till spinal is gone or do a Fascia Iliaca Block which can be done safely without a Nerve stim or US...

I've seen people do fascia iliaca blocks in asleep kids using a nerve stim. They use landmarks for placing the needle, and the stim to ensure there is NOT a twitch before injecting. The idea being that if you get a twitch, you can move the needle before injecting.

 

[BLADEMDA]

It is more common practice (standard of care even?) to do nerve blocks under GA on children. While in the adult population an awake patient is preferential for "feedback" the pediatric population is different and as such, the published data strongly suggests a high safety profile on "anesthetized" children.

 

[periopdoc]

Blade and ChrisA


Can you give me any data to support your contention that PNB is safer in a awake or sedated patient with normal sensation than in a patient who is under GA or spinal?

At one of my institutions we do 99.9% of our adult blocks under GA. Been doing it this way for years. More total blocks than any single practicioner is likely to do in a career. No nerve injury yet.

The only data that exists (so far) is in pediatric patients and supports the safety of PNBs in anesthetised patients. (stay tuned)

-pod

 

[ChrisA]

Hey Peri

Excellent point. I agree, the literature currently suggests that you can do a PNB under GA with just about every patient. I think that doing it on the awake patient just adds an extra layer of protection where the patient can be used to comment on sensations and pain etc. I think this most recent article I read (see below), while about peds, absolutely can be applied to adults.


Having said that, I was mentioning doing the FNB either before or after spinal which would be a MAC case then. But the point you are making is well taken.

PEDIATRIC ANESTHESIOLOGY

The Relationship Between Current Intensity for Nerve Stimulation and Success of Peripheral Nerve Blocks Performed in Pediatric Patients Under General Anesthesia

Harshad Gurnaney, MBBS, Arjunan Ganesh, MBBS, and Giovanni Cucchiaro, MD [SIZE=-1] From the Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. [/SIZE]
[SIZE=-1]Address e-mail to [email protected].[/SIZE]

Blade and ChrisA


Can you give me any data to support your contention that PNB is safer in a awake or sedated patient with normal sensation than in a patient who is under GA or spinal?

At one of my institutions we do 99.9% of our adult blocks under GA. Been doing it this way for years. More total blocks than any single practicioner is likely to do in a career. No nerve injury yet.

The only data that exists (so far) is in pediatric patients and supports the safety of PNBs in anesthetised patients. (stay tuned)

-pod

 

[drccw]

Blade and ChrisA


Can you give me any data to support your contention that PNB is safer in a awake or sedated patient with normal sensation than in a patient who is under GA or spinal?

At one of my institutions we do 99.9% of our adult blocks under GA. Been doing it this way for years. More total blocks than any single practicioner is likely to do in a career. No nerve injury yet.

The only data that exists (so far) is in pediatric patients and supports the safety of PNBs in anesthetised patients. (stay tuned)

-pod

Some would suggest that certain PNB under GA are unsafe... There will never be a randomized controlled trial though to produce data.. but for certain there are case reports that suggest ISB under GA is unsafe.

http://journals.lww.com/anesthesiol...=2000&issue=12000&article=00033&type=fulltext

as for standard of care in the adult population- I am going to have to say that doing PNBs under GA is not standard of care in adults. And, I bet one would be hard pressed to find someone who would argue to a jury that it is acceptable. Your institution may need to adjust its training procedures- because most people out in the real world are not putting their blocks in under GA.

drccw

 

[dhb]

Your institution may need to adjust its training procedures- because most people out in the real world are not putting their blocks in under GA.

drccw

Is this true?
I don't see performing PNB with US guidance for patients under GA as something totally reckless. Current evidence points more to injection pressure as a cause of injury rather than intra or extraneural injection.

 

[periopdoc]

Some would suggest that certain PNB under GA are unsafe...

Some would suggest, but I am interested in data. We have data demonstrating the safety in pediatric patients. I am asking if in fact adults are really just big kids.

There will never be a randomized controlled trial though to produce data..

I would not be so certain. As I alluded to in my first post there is at least one institution that has enough retrospective safety data on blocks done under GA to allow for a RCT... stay tuned...

but for certain there are case reports that suggest ISB under GA is unsafe. http://journals.lww.com/anesthesiol...=2000&issue=12000&article=00033&type=fulltext

May I recommend this article, or this article, or this article, or... All describing complications of interscalene block in awake/ sedated patients. The only thing that all of these blocks have in common is that none were done with U/S. Am I saying that they can only be done safely with U/S? Absolutely not. I am just saying that there are other factors that are much more likely to have caused the problem than if the patient was under GA or not. Given that there are no pain receptors in the spinal cord itself, I am not certain whether it would have made a difference in these cases if the patients were not under GA. It probably had more to do with bad luck or the skill of the operator or both.

as for standard of care in the adult population- I am going to have to say that doing PNBs under GA is not standard of care in adults. And, I bet one would be hard pressed to find someone who would argue to a jury that it is acceptable.

I never said it was standard of care (whatever that term really means). There is no resident here that is not aware that this falls well outside the mainstream of what is happening at other non-pediatric institutions. I can think of two individuals, who have previously served as expert witnesses, who, given our safety record, would be willing to argue to a jury that it is in fact acceptable even if it is not the norm.

Your institution may need to adjust its training procedures- because most people out in the real world are not putting their blocks in under GA.

So when academic institutions perpetuate "academic myth" they need to get with the times, but when they try to advance the field by examining new techniques they have to be brought back in line? Man there really is no winning for those academic folks is there.



- pod

 

[OB1🤙]

It is my opinion (and nothing more) that this is another useful arena for ultrasound guidance, which objectively confirms extraneural injection.

 

[2win]

It is my opinion (and nothing more) that this is another useful arena for ultrasound guidance, which objectively confirms extraneural injection.

Yep - I am doing US guided fem. catheters under SAB. There is no need of nerve stim and this is the easiest procedure ever. Take a look at this website
www.neuraxiom.com. I think it is excellent and helpful.

 

[BLADEMDA]

It is my opinion (and nothing more) that this is another useful arena for ultrasound guidance, which objectively confirms extraneural injection.

Alright. How about a real world case? A colleague of mine was doing an U/S guided block. After the first 3 ml's of local the patient screamed like he had been shot. This patient was heavily sedated but not under GA. It turns out that the provider had lost track of the tip of the needle and was at least perineural. Needless to say the needle was readjusted a few MM and the block completed without any post op complications.

While you superstuds think that U/S is perfect it isn't-yet. The pictures can be grainy and the needle difficult to visualize 100% of the time. Is U/S safe? Yes. But, does it GUARANTEE 100% no complications ever? No. Of Course, the equipment is only as good as the operator.

Blade

 

[SleepIsGood]

Alright. How about a real world case? A colleague of mine was doing an U/S guided block. After the first 3 ml's of local the patient screamed like he had been shot. This patient was heavily sedated but not under GA. It turns out that the provider had lost track of the tip of the needle and was at least perineural. Needless to say the needle was readjusted a few MM and the block completed without any post op complications.

While you superstuds think that U/S is perfect it isn't-yet. The pictures can be grainy and the needle difficult to visualize 100% of the time. Is U/S safe? Yes. But, does it GUARANTEE 100% no complications ever? No. Of Course, the equipment is only as good as the operator.

Blade

Blade is 100% correct on this.

Alain Borgeat, huge regionalist in Switzerland is against ultrasound use and the inability to not clearly see the needle tip is one of his contentions. There was a famous pic (that I can not seem to locate now) that showed how on one view the needle tip appears to be extraneural, however, when rotating, or tilting the ultrasound transducer, the needle was INTRAneural.

For this reason, I think it's advisable to have some sort of feedback from the patient. This way he/she can communicate to you if the needles where it shouldnt be.

 

[OB1🤙]

I never said u/s is perfect. I said useful.

As technology improves- better ultrasound images, echogenic needle tips, you shouldn't be losing the tip, especially if you're in plane for the whole insertion, and you watch your local as you inject. If you're injecting and you can't see local where you think your needle tip is, well, all I have to say is it would have been interesting to see what exactly his image was as he injected that 3 ccs.

I'm not saying u/s is a magic bullet and that we should all be adopting this right now, but I can easily foresee PNBs becoming ubiquitous in adults under GA with ultrasound guidance in the future.

Finally, nobody denies that success will be highly dependent on the skill of the operator. All this means is we need to have skilled operators.

 

[BLADEMDA]

I never said u/s is perfect. I said useful.

As technology improves- better ultrasound images, echogenic needle tips, you shouldn't be losing the tip, especially if you're in plane for the whole insertion, and you watch your local as you inject. If you're injecting and you can't see local where you think your needle tip is, well, all I have to say is it would have been interesting to see what exactly his image was as he injected that 3 ccs.

I'm not saying u/s is a magic bullet and that we should all be adopting this right now, but I can easily foresee PNBs becoming ubiquitous in adults under GA with ultrasound guidance in the future.

Finally, nobody denies that success will be highly dependent on the skill of the operator. All this means is we need to have skilled operators.

Sure I agree. But, in today's world with today's U/S the patient can provide value feedback that MAY prevent a serious complication. Today's needles are 100% echogenic and the tip may be lost at times. Why not err on the side of safety in adults? At least for now anyway. I know that case I presented was anectodal but his scream prevented serious injury.

Remember that case the next time you don't see the tip well and wait for the donut sign. Also, remember that current equipment is LIMITED so perhaps awake is best for 2009.

 

[2win]

Sure I agree. But, in today's world with today's U/S the patient can provide value feedback that MAY prevent a serious complication. Today's needles are 100% echogenic and the tip may be lost at times. Why not err on the side of safety in adults? At least for now anyway. I know that case I presented was anectodal but his scream prevented serious injury.

Remember that case the next time you don't see the tip well and wait for the donut sign. Also, remember that current equipment is LIMITED so perhaps awake is best for 2009.

Blade - u know, patient response means almost nothing....You can penetrate the nerve and there is no response. Guided injections are the future (if not the present...) for regional. Use or not the nerve stim is up to us... Regarsing the financial part - it is not worth to do the US based technique at this moment, better nerve stim.

 

[BLADEMDA]

Blade - u know, patient response means almost nothing....You can penetrate the nerve and there is no response. Guided injections are the future (if not the present...) for regional. Use or not the nerve stim is up to us... Regarsing the financial part - it is not worth to do the US based technique at this moment, better nerve stim.

Patient's response in not always reliable. But, my anecdotal report of the patient SCREAMING was real. Current COMMUNITY standard of care is NOT to do blocks in adults under GA. As always, the standard of care is difficult to define and nobody really knows what exactly it means. At DA U you can do pretty much anything you want because YOU MAKE THE STANDARD. I have no doubt that in the near future U/S will allow us to block patients safely under GA or SAB.

Blade

 

[dhb]

Patient's response in not always reliable. But, my anecdotal report of the patient SCREAMING was real.

The question is: does the screaming relate to nerve injury. A lot of articles describe intraneural LA injection with no morbidity...

 

[Planktonmd]

No indication for femoral block "right" after spinal. Either place the block prior to SAB or after sensory function has returned to the leg.

However, it can be done this way and I have seen it. If there is a complication (even using U/S guidance) that technique is open for criticism.

By the way the nerve stimulator will work properly with GA, Epidural or Spinal.

I do almost ALL my femoral blocks post op with the spinal anesthetic still working.
You will not penetrate the femoral nerve unless you use a sharp needle or you use unnecessary force.

 

[BLADEMDA]

The question is: does the screaming relate to nerve injury. A lot of articles describe intraneural LA injection with no morbidity...

He stopped screaming when the needle was repositioned a few Millimeters and the injected resumed.

 

[Gasmachine]

Though this thread is old and I am also old I suppose, I wish to express my input doing concurrent spinal and femoral nerve block. In this legitious age of law suits, I practice very conservative and in my mind safe anesthesia. We constantly strive to look for what is the standard of care to minimize our exposed risks giving our patients the best care.

I can only express my opinion that we are arbitrarily given direct responsibility for any anesthesia complications within the first 24 hours of their care. Where did the 24 hours come from? I have no idea maybe back in the day of ether someone says if it's remotely related to anesthesia causing bad outcomes you get pulled into QA. Not to say we can't still be blame for past 24 hours, I'm just saying 24 hours sticks out in my mind.

So back to the topic at hand. My opinion is that I do not place any femoral nerve blocks into patients if they have a spinal anesthesia. The remote chance of spinal hematoma and spinal cord nerve injury is extremely rare (maybe in 1 in 100's of thousand patient); however, why risk it by compounding it if you place a femoral nerve block and their is nerve injury? As far as I know femoral nerve blocks, U/S or nerve stim is not the standard of care for post-op pain management. Has it been mandated that we need to place femoral nerve blocks when indicated?

I would wait 24hrs after any spinal to place a femoral nerve block. Conservative? Yes. Standard of care? No. My version of safe anesthesia? Yes. Avoiding a QA session on a patient with permanent nerve injury? Possibly. Any literature to support my position? As with many things we do in medicine, the answer is No.

 

[BLADEMDA]

Though this thread is old and I am also old I suppose, I wish to express my input doing concurrent spinal and femoral nerve block. In this legitious age of law suits, I practice very conservative and in my mind safe anesthesia. We constantly strive to look for what is the standard of care to minimize our exposed risks giving our patients the best care.

I can only express my opinion that we are arbitrarily given direct responsibility for any anesthesia complications within the first 24 hours of their care. Where did the 24 hours come from? I have no idea maybe back in the day of ether someone says if it's remotely related to anesthesia causing bad outcomes you get pulled into QA. Not to say we can't still be blame for past 24 hours, I'm just saying 24 hours sticks out in my mind.

So back to the topic at hand. My opinion is that I do not place any femoral nerve blocks into patients if they have a spinal anesthesia. The remote chance of spinal hematoma and spinal cord nerve injury is extremely rare (maybe in 1 in 100's of thousand patient); however, why risk it by compounding it if you place a femoral nerve block and their is nerve injury? As far as I know femoral nerve blocks, U/S or nerve stim is not the standard of care for post-op pain management. Has it been mandated that we need to place femoral nerve blocks when indicated?

I would wait 24hrs after any spinal to place a femoral nerve block. Conservative? Yes. Standard of care? No. My version of safe anesthesia? Yes. Avoiding a QA session on a patient with permanent nerve injury? Possibly. Any literature to support my position? As with many things we do in medicine, the answer is No.

Ridiculous. My Group has placed about 14,000 Femoral nerve blocks in PACU after the spinlas have worn off. Our postop complications are minimal (only one patient complained of pain/neuritis for 6 months). The idea that any Physician thinks you need to wait 24 hours after a spinal (after the Lovenox may have been started) is preposterous and without any evidence.

 

[Idiopathic]

Though this thread is old and I am also old I suppose, I wish to express my input doing concurrent spinal and femoral nerve block. In this legitious age of law suits, I practice very conservative and in my mind safe anesthesia. We constantly strive to look for what is the standard of care to minimize our exposed risks giving our patients the best care.

I can only express my opinion that we are arbitrarily given direct responsibility for any anesthesia complications within the first 24 hours of their care. Where did the 24 hours come from? I have no idea maybe back in the day of ether someone says if it's remotely related to anesthesia causing bad outcomes you get pulled into QA. Not to say we can't still be blame for past 24 hours, I'm just saying 24 hours sticks out in my mind.

So back to the topic at hand. My opinion is that I do not place any femoral nerve blocks into patients if they have a spinal anesthesia. The remote chance of spinal hematoma and spinal cord nerve injury is extremely rare (maybe in 1 in 100's of thousand patient); however, why risk it by compounding it if you place a femoral nerve block and their is nerve injury? As far as I know femoral nerve blocks, U/S or nerve stim is not the standard of care for post-op pain management. Has it been mandated that we need to place femoral nerve blocks when indicated?

I would wait 24hrs after any spinal to place a femoral nerve block. Conservative? Yes. Standard of care? No. My version of safe anesthesia? Yes. Avoiding a QA session on a patient with permanent nerve injury? Possibly. Any literature to support my position? As with many things we do in medicine, the answer is No.

what is this

 

[imfrankie]

Blade and ChrisA


Can you give me any data to support your contention that PNB is safer in a awake or sedated patient with normal sensation than in a patient who is under GA or spinal?

At one of my institutions we do 99.9% of our adult blocks under GA. Been doing it this way for years. More total blocks than any single practicioner is likely to do in a career. No nerve injury yet.

The only data that exists (so far) is in pediatric patients and supports the safety of PNBs in anesthetised patients. (stay tuned)

-pod

The Europeans I speak with at regional meetings do tons of blocks on sleeping adult patients also. I personally have no objection to doing it myself. In the "old days" sedating a patient for a block meant essentially GA for many docs I knew anyway.

 

[imfrankie]

I personally keep the injection pressure low with every block. Lots are intraneural according to my reading of the literature.

 

[BLADEMDA]

Yep - I am doing US guided fem. catheters under SAB. There is no need of nerve stim and this is the easiest procedure ever. Take a look at this website
www.neuraxiom.com. I think it is excellent and helpful.

This procedure was easy before U/S came on the scene and is even easier now that we have U/S.

I would love to place my blocks under GA or SAB. It makes it easier on everyone. But, I do not think that is the current standard practice in most academic or private practices.
I will remain conservative for now because it seems the most prudent thing to do in a difficult medico-legal climate where anesthesia is blamed for all post op nerve injuries.

 

[BLADEMDA]

by Capdevila et al. in 2005.29 The authors prospectively reviewed 1,416 continuous peripheral nerve catheters and reported an incidence of hypoesthesia or numbness in 3% and 2.2% of patients, respectively, and paresthesias in 1.5% of patients. Three neural lesions were noted after continuous femoral nerve blockade, two of which were performed on anesthetized patients, with subsequent resolution ranging from 36 h to 10 weeks. It should be noted that data were collected only up to 5 days after surgery, except in those patients in whom a prolonged neurologic deficit already was documented. Although most cases of nerve injury likely would present during this time period, some cases of neuropathy become apparent only several days or weeks after surgery.30
Welch et al. recently reported the results of a 10-yr retrospective review of more than 380,000 consecutive patients undergoing all types of procedures and anesthetics.7 They reported an overall incidence of PNI of 0.03%, with an incidence of 0.05% in orthopedic procedures. In addition, they found that the use of general anesthesia or epidural anesthesia increased the risk of postoperative neuropathy, but there was no difference with the use of peripheral nerve blockade. It should be noted that the authors excluded nerve injuries resulting from the surgical procedure, a factor that may falsely decrease their estimated incidence. Similar to the findings of the study by Capdevila et al.,29 the authors sought information on peripheral neuropathies that were identified only during the first 48 h after surgery. Previous studies have shown that many cases of perioperative neuropathy are first identified more than 48 h after THA surgery.11,14,25,26

http://journals.lww.com/anesthesiol...perative_Nerve_Injury_after_Total_Hip.11.aspx

 

[BLADEMDA]

Blocks in anesthetized patients
Blocks in anesthetized patients should be avoided or at least an uncommon practice. When it is necessary to place blocks in anesthetized patients, this should be done only by practitioners with substantial experience with the planned technique. Such cases should NEVER be considered "teaching".

www.nysora.com

 

[BLADEMDA]

For adults, single-shot nerve blocks are a one time injection of local anesthesia given typically under sedation but before general anesthesia is started. A single-shot nerve block may also be given to children to help with pain control after surgery but in most cases, your anesthesiologist will perform the block while your child is already asleep (after general anesthesia has started). Single-shot nerve blocks are often used for pain control after orthopedic (bone and joint) surgery.

ASRA

 

[BLADEMDA]

The Europeans I speak with at regional meetings do tons of blocks on sleeping adult patients also. I personally have no objection to doing it myself. In the "old days" sedating a patient for a block meant essentially GA for many docs I knew anyway.

The Europeans don't have to deal with our legal system in the USA. Good look with your defense of routine nerve blocks under GA if/when a patient gets a complication, even a complication most likely due to the surgery/surgeon or touniquet.

The legal system is why we stress "in-plane" instead of faster, easier, less painful out of plane blocks. Since there isn't any difference in outcome/complications in NS only vs U/S only guided blocks in experienced hands why do we need to go in-plane for every block. Where is the evidence?

Many European Anesthesiologists do out of plane U/S guided blocks and report excellent success with no increase risk of complications.

Have you ever tried an out of plane ISB, Femoral or Popliteal block? If you think in plane is easy then try out of plane and see how fast/quick a block can be with minimal tissue trauma.

http://www.youtube.com/watch?v=skWTfAmAGcs
ISB Out of plane

 

[jetproppilot]

Alright. How about a real world case? A colleague of mine was doing an U/S guided block. After the first 3 ml's of local the patient screamed like he had been shot. This patient was heavily sedated but not under GA. It turns out that the provider had lost track of the tip of the needle and was at least perineural. Needless to say the needle was readjusted a few MM and the block completed without any post op complications.

While you superstuds think that U/S is perfect it isn't-yet. The pictures can be grainy and the needle difficult to visualize 100% of the time. Is U/S safe? Yes. But, does it GUARANTEE 100% no complications ever? No. Of Course, the equipment is only as good as the operator.

Blade

I've been doing ultrasound guided nerve blocks for a year now. A ton of interscalenes, popliteals, femorals...

BLADE IS SPOT ON.

I'm totally convinced it is LEVELS AND LEVELS AND LEVELS ABOVE

blind NS technique.

My blocks are much better.

After you emerge out of the learning curve the blocks are

EASY.

But ultrasound still isn't perfect.

I'm pretty deft with the ultrasound probe now and yet still sometimes I can't see my needle's exact point.....I have to extrapolate where it is from the tissue movement visible on the ultrasound picture.

Completely agree this is very operator dependent, but I feel sometimes I'm limited from seeing what I need to see by the technology.

 

[Mman]

The Europeans don't have to deal with our legal system in the USA. Good look with your defense of routine nerve blocks under GA if/when a patient gets a complication, even a complication most likely due to the surgery/surgeon or touniquet.

The legal system is why we stress "in-plane" instead of faster, easier, less painful out of plane blocks. Since there isn't any difference in outcome/complications in NS only vs U/S only guided blocks in experienced hands why do we need to go in-plane for every block. Where is the evidence?

Many European Anesthesiologists do out of plane U/S guided blocks and report excellent success with no increase risk of complications.

Have you ever tried an out of plane ISB, Femoral or Popliteal block? If you think in plane is easy then try out of plane and see how fast/quick a block can be with minimal tissue trauma.

I'm gonna go out on a limb and suggest one reason for low complication rates in Europeans is that their patients have a far lower baseline risk of nerve injury. In my limited travels in Europe, my observation is they have far less obese patients (particularly the morbid and super morbid) compared to what I'm used to dealing with. I'm guessing they also have far lower rates of diabetes.

If you subscribe to the multiple (2 for most people) hit theory of nerve injury, the Europeans have it easier. Their same technique in all likelihood could result in much higher nerve injury rates on a different population.



I stick to doing blocks on adults not under GA if at all possible. There is no benefit to me to do it under GA. Doesn't save time. Adds a little risk, even if only in the medico-legal sense.

Nerve injuries happen. Any institution doing enough of them will see plenty if they look for them hard enough. If they aren't looking, of course they won't find them.

 

[jetproppilot]

The Europeans don't have to deal with our legal system in the USA. Good look with your defense of routine nerve blocks under GA if/when a patient gets a complication, even a complication most likely due to the surgery/surgeon or touniquet.

The legal system is why we stress "in-plane" instead of faster, easier, less painful out of plane blocks. Since there isn't any difference in outcome/complications in NS only vs U/S only guided blocks in experienced hands why do we need to go in-plane for every block. Where is the evidence?

Many European Anesthesiologists do out of plane U/S guided blocks and report excellent success with no increase risk of complications.

Have you ever tried an out of plane ISB, Femoral or Popliteal block? If you think in plane is easy then try out of plane and see how fast/quick a block can be with minimal tissue trauma.

http://www.youtube.com/watch?v=skWTfAmAGcs
ISB Out of plane

Watched the video.

Looks about the same as an in plane approach...don't think it is better in terms of time or trauma but definitely another approach to learn and get good at!
Thanks for posting... I'm gonna try it.

 

[BLADEMDA]

I'm gonna go out on a limb and suggest one reason for low complication rates in Europeans is that their patients have a far lower baseline risk of nerve injury. In my limited travels in Europe, my observation is they have far less obese patients (particularly the morbid and super morbid) compared to what I'm used to dealing with. I'm guessing they also have far lower rates of diabetes.

If you subscribe to the multiple (2 for most people) hit theory of nerve injury, the Europeans have it easier. Their same technique in all likelihood could result in much higher nerve injury rates on a different population.



I stick to doing blocks on adults not under GA if at all possible. There is no benefit to me to do it under GA. Doesn't save time. Adds a little risk, even if only in the medico-legal sense.

Nerve injuries happen. Any institution doing enough of them will see plenty if they look for them hard enough. If they aren't looking, of course they won't find them.

I like U/S. I do inplane the majority of the time. I still do an occasional NS only block.
As long as your skills and technique are solid I doubt there is any difference in complication rates among any of the techniques.

IMHO, avoid even touching the nerves (esp. the small nerves) if possible and limit the needle passes around the nerves to the number actually needed for block success.

 

[Mman]

I like U/S. I do inplane the majority of the time. I still do an occasional NS only block.
As long as your skills and technique are solid I doubt there is any difference in complication rates among any of the techniques.

IMHO, avoid even touching the nerves (esp. the small nerves) if possible and limit the needle passes around the nerves to the number actually needed for block success.

I also do nearly every block with ultrasound and am quite deft with it. And complications can still happen. But I think some complications are far less likely with the ultrasound. For example, intravascular injection or pneumothorax rates have to be an order of magnitude lower than a blind technique if you know what you are doing. I mean it's hard to get a pneumothorax on a supraclavicular block under u/s if you are never near the lung.

 

[Gasmachine]

Ridiculous. My Group has placed about 14,000 Femoral nerve blocks in PACU after the spinlas have worn off. Our postop complications are minimal (only one patient complained of pain/neuritis for 6 months). The idea that any Physician thinks you need to wait 24 hours after a spinal (after the Lovenox may have been started) is preposterous and without any evidence.

Preposterous as it may sound, but I have yet to see RCT or hard data showing that it is safe to do lower extremity nerve blocks after spinal anesthesia or when the spinal is still effective. We state, discuss, and debate on the issue but I have yet to see any hard data, and I don't mean some obscure case report or retrospective data. Do you have any societal recommendation (ie ASRA), expert panel recommendation that can vouch for this practice? Just because there is no data showing it is unsafe does not mean it is prudent to practice that way.

I admit that I have no data supporting the way I practice but do not forget... First do no harm. No one can cite you for doing no harm. I am glad there are anesthesia cowboys out there that will push our field further; otherwise no one will study these important practices and provide us with hard data and actual evidence.

I practice what's in textbooks for a reason. Textbooks are written and established over years of publication. Yes some practices, drugs, and recommendations can change significantly by the time a new textbook gets published, but that's what the ASA practice guidelines, ASRA and other national societies fill in the gap. Hey, just my two cents no need to be offended. I am certainly not trying to push my way of practice on anyone.

 

[pgg]

Maybe you said and I missed it, but why do you want to do FNBs after a spinal in the first place? Extra duration vs a preop block?

Aside from the very occasional rescue block, why do them in PACU vs preop? For rescue blocks ... if they're hurting enough that one is warranted, then I'd feel comfortable with assuming the spinal has worn off enough to not be a factor.

 

[sevoflurane]

How about this one...

If you feel the need to do both (spinal for the case +/- duramorph and FNB for POPM)

Do the FNB first and then the spinal....

😛

 

[sevoflurane]

BTW... I know of a couple of groups that do this... One of them a 40 MD group in a ACT model.

Spinal then FNB.

Not my cup of tea.

I'm a FNB>LMA kinda dude.

 

[BLADEMDA]

Maybe you said and I missed it, but why do you want to do FNBs after a spinal in the first place? Extra duration vs a preop block?

Aside from the very occasional rescue block, why do them in PACU vs preop? For rescue blocks ... if they're hurting enough that one is warranted, then I'd feel comfortable with assuming the spinal has worn off enough to not be a factor.

For single shot blocks doing the FNB in PACU can mean an extra 5-6 hours of postop pain relief for the patent over doing the block preop.

In academics many places do a FNB preop then a spinal in the OR. This is common throughout many academic centers.

 

[BLADEMDA]

BTW... I know of a couple of groups that do this... One of them a 40 MD group in a ACT model.

Spinal then FNB.

Not my cup of tea.

I'm a FNB>LMA kinda dude.

I think this technique is safe using u/s. but, a complication or two is likely after several thousand FNB in any Patient population. Now, if and when a patient seeks an attorney there is more wiggle room to sue the Anesthesiologist. Would this complication have been prevented if the spinal block was not in place or feedback was utilized? I think the answer Is no but others may be willing to testify in court that placing a FNB under an active SAB is deviation from the standard of care. Hence, those guys must defend that practice as safe along with the complication. Why do you want that headache?

Ultimately, the decision is yours but until solid evidence is published regarding blocks under GA/SAB in adults I will continue to do these block in unanesthetized patients.

 

[Lisa Ann Wilson]

I never do adult PNB under GA. They cannot tell u if they feel paresthesia's and most importantly...YOU WILL NEVER WITNESS A SEIZURE UNDER GA IF YOU ACCIDENTALLY HAVE AN INTRAVASCULAR INJECTION! Pediatrics is the exception. Here is a lawsuit filed with just this situation.
News & Events Headlines
Nerve Damage Trial: New York Unanimous Defense Verdict
Informed consent is central issue at trial.
Shawnee Mission, Kansas - December 11, 2012 - Preferred Physicians
Medical (PPM), industry-leading provider of professional liability
insurance for anesthesia practices, announced today that a jury
recently returned a unanimous defense verdict in favor of a PPM
insured anesthesiologist in Dutchess County, New York.
The case involved a 72 year-old female who presented for a right total
knee replacement. The anesthesia plan was to administer a spinal block
and general anesthesia with a femoral nerve block for post-operative
pain. The patient was provided informed consent for the spinal,
general anesthesia and the femoral nerve block. The PPM insured
anesthesiologist discussed the risks associated with the various
anesthetic techniques, including the risk of nerve injury from the
blocks. The informed consent form itself was a one-page document that
indicated general anesthesia and "regional" anesthesia would be
provided; however, the form did not specify the specific type of
regional anesthesia.
The surgery was uneventful and the patient was taken to the PACU. The
femoral nerve block was placed using a nerve stimulator approximately
two hours later, after the patient had regained sensation in her legs.
The patient was discharged from the PACU approximately three hours
later with no complaints. The block continued infusing until it was
removed on post-operative day two. The patient was discharged home
with a leg brace. She had no complaints at that time regarding her
right leg.
A physical therapist went to her house to perform physical therapy
after the patient returned home. The physical therapist noted that the
patient could not elevate her right leg while lying flat. The patient
consulted her orthopedic surgeon who advised her that her recovery was
going well. However, after several weeks, the therapist stated that
further therapy would be unproductive and again advised the patient to
speak with her orthopedic surgeon. An EMG indicated an injury to her
femoral nerve that was causing weakness in her quadriceps muscle. The
patient was referred to a neurologist and a subsequent EMG revealed
injury to her femoral, peroneal and tibial nerves.
The plaintiff sued the PPM insured anesthesiologist alleging he failed
to supply a proper informed consent regarding administration of the
femoral nerve block. She also alleged that he never discussed the
femoral nerve block with her and that she was not even aware she had
received a femoral nerve block. The plaintiff alleged further that as
a result of the PPM insured anesthesiologist's negligence, her femoral
nerve was destroyed and she suffered total loss of the quadriceps
muscle supporting the right knee and thigh.
Plaintiff demanded $1 million to settle the case prior to trial. The
PPM insured anesthesiologist did not consent to settlement and no
offer was made.
Plaintiff's anesthesiology expert was John Dombrowski, M.D., an
anesthesiologist and pain management specialist from Washington, D.C.
Dr. Dombrowski testified that the PPM insured anesthesiologist
deviated from the standard of care by failing to provide the plaintiff
adequate informed consent for the femoral block. He also testified
that the informed consent form executed by the plaintiff failed to
indicate that the plaintiff would be receiving a femoral nerve block
and what risks regarding the nerve block were discussed with the
plaintiff. Additionally, Dr. Dombrowski testified that the PPM insured
anesthesiologist violated the standard of care by performing the nerve
block in the PACU before the plaintiff had an opportunity to recover
from the effects of spinal anesthesia. He opined that a femoral nerve
injury resulted when the needle came in contact with the femoral nerve
and the plaintiff was unable to react due to the lingering effects
from the spinal anesthesia.
The defense anesthesiology standard of care expert testified that the
plaintiff was given adequate informed consent. The executed form
indicated that the patient was made aware that nerve injury is a risk
of the procedure and, relying on the PPM insured anesthesiologist's
custom and practice, the discussion with the patient regarding
potential risks of the block was sufficient. Additionally, he
testified that nerve injury during a femoral nerve block is a known
and accepted complication of the block. He testified further that
ultrasound was not standard of care in 2007 or even available at the
facility where the surgery was performed. Finally, he testified that
the second EMG supports an injury to the peroneal and tibial nerves,
as well as the femoral nerve, which more likely suggests a tourniquet
injury as opposed to one related to the femoral nerve block.
The jury also heard testimony from a nurse who conducted the "Total
Joint Replacement Educational Class" the plaintiff attended prior to
her surgery. The nurse testified that during the two-hour class, the
plaintiff would have been provided an informational booklet and
informed of the mechanics of the joint replacement procedure as well
as the various forms of anesthesia the patient might receive,
including general anesthesia, spinal block and femoral nerve block. At
trial, the nurse presented the attendance sheet from the class and
noted that the plaintiff was indeed an attendee. The plaintiff had
previously testified that she attended the class and received the
booklet, but stated that it was a 30 minute class where they were
simply shown the joint replacement parts. The nurse's testimony was
highly effective in casting doubt on the plaintiff's testimony that
she had never heard of a femoral nerve block before her procedure.
The PPM insured anesthesiologist testified that the custom and
practice at his hospital for total knee replacement procedures was for
the patient to receive a femoral nerve block while in the PACU for
post-operative pain management. He further testified that he discussed
placement of the block and its risks, including nerve injury, with the
patient during his pre-operative evaluation. She executed the consent
and had no additional questions. He administered the block two hours
after the patient had arrived in the PACU once the spinal began to
wear off. During administration of the block, he utilized a nerve
stimulator and noted no complications or complaints from the
plaintiff. He was unaware of any complications she experienced until
he was contacted by the plaintiff several weeks following the
procedure.
Following a nine day trial, the six-person jury returned a unanimous
defense verdict after deliberating for approximately five hours.
The PPM policyholder was represented by Michael E. Catalinotto, Sr.,
with the law firm Maynard, O'Connor, Smith & Catalinotto, LLP in
Albany, New York. The file was managed on behalf of PPM by Tracey
Dujakovich, Senior Claims Attorney.

 

[deleted171991]

Not completely recovered spinal + no US guidance + post-GA patient = recipe for disaster.

 

[Hoya11]

Maybe you said and I missed it, but why do you want to do FNBs after a spinal in the first place? Extra duration vs a preop block?

Aside from the very occasional rescue block, why do them in PACU vs preop? For rescue blocks ... if they're hurting enough that one is warranted, then I'd feel comfortable with assuming the spinal has worn off enough to not be a factor.

You do it after the spinal because you have other rooms to start at 730, and its very safe if you are skilled with US, and the patient doesn't feel it. Surely every places set up is different, for me, doing a nerve block means finding the ultrasound machine, cleaning it, plugging it in (rearranging pre-op holding room), changing the settings, kicking family out, gathering supplies, hooking up monitors and o2 myself, finding a second pair of hands to push medications, and doing the block, all before 725 when the patient arrives at 710 and needs a 40 minute interview by the pre-op nurse about "are you safe at home".

I always prefer to do them pre-op with 4-6 of versed, then do spinal or go to sleep. But for the first case of the day it is more practical to do the spinal, walk away, and do the block after when you have time