foot drop 30 hours after sciatic....

[turnupthevapor]

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Did a femoral catheter and a single shot (labatt) sciatic yesterday at 11 am. 29 hours later patient still has limited dorsiflexion and loss of sensation of sup peroneal.

78 yo female hx Afib, Obese, HTN....nl labs

Block was with 15 ml of .25% bupivicaine for TKR. Used a landmark technique with a twitch monitor. Twitch was gone by .4 ma. Nice and easy pressure while injecting.

Was wondering what all your experiences with this situation has been? I usually only get 18 hours out of it so I am a touch concerned. I know if I injected intraneurally and caused damage most deficits return to normal in six weeks but am looking for some input. It is possible surgeon got the common peroneal.


any place to order EMG at this point?


Thank you for your input

 

[bostonblaz]

what is the physical status of the person. Is it a little old person or a healthy young one? did you add epi? where was the procedure? i would only do an emg if i felt that it could have been surgeon related and then they could localize the site of injury. How was the block otherwise, did you inject before or after the sciatic split? did they have other areas that you got numb that have recovered?blaz

 

[pgg]

What was the procedure? Total knee? The way those guys twist limbs around sometimes I'm surprised we don't see more postop nerve deficits. Also could've been a positioning injury unrelated to either the block or the surgery. The way some patients sit in the PACU as they slowly de-zonk, with their elbows and knees on or up against the rails makes me wonder how many positioning injuries happen after we leave them.

Seems unlikely that this is a block complication, though convincing the patient or surgeon of that is another issue. No awake patient is going to sit calmly through an intraneural injection.

15 mL of 0.25% bupivacaine isn't much ... but every once in a great while I'll get a superlong lasting block, 24-30 hours. If the deficit's still there tomorrow I'd start thinking about an EMG to document where the injury is.

 

[Planktonmd]

What was the surgery?
Is it possible that there was a surgical nerve injury?
It's unlikely that 0.25% Bupivacaine could cause lasting motor blockade.
Do not tell the patient that this problem was caused by the block because we don't know at this point.
Do not write any notes stating that this motor deficit is related to the block.
The good news is that most of these surgical nerve injuries are usually stretch injuries and they do resolve although this might take a few months.
If after 48 hours there is no improvement you need to arrange for long term physical therapy.
Doing EMG's or nerve conduction studies is not helpful this early but if there is no improvement in 3-4 weeks I would get a neurology consult and nerve studies.

Did a femoral catheter and a single shot (labatt) sciatic yesterday at 11 am. 29 hours later patient still has limited dorsiflexion.

Block was with 15 ml of .25% bupivicaine. Used a landmark technique with a twitch monitor. Twitch was gone by .4 ma. Nice and easy pressure while injecting.

Was wondering what all your experiences with this situation has been? I usually only get 18 hours out of it so I am a touch concerned. I know if I injected intraneurally and caused damage most deficits return to normal in six weeks but am looking for some input. It is possible surgeon got the common peroneal.


any place to order EMG at this point?


Thank you for your input

 

[sevoflurane]

If you used a tourniquet, what was the pressure and for how long was it used for?

 

[sevoflurane]

Doing EMG's or nerve conduction studies is not helpful this early but if there is no improvement in 3-4 weeks I would get a neurology consult and nerve studies.

Agree. Positive waves and fibrillations on EMG appear between 2-4 weeks after the initial insult.

 

[Narcotized]

.

 

[turnupthevapor]

You are all very helpful thank you for the input.

 

[turnupthevapor]

So far surgeon feels the injury is related to damage/stretch in the surgery site. Says he has seen it many times and feels it has a fairly good prognosis. He wants to give it a week in a brace and reevaluate. I will update this in a few weeks

Thanks

 

[proman]

So far surgeon feels the injury is related to damage/stretch in the surgery site. Says he has seen it many times and feels it has a fairly good prognosis. He wants to give it a week in a brace and reevaluate. I will update this in a few weeks

Thanks

That's amazing. I'd buy him lunch.

 

[Planktonmd]

That's amazing. I'd buy him lunch.

Yes, definitely a good guy!

 

[proman]

Reminds me of a median and ulnar nerve palsy I saw 10 days postop abdominal surgery. The patient reported to the ICU immediately on emergence, but no one did anything. No post op check by the anesthesiology attending or CRNA who did the case. 10 days later as the service wants to discharge him he tells them he's not leaving until someone looks at his hand. I saw him because I was available. Ran into neurology as they were about to write their consult. I told them the likelihood of the a-line causing the palsy (which was their impression) was very low and it was likely a positioning issue. Sure enough they included that in their consult, as opposed to blaming the a-line. Sometimes consultants can be reasonable.

 

[seamonkey]

Reminds me of a median and ulnar nerve palsy I saw 10 days postop abdominal surgery. The patient reported to the ICU immediately on emergence, but no one did anything. No post op check by the anesthesiology attending or CRNA who did the case. 10 days later as the service wants to discharge him he tells them he's not leaving until someone looks at his hand. I saw him because I was available. Ran into neurology as they were about to write their consult. I told them the likelihood of the a-line causing the palsy (which was their impression) was very low and it was likely a positioning issue. Sure enough they included that in their consult, as opposed to blaming the a-line. Sometimes consultants can be reasonable.

However, it is my understanding, at least in my state, that injury liability due to positioning issues is shared by Surgery, Nursing, and Anesthesiology equally. Have heard of 6-figure payout at another program (the Dept of Anesth share) due to a supposedly tucked arm falling out and hanging off the table for a few hours during a long robotic hysterectomy (you know, the kind where you have a lot of T-bird and can't see the patient for crap due to the robot and the surgical team). So positioning problems still can cost $$$.

 

[Arch Guillotti]

T-bird???

 

[SleepIsGood]

However, it is my understanding, at least in my state, that injury liability due to positioning issues is shared by Surgery, Nursing, and Anesthesiology equally. Have heard of 6-figure payout at another program (the Dept of Anesth share) due to a supposedly tucked arm falling out and hanging off the table for a few hours during a long robotic hysterectomy (you know, the kind where you have a lot of T-bird and can't see the patient for crap due to the robot and the surgical team). So positioning problems still can cost $$$.

Read the new ASA newsletter. Good article written by 2 MD/JDs and a MD about how it should be the surgeon's 'fault'. Anesthesiologists simply are just helping but the ultimate liability in positioning injuries should be theirs.

 

[proman]

However, it is my understanding, at least in my state, that injury liability due to positioning issues is shared by Surgery, Nursing, and Anesthesiology equally. the kind where you have a lot of T-bird and can't see the patient for crap due to the robot and the surgical team). .

Yes but we went from an injury 100% our fault to 33%? That's an improvement. Either way I don't forsee a lawsuit because of how we ultimately dealt with it. The family and patient were happy.

T-bird???

What we have for Thanksgiving

Read the new ASA newsletter. Good article written by 2 MD/JDs and a MD about how it should be the surgeon's 'fault'. Anesthesiologists simply are just helping but the ultimate liability in positioning injuries should be theirs.

We should be active participants taking care of the patient. There are something inherently surgical (like a misplaced staple line) and some things not (like a missing instrument). Positioning should fall under shared responsibility. My case was likely due to taping of the hand in a dorsiflexed position after the arterial line was placed, for 8 hours.

 

[Dejavu]

Doing EMG's or nerve conduction studies is not helpful this early but if there is no improvement in 3-4 weeks I would get a neurology consult and nerve studies.



With the possible exception of ruling out pre-existing conditions. Just a thought.

 

[kmurp]

I have read that some experts recommend early EMG studies. If they are abnormal, it can indicate a pre-existing neuropathy which could mitigate your liability exposure.

 

[lobelsteve]

I have read that some experts recommend early EMG studies. If they are abnormal, it can indicate a pre-existing neuropathy which could mitigate your liability exposure.

An EMG is not helpful in the first week clinically. If it is being done to CYA or try and prove that a pre-existing injury existed- how does that benefit the patient? It does not, and it is a painful test that is likely to agitate the patient into suing.

If you consulted a respectable electromyographer, he/she would decline until 3 weeks post-injury, and may decline altogether if the patient denies any prior symptoms to the affected limb.