For what it is worth

[bostonblaz]

Today I ran two busy shoulder rooms, 5 cases in each. The first case in each room did interscalenes splitting the 30 cc vile of 0.5% marcaine with epi 1:200k. Both under u/s. Both had complete blocks going into the or and on arrival to pacu. Cases done with 200 prop and lma, I don't let the crna's give narcotics to these cases. Get called to same day and both patients in pain, both about 4 hours after injection. None of the other 8 cases which had been done excatly the same had any issues. I assume that this was a local anesthesia issue. Has anybody else have this happen?

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[militarymd]

Today I ran two busy shoulder rooms, 5 cases in each. The first case in each room did interscalenes splitting the 30 cc vile of 0.5% marcaine with epi 1:200k. Both under u/s. Both had complete blocks going into the or and on arrival to pacu. Cases done with 200 prop and lma, I don't let the crna's give narcotics to these cases. Get called to same day and both patients in pain, both about 4 hours after injection. None of the other 8 cases which had been done excatly the same had any issues. I assume that this was a local anesthesia issue. Has anybody else have this happen?

yes, sometimes they hurt....I tell the patients that I personally have a 5% failure rate (even though I know it's lower)..

 

[Lonestar]

I roughly use the same amount as you do. I also have a similar failure rate as milmd. Some of them just do not work well for whatever reason. 1 out of every 35-40 cases is not bad at all and i tell my pts the same thing. Must have done roughly 2500 blocks my first year.

 

[SleepIsGood]

Today I ran two busy shoulder rooms, 5 cases in each. The first case in each room did interscalenes splitting the 30 cc vile of 0.5% marcaine with epi 1:200k. Both under u/s. Both had complete blocks going into the or and on arrival to pacu. Cases done with 200 prop and lma, I don't let the crna's give narcotics to these cases. Get called to same day and both patients in pain, both about 4 hours after injection. None of the other 8 cases which had been done excatly the same had any issues. I assume that this was a local anesthesia issue. Has anybody else have this happen?

where's the pain exactly?

Why are you only using 15ml? Try increasing the volume? You should get more life out of the block. Are you performing more htan just an interscalene block with the utz? from what I gather people are decreasing the volume usually because they are doing multiple blocks on the same pt. would be interested in you guys' thoughts.

 

[jwk]

Today I ran two busy shoulder rooms, 5 cases in each. The first case in each room did interscalenes splitting the 30 cc vile of 0.5% marcaine with epi 1:200k. Both under u/s. Both had complete blocks going into the or and on arrival to pacu. Cases done with 200 prop and lma, I don't let the crna's give narcotics to these cases. Get called to same day and both patients in pain, both about 4 hours after injection. None of the other 8 cases which had been done excatly the same had any issues. I assume that this was a local anesthesia issue. Has anybody else have this happen?

Why?

 

[Planktonmd]

yes, sometimes they hurt....I tell the patients that I personally have a 5% failure rate (even though I know it's lower)..

I actually think it is a great idea that you are adding my words to every thing you say on this forum, it might add some value to your otherwise worthless confabulation.
I am also going to ask the nurses on the other forum where you belong to see what happened and why they kicked you out so you decided to come back and bless us with your presence.

 

[Planktonmd]

Are you using the premixed Marcaine + epi?
If you are then that might be the issue because that Marcaine with epi usually has a lower PH and in my experience it is less stable on the shelf and frequently less potent.
Try adding your own Epinephrine.

Today I ran two busy shoulder rooms, 5 cases in each. The first case in each room did interscalenes splitting the 30 cc vile of 0.5% marcaine with epi 1:200k. Both under u/s. Both had complete blocks going into the or and on arrival to pacu. Cases done with 200 prop and lma, I don't let the crna's give narcotics to these cases. Get called to same day and both patients in pain, both about 4 hours after injection. None of the other 8 cases which had been done excatly the same had any issues. I assume that this was a local anesthesia issue. Has anybody else have this happen?

 

[thegasman]

i don't think 15 cc is enough. I use ropivicaine 30-35 cc 0.5%

 

[Noyac]

A couple points:
1) I don't agree with not letting the nurses use narc's. If the pt needs them then use them.
2) Are the shoulders performed completely under the scope or is there a mini open procedure in there? Dream is right, the intercostobrahial nerve is involved. If the surgeon is making a mini open incision (anterior shoulder in the area of the axilla) then have him inject local. Also, let the nurses give narc's if the pt needs. Small doses of fentanyl will not slow down d/c.
3) 15cc is not enough even with the US contrary to what people say. Try more volume.

 

[Frank Rizzo]

A couple points:
1) I don't agree with not letting the nurses use narc's. If the pt needs them then use them.
2) Are the shoulders performed completely under the scope or is there a mini open procedure in there? Dream is right, the intercostobrahial nerve is involved. If the surgeon is making a mini open incision (anterior shoulder in the area of the axilla) then have him inject local. Also, let the nurses give narc's if the pt needs. Small doses of fentanyl will not slow down d/c.
3) 15cc is not enough even with the US contrary to what people say. Try more volume.

Pretty much how I feel. Plus two of the ASC I work at don't have an U/S, so I always use 30 mls

 

[bostonblaz]

To answer questions, I have been doing them this way for three years now. I fine tuned it over that time using pt call back the next day. I have sampled all the different combos of local we have. The 0.5% rop only gets me on average 11.5 hrs. longest I ever got with rop is 13hrs. I switched to only marcaine 0.5% and titrated the dose up and down and found I get 18-24 hrs with the 15 cc and don't get the horners or the post op call for sob from hemi diaphragmatic pararlysis. I usually do three days a week with 5 cases in each room. The guys mostly do cuffs and labrums with some acromioplasties. Any total arthoplasties get a catheter. When I am by myself in the room I give them 2 of midaz do the block and give them prop put in the lma and run them on gas. The reason for the no fent during the case is I find they just dont need it. My CRNAS give the cookie cutter 100 mcg of fent and put them on the vent with an lma, I just dont get it. I agree that sometimes blocks fail, and sometimes the surgeon does a little more then I expected and they need some narcs. However when I do total arthroplasties with this formula they wake up with zero pain, and there is no bigger incison and messing around with the joint then that. I do however give those guys 100 mcg of fent before the DL to blunt the tachy/htn. What was very starnge about these is the 4 hr post block failure. They failed at the same excat time. I swaped out the marcaine for the one the surgeons use in the or. I started with the pre mix 6 months ago cause it was just faster( I know that sounds stupid but sometimes 30 seconds saved gets me enough time to drink some coffee and flirt with a nurse or to).

 

[Planktonmd]

As I said, don't use the premixed.
Because of the lower PH it is less stable on the shelf.
Either add your own Epi or just skip epi all together.
One other thing I do sometimes is add Buprenorphine if I want a block that lasts more than 24 hours.

To answer questions, I have been doing them this way for three years now. I fine tuned it over that time using pt call back the next day. I have sampled all the different combos of local we have. The 0.5% rop only gets me on average 11.5 hrs. longest I ever got with rop is 13hrs. I switched to only marcaine 0.5% and titrated the dose up and down and found I get 18-24 hrs with the 15 cc and don't get the horners or the post op call for sob from hemi diaphragmatic pararlysis. I usually do three days a week with 5 cases in each room. The guys mostly do cuffs and labrums with some acromioplasties. Any total arthoplasties get a catheter. When I am by myself in the room I give them 2 of midaz do the block and give them prop put in the lma and run them on gas. The reason for the no fent during the case is I find they just dont need it. My CRNAS give the cookie cutter 100 mcg of fent and put them on the vent with an lma, I just dont get it. I agree that sometimes blocks fail, and sometimes the surgeon does a little more then I expected and they need some narcs. However when I do total arthroplasties with this formula they wake up with zero pain, and there is no bigger incison and messing around with the joint then that. I do however give those guys 100 mcg of fent before the DL to blunt the tachy/htn. What was very starnge about these is the 4 hr post block failure. They failed at the same excat time. I swaped out the marcaine for the one the surgeons use in the or. I started with the pre mix 6 months ago cause it was just faster( I know that sounds stupid but sometimes 30 seconds saved gets me enough time to drink some coffee and flirt with a nurse or to).

 

[sevoflurane]

This somewhat reminds me of a case I had about 3 months back. Patient came in to drain a hip abcess. Skinny as can be. Had a full stomach. Deemed to be an emergency by orthopod . No signs of systemic infection. Plan for a spinal.

Sat her up, easy csf, 1.8 cc of .75% bup with 150 mcgs of duramorph and 10 of fentanyl. Waited, waited, waited... And got nothing. Wiggling toes like it was no ones business. I was so surprised I repeated the procedure. Again... CSF, just as clear as the first time. Waited another 5 minutes and nothing. Pain felt "better" but still had full motor function. Not acceptable for case. She went to sleep with RSI. Case went very smoothly. No issues. Woke up in recovery with no pain and motor block. Strangest thing I've ever seen with a spinal.

Anyone else see this?

 

[Noyac]

This somewhat reminds me of a case I had about 3 months back. Patient came in to drain a hip abcess. Skinny as can be. Had a full stomach. Deemed to be an emergency by orthopod . No signs of systemic infection. Plan for a spinal.

Sat her up, easy csf, 1.8 cc of .75% bup with 150 mcgs of duramorph and 10 of fentanyl. Waited, waited, waited... And got nothing. Wiggling toes like it was no ones business. I was so surprised I repeated the procedure. Again... CSF, just as clear as the first time. Waited another 5 minutes and nothing. Pain felt "better" but still had full motor function. Not acceptable for case. She went to sleep with RSI. Case went very smoothly. No issues. Woke up in recovery with no pain and motor block. Strangest thing I've ever seen with a spinal.

Anyone else see this?

Yep!

 

[militarymd]

This somewhat reminds me of a case I had about 3 months back. Patient came in to drain a hip abcess. Skinny as can be. Had a full stomach. Deemed to be an emergency by orthopod . No signs of systemic infection. Plan for a spinal.

Sat her up, easy csf, 1.8 cc of .75% bup with 150 mcgs of duramorph and 10 of fentanyl. Waited, waited, waited... And got nothing. Wiggling toes like it was no ones business. I was so surprised I repeated the procedure. Again... CSF, just as clear as the first time. Waited another 5 minutes and nothing. Pain felt "better" but still had full motor function. Not acceptable for case. She went to sleep with RSI. Case went very smoothly. No issues. Woke up in recovery with no pain and motor block. Strangest thing I've ever seen with a spinal.

Anyone else see this?

yeah ..with c-sections...had one a few weeks ago.

 

[Noyac]

To answer questions, I have been doing them this way for three years now. I fine tuned it over that time using pt call back the next day. I have sampled all the different combos of local we have. The 0.5% rop only gets me on average 11.5 hrs. longest I ever got with rop is 13hrs. I switched to only marcaine 0.5% and titrated the dose up and down and found I get 18-24 hrs with the 15 cc and don't get the horners or the post op call for sob from hemi diaphragmatic pararlysis. I usually do three days a week with 5 cases in each room. The guys mostly do cuffs and labrums with some acromioplasties. Any total arthoplasties get a catheter. When I am by myself in the room I give them 2 of midaz do the block and give them prop put in the lma and run them on gas. The reason for the no fent during the case is I find they just dont need it. My CRNAS give the cookie cutter 100 mcg of fent and put them on the vent with an lma, I just dont get it. I agree that sometimes blocks fail, and sometimes the surgeon does a little more then I expected and they need some narcs. However when I do total arthroplasties with this formula they wake up with zero pain, and there is no bigger incison and messing around with the joint then that. I do however give those guys 100 mcg of fent before the DL to blunt the tachy/htn. What was very starnge about these is the 4 hr post block failure. They failed at the same excat time. I swaped out the marcaine for the one the surgeons use in the or. I started with the pre mix 6 months ago cause it was just faster( I know that sounds stupid but sometimes 30 seconds saved gets me enough time to drink some coffee and flirt with a nurse or to).

You seem to have your system down. I just am making observations. I like ropivicaine for a couple reasons. It's slightly safer with regards to cardiac toxicity, I've seen PVC's but they didn't require intervention. Not sure what would have happened if marcaine were used. But this is also why it doesn't last as long. I get about 24 hrs of analgesia with 20-30 cc 0.5% Ropiv. That is plenty long enough for me. If any of you have ever had a block you know that it can get pretty annoying having your limb numb. By the time the block starts to wear off, you are ready for it to. When I used marcaine the blocks lasted too long at times. I know this is contrary to what some people want. Ropiv just seems to be just right for me. If I want it to last longer then I will put in a catheter. Especially in the lower limb blocks, I don't want them to last past the next morning. The pts struggle to get around too much and may end up hurting themselves in the process. I do the shoulder cases just as you do, LMA and a little gas (about 1/2 MAC). I give 50 mcgs at induction and on occasionally another 50 mcg when I'm waking them up. Seems to smooth out the re-entry. It's not for pain. I would say (total guess here) that 1 in 10 shoulders may need some local in the anterior axilla area if the surgeon gets aggressive down there.

My other preference is NO epi in the local. It doesn't reliably extend the block time. It may give some comfort during placement as to vascular injection but a few years back while doing a review of closed claims reports of nerve injury during regional the vast majority of blocks in the CC had epi in them. It wasn't even a close call. I have not used it since. I'm not saying that you shouldn't but this is my practice style.

 

[sevoflurane]

Yep!

I am happy I'm not the only one. Any Idea why??? Seems bizarre as it does not make anatomic sense to me.

 

[MDEntropy]

I am happy I'm not the only one. Any Idea why??? Seems bizarre as it does not make anatomic sense to me.

I have seen a handful of these. Always confusing and frustrating. Once, I had no block until the third dural puncture and 3rd LA (local anesthetic) placement. I have some theories but instead will point you to a recent article by Drasner in the British Journal of Anesthesia.

Some of the take home points re: causes of failed SAB...
-Older Lit suggests 1)inactive LA or 2)anatomic variations such as arachnoid adhesions, dentate ligament abnormalities, or a dilated lower thecal sac as causes.
-This article adds LA maldistribution and LA resistance as possibilities.

 

[sevoflurane]

I have seen a handful of these. Always confusing and frustrating. Once, I had no block until the third dural puncture and 3rd LA (local anesthetic) placement. I have some theories but instead will point you to a recent article by Drasner in the British Journal of Anesthesia.

Some of the take home points re: causes of failed SAB...
-Older Lit suggests 1)inactive LA or 2)anatomic variations such as arachnoid adhesions, dentate ligament abnormalities, or a dilated lower thecal sac as causes.
-This article adds LA maldistribution and LA resistance as possibilities.

Happened to me again today. 210kg female for TKA who did not want to go to sleep. Spinal, clear csf swirl, 150mcgs of duramorph, 12 mg of .75% bupivicaine with epi wash. Sat her up for 5 minutes with no results but with a slight decrease in BP (190 systolic to 175). 2nd spinal 15 mg. Waited... nothing. 3rd spinal with 11 mg. Still wiggling toes after another 5 minutes but... definate sympathectomy (130's) and quads were out. I decided to throw in a femoral block on top of 3 spinals just to ward off evil spirits. (Bad airway... did't want to mess with it in the middle of the case since this is out of the ordinary and unpredictable)... To top it off, I'm working with our slowest orthopod (1.5-2 hours for TKA vs. 45 minutes-1hr with the rest of our orthopods ).

Have another 40 minutes to go and everything looks good. This is bizarre. My last patient this happened to was also a female. I'm going to get the lot # for our spinals and see if it's linked.

 

[amyl]

happened to me once. seemed like the perfect spinal, csf, etc.
no idea why it didn't work. mine was an older gentleman. was very annoying, but no major reason not to put him to sleep so didn't try again.... staffs call.

 

[Arch Guillotti]

Happened to me again today. 210kg female for TKA who did not want to go to sleep. Spinal, clear csf swirl, 150mcgs of duramorph, 12 mg of .75% bupivicaine with epi wash. Sat her up for 5 minutes with no results but with a slight decrease in BP (190 systolic to 175). 2nd spinal 15 mg. Waited... nothing. 3rd spinal with 11 mg. Still wiggling toes after another 5 minutes but... definate sympathectomy (130's) and quads were out. I decided to throw in a femoral block on top of 3 spinals just to ward off evil spirits. (Bad airway... did't want to mess with it in the middle of the case since this is out of the ordinary and unpredictable)... To top it off, I'm working with our slowest orthopod (1.5-2 hours for TKA vs. 45 minutes-1hr with the rest of our orthopods ).

Have another 40 minutes to go and everything looks good. This is bizarre. My last patient this happened to was also a female. I'm going to get the lot # for our spinals and see if it's linked.

41 mg of bupi? Wow.

 

[thegasman]

3 spinals and a femoral block???? Are you kidding??

 

[sevoflurane]

Nope... Not kidding. I'm certain she had either LA resistance or I had chinese LA. MD entropy has had the same experience after 3 dural punctures... I actually thought of his post that day. I also consulted the board runner after the 2nd spinal. He has had the same experience.

A couple of facts:

The case was done around 9:30am. By 2:00pm she was up and walking... By 5:00 pm she had made it 350 ft.

Having seen this twice in the past 6 months, and having to put someone to sleep with a full stomach (after 2 spinals) I took it upon myself to learn from this unusual and bizarre situation- although with good anesthesia backup.

Regarding Dream Machines, question. Very reasonable question for sure. I did not think I was anywhere close to having a total spinal. After 5 minutes motors are 5/5 throughout, and there is absolutely no level. Total spinal is very unlikely to happen if you don’t have any evidence of a working block after 5 minutes. Mechanical explanation? Maybe a connection with a dural sleeve and loss of intrathecal LA? Maybe... Maybe not. If she wanted to, she could have got on her feet and walked right out of the OR. I guess you just had to be there to fully appreciate the scenario.

After the 2nd spinal, she still had full motors (15 minutes later). This was the point where I decided to either:

A) go to sleep with a nasty airway or

B) try and achieve neuraxial blockade and learn a bit more regarding failed SAB.

After the third spinal, (20 minutes after the first one), she still didn’t have full motor function, but she did have substantial weakness.

Pressures stayed in the 130’s for about 30 minutes... and gradually climbed to almost pre-existing levels after about an hour (170’s)

All in all, she received 38 mg of intrathecal bupi and 15 mls of .25% bupi to her fem. nerve. I don’t think the femoral block is a big deal. Some of my partners do them all the time with spinals. I placed it mainly because I didn’t want the spinal to wear off in the middle of the case. T10 was the highest level I got and it did not last long at that.

I’ve posted this case so I can share my experience and others can learn from what I have seen. I know 3 spinals is sort of like Taboo. What would others have done? GA on a 210KG nasty airway after failed SAB. Could it have been done. Of course. Difficult airways is what we do. How about waiting for 30 minutes in hopes that the block would take... while the orthopod is pacing not so patiently?. Yes, I could have gone this route with or without a result (highly doubt I would have achieved surgical anesthesia)

In the end. This patient received exactly what she wanted. She did not get a GA, had great pain control and did not require any narcs for at least 24 hrs.

Did I learn from this patient? Hell yeah. I don’t fancy 3 SAB, but this is an experience in my time as a provider. I will not forget it.

Fire away!

 

[Frank Rizzo]

the three spinals scares the shat out of me.

 

[dA pilot]

The case was done around 9:30am. By 2:00pm she was up and walking... By 5:00 pm she had made it 350 ft.

210 KG patient walking around is amazing itself!

If you are that worried about airway, would you ever consider putting in a spinal catheter after second attempt to titrate up instead of bolusing?

 

[pgg]

A couple of thoughts -

After two failed spinals, if I still really wanted to go neuraxial, I might consider an epidural. More freedom to titrate different volumes and drugs, slightly different site of action (more DRG than DH / cauda equina).

Also, I wonder if there would have been any difference if the 3rd attempt had been with a different local anesthetic. The case reports of "LA resistance" I've read often speculate about abnormal sodium channels, and I remember one in which people with a history of "resistance" to LAs were given skin injections of three different LAs, and there were subtle differences in the anesthetic effects. Maybe resistance varies between amide and ester. So after a couple of bupiv SAB failures, maybe an attempt with epidural chloroprocaine?

 

[sevoflurane]

With full motors on board after the first SAB, I thought it was safe to do a 2nd, and then a third. Intrathecal catheter or epidural would have been a more elegant way to go. I wish I would have thought of that at the time. Switching to another local anesthetic is also a great idea. This is a rare enough event (some of my partners have had this happen 3-4 times in 15+ years).
Next time I see this, I think I will use an intrathecal catheter/epidural and different LA after the first spinal. Excellent points.

 

[IN2B8R]

The most likely reason for your failed spinals was using inactive LA. Heavy Bupivicaine 0.75%, when laying around on loading docks of hospitals on sunny days, will easily get deactivated, leading to failed spinals. If you run into this situation again, where you are sure that you were intrathecal and in spite of your proper technique your spinal failed, then switch to isobaric bupivicaine or another LA all together.... And by the way, this has happened frequently in such settings as OB and elsewhere.

I am happy I'm not the only one. Any Idea why??? Seems bizarre as it does not make anatomic sense to me.