patients still having signif pain in pacu after multimodal (tylenol, nsaid, precedex, ketamine, mgso4, flexaril) + lumbar plexus block. Any other suggestions? I am contemplating adding parasacral sciatic blocks.
hip arthroscopy
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How about adding some opioid?
D
deleted682700
Make sure patient is not infected
How about fascia iliaca block under usg
How about fascia iliaca block under usg
Yes we add opioid but then postop is sleepy and doesn't relieve pain as conete regional anesthesia will.
I don't see how fascia iliaca would help. Lumbar plexus provide wider block than fascia iliaca so perhaps a sciatic block would be a useful addition.
I don't see how fascia iliaca would help. Lumbar plexus provide wider block than fascia iliaca so perhaps a sciatic block would be a useful addition.
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If pts are still having that much pain after all that + LP block/fascia iliaca block, I might start to question the quality of the block. If you add a sciatic block, you're basically blocking the entire leg for a freaking hip scope
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I generally give tylenol, toradol, ketamine, and a little fentanyl for hip scopes, and they seem to do just fine in the PACU, and leave within an hour. If you are doing all of that, AND a block, something is very wrong with your patient population, block, or surgeon. Hip scopes should not hurt that much.
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I do blind fascia iliaca blocks and Tylenol and with that most patients need no additional analgesics post op.
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Huh? What are they doing in there with that scope? Most of my total hip arthroplasty patients are comfy in PACU with no block, some tylenol, some NSAID, and a little narcotic.
Thanks for the feedback
I think the lumbar plexus blocks are ok, US guided, +pns, flaccid quad.
2 blocks seems like overkill but we do proximal block for the shoulder all the time, just fortunate that one injection will get it all for the upper extremity.
The patients have been young, not chronic pain / opioid tolerant
Maybe I could reserve para sacral for those who have signif pain in pacu only
Anyone done para sacral blocks?
Would they be better than mod labat sciatic blocks for hip pain?
Anyone have problems with urinary retention after hip arthroscopy or para sacral blocks?
I think the lumbar plexus blocks are ok, US guided, +pns, flaccid quad.
2 blocks seems like overkill but we do proximal block for the shoulder all the time, just fortunate that one injection will get it all for the upper extremity.
The patients have been young, not chronic pain / opioid tolerant
Maybe I could reserve para sacral for those who have signif pain in pacu only
Anyone done para sacral blocks?
Would they be better than mod labat sciatic blocks for hip pain?
Anyone have problems with urinary retention after hip arthroscopy or para sacral blocks?
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We don't block hip scopes and I don't remember a rescue block in the past 3 yrs.....
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Tetracaine spinal if you really want no pain for a while after they get done, but then they hurt just as bad starting at 6 hours later...
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I can't believe these hip scopes are hurting this badly.
Plus, a spinal for a hip scope is a bad choice IMO. The pressure in the hip joint when they stretch it and dislocate the socket will break through the spinal.
Plus, a spinal for a hip scope is a bad choice IMO. The pressure in the hip joint when they stretch it and dislocate the socket will break through the spinal.
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Full disclosure, I dont do tetracaine spinals, was just pointing out that would make them never ever hurt in PACU. One of my surgeons asks for this because he feels it gives the fluid time to reabsorb, but just because he asks for something doesnt mean he gets it. We tried a few times and they sat around for 6 hours then felt miserable, got a ton of meds for 2 hours then either went home a bit uncomfortably or stayed overnight. I would not recommend this approach. I guess that is the issue with not being able to use a sarcastic tone on the internet.
I do GA most often with basically original poster cocktail, minus the LP block, and some narcotics. Bup spinals with moderate propofol works very well with my surgeons, but is kind of a pain with positioning.
If they hurt in PACU to the point where we are considering keeping overnight, I will do a fascia illiaca block. This takes away 40-60% of their pain, and the point of doing it as a rescue block is purely to make them comfortable enough to go home. I probably do this less than 10%.
I toyed with pre-emptive fascia illiaca for these, and basically because they still had pain the patients were just as likely to "need" further care as without. On a rescue basis I am 100% for having them comfortable enough to go home.
I do GA most often with basically original poster cocktail, minus the LP block, and some narcotics. Bup spinals with moderate propofol works very well with my surgeons, but is kind of a pain with positioning.
If they hurt in PACU to the point where we are considering keeping overnight, I will do a fascia illiaca block. This takes away 40-60% of their pain, and the point of doing it as a rescue block is purely to make them comfortable enough to go home. I probably do this less than 10%.
I toyed with pre-emptive fascia illiaca for these, and basically because they still had pain the patients were just as likely to "need" further care as without. On a rescue basis I am 100% for having them comfortable enough to go home.
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last patient i did was young female, long duration of traction hip A/S
multimodal + preop lumbar plexus + preop parasacral sciatic
minimal pain in pacu, blocks lasted ~30 hours, pain managable after that
multimodal + preop lumbar plexus + preop parasacral sciatic
minimal pain in pacu, blocks lasted ~30 hours, pain managable after that
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But you gave ketamine and precedex. They are already sleepy except that you haven't treated their pain so they are awake.
Multimodal includes OPIOIDS.
Also, all those things you gave (except for the regional) are usually in addition to small amounts of opioids. That's how it works. I know you can get away with this approach on some cases but that is unusual.
So when the blocks are not cutting it then admit defeat and give some opioids.
