How much is too much

[bostonblaz]

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I will keep this short. 1 month ago had a pt for total knee. Got fem cath, spinal with duramorph and pac for post op(our standard protocol). She wigs out on the floor and it is blamed on the interthecal and iv opoids. She gets discharged on lovenox and pod #7 comes for a hemarthosis and needs an I/d. She has some sort of dvt in the past issue where heme wants her always covered for clot so she is on lmwh. I do single shot fem/sciatic and slide in an lma. She does great, daughters(both nurses) are happy. I go on vacation and she has two more washouts and both times was doe with narcs and ga. She freaks out both times. Now I am back and so is she with an infected joint. She had a removal and placement of antibiotic spacer. Did blocks and she did great. Ortho tells me she needs four more washouts and then he will do the arthoplasty. My question is how many times can I do repeated blocks over a short period of time? I was unable to find anything when I searched. Does anybody know? Thanks for the help. Blaz

 

[SleepIsGood]

I will keep this short. 1 month ago had a pt for total knee. Got fem cath, spinal with duramorph and pac for post op(our standard protocol). She wigs out on the floor and it is blamed on the interthecal and iv opoids. She gets discharged on lovenox and pod #7 comes for a hemarthosis and needs an I/d. She has some sort of dvt in the past issue where heme wants her always covered for clot so she is on lmwh. I do single shot fem/sciatic and slide in an lma. She does great, daughters(both nurses) are happy. I go on vacation and she has two more washouts and both times was doe with narcs and ga. She freaks out both times. Now I am back and so is she with an infected joint. She had a removal and placement of antibiotic spacer. Did blocks and she did great. Ortho tells me she needs four more washouts and then he will do the arthoplasty. My question is how many times can I do repeated blocks over a short period of time? I was unable to find anything when I searched. Does anybody know? Thanks for the help. Blaz

possible case report bud👍

 

[sevo85288]

Are washouts that painful.? Try to rotate the IV opioids...Hydromorphone? Be careful here...

 

[BLADEMDA]

I will keep this short. 1 month ago had a pt for total knee. Got fem cath, spinal with duramorph and pac for post op(our standard protocol). She wigs out on the floor and it is blamed on the interthecal and iv opoids. She gets discharged on lovenox and pod #7 comes for a hemarthosis and needs an I/d. She has some sort of dvt in the past issue where heme wants her always covered for clot so she is on lmwh. I do single shot fem/sciatic and slide in an lma. She does great, daughters(both nurses) are happy. I go on vacation and she has two more washouts and both times was doe with narcs and ga. She freaks out both times. Now I am back and so is she with an infected joint. She had a removal and placement of antibiotic spacer. Did blocks and she did great. Ortho tells me she needs four more washouts and then he will do the arthoplasty. My question is how many times can I do repeated blocks over a short period of time? I was unable to find anything when I searched. Does anybody know? Thanks for the help. Blaz

I had one patient where I performed a Lumbar Plexus/sciatic block once a week for 4 weeks. No problems. IMHO, just give the nerve time to recover from the block before repeating the process. Perhaps, you could vary the injection sites as well.

 

[Idiopathic]

i think you are taking a chance doing that many proximal femoral injections, but im not sure the literature backs it up, its probably just anecdotal. if you are careful and skilled then i would think you could do a block every 2nd day if you needed to. consider using short acting LA?

 

[rsgillmd]

My guess is that the number of injections probably won't matter as long as the nerve has time to recover -- it's sort of the equivalent of a long nerve block infusion.

I think your bigger concern would be going through the same puncture site repeatedly, which theoretically may increase risk of tract formation, which may in turn lead to infection risk. Multiple punctures alone probably increase risk of infection.

So in my humble opinion, you should be OK if you:

a) Avoid going through the same puncture site
b) Continue to be meticulous about aseptic precautions
c) Allow for recovery from block between procedures -- related to this might be using shorter acting agents for control of intraop pain, and then narcotics primarily for post-op pain.

The disclaimer is that is purely theoretical conjecture. As one other poster said, this could be a good case report. Good luck!

 

[proman]

Why not just do a tunneled catheter? Assuming 4 washouts will be every other day? That's within the lifespan of a catheter.