how much local and steroids do you inject in your blocks ?

[painfre]

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I usually inject
Lumbar/caudal epidural 3ml marcaine + 80 Depomedrol + NS 5ml
TFESI 2 ml marcaine + 2 ml celestone
Cervical Epi 2 ml celestone + 2 ml NS
SIJ 9ml marcaine + 40 mg Depomedrol
MBB 1 ml marcaine at each level
Sympathetic block 10-15 ml marcaine (mixed with steroids occasionaly)
Stellate ganglion block 4 ml marcaine ( +/- 25 mcg clonidine)
Knee/shoulder, Peripheral nerve blocks 5 ml marcaine with 40 mg kenalog

 

[epidural man]

I usually inject
Lumbar/caudal epidural 3ml marcaine + 80 Depomedrol + NS 5ml
TFESI 2 ml marcaine + 2 ml celestone
Cervical Epi 2 ml celestone + 2 ml NS
SIJ 9ml marcaine + 40 mg Depomedrol
MBB 1 ml marcaine at each level
Sympathetic block 10-15 ml marcaine (mixed with steroids occasionaly)
Stellate ganglion block 4 ml marcaine ( +/- 25 mcg clonidine)
Knee/shoulder, Peripheral nerve blocks 5 ml marcaine with 40 mg kenalog

I tell the fellows at my place - "the only people that put local in their ILESI were either trained in the military, or over 30 years ago!"

I guess I'll have to change my story now. (Unless you were military trained or did it 30 yrs ago...did you?)

I usually use 0.3 ml for my Dx MBB. Also, rather than what most textbooks recommend by placing the needle at the junction of the TP and superior articulating process, I use Bogduk's suggestion and place the needle mid transfers process. Apparently this is a lot more specific.

 

[lobelsteve]

I usually inject
Lumbar/caudal epidural 3ml marcaine + 80 Depomedrol + NS 5ml
TFESI 2 ml marcaine + 2 ml celestone
Cervical Epi 2 ml celestone + 2 ml NS
SIJ 9ml marcaine + 40 mg Depomedrol
MBB 1 ml marcaine at each level
Sympathetic block 10-15 ml marcaine (mixed with steroids occasionaly)
Stellate ganglion block 4 ml marcaine ( +/- 25 mcg clonidine)
Knee/shoulder, Peripheral nerve blocks 5 ml marcaine with 40 mg kenalog

ILESI 2NSS + 2 Celestone (12mg)
TFESI 2NSS + 1.2 Dex
MBB 0.3 ml 0.5% marcaine at each level (#1) then 2% lidocaine (#2)
Sympathetic block 10-15 ml marcaine (mixed with steroids occasionaly)
Stellate ganglion block 10-12 ml marcaine
Knee/shoulder, Peripheral nerve blocks 5 ml marcaine, 2 ml lido, 2 Celestone
SIJ 2cc marcaine 2 Celestone- 1.5-2cc in joint, then the rest around the capsule (if therapeutic). If diagnostic- then 1.5cc marcaine in the joint only.

9cc in an around the SIJ lacks any Dx specificity and will not have intended effect. It can go epidural, leak to the L5-S1 facet, go into the pelvis, etc. Where the heck did that come from?

 

[SSdoc33]

a competent SIJ only hold 2 mL volume

 

[painfre]

Thanks for your comments. I was not trained at military but working for veterans since last 1 year after finishing my fellowship (under anesthesiology) a year ago. Probably, all my attendings were trained in military🙂. They use marcaine or ropivicaine almost in all blocks. For SI joint they use 5 ml in the inferior portion of SI joint and 5 ml in the peri articular areas.
I have to change my dosage amounts now. I wish that all the fellowship programs should train their fellows in same way.

 

[Tenesma]

re: SIJ - agree w/ ssdoc33... usually use 1.5cc lido and 20mg kenalog...

it always amazes me that ortho/rheum has no problem injection 8-10 cc of marcaine into the shoulder/hip/troch bursa... where does that volume go? --- i usually do fine with 2cc of local for those areas.

 

[SSdoc33]

re: SIJ - agree w/ ssdoc33... usually use 1.5cc lido and 20mg kenalog...

it always amazes me that ortho/rheum has no problem injection 8-10 cc of marcaine into the shoulder/hip/troch bursa... where does that volume go? --- i usually do fine with 2cc of local for those areas.

the ortho guys pump the joint full of tons of saline when they do arthroscopies, so the hip especially can hold a lot. bursas? no.

 

[Pain Applicant1]

I think it's better to use a more generous volume when injection the GT bursa because I don't think the pain mainly comes from the bursa in most cases. It more likely comes from tendon attachments in the area.

 

[ampaphb]

Also, rather than what most textbooks recommend by placing the needle at the junction of the TP and superior articulating process, I use Bogduk's suggestion and place the needle mid transfers process. Apparently this is a lot more specific.

This is entirely level dependent. Ask Nick to or Charlie to show you Suzie Lord's PhD. Dissertation the next time you see one of the,

 

[ampaphb]

a competent SIJ only hold 2 mL volume

1cc, in my experience

 

[ampaphb]

I tell the fellows at my place - "the only people that put local in their ILESI were either trained in the military, or over 30 years ago!"

Steroids typically dont demonstrate efficacy for 1-2 days post injection. Unless you are concerned about intrathecal needle placement, giving the patient relief for those 1-2 days by adding local seems the humane thing to do.

 

[Tenesma]

ampa.... local will last 2-6 hours... what is the humane thing to do between wearing off of the local and the start of steroid effect?

ssdoc33... 8-10ccs into a joint under spinal or general anesthesia doesn't count... 8-10ccs into an awake, sensate patient is very uncomfortable...

i personally don't see the point of 8ccs of local if we are using fluoro guided procedures, if we are confident of our accuracy, the local amount is tiny (just to take the edge off the procedure) while the steroid does the trick...

 

[bedrock]

Steroids typically dont demonstrate efficacy for 1-2 days post injection. Unless you are concerned about intrathecal needle placement, giving the patient relief for those 1-2 days by adding local seems the humane thing to do.

you mean 1-2 hours right? Adding local isn't going to give anyone a few days of relief, just a few pointless hours, but with the risk of local going where you don't want it.

If you really wanted to give them as much short term relief before your particulate steroid starting working, I guess you could mix in bupivacaine & dexamethasone to optimize the first 24-48 hours of relief, but not worth it in my opinion. Saline and triamcinolone work just fine.

 

[SSdoc33]

ssdoc33... 8-10ccs into a joint under spinal or general anesthesia doesn't count... 8-10ccs into an awake, sensate patient is very uncomfortable...

you can easily put 10 mL into a hip. EASILY. not sure why you would need to, but it can be done without any signficant pain of capsular distention. I have aspirated 120mL from a hip.

 

[101N]

you can easily put 10 mL into a hip. EASILY. not sure why you would need to, but it can be done without any signficant pain of capsular distention. I have aspirated 120mL from a hip.

Hips, shoulders, knees, & GTBs all get 10cc from me. Some times 10cc in a hip is painfully if there is synovitis.

 

[Tenesma]

i agree that 10 ccs can fit into some of these joints before intra-capsular pressure increases to the point of significant pain, but for the most part, most of my patients start complaining about discomfort into the join with larger volumes (ie: >5cc)...

look at how well 1-2 ccs of contrast spread around the hip joint, do you really need 10cc to get the steroid swishing around?

i guess it comes down to preference/habits

the ONLY injection that I do that has volume (ie: >2 cc) is for caudal injection...

 

[Ligament]

I blocked my medial plantar nerve once with .75% marcaine and was insensate for 48 hours.

 

[lobelsteve]

I blocked my medial plantar nerve once with .75% marcaine and was insensate for 48 hours.

0.5cc lidocaine subq to the forearm lasted 18 hrs and was insensate over 1"

I had a massive ice cream headache today. Stupid frappes.

 

[ampaphb]

OF course if you have your injections done in Padukah, KY, local anesthetic will last between one (http://goo.gl/Nm0Zj) and two (http://goo.gl/vgzYh) YEARS

 

[SSdoc33]

look at how well 1-2 ccs of contrast spread around the hip joint, do you really need 10cc to get the steroid swishing around?

nope. i typically put 5 mL tops in hip injections. im just saying the joint HOLDS that amount easily, where the SI only holds 2 (or 1 if you want to be argumentative)

 

[101N]

You guys are using homeopathic volumes. Wussies.

 

[Jcm800]

nope. i typically put 5 mL tops in hip injections. im just saying the joint HOLDS that amount easily, where the SI only holds 2 (or 1 if you want to be argumentative)

2 cc of a tfesi total.

0.5 cc for mbb

3 cc for si joint

5 cc for hip,shoulder, bursa, knee

3 cc for gh

3 cc for ilesi

Less is more i thinks

 

[drf]

You guys are using homeopathic volumes. Wussies.

For specificity when doing diagnostic nerve blocks in the axilla, I will separately block the ulnar, median, and radial with 1 ml. 0.25 ml each corner.

 

[clubdeac]

2 cc of a tfesi total.

0.5 cc for mbb

3 cc for si joint

5 cc for hip,shoulder, bursa, knee

3 cc for gh

3 cc for ilesi

Less is more i thinks

I agree with Docshark on this. And 9cc's into an SIJ, wowzers that's crazy talk

 

[PMR 4 MSK]

IL or TFESI - 1 ml Depomedrol 80 mg/ml
SIJ - 1 ml Depomedrol or Kenalog + 2 cc 1% lido
Facet - 1 cc at most per joint, 1 ml steroid in 1-2 ml 1% lido depending on # joints injected.
MBB - 1/3 cc 1% lido
Shoulder, hip - 1 ml steroid 2-4 cc 1 or 2 % lido
smaller joints - less volume.
Fingers - 1/2 cc steroid

I use the smallest amount of fluid necessary to get the job done. No local in my ESIs. Minimal local for all else - it's only gonna last a short while anyway.