ICNBs with thrombocytopenia

[clubdeac]

Got a consult for a very sick stage IV lung cancer patient with chest wall pain secondary to radiation. His plt's are 40k, WBC 2. Would you guys go ahead and do the blocks?

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[pastafan]

Yes, small caliber needle. Terminal patient, benefit>risk IMO.

 

[EtherBunny]

Got a consult for a very sick stage IV lung cancer patient with chest wall pain secondary to radiation. His plt's are 40k, WBC 2. Would you guys go ahead and do the blocks?

Yes, same reasoning as above.

 

[Timeoutofmind]

Would go ahead and just add risks to consent

risks pretty minimal

 

[Orin]

High volume PVB with fluoro/ultrasound as a temporizing maneuver.
One needle, less large vessels, good spread.

Would discuss intrathecal pump or intercostal ablation for durable relief if they bounce back a little.

 

[Ligament]

Fine to proceed. Risk is minimal if bleeding does happen.

 

[painfree23]

High volume PVB with fluoro/ultrasound as a temporizing maneuver.
One needle, less large vessels, good spread.

Would discuss intrathecal pump or intercostal ablation for durable relief if they bounce back a little.

Do you pulse or straight 80 degrees?

 

[clubdeac]

High volume PVB with fluoro/ultrasound as a temporizing maneuver.
One needle, less large vessels, good spread.

Would discuss intrathecal pump or intercostal ablation for durable relief if they bounce back a little.

Ok I am ashamed to admit but I've never done a PVB. Is that essentially a LSB in the thoracic region? Do you advance all the way to the anterior border of the vertebral body? And do you hug the body like in an LSB?

 

[Ducttape]

easiest way to explain:
Thoracic Paravertebral Block - NYSORA The New York School of Regional Anesthesia

 

[Orin]

Do you pulse or straight 80 degrees?

Sorry, when I think ablate I think heat and chemical. So you can block and burn if you don't think it's stim-able or pump-able, or you could neurolyse.

Pulse is safer for heat damage to the other areas, but I haven't had much luck with it for anything, and in that area with the relatively large intercostal vessels and pleura, you'll have a hard time maintaining significant heat on the nerve.

If they are as terminal as you're describing though, you can also chemically ablate with low volumes of phenol or alcohol. The intercostal space communicates with the paravertebral space very easily if you're proximal to the neuraxis, so I would use less than 2 or 3 mLs of your neurolytic of choice.

Intercostal Nerve Block and Neurolysis for Intractable Cancer Pain. - PubMed - NCBI

These folks did it in from T1 to T11 for non-terminal pain, so you can use that as a guide for what it's worth.
Ultra-sound Guided Intercostal Neurolysis for Intractable Pain Arising out of Rib Fracture

 

[clubdeac]

Sorry, when I think ablate I think heat and chemical. So you can block and burn if you don't think it's stim-able or pump-able, or you could neurolyse.

Pulse is safer for heat damage to the other areas, but I haven't had much luck with it for anything, and in that area with the relatively large intercostal vessels and pleura, you'll have a hard time maintaining significant heat on the nerve.

If they are as terminal as you're describing though, you can also chemically ablate with low volumes of phenol or alcohol. The intercostal space communicates with the paravertebral space very easily if you're proximal to the neuraxis, so I would use less than 2 or 3 mLs of your neurolytic of choice.

Intercostal Nerve Block and Neurolysis for Intractable Cancer Pain. - PubMed - NCBI

These folks did it in from T1 to T11 for non-terminal pain, so you can use that as a guide for what it's worth.
Ultra-sound Guided Intercostal Neurolysis for Intractable Pain Arising out of Rib Fracture

Intercostal alcohol or phenol neurolysis is very dangerous. I did this to a few patients before I didn't know what I didn't know. One developed severe chronic neuritis. There is at least one case in the literature of paralysis following this procedure. Proceed with caution if using chemicals

 

[Orin]

Agreed.

What concentration/volume did you use clubdeac?

The difficulty with that technique is the space. If you don't do fluoroscopic guided intercostals, you may not appreciate how far a small amount of volume spreads.

Thermal ablation is simpler, and if you have it, I hear good things about the cryo ablation techniques for intercostal issues.

 

[clubdeac]

Agreed.

What concentration/volume did you use clubdeac?

The difficulty with that technique is the space. If you don't do fluoroscopic guided intercostals, you may not appreciate how far a small amount of volume spreads.

Thermal ablation is simpler, and if you have it, I hear good things about the cryo ablation techniques for intercostal issues.

It's been awhile but I think I only used 1cc when doing neurolysis. Have only done thermal ablation in the last 4 years

 

[painfree23]

It's been awhile but I think I only used 1cc when doing neurolysis. Have only done thermal ablation in the last 4 years

Thermal---80 for 90?
How early do u try to catch it from the spine?

 

[clubdeac]

Thermal---80 for 90?
How early do u try to catch it from the spine?

2" from spine. I always used 80 degrees. A new study showed that 90s for lumbar facet pain was superior to 80 though

 

[painfree23]

would you give platelets to cirrhotic for pt who may need an epidural? the liver team sent it to me, wants to admit patient, get platelets/FFP, do the epidural, watch the patient overnight and then discharge the next day. INR 1.4, plats < 50k

 

[lobelsteve]

would you give platelets to cirrhotic for pt who may need an epidural? the liver team sent it to me, wants to admit patient, get platelets/FFP, do the epidural, watch the patient overnight and then discharge the next day. INR 1.4, plats < 50k

Risk to benefit just isn't there. This guy is not getting an epidural

 

[BobBarker]

Platelets are the most likely blood product to introduce bacteremia. They are stored at room temperature.

Anesthesiology residency: not just a means to an end.

 

[painfree23]

Risk to benefit just isn't there. This guy is not getting an epidural

agreed. just wanted to make sure i wasn't crazy. would u try butrans on him? really bad liver and heart