Injectate for lumbar sympathetic block

[GottaHaveIt]

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Just wanted to see what people are using out there.

This is my first year as an attending. I am currently using a 10cc mixture containing 1% lido, 0.25% bupi, and 10mg of dexamethasone.

Any people out there using more than 10mg dex?

 

[RoloTomassi]

Just wanted to see what people are using out there.

This is my first year as an attending. I am currently using a 10cc mixture containing 1% lido, 0.25% bupi, and 10mg of dexamethasone.

Any people out there using more than 10mg dex?

Looks good to me

 

[chibadriver]

Just wanted to see what people are using out there.

This is my first year as an attending. I am currently using a 10cc mixture containing 1% lido, 0.25% bupi, and 10mg of dexamethasone.

Any people out there using more than 10mg dex?

That should do, I do 5 mLs 2% lido, 5 mLs 0.5% marcaine and 40mg kenalog.

 

[willabeast]

That should do, I do 5 mLs 2% lido, 5 mLs 0.5% marcaine and 40mg kenalog.

Nice thing about 2% lido is i think it speeds up the temperature rise so i can turn over the room.

 

[soccrwz]

No clinical advantage when mixing, and you are getting 50% strength bc now lidocaine 2%in 10mL is half strengths 1% if diluted. Concentration gradient is a big part of effect which is now lessened. The only advantages are lowering the concentration of marcaine dose so not to get LAST, and if lidocaine has epi, which I do mix for perms to decrease bleeding. There have been studies that mixing does not improve onset with lidocaine lido/marcaine, this is an academic thing that has persisted but is untrue

 

[Espn123]

Is there any reason to add the steroid??

 

[Gnarvin]

I use 10mL of 0.5% bupi with 10mg dexamethasone.

 

[Gnarvin]

My reasoning for adding the steroid is that there have been some studies showing that dexamethasone added to nerve blocks increases the duration of block.

 

[lobelsteve]

My reasoning for adding the steroid is that there have been some studies showing that dexamethasone added to nerve blocks increases the duration of block.

Yes. I do same but .25% bup and 4mg dec.

 

[deleted875186]

Contrast, 2 cc lidocaine test dose because I’m neurotic, then 5 mL 0.25% and 40 mg depo

 

[clubdeac]

I was told by several attendings years ago that sympathetic nerves were the most sensitive to local anesthetic so no need using higher concentrations like 2% lido or 0.5% marcaine?

 

[willabeast]

I was told by several attendings years ago that sympathetic nerves were the most sensitive to local anesthetic so no need using higher concentrations like 2% lido or 0.5% marcaine?

This is true but you will get a faster response with a higher concentration of local and sitting around for an extra 10 minutes in a procedure room waiting for a skin temperature change is not optimal.

 

[callmeanesthesia]

This is true but you will get a faster response with a higher concentration of local and sitting around for an extra 10 minutes in a procedure room waiting for a skin temperature change is not optimal.

But what do you do if the skin temp doesn’t change?
I use 9-10 mL 1% lidocaine, and usually 4 mg of dex. I tell them their leg may feel very warm, and that’s just a sign it’s working.

 

[chibadriver]

No clinical advantage when mixing, and you are getting 50% strength bc now lidocaine 2%in 10mL is half strengths 1% if diluted. Concentration gradient is a big part of effect which is now lessened. The only advantages are lowering the concentration of marcaine dose so not to get LAST, and if lidocaine has epi, which I do mix for perms to decrease bleeding. There have been studies that mixing does not improve onset with lidocaine lido/marcaine, this is an academic thing that has persisted but is untrue

I’m aware of the literature as it pertains to somatic nerve blocks, can you share this information for sympathetic blocks? I have done mixed and long-acting alone and the mixed concentration certainly sets up quicker. Perhaps I should transition to short acting alone?

Temperature assessment can be difficult with the skin thermometer as these patients are usually quite sensitive on the affected extremity, I’ve gone to using a laser temperature gun. We also photo document the extremities before and after the block. Any other pearls anyone?

 

[willabeast]

But what do you do if the skin temp doesn’t change?
I use 9-10 mL 1% lidocaine, and usually 4 mg of dex. I tell them their leg may feel very warm, and that’s just a sign it’s working.

if skin temp does not change, repeat the block after reviewing the contrast pics. might have to try the injection at a different level.

 

[Ducttape]

I use 10 ml 0.25% bupivacaine for block 1 and 2 (if indicated), and then 10 ml 0.25% bupivacaine and 4-10 mg dex for injection 3

if any of an injection fails, then none further.

I don't wait for temperature change. takes too long, thermometers can be inaccurate, and if it is sympathetically mediated, the injection will help. if not, c'est la vie, with 10 ml bupiv, it should cover most of the sympathetics.

 

[mid|ine]

11ml of 1% lido w 1ml of contrast

 

[soccrwz]

I’m aware of the literature as it pertains to somatic nerve blocks, can you share this information for sympathetic blocks? I have done mixed and long-acting alone and the mixed concentration certainly sets up quicker. Perhaps I should transition to short acting alone?

Temperature assessment can be difficult with the skin thermometer as these patients are usually quite sensitive on the affected extremity, I’ve gone to using a laser temperature gun. We also photo document the extremities before and after the block. Any other pearls anyone?

Local anesthetics. Is there an advantage to mixing solutions? - PubMed

The advantages to using a 50/50 mixture of lidocaine and bupivacaine with respect to onset and duration of local anesthesia instead of using the solutions independently were evaluated. In a double-blind randomized experiment, 12 subjects, each volunteering both feet, were studied. One foot was...

pubmed.ncbi.nlm.nih.gov

"The advantages to using a 50/50 mixture of lidocaine and bupivacaine with respect to onset and duration of local anesthesia instead of using the solutions independently were evaluated. In a double-blind randomized experiment, 12 subjects, each volunteering both feet, were studied. One foot was injected with 1 ml of one of the following three solutions: 1% plain lidocaine, 0.25% plain bupivacaine (Marcaine), or a 50/50 mixture of 1% lidocaine and 0.25% bupivacaine; and in the other foot, a 1-ml injection of normal saline as a blinded control. A 5.07 (10 g) Semmes-Weinstein monofilament wire was used for testing for sensory blockade, and the onset and duration of anesthesia was recorded for each subject. It was determined that there was no significant difference in the mean onset times for the three solutions, and no significant difference between the durations of anesthesia of plain lidocaine and the 50/50 mixture. Additionally, it was determined that bupivacaine had a prolonged duration of anesthesia compared with the other two solutions"

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Steroids can prolong the duration of the block, I believe thats been published a couple of times

 

[kstarm]

contrast then 1ml of lido/epi test dose and then 20ml of 0.2% ropivacaine. Looks like a lot of dex user, I may have to switch things up.

 

[nvrsumr]

I added dex to all nerve blocks for a few years and now have stopped for several years and haven’t noticed a difference.

10cc 1% lido. I only do a few a year now and mainly diagnostic. Would do differently if doing serial blocks

 

[painfree23]

What level are you doing these typically? Does the level effect how much u use?

 

[soccrwz]

What level are you doing these typically? Does the level effect how much u use?

L4

 

[Ronin1]

There was a study at some point showing that giving steroid iv was equivalent to adding to the mixture for duration of blockade… I don’t add any steroids for LSB

 

[deleted875186]

There was a study at some point showing that giving steroid iv was equivalent to adding to the mixture for duration of blockade… I don’t add any steroids for LSB

That was for postoperative pain for nerve blocks with anesthesia, no such study that I know of measuring pain relief for chronic pain.

 

[gaseous_clay]

Just wanted to see what people are using out there.

This is my first year as an attending. I am currently using a 10cc mixture containing 1% lido, 0.25% bupi, and 10mg of dexamethasone.

Any people out there using more than 10mg dex?

Same

 

[Ferrismonk]

Nice thing about 2% lido is i think it speeds up the temperature rise so i can turn over the room.

This is true but you will get a faster response with a higher concentration of local and sitting around for an extra 10 minutes in a procedure room waiting for a skin temperature change is not optimal.

You don't need to wait in the room. Do the block then bring them to your recovery area. Check them again before they leave.

 

[SpineandWine]

10 cc of Ropi 0.1% or Bupi 0.25%- no steroids.
Mixing Lidocaine with Bupi will reduce how long Bupi's duration of action is. This is not just about diluting Lidocaine from 2% to 1% - overall, duration of long acting local anesthetic is decreased when mixed with lidocaine.

 

[Gnarvin]

10 cc of Ropi 0.1% or Bupi 0.25%- no steroids.
Mixing Lidocaine with Bupi will reduce how long Bupi's duration of action is. This is not just about diluting Lidocaine from 2% to 1% - overall, duration of long acting local anesthetic is decreased when mixed with lidocaine.

This is true. Because if you mix 5cc of 2% lido with 5 cc of 0.5% bupi you end up with a 10cc solution of 1% lido with 0.25% bupi.

 

[SpineandWine]

Partly and most likely- you are correct in that majority of the influence is due to local anesthetic concentration (I agree with you). However, Bupivicaine 0.25% in my opinion would still have prolonged duration compared to 10 cc of 1% Lido and 0.25% Bupi without significant increase in onset time! There are also other consequences too - having to do with pH/pKa, protein binding which in large part, as you said, have to do with diluting the substance.

Mixing local anesthetics - yay or nay?

Dr. Erik Hofmeister, Professor of Anesthesia at Auburn University College of Veterinary Medicine, Deputy Editor for Veterinary Anaesthesia and Analgesia, and The Vetducator (vetducator.com) blogger, discusses the practice of mixing short- and long-acting local anesthetics. I think I was in my...

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