Interscalene with decadron + buprenorphine

[excalibur]

---

Members don't see this ad.

57 y/o nondiabetic woman for shoulder arthroscopy. USG ISB block at 0730. 30 mL of Bupi 0.5% + 4 mg of PF Dexamethasone + 150 mcg PF buprenorphine.

Pt had 32.5 hrs of 0/10 analgesia. On average I get 28 hrs with just the decadron.

Side effects: Pt had significant somnolence postop that required prolonged stay in our PACU and her one day surgery room. Pt would just doze off/shut her eyes for several hours postop. Her somnolence was accompanied by sats of 87-89 on room air shortly postop, which made weaning from nasal cannula a more lengthy endeavor. She reported only mild nausea in hospital postop. She was observed for a long time, and we finally gave the go ahead to dc home at 5 pm as she had been off nasal cannula for 3 hrs by that time with sats of 93-94 and patient was awake and alert. Earlier she had complained of difficulty taking a deep breath which we attributed to ipsilateral hemidiaphragm paralysis. Per nurse pt even maintained sats of 93-94 when she dozed off for a bit while off nasal cannula. As a result we were comfortable in sending her home, but obviously discharge took much longer than anticipated. Furthermore, on phone follow up, pt reported episodes of retching on drive home and overnight, which were relieved by phenergan.

So although the analgesia was extended slightly, the drawbacks stated above were too much for me.

Unless you gurus end up showing me some great results on multiple patients with your personal concoctions, I am done with Buprenex. One patient with somnolence, prolonged postop stay, and retching was enough for me.

 

[sevoflurane]

Well said, although your N=1. (I'm curious as to the rest of your anesthetic.)

That being said, I can honestly say that:

For me, I find decadron excellent... and with the least s/e and complications.

 

[BobBarker]

We are just using 100mcg at the ASC now due to similar issues with somnolence. Adds 5 hours block duration but there seems to be a more prolonged analgesic effect. It's a bit harder to deduce as patient's have a harder time understanding what you are asking exactly.

 

[excalibur]

I was supervising a CRNA. I handled the sedation for the block. I gave 2 mg versed, 50 mcg fent, and 10 mg propofol for the block. If I were doing it, after that it would have been propofol push, LMA, and game over. The CRNA was set up to intubate. I was not going to fight that battle. I explained that you would very likely not need any more narcotic after intubation.

She gave 100 fent for intubation. And that is all narcotic she got. 150 mcg fent IV. 150 mcg Buprenorphine in block. I have done numerous interscalene blocks with just decadron where the sedation was 2 mg versed, 100 mcg fentanyl, and a touch of propofol. I have never gotten somnolence like this before. This scenario with the buprenorphine was just 50 mcg fentanyl more than what I would have used so I can't blame the somnolence on the fentanyl. If I would do it over I would just ditch the fentanyl sedation and use versed + propofol. However, until you guys give me good data with your patients, no more buprenorphine for me. Certainly feel that it can increase analgesia but too many SE too worry about.

 

[excalibur]

We are just using 100mcg at the ASC now due to similar issues with somnolence. Adds 5 hours block duration but there seems to be a more prolonged analgesic effect. It's a bit harder to deduce as patient's have a harder time understanding what you are asking exactly.

You using just buprenorphine or buprenorphine plus decadron? What is your cocktail? Didn't u say you were doing them postop? Yikes!

 

[BLADEMDA]

We are just using 100mcg at the ASC now due to similar issues with somnolence. Adds 5 hours block duration but there seems to be a more prolonged analgesic effect. It's a bit harder to deduce as patient's have a harder time understanding what you are asking exactly.

Thanks. I'll reduce the dosage for outpatients to 90 ug (30 ug per 0.1 ml) in younger patients and won't be adding it in the older ones.

I see Buprenorphine as more of an inpatient TAP adjunct than anything else. For open Belly/hernia repairs which require an overnight stay the Buprenorphine would be a nice adjunct. Still, I'll play with the dosage.

I appreciate the post. The sweet spot is probably the 60-90 ug dosage for younger patients having Same day surgery then going home.

I wouldn't give up on it until you have tried the 60 ug dosage as that may give the extra 4 hours without any significant side-effects.

 

[BLADEMDA]

I was supervising a CRNA. I handled the sedation for the block. I gave 2 mg versed, 50 mcg fent, and 10 mg propofol for the block. If I were doing it, after that it would have been propofol push, LMA, and game over. The CRNA was set up to intubate. I was not going to fight that battle. I explained that you would very likely not need any more narcotic after intubation.

She gave 100 fent for intubation. And that is all narcotic she got. 150 mcg fent IV. 150 mcg Buprenorphine in block. I have done numerous interscalene blocks with just decadron where the sedation was 2 mg versed, 100 mcg fentanyl, and a touch of propofol. I have never gotten somnolence like this before. This scenario with the buprenorphine was just 50 mcg fentanyl more than what I would have used so I can't blame the somnolence on the fentanyl. If I would do it over I would just ditch the fentanyl sedation and use versed + propofol. However, until you guys give me good data with your patients, no more buprenorphine for me. Certainly feel that it can increase analgesia but too many SE too worry about.

I bet you are correct. See my previous post. I suspect the side-effects are dose related so why not try just 60 ug next time? I respect your decision to give up on it but one more try with the 60 ug dose seems quite reasonable.

Appreciate your post and the case report.

 

[BobBarker]

We are using 10mg decadron (not the dosage I recommended, FYI), 100mcg buprenorphine and 0.25% bupivicaine. Yes, the block is postop.

 

[excalibur]

We are using 10mg decadron (not the dosage I recommended, FYI), 100mcg buprenorphine and 0.25% bupivicaine. Yes, the block is postop.

Ok. How many hours after the block until your patients first report pain?

You are not having any of the side effects I described with 100 mcg?

What is the typical narcotic regimen these pts are getting intraop? I know u stated that there were some PONV respiratory depression disasters with dilaudid intraop and higher dose buprenex for block

 

[BLADEMDA]

We are using 10mg decadron (not the dosage I recommended, FYI), 100mcg buprenorphine and 0.25% bupivicaine. Yes, the block is postop.

How many have you performed with that cocktail? 100ug of Burprenorphine? It comes 300 ug/ml so you draw up 0.33 mls instead of 0.3 mls (90 ug)?

What kind of side-effects? Also, I have never seen any evidence for adding more than 8mg of decadron to the local to enhance duration. Why are you using 10 mg?

 

[excalibur]

I bet you are correct. See my previous post. I suspect the side-effects are dose related so why not try just 60 ug next time? I respect your decision to give up on it but one more try with the 60 ug dose seems quite reasonable.

Appreciate your post and the case report.

I am certain I will be put on two shoulders tomorrow. Truthfully, I am reluctant. I have seen what 150 mcg can do. I agree that reducing the dose "probably" will eliminate the SE. 60 mcg sounds reasonable. Not sure 60 mcg will increase analgesia that much though. In truth 150 mcg didn't really wow me in terms of duration. 32 hrs with buprenex vs 28 hrs without. Is that a meaningful difference? Sure, if no side effects are in play I would choose the stuff that reliably gives me 32 hrs.

Hmmm. Will consider 60 mcg. What's too funny is that the anesthesiology articles on the subject report doses of over 300 mcg being given. Others the low dose is 300 mcg or maybe 3 mcg/kg. I gave 150 mcg or 2 mcg/kg and now we are talking about dropping it to 60 mcg

 

[BobBarker]

How many have you performed with that cocktail? 100ug of Burprenorphine? It comes 300 ug/ml so you draw up 0.33 mls instead of 0.3 mls (90 ug)?

What kind of side-effects? Also, I have never seen any evidence for adding more than 8mg of decadron to the local to enhance duration. Why are you using 10 mg?

I think among all residents probably around 15 patients. That is the dose of decadron that the boss wants to use. I draw up .33mls but I bet plenty of patients are getting .3mls instead. We are consistently around 35 hours with this cocktail and 0.25% bupi. If you have a savvy patient and after the anesthetic block has worn off you can deduce that they tend to have an additional 10 hours minimum analgesic effect. But to most people once they are no longer numb then the block is "over".

 

[excalibur]

I think among all residents probably around 15 patients. That is the dose of decadron that the boss wants to use. I draw up .33mls but I bet plenty of patients are getting .3mls instead. We are consistently around 35 hours with this cocktail and 0.25% bupi. If you have a savvy patient and after the anesthetic block has worn off you can deduce that they tend to have an additional 10 hours minimum analgesic effect. But to most people once they are no longer numb then the block is "over".

Cool. Those 15 pts or so, any side effects to report?

I feel the best question to ask patients postop is "When did you fist start hurting?". They usually give an exact time and it correlates with the 26-30 hrs I have been seeing.

Well my patient today is a 69 y/o lady. I am going to pass on the buprenex today, but I do think the 60 mcg might be something to explore.

Do it, Blade, and let me know how it goes!!!!

 

[Planktonmd]

Could it be that your patient was somnolent because she was hypoxic and hypercarbic due to paralyzed hemidiaphragm?

 

[excalibur]

Could it be that your patient was somnolent because she was hypoxic and hypercarbic due to paralyzed hemidiaphragm?

Think it was more likely that she was somnolent from the buprenorphine->hypoventilating->hypoxic. The hemidiaphragm paralysis did not help matters though.

I say this because I have seen a number of ISB patients complain of not being able to take a deep breath and hang around 93-94% on RA. None of those patients were as somnolent as this one even though those other patients also had hemidiaphragm paralysis. So since the main difference is that this patient got buprenorphine and somnolence is a known SE of that med, I would have to figure that the narcotic is the cause of her sleepiness.

 

[BLADEMDA]

Think it was more likely that she was somnolent from the buprenorphine->hypoventilating->hypoxic. The hemidiaphragm paralysis did not help matters though.

I say this because I have seen a number of ISB patients complain of not being able to take a deep breath and hang around 93-94% on RA. None of those patients were as somnolent as this one even though those other patients also had hemidiaphragm paralysis. So since the main difference is that this patient got buprenorphine and somnolence is a known SE of that med, I would have to figure that the narcotic is the cause of her sleepiness.

I'm sorry you won't try the Buprenorphine just one more time. My hunch is that the 0.5 percent Bup, 6-8 mg of decadron and Buprenorphine 60 ug will deliver the 34 hours of postop pain relief you are seeking from a single shot block.

 

[excalibur]

I will do it on right patient. Today's patient was not it. BobBarker's data is reassuring. On the right patient 90 mcg could have some benefit. Will try 60 mcg on right patient.

 

[DrRobert]

I was supervising a CRNA. I handled the sedation for the block.

You let CRNAs do blocks?

 

[excalibur]

You let CRNAs do blocks?

No.

The CRNA was scheduled for the case. I was the board runner supervising 4 rooms. We brought the patient in the room. I sedated the patient to my liking, and I did the block. Once the block was in, I did my charting and left the OR.

 

[excalibur]

Friday case. 58 yo 84 kg healthy man for shoulder arthroscopy with subacromial decompression. Opted to do block with buprenorphine.

25 mL Bupi 0.5% + 4 mg Dex + 90 mcg Buprenorphine gave 32.5 hr of 0/10 analgesia. About 4-4.5 hrs more than my average with just decadron. Exact same time length as with 150 mcg. Although with 90 mcg I got no N/V, respiratory depression, or somnolence.

Let me just add that the motor block lasted the same amount of time as it does with my decadron only blocks, about 26 hrs. With decadron only the motor block leaves around hour 26 and pain starts at hr 28, with my 2 decadron + buprenorphine blocks, motor block leaves at hour 26 and pain start hr 32.5.

 

[Libertas]

how about some clonidine, perhaps instead of buprenorphine?

 

[excalibur]

how about some clonidine, perhaps instead of buprenorphine?

From what I can remember from my lit review, clonidine does not extend the length of blocks when long acting LA's like bupivacaine are used.

To further this point, a review article from Pitt that Blade has posted in the past had that group using a cocktail of decadron, buprenorphine, and clonidine, and the length of their blocks were 32-34 hrs which is what I have gotten with just decadron and buprenorphine.

 

[Oggg]

Some studies say clonidine works, some say it doesn't. New article in BJA says clonidine IV is equivalent to bupiv/clonidine wound infiltration, but with more side effects

 

[excalibur]

Some studies say clonidine works, some say it doesn't. New article in BJA says clonidine IV is equivalent to bupiv/clonidine wound infiltration, but with more side effects

The side effect component was the other thing I was going to post. With PNB and light GA, my patients are often bradycardic and hypotensive already. I am not keen on risking more hypotension and bradycardia with a drug that may or may not extend a block.

Seems like the articles say yes buprenorphine works in extending blocks. Again from what I remember clonidine does not appear to extendthe duration of a block a clinically significant amount of time when long acting LA's are used.

 

[BLADEMDA]

I am using Buprenorphine in my blocks (selectively). My dosage is 60-120 ugs depending on the type of block and patient. I have zero side-effects with the 60 mic dosage and minimal side effects (mild sedation) with the 90 ug dosage. The 90 ug dosage seems more effective in providing an additional 4 hrs of analgesia. I encourage others to try these lower doses and report their findings here.

 

[somedumbDO]

Some studies say clonidine works, some say it doesn't. New article in BJA says clonidine IV is equivalent to bupiv/clonidine wound infiltration, but with more side effects

Data in pnb is mixed however the data in caudal and epidurals is well established incr block time by approx 4-6 hrs. I use a lot of clonidine in kiddy caudals