Interscalenes with Depo Medrol to enhance block duration.

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Any of you using steroids in your interscalene single shots? 30-40mg of Depo Medrol mixed in with your local?

I never engaged in this practice as it was never taught to me in residency and I can't find any literature regarding this method of prolonging a shoulder block.

What I've heard is that the steroid absorbs some LA and acts as a controlled release mechanism of drug delivery thereby prolonging the block.

I first heard about it 3 years ago when I was on the interview trail. Several different groups had mentioned this adjunct to regional anesthesia. I'm still a bit curious.

I've heard of Interscalenes with steroids + local to be pain free for 30+ hrs.

Anybody doing this?

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yep, as long as they arent diabetic we are adding 4 of decadron to 30 of ropiv for most blocks, although it is provider preference
 
Thanks Idio. I found this from the ASA:

http://www.asa-abstracts.com/strand...B1D7666F242ED35?year=2009&index=17&absnum=901

2009.

Then I found this from 2006:

http://206.82.221.135/showthread.php?t=348824

Kinda funny how things can change.

Does it matter what you use? Decadron vs Depo Medrol. Decadron is a liquid and Depo Medrol comes in anhydrous form. Depo Medrol does not dissolve in LA very well. You can certainly see particulate matter if mixed this way, yet the above study uses it. Interesting.

Do you need to let the mixture sit for a couple of minutes and then give it? Or mix and give right away?

I'm going to give it a go a see how much I get out of them.
 
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There are a few attendings at HSS who started adding 10mg of PF dexamethasone to upper and lower extremity blocks. Anecdotally they were getting well over 24 hours of block duration.
 
I have not started adding it to any blocks and I was wondering myself if anyone else has tried. My standard mixture for isb is marciane 0.5% with epi 1:400k plus 1 mcg/kg clondine pf. For a while I sent them home with a form to mail back into me with the time they first had pain. I was getting an average of 22.25 hrs with the lowest being 18, the longest was 31. with out the epi and clonadine i was getting average of 19.5. if anyone tires this and works please let me know cause I would love to start using it.
 
I have not started adding it to any blocks and I was wondering myself if anyone else has tried. My standard mixture for isb is marciane 0.5% with epi 1:400k plus 1 mcg/kg clondine pf. For a while I sent them home with a form to mail back into me with the time they first had pain. I was getting an average of 22.25 hrs with the lowest being 18, the longest was 31. with out the epi and clonadine i was getting average of 19.5. if anyone tires this and works please let me know cause I would love to start using it.

You should keep doing this and publish it. Even though your PP you can still contribute.
 
weve seen some scary long block times with epi/clonidine/dex/ropi (like 40+ hours) so i will do it on shoulders who arent getting catheters but usually not on others
 
If I can routinely get 30 hrs out of mine my patients would be a lot more comfortable through the night and into the next day w/o the need of additional PO/IV analgesia. If you get around 20 hrs w/o steroids and do the block at 7:15 a.m, that means that unless you have systemic narcs on board, they will wake up in pain at around 3:00 a.m. That extra 8-10 hours would do wonders.

Nothing worse than a patient waking up at 3:00am with a block that has worn off and a nurse that has neglected to give narcs cause it wasn't needed at midnight.

I guess this is not limited to interscalenes as some have mentioned. I wonder if there is any difference in motor blockade? A common complaint with orthopods is quad weakness with femoral n. blocks... especially if you are getting them up and walking on POD 0.

If I was still in academics/residency I would be doing a couple of studies on this topic. I'm always looking for ways to get people up and walking with good analgesia and w/o motor weakness.

Does a dose of steroids placed in the brachial plexus or other peripheral nerve location raise blood glucose levels in diabetics? I don't know. Certainly IV routes do. Diabetics are already prone to neuropathies and there is such a thing as steroid induced neuropathy/myopathy. Is this clinically significant? I don't know.

Any of you young bucks in residency should grab this bull by the horns and do a couple of studies. It would be easy and well worth the research IMO.

Popped an interscalene last night. 35 mls of .375% marcaine with 40mg of depo medrol.
 
Higher volume with slightly less macracine compared to .5% and 30 mls. 131mg vs. 150mg. Onset seems to be quicker with higher volumes with certain body types and certain approaches. Lasts just as long. Difference is about 4cc's of .5%

Normal BMI's get .5% with 30ml of local. They set up pretty quick for shoulders. Can't say the same for hand surgery and supraclavicular/axillary or the large 350lb monster shoulder.

I really like to see good spread with my blocks. Most of the time 30 mls will do it. 35 mls nearly always does it. Take it with a grain of salt as this is nearly anecdotal. Just what I've come to over the years.
 
i do 35-40cc 0.5% ropi quite frequently. im questioning the step down in dose regarding duration of block. i understand the potential benefit to decreasing concentration but id think you would keep dose the same. just my thoughts

regarding 3-d spread in a 2-d view, its just not very sensitive. yeah we all like to see it, but you usually know after 5 cc are in and im not sure the last 5cc are that important
 
Here is a recent article from anesthesiology. It is somewhat different than our discussion here as they add a low dose rop. infusion via catheter. Good read nonetheless.

http://journals.lww.com/anesthesiol...tance_of_Volume_and_Concentration_for.17.aspx

It brings up some good points regarding the use of different volumes and concentrations of local anesthesia. 40cc’s of .5% ropivicaine will certainly give you a motor block lasting hours. Some patients do not like motor blocks. Motor blocks can impede active therapy. Yet, in regards to interscalene blocks, it does not necessarily mean longer duration to a significant degree when compared to .375%. I don’t think the verdict is completely out on this one, especially when you are adding epi, clonidine and dex.

All of our blocks are tracked by our nurses on the outpatient side. They get a call the next day or two and get asked when the block wore off. I f/u on all my inpatient interscalenes. In regards to duration, I have seen little difference between .5% bupi and .375% bupi with 1:400k +/- clonidine. They usually last about 16-22 hours with 35mls.

If I can get and extra 6-8 hours with the addition of dex or depo medrol I think it might be overkill to use .5% rop. I start to get nervous after 30 hours anyhow. I’m shooting for 24-30 hrs. of analgesia with consistency. 30hrs. being the absolute longest I want my patients to have a sensory deficit.

How long are interscalenes routinely lasting when 40mls of .5% with epi, clonidine, and decadron? How long does the motor block last?

These guys are using 20 ml of .5 % bupi (31 mg less than what I use) + 8mg of dexamethasone. They are getting 24 hrs out of their blocks.

http://journals.lww.com/ejanaesthes...e_with_bupivacaine_increases_duration.12.aspx

I think I was finishing residency when this was first being used.... hence my ignorance on the topic of steroids as an adjuvant of regional anesthesia.

Good practical discussion. :thumbup:
 
Followed up on my interscalene from a couple days ago. I got 25ish hours out of it. This supports that the addition of steroids to interscalene block cocktail has a benefit in prolonging the block. My N=1.
 
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488
October 21, 2009
9:00 AM - 11:00 AM
Room Area C Does Adding Depomedrol to Interscalene Nerve Blocks Prolong the Duration of the Block? ** Heather D. McFarland, D.O., Asra A. Ali, M.D., Evan J. Goodman, M.D., Raymond G. Graber, M.D., Subhalakshmi Sivashankaran, M.D.
Anesthesiology, University Hospitals Case Medical Center, Cleveland, Ohio INTRODUCTION

Prolonging the duration of action of local anesthetics is often desirable when performing regional anesthesia. An increased duration of the block leads to longer span of surgical anesthesia, and it can provide analgesia further into the postoperative period. At our institution we have been using Depomedrol (methylprednisone acetate) for years in an attempt to improve the quality and duration of peripheral nerve blocks. At our institution, a study 1 was performed demonstrating that adding 40 mg of Depomedrol to an interscalene block can extend the benefit of the block. However, the trial was poorly randomized and only one dose of the drug was tested. In this study, we aimed to confirm findings of this previous study, as well as to determine whether a lower dose of Depomedrol would provide equal duration of an anesthetic and analgesic blockade.

METHODS

This was a prospective, randomized, double-blinded study to evaluate the effectiveness and duration of an interscalene block with the addition of Depomedrol. Candidates selected for this study were undergoing upper extremity orthopedic surgery who had been consented to have an interscalene peripheral nerve block prior to surgery for postoperative pain control. All participants received a general anesthetic which was the primary anesthetic for the surgery. Exclusion criteria included an allergy to Depomedrol, high glucose levels or using insulin, and chronic narcotic use.

The interscalene block was performed using both ultrasound and nerve stimulator guidance and bupivicaine 0.5% 30 ml with epinephrine 1:300,000. Patients were randomized into one of three groups using the block mixture with: Group I - no Depomedrol, Group II - Depomedrol 20 mg, or Group III - Depomedrol 40 mg. After surgery the success of the block was confirmed by measuring the VAS for pain, along with the presence of neurosensory and motor blockade. The following day, the patient was questioned about when the sensory and motor blockade wore off, their POD#1 pain score, and quantity of pain medication consumed. Demographic data was also collected for each patient regarding sex, age, height, weight, and duration of surgery.

RESULTS

The analysis included 58 participants; Group I had a total of 20 participants, Group II had 16, and Group III had 22. The study demonstrated a statistically significant increase in block length in the Group III as compared with the control Group I (p<0.0001). The average duration of a block in Group III was 27.7 hours as compared with the control Group I of 21.3 hours. We also found an increase in Group II of 23 hrs; however, it was not statistically significant when compared with the control Group I (p<0.135). The three groups demonstrated no difference in demographic data or pain scores in either the PACU and 24 hours postoperatviely.

DISCUSSION

Prolonging the duration of local anesthetics provides patient with analgesia further into the postoperative period. In this study we were able to demonstrate a significant increase in block duration with the addition of 40 mg of Depomedrol. There was an extended block duration with the group that received 20 mg of Depomedrol, but this was not significant. Our study was able to substantiate the practice of adding a steroid to the local anesthetic mixture, thus maximizing the analgesic benefit to patients.

REFERENCE

1. Regional Anesthesia 2004;29:380-1.

From Proceedings of the 2009 Annual Meeting of the American Society Anesthesiologist
 

A1496
October 21, 2009
9:00 AM - 11:00 AM
Room Area C An Evaluation of Nerve Block Duration and Patient Satisfaction ** Martin Harrell, M.D., Monika Nanda, M.D., M.P.H., Haley Meyer, B.S., Karamarie Fecho, Ph.D.
Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Introduction : Quality and safety in medicine are issues of great importance in today's healthcare system. 1 Anesthesiologists, among other healthcare providers, are being pressured to track their practices and outcomes and improve perceived weaknesses. 2 The aim of this study was to determine the effectiveness of nerve blocks, in terms of patient satisfaction, complications, and the duration of pain control, numbness and loss of strength. We further aimed to explore factors that might be associated with increased block duration.

Method : After receiving approval from the Institutional Review Board, prospective data were obtained from patients undergoing peripheral nerve blocks. Data related to the block itself included the type of block, time of block onset, drugs administered, whether epinephrine and clonidine were administered, and whether ultrasound and/or nerve stimulation were used. A follow-up telephone questionnaire for outpatients and a follow-up bedside visit questionnaire for inpatients were used to collect additional information within 24-48 hours after the block. The questionnaire included questions on time to pain onset, return of strength, return of sensation, and complications (i.e., bruising, drowsiness, soreness, and swelling). Patient satisfaction was recorded using a 10 point scale (0=completely dissatisfied; 10=completely satisfied). Data were analyzed using descriptive statistics and Analysis of Variance.

Results: The follow-up response rate was 63.8%. Data were gathered from 118 subjects. Nerve blocks were performed using ultrasound with (41.3%) or without (39.1%) nerve stimulation, nerve stimulation alone (19.6%). The blocks included brachial plexus (34.5%), femoral (19.0%), sciatic (23.2%), trunk blocks (11.3%) and other peripheral extremity blocks (10.1%). Local anesthetics were ropivacaine (52.4%), bupivacaine (29.8%), mepivacaine (7.7%) and lidocaine (5.4%). Epinephrine was used in 49.4% and clonidine in 26.8% of local anesthetic mixtures. The mean±SD time to pain onset was 15.1±9.8 hours. Strength returned in 16.7±10.7 hours and numbness was gone after 17.1±11.4 hours. Block duration was not influenced by epinephrine, clonidine or the use of ultrasound or nerve stimulation (alone or in combination). Complications occurred in 12 (10.2%) blocks, with bruising being most common. The mean±SD patient satisfaction score was 8.8±2.3 and only 10 (8.5%) subjects reported a patient satisfaction score &#8804;5. One hundred two (86.4%) subjects reported that they would have a future nerve block.

Conclusions: These results show that the duration of nerve block, in terms of pain control, strength and numbness, is generally over 12 hours, although significant variability exists and factors that might account for that variability were not identified. Complications were minor and occurred in 10% of all blocks. Patients were generally very satisfied with their experience, suggesting a high quality of care.

References:

1 Committee on Quality of Health Care in America, Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, Eds. To err is human: Building a safer health system. Washington, D.C.: National Academies Press, 1999.

2 Woolf SH. Patient safety is not enough: Targeting quality improvements to optimize the health of a population. Ann Intern Med 240:33-36, 2004.

From Proceedings of the 2009 Annual Meeting of the American Society Anesthesiologists.
 
One word of caution: the addition of additives may increase your incidence of neuropraxia.

At this point, there isn't good evidence to support this and you actually have to follow your patients until their block completely resolves to appreciate it. We have a very large, very detailed database that we keep for every block that is done at our outpatient surgical center that does suggest the relationship of additive use, length of block and neuropraxia (either sensory or motor).

It is really nice to give patients that receive a single shot block the additional analgesic time, but I think that you really need to discuss the real possibility of nerve dysfunction secondary to the block. Current literature is all over the place in regard to the incidence of neuropraxia but it is likely under-reported.

We have several attendings that have changed their practice based on the prelim results of the database, it will be interesting to see what the final statistical analysis suggests.
 
One word of caution: the addition of additives may increase your incidence of neuropraxia.

At this point, there isn't good evidence to support this and you actually have to follow your patients until their block completely resolves to appreciate it. We have a very large, very detailed database that we keep for every block that is done at our outpatient surgical center that does suggest the relationship of additive use, length of block and neuropraxia (either sensory or motor).

It is really nice to give patients that receive a single shot block the additional analgesic time, but I think that you really need to discuss the real possibility of nerve dysfunction secondary to the block. Current literature is all over the place in regard to the incidence of neuropraxia but it is likely under-reported.

We have several attendings that have changed their practice based on the prelim results of the database, it will be interesting to see what the final statistical analysis suggests.


KISS. Until the literature is Crystal clear I keep it that way. This means 0.5% Ropivacaine with or without dilute Epi (1:400,000). I don't mess with any other "secret ingredients" because of my location (high Malpractice State).
 
Followed up on my interscalene from a couple days ago. I got 25ish hours out of it. This supports that the addition of steroids to interscalene block cocktail has a benefit in prolonging the block. My N=1.

I would love to add that special ingredient which is "safe" and reliably gives a sensory block for more than 24 hours. Is that Decadron? Is it "safe"? Where is the data supporting safety in all patient populations? Do you use preservative free Decadron or "regular" 30 cent Decadron? How much is best for a Diabetic? 4 mg? 6mg? Does Decadron promote Second crush neuronal injury? Which is safer? Depo-Medrol or Decadron?
 
I have questions about my nerveNerve biopsy
Nerve conduction velocity
-block anesthesia two weeks ago for surgery to repair my lower fibula, I still have numbnessNumbness and tingling
, burning pain, etc. I have seen on the web that nerveNerve biopsy
Nerve conduction velocity
damage can occur from nerveNerve biopsy
Nerve conduction velocity
blocks, but not much other followup info about the natural history of this kind of damage and followup treatment. I know you can't diagnose over the web, but I'd like some general information: how long can it take for nerveNerve biopsy
Nerve conduction velocity
blocks (for surgical anesthesia) to resolve? How often does nerveNerve biopsy
Nerve conduction velocity
damage occur? How can you distinguish normal slow resolution from nerve damage? What can be done to hasten healing and/or prevent permanent damage? Or could my symptoms be from the fibula surgery itself? (I had no foot numbness before the surgery).

The nerve block wore off slowly in the [COLOR=#006CC8 ! important][FONT=inherit ! important][COLOR=#006CC8 ! important][FONT=inherit ! important]hospital..[/COLOR][/COLOR], so I didn't need much pain drip (Next day, it was maybe 60% effective.) Two weeks after surgery, the nerves of my foot are still affected. The top of my foot & the tops of my four toes (not counting the big toe area) are numb with burning pain and occasional creepy feelings. I still have my cast on, but it feels like the middle of my foot, outside-edge, bottom+side +top, are either completely numb or [COLOR=#006CC8 ! important][FONT=inherit ! important][COLOR=#006CC8 ! important][FONT=inherit ! important]muscle..[/COLOR][/COLOR]-clenched. I have had a few "charlie-horses" of other small muscles in the sole of my foot. I can clench & wiggle my toes, though it hurts both the toes and the top of my foot when I do so, and I think I can flex my foot, but it is hard to tell with the cast on.

In the last few days these sensations are becoming more bothersome with burning pain and creepy feelings.
 
Conditions that may Predispose Patients to
Neuropathies:
Acromegaly
Amyloidosis
Carcinoma
Cryoglobulinaemia
COPD
Diabetes Mellitus – most common
Drugs – incl cancer chemotherapeutics
(eg vincristine,cisplatin)
Hypothyroidism
Liver disease
Lymphoma
Multiple Myeloma
Porphyrias
Uraemia
 
Nerve injury and regional anaesthesia

Borgeat, Alain; Blumenthal, Stephan






icon-minus.gif
Abstract



Purpose of review: In recent years there has been a renewed interest in regional anaesthesia, particularly peripheral nerve blockade, not only to improve the patient's well being, but also to meet the requirements of modern orthopaedic surgery. Nerve injury in this context is the complication most feared by the patient, the anaesthesiologist and the surgeon.
Recent findings: To date, data dealing with the incidence of nerve injury in regional anaesthesia have almost exclusively been retrieved from close claims analysis. Recently, prospective, well controlled studies have shown that severe neurologic complications rarely occur: for the upper extremity, an incidence of 0.2-1% has been reported. New insights into the mechanisms of local anaesthetic neurotoxicity have demonstrated that ropivacaine has the least potential for neurotoxicity. Administration of the lowest possible concentrated solution of local anaesthetic is likely to be even less neurotoxic. The role of local anaesthetics in the development of apoptosis is nowadays well recognized. The consequences of other factors, such as nerve stretching and compression, in the pathology of nerve damage are emphasized.
Summary: Significant advances have been made in regional anaesthesia in the past 10 years. The introduction of catheter techniques has cleared the way for better regional anaesthetic and analgesic blocks. Studies dealing with placement of perineural catheters show that the catheter does not increase neurological complications. Properly performed, regional anaesthesia is a safe form of anaesthesia and the benefits far outweigh the risks.
 
Neurotoxicity varies with the local anesthetic solution. In histopathologic, electrophysiologic, and neuronal cell models, lidocaine and tetracaine have been shown to have a greater potential for neurotoxicity than bupivacaine.63 Additives, i.e. epinephrine, can increase the toxicity of both lidocaine and bupivacaine.64 A preexisting neurologic condition, i.e. peripheral neuropathy, injury, surgery, may predispose the patient to nerve injury from toxicity at clinical doses (i.e. double crush concept).65


http://www.nysora.com/regional_anes...complications_of_peripheral_nerve_blocks.html
 
I would love to add that special ingredient which is "safe" and reliably gives a sensory block for more than 24 hours. Is that Decadron? Is it "safe"? Where is the data supporting safety in all patient populations? Do you use preservative free Decadron or "regular" 30 cent Decadron? How much is best for a Diabetic? 4 mg? 6mg? Does Decadron promote Second crush neuronal injury? Which is safer? Depo-Medrol or Decadron?

Ditto my thinking on this topic: until these practices become the standard of care, I will stick to what, thus far, has been shown to be safe when doing PNB's--plain Ropivicaine. Sure, we have done ESI's for years, but not too many (any?) people are nuts about intrathecal steroids, much less direct nerve application (which, essentially, is what a peripheral nerve block is...). Some of my partners are using Decadron 4-8mg for increasing the longevity of the block--it works, no doubt. But I do not want to get caught with my pants down, so-to-speak....
 
Ditto my thinking on this topic: until these practices become the standard of care, I will stick to what, thus far, has been shown to be safe when doing PNB's--plain Ropivicaine. Sure, we have done ESI's for years, but not too many (any?) people are nuts about intrathecal steroids, much less direct nerve application (which, essentially, is what a peripheral nerve block is...). Some of my partners are using Decadron 4-8mg for increasing the longevity of the block--it works, no doubt. But I do not want to get caught with my pants down, so-to-speak....


http://www.ringvet.se/Kiropraktik_filer/dexandblflow.pdf


More research needs to be done on Decadron and Depo-Medrol. TAke a look at the above study.
 

Although basically true in concept suspensions of synthetic glucocorticoids are effective anti-inflammatory agents but they also contain preservatives such as polyethylene glycol, known better as a anti-freeze in car cooling systems. Other preservatives include alcohol. Both ethylene glycol and alcohol are well-recognized toxic agents if introduced into the sub-arachnoid space.

Wood (1) studied the effects of injections of methylprednisolone acetate into rat sciatic nerves. Nerves treated with either the steroid or its vehicle showed damage, including collagen (scar) formation and demyelination.
 

Although basically true in concept suspensions of synthetic glucocorticoids are effective anti-inflammatory agents but they also contain preservatives such as polyethylene glycol, known better as a anti-freeze in car cooling systems. Other preservatives include alcohol. Both ethylene glycol and alcohol are well-recognized toxic agents if introduced into the sub-arachnoid space.

Wood (1) studied the effects of injections of methylprednisolone acetate into rat sciatic nerves. Nerves treated with either the steroid or its vehicle showed damage, including collagen (scar) formation and demyelination.

Yep. Thanks for posting....definitely an interesting topic....:thumbup:
 

Although basically true in concept suspensions of synthetic glucocorticoids are effective anti-inflammatory agents but they also contain preservatives such as polyethylene glycol, known better as a anti-freeze in car cooling systems. Other preservatives include alcohol. Both ethylene glycol and alcohol are well-recognized toxic agents if introduced into the sub-arachnoid space.

Wood (1) studied the effects of injections of methylprednisolone acetate into rat sciatic nerves. Nerves treated with either the steroid or its vehicle showed damage, including collagen (scar) formation and demyelination.

Polyethylene glycol is Miralax and not antifreeze.
 
Just to step back a little and look at how “safe” our nerve blocks are:

I’m sure a lot of you saw this 20 yr. study that came out last month in anesthesiology. It looks at nerve injury with and without the use of regional anesthesia. Bottom line is regional anesthesia for TKA is extremely safe. Lot’s of people using epi and clonidine for these blocks. In fact, nerve injury was more prevalent in the arm that did not use regional anesthesia. Issues that were associated with nerve injuries were tourniquet time, bilateral procedures, etc.

In the big scheme of things, RA is extremely safe when done correctly. I agree, more studies need to be conducted with steroids. However, it’s use is not limited to 1 large institution. It has been gaining popularity over the last 5 years or so. Just something to keep on the radar as a a mechanism to aid in better patient care.

Background: Perioperative nerve injury (PNI) is one of the most debilitating complications after total knee arthroplasty (TKA). Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. The objective of this study was to test the hypothesis that PNI risk differs among patients according to RA use during TKA.

In summary, the use of RA techniques (neuraxial anesthesia or peripheral nerve blockade) does not increase the risk for PNI. Therefore, the known functional and clinical benefits of RA for patients undergoing TKA14 can be achieved without increasing the risk of neurologic injury. If a PNI does occur, most patients will experience complete or partial recovery of their neurologic deficit within 12 months of surgery. However, complete recovery may be less likely in the rare instance when a neurologic deficit develops in the setting of peripheral nerve blockade.

What This Article Tells Us That Is New
In a review of more than 12,000 total knee arthroplasty patients during 20 yr, use of peripheral nerve blockade was not associated with peripheral nerve injury. However, patients with peripheral nerve injury were less likely to recover completely if they had received peripheral nerve blockade.

http://journals.lww.com/anesthesiol...erative_Nerve_Injury_after_Total_Knee.19.aspx
 
Just to step back a little and look at how "safe" our nerve blocks are:

I'm sure a lot of you saw this 20 yr. study that came out last month in anesthesiology. It looks at nerve injury with and without the use of regional anesthesia. Bottom line is regional anesthesia for TKA is extremely safe. Lot's of people using epi and clonidine for these blocks. In fact, nerve injury was more prevalent in the arm that did not use regional anesthesia. Issues that were associated with nerve injuries were tourniquet time, bilateral procedures, etc.

In the big scheme of things, RA is extremely safe when done correctly. I agree, more studies need to be conducted with steroids. However, it's use is not limited to 1 large institution. It has been gaining popularity over the last 5 years or so. Just something to keep on the radar as a a mechanism to aid in better patient care.

Background: Perioperative nerve injury (PNI) is one of the most debilitating complications after total knee arthroplasty (TKA). Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. The objective of this study was to test the hypothesis that PNI risk differs among patients according to RA use during TKA.

In summary, the use of RA techniques (neuraxial anesthesia or peripheral nerve blockade) does not increase the risk for PNI. Therefore, the known functional and clinical benefits of RA for patients undergoing TKA14 can be achieved without increasing the risk of neurologic injury. If a PNI does occur, most patients will experience complete or partial recovery of their neurologic deficit within 12 months of surgery. However, complete recovery may be less likely in the rare instance when a neurologic deficit develops in the setting of peripheral nerve blockade.

What This Article Tells Us That Is New
In a review of more than 12,000 total knee arthroplasty patients during 20 yr, use of peripheral nerve blockade was not associated with peripheral nerve injury. However, patients with peripheral nerve injury were less likely to recover completely if they had received peripheral nerve blockade.

http://journals.lww.com/anesthesiol...erative_Nerve_Injury_after_Total_Knee.19.aspx

I bet I have personally performed more than 12,000 nerve blocks in my career. I did 5 today for example. I know the "safety profile" of peripheral nerve blocks.

But, I also know the "legal system" we face on a regular basis. Do a literature search on Clonidine and you will fixed mixed results on effectiveness with reported systemic hypotension. NO thanks.

As for Epi I either dilute to 1:400,000 these days or just omit entirely. I also prefer Ropivacaine for extra safety although I admit you get reliably longer blocks with Bupivacaine.

THe verdict is still out on the safety of Decadron and PNBs. However, it is effective in prolonging blocks. No doubt about it. I will wait a few more years for some well conducted studies before adding the "secret ingredient" to my Ropivacaine. My motto is "DO NO HARM" which keeps me away from the local malpractice lawyers.
 
KISS. Until the literature is Crystal clear I keep it that way. This means 0.5% Ropivacaine with or without dilute Epi (1:400,000). I don't mess with any other "secret ingredients" because of my location (high Malpractice State).

I'm with you. That supplemental stuff is neat but I'm a plain ropivacaine no epi guy. And my practice environment confers near immunity to malpractice suits ...
 
Can you guys believe there are emergency physicians who are doing peripheral nerve blocks in the ED?

Yep.

They go to a weekend course at their conferences and "learn" this. Anesthesiologists are among the teachers.

30 pieces of silver spends nice.
 
My motto is "DO NO HARM".

No argument with that line for sure. The reason I started this post is to see who is doing these blocks and what their experience has been while trying to spark a discussion on the subject. I appreciate the input.

I do think steroids in blocks necessitates further study... The numbers aren't there although I get the feeling that there are a lot of people doing this both in PP and in academics. There are small studies being published and I'm pretty sure it’s long term effects are being researched right now.

I'll be the first to say that I don't think that one single shot of 4mg of PF decadron would do much harm. My N=1, so I'm not an expert on the subject and therefore need to relly on small studies, anectodal information and personal experience. What I can say is that steroids are anti-inflammatory, Orthopods inject 40 mg of depo medrol + LA into intra-articular spaces all the time and pain docs inject steroids into nerve containing spaces. I also know that ropivicaine, marcaine and lidocaine have all been shown to increase apoptosis yet they are regarded as safe agents in regional anesthesia.

Sometimes it is always difficult to separate fact from fiction and that’s the beauty of what we do and this forum. It is also why we are cautious in our medical legal system.

To me, this is an interesting topic I will be following very closely. It would be nice to remove other agents from the picture (epi/clonidine) and if deemed safe, replace them with a small dose of steroids that prolongs the block while providing anti-inflammatory properties to the cocktail. In theory, it sounds pretty good.
 
Anesth Analg. 2001 Jan;92(1):199-204.
Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes.

Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z.
Division of Anesthesiology, Geneva University Hospitals, Geneva 14, Switzerland. [email protected]
Comment in:

Abstract

Clonidine in brachial plexus block prolongs analgesia of local anesthetics of short and intermediate duration. We performed a prospective randomized double-blinded study to determine the efficacy and adverse effects of clonidine mixed with a long-acting local anesthetic on postoperative analgesia. Sixty adult patients underwent elective rotator cuff repair using interscalene brachial plexus block combined with general anesthesia and were randomly divided into one of the following three groups. Placebo (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine (1/200000) and 1 mL of 0.9% saline, completed by 1 mL of 0.9% saline IM in the controlateral shoulder; Control (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 1 mL of 0. 9% saline, completed by 150 microg (=1 mL) of clonidine IM; Clonidine (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 150 microg (=1 mL) of clonidine, completed by 1 mL of 0.9% saline IM. During anesthesia hemodynamic variables and fractional expired isoflurane concentration (FeISO) were recorded. The following postoperative variables were assessed: duration of interscalene block, quality of pain relief on a visual analog scale, side effects, and consumption of morphine with a patient-controlled analgesia device over 48 h. Patient characteristics were comparable. During anesthesia mean arterial pressure, heart rate, and FeISO were significantly decreased in Clonidine and Control groups compared with Placebo group. Duration of analgesia, defined as the time elapsed from interscalene injection to the first morphine request, was 983 +/- 489 min in the Placebo, 909 +/- 160 min in the Control, and 829 +/- 159 min in the Clonidine groups. Pain scores and consumption of morphine at 24 h and 48 h showed no differences among the three groups. We conclude that adding 150 microg of clonidine in interscalene block does not prolong analgesia induced by 40 mL of bupivacaine 0.5% with epinephrine, but decreases mean arterial blood pressure and heart rate. Implications: Clonidine in brachial plexus block does not improve postoperative analgesia when mixed with a long-lasting anesthetic. Nevertheless, with or without clonidine, bupivacaine in interscalene block provides a long-lasting analgesia of approximately 15 h.

PMID: 11133627 [PubMed - indexed for MEDLINE]Free Article

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No argument with that line for sure. The reason I started this post is to see who is doing these blocks and what their experience has been while trying to spark a discussion on the subject. I appreciate the input.

I do think steroids in blocks necessitates further study... The numbers aren't there although I get the feeling that there are a lot of people doing this both in PP and in academics. There are small studies being published and I'm pretty sure it’s long term effects are being researched right now.

I'll be the first to say that I don't think that one single shot of 4mg of PF decadron would do much harm. My N=1, so I'm not an expert on the subject and therefore need to relly on small studies, anectodal information and personal experience. What I can say is that steroids are anti-inflammatory, Orthopods inject 40 mg of depo medrol + LA into intra-articular spaces all the time and pain docs inject steroids into nerve containing spaces. I also know that ropivicaine, marcaine and lidocaine have all been shown to increase apoptosis yet they are regarded as safe agents in regional anesthesia.

Sometimes it is always difficult to separate fact from fiction and that’s the beauty of what we do and this forum. It is also why we are cautious in our medical legal system.

To me, this is an interesting topic I will be following very closely. It would be nice to remove other agents from the picture (epi/clonidine) and if deemed safe, replace them with a small dose of steroids that prolongs the block while providing anti-inflammatory properties to the cocktail. In theory, it sounds pretty good.

I have been at this gig for quite some time. Huge Volume of nerve blocks.
Seen a lot of things from Cardiac Arrest, Seizure, Neuropathy, etc.

I also don't mind adapting my practice when the data becomes clear. For example, I only do U/S guided Supra and Infraclavicular blocks these days.
But, I don't U/S for ISB, Femoral, Lumbar Plexus, Axillary or Sciatic.
I changed to Ropivacaine because it is a safer local anesthetic and possibly less toxic to peripheral nerve.

So, when Decadron 4-8 mg gets that BIG Anesthesiology or A &A publication I will be on board. I suspect Preservative free Decadron will be the recommendation.
 
I hear you Blade. I appreciate your experience and I certainly have not done 12,000 regional anesthetics. I do come from a regional heavy program with many leaders in the field. I use USD for everything except ant. sciatics, lumbar plexus and sometimes axillary. Everything else I use USD. My cocktail is .375% marcaine + 1:400k epi. It’s safe, it’s not as concentrated and therefore less toxic and I feel that it gets the job done.

Clonidine is added from time to time to my lower extremity blocks. I think it does add a couple of hours to the block and when done in the lower extremity, hypotension and bradycardia is rare. I think it’s useful in certain blocks but not all (ie lumbar plexus).

He is a review of clonidine as a adjuvant of regional anesthesia. N=>1000

http://rileyanesthesia.org/ftp_folders/staff_folders/green/articles/Clonidine Block.pdf

2007.

Thanks again for all the input. :thumbup:
 
Any of you using steroids in your interscalene single shots? 30-40mg of Depo Medrol mixed in with your local?

I never engaged in this practice as it was never taught to me in residency and I can’t find any literature regarding this method of prolonging a shoulder block.

What I’ve heard is that the steroid absorbs some LA and acts as a controlled release mechanism of drug delivery thereby prolonging the block.

I first heard about it 3 years ago when I was on the interview trail. Several different groups had mentioned this adjunct to regional anesthesia. I’m still a bit curious.

I’ve heard of Interscalenes with steroids + local to be pain free for 30+ hrs.

Anybody doing this?

I've been adding 8 of decadron to the mix also.
 
I've been adding 8 of decadron to the mix also.

Make sure you are using preservative free decadron and not the stuff we use to prevent nausea. Also, I'm not sure adding 8mg in an elderly diabetic is the wisest course of action at this juncture. This subgroup is at risk of nerve injury as it is and has well described neuropathy.

My inter scalene blocks with just plain 0.5 percent bupivacaine routinely last 24 hours. Ropivacaine seems to last only 16 hours. That's my experience based on thousands of cases. YMMV
 
Conclusions: The duration of sciatic nerve block with local anesthetics is longer in diabetic compared with nondiabetic rats. A small, but statistically significant, increase in nerve damage occurred in diabetic rats after nerve block with ropivacaine alone or when duration of lidocaine block was extended with clonidine. These findings may have implications for dosing of local anesthetics in diabetic patients undergoing regional analgesia with nerve blocks.
 
http://www.ncbi.nlm.nih.gov/pubmed/19920420


This is important because anesthesiologists do not want to potentially accelerate peripheral nerve dysfunction in diabetic patients at risk. This translational vignette (i) examines laboratory models of diabetes, (ii) summarizes the pharmacology of perineural adjuvants (epinephrine, clonidine, buprenorphine, midazolam, tramadol, and dexamethasone), and (iii) identifies areas that warrant further research to determine viability of monotherapy or combination therapy for peripheral nerve analgesia in diabetic patients. Conceivably, future translational research regarding peripheral nerve blocks in diabetic patients may logically include study of nontoxic injectable analgesic adjuvants, in combination, to provide desired analgesia, while possibly avoiding peripheral nerve toxicity that diabetic animal models have exhibited when exposed to traditional local anesthetics.
 
There are well documented age-related physiologic changes that occur in the central and peripheral nervous systems. Studies have demonstrated that aging affects the anatomy, pharmacokinetics, and pharmacodynamics of local anesthetics used in central neuraxial blockade (9–12), as well as the structural and functional properties of the peripheral nervous system. There is loss of both myelinated and unmyelinated nerve fibers (13,14), potentially rendering peripheral nerves more sensitive to the effects of local anesthetics. Decreased expression of myelin proteins may lead to a deterioration of myelin sheaths (15). A reduction in the expression and axonal transport of cytoskeletal proteins may lead to axonal atropy, often seen in older nerves (16). Age-dependent changes in sodium and potassium channel function are poorly characterized (13). Aging has well-documented effects on the functional and electrophysiologic properties of peripheral nerves, all of which may impact on the response to local anesthetics. These include a decline in nerve conduction velocity, muscle strength, sensory discrimination, autonomic responses, and endoneurial blood flow (15). In a clinical model, Lafratta and Canestrari (17) studied sensory and motor action potentials in the median nerve in 23- to 91-year-old males. They demonstrated a greater diminution of sensory nerve conduction velocity compared with motor conduction velocity and a higher magnitude of sensory latency compared with motor latency with advancing age.
 
I think adding Decadron 4-8 mg to prolong PAIN RELIEF for a patient is a great idea. I'm all for it. It's easy and it works.

But, is it safe? That's the $1 million malpractice question. I'm sure it's safe in your ASA 1 28 year old downhill skier. But, what about the 85 year old diabetic with lower extremity peripheral neuropathy? How much Decadron, if any, are you going to add to your local anesthetic for that patient?

Also, is 4 mg enough? 8 mg? 12mg? at what point does neurotoxicity increase with Decadron? Questions that need answers. At least stick with the Preservative free stuff until Academia begins to address the issue.
 
One word of caution: the addition of additives may increase your incidence of neuropraxia.

At this point, there isn't good evidence to support this and you actually have to follow your patients until their block completely resolves to appreciate it. We have a very large, very detailed database that we keep for every block that is done at our outpatient surgical center that does suggest the relationship of additive use, length of block and neuropraxia (either sensory or motor).

It is really nice to give patients that receive a single shot block the additional analgesic time, but I think that you really need to discuss the real possibility of nerve dysfunction secondary to the block. Current literature is all over the place in regard to the incidence of neuropraxia but it is likely under-reported.

We have several attendings that have changed their practice based on the prelim results of the database, it will be interesting to see what the final statistical analysis suggests.

Any follow-up here? Your data base would be quite informative.
 
I heard about a patient who suffered a stroke after bupivacaine with depomedrol was injected into the vertebral artery during an interscalene block. Using a particulate solution close to those vessels has unique risks.
 
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