Is this an option

[LifeTake2]

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Ok, semi-personal question but figured you all would have an idea so going to avail myself of the resource.

Several years back I had a SLAP repair by a good friend/ortho and the anesthesiologist put a nerve block in the neck/shoulder pre-induction for post-op pain management. I was extremely grateful for the few hours to get home, settled and get oral pain meds on board before it wore off.

Jumping forward, in a couple of weeks I'm having a ray resection of the 2nd toe & metatarsal in an otherwise healthy male (congenital megadactyly now showing abnormal soft-tissue growth). The procedure is being done 1.5hrs away from home outpatient, and I'm just wondering if there is something comparable for the foot and what would the anesthesiologist call it if I wanted to discuss?

 

[dhb]

Ok, semi-personal question but figured you all would have an idea so going to avail myself of the resource.

Several years back I had a SLAP repair by a good friend/ortho and the anesthesiologist put a nerve block in the neck/shoulder pre-induction for post-op pain management. I was extremely grateful for the few hours to get home, settled and get oral pain meds on board before it wore off.

Jumping forward, in a couple of weeks I'm having a ray resection of the 2nd toe & metatarsal in an otherwise healthy male (congenital megadactyly now showing abnormal soft-tissue growth). The procedure is being done 1.5hrs away from home outpatient, and I'm just wondering if there is something comparable for the foot and what would the anesthesiologist call it if I wanted to discuss?

Sciatic nerve block at the popliteal level, i'd tell the anesthesiologist to throw in 5mg of decadron in the local anesthesia for better post-op pain relief.
Fiddling with bones in young patients can be pretty painful a nerve block would be much more comfortable than waking up every 2h to take some po medication.

 

[ssmallz]

Popliteal and saphenous nerve blocks. Ask for 0.5% marcaine. For maximal duration you ask for marcaine w/epi but there is some question about using on the sciatic and since the popliteal is the continuation of the saphenous some people may not use marcaine. This is slowly becoming one of my favorite blocks b/c people who come out w/a 10/10 pain can often go to 0/10 pain w/in 10 minutes and limp away happy.

 

[ok4ever]

Would you consider an ankle block?

 

[Idiopathic]

Would you consider an ankle block?

i wouldnt. you might get away with it but i doubt it, especially with a metatarsal resection, and your postop pain relief wouldnt be very good.

 

[Idiopathic]

Sciatic nerve block at the popliteal level, i'd tell the anesthesiologist to throw in 5mg of decadron in the local anesthesia for better post-op pain relief.
Fiddling with bones in young patients can be pretty painful a nerve block would be much more comfortable than waking up every 2h to take some po medication.

i think that while you shouldnt need to cover saphenous based on anatomy, the medial foot can be very fickle, id probably block it at the knee after the popliteal either with US or as a field block.

also, the jury is still out on decadron, many of us are shying away from it as it may promote nerve ischemia with increased risk of neuropraxia. id go for a long acting local and no additives, be comfortable for the rest of the day, hopefully, and start PO meds before bed that night.

 

[BLADEMDA]

i think that while you shouldnt need to cover saphenous based on anatomy, the medial foot can be very fickle, id probably block it at the knee after the popliteal either with US or as a field block.

also, the jury is still out on decadron, many of us are shying away from it as it may promote nerve ischemia with increased risk of neuropraxia. id go for a long acting local and no additives, be comfortable for the rest of the day, hopefully, and start PO meds before bed that night.

If a thigh tourniquet is being used for the surgery then I'd prefer to block the popliteal and saphenous postop.

I'd do a popliteal using Rop and Decadron. Ditto for the saphenous (mid thigh using u/s means high success rate). So far hundreds of blocks using low dose Decadron in my mix with zero long term complications (I use 3-4 mg). I don't utilize Decadron if the patient has diabetes or any preexisting neurological diseases/neuropathy.

With my blocks I can pretty much guarantee you will sleep all night with zero pain meds

 

[dhb]

Would you consider an ankle block?

Yes with steroids i can give you good pain relief

 

[HalO'Thane]

Yes with steroids i can give you good pain relief

Two Questions:

1. For decadron are you guys using 0.1 mg/kg? What about the max dose?

2. Anyone using clonidine in there blocks?

Thanks.

 

[LifeTake2]

Firstly, thank you all for the suggestions.

With my blocks I can pretty much guarantee you will sleep all night with zero pain meds

Blade, what are you doing in late July? Ever visited upstate NY? I'm thinking I'm going to see if I the hospital allows BYOA (bring your own anesthesiologist) 😀

 

[ASA6]

really? no one else is going to comment on the YOLO in his signature? I guess that's the motto.

 

[BLADEMDA]

Two Questions:

1. For decadron are you guys using 0.1 mg/kg? What about the max dose?

2. Anyone using clonidine in there blocks?

Thanks.

My personal data doesn't show much of a duration enhancement with 8 mg over 4 mg. you get maybe an hour or so longer duration of post op pain relief. Also, clonidine has been looked at with and without decadron. Mixed results and when you added decadron clonidine didn't provided much more benefit to decadron plus local alone.

Finally, preliminary data is showing decadron may have some nerve toxicity so I limit its use to major plexus and large nerves. I do not use decadron for selective nerve blocks at the ankle.

At this point in time the safety data on decadron is minimal at best

 

[doctor712]

Two Questions:

1. For decadron are you guys using 0.1 mg/kg? What about the max dose?

2. Anyone using clonidine in there blocks?

Thanks.

HalO'Thane,

If you do use the Dexamethasone, might I humbly suggest this little BLADEMDA pearl to help avoid 'the itch'...

Simply diluting the higher dosages of Decadron in a 20 ml syringe and pushing it slowly over 60 seconds will decrease the incidence of major complaints to 1%.

😀
Protecting asses from the inter web,
D712

 

[pgg]

HalO'Thane,

If you do use the Dexamethasone, might I humbly suggest this little BLADEMDA pearl to help avoid 'the itch'...

He's talking about a dexamethasone additive to a nerve block, which doesn't risk the great balls of fire side effect the way IV dexamethasone does.

 

[dhb]

HalO'Thane,

If you do use the Dexamethasone, might I humbly suggest this little BLADEMDA pearl to help avoid 'the itch'...

D712

Only happens for iv injection in this case it's an adjunct to a nerve block

I didn't mention decadron specifically for ankle block.
I met a lady that worked in a busy private practice where they perfomed a lot of foot surgery. She said they had been using steroids (Solu-Medrol i think) in their ankle blocks for 15years and rarely did the patients need morphine post-op.

 

[doctor712]

I am going to be the most well rounded pre-med student when it comes
To the ball itching side effects of decadron!!


D712

 

[Mman]

The study of additives to local anesthetics for nerve blocks is long and varied and the moral of the story is there is very weak evidence in support of any additive (other than epi) in terms of either length of nerve block.

The data just isn't there. People have tried everything under the sun to make a single shot last longer. Small studies here and there will show one thing is good and then another study fails to confirm it.

 

[BLADEMDA]

The study of additives to local anesthetics for nerve blocks is long and varied and the moral of the story is there is very weak evidence in support of any additive (other than epi) in terms of either length of nerve block.

The data just isn't there. People have tried everything under the sun to make a single shot last longer. Small studies here and there will show one thing is good and then another study fails to confirm it.

Really? Decadron works to enhance the block. Those of you haven't tried it just don't know what your are missing out on (or the patient in this case). Decadron added to the 0.5% Rop RELIABLY gives over 20 hours of post op pain relief. Instead of the average patient getting 14-16 hours the patient gets 20-22 hours. Amazing. Nothing else works as consistently and reliably as Decadron added to BUP or ROP. Epi simple isn't needed nor is Clonidine because the Decadron does the trick.



CONCLUSION:

The addition of dexamethasone to bupivacaine significantly prolonged the duration of the motor block and improved the quality of analgesia following interscalene block. There was no difference in the duration of analgesia and motor block between low-dose and high-dose dexamethasone
http://www.ncbi.nlm.nih.gov/pubmed/21681533

 

[Mman]

Really? Decadron works to enhance the block. Those of you haven't tried it just don't know what your are missing out on (or the patient in this case). Decadron added to the 0.5% Rop RELIABLY gives over 20 hours of post op pain relief. Instead of the average patient getting 14-16 hours the patient gets 20-22 hours. Amazing. Nothing else works as consistently and reliably as Decadron added to BUP or ROP. Epi simple isn't needed nor is Clonidine because the Decadron does the trick.



CONCLUSION:

The addition of dexamethasone to bupivacaine significantly prolonged the duration of the motor block and improved the quality of analgesia following interscalene block. There was no difference in the duration of analgesia and motor block between low-dose and high-dose dexamethasone
http://www.ncbi.nlm.nih.gov/pubmed/21681533

As I said, a study with 30 patients in each arm is teeny tiny and essentially worthless when it comes to making a conclusion. There are loads of small studies showing the benefit of adding all kinds of things to a block, and I've yet to see one other than epi proven effective in a larger study.

I'm all about the continued effort to find a better way to do it. If I want something longer lasting, I put in a catheter. It is far more effective than adding anything to a single shot.

 

[BLADEMDA]

As I said, a study with 30 patients in each arm is teeny tiny and essentially worthless when it comes to making a conclusion. There are loads of small studies showing the benefit of adding all kinds of things to a block, and I've yet to see one other than epi proven effective in a larger study.

I'm all about the continued effort to find a better way to do it. If I want something longer lasting, I put in a catheter. It is far more effective than adding anything to a single shot.

Sure. Tell that to my last 100 patients who got Decadron and a MINIMUM of 21 hours of pain relief. Some reported minimal to no pain for up to 30 hours from a single shot.

I'm not the only one reporting great success with Decadron. Have you even tried it ONCE?

 

[BLADEMDA]

Korean J Anesthesiol. 2012 Feb;62(2):130-4. Epub 2012 Feb 20.
Dexamathasone added to levobupivacaine improves postoperative analgesia in ultrasound guided interscalene brachial plexus blockade for arthroscopic shoulder surgery.

Kim YJ, Lee GY, Kim DY, Kim CH, Baik HJ, Heo S.
Source

Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea.

Abstract

BACKGROUND:

The purpose of this study was to evaluate the effect of the addition of 5 mg dexamethasone to 10 ml of 0.5% levobupivacaine on postoperative analgesic effects of ultrasound guided-interscalene brachial plexus block (ISBPB) in arthroscopic shoulder surgery under general anesthesia.
METHODS:

In 60 patients scheduled for arthroscopic shoulder surgery that underwent general anesthesia, ISBPB was preoperatively performed with 10 ml of 0.5% levobupivacaine under the guidance of ultrasound and a nerve stimulator. Patients were randomly allocated to receive the same volume of normal saline (Group I), 5 mg of dexamethasone (Group II), or 1 : 400,000 epinephrine (Group III) as an adjuvant to the mixture. A blind observer recorded total analgesic consumption, sleep quality, complication, and patient satisfaction using a verbal numerical rating scale (VNRS) at 0, 1, 6, 12, 24, 48 h after the operation.
RESULTS:

All patients had successful ISBPB and excellent analgesic effects less than VNRS 4 up to discharge time. VNRS in Group II at 12 h and 48 h was statistically much lower than in Group I and III. There were no differences in total analgesic consumption, sleep quality, complications, and patient satisfaction.
CONCLUSIONS:

We conclude that the addition of 5 mg of dexamethasone to 10 ml of 0.5% levobupivacaine in ISBPB showed improvement of postoperative analgesia for arthroscopic shoulder operation without any specific complications.

 

[BLADEMDA]

Br J Anaesth. 2011 Sep;107(3):446-53. doi: 10.1093/bja/aer159. Epub 2011 Jun 14.
Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine.

Cummings KC 3rd, Napierkowski DE, Parra-Sanchez I, Kurz A, Dalton JE, Brems JJ, Sessler DI.
Source

Department of Regional Practice Anesthesiology, Cleveland Clinic, Lakewood Hospital Department of Anesthesiology, 14519 Detroit Avenue, Lakewood, OH 44107, USA. [email protected]

Abstract

BACKGROUND:

Pain after shoulder surgery is often treated with interscalene nerve blocks. Single-injection blocks are effective, but time-limited. Adjuncts such as dexamethasone may help. We thus tested the hypothesis that adding dexamethasone significantly prolongs the duration of ropivacaine and bupivacaine analgesia and that the magnitude of the effect differs among the two local anaesthetics.
METHODS:

In a double-blinded trial utilizing single-injection interscalene block, patients were randomized to one of four groups: (i) ropivacaine: 0.5% ropivacaine; (ii) bupivacaine: 0.5% bupivacaine; (iii) ropivacaine and steroid: 0.5% ropivacaine mixed with dexamethasone 8 mg; and (iv) bupivacaine and steroid: 0.5% bupivacaine mixed with dexamethasone 8 mg. The primary outcome was time to first analgesic request after post-anaesthesia care unit discharge. The Kaplan-Meier survival density estimation and stratified Cox's proportional hazard regression were used to compare groups.
RESULTS:

Dexamethasone significantly prolonged the duration of analgesia of both ropivacaine [median (inter-quartile range) 11.8 (9.7, 13.8) vs 22.2 (18.0, 28.6) h, log-rank P<0.001] and bupivacaine [14.8 (11.8, 18.1) and 22.4 (20.5, 29.3) h, log-rank P<0.001]. Dexamethasone prolonged analgesia more with ropivacaine than bupivacaine (Cox's model interaction term P=0.0029).
CONCLUSIONS:

Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that of bupivacaine, the combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia

 

[BLADEMDA]

Dexamethasone prolonged median sensory (1457 vs. 833 min, P < 0.0001) and motor (1374 vs. 827 min, P < 0.0001) blockade compared with the control. At 24 h, the dexamethasone group had lower median verbal analogue scale scores compared with control (3.0 vs. 6.0). At 48 h, the two groups had similar median pain scores (4.0 vs. 5.0, dexamethasone vs. control, respectively). The opioid requirement in oxycodone equivalency was lower in the dexamethasone group than in the control group for the first 24 h, and similar thereafter.

http://www.ncbi.nlm.nih.gov/pubmed/20009936

 

[BLADEMDA]

As I said, a study with 30 patients in each arm is teeny tiny and essentially worthless when it comes to making a conclusion. There are loads of small studies showing the benefit of adding all kinds of things to a block, and I've yet to see one other than epi proven effective in a larger study.

I'm all about the continued effort to find a better way to do it. If I want something longer lasting, I put in a catheter. It is far more effective than adding anything to a single shot.

Really? How about a personal bet then between the two of us? You try 0.5% Rop with Decadron or 0.5% Bup with Decadron in your next 5 blocks (ISB, SCB, Femoral, Popliteal) and report your results. Just 5 blocks. I bet you they all get RELIABLE pain relief for more than 20 hours with most reporting about 22 hours or better provided you do a good block (with sufficient volume-no less than 23-25 mls).

Are you in?

 

[Oggg]

1. For the best pain relief, find an anesthesiologist who will put it a sciatic nerve catheter and send you home with a disposable pump. The pump can last 2-5 days.
2. Decadron (preservative free) will prolong the block if you get a single shot nerve block. I'd use 0.5% bupivacaine with decadron 4mg
3. Several of our podiatrists have been using steroids in their foot and ankle blocks for years.
4. Ankle/foot blocks last somewhere between 6-30 h depending on luck and drug combo. Most will last closer to 6h, so the sciatic nerve block will be more likely to last longer.
5. 99% of patients having foot surgery will get a foot block from the podiatrist so if your anesthesiologist can't do it, I wouldn't worry

 

[pgg]

This thread needs to stay away from medical advice ...

 

[Idiopathic]

.

 

[Mman]

Really? How about a personal bet then between the two of us? You try 0.5% Rop with Decadron or 0.5% Bup with Decadron in your next 5 blocks (ISB, SCB, Femoral, Popliteal) and report your results. Just 5 blocks. I bet you they all get RELIABLE pain relief for more than 20 hours with most reporting about 22 hours or better provided you do a good block (with sufficient volume-no less than 23-25 mls).

Are you in?

No, most single shots without decadron get a motor block for 12-16 hours and reliable analgesia for 18+ hours anyways. And 5 isn't enough for me to make a clinical judgment. I've got data on my last 500+. Why would I care about only 5?