LAST with local anesthetic at different sites

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gasman654

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Hello SDN, this is embarrassing to post but it’s a big F up on my part and I would like to learn from it.

I had a case recently, patient is 67 yo and 50kg and came for hand surgery. Skinny. I did a Supraclavicular block, I injected 15 mL of .5% ropivacaine perineural and 13 mL of .5% subQ around the intercostobrachial nerve in the arm. Her max dose is 150 mg so I thought I was ok. However, I failed to realize the 1% lidocaine 5 mL I injected subQ for infiltration and 5 mL 1% lidocaine IV I injected for the propofol I gave. Combined, I exceed max dose by a lot. Has anyone done this before? Is there less risk of LAST if you exceed max dose but it’s in different areas ?
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So I do a fair amount of regional and I can give you some feedback. First, I was always taught that when doing regional and using two different LAs you make your calculations for max dose based on the one with the lowest toxic dose. Meaning, if combining bupi and lido you make the max dose based on the idea that the entire volume is bupi. Second, your volumes for these blocks are a little off. An intercostobrachial typically doesn’t need such a large volume. I usually get away with 5-8mls when done under ultrasound. Next, I almost never use local for the skin. Our block needles are 22g and no one complains after 2-4mg of midazolam. My last point, if I have done a nerve block I NEVER give IV LA with or prior to propofol. Lido prior to propofol isn’t worth the potential to tip that person over the edge and cause a LAST reaction.
 
gasman654 said:
Hello SDN, this is embarrassing to post but it’s a big F up on my part and I would like to learn from it.

I had a case recently, patient is 67 yo and 50kg and came for hand surgery. Skinny. I did a Supraclavicular block, I injected 15 mL of .5% ropivacaine perineural and 13 mL of .5% subQ around the intercostobrachial nerve in the arm. Her max dose is 150 mg so I thought I was ok. However, I failed to realize the 1% lidocaine 5 mL I injected subQ for infiltration and 5 mL 1% lidocaine IV I injected for the propofol I gave. Combined, I exceed max dose by a lot. Has anyone done this before? Is there less risk of LAST if you exceed max dose but it’s in different areas ?
Click to expand...

#1. Why not JUST do infraclav? Better hand coverage without a doubt. Then you have good block with one injection.

#2. 1mL of lidocaine at each injection site is more than enough. 5mL?

#3. When I am approaching max dose with a block, I forego any lidocaine with induction.
 
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abolt18 said:
#1. Why not JUST do infraclav? Better hand coverage without a doubt. Then you have good block with one injection.

#2. 1mL of lidocaine at each injection site is more than enough. 5mL?

#3. When I am approaching max dose with a block, I forego and lidocaine with induction.
Click to expand...
Why not do axillary? Works great and really hard to drop a lung.
 
One thing I've been doing for the past couple years is just asking patients if they want two pokes (w/ skin localizing) or just one poke (w/o skin localizing). Most people will just say one poke. Versed does most of the work and god forbid you get a little too close to the nerve they're not going to thank you for the subq anyways.
 
Thanks for the advice. I don’t know why I put so much local at the intercostobrachial, maybe i felt I was being rushed and was just trying to ensure I had good coverage.

The patient was doing fine 2.5 hours post procedure and was then sent home. If you injected this much, would you admit the patient because of possible delayed presentation of LAST?
 
gasman654 said:
Thanks for the advice. I don’t know why I put so much local at the intercostobrachial, maybe i felt I was being rushed and was just trying to ensure I had good coverage.

The patient was doing fine 2.5 hours post procedure and was then sent home. If you injected this much, would you admit the patient because of possible delayed presentation of LAST?
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A few years back a colleague was doing an ankle case under block. He had done popliteal and adductor blocks using bupi and then without telling anyone or informing the anesthesiologist the surgeon gave an additional 20-30mls of 0.5%; basically doubling the patient’s max dose. My colleague was concerned and had the patient admitted overnight on tele. Her EKG did show some PVCs but it wasn’t known if this was her baseline.

For the low dosing error you made I would have watched her for two extra hours in pacu and then sent her home.
 
caligas said:
Why not do axillary? Works great and really hard to drop a lung.
Click to expand...
2014 study of >6K patients had less than 0.06% incidence of PTX with ultrasound guided infraclavicular block.

Personal preference, but I'm going to do infraclav over axillary every time. It's also typically faster than an axillary block.
 
It’s really hard to drop a long with infraclavicular block. you would have to really mess it up. You don’t even see the lung when you scan because you are lateral at the coracoid process. If you see pleura you are too medial.i don’t do axillary either. Just Supraclav or infraclavicular.
 
Patients that are 50kg or less are higher risk due to low muscle mass.
If the patient was 2.5 hours post op and doing fine, you likely dodged a bullet. I might watch them just a bit longer to feel more secure. The ASRA LAST guidelines state recommendations for monitoring times after limited LAST events.
 
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gasman654 said:
Hello SDN, this is embarrassing to post but it’s a big F up on my part and I would like to learn from it.

I had a case recently, patient is 67 yo and 50kg and came for hand surgery. Skinny. I did a Supraclavicular block, I injected 15 mL of .5% ropivacaine perineural and 13 mL of .5% subQ around the intercostobrachial nerve in the arm. Her max dose is 150 mg so I thought I was ok. However, I failed to realize the 1% lidocaine 5 mL I injected subQ for infiltration and 5 mL 1% lidocaine IV I injected for the propofol I gave. Combined, I exceed max dose by a lot. Has anyone done this before? Is there less risk of LAST if you exceed max dose but it’s in different areas ?
Click to expand...
Did she get LAST?

SubQ absorption rates are slow. So her serum concentration won't exceed toxic levels.

Most docs go way over with total joint injections, done thousands without issues. Some data on it as well
 
Arch Guillotti said:
Still do them every once in a while usually for really crappy patients.
Click to expand...
Axillary and musculocutaneous block together for elbow, wrist, AVF cases. No risk of lung, phrenic, or non-compressible vessel involvement and the MC block covers the tourniquet. I sometimes even get paid for both blocks separately.
 
I don’t give iv lidocaine either if I plan on or did a block. It helps with blunting sympathetic response and preventing postoperative myalgia when given on induction though.
 
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Simba1711 said:
I don’t give lidocaine either if I plan on or did a block. It helps with blunting sympathetic response and preventing postoperative myalgia when given on induction though.
Click to expand...

pubmed.ncbi.nlm.nih.gov

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block - PubMed

Total serum concentration of ropivacaine after LIA using 270 mg ropivacaine with and without an additional 100 mg perineural ropivacaine remained well below the toxicity threshold of 3.0 µg/mL at all time points. Additional studies are needed to ascertain the safety of combining LIA with...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

They have 370mg of ropi via blocks, serum concentration never rose above 0.75. Toxic levels are at 3.0
 
nimbus said:
Likely depends on size of vein. I had some in a wrist vein. Just felt cold.
Click to expand...
Yes.

Vein size (small hurts more)
location (distal tend to hurt more than proximal)
Dilution (dilution reduces pain)
Lidocaine reduces pain
Zofran reduces pain (think there is a study on zofran vs saline )

The pain can be quite memorable for many patients. I have had many nurses ask "Why don't your patient scream with the prop". I assume it's because some others don't use lidocaine
 
UscGhost said:
Yes.

Vein size (small hurts more)
location (distal tend to hurt more than proximal)
Dilution (dilution reduces pain)
Lidocaine reduces pain
Zofran reduces pain (think there is a study on zofran vs saline )

The pain can be quite memorable for many patients. I have had many nurses ask "Why don't your patient scream with the prop". I assume it's because some others don't use lidocaine
Click to expand...
My patients also never scream from prop. Bolus remi or suf does wonders.. and helps with intubation conditions
Esp for lmas

Fentanyl really isn't as good in the time frame required from induction to intubation @ least in my hands idk why
 
PpfSuxTube said:
My patients also never scream from prop. Bolus remi or suf does wonders.. and helps with intubation conditions
Esp for lmas

Fentanyl really isn't as good in the time frame required from induction to intubation @ least in my hands idk why
Click to expand...


Do you get postinduction/preincision hypotension? I omit opioids in many of my inductions nowadays and find myself pushing a lot less pressor. For LMAs I usually induce with lidocaine, propofol, and 25-30mg of roc. Then turn on the vent until the roc wears off.
 
PpfSuxTube said:
My patients also never scream from prop. Bolus remi or suf does wonders.. and helps with intubation conditions
Esp for lmas

Fentanyl really isn't as good in the time frame required from induction to intubation @ least in my hands idk why
Click to expand...
We don't have remi or sufent on formulary. But yes, those would work as well.

Lido is pretty easy and more universally available (ASCs, small hospitals, etc)
 
PpfSuxTube said:
My patients also never scream from prop. Bolus remi or suf does wonders.. and helps with intubation conditions
Esp for lmas

Fentanyl really isn't as good in the time frame required from induction to intubation @ least in my hands idk why
Click to expand...
I notice it a lot more at the VA than my suburban PP patients. Substance abuse patients also have more pain. I think there's a big central nervous system/mental health component to this, but, even then, the lidocaine helps. I've swung both ways on opiates with induction. If I give them, I cut way back on the propofol, like to < 1mg/kg. I almost never give opiates with inductions for LMAs because I want them spontaneously ventilating and I find that even small doses of fentanyl delay this. I suppose remi would have less of a delay, but it's a lot of fuss and waste, given the vial sizes we have.
 
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nimbus said:
Do you get postinduction/preincision hypotension? I omit opioids in many of my inductions nowadays and find myself pushing a lot less pressor. For LMAs I usually induce with lidocaine, propofol, and 25-30mg of roc. Then turn on the vent until the roc wears off.
Click to expand...
I work in cardiac vascular neuro surg hospital predominantly. Everyone gets phenyl @ induction.
Honestly cant remember a case when I dont have hypotension.

Opioids like suf are very cardiac stable and allow lower doses of prop which definitely isn't cardiac neutral obviously...

Remi also obviously isn't cardiac stable but I find giving 1mcg/kg allows a lower dose of prop, and when coupled with even a low dose of ephedrine like 10mg @ induction i don't get much more hypotension. Rsi like conditions @ 40 seconds, and then the case cracks on quick so hypotension phase is done...

For some of our sickest patients like mitralclip, I use remi and it works great but I always use lower dose and pair it with a pressor push without even waiting...
 
gasman654 said:
Hello SDN, this is embarrassing to post but it’s a big F up on my part and I would like to learn from it.

I had a case recently, patient is 67 yo and 50kg and came for hand surgery. Skinny. I did a Supraclavicular block, I injected 15 mL of .5% ropivacaine perineural and 13 mL of .5% subQ around the intercostobrachial nerve in the arm. Her max dose is 150 mg so I thought I was ok. However, I failed to realize the 1% lidocaine 5 mL I injected subQ for infiltration and 5 mL 1% lidocaine IV I injected for the propofol I gave. Combined, I exceed max dose by a lot. Has anyone done this before? Is there less risk of LAST if you exceed max dose but it’s in different areas
Click to expand...
You didn't put this patient at high risk of LAST.

But, if you want some feedback, you don't ever need to block ICBN/MBC for hand surgery if you are going to deeply sedate anyways through the upper arm tourniquet. If you are staying wide awake and it's an upper arm tourniquet, then sure, go for it. If you are going to do ICBN/MBC, use lidocaine and there's no reason to ever give 13cc (5-8cc is more than plenty). No one needs their ICBN/MBC blocked for 12+ hours. I usually skip the IV lidocaine prior to the propofol when I've already given a good amount of local. Just not necessary for the vast majority of patients. At most, 1-2cc of 2% lidocaine if I am feeling generous.

Have no clue why people are advocating for IC or axillary. Makes no difference. Just a simple lack of understanding the anatomy. If there are no concerns about phrenic blockade (which is generally 99.9% of patients), do whatever brachial plexus you want. They all cover median/ulnar/radial with 100% efficacy for surgical anesthesia if you do them correctly.
 
Maz777 said:
You didn't put this patient at high risk of LAST.

But, if you want some feedback, you don't ever need to block ICBN/MBC for hand surgery if you are going to deeply sedate anyways through the upper arm tourniquet. If you are staying wide awake and it's an upper arm tourniquet, then sure, go for it. If you are going to do ICBN/MBC, use lidocaine and there's no reason to ever give 13cc (5-8cc is more than plenty). No one needs their ICBN/MBC blocked for 12+ hours. I usually skip the IV lidocaine prior to the propofol when I've already given a good amount of local. Just not necessary for the vast majority of patients. At most, 1-2cc of 2% lidocaine if I am feeling generous.

Have no clue why people are advocating for IC or axillary. Makes no difference. Just a simple lack of understanding the anatomy. If there are no concerns about phrenic blockade (which is generally 99.9% of patients), do whatever brachial plexus you want. They all cover median/ulnar/radial with 100% efficacy for surgical anesthesia if you do them correctly.
Click to expand...
Yeah there's a reason supraclav is called the spinal of the arm. You don't ever need any of the other blocks unless you want to spare the diaphragm
 
Maz777 said:
Why are you doing supraclavs for shoulders?
Click to expand...
Less phrenic, lower dose required (this is all evidence based), and easier and faster (not evidence based). Blade actually posted a randomized trial a few years back showing equivalent pain scores postop between this and interscalene, and given all of the above, that’s just what I do. I can’t say I recall anybody having shoulder pain, postop, but most of them can still move their hands, so I wouldn’t do this block for wrist surgery.
 
An ISB is the standard of care for shoulder surgery. An ISB takes approximately 5 seconds skin to skin and it's literally the easiest block to perform. A proper supraclav takes at least 15 seconds and you need multiple needle redirections to do it properly unlike an ISB. You can get "fancy" and attempt a phrenic-sparing block (STB, combined posterior suprascap/axillary, isolated anterior suprascap, etc.) to attempt to mimic an ISB but you will always have a worse analgesic outcome. You will miss suprascapular in a decent percentage of patients with a medium-volume supraclav. It frequently exits the brachial plexus just cephalad to where a supraclav is done. This is just anatomy. You need two terminal nerves blocked for shoulder surgery (suprascap and ax). If you don't cover both reliably well, there's no point in doing a block. Shoulder patients should have no pain in PACU after an ISB. The only exception is if they venture into ICBN territory (biceps tenodesis). Don't get me wrong, I love doing supraclavs. It's my go-to block for mid-humerus and down when I'm not placing a catheter. But doing them routinely for shoulders makes no sense.
 
Do interscalene for shoulders unless the person is a pulmonary cripple. Some supraclavs work for shoulders and others do not. It isn’t reliable and we do a ton of shoulder replacements under block/mac, those need to be 100%.

Supraclavs do spare the ulnar distribution at times and it can be a pain in the @$$ when doing wrist fx repairs under block. A well placed infraclav is the best block for wrist and hand, axillary a close second.
 
cchoukal said:
Kind of. I do a lot of supraclavicular for shoulders and often get ulnar sparing. Would love some tips!
Click to expand...


How much volume? Do you specifically target the corner pocket? Maybe not if you’re just trying to block the shoulder. You can reliably get ulnar if you put the needle tip deep in the corner and “lift” the artery off the 1st rib with a little local.
 
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nimbus said:
How much volume? Do you specifically target the corner pocket? Maybe not if you’re just trying to block the shoulder. You can reliably get ulnar if you put the needle tip deep in the corner and “lift” the artery off the 1st rib with a little local.
Click to expand...
couldnt agree more!
 
Maz777 said:
An ISB is the standard of care for shoulder surgery. An ISB takes approximately 5 seconds skin to skin and it's literally the easiest block to perform. A proper supraclav takes at least 15 seconds and you need multiple needle redirections to do it properly unlike an ISB. You can get "fancy" and attempt a phrenic-sparing block (STB, combined posterior suprascap/axillary, isolated anterior suprascap, etc.) to attempt to mimic an ISB but you will always have a worse analgesic outcome. You will miss suprascapular in a decent percentage of patients with a medium-volume supraclav. It frequently exits the brachial plexus just cephalad to where a supraclav is done. This is just anatomy. You need two terminal nerves blocked for shoulder surgery (suprascap and ax). If you don't cover both reliably well, there's no point in doing a block. Shoulder patients should have no pain in PACU after an ISB. The only exception is if they venture into ICBN territory (biceps tenodesis). Don't get me wrong, I love doing supraclavs. It's my go-to block for mid-humerus and down when I'm not placing a catheter. But doing them routinely for shoulders makes no sense.
Click to expand...
I would be careful throwing around words like "standard of care." It makes you sound unnecessarily dogmatic, and the glaring inaccuracy impacts the credibility of your other points, all of which are good. I have been doing and teaching supraclavicular blocks for shoulder scopes for 15 years. I track all my PACU re-blocks, and there have been 5 in that time. Your points about the anatomy are well-taken, but regardless of what does or doesn't get blocked, in a theoretical sense, the fact of the matter is post-op pain (my #2 priority) is the same, and complications (my #1 priority) are fewer with the supraclavicular block. Here's one small trial:

journals.lww.com

Comparison Between Supraclavicular and Interscalene... : Journal of Datta Meghe Institute of Medical Sciences University

h of the brachial plexus block is associated with a high success rate and provides anesthesia of the entire upper extremity in the most consistent, time-efficient manner. However, there is little information regarding its efficacy for providing analgesia for shoulder surgeries. This study was...
journals.lww.com journals.lww.com

They note more patients with the supraclavicular received intra-op fentanyl, but the difference was actually quite small. The most notable thing about this trial is that they found significant differences in the safety outcome in a trial that was not powered to do so.
 
cchoukal said:
I would be careful throwing around words like "standard of care." It makes you sound unnecessarily dogmatic, and the glaring inaccuracy impacts the credibility of your other points, all of which are good. I have been doing and teaching supraclavicular blocks for shoulder scopes for 15 years. I track all my PACU re-blocks, and there have been 5 in that time. Your points about the anatomy are well-taken, but regardless of what does or doesn't get blocked, in a theoretical sense, the fact of the matter is post-op pain (my #2 priority) is the same, and complications (my #1 priority) are fewer with the supraclavicular block. Here's one small trial:

journals.lww.com

Comparison Between Supraclavicular and Interscalene... : Journal of Datta Meghe Institute of Medical Sciences University

h of the brachial plexus block is associated with a high success rate and provides anesthesia of the entire upper extremity in the most consistent, time-efficient manner. However, there is little information regarding its efficacy for providing analgesia for shoulder surgeries. This study was...
journals.lww.com journals.lww.com

They note more patients with the supraclavicular received intra-op fentanyl, but the difference was actually quite small. The most notable thing about this trial is that they found significant differences in the safety outcome in a trial that was not powered to do so.
Click to expand...
Dude, you gotta have some discretion about the publications you cite. That pained me to click on that. 30cc for an ISB and ultrasound was not used? I am SHOCKED they had issues. ****ty technique/methodology = ****ty results.

Let me rephrase my "dogma." Doing supraclaviculars for shoulders is outside the standard of care for appropriate analgesia for shoulder surgery. If any of your shoulder patients have pain scores greater than 0 in the PACU, you are doing something wrong anatomically. Keep track of your patient's in the PACU and follow your blocks. The goal should be zero pain in the PACU for 99% of shoulder patients.

Again. You are missing suprascapular in a large proportion of the supraclavs you are doing unless you are doing a block somewhere between a traditional ISB and a supraclavicular. Some call it a low interscalene or a selective trunk block. You don't need a completely dead arm for shoulder surgery. Patients generally don't like that.

That being said, the rate of ulnar sparing for a supraclav should be 0% if done correctly. You need to bath the inferior/lower trunk with LA circumferentially to achieve that result. The "corner pocket" teaching is insufficient if you are a layer off and just lifting the plexus/inferior trunk off of the 1st rib. That won't achieve circumferential spread. That being said, the ulnar nerve does not contribute any sensory innervation to the shoulder, so none of this matters for shoulder surgery. Don't target a nerve that doesn't go to your operative field. Just a waste of time.
 
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PainDrain said:
Do interscalene for shoulders unless the person is a pulmonary cripple. Some supraclavs work for shoulders and others do not. It isn’t reliable and we do a ton of shoulder replacements under block/mac, those need to be 100%.

Supraclavs do spare the ulnar distribution at times and it can be a pain in the @$$ when doing wrist fx repairs under block. A well placed infraclav is the best block for wrist and hand, axillary a close second.
Click to expand...
All the nerves are there for each block (IC, SC, axillary). You aren't magically missing a nerve outside your block if the blocks are done correctly. Coverage is the same below the distal humerus (assuming you get musculocutaneous appropriately with ax) for hand/forearm surgery. The only difference is your ability to get good spread around all components. It doesn't matter if you are blocking at the trunk/division level, cord level, or terminal nerve level. All the necessary nerves are there for each of those brachial plexus blocks in your ultrasound field of view.
 
UscGhost said:
pubmed.ncbi.nlm.nih.gov

Serum ropivacaine levels after local infiltration analgesia during total knee arthroplasty with and without adductor canal block - PubMed

Total serum concentration of ropivacaine after LIA using 270 mg ropivacaine with and without an additional 100 mg perineural ropivacaine remained well below the toxicity threshold of 3.0 µg/mL at all time points. Additional studies are needed to ascertain the safety of combining LIA with...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

They have 370mg of ropi via blocks, serum concentration never rose above 0.75. Toxic levels are at 3.0
Click to expand...
LAST is an uncommon event. This study is not powered to demonstrate safety of toxic doses of ropivacaine.

1736984349792.png


There are only 7 patients in each arm of the study and they excluded anyone less than 80 kg (so only 7 patients received the high dose ropivacaine). So, they have set the study up to exclude the patients at highest risk (especially when standardized cocktails are utilized), which are the low weight patients. This study may lull some into assuming safety in these situations with these high doses of local, but the literature is full of case reports and studies that show toxic serum levels can occur in patients in these situations. Just because they got away with it in 7 patients hand selected to be of above average weight doesn't mean you will get away with it always. Caution and proper dosing should still be the norm.

A retrospective study of erector spinae blocks by Tulgar et al found a 2% incidence of LAST (4/182). Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT. Ultrasound-guided erector spinae plane block: indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureus. 2019;11:e3815.

So, I would say, LAST is uncommon, but not rare. Sometimes LAST can be mild and present with different symptoms (such as rigidity or mild cognitive symptoms) and can be easy to attribute to other factors.

You could probably do a slow inhalation induction on a small bowel obstruction and get away with it more often than not. That doesn't mean you should. It is the one patient that aspirates and dies that should cause you to adhere to safe practices as the norm. If a colleague told you they did a sevo inhalation induction on 7 small bowel obstructions in a row and they all did great, would that cause you to change practice to match theirs?

For the same reason, I would not change my practice based on the study you cited.
 
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