Lumbar sympathetic blocks

[schmee90]

---

Members do not see this ad.

Relatively new Attending, haven’t actually done a a lumbar sympathetic block or hypogastric blocks.

I looked up a bunch of sources on how to actually do the blocks and they actually look fairly technically straightforward in terms of obliquing until the transverse processes lines up with the VB touching os and then walking off from a lateral position until the needle is dorsal a few mm to the anterior edge of the vert body to stay away from great vessels. Go back to back AP and making sure you’re in mid pedicular period inject contrast make sure you’re not in muscle or vasculature

Hypogastric block I know you’re dealing with iliac crest which makes life a little harder but other then that any pearls from more seasoned docs? Thanks in advance.

 

[willabeast]

I like a stick on temperature probe on both legs with a digital readout, usually can tell quickly if got the sympathetics. Combine a short acting with a long acting local anesthetic.

 

[Logano2230]

I would recommend bending the needle further back than you normally would, around 1cm from the tip. Keep in mind you are crawling around 3 dimensional cylindrical structure. Aligning TP within the vertebral body usually means you’re touching os at about 40% depth on vertebral body. One move lateral gets around the apex, then advance with bend pointed medially until depth is just short of anterior cortex.

Contrast should look bubbly like an interlam and be medial to lateral cortex on AP. If it’s a dark vertical stripe you’re probably in muscle and not medial enough. Can always reset with a more oblique approach if it’s not working.

 

[pastafan]

Review Furman's atlas. Very easy block to perform.

 

[schmee90]

Thanks all appreciate it, the insights

 

[giddyup]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

 

[schmee90]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

Im assumig you add quite a big of cephalad tilt to go over the top ofthe crest?

 

[painfree23]

What do you bill for the hypogastrics?

 

[interjectionreflection]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

Do you do transdiscal approach or above TP?

 

[hopefulgasman]

What are y'all putting for the injectate for this block

 

[giddyup]

Im assumig you add quite a big of cephalad tilt to go over the top ofthe crest?

Yes, up to 30 degrees. Ferguson view

 

[giddyup]

What do you bill for the hypogastrics?

64517

 

[giddyup]

Do you do transdiscal approach or above TP?

Above TP

 

[giddyup]

What are y'all putting for the injectate for this block

20ml 0.5 bup, would use rop if I was hopd but too $$ for private practice

 

[painfree23]

20ml 0.5 bup, would use rop if I was hopd but too $$ for private practice

Wow, that’s a strong block. How hypotensive do they get?

 

[Ducttape]

not usually hypotensive but it is a risk.
not as much tissue to vasodilate as, say a celiac.

for hypogastric, i use 10 ml 0.25% bupiv.


there is another way...

 

[giddyup]

Wow, that’s a strong block. How hypotensive do they get?

i do 10ml each side. i give them IV fluids. in 15 years never had an episode of hypotension

 

[BobBarker]

I give around 15ml local. Mix of lido and ropi.