Nerve block pre existing deficit

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caligas

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What is your approach to the patient with a pre-existing peripheral nerve deficit (not MS etc) who wants a PNB?

Document deficit and go?

What till PACU to document any changes from surgery?
 
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okayplayer said:
I’m a bit surprised this is so cut and dried for you guys. Surgeon wants a block, patient wants a block and you guys just say no? Seems like documenting the preop deficit and proceeding is also a reasonable option.
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There would have to be an overwhelming reason skewing the risk benefit toward benefit of doing an elective pain procedure with an above average risk of permanent neurological injury (in this case), especially when reasonable alternatives exist.

The very same surgeon requesting the block will happily throw you under the bus and say the nerve injury is your fault, and the very same patient requesting the block can still sue you, regardless of what you told them or what’s written in the consent.
 
nimbus said:
It’s completely a medicolegal issue and not a medical issue.
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Can you explain what you mean here?

I believe these other guys are implying it’s a medical issue due to risk of “double hit” nerve injury. Not sure about that given the location of nerve injury is quite remote from location of block for proximal humerus for instance.

By the way, I am just playing devil’s advocate here. I am enjoying the discussion.
 
okayplayer said:
I’m a bit surprised this is so cut and dried for you guys. Surgeon wants a block, patient wants a block and you guys just say no? Seems like documenting the preop deficit and proceeding is also a reasonable option
Click to expand...
It has a deficit preoperatively. It will likely have one postoperatively even if no further interpraoperative injury occurs. Probably inadvisable to put neurotoxic agents next to it even if proximal to it. Documenting it sounds like it is to preclude medicolegal stuff - which it won’t.
 
okayplayer said:
Can you explain what you mean here?

I believe these other guys are implying it’s a medical issue due to risk of “double hit” nerve injury. Not sure about that given the location of nerve injury is quite remote from location of block for proximal humerus for instance.

By the way, I am just playing devil’s advocate here. I am enjoying the discussion.
Click to expand...
I don’t think double hit has to be same location proximal/distal wise?
 
okayplayer said:
Can you explain what you mean here?

I believe these other guys are implying it’s a medical issue due to risk of “double hit” nerve injury. Not sure about that given the location of nerve injury is quite remote from location of block for proximal humerus for instance.

By the way, I am just playing devil’s advocate here. I am enjoying the discussion.
Click to expand...


I misposted. I should have said the primary reason I wouldn’t block is medicolegal. I admit there could be an increase risk of actual harm from a block due to a double crush or double hit mechanism.
 
So what if it’s a chronic/old deficit unrelated to the current surgery? Double crush wouldn’t be an issue right?
 
caligas said:
So what if it’s a chronic/old deficit unrelated to the current surgery? Double crush wouldn’t be an issue right?
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Depends what it’s from. If they’re weak from a prior stroke, I would likely still do the block as the deficit is central, not peripheral.

Alternatively I had a patient come in for a hand surgery a few months ago that had previously dislocated same side shoulder with associated brachial plexus injury requiring 6 months of occupational therapy to recover from. Shoulder injury was unrelated to hand injury. She got a tube and some local on the field.
 
okayplayer said:
I’m a bit surprised this is so cut and dried for you guys. Surgeon wants a block, patient wants a block and you guys just say no? Seems like documenting the preop deficit and proceeding is also a reasonable option.
Click to expand...
i agree with you as long as patient and surgeon are on board and the risks have been explained and I believe its in the patients best interest
 
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Depends on the exact type of pre-exisiting neuro deficit and your relationship with that particular surgeon.

A surgeon that blames anesthesia for everything and routinely has 3-hr tourniquet times? Eff no.

A competent, pleasant surgeon that won't throw you or hasn't thrown a colleague under the bus? Possibly.

Most younger patients with prior surgical or traumatic nerve injuries usually won't want a block if you fully consent them about the (theoretical) risks.

The urge to act like nerve blocks are medically necessary for any anesthetic is something I fail to grasp.
 
Maz777 said:
Depends on the exact type of pre-exisiting neuro deficit and your relationship with that particular surgeon.

A surgeon that blames anesthesia for everything and routinely has 3-hr tourniquet times? Eff no.

A competent, pleasant surgeon that won't throw you or hasn't thrown a colleague under the bus? Possibly.

Most younger patients with prior surgical or traumatic nerve injuries usually won't want a block if you fully consent them about the (theoretical) risks.

The urge to act like nerve blocks are medically necessary for any anesthetic is something I fail to grasp.
Click to expand...

The anesthetic for a 80yo prox humeral fx is a lot different without a block. As is recovery.. I would just make sure there is a legit reason to withhold that from your patient
 
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Hoya11 said:
The anesthetic for a 80yo prox humeral fx is a lot different without a block. As is recovery...
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First of all, proximal humerus fractures are not associated with traumatic nerve injuries. Unlike mid-shaft and distal humerus fractures.

But, you're right, your IS SS has magically decreased their POCD and ability to get to a rehab facility. Probably increased her life expectancy by 5-10 years. Kudos to you. Blocks are magical.
 
Maz777 said:
Depends on the exact type of pre-exisiting neuro deficit and your relationship with that particular surgeon.

A surgeon that blames anesthesia for everything and routinely has 3-hr tourniquet times? Eff no.

A competent, pleasant surgeon that won't throw you or hasn't thrown a colleague under the bus? Possibly.

Most younger patients with prior surgical or traumatic nerve injuries usually won't want a block if you fully consent them about the (theoretical) risks.

The urge to act like nerve blocks are medically necessary for any anesthetic is something I fail to grasp.
Click to expand...

They are medically necessary for the anesthesiologist's sanity
I hate when surgeons suck with local and I'm constantly getting phone calls from pacu.
"The patient is basically apneic but every time she wakes up she complains of 12/10 pain"
 
Maz777 said:
First of all, proximal humerus fractures are not associated with traumatic nerve injuries. Unlike mid-shaft and distal humerus fractures.

But, you're right, your IS SS has magically decreased their POCD and ability to get to a rehab facility. Probably increased her life expectancy by 5-10 years. Kudos to you. Blocks are magical.
Click to expand...

Blocks undoubtedly help fragile patients get through painful surgeries more smoothly. Im not sure that is a debate.

Not only for the anesthesiologist sanity but because it’s the right thing to do for the patient. No one is going to consent to a block when you read them the massive list of all possible ( extremely rare) complications. You have to lead a patient in the direction you feel is best for them. Not what is best to assuage your paranoia of avoiding a lawsuit from a procedure with such a rare instance of complications, and such a benefit to the patients ..
 
caligas said:
So what if it’s a chronic/old deficit unrelated to the current surgery? Double crush wouldn’t be an issue right?
Click to expand...
Probably would do it. Not on a concert pianist or football kicker or anything.

Since residency I’ve seen many of the newer videos that demonstrate increasingly more conservative techniques. C5-c6 injection only. Outside the sheath duke video. I’ve tried them at their volumes/doses and noticed they don’t last very long. They get out of pacu and home but in pain by the time they are thinking about going to sleep - surprise. I call them all - they seem to think what’s the point as do I.

On the other extreme, I know people who boast of their “three day blocks” poking this way and that - not exactly comfortable with that either.
 
okayplayer said:
I’m a bit surprised this is so cut and dried for you guys. Surgeon wants a block, patient wants a block and you guys just say no? Seems like documenting the preop deficit and proceeding is also a reasonable option.
Click to expand...

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures - PMC

Background Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov



Now, I’m a little older than some of you guys (younger than a few). I know I may sound like an “old fart”, but honestly, I think some folks are getting WAY too “carried away” with trying to do regional on so many folks.

I’ve done too many cases for too many years to believe that most of these folks won’t do just FINE without me sticking needles in their body, next to important motor/sensory nerves. Believe me, they do ok.

Yeah, you can get them out the door a bit faster. Yeah, they may be “more comfortable” for an extra day or two. Then again, look at those studies above. The complication rate is NOT zero. It’s not “practically zero”, either.

If you asked ME as a patient, “Do you want to be more comfortable for an extra day or two, with a possible risk of having a “gimpy” arm or leg for months, or maybe even the rest of your life??”, I’d tell you to let me hurt a little.

Look at the study above on young folks with ACL repair at 6 months. If you were a Jr/Sr high schooler (trying to get a scholarship) or a college athlete, would YOU want regional?? Still weak at 6 months??

I know some of you are “experts”, and never have a complication. Congrats. Studies, and the ASA closed claims data, say different.

Feel free to send me a post card from whatever exotic location your legal deposition takes place at, and tell me if you still think that an extra 24-48 hours of pain control was worth a lifetime of disability and a 6-7 figure plus payout to someone.
 
DirtDocMD said:

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures - PMC

Background Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov



Now, I’m a little older than some of you guys (younger than a few). I know I may sound like an “old fart”, but honestly, I think some folks are getting WAY too “carried away” with trying to do regional on so many folks.

I’ve done too many cases for too many years to believe that most of these folks won’t do just FINE without me sticking needles in their body, next to important motor/sensory nerves. Believe me, they do ok.

Yeah, you can get them out the door a bit faster. Yeah, they may be “more comfortable” for an extra day or two. Then again, look at those studies above. The complication rate is NOT zero. It’s not “practically zero”, either.

If you asked ME as a patient, “Do you want to be more comfortable for an extra day or two, with a possible risk of having a “gimpy” arm or leg for months, or maybe even the rest of your life??”, I’d tell you to let me hurt a little.

Look at the study above on young folks with ACL repair at 6 months. If you were a Jr/Sr high schooler (trying to get a scholarship) or a college athlete, would YOU want regional?? Still weak at 6 months??

I know some of you are “experts”, and never have a complication. Congrats. Studies, and the ASA closed claims data, say different.

Feel free to send me a post card from whatever exotic location your legal deposition takes place at, and tell me if you still think that an extra 24-48 hours of pain control was worth a lifetime of disability and a 6-7 figure plus payout to someone.
Click to expand...


In our practice, no FNBs in high school or college athletes getting ACLRs since that study came out. Sports docs don’t want them.
 
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DirtDocMD said:

Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures - PMC

Background Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov



Now, I’m a little older than some of you guys (younger than a few). I know I may sound like an “old fart”, but honestly, I think some folks are getting WAY too “carried away” with trying to do regional on so many folks.

I’ve done too many cases for too many years to believe that most of these folks won’t do just FINE without me sticking needles in their body, next to important motor/sensory nerves. Believe me, they do ok.

Yeah, you can get them out the door a bit faster. Yeah, they may be “more comfortable” for an extra day or two. Then again, look at those studies above. The complication rate is NOT zero. It’s not “practically zero”, either.

If you asked ME as a patient, “Do you want to be more comfortable for an extra day or two, with a possible risk of having a “gimpy” arm or leg for months, or maybe even the rest of your life??”, I’d tell you to let me hurt a little.

Look at the study above on young folks with ACL repair at 6 months. If you were a Jr/Sr high schooler (trying to get a scholarship) or a college athlete, would YOU want regional?? Still weak at 6 months??

I know some of you are “experts”, and never have a complication. Congrats. Studies, and the ASA closed claims data, say different.

Feel free to send me a post card from whatever exotic location your legal deposition takes place at, and tell me if you still think that an extra 24-48 hours of pain control was worth a lifetime of disability and a 6-7 figure plus payout to someone.
Click to expand...

A single surgeon’s patient series; with no comparator group?

C’mon….

There’s a reason this was published in Cereus and not in a real journal.

The title of the article should read: “PNB allows shifting of blame for nerve injuries due to tourniquet use”

I’m not arguing that nerve injuries don’t happen, but this study won’t be the one that changes my practice.
 
teacher2md said:
A single surgeon’s patient series; with no comparator group?

C’mon….

There’s a reason this was published in Cereus and not in a real journal.

The title of the article should read: “PNB allows shifting of blame for nerve injuries due to tourniquet use”

I’m not arguing that nerve injuries don’t happen, but this study won’t be the one that changes my practice.
Click to expand...
Google “nerve block injury”, and you can find dozens more.

We’re not talking about “curative” procedures, here (to avoid a lifetime of pain). We’re talking about something that’s being done so that the patient can be “discharged” (kicked out) of the hospital/surgery center, a little quicker, or to get 24-48 hours of “better pain control”.

THAT does not spell “good risk to reward ratio”, for me, and, to be honest, I doubt most patients would consider it a worthwhile risk, either.

Folks are willing to endure an ACL or rotator cuff procedure (and the associated days of discomfort) to avoid 30 YEARS of dysfunction/pain, but risking injury for 2 DAYS of pain relief??

I can’t avoid them all (blocks), but I certainly don’t make a habit of getting creative with them, or pushing them hard.

Are blocks “helpful”?? Sure.
Are they “necessary”?? Never.

I know you know this, as well.

You’ll find out REAL quick how good a “buddy” your ortho surgeon is, when those phone calls about “My arm is still numb!” And “I can’t move my leg!”, come in, 7-10 days, later……
 
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