New Regional Case

[USAnesthesiaDoc]

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How would you attempt this case?

41 year old female with history of moderate asthma and significant inhaler use, PONV after general anesthesia, history of anaphylaxis to morphine and significant sensitivity including hives to other narcotics, who is otherwise healthy presents for left knee arthroscopy and patellar realignment. Surgeon is amenable to regional anesthesia, and patient will be admitted overnight after surgery for pain management.

 

[Planktonmd]

How would you attempt this case?

41 year old female with history of moderate asthma and significant inhaler use, PONV after general anesthesia, history of anaphylaxis to morphine and significant sensitivity including hives to other narcotics, who is otherwise healthy presents for left knee arthroscopy and patellar realignment. Surgeon is amenable to regional anesthesia, and patient will be admitted overnight after surgery for pain management.

Femoral Nerve block with catheter placement preop, bolus with 20 cc Bupivacaine 0.5 % with epi and 10 cc Lidocaine 2 % with epi.
Take her to the OR and induce with Propofol and place LMA, maintain with Sevo/ N2O in Oxygen (yes I said Nitrous 🙂), If the femoral block is not enough for intraop give small touches of Ketamine.
Post op Bupivacaine 0.125 % infusion PCA, she will have no pain.

 

[huktonfonix]

As stated above would do fem block with cath plus toradol (at end of surg/post op) for breakthrough pain. Toradol, IV/PO ketamine, there are other alternatives to opioids.

 

[fval28]

How would you attempt this case?

41 year old female with history of moderate asthma and significant inhaler use, PONV after general anesthesia, history of anaphylaxis to morphine and significant sensitivity including hives to other narcotics, who is otherwise healthy presents for left knee arthroscopy and patellar realignment. Surgeon is amenable to regional anesthesia, and patient will be admitted overnight after surgery for pain management.

I would place a continuous FNB catheter preop and plan to run 0.2% naropin overnight, For the case I would probably do a spinal 8-12 mg heavy marcaine, lay her on her left side for 3-5 min then turn her supine- if patient wants to watch surgery then no sedation, if she wants to be asleep then propofol gtt. Given her hx of PONV and asthma, I would stay away from instrumenting her airway if possible.

 

[Planktonmd]

I would place a continuous FNB catheter preop and plan to run 0.2% naropin overnight, For the case I would probably do a spinal 8-12 mg heavy marcaine, lay her on her left side for 3-5 min then turn her supine- if patient wants to watch surgery then no sedation, if she wants to be asleep then propofol gtt. Given her hx of PONV and asthma, I would stay away from instrumenting her airway if possible.

How does "instrumenting the airway" contribute to PONV?
a continous femoral block and a spinal is way too much work for a knee scope.

 

[fval28]

How does "instrumenting the airway" contribute to PONV?
a continous femoral block and a spinal is way too much work for a knee scope.

i should have been more clear, instrumenting the airway is going to increase the likelihood of asthma exacerbation, providing inhalational GA thru that instrumented airway will almost certainly increase her risk of developing PONV.

I disagree about the SAB and CFNB being too much work, especially for this patient with a documented history of difficulty with narcotics- also this isn't just a run of the mill knee scope. She is being admitted post op for pain control. Why is a spinal "way too much work"?

 

[Planktonmd]

i should have been more clear, instrumenting the airway is going to increase the likelihood of asthma exacerbation, providing inhalational GA thru that instrumented airway will almost certainly increase her risk of developing PONV.

I disagree about the SAB and CFNB being too much work, especially for this patient with a documented history of difficulty with narcotics- also this isn't just a run of the mill knee scope. She is being admitted post op for pain control. Why is a spinal "way too much work"?

Do you have data showing increased asthma complications with an LMA?
Spinal + Fem block are 2 anesthetics for 1 procedure, if you want to do a neuraxial anesthetic just do an epidural and skip the fem block.

 

[fval28]

Do you have data showing increased asthma complications with an LMA?- Nope, just common sense (and a few years experience) telling me that leaving the airway alone in a patient with asthma will be one less thing to worry about post op.
Spinal + Fem block are 2 anesthetics for 1 procedure, if you want to do a neuraxial anesthetic just do an epidural and skip the fem block.

Which would probably work just as well, except perhaps that she may not be getting out of bed as soon with your epidural as she will with my CFNB/ SAB- my SAB will be worn off in ~ 2 hours and I have seen VERY little motor block with 0.2% naropin, she could be up on crutches by dinner time. With an epidural, she will most likely be nailed to the bed, especially if you avoid neuraxial narcotics. [/COLOR

 

[Planktonmd]

Which would probably work just as well, except perhaps that she may not be getting out of bed as soon with your epidural as she will with my CFNB/ SAB- my SAB will be worn off in ~ 2 hours and I have seen VERY little motor block with 0.2% naropin, she could be up on crutches by dinner time. With an epidural, she will most likely be nailed to the bed, especially if you avoid neuraxial narcotics. [/COLOR

Not if you know what you are doing.
But I still wouldn't do an epidural for this case, all you need is a good femoral block and optional Sedation or a well titrated GA (done correctly).

 

[Noyac]

I'd do the CFNB and the SAB as well. Most people will not tolerate the surgery with just a FNB unless heavily sedated or asleep. I'd add the SAB for the surgery.

If she wanted to go to sleep then an LMA and no SAB.

Celebrex or toradol pre-op.

Toradol intra-op.

Celebrex or toradol post-op.

All standard doses.

 

[USAnesthesiaDoc]

This was actually my case yesterday. Our hospital (small, private) hasn't been doing PNB catheters, so I opted to do combined femoral/sciatic single shot nerve blocks. Performed femoral with bupivicaine 0.5% + epi 30 ml and sciatic with ropivicaine 0.5% plain 30 ml. Propofol infusion for sedation during the case. Patient was pain free throughout the night. Had oral demerol the next morning when the blocks had worn off and was discharged home (she had previously had demerol without problems). No problems with PONV, no asthma exacerbation. Patient was very happy.

 

[fval28]

Not if you know what you are doing.
But I still wouldn't do an epidural for this case, all you need is a good femoral block and optional Sedation or a well titrated GA (done correctly).

So you wouldn't do an epidural, but you brought it up as an option... and criticized my management as excessive, and then implied that I don't know how to manage an epidural--- sir might I suggest you get laid?

 

[VentdependenT]

Fem Sciatic with 50-50 lidocaine 2%/Ropivicaine 0.5% + clonidine 5ucg/ml + 1:200k epi.

If stay in house a CFNB sounds like a great idea. I've only done 1-2 of em and would like to do more.

If the patient is gonna stay in-house and you have peeps who can easily manage an epidural afterwards then go fer it.

 

[Planktonmd]

So you wouldn't do an epidural, but you brought it up as an option... and criticized my management as excessive, and then implied that I don't know how to manage an epidural--- sir might I suggest you get laid?

Madam,
Thank you very much for the invitation but allow me to decline, although your offer is appreciated.
Now,
Let me explain to you what the issues are:
First you said you wouldn't instrument the airway because of "Asthma and PONV".
Then you said that inhaled agents "almost certainly" will cause nausea and vomiting.
Then you said that an epidural will "certainly" mean the patient will remain "nailed" to bed.
I was just trying to point out that there are several ways to do an anesthetic and that your "assertions" and "certainties" are based on anecdotes and urban legends.
Sure, your planned anesthetic is valid but there are other valid plans as well.
So, don't take it too personally.

 

[fval28]

Madam,
Thank you very much for the invitation but allow me to decline, although your offer is appreciated. First off, it wasn't an invitation but rather a suggestion-- your posts as of late seem to be a bit, shall we say less than relaxed--plus it was meant as a joke- seems as if you may have proven my point
Now,
Let me explain to you what the issues are:
First you said you wouldn't instrument the airway because of "Asthma and PONV". Correct
Then you said that inhaled agents "almost certainly" will cause nausea and vomiting. Correct
Then you said that an epidural will "certainly" mean the patient will remain "nailed" to bed. Actually I wrote she "most likely" will be nailed to the bed, might want to read a bit more carefully...
I was just trying to point out that there are several ways to do an anesthetic and that your "assertions" and "certainties" are based on anecdotes and urban legends. What you classify as assertions and certainties are what I call experience and patient centered care. This woman was being ADMITTED post op for pain control- there is no need to expose her to anything that may trigger either her asthma or PONV. Why would you want to expose her to something she has had a bad experience with before when there are alternatives available?
Sure, your planned anesthetic is valid but there are other valid plans as well. I know it is and I never expressed that others were not- you on the other hand seem to be very quick with criticism that seems not all that well thought out
So, don't take it too personally.

I haven't, thanks for the discussion, and think about taking my advice😀

 

[Planktonmd]

I haven't, thanks for the discussion, and think about taking my advice😀

🙄
Ok,
Enjoy having the last word.

 

[epidural man]

How would you attempt this case?

41 year old female with history of moderate asthma and significant inhaler use, PONV after general anesthesia, history of anaphylaxis to morphine and significant sensitivity including hives to other narcotics, who is otherwise healthy presents for left knee arthroscopy and patellar realignment. Surgeon is amenable to regional anesthesia, and patient will be admitted overnight after surgery for pain management.

Celebrex 400mg PO preop. Spinal for the case. Fascia Iliaca catheter placed post op. Ropivicaine 0.2% first 24 hrs. If she is doing well, would decrease to 0.1% to help with physical therapy and decrease quad weakness.

 

[beezar]

continuous fem block, single shot sciatic block, run a MAC with propofol. discharge the patient the same day with the femoral nerve block cath attached to a pump. no reason to keep the pt in-house.

the only possible issue with the above is that if you miss the obturator nerve with the fem block, you might miss a variable portion of the medial knee. unlikely, but can occur. to be absolutely safe, SAB + fem block works great, or you can try fem/sciatic and convert to GA if need be.

but again, why keep the pt in-house if they are comfortable and nausea free?

 

[USAnesthesiaDoc]

I agree that she did not need to be kept overnight in the hospital because the fem/sciatic blocks were successful and long-lasting. However, the surgeon wanted to be conservative since she had had so many issues in the past. Also, with single shot blocks in younger patients, sometimes they wear off sooner than expected, and the surgeon didn't want to have to deal with severe pain issues while the patient was at home in the middle of the night. I also agree that a femoral catheter would have been the best way to go, but my hospital has not been offering them (yet).