Obturator block

[anbuitachi]

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Trying to find a good guide for obturator block prior to bifurcation (for TURBT). anyone know of any? Couldnt find much on google search.

Ive read it should be blocked prior to bifurcation for TURBT which seems kind of high up. I've only done posterior obturator blocks for knee cases ... I imagine blocking a bit more distally both anterior and posterior would work fine for TURBT as well, but I've never tested..

 

[deleted162650]

Try injecting 30mg of rocuronium directly into a peripheral vein. Works great.

 

[norski]

Our shop likes mivacron.

 

[anbuitachi]

mainly wondering for people i want to avoid paralytics on 🙂

 

[Arch Guillotti]

mainly wondering for people i want to avoid paralytics on 🙂

Are you going to do spinals on these patients?

 

[BLADEMDA]

Ultrasound-Guided Obturator Nerve Block: A Focused Review on Anatomy and Updated Techniques

I honestly have no interest in doing this block. I'll either do a spinal or GA with LMA vs ETT. Certain Urologists will request GA with ETT (paralysis) for these cases.
For the "sicker" patients I prefer SAB plus sedation.

 

[BLADEMDA]

Ultrasound-Guided Obturator Nerve Block: A Focused Review on Anatomy and Updated Techniques

I honestly have no interest in doing this block. I'll either do a spinal or GA with LMA vs ETT. Certain Urologists will request GA with ETT (paralysis) for these cases.
For the "sicker" patients I prefer SAB plus sedation.

Anaesthesia. 2016 Mar;71(3):291-7. doi: 10.1111/anae.13336. Epub 2015 Dec 1.
A new ultrasound-guided pubic approach for proximal obturator nerve block: clinical study and cadaver evaluation.
Yoshida T1, Onishi T2, Furutani K2, Baba H2.
Author information

Abstract
We evaluated an alternative technique for ultrasound-guided proximal level obturator nerve block that might facilitate needle visualisation using in-plane ultrasound guidance. Twenty patients undergoing transurethral bladder tumour resection requiring an obturator nerve block were enrolled into a prospective observational study. With the patient in the lithotomy position, the transducer was placed on the medial thigh along the extended line of the inguinal crease, and aimed cephalad to view a thick fascia between the pectineus and obturator externus muscles that contains the obturator nerve. A stimulating nerve block needle was inserted at the pubic region and advanced in-plane with the transducer in an anterior-to-posterior direction. Eight ml levobupivacaine 0.75% was injected within the fascia. The median (IQR [range]) duration for ultrasound identification of the target and injection were 8.5 (7-12 [5-24]) s and 62 (44.5-78.25 [39-383]) s, respectively. All blocks were successful. A cadaver evaluation demonstrated that the dye injected into the target fascia using our technique travelled retrogradely through the obturator canal, and surrounded the anterior and posterior branches of the obturator nerve both proximally and distally to the obturator canal. We believe that this is a promising new technique for ultrasound-guided proximal level obturator nerve block.

 

[zizzer]

So none of you have had problems with the urologist getting kicked during a spinal w/ sedation here? I've only done these under general anesthesia in residency.

 

[anbuitachi]

Are you going to do spinals on these patients?

Yea

 

[norski]

So none of you have had problems with the urologist getting kicked during a spinal w/ sedation here? I've only done these under general anesthesia in residency.

Has happened when the urologist failed to inform us that the tumor in question was in direct proximity to n.obturator. If that's something discovered on the first cystoscopy,we know about it,and do the roc-tube dance from the get go,but if the exact tumor location isn't known and the cysto is performed under spinal with fent+prop/midaz, we just convert to GA with an LMA,TOF them and administer mivacron. The fancy blocks,I don't know. Will have to consult either of my anesthesiologists.

 

[dhb]

So none of you have had problems with the urologist getting kicked during a spinal w/ sedation here? I've only done these under general anesthesia in residency.

No never seen it

 

[Arch Guillotti]

So none of you have had problems with the urologist getting kicked during a spinal w/ sedation here? I've only done these under general anesthesia in residency.

I have. Not pretty.

 

[Hork Bajir]

Has happened when the urologist failed to inform us that the tumor in question was in direct proximity to n.obturator. If that's something discovered on the first cystoscopy,we know about it,and do the roc-tube dance from the get go,but if the exact tumor location isn't known and the cysto is performed under spinal with fent+prop/midaz, we just convert to GA with an LMA,TOF them and administer mivacron. The fancy blocks,I don't know. Will have to consult either of my anesthesiologists.

Shouldn’t a spinal take care of the obturator reflex? If they can’t move their legs... can’t kick anyone

 

[deleted162650]

Shouldn’t a spinal take care of the obturator reflex? If they can’t move their legs... can’t kick anyone

Nope. Nerve gets stimulated in the field distal to the spinal cord. Impulse travels directly down the nerve to the adductor muscles and bam - urologist knocked out cold and the patient has a hole in their bladder.

Typically a problem on TURBT’s with a lateral wall tumor. Less of a problem on TURPs.

 

[nimbus]

Shouldn’t a spinal take care of the obturator reflex? If they can’t move their legs... can’t kick anyone

No they’re directly stimulating the nerve. Before ultrasound became popular, I used to do nerve stimulator femoral nerve blocks on patients with spinals all the time.

 

[Hork Bajir]

Ah, makes sense. I haven’t done a spinal for a cysto in ages, just not the culture at my hospital.

On a semi-related note, anyone have experience with Chloro spinals for short outpatient cystos? What kind of doses? I’ve wanted to try it a few times, but been warned by some older ninjas that the chloro spinal is too unpredictable