Rectus sheath block +/- catheter

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Oggg

Oggg

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I do not like blocks like this IE Tap blocks. First with the tap does the local anesthetic really travel allong the fascial plane? Do not quote cadaveric studies where the tissues become hardened. Im talking a living patient with active transport cell membranes. Secondily you only take care of the somatic component of pain control and not the visceral portion.
 
Oggg said:
http://update.anaesthesiologists.or.../03/Ultrasound-guided-rectus-sheath-block.pdf

Anyone doing these? Author says 6h only for a single shot of 0.25 bupiv and recommends q6h hand bolusing of bilateral catheters which is crazy if you don't have residents to scut out. On the other hand it might be nice to do single shots as rescue in PACU for ex laps, VHR, maybe even lap chole pain at the umbilicus.
Click to expand...



I've read that article before. Another great article:
http://ceaccp.oxfordjournals.org/content/early/2010/09/10/bjaceaccp.mkq035.full

This month rotation is Preop/PACU procedures. I have been really pushing for regional/neuroaxial blocks. I go fishing for blocks in the PACU/Or emergence (do 10+/day). I've been practically blocking anyone in PACU complaining of incision pain (except some pts of a couple a*hole surgeons who don't believe in blocks).

My observations regarding blocks:
1) Traditional taps are the worst blocks unless localized pain inferior to umbilicus. It covers T10 to L1. Its sometime marginal for even hernia repairs because it has little L2 coverage.

2) Rectus sheath is a good temporary block and are very quick to perform. They are excellent for PACU however they do wear off pretty quick (4-6 hrs).

3) As Blade mentioned subcostal TAP blocks I think are the holy grail of abdominal blocks. The trick is to use a nice length spinal needle and hydrodissect the plane all the way to the flanks. These work remarkable for anything in the abdomen. Its taught it only works from T6 to T10 but I found it extends even below umbilicus most times. A good 20 cc of long acting of your choice. I've seen pts go from a 10/10 pain to sleeping in matter of minutes after a good bilateral subcostal TAP.


Capture.jpg


Picture included in article is pretty accurate except for subcostal. Subcostals coverage will extend from umbilicus to xiphoid and from entire lateral to midline.


other random observations:
4) No block will ever compare to a good epidural (except PVNB). If they are in excruciating pain in PACU for abdominal cases, I just throw in a epidural for inpatients.

5) US guided supraclavicular blocks are the only way to go for UE blocks (unless shoulder). I can do the actual block in 2 minutes now. I try to never use more than 20 cc's, never seen phrenic involvement. Used to love doing ax blocks, now I can't remember the last time I have done one. UE blocks work great for fistula creations as well. Any given day we have 4-5/day.

6) I learned most of these US blocks on my own as a resident (articles/videos). My attendings are very lax regarding my autonomy and willingness to let me try. I am now teaching some of my attendings how to do them. These are all billable, have not the slightest idea how much money I am generating for the group. I still haven't ventured into catheter placements, although later in my CA3 year I'll do a month rotation at an othropedic ASC and we do 5+ catheters/day with our block guru.
 
I do these occasionally in pts with a midline incision who aren't appropriate for an epidural (coagulopathy, etc), and find them to be very effective. I actually did a case with rectus sheath blocks as the primary anesthetic not too long ago. Pt was anticoagulated, had pretty bad guillan-barre syndrome where he had just gotten off the vent but was still so weak he could barely move and respiratory status extremely of tenuous. My partners had cancelled his surgery earlier in the week because they felt he'd never get off the vent. The case was open G-tube replacement (had failed IR/perc placement twice because his liver overlaid his stomach). The procedure was palliative. I talked to the pt and surgeon about it, and we gave it a go. No sedation, pt did very well, and lived to leave the hospital.
 
RxBoy said:
I've read that article before. Another great article:
http://ceaccp.oxfordjournals.org/content/early/2010/09/10/bjaceaccp.mkq035.full

This month rotation is Preop/PACU procedures. I have been really pushing for regional/neuroaxial blocks. I go fishing for blocks in the PACU/Or emergence (do 10+/day). I've been practically blocking anyone in PACU complaining of incision pain (except some pts of a couple a*hole surgeons who don't believe in blocks).

My observations regarding blocks:
1) Traditional taps are the worst blocks unless localized pain inferior to umbilicus. It covers T10 to L1. Its sometime marginal for even hernia repairs because it has little L2 coverage.

2) Rectus sheath is a good temporary block and are very quick to perform. They are excellent for PACU however they do wear off pretty quick (4-6 hrs).

3) As Blade mentioned subcostal TAP blocks I think are the holy grail of abdominal blocks. The trick is to use a nice length spinal needle and hydrodissect the plane all the way to the flanks. These work remarkable for anything in the abdomen. Its taught it only works from T6 to T10 but I found it extends even below umbilicus most times. A good 20 cc of long acting of your choice. I've seen pts go from a 10/10 pain to sleeping in matter of minutes after a good bilateral subcostal TAP.


Capture.jpg


Picture included in article is pretty accurate except for subcostal. Subcostals coverage will extend from umbilicus to xiphoid and from entire lateral to midline.


other random observations:
4) No block will ever compare to a good epidural (except PVNB). If they are in excruciating pain in PACU for abdominal cases, I just throw in a epidural for inpatients.

5) US guided supraclavicular blocks are the only way to go for UE blocks (unless shoulder). I can do the actual block in 2 minutes now. I try to never use more than 20 cc's, never seen phrenic involvement. Used to love doing ax blocks, now I can't remember the last time I have done one. UE blocks work great for fistula creations as well. Any given day we have 4-5/day.

6) I learned most of these US blocks on my own as a resident (articles/videos). My attendings are very lax regarding my autonomy and willingness to let me try. I am now teaching some of my attendings how to do them. These are all billable, have not the slightest idea how much money I am generating for the group. I still haven't ventured into catheter placements, although later in my CA3 year I'll do a month rotation at an othropedic ASC and we do 5+ catheters/day with our block guru.
Click to expand...

Good job. One question: Would a well placed PVNB at let's say T8/T9 be superior to any rectus sheath/subcostal TAP block? My hunch is 20 mls placed at T8 bilaterally would be the best post op block (when comparing TAP, Subcostal TAP, Rectus Sheath).
 
B-Bone said:
I do these occasionally in pts with a midline incision who aren't appropriate for an epidural (coagulopathy, etc), and find them to be very effective. I actually did a case with rectus sheath blocks as the primary anesthetic not too long ago. Pt was anticoagulated, had pretty bad guillan-barre syndrome where he had just gotten off the vent but was still so weak he could barely move and respiratory status extremely of tenuous. My partners had cancelled his surgery earlier in the week because they felt he'd never get off the vent. The case was open G-tube replacement (had failed IR/perc placement twice because his liver overlaid his stomach). The procedure was palliative. I talked to the pt and surgeon about it, and we gave it a go. No sedation, pt did very well, and lived to leave the hospital.
Click to expand...

You have balls. I'd rather give some FFP and/or platelets then do a spinal. What if you got internal bleeding from the block? Anyways, I'm impressed you had the balls to do this block as the entire anesthetic.
 
narcusprince said:
I do not like blocks like this IE Tap blocks. First with the tap does the local anesthetic really travel allong the fascial plane? Do not quote cadaveric studies where the tissues become hardened. Im talking a living patient with active transport cell membranes. Secondily you only take care of the somatic component of pain control and not the visceral portion.
Click to expand...

The EVIDENCE for the superiority of these blocks over other commonly used postop pain modalities (Spinal duramorph, local infiltration by the surgeon) is scarce. I like doing blocks so i'll do them from time to time. But, are they truly needed? No.
 
Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.



Author(s): McMorrow RC, Ni Mhuircheartaigh RJ, Ahmed KA, Aslani A, Ng SC, Conrick-Martin I, Dowling JJ, Gaffney A, Loughrey JP, McCaul CL
Affiliation(s): Department of Anesthesia, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
Publication date & source: 2011-05, Br J Anaesth., 106(5):706-12.
Publication type: Comparative Study; Randomized Controlled TrialBACKGROUND: Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial. METHODS: Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 microg (S(M)) or saline (S(S)) and a postoperative bilateral TAP block with either bupivacaine (T(LA)) 2 mg kg(-1) or saline (T(S)). RESULTS: Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S(M)T(LA) (20 mm)<S(M)T(S) (27.5 mm)<S(S)T(S) (51.5 mm)<S(S)T(LA) (52.0 mm) (P<0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: S(M)T(S) (4.0 mg)<S(M)T(LA) (5.0 mg)<S(S)T(LA) (8.0 mg)<S(S)T(S) (12.0 mg) and at 24 h was: S(M)T(LA) (5.0 mg)<S(M)T(S) (6.0 mg)<S(S)T(S) (9.5 mg)<S(S)T(LA) (15.0 mg) (P<0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the S(M)T(LA) group. CONCLUSIONS: Spinal morphine-but not TAP block-improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg(-1) to spinal morphine did not further improve analgesia.
 
BLADEMDA said:
Good job. One question: Would a well placed PVNB at let's say T8/T9 be superior to any rectus sheath/subcostal TAP block? My hunch is 20 mls placed at T8 bilaterally would be the best post op block (when comparing TAP, Subcostal TAP, Rectus Sheath).
Click to expand...

A PVNB would actually be a superior block in theory as it will cover the visceral component pain as well.

The disadvantages to the PVNB for abdominal surgery:
1) Abdominal blocks are pretty benign when it comes to complications. The worst I have seen was a unilateral femoral nerve involvement which resolved in a couple hours. With PNVB, there is a small risk of PTX and I would rather not take that risk this early in the game while the relationship with our surgeons is all time high.

2) Its more discomforting to the patient to get them to roll over and get in fetal position/sitting up after surgery. With abdominal blocks, I just walk in with the US and needle. They don't even have to move. Sometimes the dressing needs to be adjusted for the abdominal blocks but I have the PACU nurses or surgical residents adjust it if its really in the way. With subcostals, this is rarely an issue.

3) B/L PNVB are needed for midlines, If I am going to be poking in the back I might as well place an epidural as its quicker then 2 pokes and I would have a catheter to infuse. Never put in bilateral catheters for PVNB as I am sure the PACU nurses would murder me.

4) Abdominal blocks are great for getting patients over that 1st day of intense pain and getting them out of PACU. Work excellent for laproscopic procedures. Some might find it overkill but the patients will fall in love. I view PNVB is a more long term fix although single shot is always an option. PNVB is the perfect block for thoracotomies. Unilateral and the HD side effects are near non-existent compared to epidural.
 
BLADEMDA said:
Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.



Author(s): McMorrow RC, Ni Mhuircheartaigh RJ, Ahmed KA, Aslani A, Ng SC, Conrick-Martin I, Dowling JJ, Gaffney A, Loughrey JP, McCaul CL
Affiliation(s): Department of Anesthesia, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
Publication date & source: 2011-05, Br J Anaesth., 106(5):706-12.
Publication type: Comparative Study; Randomized Controlled TrialBACKGROUND: Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial. METHODS: Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 microg (S(M)) or saline (S(S)) and a postoperative bilateral TAP block with either bupivacaine (T(LA)) 2 mg kg(-1) or saline (T(S)). RESULTS: Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S(M)T(LA) (20 mm)<S(M)T(S) (27.5 mm)<S(S)T(S) (51.5 mm)<S(S)T(LA) (52.0 mm) (P<0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: S(M)T(S) (4.0 mg)<S(M)T(LA) (5.0 mg)<S(S)T(LA) (8.0 mg)<S(S)T(S) (12.0 mg) and at 24 h was: S(M)T(LA) (5.0 mg)<S(M)T(S) (6.0 mg)<S(S)T(S) (9.5 mg)<S(S)T(LA) (15.0 mg) (P<0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the S(M)T(LA) group. CONCLUSIONS: Spinal morphine-but not TAP block-improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg(-1) to spinal morphine did not further improve analgesia.
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I think traditional tap blocks are nearly useless especially blind (double pop through triangle of petit) technique. With c/s there is a large visceral component. Neuraxial block is always superior.
 
RxBoy said:
A PVNB would actually be a superior block in theory as it will cover the visceral component pain as well.

The disadvantages to the PVNB for abdominal surgery:
1) Abdominal blocks are pretty benign when it comes to complications. The worst I have seen was a unilateral femoral nerve involvement which resolved in a couple hours. With PNVB, there is a small risk of PTX and I would rather not take that risk this early in the game while the relationship with our surgeons is all time high.

2) Its more discomforting to the patient to get them to roll over and get in fetal position/sitting up after surgery. With abdominal blocks, I just walk in with the US and needle. They don't even have to move. Sometimes the dressing needs to be adjusted for the abdominal blocks but I have the PACU nurses or surgical residents adjust it if its really in the way. With subcostals, this is rarely an issue.

3) B/L PNVB are needed for midlines, If I am going to be poking in the back I might as well place an epidural as its quicker then 2 pokes and I would have a catheter to infuse. Never put in bilateral catheters for PVNB as I am sure the PACU nurses would murder me.

4) Abdominal blocks are great for getting patients over that 1st day of intense pain and getting them out of PACU. Work excellent for laproscopic procedures. Some might find it overkill but the patients will fall in love. I view PNVB is a more long term fix although single shot is always an option. PNVB is the perfect block for thoracotomies. Unilateral and the HD side effects are near non-existent compared to epidural.
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Rectus Sheath blocks last 6 hours. The needle tip is mm from the Peritoneum. You haven't seen a complication yet because your N is too low.

Also, you could place these blocks preop and then positioning wouldn't be an issue.
Single shot PVNB with Bup plus decadron will last 18 hours (no catheter) and hemodynamics aren't an issue.

Of all the blocks discussed here the subcotal TAP is the best choice as a single shot block.

Please remember your "N" is still too low to make broad, generalized statements. I do appreciate your posts however.
 
Rectus Sheath Blocks:


With the posterior wall of the rectus sheath lying superficial to the peritoneal cavity, needle misplacement may lead to complications. Injection into the peritoneal cavity will lead to failure of the block and may risk bowel perforation or puncture of blood vessels, usually the inferior epigastric vessels.
In addition to incorrect placement of local anaesthetic, incomplete block may result from anatomical variance, as in up to 30% of the population, the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath.2
 
BLADEMDA said:
The needle tip is mm from the Peritoneum.
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In reality, how much damage could a 21 gauge needle through the peritoneum really do? If the abdominal contents were that sensitive, sutures on peritoneum would literally have to be airtight. Laproscoic ports would be very dangerous. And needle aspiration biopsies would never be done.
 
RxBoy said:
In reality, how much damage could a 21 gauge needle through the peritoneum really do? If the abdominal contents were that sensitive, sutures on peritoneum would literally have to be airtight. Laproscoic ports would be very dangerous. And needle aspiration biopsies would never be done.
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I know pro regionalists who say "no way am I getting near the incision" Any kind of infection and guess who did it? Bosie says three on each side for the six pack. Don't do them myself cause of first comment. Would certainly do so in a pinch however.
 
imfrankie said:
I know pro regionalists who say "no way am I getting near the incision" Any kind of infection and guess who did it? Bosie says three on each side for the six pack. Don't do them myself cause of first comment. Would certainly do so in a pinch however.
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Exactly my point.
 
Anyone ever done bilateral combined Subcostal TAP plus traditional TAP blocks under U/S?
I was thinking of 0.375% Rop 15 mls for each injection for a total of 60 mls. There would be 4 injections.

For the big midline Expl. Lap procedures it would be interesting looking at pain scores of 4 injections vs just 2 (one Subcostal block on each side). Yes, the majority of the post op pain is covered by the Subcostal TAP but would the lower, traditional TAP add anything postoperatively?

RXBoy will probably say it isn't needed as 20 mls on each side does the trick. Any comments?
 
I have done subcostal yet, but as I understand it, subcostal won cover the entire length of a long ex lap wound, so you're stuck with 4 injections which are somewhat painful and take more time. That's the main downside. Plus in fattier patients the TAP is pretty deep, and as a beginner I've struggled seeing my in plane Tuohy tip that deep. I'd say that the risk of going thru peritoneum is the same for TAP and rectus sheath.

The advantage of the subcostal TAP would definitely be longer duration and avoidance of the wound&dressing.

The theoretical advantages of rectus sheath block would be the simple anatomy and 2 injections should cover an entire midline incision. The disadvantages are proximity to the wound and shorter duration. I think you can go in plane from far lateral or from far cephalad of the wound, so you may be able to avoid disturbing the dressing sometimes. Yesterday I had two ex laps with retention sutures so I didn't even think about suggesting RSB.

I see RSB as being useful as a quick rescue block for long midline incisions.
 
Oggg said:
I have done subcostal yet, but as I understand it, subcostal won cover the entire length of a long ex lap wound, so you're stuck with 4 injections which are somewhat painful and take more time. That's the main downside. Plus in fattier patients the TAP is pretty deep, and as a beginner I've struggled seeing my in plane Tuohy tip that deep. I'd say that the risk of going thru peritoneum is the same for TAP and rectus sheath.

The advantage of the subcostal TAP would definitely be longer duration and avoidance of the wound&dressing.

The theoretical advantages of rectus sheath block would be the simple anatomy and 2 injections should cover an entire midline incision. The disadvantages are proximity to the wound and shorter duration. I think you can go in plane from far lateral or from far cephalad of the wound, so you may be able to avoid disturbing the dressing sometimes. Yesterday I had two ex laps with retention sutures so I didn't even think about suggesting RSB.

I see RSB as being useful as a quick rescue block for long midline incisions.
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6 hour post op pain blocks? Either place a catheter or I'm not interested in doing any post op pain blocks with a 6 hour duration.

Also, I use an Echogenic needle for Subcostal TAP blocks in obese patients. It helps to visualize the tip.
 
Rx sounds like your on a awesome rotation with a ton of autonomy. I am on a acute pain rotation and have done a ton of catheters. One block you should become facile with is the infraclavicular block/ catheter. Its a tough block because the space between the clavicle and the probe is very close limiting needle entry. I find that infraclavicular block has greater coverage than supraclavicular for lower arm and hand surgery also the catheter position is deeper and better fixed to the tissues. Also another misnomer is that for shoulder surgery you can't do a supraclavicular block which is wrong. With a high supraclavicular block and +_ supra scapular nerve block you can do it. The more and more blocks I perform the more more I'm set on doing a regional fellowship pending the Navy. The toughest block I have performed is the sciatic nerve block especially in our 300lb + patient population its tough.
Also, Liposomal Bupivicaine will change the game for catheters. One injection with decadron may get you into the 48-72 hour time frame for postop analgesia making catheters and pumps useless. The only issue I have with this liposomal preparation that they are not telling me is what happens if the that S@#$ goes intravascular and into the heart will intralipid work? Will the patient have to go on a intralipid infusion? Or is it game over?
 
narcusprince said:
Rx sounds like your on a awesome rotation with a ton of autonomy. I am on a acute pain rotation and have done a ton of catheters. One block you should become facile with is the infraclavicular block/ catheter. Its a tough block because the space between the clavicle and the probe is very close limiting needle entry. I find that infraclavicular block has greater coverage than supraclavicular for lower arm and hand surgery also the catheter position is deeper and better fixed to the tissues. Also another misnomer is that for shoulder surgery you can't do a supraclavicular block which is wrong. With a high supraclavicular block and +_ supra scapular nerve block you can do it. The more and more blocks I perform the more more I'm set on doing a regional fellowship pending the Navy. The toughest block I have performed is the sciatic nerve block especially in our 300lb + patient population its tough.
Also, Liposomal Bupivicaine will change the game for catheters. One injection with decadron may get you into the 48-72 hour time frame for postop analgesia making catheters and pumps useless. The only issue I have with this liposomal preparation that they are not telling me is what happens if the that S@#$ goes intravascular and into the heart will intralipid work? Will the patient have to go on a intralipid infusion? Or is it game over?
Click to expand...

1. SCB lasts longer than a ICB when given as a single shot technique. This means longer post op pain relief for the patient. That said, if you place a catheter then an ICB is a sound choice. I use more single shot blocks than catheters in my practice so this translates into more SCBs over ICBs.

2. A good SCB at the 1200 position (plus a few mls at 300) and the patient has solid post op pain relief after shoulder surgery. A supplmental Suprascapular nerve block isn't needed for post op pain relief. I have not compared a SCB vs ISB for SURGICAL level anesthesia but I can tell you that an ISB plus local at the skin (over the incision/portal sites) works well.

3. Sciatic nerve blocks may be tougher in 400 pound patients because the landmarks are harder to find. The block itself is no harder but I rec. a 6" Braun needle.😱
I use the Labat or Raj technique in obese patients. Others use a subgluteal U/S guided sciatic block (follow the nerve up from the popliteal fossa).

4. Liposomal Bupivacaine is safe when used at clinical concentrations. There should be decreased toxicity from an IV injection of Liposomal Bup compared to plain Bup (clinical doses). In addition, Liposomal Bup should last over 48 hours when given as a single shot block in certain areas (ISB, Femoral, SCB, Sciatic, etc) without Decadron.
 
SPEED OF ONSET OF ULTRASOUND GUIDED SUPRACLAVICULAR AND INFRACLAVICULAR BLOCK FOR AMBULATORY HAND SURGERY: A DOUBLE BLINDED RANDSOMISED TRIAL

  1. A Patelhttp://www.bjjprocs.boneandjoint.org.uk/content/92-B/SUPP_I/222.1.short#target-1
+ Author Affiliations
  1. Department of Orthopaedics, North Shore Hospital
Abstract

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery.
With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist.
Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance.
Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia.
 
BLADEMDA said:
SPEED OF ONSET OF ULTRASOUND GUIDED SUPRACLAVICULAR AND INFRACLAVICULAR BLOCK FOR AMBULATORY HAND SURGERY: A DOUBLE BLINDED RANDSOMISED TRIAL

  1. A Patel
+ Author Affiliations
  1. Department of Orthopaedics, North Shore Hospital
Abstract

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery.
With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist.
Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance.
Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia.
Click to expand...

ICBs are better surgical blocks because they set up faster, much faster. SCBs take up to 45 minutes to block the ulnar nerve. I use a low volume SCB technique to decrease Horner's syndrome and phrenic nerve block (a total of 20-25 mls of local) with most being injected into the corner pocket. (12 mls at 500, 4 mls at 300 and 4 mls at noon)

My success rate for post op pain relief is about 99% for either of them so "mission accomplished" with ICB or SCB. That said, only the SCB with Decadron reliably gives solid, post op pain relief for greater than 20 hours duration (greater than 24 with Bup and Decadron). An ICB only lasts 12-16 hours with Rop/Bup plus decadron with most falling into the 14 hour range.
 
BLADEMDA said:
SCBs take up to 45 minutes to block the ulnar nerve.
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Well despite what you say i still use 10cc injected in the plexus sheath and it sets up in 5-10 min.

Can't believe those dissing the TAP, i've done some great things with it.
 
Last edited:
dhb said:
Well despite what you say i still use 10cc injected in the plexus sheath and it sets up in 5-10 min.
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I'm only reporting my findings. I wish my ulnar nerve set-up was 10 min. Last week it took 34 minutes and I used 14 mls (just in the corner pocket alone at 500); I am not shy about getting way down low in that pocket either.

I also wish I could get those single shot ICBs to last 24 hours. But, I'm not willing to using Bup in that location because the vein and artery are so close to my injection points. Perhaps, with 0.5% Bup and Decardon 8 mg with a total volume in excess of 30 mls I could get 24 hours. I haven't tried this exact cocktail yet for an ICB.
 
BLADEMDA said:
I'm only reporting my findings. I wish my ulnar nerve set-up was 10 min. Last week it took 34 minutes and I used 14 mls (just in the corner pocket alone at 500); I am not shy about getting way down low in that pocket either.
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If you are getting 24+h from your SCB then you injecting in the plexus sheath and if you are doing so there's no way you can miss the ulnar especially if going down in the pocket. I would guess this one block would be an exception, my SCB always set up extremely fast.
I don't believe volume will get you more duration. The loose anatomy of the plexus in the IC region makes it less susceptible to a long lasting block.
 
dhb said:
If you are getting 24+h from your SCB then you injecting in the plexus sheath and if you are doing so there's no way you can miss the ulnar especially if going down in the pocket. I would guess this one block would be an exception, my SCB always set up extremely fast.
Click to expand...

It sets up in 5-10 minutes EXCEPT for the ulnar nerve which can take longer. That is my experience so far. If you are doing surgery around the elbow or 5th digit please let it "soak in" for at least 30 min. prior to incision.
 
BLADEMDA said:
It sets up in 5-10 minutes EXCEPT for the ulnar nerve which can take longer. That is my experience so far. If you are doing surgery around the elbow or 5th digit please let it "soak in" for at least 30 min. prior to incision.
Click to expand...

Elbow surgery shouldn't involve the ulnar. For hands i prefer to go infra-clav
 
The aim of this anatomical study was to find out if total denervation of the elbow joint is technically feasible. The endbranches of the brachial plexus of eight fresh-frozen upper arm cadavers were dissected with optical loupe magnification. All major nerves of the upper limb (except the axillary and the medial brachial cutaneous nerve) give some terminal articular endbranches to the elbow. The articular endbranches arise from muscular endbranches, cutaneous endbranches, or arise straight from the main nerves of the brachial plexus. A topographic diagram was made of the different nerves innervating the elbow joint. The ulno-posterior part of the elbow is innervated by the ulnar nerve and some branches of medial antebrachial cutaneous nerve. The radial-posterior part of the elbow is innervated exclusively by the radial nerve. The ulno-anterior part of the elbow is innervated by the median nerve and the musculocutaneous nerve. The radio-anterior part of the elbow is innervated by the radial nerve and the musculocutaneous nerve. These elbow innervation findings are relevant to both anatomical and clinical field as they provide evidence that the total denervation of the elbow joint is impossible. Nevertheless, partial denervation, like denervation of the lateral epicondyle or the ulnar part of elbow, is technically possible. Clin. Anat., 2012. © 2012 Wiley Periodicals, Inc.
 
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http://www.swanesthesia.cn/UserFiles/File/%E5%9B%BD%E5%A4%96%E5%8A%A8%E5%90%91/Low%20interscalene%20block%20provides%20reliable%20anesthesia%20for%20surgery%20at%20about%20the%20elbow.pdf

Most sensory innervation of the elbow is from the inferior trunk (C8/T1). Specifically, T1 is the dermatome most commony associated with the elbow.

Hence, when doing a SCB block for surgery around the elbow (or ulnar nerve in the hand) the C8/T1 trunk must be blocked and this means the corner pocket technique is essential along with allowing sufficient time for the block to set-up (30 min).
 
dhb said:
Elbow surgery shouldn't involve the ulnar. For hands i prefer to go infra-clav
Click to expand...

I've got NO ISSUES with an ICB. Please describe your local, volume, mixture, etc and DURATION of post op pain relief rom a single shot ICB.

I'm not aware of any good case series or anecdotal evidence of 22 hour blocks with an ICB. I'm very hopeful you can shed some personal experience to the contrary as I'd like to do more ICBS and less SCBs once duration of analgesia exceeds 22 hours.
 
This guy is doing a study on ICB with Decadron and how long they last:

http://anesthesiology.osu.edu/12695.cfm

3. Dexamethasone added to 0.75% Ropivicaine for Infraclavicular Brachial Plexus Block: Does Adjunctive Dexamethasone
Prolong Analgesia for Orthopedic Procedures of the Hand/Wrist.




Anyone have any preliminary data from Ohio State? I guess I can e-mail him.
 
BLADEMDA said:
I've got NO ISSUES with an ICB. Please describe your local, volume, mixture, etc and DURATION of post op pain relief rom a single shot ICB.

I'm not aware of any good case series or anecdotal evidence of 22 hour blocks with an ICB. I'm very hopeful you can shed some personal experience to the contrary as I'd like to do more ICBS and less SCBs once duration of analgesia exceeds 22 hours.
Click to expand...

Sorry can add my anecdotal data for ICB because i've used shorter acting LA for outpatients and for inpatients i've gone with a cath if needed or SCB + decadron. I'll have to try and see how much i can get out of them.
 
Blade when you do the subcostal TAP, do you just inject everything as soon as you hit the interfacial plane, or do you hydro dissect and advance your needle?

Hebbard describes an oblique subcostal TAP that is supposed to cover the whole belly, as I understand it. I believe it starts like the subcostal TAP but you try to hydro dissect all the way down to the standard TAP area. It sounds like a pain in the butt. Anesth&analgesia. Good review of the anatomy.
 
Oggg said:
Blade when you do the subcostal TAP, do you just inject everything as soon as you hit the interfacial plane, or do you hydro dissect and advance your needle?

Hebbard describes an oblique subcostal TAP that is supposed to cover the whole belly, as I understand it. I believe it starts like the subcostal TAP but you try to hydro dissect all the way down to the standard TAP area. It sounds like a pain in the butt. Anesth&analgesia. Good review of the anatomy.
Click to expand...

Always hydrodissect a bit with any TAP block including Subcostal. The question is will hydrodissection with a subcostal block be sufficient to provide analgesia down low in the abdomen or do we need to add a traditional TAP block?
 
BLADEMDA said:
Always hydrodissect a bit with any TAP block including Subcostal. The question is will hydrodissection with a subcostal block be sufficient to provide analgesia down low in the abdomen or do we need to add a traditional TAP block?
Click to expand...

I do them. Work excellent. Like I previously said, usually gives >T10 coverage. I use a spinal needle. However they are almost impossible to do on the obese.

[YOUTUBE]http://www.youtube.com/watch?v=JiTXQEx3Y0o[/YOUTUBE]
 
Is a spinal needle easier to steer than a 20g or 18g Tuohy? Is that why you use a spinal (22g quincke?)

I like the Tuohy because it's easier to see? But I've had trouble visualizing the needle tip on fatties with Tuohy and Sonoplex. I hope it's just lack of experience
 
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