Regional Orthopedic Anesthesia

[jetproppilot]

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This is a good topic that always brings alotta input...and it is Mil's nemesis since he is the president of the AARA (anesthesiologists against regional anesthesia)....anyhow good to see opinions from colleagues.

One of our CRNAs has teenage athletic daughters....2 of them popped their ACLs in one week. 😱

Both are coming for surgery this week...

will perform Jet's usual ACL protocol:

to holding at 0640 or so. Midazolam 4-5 mg

femoral nerve block...bupiv .5% w/epi 20mL

sciatic NB, Labat's approach..bupiv .5% again...20mL

To the back, monitors on, propofol 200 mg, LMA #4. NO OPIODS.

They'll only require a wiff of sevo (usually less than 1%) for the case's entirety.

Since no opiods will be used, and blocks were instituted preoperatively, PACU stay will be a non event. Usually there less than 30 minutes. No pain, minimal chance of nausea.

Say I wanted to use ropiv....have never used it for these blocks....could I use .2% with similar results? I think thats all our hospital has.

Anyway, nice educational cases, performed in a way superior to GA-only, IMHO.

 

[OldManDave]

JPP,

Sounds like a smooth technique! As for Ropiv, only used it once - but allegedly .2% is equivalent to .25% Bupiv, but somewhat "safer" from a CV toxicity standpoint.

Let me ask you a couple of questions about the "real world".

1 - Do you use ultrasound guidance for your blocks?

2 - Would you consider a graduating resident well-trained w/ u/s guided blocks, but with minimal to zero anatomically guided technique exposure an asset or a liability?

3 - How "open" or interested would your colleagues be to learning u/s-guided block techniques?

The reason I am asking these questions is that at Dartmouth, u/s guided techniques are tantamount to Godliness. We are extensively trained to do them & typically our grads come out having done on the order of 150 + blocks. However, we get almost zero exposure to anatomically-guided techniques. Dartmouth is allegedly 1 of the big 4 in the world of u/s guided block research.

Thanks in advance for your insight!

 

[jetproppilot]

JPP,

Sounds like a smooth technique! As for Ropiv, only used it once - but allegedly .2% is equivalent to .25% Bupiv, but somewhat "safer" from a CV toxicity standpoint.

Let me ask you a couple of questions about the "real world".

1 - Do you use ultrasound guidance for your blocks?

2 - Would you consider a graduating resident well-trained w/ u/s guided blocks, but with minimal to zero anatomically guided technique exposure an asset or a liability?

3 - How "open" or interested would your colleagues be to learning u/s-guided block techniques?

The reason I am asking these questions is that at Dartmouth, u/s guided techniques are tantamount to Godliness. We are extensively trained to do them & typically our grads come out having done on the order of 150 + blocks. However, we get almost zero exposure to anatomically-guided techniques. Dartmouth is allegedly 1 of the big 4 in the world of u/s guided block research.

Thanks in advance for your insight!

Sorry Dave,

Can't give you an educated answer since I've never done US guided blocks.

If the majority of a clinician's blocks work utilizing traditional approaches, whats the advantage of US guidance?

Nor do I know any clinician buddies who are doing US guided regional.

Not saying (new technology) isnt good, but if your blocks work already, whats the advantage?

 

[sevoflurane]

Do practices exist where the anesthesiologist does mostly (80%) regional?

I don't mean pain though (I'm not into clinics or a lot of the patients that come to them).

I've heard of this sweet gig in Vail Colorado where the anesthesiologist works hand in hand with orthopods doing blocks all day from ski/snowboard wrecks on the mountain. Sounds pretty sweet. I hear compensation is much better too. Any truth to this? Is this type of practice seen in the "real world"? Any fellowship required?

 

[militarymd]

It pains me to say it, but during that first 24 hours, blocks make a huge difference in subjective aspects of recovery from anesthesia.

However, I will argue to my last breath that the ultimate outcome....why patients have surgery....busted joints etc.....there is no difference in how you do the anesthesia.

Having said that....I do a fair number of blocks (upper and lower extremity) and I frequently will use the ultrasound (Sonosite Titan) in patients with challenging anatomy.

In the last week, I had 2 separate morbidly obese patients (one interscalene/one femoral nerve block) that I was unable to perform the block using land marks....both patients...after trying for 5 minutes or so (I try not to do anything for longer than 5 minutes), I got the ultrasound...and put the block in....with excellent results.

 

[jetproppilot]

Do practices exist where the anesthesiologist does mostly (80%) regional?

I don't mean pain though (I'm not into clinics or a lot of the patients that come to them).

I've heard of this sweet gig in Vail Colorado where the anesthesiologist works hand in hand with orthopods doing blocks all day from ski/snowboard wrecks on the mountain. Sounds pretty sweet. I hear compensation is much better too. Any truth to this? Is this type of practice seen in the "real world"? Any fellowship required?

Looked into a job in Vail around year 2000...talked with one of the dudes there...nice gig...

Yes, their compensation is good, but their lifestyle and caseload (mild to moderate) means overall dollars are relatively low (around 250ish back then)...that kinda income will buy you a nice highway-side (as opposed to slopeside) tent that sleeps six in Vail. Outhouse/runnng water not included.

But if you are young, single, devoid of student loans, and love the ski life, this is the ultimate job.

 

[jetproppilot]

It pains me to say it, but during that first 24 hours, blocks make a huge difference in subjective aspects of recovery from anesthesia.

However, I will argue to my last breath that the ultimate outcome....why patients have surgery....busted joints etc.....there is no difference in how you do the anesthesia.

Having said that....I do a fair number of blocks (upper and lower extremity) and I frequently will use the ultrasound (Sonosite Titan) in patients with challenging anatomy.

In the last week, I had 2 separate morbidly obese patients (one interscalene/one femoral nerve block) that I was unable to perform the block using land marks....both patients...after trying for 5 minutes or so (I try not to do anything for longer than 5 minutes), I got the ultrasound...and put the block in....with excellent results.

First off,

Cmon Asian Stud. Admit it. Regional is better in this situation. For the patient.

We're in the comfort business, right? Analgesia, right?

Changing gears, from an ignorant standpoint, lets say you need to do an interscalene on a patient with a blowspout (i.e. whale).

No anatomic landmarks can be identified through the Double-Whopper-with-cheese adipose neck tissue. As a matter of fact, the adipose has swallowed the neck. There is no neck.

Walk me through the utilization of US in an interscalene block.

 

[militarymd]

I admitted that they recover better....don't rub it in.

Use an ultrasound probe that penetrates around 4 cm or so....frequency range will vary depending on your probe.

At the cricoid level or lower, obtain an axial image over the carotid artery.

Carotid and IJ are very easy to identify.

The muscle belly anterior to it is the SCM.

The muscle bellies posterior and lateral to it are the scalene muscles.

Between the muscles, you will see hyperechoic structures that will be the brachial plexus.......the text books make it very easy, but in real life, they aren't as clear, but with practice you can see them......

stick a needle in under direct visualization with a nerve stim and there you have it.

 

[jetproppilot]

I admitted that they recover better....don't rub it in.

Use an ultrasound probe that penetrates around 4 cm or so....frequency range will vary depending on your probe.

At the cricoid level or lower, obtain an axial image over the carotid artery.

Carotid and IJ are very easy to identify.

The muscle belly anterior to it is the SCM.

The muscle bellies posterior and lateral to it are the scalene muscles.

Between the muscles, you will see hyperechoic structures that will be the brachial plexus.......the text books make it very easy, but in real life, they aren't as clear, but with practice you can see them......

stick a needle in under direct visualization with a nerve stim and there you have it.

very cool.

I'm gonna look with US next time.

 

[IN2B8R]

We use a mepivicaine/tetracaine mix for our femoral/sciatic/obturator blocks (20cc, 30cc, 10cc), as well as our upper extremity blocks. Can add Clonidine for longer duration of block if desired. If really a short case, then we have used chloroprocaine. We like to run ropivicaine for our continous catheters. For intra-op sedation, we use ketafol. Slipped in an LMA for those patients who like to obstruct....

 

[MDEntropy]

Jet, might want to consider lumbar plexus for knees. 1 block rather than 2.

Ropiv is weaker than Bupiv. It is debatable how much but it probably only has about 0.6 to 0.75 the potency of bupiv. By the time you use more a potent ropiv concentration to equate what you were getting with bupiv, some argue that you lose much of the cv toxicity benefit. 0.2 Ro won't subsitute for 1/2% Bupiv, but you might be able to supplement with some tetracaine crystals. Actually, since your blocks are primarily for post-op pain. 0.2% ropiv may do the job, but why? Bupiv is less expensive and your risk is pretty low. Just don't dump it all into a femoral vessel.
Levo is probably the best of the 3 in terms of potency:cv toxicity (ratio).

Dave, what are the other 3 of the u/s regional big 4? How often do use a nerve stim with your u/s? what blocks do you most commonly do with ultrasound? Any you do without u/s?

 

[jetproppilot]

Jet, might want to consider lumbar plexus for knees. 1 block rather than 2.

Ropiv is weaker than Bupiv. It is debatable how much but it probably only has about 0.6 to 0.75 the potency of bupiv. By the time you use more a potent ropiv concentration to equate what you were getting with bupiv, some argue that you lose much of the cv toxicity benefit. 0.2 Ro won't subsitute for 1/2% Bupiv, but you might be able to supplement with some tetracaine crystals. Actually, since your blocks are primarily for post-op pain. 0.2% ropiv may do the job, but why? Bupiv is less expensive and your risk is pretty low. Just don't dump it all into a femoral vessel.
Levo is probably the best of the 3 in terms of potency:cv toxicity (ratio).

Dave, what are the other 3 of the u/s regional big 4? How often do use a nerve stim with your u/s? what blocks do you most commonly do with ultrasound? Any you do without u/s?

Nice post, Entropy.

Thanks.

 

[Noyac]

IMHO, replace the bupiv with 0.5% Ropiv.
Its safer. I have seen 2 seizures with ropiv and neither had any cardiac symptoms. They may or may not have occured with bupiv but I don't want to find out.

About Vail, I have one of those jobs (lots and lots of blocks on snowboarders/skiers/mtnbikers/kayakers/motorcyclists/etc. except that I can afford to live in my town. Jet, you are absolutely right on this one. If you work in Vail you will have to live 30-90 minutes away in order to afford shelter.

 

[Noyac]

Jet, might want to consider lumbar plexus for knees. 1 block rather than 2.

Ropiv is weaker than Bupiv. It is debatable how much but it probably only has about 0.6 to 0.75 the potency of bupiv. By the time you use more a potent ropiv concentration to equate what you were getting with bupiv, some argue that you lose much of the cv toxicity benefit. 0.2 Ro won't subsitute for 1/2% Bupiv, but you might be able to supplement with some tetracaine crystals. Actually, since your blocks are primarily for post-op pain. 0.2% ropiv may do the job, but why? Bupiv is less expensive and your risk is pretty low. Just don't dump it all into a femoral vessel.
Levo is probably the best of the 3 in terms of potency:cv toxicity (ratio).

Dave, what are the other 3 of the u/s regional big 4? How often do use a nerve stim with your u/s? what blocks do you most commonly do with ultrasound? Any you do without u/s?

I must disagree here. The 2 seizures that I saw with ropiv never had any blood aspiration. One was 5 minutes after the completion of the block and the other was after 25cc ( I know, the needle can migrate). Each successfully treated with 2-4 mg versed. And both blocks worked fine after the seizure. After this I don't take chances. But thats just me.

 

[jetproppilot]

I must disagree here. The 2 seizures that I saw with ropiv never had any blood aspiration. One was 5 minutes after the completion of the block and the other was after 25cc ( I know, the needle can migrate). Each successfully treated with 2-4 mg versed. And both blocks worked fine after the seizure. After this I don't take chances. But thats just me.

Whaddya mean by you dont take chances, Noy?

 

[Noyac]

Jet, might want to consider lumbar plexus for knees. 1 block rather than 2.

Ropiv is weaker than Bupiv. It is debatable how much but it probably only has about 0.6 to 0.75 the potency of bupiv. By the time you use more a potent ropiv concentration to equate what you were getting with bupiv, some argue that you lose much of the cv toxicity benefit. 0.2 Ro won't subsitute for 1/2% Bupiv, but you might be able to supplement with some tetracaine crystals. Actually, since your blocks are primarily for post-op pain. 0.2% ropiv may do the job, but why? Bupiv is less expensive and your risk is pretty low. Just don't dump it all into a femoral vessel.
Levo is probably the best of the 3 in terms of potency:cv toxicity (ratio).

Dave, what are the other 3 of the u/s regional big 4? How often do use a nerve stim with your u/s? what blocks do you most commonly do with ultrasound? Any you do without u/s?

Also, I have done the Lumbar plexus/psoas blocks and have retired that block for a few reasons.
1) All the pts get lovenox and/or coumadin after TKA/THA's and the risk of unnoticed vascular (renal) puncture is higher with this block leading to hematoma which will continue to enlarge until total vascular compromise or in effect a epidural hematoma after pulling the catheter. This is a small risk altogether, I am aware. But the name of the game is to limit risks and deliver effective care. Therefore
2) The FNB and Sciatic block is just as effective. And you can add intrathecal morphine if you wish. (My practice currently is FNB with IT morphine)
3) Also, the risk of epidural spread is high. But I don't consider this as a huge dilemma

 

[CanGas]

Here we do close to the same. Usually a spinal +LMA for the case then a stimulating femoral catheter threaded post-op, hooked up to a "Baby bottle" (mechanical, disposable infusion pump that lasts 60hrs at 5cc/hr, 30hrs at 10cc/h). Usually 5cc/hr Ropi 0.2% and have the pt pull the cath in 2-3 days. Pain free for 60hrs with no narcotics baby! Similar for total knees (though they don't go home same day) 10% need a subsequent Sciatic block but 90% are covered just fine with the pure femoral blockade. Saves an extra procedure without the hamstring and lower leg weakness.

This is a good topic that always brings alotta input...and it is Mil's nemesis since he is the president of the AARA (anesthesiologists against regional anesthesia)....anyhow good to see opinions from colleagues.

One of our CRNAs has teenage athletic daughters....2 of them popped their ACLs in one week. 😱

Both are coming for surgery this week...

will perform Jet's usual ACL protocol:

to holding at 0640 or so. Midazolam 4-5 mg

femoral nerve block...bupiv .5% w/epi 20mL

sciatic NB, Labat's approach..bupiv .5% again...20mL

To the back, monitors on, propofol 200 mg, LMA #4. NO OPIODS.

They'll only require a wiff of sevo (usually less than 1%) for the case's entirety.

Since no opiods will be used, and blocks were instituted preoperatively, PACU stay will be a non event. Usually there less than 30 minutes. No pain, minimal chance of nausea.

Say I wanted to use ropiv....have never used it for these blocks....could I use .2% with similar results? I think thats all our hospital has.

Anyway, nice educational cases, performed in a way superior to GA-only, IMHO.

 

[Noyac]

Whaddya mean by you dont take chances, Noy?

Sorry, Let me rephrase!
I try not to take chances in the OR.
I spend the rest of the day taking all the chances that my body can handle. Recently fell off 6ft high log while riding my bike across it. Damage report: nearly fractured right ring finger, left ankle, left wrist. The bike was not damaged though. 😉

 

[Noyac]

Here we do close to the same. Usually a spinal +LMA for the case then a stimulating femoral catheter threaded post-op, hooked up to a "Baby bottle" (mechanical, disposable infusion pump that lasts 60hrs at 5cc/hr, 30hrs at 10cc/h). Usually 5cc/hr Ropi 0.2% and have the pt pull the cath in 2-3 days. Pain free for 60hrs with no narcotics baby! Similar for total knees (though they don't go home same day) 10% need a subsequent Sciatic block but 90% are covered just fine with the pure femoral blockade. Saves an extra procedure without the hamstring and lower leg weakness.

Ditto, Our surgeons don't really like the sciatic b/c they can't evaluate the nerve function after a TKA. 😕

 

[VentdependenT]

This is a good topic that always brings alotta input...and it is Mil's nemesis since he is the president of the AARA (anesthesiologists against regional anesthesia)....anyhow good to see opinions from colleagues.

One of our CRNAs has teenage athletic daughters....2 of them popped their ACLs in one week. 😱

Both are coming for surgery this week...

will perform Jet's usual ACL protocol:

to holding at 0640 or so. Midazolam 4-5 mg

femoral nerve block...bupiv .5% w/epi 20mL

sciatic NB, Labat's approach..bupiv .5% again...20mL

To the back, monitors on, propofol 200 mg, LMA #4. NO OPIODS.

They'll only require a wiff of sevo (usually less than 1%) for the case's entirety.

Since no opiods will be used, and blocks were instituted preoperatively, PACU stay will be a non event. Usually there less than 30 minutes. No pain, minimal chance of nausea.

Say I wanted to use ropiv....have never used it for these blocks....could I use .2% with similar results? I think thats all our hospital has.

Anyway, nice educational cases, performed in a way superior to GA-only, IMHO.

why not just throw in a spinal or a cse?

 

[CanGas]

why not just throw in a spinal or a cse?

I think because ACL's hurt like hell post-op. ACLs can be done as a day surgery case IF you can manage their pain appropriatly. Spinals are great for the case but post-op managment with PO opiods can be a nasty experience. Yes a CSE would work but you can't really send them home with an epidural.

I have been sold on the continous femoral catheter approach (with baby bottle) since consistently seeing (well phoning them at home) people needing NO narcotics for the 2-3 days post-op while the catheter is in place.

 

[jetproppilot]

why not just throw in a spinal or a cse?

1)Because post op pain relief can be afforded by the blocks for up to 24 hours

2)An ACL takes about 90 minutes. A spinal or CSE in a young person frequently causes urinary retention, which'll cause them to hang around the hospital for sometimes hours.

With the blocks/light-general technique you can have them out of the hospital usually in less than an hour after emerging from the OR.

 

[OldManDave]

If the majority of a clinician's blocks work utilizing traditional approaches, whats the advantage of US guidance?

According to the block gurus around here, landmark guided has approx an 85% success rate, per the literature. However, they contest that direct visualization vis a vis u/s moves the success rate into the upper 90s. Another alleged advantage is the capacity to use less for an equally dense & as long or longer lasting block due to the precision of lacing your local anesth agent under visul guidance.

Not saying (new technology) isnt good, but if your blocks work already, whats the advantage?

Again, according tour block gurus, which are admittedly not an unbiased group, why not adopt a technique that improves your success rate, density & longevity of block all with a smaller quantity of agent...plus, allegedly easier to teach & gain proficiency.

Now, I have not had my block rotation yet, but it sounds pretty snazzy to me.

 

[OldManDave]

Dave, what are the other 3 of the u/s regional big 4? How often do use a nerve stim with your u/s? what blocks do you most commonly do with ultrasound? Any you do without u/s?

MDEntropy,

Thanks for the info. As I said above, I have yet to do my block rotation; so the words I am blowing out are purely from other sources, chatting with attendings & the other residents who have done a block rotation...so, please qualify what ever I say with that knowledge.

Most all of our blocks are done under u/s. Only a couple [Bier & ankle] are done without...at least in my "wealth" of experience...sarcasm intended.

All of our u/s blocks also use a neurostim needle for double verification of proper location. In fact, for better or for worse, the concept of redundancy/double-verification drives a lot of processes at Dartmouth.

The other three - I don't recall all three, but one of them is in Montreal & think...oh nevermind...let me pick someone's brain at work before I go starting rumors!

The impetus behind my questions is I am always interested in learning non-Dartmouth ways. As do all academic institutions, there is a significant amount of in-breeding here & it is most interesting & educational to learn how folks do & see things who trained elsewhere. I love it when we inherit a strong attending from another facility. I usually request to spend more time with them just to broaden my perspective.

 

[militarymd]

Some place in Utah is another big U/S place...they offer a pretty comprehesive course.

 

[MDEntropy]

I must disagree here. The 2 seizures that I saw with ropiv never had any blood aspiration. One was 5 minutes after the completion of the block and the other was after 25cc ( I know, the needle can migrate). Each successfully treated with 2-4 mg versed. And both blocks worked fine after the seizure. After this I don't take chances. But thats just me.

Seizures do happen.I have seen seizures from bupiv with no cardiac toxicity. This is just the hierarchy of local anesthetic toxicity.

I think doing any block is certainly taking a chance but I don't think using equipotent bupiv rather than ro means taking additional risk. Just substitute 3/8 Bupiv for your 1/2 Ropiv and your block will be just as good. Your CNS toxicity will be no different and thus your cardiovascular toxicity will be no different (cause it takes about twice as much of either one to get cardiovascular toxicity as opposed to seizures).

Astra has really tried to push this stuff but the evidence really isn't there. Ropiv is fine and if money is no object, may as well use it. I just don't think you get much benefit from it when dosed equipotent. If some new data have come out or do come out to disprove this then I will go with it but currently the justification for ropiv is weak if you subsitute with bupiv that is only about .6 to .75 your ropiv concentration.

Noyac, I am wondering, do you run ropiv in your labor epidurals also? what concentration?

 

[jetproppilot]

Seizures do happen.I have seen seizures from bupiv with no cardiac toxicity. This is just the hierarchy of local anesthetic toxicity.

I think doing any block is certainly taking a chance but I don't think using equipotent bupiv rather than ro means taking additional risk. Just substitute 3/8 Bupiv for your 1/2 Ropiv and your block will be just as good. Your CNS toxicity will be no different and thus your cardiovascular toxicity will be no different (cause it takes about twice as much of either one to get cardiovascular toxicity as opposed to seizures).

Astra has really tried to push this stuff but the evidence really isn't there. Ropiv is fine and if money is no object, may as well use it. I just don't think you get much benefit from it when dosed equipotent. If some new data have come out or do come out to disprove this then I will go with it but currently the justification for ropiv is weak if you subsitute with bupiv that is only about .6 to .75 your ropiv concentration.

Noyac, I am wondering, do you run ropiv in your labor epidurals also? what concentration?

Not from Noy,

but IMHO the Jedi Warrior labor analgesia infusion is .2% ropiv with sufentanil .5 ug/mL at 12 mL/hr.

Thats the George Foreman Grill Recipe.

Set-It-And-Forget-It.

 

[MDEntropy]

Also, I have done the Lumbar plexus/psoas blocks and have retired that block for a few reasons.
1) All the pts get lovenox and/or coumadin after TKA/THA's and the risk of unnoticed vascular (renal) puncture is higher with this block leading to hematoma which will continue to enlarge until total vascular compromise or in effect a epidural hematoma after pulling the catheter. This is a small risk altogether, I am aware. But the name of the game is to limit risks and deliver effective care. Therefore
2) The FNB and Sciatic block is just as effective. And you can add intrathecal morphine if you wish. (My practice currently is FNB with IT morphine)
3) Also, the risk of epidural spread is high. But I don't consider this as a huge dilemma

The lovenox doesn't matter with and one shot lumbar plexus block. But in truth, I think for a tka a femoral nerve catheter +/- and sciatic block is better than a lumbar plexus block (yes, the femoral nerve catheter with the lovenox and it only takes a minute to round on them once a day for 2 days) For simpler knee stuff, often done arthroscopically, where people go home quickly, I think a lumbar plexus can be great. When is the last time you saw an epidural hematoma (maybe you have seen ione or two in your career?) and certainly not from a lumbar plexus block. The risk of post dural puncture headache from doing the spinal is much greater than complication from the lumbar plexus block and the risk of epidural hematoma is probably higher too.

But i think their is a big distinction between a tka and an arthroscopic ligament repair.

And for primary THA - spinal.
Revision - spinal with duramoprh and general or lumbar plexus and general.

Bottom line though - i am not saying your way is wrong. But i think we have to differentiate the surgeries first and then after that I think the risks you are talking about are miniscule.

 

[MDEntropy]

Not from Noy,

but IMHO the Jedi Warrior labor analgesia infusion is .2% ropiv with sufentanil .5 ug/mL at 12 mL/hr.

Thats the George Foreman Grill Recipe.

Set-It-And-Forget-It.

That is some expensive stuff tho - both the local and the narcotic. Why don't you do a trial comparing say 1/8 bupiv with like 3-5 mcg of fentanyl and see if you find much difference.

Do you have pcea's?

 

[MDEntropy]

MDEntropy,

Thanks for the info. As I said above, I have yet to do my block rotation; so the words I am blowing out are purely from other sources, chatting with attendings & the other residents who have done a block rotation...so, please qualify what ever I say with that knowledge.

Most all of our blocks are done under u/s. Only a couple [Bier & ankle] are done without...at least in my "wealth" of experience...sarcasm intended.

All of our u/s blocks also use a neurostim needle for double verification of proper location. In fact, for better or for worse, the concept of redundancy/double-verification drives a lot of processes at Dartmouth.

The other three - I don't recall all three, but one of them is in Montreal & think...oh nevermind...let me pick someone's brain at work before I go starting rumors!

The impetus behind my questions is I am always interested in learning non-Dartmouth ways. As do all academic institutions, there is a significant amount of in-breeding here & it is most interesting & educational to learn how folks do & see things who trained elsewhere. I love it when we inherit a strong attending from another facility. I usually request to spend more time with them just to broaden my perspective.

You can actually block some of the nerves of the ankle w/ ultrasound, not that you need to.

I think doing blocks with both u/s and nerve stim can be a strange experience. At times you can have the needle right next to the nerve or sometimes seemingly in the nerve and get no muscle response with a high level of current. Advance the needle further or bend it a bit to compress the nerve and you get a response. but, to get that twitch, you are sometimes much closer than you need to be to bathe the nerve with local and get a good block.

When do you start doing these blocks on your rotation, I will be interested to see how long they take, if you are draping the probe with a sterile cover, etc.

 

[militarymd]

Jet,


Have you looked with the ultrasound yet?]

 

[jetproppilot]

Jet,


Have you looked with the ultrasound yet?]

Never have for blocks, Mil.

Did the ACL this morning...also had a heart to line and an epidural for a TKA so didnt have time to mess sround with it.

Only did the FNB (no sciatic)....she did fine.

 

[Noyac]

The lovenox doesn't matter with and one shot lumbar plexus block. But in truth, I think for a tka a femoral nerve catheter +/- and sciatic block is better than a lumbar plexus block (yes, the femoral nerve catheter with the lovenox and it only takes a minute to round on them once a day for 2 days) For simpler knee stuff, often done arthroscopically, where people go home quickly, I think a lumbar plexus can be great. When is the last time you saw an epidural hematoma (maybe you have seen ione or two in your career?) and certainly not from a lumbar plexus block. The risk of post dural puncture headache from doing the spinal is much greater than complication from the lumbar plexus block and the risk of epidural hematoma is probably higher too.

But i think their is a big distinction between a tka and an arthroscopic ligament repair.

And for primary THA - spinal.
Revision - spinal with duramoprh and general or lumbar plexus and general.

Bottom line though - i am not saying your way is wrong. But i think we have to differentiate the surgeries first and then after that I think the risks you are talking about are miniscule.

I totally agree Entropy.
You do have to think about the surgery being performed and the R&B's. I was talking about Lovenox with continuous block catheters in the Psoas compartment. The incidence of hematoma is larger than I wish to see. I don't remember the #'s but still I would rather a Fem. Nerve cath when the pt is going to get lovenox post op. I have no problem with that.
I have only seen one epidural hematoma in my short career but that is because we choose our pts carefully these days. I would much rather send them home after ACL with a FNB and a grenade (continuous infusion bulb) for 2 days. But thats my practice and everyone is different w/c is what makes anesthesia an art. 🙂