Regional question

[epidural man]

First - imagine a scenario where you practice without threat of litigation, and your only decision is - is it the best clinical decision? (I know...I know...you all practice like that already, correct?)

Here is clinical situation. A 33 y/o was in a motorcycle MVA, had an open book pelvis fracture and a right humerus fracture injuring the radial nerve (in Japan). Had a pelvic ex-fix placed and splint to the humerus and was then sent to US. I actually performed the anesthesia on the kid (maybe 8 days after the injury) where they revised the ex-fix and pinned the humerus.

I was consulted a few days later because of inability to control pain from the humerus (he had now been on a dilaudid PCA since injury). (Also, parenthetically - I induced with 20mg methadone, gave another 10 during the case - woke up beautifully and pain free. I love using that drug intraoperatively).

when I say radial nerve injury, he couldn’t extend his wrist at all.

Would anyone use a regional technique to help control his pain for a few days way his humerus heals and lain improves? His pelvis didn’t seem to bother him anymore.

---

Members don't see this ad.

 

[nimbus]

I would want to know why his humerus so painful a few days postop.

 

[anbuitachi]

First - imagine a scenario where you practice without threat of litigation, and your only decision is - is it the best clinical decision? (I know...I know...you all practice like that already, correct?)

Here is clinical situation. A 33 y/o was in a motorcycle MVA, had an open book pelvis fracture and a right humerus fracture injuring the radial nerve (in Japan). Had a pelvic ex-fix placed and splint to the humerus and was then sent to US. I actually performed the anesthesia on the kid (maybe 8 days after the injury) where they revised the ex-fix and pinned the humerus.

I was consulted a few days later because of inability to control pain from the humerus (he had now been on a dilaudid PCA since injury). (Also, parenthetically - I induced with 20mg methadone, gave another 10 during the case - woke up beautifully and pain free. I love using that drug intraoperatively).

when I say radial nerve injury, he couldn’t extend his wrist at all.

Would anyone use a regional technique to help control his pain for a few days way his humerus heals and lain improves? His pelvis didn’t seem to bother him anymore.

just document the pre op exam and do it.

Edit: just realized you wrote without threat of litigation. so i guess you dont even have to document preop exam. just do it

 

[epidural man]

I would want to know why his humerus so painful a few days postop.

I suspect it is from several days of his opioid receptors being banged on by a PCA. I mean - it didn't hurt as bad before the pinning. After the surgery, it was much worse. But it I a good question.

 

[deleted697127]

First - imagine a scenario where you practice without threat of litigation, and your only decision is - is it the best clinical decision? (I know...I know...you all practice like that already, correct?)

Here is clinical situation. A 33 y/o was in a motorcycle MVA, had an open book pelvis fracture and a right humerus fracture injuring the radial nerve (in Japan). Had a pelvic ex-fix placed and splint to the humerus and was then sent to US. I actually performed the anesthesia on the kid (maybe 8 days after the injury) where they revised the ex-fix and pinned the humerus.

I was consulted a few days later because of inability to control pain from the humerus (he had now been on a dilaudid PCA since injury). (Also, parenthetically - I induced with 20mg methadone, gave another 10 during the case - woke up beautifully and pain free. I love using that drug intraoperatively).

when I say radial nerve injury, he couldn’t extend his wrist at all.

Would anyone use a regional technique to help control his pain for a few days way his humerus heals and lain improves? His pelvis didn’t seem to bother him anymore.

What’s keeping him in the hospital? I wouldn’t block someone this far out. Especially if pain is the reason he’s still there. Like what would that even do, kick the can down the road. I would maximize schedules Tylenol, NSAID, gabapentin if seems nerve related, consider ketamine infusion if he’s going to be there for a bit and your hospital will let you, but most importantly if he has a functional GI tract, he needs to be switched to PO and off that PCA.

 

[IMGASMD]

Are you blocking to diagnose? Are you blocking to pain relief? How was the surgery?

I would block and see what happens, if no “justification” needed for whatever my treatment plan is.... is it “standard of care”, probably not. But certainly satisfied my curiosity.

 

[epidural man]

What’s keeping him in the hospital? I wouldn’t block someone this far out. Especially if pain is the reason he’s still there. Like what would that even do, kick the can down the road. I would maximize schedules Tylenol, NSAID, gabapentin if seems nerve related, consider ketamine infusion if he’s going to be there for a bit and your hospital will let you, but most importantly if he has a functional GI tract, he needs to be switched to PO and off that PCA.

He was getting set up for rehab. The humerus surgery was on a Wed. We were consulted on a Friday. Plan was for rehab on Monday. The reason question about regional was that if you ran a catheter for a week, hopefully, the humerus surgery pain would be much better by then.

 

[Consigliere]

Regional question, general answer - don't do it.

 

[deleted59964]

we sometimes do blocks for people a fair way down the track, to give them an opportunity to wean opioids and get their mu receptors working again.
an infraclav catheter would be my choice

 

[Hoya11]

First - imagine a scenario where you practice without threat of litigation, and your only decision is - is it the best clinical decision? (I know...I know...you all practice like that already, correct?)

Here is clinical situation. A 33 y/o was in a motorcycle MVA, had an open book pelvis fracture and a right humerus fracture injuring the radial nerve (in Japan). Had a pelvic ex-fix placed and splint to the humerus and was then sent to US. I actually performed the anesthesia on the kid (maybe 8 days after the injury) where they revised the ex-fix and pinned the humerus.

I was consulted a few days later because of inability to control pain from the humerus (he had now been on a dilaudid PCA since injury). (Also, parenthetically - I induced with 20mg methadone, gave another 10 during the case - woke up beautifully and pain free. I love using that drug intraoperatively).

when I say radial nerve injury, he couldn’t extend his wrist at all.

Would anyone use a regional technique to help control his pain for a few days way his humerus heals and lain improves? His pelvis didn’t seem to bother him anymore.

Its already been a few days after surgery, your going to intervene with a block now? At this point I would look to optimize medical management, maybe needs a long acting oral opiate regimen for now to wean from the PCA.. Im not convinced that the situation would be different after the block wears off

 

[BloodySurgeon]

The worsening pain following ex-fix could be from increase swelling that exacerbated his radial nerve injury. Maxamize adjunctives NSAIDs/lidocaine/Gabanoids/TCA/etc. I would be curious to hear from a surgeon if a nerve exploration would be indicated prior to ex-fix but thet would be too late now. Unfortunately there is no regenerative or protective property of a regional block at this time so its not a strong indication. As others mentioned you may consider a selective nerve root block for diagnostic purposes but can follow up with maybe a Peripheral Nerve Stimulator. Not sure if Sprint PNS is FDA approved for brachial plexus injury but would look into.

The point is, rule out reversal causes and if none consider long term plan. Regional catheter will buy your patient delayed discharge and increase length of stay

 

[shepardsun]

Random tangent but I'm interested in learning how to use methadone intraoperatively. Any good sources or tips?

 

[axeon123]

Discuss with surgeon, discuss risks/benefits with patient, document the exam/sensory exam/etc, discuss with your group, follow-up post-block after it wears off. I think it should not be easy to cause isolated radial nerve injury with interscalene block, right?

 

[anbuitachi]

Random tangent but I'm interested in learning how to use methadone intraoperatively. Any good sources or tips?

and things to watch out for?

ive only really used it for long cases like long spines or stuff like that. curious how well it would work in other cases (thoracic?)

 

[epidural man]

So I placed an infraclavicular catheter (after a good discussion of risks and such) and immediately regretted it.

Bolused 0.5% lidocaine and his pain was nearly resolved. The patient was very happy.

I tried to get the pharmacy to infuse 0.5% mepiviciane, but they wouldn't. Apparently physicians don't make clinical decisions anymore.

I fretted all night about it - wasn't settled. I told the residents to work the infusion down to the very minimal rate as possible. The patient had the best sleep he had had in nearly two weeks - so there is that. The pain staff the next day put the rate at 1cc/hr - and then "luckily", the catheter clotted so it was pulled - so I guess that made the decision for me.

anyway, just thought I'd inquire about thoughts.

 

[IMGASMD]

Why the regret?

 

[epidural man]

I was worried about his nerve. I wasn't clear I should have placed it in the first place. I wasn't sure we had maximized non-regional techniques before going to that. He was leaving the hospital soon and originally, I knew I didn't have time to get his pain under control and on a good regimen....so I jumped to regional.

 

[secretasianman]

Pain out of proportion after surgery for trauma injury, I wouldn’t block. Why the methadone? Is this regularly used at your shop? Could this be crps? I’m too lazy to look it up.

 

[anbuitachi]

I was worried about his nerve. I wasn't clear I should have placed it in the first place. I wasn't sure we had maximized non-regional techniques before going to that. He was leaving the hospital soon and originally, I knew I didn't have time to get his pain under control and on a good regimen....so I jumped to regional.

does blocking the nerve cause reduced healing ?

 

[epidural man]

Regarding the methadone - I just think it works wonderful for intraoperative use.

it hits faster than fentanyl so great for induction. It lasts a long time. It has NMDA receptor antagonism and is a Na channel blocker. Studies show that it’s intraoperative use decreases post operative opioid and pain scores for several hours, maybe for a couple of days.

I am unaware that blocking a nerve impedes healing. It probably increases it. However, all local anesthetics are neurotoxic and probably not good on a nerve struggling to heal.