rib fractures

[Timeoutofmind]

I have gotten a few calls on these from PCPs/surgeons.

Asking if "I can do a block".

In house we used to do thoracic epidural catheters and/or intercostal nerve block with liposomal bupvicaine when I was an anesthesia resident.

Anything reasonable to offer these people outpatient? Just seems nothing would last long enough to be meaningful...Are you guys doing paravertebrals/intercostals/something else? Or just telling them tincture of time?

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[mazinger]

I have gotten a few calls on these from PCPs/surgeons.

Asking if "I can do a block".

In house we used to do thoracic epidural catheters and/or intercostal nerve block with liposomal bupvicaine when I was an anesthesia resident.

Anything reasonable to offer these people outpatient? Just seems nothing would last long enough to be meaningful...Are you guys doing paravertebrals/intercostals/something else? Or just telling them tincture of time?

Iovera Ice balls..

 

[Timeoutofmind]

Iovera Ice balls..

With imaging guidance?
Is that covered by insurance?
Isnt that prohibitively expensive technology? I heard the handle is 10K or something? And how does Iovera really differ from standard cryoablation techniques is another point I am not clear on? Is it likewise non-neurolytic (sort of analogus to pulsed RF?)

 

[Arch Guillotti]

I have gotten a few calls on these from PCPs/surgeons.

Asking if "I can do a block".

In house we used to do thoracic epidural catheters and/or intercostal nerve block with liposomal bupvicaine when I was an anesthesia resident.

Anything reasonable to offer these people outpatient? Just seems nothing would last long enough to be meaningful...Are you guys doing paravertebrals/intercostals/something else? Or just telling them tincture of time?

I am surprised they are calling you and not the anesthesiologist.

 

[Timeoutofmind]

I am surprised they are calling you and not the anesthesiologist.

These are outpatients.

 

[Arch Guillotti]

These are outpatients.

That makes more sense but why is a surgeon seeing a patient with rib fx?

 

[Timeoutofmind]

That makes more sense but why is a surgeon seeing a patient with rib fx?

If they are displaced, sometimes they will operate, no?

 

[Arch Guillotti]

If they are displaced, sometimes they will operate, no?

I would think that if rib fx or a flail chest were bad enough to be seen by a surgeon, then the patient would be admitted to the hospital.

 

[mazinger]

With imaging guidance?
Is that covered by insurance?
Isnt that prohibitively expensive technology? I heard the handle is 10K or something? And how does Iovera really differ from standard cryoablation techniques is another point I am not clear on? Is it likewise non-neurolytic (sort of analogus to pulsed RF?)

Always do my intercostal procedures under US.
Nope not covered by insurance.
I do not know the difference between regular old school cryo and the Iovera, besides convenience.
The Iovera is 5 k, the needles are 200 and the procedure is lengthy.
It is neurolytic.

 

[Aether2000]

Paravertebral block

 

[Timeoutofmind]

Paravertebral block

How r they gonna get any sustained relief from this?
R u adding steroid?

 

[Aether2000]

Nothing you can do will give sustained relief from a rib fracture unless you place an epidural catheter and run an infusion or an IT pump with placement of the catheter at the fracture level and use a bupivicaine infusion. All other measures are transient and will not in any way help more than 24 hours. Intercostal cryo is difficult because the IC nerve 50% of the time lies between the ribs rather than tucked under the rib. Neurolytic solutions for IC blocks may cause worsened pain in some. I have done extraforaminal cryo of the exiting IC nerve with some success but their size is huge. I have had no positive response from PRF DRG or of the exiting spinal nerve for rib fracture pain.

 

[Ducttape]

tincture of time.
intercostal nerve blocks under fluoro occasionally benefit short term, but I have found more and more insurances are denying. for those that cover, ive done a few pulsed RFA that have provided short term benefit for the rib to heal. dont forget to also treat nerve above. (https://www.ncbi.nlm.nih.gov/pubmed/22996865 )

 

[mazinger]

Always do my intercostal procedures under US.
Nope not covered by insurance.
I do not know the difference between regular old school cryo and the Iovera, besides convenience.
The Iovera is 5 k, the needles are 200 and the procedure is lengthy.
It is neurolytic.

http://journals.lww.com/anesthesia-...Guided_Intercostal_Nerve_Cryoablation.44.aspx

 

[Timeoutofmind]

http://journals.lww.com/anesthesia-...Guided_Intercostal_Nerve_Cryoablation.44.aspx

Anyway, side point, Iovera on there website claims to be non neurolytic (more details below)
"The effect of the cold on the nerve is temporary and does not cause permanent damage because it leaves the structural components of the nerve intact. "

Seems like the equivalent of pulsed RF (neuromodulation). Why not just charge people cash for pulsed RF vs charging cash for Iovera? They achieve a similar outcome...but I already have the pulsed RF system and dont have to buy anything and the disposables are quite a bit cheaper...and also it seems so awkward with some big handle and a really short needle

http://iovera.com/pdf/mkt-0397_rev_a_iovera-brochure.pdf

I found the section on cryo in this review helpful (short answer, seems to depend how cold you go):
http://iovera.com/pdf/zhou-2014-current-concepts-of-neurolysis-and-clinical-applications.pdf

 

[neutro]

multimodal analgesia + intercostal nerve blocks under fluoro/ possible ESI and SCS if pain is neuropathic and chronic (i.e > 6 months out)

I am seeing a patient right now...in his 60s, nice guy, guitarist...no previous PMH besides cigar use, involved in an MVA, injured his neck (no neurological deficit expect right C6-7 distal numbness which was significantly improved by CESI and numbness is returning so we have to repeat that, and also has axial neck pain and he's lined up for cervical MBBs next week).
He was taken to a trauma center in Philly and had his right distal 5, 6, 7 ribs resected they were protruding inwards and impairing lung function...he is now 8 months out and in severe pain still. I sent him back to the CT surgeon because his pain is constant and he has difficult taking a deep breath and had an effusion develop, and all they did was remove the scar and stating that they cannot do anything more otherwise the lung will herniate and its a pain management issue - which I understand.
I have scheduled him for a thoracic ESI after exam under fluoro, and possible SCS. He got 2-3 months of pain relief from intercostal nerve blocks at right T5, 6, 7. I used 0.25% bupivacaine and depo...I am not sure what else to do besides that and meds...
I find fluoro based INCB challenging because I never can get a true sense of depth, because a lateral is not very clear and you wont see the pleural margin obviously...the patient is prone, and sometimes the "pop" is not present after hitting the bottom of the rib and advancing the needle.

 

[Aether2000]

US is the best way to deliver ICNB: you know the exact depth.

 

[Ducttape]

US is the best way to deliver ICNB: you know the exact depth.

Agree.

Otoh, there was a recent article in the ER lit that suggested a targetted injection right on the fractured rib may be as effective as an ICNB...

I plan on doing a few of these over the next few weeks, as trigger point/intralesional injections (under fluoro), to see if they help for a few ppl that their insurance has deemed ICNB as experimental.


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[Aether2000]

I remember the days when we did them all by palpation of the rib. With the obesity epidemic, I am now finding ribs are frequently not locatable by palpation....

 

[DODOCSS]

omoigui diffusion technique

 

[pastafan]

https://www.omicsonline.org/omoigui...intercostal-nerve-block-2155-6148.1000344.pdf

Placing needle on lower edge of rib using fluoro has worked well with slightly higher volume.

 

[gdub25]

Could you get an On-Q ball and place a paravertebral catheter? The On-Q is $250 dollars and the catheter less than $20. For $500 cash the patient could walk out with a solution that could last them 5-7 days depending on how high you run the infusion. I placed a whole bunch of these for patients undergoing outpatient mastectomies and the single catheter often would cover 4 to 5 dermatomes and they routinely left them in for several days.

 

[Aether2000]

Interesting....it might work if the catheter could be placed exactly at the fracture site....

 

[lobelsteve]

10 bucks of tramadol doc, it'll be good enough.

 

[neutro]

US is the best way to deliver ICNB: you know the exact depth.

yeah, I may just do that.
I have been using contrast thus far. I forgot to mention in my post, I apologize.
When I did the ICNB on that patient, right 5 and 7 nerves showed good contrast spread, but 6th did not. However, I did not advance the needle further and just went by comparing the depth with the two needles. I was afraid that if I advance the needle further I may cause PTX. I felt I was close enough and higher volume may take care of it and fortunately he got good pain relief.
I did his thoracic epidural today - that went well. lets see how it works.