GoodmanBrown

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A year or so ago, I was shadowing a resident in a surgicenter-type shop with lots of quick surgeries and regional, etc.

The resident was giving a nerve block to an older Navy vet who was going in for rotator cuff surgery. I forget the block name (my bad), but I'm sure a lot of you vets (of the anesthesiology variety, not necessarily the military kind) already know what it was.

At any rate, the resident gave a shot of lidocaine and proceeded with the block about 3 minutes later when the attending rolled in. The block was US-guided and about half way to the destination, I noticed the vet was in quite a bit of pain. Every time the needle inched a bit deeper, he would grimace pretty badly. He was starting to sweat and his breathing was getting pretty quick. The resident and the attending didn't notice as they were both pretty fixated on the monitor. Neither I nor the vet said anything and the block was placed maybe 2 minutes later.

So, my question is, how should the compassionate anesthesiologist respond to this situation? It seems like a horrible idea to pull the needle out, re-apply lidocaine and try again. It also seems like a terrible idea to try to leave the needle in mid-block and inject more lido with a separate needle. Did they do the right thing by just getting it over and done with? Is the take-home lesson just to be generous with the lidocaine in the first place?
 

Planktonmd

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The block is most likely an interscalene but it could be a supra-clavicular as well.
The problem with ultrasound guided blocks especially in inexperienced hands is that people most of the time are focused on holding the probe and driving the needle towards the target that they forget about other basics like good anesthesia to the skin and soft tissue.
Also when using ultrasound for an interscalene block you are forced to enter more posteriorly in the neck and many times through the middle scalene muscle which is very painful so subcutaneous lidocaine alone might not be enough.
Doing an interscalene block with nerve stimulation without ultrasound is less painful because you only have to penetrate the skin.
This is why if you are inexperienced and trying to do an ultrasound guided interscalene you need good sedation.
If the pain happened when the injection started then you should stop immediately because this could mean intraneural injection.

A year or so ago, I was shadowing a resident in a surgicenter-type shop with lots of quick surgeries and regional, etc.

The resident was giving a nerve block to an older Navy vet who was going in for rotator cuff surgery. I forget the block name (my bad), but I'm sure a lot of you vets (of the anesthesiology variety, not necessarily the military kind) already know what it was.

At any rate, the resident gave a shot of lidocaine and proceeded with the block about 3 minutes later when the attending rolled in. The block was US-guided and about half way to the destination, I noticed the vet was in quite a bit of pain. Every time the needle inched a bit deeper, he would grimace pretty badly. He was starting to sweat and his breathing was getting pretty quick. The resident and the attending didn't notice as they were both pretty fixated on the monitor. Neither I nor the vet said anything and the block was placed maybe 2 minutes later.

So, my question is, how should the compassionate anesthesiologist respond to this situation? It seems like a horrible idea to pull the needle out, re-apply lidocaine and try again. It also seems like a terrible idea to try to leave the needle in mid-block and inject more lido with a separate needle. Did they do the right thing by just getting it over and done with? Is the take-home lesson just to be generous with the lidocaine in the first place?
 

GoodmanBrown

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The block is most likely an interscalene but it could be a supra-clavicular as well.
I looked up interscalene blocks and supraclavicular blocks on these sites, and I'm leaning toward the supraclavicular. I distinctly remember the attending emphasizing the needle sit between two nerves which kinda matches Figure 8-8 on the supraclavicular site. Anyway, that's just my guess.

The problem with ultrasound guided blocks especially in inexperienced hands is that people most of the time are focused on holding the probe and driving the needle towards the target that they forget about other basics like good anesthesia to the skin and soft tissue.
Also when using ultrasound for an interscalene block you are forced to enter more posteriorly in the neck and many times through the middle scalene muscle which is very painful so subcutaneous lidocaine alone might not be enough.
What techniques do you use if subcutaneous lido isn't enough? Not that I've got huge experience in this department, but I've never heard of intramuscular lido. Do you move toward general sedation if you're going to push a big needle through muscle?

Doing an interscalene block with nerve stimulation without ultrasound is less painful because you only have to penetrate the skin.
This is why if you are inexperienced and trying to do an ultrasound guided interscalene you need good sedation.
If the pain happened when the injection started then you should stop immediately because this could mean intraneural injection.
I'm very certain it wasn't an intraneural injection as the attending and resident had good visualization of the needle and nerve branches.

What exactly happens in the event of intraneural injection? Is it possible to rupture the nerve and permanently damage/destroy it?
 

Planktonmd

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A supraclavicular block is not very painful since it is pretty shallow.
As for how to inject the local I usually make a skin wheal then inject deeper subcutaneously following the same path the block needle is going to follow just stop before you reach the nerves.
It is always a good idea to have some sedation and this sedation should be more for deeper blocks.
Intraneural injection could permanently damage the nerve fibers and the damage is probably proportional to the pressure of the injection.
 

urge

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No block, no problems.

Any questions?
 

IN2B8R

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A year or so ago, I was shadowing a resident in a surgicenter-type shop with lots of quick surgeries and regional, etc.

The resident was giving a nerve block to an older Navy vet who was going in for rotator cuff surgery. I forget the block name (my bad), but I'm sure a lot of you vets (of the anesthesiology variety, not necessarily the military kind) already know what it was.

At any rate, the resident gave a shot of lidocaine and proceeded with the block about 3 minutes later when the attending rolled in. The block was US-guided and about half way to the destination, I noticed the vet was in quite a bit of pain. Every time the needle inched a bit deeper, he would grimace pretty badly. He was starting to sweat and his breathing was getting pretty quick. The resident and the attending didn't notice as they were both pretty fixated on the monitor. Neither I nor the vet said anything and the block was placed maybe 2 minutes later.

So, my question is, how should the compassionate anesthesiologist respond to this situation? It seems like a horrible idea to pull the needle out, re-apply lidocaine and try again. It also seems like a terrible idea to try to leave the needle in mid-block and inject more lido with a separate needle. Did they do the right thing by just getting it over and done with? Is the take-home lesson just to be generous with the lidocaine in the first place?
That's rather presumptious on your part, isn't it? You knew that they were fixated? Somehow, magically, you knew that they blocked the patient out of their brains at the very moment the patient was "breathing heavy, grimacing and sweating." How do you know that the patient was not breathing heavily, sweating and grimacing from looking at you? Nothing personal, just thought that I would ask the above as a compassionate anesthesiologist reading your post.
 

Eta Carinae

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OP, by MS3, you may have the appropriate context with which to properly frame your question and understand the medicine involved...including a better grasp of the anatomy.

I suggest waiting a bit...
 

GoodmanBrown

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I don't think the OP intended to offend anyone.
Thanks, Plank. No, I didn't intend to offend anyone. The "compassionate" in my original post was a supposed to be tongue-in-cheek. I didn't mean to imply the resident and attending were jerks or anything.

urge said:
No block, no problems.

Any questions?
Makes sense. This one was a bolus block, but then they also put in a catheter with a 7-day auto infuser. The guy took the device home with him and when the bag had deflated he was supposed to pull the cath himself.