Single Shot Nerve Blocks which last over 24 hours

[BLADEMDA]

There are big days and small days with most being small days. This month's Regional Anesthesia Journal was a big day.

Anesthesiologists out of Pittsburgh confirmed what my clinical work has been telling me for over a year now: adding Decadron prolongs single shot nerve blocks significantly.
These guys at Pitt are to be commended for their outstanding clinical and bench research on additives to nerve block solutions. Pitt is a great program and their Regional dept. is as as good as any.

I'll post some of the findings on this thread for a discussion. As a result of their evidence combined with my clinical work I feel much more comfotable addng Dexamethasone 2mg to my local solution for patients with NIDDM.

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[BLADEMDA]

Our group recently showed 50% neuronal cytotoxicity in nondiabetic cultured primary sensory neurons after 24-hour exposure to 0.25% ropivacaine, whereas clinically relevant concentrations of clonidine, buprenorphine, dexamethasone, and midazolam were nontoxic.7 As such, we feel that the investigation into the use of these perineural adjuvants should continue, especially within the framework of the ZDF model. The studies in this issue of Regional Anesthesia and Pain Medicine even suggest that dexamethasone is now a viable perineural adjuvant to study in DM because acute tissue hyperglycemia does not appear to influence neurotoxicity sequelae in primary sensory neurons in vitro and does not appear to influence crude long-term sensorimotor outcomes in vivo.
Buoyed by our report that clonidine, buprenorphine, and dexamethasone are nontoxic in cultured neurons,7 we created a clinical pathway at the Veterans Affairs Pittsburgh Medical Center involving the routine use of these perineural adjuvants with bupivacaine for single-injection regional anesthesia. The plan, which included the off-label perineural use of clonidine, buprenorphine, and dexamethasone, was presented to and approved by the hospital's Medical Executive Board before proceeding. Bupivacaine concentrations and analgesic adjuvant doses, as they differed for diabetic and nondiabetic in our clinical pathway, are presented in Tables 1 and 2. We analyzed quality improvement (QI) data for 101 lower-extremity joint replacement patients thus far (not intended to be interpreted as peer reviewed). Our mean nerve block "durations of meaningful patient analgesia" have been 41 hours (95% confidence interval, 36–46 hours) for diabetic patients and 38 (34–41 hours) for nondiabetic patients. If we include all regional anesthesia patients, there have been QI data entered for a total of 275 patients as of this writing, and there have been no peripheral nerve complications to date with respect to multimodal perineural analgesia.

Table 1
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Table 2
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There seems to be very promising reasons to continue to explore the coadministration of perineural adjuvants in combination with lower-concentration local anesthetics, even if local anesthetic toxicity risk with conventional concentrations is "only minimally worsened" by DM in current translational research. A recent review of peripheral nerve block complications suggests an incidence of 0.05%, or 1:20008; this does not appear to have changed over the past decade, despite the increasing use of ultrasound guidance and reduced local anesthetic volumes and concentrations.9 Others suggest that perineural complication rates for diabetic patients are 10 times greater than that for nondiabetic patients.10 Our specialty's diligence in the area of malignant hyperthermia has led to a remarkable small incidence, estimated to be 1:100,000.11 Can we not reach similar numbers with peripheral nerve block complications?
Clearly, continuing to allocate scarce research resources only to the study of local anesthetics in diabetic rat nerve block models appears to be somewhat wasteful, unless these studies actively adopt treatments that involve perineural analgesic adjuvants in an effort to significantly reduce (for surgical anesthesia) or eliminate (for perineural analgesia) local anesthetic use.


Ibinson, James W. MD, PhD; Mangione, Michael P. MD; Williams, Brian A. MD, MBA

 

[BLADEMDA]

For better or worse, it appears that the battle of nerve localization methods is over and ultrasound has won. The article by Orebaugh et al, even with its practical and theoretical shortcomings, is important not least for providing a clear topographical map of that changing landscape. It is possibly one of the last studies to compare "what was" with "what has come to be."



Laur, John J. MD, MS*; Weinberg, Guy L. MD†



http://www.ncbi.nlm.nih.gov/pubmed/22996199 (Pittsburgh again)

 

[BLADEMDA]

Conclusions: Neuraxial anesthesia for BTKA is associated with significantly lower rates of blood transfusions and, by trend, decreased morbidity. Although by itself the effect may be limited, N might be used within a multimodal approach to reduce complications after BTKA



http://www.hss.edu/newsroom_anesthesia-affects-bilateral-knee-replacement.asp

 

[BLADEMDA]

Conclusions: In vitro, local anesthetic neurotoxicity was more pronounced on neurons from diabetic animals, but the survival difference was small. In vivo, subclinical neuropathy leads to substantial prolongation of block duration. We conclude that early diabetic neuropathy increases block duration, whereas the observed increase in toxicity was small.


http://www.ncbi.nlm.nih.gov/pubmed/23011115

 

[BLADEMDA]

So, what does this mean for the daily routine practice of anesthesia for us grunts?

1. I was using PF decadron sparingly in my diabetic patients to prolong single shot blocks. My work agrees with the guys from Pitt that all you need is 1-2 mg of Decadron to prolong the block. Because the guys at Pitt use a "cocktail of additives" and I just use Decadron my Diabetic dose is 2 mg to the block solution. I'm finding that 0.25% Bup with 2 mg of decadron in a 20 ml mixtures gives 24 hrs of post op pain relief or more for ICB, ISB, Femoral and Popliteal Blocks.

2. Non Diabetics will keep getting the 4 mg of PF Decadron for prolonged analgesia. Younger patients (18-35) need Bupivacaine 0.5% with the decadron to reliably get 24 hrs or more of post op pain relief. Ropivacaine (even 0.5%) isn't as reliable at the 20 hr mark as 0.5% Bup.

3. The guys at Pitt have a cocktail of additives which they report prolonged analgesia of more than 35 hrs from a single shot. on my young ASA 1 and 2 patients I may try that cocktail. That said, on my older patients I'll stick with just the Decadron.

 

[BLADEMDA]

Here is the Univ. of Pittsburgh Cocktail (please read the editorial for details):

1. Perineural Clonidine (80-100 ug)
2. Buprenorphine (300ug-900 ug)
3. Dexamethasone (2mg-4mg)

The authors states they are getting prolongation of nerve blocks in diabetics with as little as 1 mg of PF Decadron. (I'll still be using 2 mg though).

If I was going to use the cocktail I'd go with low dose Clonidine ( 80 ug TOTAL), Buprenorphine 400-500 ug and Dexamethasone 2-4 mg.

 

[excalibur]

You are right, Blade. Big day. I have already started with Dexamethasone. I started with Ropivacaine and 8 mg Dexamethasone. I didn't get to the 24 hour mark as you said. Up next is Bupivacaine with Dexamethasone, as I want that 30+ hour relief. I will probably just start with 8 mg, knowing that I could taper to 4 mg with similar results. This article has made me feel more comfortable with its administration. I had to ask our pharmacist to order PF dexamethasone. Now there is a box in the pharmacy of PF Dexamethasone that is all mine and just for my blocks.

 

[BLADEMDA]

You are right, Blade. Big day. I have already started with Dexamethasone. I started with Ropivacaine and 8 mg Dexamethasone. I didn't get to the 24 hour mark as you said. Up next is Bupivacaine with Dexamethasone, as I want that 30+ hour relief. I will probably just start with 8 mg, knowing that I could taper to 4 mg with similar results. This article has made me feel more comfortable with its administration. I had to ask our pharmacist to order PF dexamethasone. Now there is a box in the pharmacy of PF Dexamethasone that is all mine and just for my blocks.

If you use 0.5% Bup (at least 20 mls) combined with 8 mg of PF Decadron then block analgesia will exceed 24 hrs with most greater than 28 hrs. For some reason the Bup plus Deacdron has a consisently greater duration of analgesia than Rop with Decadron.

 

[Oggg]

1. Can anyone comment on decadrons effect on block density? Has anyone tried ropiv 0.2% or bupiv 0.1% with decadron? I suspect it makes more motor block (which really only matters for TKA)

2. Did the Pitt data comment on age? How much decadron for an 80yo? 80yo w/diabetes?

3. Blade are you seeing 24h for infraclavicular block with decadron? I thought you said before that a plain ICB gets you only 8h

 

[ANSER]

Hi

Do you have the reference for this one? I would like to read the whole article.

Thanks

Our group recently showed 50% neuronal cytotoxicity in nondiabetic cultured primary sensory neurons after 24-hour exposure to 0.25% ropivacaine, whereas clinically relevant concentrations of clonidine, buprenorphine, dexamethasone, and midazolam were nontoxic.7 As such, we feel that the investigation into the use of these perineural adjuvants should continue, especially within the framework of the ZDF model. The studies in this issue of Regional Anesthesia and Pain Medicine even suggest that dexamethasone is now a viable perineural adjuvant to study in DM because acute tissue hyperglycemia does not appear to influence neurotoxicity sequelae in primary sensory neurons in vitro and does not appear to influence crude long-term sensorimotor outcomes in vivo.
Buoyed by our report that clonidine, buprenorphine, and dexamethasone are nontoxic in cultured neurons,7 we created a clinical pathway at the Veterans Affairs Pittsburgh Medical Center involving the routine use of these perineural adjuvants with bupivacaine for single-injection regional anesthesia. The plan, which included the off-label perineural use of clonidine, buprenorphine, and dexamethasone, was presented to and approved by the hospital’s Medical Executive Board before proceeding. Bupivacaine concentrations and analgesic adjuvant doses, as they differed for diabetic and nondiabetic in our clinical pathway, are presented in Tables 1 and 2. We analyzed quality improvement (QI) data for 101 lower-extremity joint replacement patients thus far (not intended to be interpreted as peer reviewed). Our mean nerve block “durations of meaningful patient analgesia” have been 41 hours (95% confidence interval, 36–46 hours) for diabetic patients and 38 (34–41 hours) for nondiabetic patients. If we include all regional anesthesia patients, there have been QI data entered for a total of 275 patients as of this writing, and there have been no peripheral nerve complications to date with respect to multimodal perineural analgesia.

Table 1
Image Tools
Table 2
Image Tools
There seems to be very promising reasons to continue to explore the coadministration of perineural adjuvants in combination with lower-concentration local anesthetics, even if local anesthetic toxicity risk with conventional concentrations is “only minimally worsened” by DM in current translational research. A recent review of peripheral nerve block complications suggests an incidence of 0.05%, or 1:20008; this does not appear to have changed over the past decade, despite the increasing use of ultrasound guidance and reduced local anesthetic volumes and concentrations.9 Others suggest that perineural complication rates for diabetic patients are 10 times greater than that for nondiabetic patients.10 Our specialty’s diligence in the area of malignant hyperthermia has led to a remarkable small incidence, estimated to be 1:100,000.11 Can we not reach similar numbers with peripheral nerve block complications?
Clearly, continuing to allocate scarce research resources only to the study of local anesthetics in diabetic rat nerve block models appears to be somewhat wasteful, unless these studies actively adopt treatments that involve perineural analgesic adjuvants in an effort to significantly reduce (for surgical anesthesia) or eliminate (for perineural analgesia) local anesthetic use.


Ibinson, James W. MD, PhD; Mangione, Michael P. MD; Williams, Brian A. MD, MBA

 

[BLADEMDA]

Hi

Do you have the reference for this one? I would like to read the whole article.

Thanks

Editorial section of this Montth's Regional Anesthesia and Pain Medicine Journal


http://journals.lww.com/rapm/Citati...etics_in_Diabetic_Rats__and_Patients__.4.aspx

 

[BLADEMDA]

1. Can anyone comment on decadrons effect on block density? Has anyone tried ropiv 0.2% or bupiv 0.1% with decadron? I suspect it makes more motor block (which really only matters for TKA)

2. Did the Pitt data comment on age? How much decadron for an 80yo? 80yo w/diabetes?

3. Blade are you seeing 24h for infraclavicular block with decadron? I thought you said before that a plain ICB gets you only 8h

Perhaps a resident at Pittsburgh can provide more input. The editorial mentioned they were using dilute local solutions with their cocktail and still getting 30 plus hours of analgesia.

I'm getting 24 hrs with 0.5 percent Bup and Decadron for infraclavicular nerve blocks. I wouldn't hesitate to use 30 mls of Bup with decadron to reliably get 24 hrs of solid post op pain relief (ICB)

 

[Mman]

If we include all regional anesthesia patients, there have been QI data entered for a total of 275 patients as of this writing, and there have been no peripheral nerve complications to date with respect to multimodal perineural analgesia.

I commend their work, but a sample size of 275 patients isn't enough to make a determination of the relative safety when your expected safety profile is so high.

 

[BLADEMDA]

I commend their work, but a sample size of 275 patients isn't enough to make a determination of the relative safety when your expected safety profile is so high.

By the time we are discussing this topic they are likely over 400. In a year they should be at over 1,000. At some point you may feel comfortable with their data. For you that may mean 2 years from now. For me the evidence from bench research, early clinical data and my own experience is that low dose decadron (2mg) is safe in diabetics.

 

[dhb]

3. Blade are you seeing 24h for infraclavicular block with decadron? I thought you said before that a plain ICB gets you only 8h

I was using ropivacaine in the past and i would only get 24h+ for popliteal blocks. did a couple of femorals with bupivacaine the other day and got more than 24h.

 

[Mman]

By the time we are discussing this topic they are likely over 400. In a year they should be at over 1,000. At some point you may feel comfortable with their data. For you that may mean 2 years from now. For me the evidence from bench research, early clinical data and my own experience is that low dose decadron (2mg) is safe in diabetics.

I'm not making a statement one way or the other. Everybody can decide for themselves what level of safety is important to their patients. Peripheral nerve blocks have complication rates somewhere in the neighborhood of 1-2% depending on how you measure and your definition. For a study to have an 80% power of detecting a 50% increase in relative risk of a nerve injury, you likely need thousands and thousands of patients (perhaps 10s of thousands I'm too lazy to do the exact math).

I hope we see far more patients in trials like this with detailed followup so we can have more exact data. I'm just pointing out that it's pointless for someone to see a few hundred patients not have an injury (how detailed was their followup) and say it's safe. I could probably dip my needle in a patient's saliva and not prep their skin prior to doing a block and have several hundred with no complications. Doesn't mean I plan on doing it for all my patients in the future.

The safety data at this point is inconclusive at best.

 

[BLADEMDA]

I'm not making a statement one way or the other. Everybody can decide for themselves what level of safety is important to their patients. Peripheral nerve blocks have complication rates somewhere in the neighborhood of 1-2% depending on how you measure and your definition. For a study to have an 80% power of detecting a 50% increase in relative risk of a nerve injury, you likely need thousands and thousands of patients (perhaps 10s of thousands I'm too lazy to do the exact math).

I hope we see far more patients in trials like this with detailed followup so we can have more exact data. I'm just pointing out that it's pointless for someone to see a few hundred patients not have an injury (how detailed was their followup) and say it's safe. I could probably dip my needle in a patient's saliva and not prep their skin prior to doing a block and have several hundred with no complications. Doesn't mean I plan on doing it for all my patients in the future.

The safety data at this point is inconclusive at best.

Bench research on Diabetic induced Rats shows Decadron is safe when injected around nerves. In fact, decadron is safer than the local anesthetic itself. IMHO, Decadron is safer for long standing diabetic patients as an adjuvant than Epi which is still used daily thousands of times every day.

I respect your decision to stay the course and not change your practice to include dexamethasone even though I disagree and will be adding Dexamethasone (2 mg) when appropriate to my local anesthetics for Diabetic patients.

 

[BLADEMDA]

"Our group recently showed 50% neuronal cytotoxicity in nondiabetic cultured primary sensory neurons after 24-hour exposure to 0.25% ropivacaine, whereas clinically relevant concentrations of clonidine, buprenorphine, dexamethasone, and midazolam were nontoxic."

 

[ANSER]

One quick additional question

Is everyone using PF decadron ONLY or is non PF acceptable? I cannot find anywhere that shows a risk with Non PF yet all the studies seem to use PF.

 

[BLADEMDA]

One quick additional question

Is everyone using PF decadron ONLY or is non PF acceptable? I cannot find anywhere that shows a risk with Non PF yet all the studies seem to use PF.

If you use really low dose decadron 2-4 mg then I doubt the small amount of preservative causes you any problems clinically.

 

[BLADEMDA]

One quick additional question

Is everyone using PF decadron ONLY or is non PF acceptable? I cannot find anywhere that shows a risk with Non PF yet all the studies seem to use PF.

Each ml of regular decadron contains 10 mg of alcohol. As you know alcohol can injure a nerve so I would not use preservative based decadron for any individual small nerve blocks like axillary or distal nerves.

 

[BLADEMDA]

Dexamethasone Sodium Phosphate Injection, USP is a sterile solution of dexamethasone sodium phosphate in Water for Injection for intravenous (IV), intramuscular (IM), intra-articular, soft-tissue or intrale- sional use.
Each mL contains dexamethasone sodium phos- phate equivalent to dexamethasone phosphate 4 mg or dexamethasone 3.33 mg; benzyl alcohol 10 mg added as preservative; sodium citrate dihydrate 11 mg; sodium sulfite 1 mg as an antioxidant; Water for Injection q.s. Citric acid and/or sodium hydroxide may have been added for pH adjustment (7.0-8.5). Air in the container is displaced by nitrogen.

 

[BLADEMDA]

The safety of perineural adjuvants has recently been the subject of debate that centers on the potential for neurotoxicity of the adjuvant drug itself or any co-administered preservatives.16,17 Dexamethasone is not approved as a perineural adjuvant to local anesthetic by the US Food and Drug Administration or the Federal Health Department in Canada. However, the use of dexametha- sone at doses between 4 and 12 mg via the intravenous, perineural, and epidural routes is described in regional anesthesia and pain medicine textbooks.18,19 Reports of corticosteroid-mediated neurotoxicity seem to be related to the vehicle polyethylene glycol and the preservative benzyl alcohol in steroid preparations as well as the presence of insoluble steroid particulate matter in the injectate.20,21 In vivo and in vitro animal studies have dem- onstrated that locally applied corticosteroids have no long-term effect on the structure, electrical properties, or function of pe- ripheral nerves22and that the extrafascicular and intrafascicular injection of dexamethasone in a rat sciatic nerve experimental model caused no or minimal peripheral nerve damage, respec- tively, when compared with other steroids such as hydrocortisone or triamcinolone.23 Although our results suggest similar rates of postoperative neurologic symptoms between groups, the present study was not powered to evaluate safety.

 

[BLADEMDA]

http://www.cairnsanaes.org/page11/files/Parrington.pdf

They used decadron with preservative.


The decadron from app comes in preservative and preservative free bottles. The single dose 10 mg/ml vial Is prservative free and the one mostly highly recommended by the data.

I probably wouldn't use the preservative based stuff in diabetics but I would use it sparingly in non diabetics.

If you can get the 4 mg/ ml version then inquire about the single dose 10 mg/ml preservative free version.

 

[ANSER]

thank you!

 

[excalibur]

Anyone using PF decadron for TAP blocks? Just curious

 

[ANSER]

Yes

I put in 4mg and from my totally unscientific observations the blocks last a bit longer. I get about 24 hours of relief with Taps even on rad. prostates.

Anyone using PF decadron for TAP blocks? Just curious

 

[Mman]

Bench research on Diabetic induced Rats shows Decadron is safe when injected around nerves. In fact, decadron is safer than the local anesthetic itself. IMHO, Decadron is safer for long standing diabetic patients as an adjuvant than Epi which is still used daily thousands of times every day.

I respect your decision to stay the course and not change your practice to include dexamethasone even though I disagree and will be adding Dexamethasone (2 mg) when appropriate to my local anesthetics for Diabetic patients.

I haven't mentioned what I'm doing in relation to this topic. Just pointing out that the safety data from the clinical trials is not adequate to make a statement that it is safe. I'm also aware of the lab data.

 

[BLADEMDA]

I haven't mentioned what I'm doing in relation to this topic. Just pointing out that the safety data from the clinical trials is not adequate to make a statement that it is safe. I'm also aware of the lab data.

Fine. Do as you please at work. I use PF decadron in my practice and have personally administered over 150 nerve blocks with decadron plus local. My results so far are excellent with no reports of excessively prolonged nerve blocks or significant nerve injury.

I'll continue with this practice and have started including diabetic patients (2 mg dose)
I suspect in about a year I'll have 500-600 more patients to report about.

 

[Mman]

Fine. Do as you please at work. I use PF decadron in my practice and have personally administered over 150 nerve blocks with decadron plus local. My results so far are excellent with no reports of excessively prolonged nerve blocks or significant nerve injury.

I'll continue with this practice and have started including diabetic patients (2 mg dose)
I suspect in about a year I'll have 500-600 more patients to report about.

That is excellent. Just out of curious, what sort of followup do you have with your patients? Anything beyond 1-2 days out? IMHO anesthesiology as a specialty is terrible overall at seeing longterm outcomes of our care. The longer and longer people get a block to last for, the more diligent they must be in followup.

 

[excalibur]

UPDATE

Yesterday I did an USG interscalene block with nerve stimulator attached for rotator cuff repair. 30 mL PF Bupi 0.5% plain + PF Dexamethasone 4 mg. Loss of twitch at 0.44 mAmps. Block in at 0730. Block time was 4 minutes.

F/u call today. Pt reveals that she regained sensation at 1030 this AM. 27 hour block. Pt reveals at 1030 this AM pain went from 0 to 8/10 despite her taking pain pills yesterday afternoon and night plus one this morning in anticipation of the block receding. Pt slept soundly through the night and very satisfied.

This time length was far better than my ropivacaine with Decadron block which only lasted about 16 hours and patient said he slept like crap due to pain and ge was inpatient.

So Bupi plus Decadron was 27 hrs for me. N = 1. Will try and keep up with data and update on the site.

 

[BLADEMDA]

UPDATE

Yesterday I did an USG interscalene block with nerve stimulator attached for rotator cuff repair. 30 mL PF Bupi 0.5% plain + PF Dexamethasone 4 mg. Loss of twitch at 0.44 mAmps. Block in at 0730. Block time was 4 minutes.

F/u call today. Pt reveals that she regained sensation at 1030 this AM. 27 hour block. Pt reveals at 1030 this AM pain went from 0 to 8/10 despite her taking pain pills yesterday afternoon and night plus one this morning in anticipation of the block receding. Pt slept soundly through the night and very satisfied.

This time length was far better than my ropivacaine with Decadron block which only lasted about 16 hours and patient said he slept like crap due to pain and ge was inpatient.

So Bupi plus Decadron was 27 hrs for me. N = 1. Will try and keep up with data and update on the site.

That's my typical duration for an interscalene block with 0.5 percent Bup and 4 mg of decadron: 27-28 hours. I use u/s wth nerve stimulator these days so my volume is 20 mls but block duration is still preserved at 27-28 hours. I've never had a block last less than 22 hours using these meds and my longest block was 47 hours.

 

[excalibur]

Thanks, Blade. Just trying to post data to reinforce your findings along with the regional/pain journal articles. Consider the above data you residents in training. In my training nothing was worse than a perfect block placed at 0700 with the patient being all smiles only to find out at 0700 the next day that the patient reports the block wore off at midnight and he hasn't slept all night. What was the point, then I thought?

I feel that it is crucial to get your block patients to make it through the night without pain for patient satisfaction. This means 24 hr + blocks for 1st start cases. So for me this means bupi + Decadron.

Also a quick side note on US which has been discussed before. For some reason I have found many people in medicine resistant to change even when new technology comes out for the simple reason that "I have done it the old way for years without any problems, why should I change?".

A simple fact with Ultrasound. YOU SEE THE TARGET!! Sure anatomical knowledge and references are crucial, but my gosh after 15 seconds with the US you SEE the target! There is no if you get diaphragm contractions, withdraw needle and re-angle 15 degrees deeper. No if you get blood, withdraw needle and flush. In 15 seconds with US, it's the target is there, get the needle there

 

[h2oriderz]

I will never forget the first time I used decadron in one of my blocks. Young guy for an ankle case. I did an ultrasound guided distal sciatic block with 0.5% ropiv with 4mg of decadron and it lasted 46hrs. I had been an attending for maybe a month and I thought I was headed to court. By the second day I was calling the patient hoping he was going to be in pain - as sad as that sounds. I was relieved to hear that he was by the 46hr mark. I respect decadron in our PNB's and I use it almost every time I perform a single shot technique. The results have been overwhelming and I'm glad to see that there is new data to support it.

 

[excalibur]

I will never forget the first time I used decadron in one of my blocks. Young guy for an ankle case. I did an ultrasound guided distal sciatic block with 0.5% ropiv with 4mg of decadron and it lasted 46hrs. I had been an attending for maybe a month and I thought I was headed to court. By the second day I was calling the patient hoping he was going to be in pain - as sad as that sounds. I was relieved to hear that he was by the 46hr mark. I respect decadron in our PNB's and I use it almost every time I perform a single shot technique. The results have been overwhelming and I'm glad to see that there is new data to support it.

Was that a 46 hr motor block? Have you continued to have 40+ hr blocks and if so, how frequently? Have those 40+ hour blocks been more so with sciatics or do you think the block you do doesn't matter?

Hey Blade, I have read your previous posts on your Decadron data and I know u also have gotten an occasional 40+ hour block. How often do you, Blade, get 40+ hr Blocks on your interscalenes? Are those 40+ hr motor blocks? Do you get 40+ hr blocks on other PNB's?

 

[BLADEMDA]

Was that a 46 hr motor block? Have you continued to have 40+ hr blocks and if so, how frequently? Have those 40+ hour blocks been more so with sciatics or do you think the block you do doesn't matter?

Hey Blade, I have read your previous posts on your Decadron data and I know u also have gotten an occasional 40+ hour block. How often do you, Blade, get 40+ hr Blocks on your interscalenes? Are those 40+ hr motor blocks? Do you get 40+ hr blocks on other PNB's?

Let's have a frank discussion here. I know a big, bad ass Regional guy who does tons of videos online (most of you have seen one). He reports that Decadron when added as an adjunct at the axillary level or distal block sites may prolong the sensory analgesia for days. I had a discussion with him personally about his experiences and we agreed avoiding Decadron for blocks at the axillary level and below (for upper extremity) seemed like a wise idea at this juncture. I suspect he was using regular Decadron with an alcohol preservative and that the Alcohol acted as a destructive agent to the nerve. That said, I don't add Decadron to the local for my distal nerve blocks.

I have been utilizing Decadron for ISB, SCB, ICB, TAP, Subcostal TAP, Popliteal and Paravertebral blocks without any issues. I avoid Decadron in my Axillary, selective individual distal and ankle blocks. Again, if you are utilizing preservative free decadron at a low dose (2 mg) the decradron is probably safe as an adjunct but I'm a bit hesitant right now.

I'm finding my motor block with 0.5% Bup plus PF Decadron 4-5 mg lasts about 20 hours until the patients report use of their hand and fingers. The additional analgesia of 7-20 hrs is sensory in nature only.

My typical ISB with 0.5% Bup plus PF decadron 4-5 mg (20-24 ml total volume) lasts 27-30 hrs before patients start complaining of pain requiring medication.

 

[PinchandBurn]

most of us pain providers routinely use local + depomedrol . Provides longer relief than dexameth

 

[excalibur]

Great stuff, Blade. How often u see the 40 hour sensory block with your ISB?

 

[ketap]

hi, interesting..is there any reason why dexamethason can prolong the duration of action of bupivacaine? thx u 🙂
best regards,Ketap

 

[pgg]

I suspect he was using regular Decadron with an alcohol preservative and that the Alcohol acted as a destructive agent to the nerve. That said, I don't add Decadron to the local for my distal nerve blocks.

The group before us here was using PF clonidine + Decadron from multi-dose vials as their single shot adjuncts. (Also, all blocks were done under GA with u/s.) I'd have to check the log book again but I'd guess ~50-75 blocks done that way, with no reported complications. 100% young healthy population, no diabetics.

Back home, I quit adding Decadron to my blocks when the pharmacy switched from a PF to non-PF formulation. Until the local pharmacy can get some PF stuff, I'm not going to use it. Which is too bad - femoral block yesterday wore off after 18 hrs, at 2 AM.

 

[Mr Wizard]

Does anyone know if there are any ongoing studies evaluating dexmedetomidine vs clonidine as a PNB adjunct?

Came across this study from the Indian Journal of Anesthesia. Granted, it is not one of the most widely cited journals, I still find this interesting since it seems to be problematic to get some hospital pharmacies to stock the PF decadron. On a cost basis, PF dexamethasone is the way to go. If we can't get the PF version, I might consider testing this out to help get my blocks to work through the night.

Comparison of dexmedetomidine and clonidine (α2 agonist drugs) as an adjuvant to local anaesthesia in supraclavicular brachial plexus block: A randomised double-blind prospective study
Sarita S Swami, Varshali M Keniya, Sushma D Ladi, and Ruchika Rao

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425283/

 

[desflurane]

Feel the need to weigh in here. I'm a Regional/Acute Pain guy and I know some of the heavy-hitters in the field very well. Yes, you can prolong the block with adjuvants. There is no question about that. There is a lot of solid data showing that adding PF Dex to any PNB you prolong the duration of action of LA in a significant way. That being said, we rarely, if EVER do that. Why? Catheters are a far superior method of analgesic titration. Single injections rely purely on the dose-response of whatever you are putting in. Sometimes you get lucky and "goldilocks" it and everyone is happy.

Quick example, for our rotator cuff repairs, many patients on 24 hours follow-up want their catheter out because of the motor block. We turn it off, and 75% want it back on. There is just much higher patient satisfaction that way. Catheters definitely require more work and skill and see the benefits of a "setting it and forgetting it" but I just don't think its the way to go. There is a place for long acting single-injections (TAP etc), I just don't think it belongs anywhere you need long-term control.

My two cents.

 

[excalibur]

The group before us here was using PF clonidine + Decadron from multi-dose vials as their single shot adjuncts. (Also, all blocks were done under GA with u/s.) I'd have to check the log book again but I'd guess ~50-75 blocks done that way, with no reported complications. 100% young healthy population, no diabetics.

Back home, I quit adding Decadron to my blocks when the pharmacy switched from a PF to non-PF formulation. Until the local pharmacy can get some PF stuff, I'm not going to use it. Which is too bad - femoral block yesterday wore off after 18 hrs, at 2 AM.

Can't you just ask the pharmacy to order PF decadron? That's what I did. I gave them the ID number (or whatever you call it) of the drug I wanted, and they ordered it. was in stock in 2 days. I have my reserved stash of it just for the blocks in the pharmacy

 

[excalibur]

Feel the need to weigh in here. I'm a Regional/Acute Pain guy and I know some of the heavy-hitters in the field very well. Yes, you can prolong the block with adjuvants. There is no question about that. There is a lot of solid data showing that adding PF Dex to any PNB you prolong the duration of action of LA in a significant way. That being said, we rarely, if EVER do that. Why? Catheters are a far superior method of analgesic titration. Single injections rely purely on the dose-response of whatever you are putting in. Sometimes you get lucky and "goldilocks" it and everyone is happy.

Quick example, for our rotator cuff repairs, many patients on 24 hours follow-up want their catheter out because of the motor block. We turn it off, and 75% want it back on. There is just much higher patient satisfaction that way. Catheters definitely require more work and skill and see the benefits of a "setting it and forgetting it" but I just don't think its the way to go. There is a place for long acting single-injections (TAP etc), I just don't think it belongs anywhere you need long-term control.

My two cents.

I agree with you on the catheters, that they are a better approach to treating the pain. The problem is that my practice doesn't use catheters. So dexamethasone is a much better option than straight local. I also feel that once exaprel gets approved for PNB, that catheters are going to go bye bye.

 

[BLADEMDA]

Feel the need to weigh in here. I'm a Regional/Acute Pain guy and I know some of the heavy-hitters in the field very well. Yes, you can prolong the block with adjuvants. There is no question about that. There is a lot of solid data showing that adding PF Dex to any PNB you prolong the duration of action of LA in a significant way. That being said, we rarely, if EVER do that. Why? Catheters are a far superior method of analgesic titration. Single injections rely purely on the dose-response of whatever you are putting in. Sometimes you get lucky and "goldilocks" it and everyone is happy.

Quick example, for our rotator cuff repairs, many patients on 24 hours follow-up want their catheter out because of the motor block. We turn it off, and 75% want it back on. There is just much higher patient satisfaction that way. Catheters definitely require more work and skill and see the benefits of a "setting it and forgetting it" but I just don't think its the way to go. There is a place for long acting single-injections (TAP etc), I just don't think it belongs anywhere you need long-term control.

My two cents.

My patient satisfaction is high with nerve blocks lasting over 24 hours. Could it be higher with a catheter? maybe. I prefer the single shot blocks for speed, success and convenience. For those patients who have extremely low pain tolerance or "allergy" to narcotics I'll place a catheter and pump. In my experience, I don't think a catheter is necessary and I wouldn't request one for myself or a family member unless the procedure was a total joint replacement.

I can see an ACL repair being the one procedure where you may want a catheter but again I'd go with a long acting single shot block for myself (Femoral plus Popliteal)

 

[emd123]

We do this in the Pain world all the time.

Add steroids and your block works way, way longer than with just local alone.

(Usually with a particulate though, like PinchandBurn said, i.e., kenalog, Depo-medrol, celestone, etc)

 

[fakin' the funk]

Quick example, for our rotator cuff repairs, many patients on 24 hours follow-up want their catheter out because of the motor block. We turn it off, and 75% want it back on.

1) This ain't Burger King!

2) Not every group/hospital/university has the staff to trot out a physician to adjust, turn on, or turn off, every catheter out there. I admire your titratability but that's just f'in ridiculous. I hope you're getting paid straight cash for this concierge medicine.

 

[pgg]

Can't you just ask the pharmacy to order PF decadron? That's what I did. I gave them the ID number (or whatever you call it) of the drug I wanted, and they ordered it. was in stock in 2 days. I have my reserved stash of it just for the blocks in the pharmacy

Filled out the forms this morning.

There are some logistic hurdles at my current location. We'll see.

 

[desflurane]

1) This ain't Burger King!

2) Not every group/hospital/university has the staff to trot out a physician to adjust, turn on, or turn off, every catheter out there. I admire your titratability but that's just f'in ridiculous. I hope you're getting paid straight cash for this concierge medicine.

Trust me, I want there to be a better alternative to catheters. We only do them because there isn't. We don't adjust the infusions manually, we take 15 minutes before they leave the hospital/asc and explain how the pump works to them and a caretaker. We follow up over the phone and have them come in if they can't. It's not concierge medicine, its acute pain management.

Exparel may or may not be the answer, the same argument against dex applies...one its in its in, including all the badness. Just don't want that stuff going intravascular. Lipid emulsion and lipid reuse seem incompatible to me. Just sayin.

I just think all the excitement over dex needs a little perspective is all. Most of the nerds that I know in regional have concluded that for most blocks you get the same effect giving it IV. Thats what they do. I like catheters.