Single Shot Nerve Blocks which last over 24 hours

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emd123 said:
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)
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Any articles or evidence comparing steroids with local and duration of block/analgesia?
Any personal experience using depomedrol vs decadron vs Kenalog?
 
ORIF for lateral malleolus fracture on 45 y/o healthy nondiabetic patient. Performed USG femoral nerve block (20 mL of Bupi 0.5% with 2 mg PF decadron) followed by an USG distal sciatic block from the lateral approach in the supine position (25 mL of Bupi 0.5% with 2 mg PF decadron). After blocks pt received LMA for the case.

Blocks placed Monday at 1200. On f/u pt reported return of sensation on Wednesday at 0600 for a 42 hr block. She stated the pain woke her up at 0600 on Wednesday and it was an 8/10. She states that the entire time she was numb she had a motor block as well. Although it is possible that the motor block dissipated during the night when she was asleep but still received analgesia until 0600.

Pt states that she loved it, and she was really glad she did it.

I went with small dose of Dexamethasone for the sciatic block as it is distal nerve and reports of prolonged block on SDN. However, I feel 40+ hours of analgesia from a 7-8 min procedure is fantastic.
 
excalibur said:
ORIF for lateral malleolus fracture on 45 y/o healthy nondiabetic patient. Performed USG femoral nerve block (20 mL of Bupi 0.5% with 2 mg PF decadron) followed by an USG distal sciatic block from the lateral approach in the supine position (25 mL of Bupi 0.5% with 2 mg PF decadron). After blocks pt received LMA for the case.

Blocks placed Monday at 1200. On f/u pt reported return of sensation on Wednesday at 0600 for a 42 hr block. She stated the pain woke her up at 0600 on Wednesday and it was an 8/10. She states that the entire time she was numb she had a motor block as well. Although it is possible that the motor block dissipated during the night when she was asleep but still received analgesia until 0600.

Pt states that she loved it, and she was really glad she did it.

I went with small dose of Dexamethasone for the sciatic block as it is distal nerve and reports of prolonged block on SDN. However, I feel 40+ hours of analgesia from a 7-8 min procedure is fantastic.
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I do popliteal and adductor canal (saphenous) nerve blocks for ankle fractures. They work great. I use 8-10 mls of local with 2 mg of decadron for the adductor canal. For the popliteal I use local 20-25 mls with 4 of decadron. My patients are quite happy
 
BLADEMDA said:
I do popliteal and adductor canal (saphenous) nerve blocks for ankle fractures. They work great. I use 8-10 mls of local with 2 mg of decadron for the adductor canal. For the popliteal I use local 20-25 mls with 4 of decadron. My patients are quite happy
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I know you said you get 27-30 hrs with ISB Bupi with 4 mg Decadron.

Are you seeing longer sciatic/popliteal blocks (40 hr) with same solution?

You have any personal time references for sciatics with ropi+decadron vs bupi+decadron? I am just wondering if 42 hrs is "too" long. My pt likely had at least a 36 hr motor block. Again wondering if that is too long. Was wondering some ropi+decadron times on sciatic as something like a 30-36 hr sensory block could be ideal in many scenarios.

Other point of view is that my patient really didn't need any immediate physical rehab and she loved the fact that she was pain free to POD 2. She was also ecstatic because she required no narcotics in PACU. She expressed how her last ortho procedure required demerol and other narcs for postop pain control which left her quite nauseous and throwing up. In looking at things, 40 hrs of 0 pain is a good thing even if you can't move your extremity.
 
Okay what I am I missing here? Can someone explain why you would place a Fem block, or even an adductor canal block for a lateral mal Fx? If there is no medial work being done then you shouldn't need any saphenous coverage. To me your just giving someone a whole lot of unnecessary motor block with 0 benefit and even setting them up for a potential postion related nerve injury at home since they have a completely dead leg. Popliteal is favorable as well over the sciatic, why knock out the hamstrings if you don't have to?
 
I have done distal sciatics ONLY for lateral malleolar fractures before and pts have woken up complaining of ankle pain and they point right at their medial malleolus. It hurts right here doc.Could be associated with edema in the joint. Think also why ACL repairs get posterior knee pain when the incision is in femoral distribution. This posterior knee pain can occur whether or not ortho uses a hamstring graft. The mechansism is thought to be related to edema.

I considered doing just a saphenous nerve block to cover medial malleolus by doing a perivascular injection around great saphenous vein around mid calf with USG. However, I have never done that before, and she had a cast that went up to mid calf so I went with what I knew--the femoral nerve block. The patient needs no physical therapy, and she receives instruction not to walk, and to get up and use crutches only with assistance.

A distal sciatic from the lateral approach under USG is performed at the same level as a popliteal block. A popliteal block is done 7-8 cm above popliteal crease. USG sciatic block with lateral approach is done ...7-8 cm from popliteal creas. You just come from the later side instead of posterior leg. Alos with USG you perform the block at the level when you visually see the sciatic just prior to the divide into common peroneal and tibial nerve. Furthermore with USG, you can surround the nerve with local. This is difficult to do with a classic anatomical approach as once you get twitches you inject all your local, so you might have injected 20 mLs lateral, medial, or superficial to the nerve, and as a result you might just get one component of the sicatic
 
Well I still think a fem block for referred medial mal pain after lateral mal ORIF is using a sledgehammer to kill a fly. I'm totally on board for the adductor canal block in this situation however.

We are talking about the same block when I say popliteal and you say distal sciatic. I use U/S and block right at the sciatic bifurcation into the tibial and peroneal. I also come in from the lateral side. I do most w/ the pt prone, especially if I'm doing a catheter for sterile field reasons, but have done them lateral and supine as well.
 
SaltyDog said:
Well I still think a fem block for referred medial mal pain after lateral mal ORIF is using a sledgehammer to kill a fly. I'm totally on board for the adductor canal block in this situation however.

We are talking about the same block when I say popliteal and you say distal sciatic. I use U/S and block right at the sciatic bifurcation into the tibial and peroneal. I also come in from the lateral side. I do most w/ the pt prone, especially if I'm doing a catheter for sterile field reasons, but have done them lateral and supine as well.
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I agree with you. I wanted to just do saphenous nerve block. I have never done one. I was going to go up medial malleolus and inject around the great saphenous vein. When I couldn't do that, I just did a femoral nerve block. Maybe I look up how to do a saphenous nerve block at the level of the knee.
 
once exparel gets approved for PNBs none of this will matter.
single shot up to 72 hours.
 
excalibur said:
I agree with you. I wanted to just do saphenous nerve block. I have never done one. I was going to go up medial malleolus and inject around the great saphenous vein. When I couldn't do that, I just did a femoral nerve block. Maybe I look up how to do a saphenous nerve block at the level of the knee.
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I learnerd all my u/s blocks on the job and from courses/conferences/videos. I never did an u/s guided block until late 2010. Now, I do all my blocks under u/s and recommend it as the standard of care.

An adductor canal block is an easy u/s block.

You must learn to adapt and pick up new things after Residency. The field is always changing so staying current with your skill set matters a lot.

By the way my patients and I are very happy with 40 hour blocks after surgery. If they are older people the block is more likely to exceed 30 hours. Young healthy patients usually get 24-27 hours out of 0.5% Bup with Decadron. My older patients get longer blocks so I do cut back to 0.25% Bup with Decadron when appropriate to decrease the motor portion of the block. Duration of analgesia is still in excess of 24 hours provided decadron is added.
 
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SaltyDog said:
Okay what I am I missing here? Can someone explain why you would place a Fem block, or even an adductor canal block for a lateral mal Fx? If there is no medial work being done then you shouldn't need any saphenous coverage. To me your just giving someone a whole lot of unnecessary motor block with 0 benefit and even setting them up for a potential postion related nerve injury at home since they have a completely dead leg. Popliteal is favorable as well over the sciatic, why knock out the hamstrings if you don't have to?
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Completely agree here. It's nice to see a patient completely pain free but the cost of quad weakness is way too high. If the patient fell at home I couldn't defend you in court. I'm not sure it's clear why but yes the saphenous distribution can hurt even if the operation is all lateral. Either block the femoral n mid thigh or below or not at all. Multimodal works quite well too.

Way too early to call Exparel the silver bullet IMHO. Prelim stuff looks promising for epidurals though. Like I mentioned before, 72 hrs of effect also has the potential of 72 hours of side effect.
 
desflurane said:
Completely agree here. It's nice to see a patient completely pain free but the cost of quad weakness is way too high. If the patient fell at home I couldn't defend you in court. I'm not sure it's clear why but yes the saphenous distribution can hurt even if the operation is all lateral. Either block the femoral n mid thigh or below or not at all. Multimodal works quite well too.

Way too early to call Exparel the silver bullet IMHO. Prelim stuff looks promising for epidurals though. Like I mentioned before, 72 hrs of effect also has the potential of 72 hours of side effect.
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I have found even when all the instrumentation or operation is confined to the lateral malleolus/lateral ankle the patient may still complain of pain despite a good popliteal block. Hence, I've added the adductor canal block to my routine and now all patients are pain free after surgery.

The other thing I have found is that one bottle of local ( 30 ml) with decadron added is all you need to do both blocks. I also reuse the needle for both blocks.
 
I read previous posts and threads on adductor canal blocks. Thanks. Good stuff.

I was looking up stuff on USG ankle blocks. US is used to block each of the 5 nerves. This is where i saw that the saphenous nerve can be blocked at the high ankle/low calf level. At the medial malleolus the great saphenous vein is located and then traced cephalad. Block is done at high ankle or low calf just because there is less bony tissue there making for easier needle course. It seems that local is just dumped circumferentially around the saphenous vein about 5-10 mL. Typically nerve is in 5 o'clock position to the vein but can be difficult to see.

Has anyone tried this? This is what I initially was trying to do and wanted to see if anyone got good results with it. I did not know about adductor canal block, but now I do. Thanks, SDN.
 
excalibur said:
I read previous posts and threads on adductor canal blocks. Thanks. Good stuff.

I was looking up stuff on USG ankle blocks. US is used to block each of the 5 nerves. This is where i saw that the saphenous nerve can be blocked at the high ankle/low calf level. At the medial malleolus the great saphenous vein is located and then traced cephalad. Block is done at high ankle or low calf just because there is less bony tissue there making for easier needle course. It seems that local is just dumped circumferentially around the saphenous vein about 5-10 mL. Typically nerve is in 5 o'clock position to the vein but can be difficult to see.

Has anyone tried this? This is what I initially was trying to do and wanted to see if anyone got good results with it. I did not know about adductor canal block, but now I do. Thanks, SDN.
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The adductor canal block is easier than your saphenous approach at the ankle/calf. I simply deposit local around the artery in the mid thigh region. I can sometimes see the saphenous nerve but if not i deposit 5 mls near the top and bottom of the artery. Total 10 mls. So far 100 percent success with zero complications.

Do a scan of the mid thigh region. Look for the artery under the sartorious muscle. Remember to look for venous structures as well near the artery. I usually do a quick scan using PDI for blood flow. Then simply place a needle perpendicular to the skin towards the artery under the sartorious muscle.

Why reinvent the wheel? Adductor canal is pretty darn simple and effective.

http://m.youtube.com/watch?v=EKVVNzd4OEI&feature=related#/watch?v=EKVVNzd4OEI&feature=related

http://m.youtube.com/#/watch?v=bsUlZLghnpU&desktop_uri=/watch?v=bsUlZLghnpU
 
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Because of the proximity of the saphenous nerve to the femoral artery, there is an inherent risk of vascular puncture when advancing the needle tip toward to the nerve. Patients with failed or partially effective saphenous nerve blocks will often report postoperative pain localized to the medial ankle, even if the surgical procedure on the lower extremity did not involve a surgical incision on the medial leg. For this reason, many believe that the innervation of the saphenous nerve includes not only cutaneous branches but also articular branches to the ankle joint and related structures deep to the skin. The clinical observation is that the addition of a saphenous nerve block to the sciatic nerve block as a rescue after ankle surgery has a surprising effect that is difficult to justify by the cutaneous distribution alone. It is theoretically possible to place the needle tip through or into one or more nerve branches during saphenous nerve block in the mid-thigh.
Although nerves to the vastus medialis muscle lie within the subsartorial plane, studies have found no measurable motor block from saphenous nerve blocks performed in this location.16-18 Arecentcaseseriesinvestigatingthecontinuous saphenous nerve block after total knee arthroplasty (TKA) showed no clinically-apparent motor blockade while weight-bearing.17


Feb 2012 ASRA newsletter
 
I'm gonna have to try that technique. I have been doing my saphenous blocks for ankle surgery at the level of the tibial tuberosity, which has always worked fine for me. (See NYSORA site- http://www.nysora.com/peripheral_ne...ock_tecniques/3080-saphenous_nerve_block.html)

But since the u/s guided adductor canal is probably a more efficient block than mine as a targeted block vs. field block, I'm sure it lasts longer and is more reliable. Will have to give it a whirl.
 
Ultrasound imaging can be used to guide saphenous nerve block anywhere along its course, so the choice of approach is somewhat arbitrary. However, we typically do not choose the distal part of the adductor canal in order to minimize the risk of nerve puncture, paresthesia, or even nerve entrapment. This level is where the saphenous nerve is least mobile and to a variable degree fixed in the vastoadductor membrane.14 Furthermore, we have found the suggested techniques described here to be highly efficacious, safe, and robust within the broad spectrum of clinical practice.
Place the ultrasound machine on the opposite side of the bed so that the block site and display are both in front of the operator. Perform the saphenous nerve block with the sartorius muscle viewed in short axis while advancing the needle in the plane of imaging. The preferred direction is from the anterior side at the level of the mid-thigh just proximal to the take-off of the nerve and artery to the vastus medialis muscle. Because of the relatively-steep angle of insertion through the sartorius muscle an echogenic needle is typically selected with this approach.
The needle is placed through the sartorius muscle to enter the plane deep to the muscle (a trans-sartorial approach). There can be a loss-of-resistance as the needle tip crosses the vastoadductor membrane. Three to 5 mL of local anesthetic is injected within this plane, adjacent to the femoral artery. Initially the bevel of the needle faces the transducer to improve needle tip visibility.
 
Hawaiian Bruin said:
I'm gonna have to try that technique. I have been doing my saphenous blocks for ankle surgery at the level of the tibial tuberosity, which has always worked fine for me. (See NYSORA site- http://www.nysora.com/peripheral_ne...ock_tecniques/3080-saphenous_nerve_block.html)

But since the u/s guided adductor canal is probably a more efficient block than mine as a targeted block vs. field block, I'm sure it lasts longer and is more reliable. Will have to give it a whirl.
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The adductor canal is an effective, reliable and long acting nerve block under u/s. IMHO, it is a superior block to your traditional field block for the saphenous nerve
 
Some experts feel that blocking the saphenous nerve too distal in the thigh may cause entrapment of the nerve. I don't do distal thigh saphenous nerve blocks for that reason. Please take a look at this image for a disal thigh blockhttp://usra.ca/sapclinic.php

I block the nerve just a bit more proximally in the thigh. I look for the femoral artery under the sartorious muscle and the follow it distally. You want to block the nerve before the femoral artery becomes too distal and small in the thigh and the nerve moves away from the artery. This provides a safe and effective location to block the nerve not to mention an easy to perform block.

Take a look at the video link posted below and the other link which explains this in more detail

http://m.youtube.com/#/watch?v=EKVVNzd4OEI&feature=related
 
3. Nerve stimulation is rarely helpful for saphenous block (a pure sensory nerve).

4. Place probe on the medial/inner aspect of the mid thigh and locate the femoral artery (Fig. 2). Trace the artery distally to locate the point just before it starts to dive down to form the popliteal artery, which is approximately 13 cm proximal to the knee. At this location, the vastus medialis muscle lies anterolateral, the adductor magnus muscle posteromedial and the sartorius muscle medial (Fig. 3). The appropriate probe position is just proximal to where the femoral artery "dives" posteriorly. The saphenous nerve may or may not be visible posteromedial or anterolateral to the femoral artery.

5. With a 10-20 ml LA filled syringe attached directly to the Tuohy needle, advance towards the femoral artery and pierce the fascia on the inner aspect of the sartorius muscle, ideally anterolateral and posteromedial to the femoral artery. Penetration of the fascia with a Tuophy needle requires short, sharp, needle thrusts and is facilitated by orientation of the bevel towards the fascia (i.e. posteriorly).

6. Deposit 7.5-10 mL LA at these two points.





Fig. 2. Saphenous block (adductor canal). Access to the medial side of the thigh is facilitated by slight external leg rotation. A needle entry point as close as possible to the probe (i.e. as posteriorly as feasible) facilitates access to the posteromedial side of the femoral artery.
 
New article in the Br J Anaesthesia comparing IV and perineural dexamethasone: Small n but this could be helpful for those who cannot get the PF stuff to use perineural with their blocks.

Abstract
Background Interscalene brachial plexus block (ISB) provides excellent, but time-limited analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a single-shot ISB. However, systemic glucocorticoids also improve postoperative analgesia. The hypothesis was tested that perineural and i.v. dexamethasone would have an equivalent effect on prolonging analgesic duration of an ISB.
Methods We performed a prospective, double blind, randomized, placebo-controlled study. Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD); and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first analgesic request. Standard hypothesis tests (t-test, Mann–Whitney U-test) were used to compare treatment groups. The primary outcome was analysed by Kaplan–Meier survival analysis with a log-rank test and Cox's proportional hazards regression.
Results One hundred and fifty patients were included after obtaining ethical committee approval and patient informed consent. The median time of a sensory block was equivalent for perineural and i.v. dexamethasone: 1405 min (IQR 1015–1710) and 1275 min (IQR 1095–2035) for RD and RDiv, respectively. There was a significant difference between the ropivacaine group: 757 min (IQR 635–910) and the dexamethasone groups (P<0.0001).
Conclusions I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.




I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study
M. Desmet1,
 
Yes very interesting!
I have been adding Dexamethasone And Buprenorphine to Bupivacaine Interscalenes for a while now with great results (up to 30 hours analgesia).
I am now going to start giving Dexamethasone IV at the time of the block and see what happens.
 
Planktonmd said:
Yes very interesting!
I have been adding Dexamethasone And Buprenorphine to Bupivacaine Interscalenes for a while now with great results (up to 30 hours analgesia).
I am now going to start giving Dexamethasone IV at the time of the block and see what happens.
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You can get rid of the buprenorphine. Just the dexamethasone will get you 24-30 hr blocks. With most being between 26-28 hrs.

The IV dexamethsone is interesting though
 
Planktonmd said:
Yes very interesting!
I have been adding Dexamethasone And Buprenorphine to Bupivacaine Interscalenes for a while now with great results (up to 30 hours analgesia).
I am now going to start giving Dexamethasone IV at the time of the block and see what happens.
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If you bolus iv decadron to awake female patients you will be in for a world of embarrassment.
 
excalibur said:
You can get rid of the buprenorphine. Just the dexamethasone will get you 24-30 hr blocks. With most being between 26-28 hrs.

The IV dexamethsone is interesting though
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1. I give it routinely as a preop med with Midazolam. I use 4mg IV with minimal complaints/side effects (less than 1%).

2. I still recommend adding PF decadron to your local PLUS giving 4 mg IV of decadron.
Decadron is cheap, safe and effective.

3. I'm well over 700 blocks with Decadron at this point with excellent results and no complications.

4. You only need 2-4 mg of decadron to get a significant prolongation of your block.
 
Mr Wizard said:
Conclusions I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.
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I'm skeptical.

I've routinely given just about every one of my GA patients 4 mg of IV dexamethasone as an antiemetic and for its pain adjunct effects, and it hasn't prolonged my PNBs the way adding it to the local has.
 
pgg said:
I'm skeptical.

I've routinely given just about every one of my GA patients 4 mg of IV dexamethasone as an antiemetic and for its pain adjunct effects, and it hasn't prolonged my PNBs the way adding it to the local has.
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More interesting
 
pgg said:
I'm skeptical.

I've routinely given just about every one of my GA patients 4 mg of IV dexamethasone as an antiemetic and for its pain adjunct effects, and it hasn't prolonged my PNBs the way adding it to the local has.
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Agree!

I am wondering if the timing of the injection is of value here?
Do we have to give Dexamethasone at the same time we inject the local anesthetic to get the max effect?
No one knows at this point.
 
Yes I do lots of ankle blocks, US for all 5 nerves, saphenous n is adjacent to greater saphenous vein from the lower leg to the ankle and you can just inject local in the plane that contains the vein.

OTOH Usually when I do distal sciatic / popliteal blocks for foot/ankle surgery I add saphenous block in the thigh. Look for the nerve after superficial femoral artery dives deeper, consider using nerve stim on the needle to elicit distal sensory parenthesis if you can't see the nerve well. Stay more distal in the thigh to reduce your chances of motor block to some of the quadriceps muscle. You are trying to get a selective saphenous block - purely sensory, and no block of the femoral nerve with associated weakness requiring crutches and knee immobilizer.

I am not familiar with recommendations to avoid distal saphenous blocks and would like to see references.

I would like to see other studies confirming IV decadronproviding analgesia as long as peri neural.

I stopped using buprenorophine' to prolong blocks because I had a few patients with prolonged nausea.
 
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sevoflurane said:
Has anyone actually seen this reaction?
I haven't.

But I don't give it pre-op either.
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Oh I've seen it. Big time.

Yarn: I was a CA-2 working with a new grad attending. I go to preoxygenate. Attending goes to push drugs. All of a sudden the patient starts screaming at the top of her lungs (and I quote verbatim):

"CRABS CRABS OH MY GOD THERE ARE CRABS IN MY VAG CRABS CRABSzzzzzzzzzzzzzzzzzz"

and trailed off as the propofol hit her.

I asked her if she had given her decadron. Yup. She'd never heard of that reaction.

But it's real. Ohhh yes, it's real.
 
They describe it in the literature as "intense perineal itching." But make no mistake- the reaction is better described as crabs in the vag.
 
I have seen it too. Can't remember why I gave it. Most likely reason was severe PONV and I opted to give IV dexamethsone preop. This was in residency. Patient then has bizarre look on her face. She says, "I know this may sound weird, but all of a sudden I have this strange tingling sensation down...(begins pointing) there". Thankfully she wasn't screaming or anything, but yes she got the "down there pruritus".
 
BLADEMDA said:
The adductor canal block is easier than your saphenous approach at the ankle/calf. I simply deposit local around the artery in the mid thigh region. I can sometimes see the saphenous nerve but if not i deposit 5 mls near the top and bottom of the artery. Total 10 mls. So far 100 percent success with zero complications.
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The "adductor canal" block is really just the U/S-guided saphenous block that we used to do low in the thigh, only, this time it's a little higher.

Somewhere in the middle third of the thigh -- and I say somewhere because the anatomy is very variable -- the proximal femoral/saphenous nerve is anterolateral to the SFA, then "crosses over" superficially to the SFA, and then courses distally posteromedial to the SFA. Just above this "cross over" is where it gives off its last fibers to the vastus medialus, so you want to go at or just below this "cross over." Many times you can see the nerve anteromedial/superficial to the SFA, sometimes you can't.

I describe this block as "trans-vastus, sub-sartorial." I agree that if you can't see a slam dunk nerve near the artery you can probably put some local around the artery and call it a day -- just make sure the local doesn't squirt "out" of the canal into the vastus itself.
 
fakin' the funk said:
The "adductor canal" block is really just the U/S-guided saphenous block that we used to do low in the thigh, only, this time it's a little higher.

Somewhere in the middle third of the thigh -- and I say somewhere because the anatomy is very variable -- the proximal femoral/saphenous nerve is anterolateral to the SFA, then "crosses over" superficially to the SFA, and then courses distally posteromedial to the SFA. Just above this "cross over" is where it gives off its last fibers to the vastus medialus, so you want to go at or just below this "cross over." Many times you can see the nerve anteromedial/superficial to the SFA, sometimes you can't.

I describe this block as "trans-vastus, sub-sartorial." I agree that if you can't see a slam dunk nerve near the artery you can probably put some local around the artery and call it a day -- just make sure the local doesn't squirt "out" of the canal into the vastus itself.
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Recent published study shows that an adductor canal block in the middle of the thigh doesn't cause signifucant muscle weakness. This is a sensory block with minimal loss of motor ability. Thus, there is little need to go more distal with the adductor canal block; instead I use the same approach as blockjock.com with excellent results.

http://vimeo.com/45462736

Blockjocks has placed over a hundred of these adductor canal catheters and they report minimal to no muscle weakness.
 
sevoflurane said:
Has anyone actually seen this reaction?
I haven't.

But I don't give it pre-op either.
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I give a ton of decadron preop. A ton. The vaginal burning and pain is dose dependent and occurs more frequently with higher doses (greater than 4mg) and fast push. Slow down or dilute the decadron and the side effect is much less likely to occur.

That said, I have had about 0.1 percent of patients complain of severe vaginal or rectal burning after a 4 mg dose. I've even had a male state his anus was on fire

Since diluting the decadron and limiting preop dose to 4 mg I've not had a single patient complain of any significant discomfort. My N is well over 2,000.
 
BLADEMDA said:
That said, I have had about 0.1 percent of patients complain of severe vaginal or rectal burning after a 4 mg dose. I've even had a male state his anus was on fire.
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:whoa: 😀

That is some serious stuff there... I can't help but to wonder what the mechanism of action is. Interesting.

Reminds me of pain guys hitting the G spot when doing a dorsal column stimulator... that one actually makes sense to me though.

With few exceptions, I use dex in just about everybody. Always after they are asleep or as they are going to sleep.
 
BLADEMDA said:
I have had about 0.1 percent of patients complain of severe vaginal or rectal burning after a 4 mg dose.
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I bet the real incidence is a lot higher than that. It's kind of an embarrassing symptom, the sort of thing a lot of patients would say nothing about.

I chase the propofol (+/- relaxant) with the dexamethasone and sidestep it altogether.
 
pgg said:
I bet the real incidence is a lot higher than that. It's kind of an embarrassing symptom, the sort of thing a lot of patients would say nothing about.

I chase the propofol (+/- relaxant) with the dexamethasone and sidestep it altogether.
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Real incidence of mild discomfort may be higher but I myself have received IV decadron without any issues whatsoever.

One of the benefits of doing your OWN cases is being able to guarantee your patients receive decadron with induction or shortly thereafter.
 
Intravenous Dexamethasone Induced-Perineal Irritation

Adriana Nizam, Registrar, Noreen Dowd
Dept. of Anaesthesia St. James's Hospital, Dublin, Ireland







Dear Editor

Single dose intravenous administration of dexamethasone reduces the incidence of post-operative nausea and vomiting 1;2. Its effectiveness when administered before the induction of anaesthesia is well described 3- 4. However there is little in the anaesthetic literature on a unique and unpleasant side effect we recently observed following intravenous dexamethasone (Faulding), in two female patients undergoing day case gynaecological surgery 5-7.

Case 1: A 32-year-old female, undergoing diagnostic laparoscopy, complained of an excruciating, sharp pain and burning sensation in her perineal area approximately 20 s after an intravenous dexamethasone bolus (8mg). The pain was so severe that the patient screamed and sat up abruptly. Fentanyl (100 mcg) and midazolam (2 mg) were given intravenously and the patient was reassured. The pain subsided in less than 30 s. Anaesthesia was induced and the procedure was otherwise uneventful. Post-operatively the patient remained stable, comfortable and pain free. She recalled the incident and was satisfied with the explanation given.

Case 2: A 27-year-old female, undergoing hysteroscopy complained of severe, sharp, burning pain in her perineum approximately 15 s after an intravenous bolus of dexamethasone (8 mg). Anaesthesia was immediately induced. The procedure continued uneventfully. Post-operatively, the patient recalled the pain and was satisfied with the explanation given.

Dexamethasone alone or in combination with other antiemetics is an effective antiemetic 1; 8-9. It is suggested that when administered immediately prior to induction of anaesthesia it provides effective antiemesis throughout the first 24 hours post-operatively 3. Intravenous dexamethasone-induced perineal irritation has been described in association with antiemetic use in chemotherapy, during treatment of acute head injury and when dexamethasone is used as an anti-inflammatory agent in maxillo-facial surgery. This side effect of dexamethasone is described in British National Formulary (BNF)10. However there is a paucity of information in the anaesthetic literature 5-7. Furthermore in systematic reviews and anaesthetic text books observed, there was no reference to this distressing side effect 1-2. In the cases described both patients reported that the pain was very distressing. They both recalled the pain postoperatively but reported that it was short-lived and caused them no further distress.

The cause of this phenomenon is still not fully understood. A phosphate ester which is part of this corticosteroid (dexamethasone sodium phosphate) might play an important role. The short nature of the pain could be due to the short duration needed to hydrolyse the compound to phosphate ions and dexamethasone 11. The lack of reports in the anaesthetic literature may be because patients are never asked regarding this pain or are embarrassed to mention it.

To conclude, we report this observation to increase awareness of this side effect among anaesthetists. Based on the experience of our patients, when dexamethasone is used for prophylaxis of PONV, it should be given after induction of anaesthesia. If administering it prior to induction, it seems reasonable to advise the patient of potential perineal pain before administration. Furthermore, diluting the drug in 50 ml of normal saline and administering it over 2 mins may reduce the incidence of pain 12.
 
Those who dilute it, do you really use 50 mL of saline as the above article suggests? When I was hearing you guys talk about diluting it, I was thinking 10 mL
 
pgg said:
I bet the real incidence is a lot higher than that. It's kind of an embarrassing symptom, the sort of thing a lot of patients would say nothing about.

I chase the propofol (+/- relaxant) with the dexamethasone and sidestep it altogether.
Click to expand...

I have found over the years that you can drastically reduce unpleasant side-effects from IV Decadron by doing the following:

1. Limit the dose in holding to 4 mg. If you want to give more then administer in the OR
2. Push the drug slowly or dilute it in a 20 ml syringe (still limit to 4 mg).
3. The most common complaint by following items 1 and 2 is mild itching which lasts for around 30 seconds to a minute.
4. Give the decadron after the Midazolam

Finally, I agree administration of decadron with induction is preferential but some authors think there may be some additional benefit by administration of dexamethasone 1 hour prior to incision.
 
We administered dexamethasone before the patient was
taken to the operating room rather than after induction of
anaesthesia which is more commonly done in clinical practice.
We did this to optimize the effect of dexamethasone
(peak effect 45 min to 1 h) on the stress response during surgical
incision and other stress generating portions of surgery
especially during the short ambulatory procedures studied.
 
Planktonmd said:
Agree!

I am wondering if the timing of the injection is of value here?
Do we have to give Dexamethasone at the same time we inject the local anesthetic to get the max effect?
No one knows at this point.
Click to expand...

You should plan on diluting any decadron dose greater than 4 mg in a 60 ml syringe and administer over 1-2 minutes. Up to 25% of patients who receive 6mg-8mg of IV decadron PUSH will experience serious Perineal Burning.


http://link.springer.com/content/pdf/10.1007/BF03018722.pdf
 
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