Thoracic TFESI and anticoagulation
Started by oneforfighting
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a patient on dual agents.... kinda concerning.
would probably not offer the procedure.
would probably not offer the procedure.
Hard no
Is Thoracic esi even covered??
90yo with worsening post herpetic neuralgia. Seeing later this afternoon. Renal function in the dumps, so not lots of options for meds.
What about ICNB?
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1. Assuming unilateral dermatomal distribution of pain.
2. Assuming lower risk of clinical hematoma via transforaminal approach if continuing AP/AC
I always use dex for TFESIs
Intercostal. Omoigui diffusion technique.
PE/DVT and CAD
I'm thinking this would be most reasonable. Would you do them with above AP/AC on board?
For sure. Especially diffusion technique since you’re just landing on the superficial side of the rib. Easily compressible. Also I think I’m about 0 for 5 with thoracic epidurals helping with PHN…
Intercostal for PHN and get it by the DRG.
i would do intercostal and not esi, and i would not hold either, even though you might be close to the artery.
Just saw pt. Just had 2 cardiac stents placed last month so no way can come off Plavix. And had PE/DVT during same hospitalization so same goes for apixaban.
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Are people still doing series of 3 for these? What's your cocktail if you don't mind me asking, Steve?
Mark off a rib in the approximate center of the pain, drop a 25g onto the center of the rib shadow until it touches bone. Put a finger on each side of the needle oriented cephalad/caudad, and apply pressure to constrain the spread in a superior/inferior direction, and inject about 10 mL lido/steroid.
2 level unless 1 clear band. 2cc bup 0.25% and 5mg 0.5ml dex.
Why center of rib though? Easy enough to touch inferior aspect safely, especially with caudal tilt, it's the walking off that gets riskier. Would seem like you'd more likely diffuse to intended target if starting closer
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Minimize risk. Definitely more diffuse - I’ve added contrast to it to see, and one shot hits 2-3 intercostal levels.
Yes
Fluoro with slight caudal tilt
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How close to the spine do you catch the intercostal nerve?
100%
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callmeanesthesia is using the omiguoi technique.
i will use that and traditional technique, under fluoro.
target and hit lower 1/3rd of rib. lots of local anesthetic, up to 5 ml on to each rib.
then angle downwards until off edge of bone, advance 1mm, no more, and reimage. then give 2 ml 025% bupiv and dex.
i get a lot of inpatient rib fracture patients, so the 1% on rib helps a lot, and want subjectively faster effect from that and dex and dont need longer term effect of depo.
i will use that and traditional technique, under fluoro.
target and hit lower 1/3rd of rib. lots of local anesthetic, up to 5 ml on to each rib.
then angle downwards until off edge of bone, advance 1mm, no more, and reimage. then give 2 ml 025% bupiv and dex.
i get a lot of inpatient rib fracture patients, so the 1% on rib helps a lot, and want subjectively faster effect from that and dex and dont need longer term effect of depo.
So even with pressure superior and inferior to rib, you get spread to adjacent levels? I guess that makes sense with 10cc.
No, I hold pressure lateral and medial to the needle so the medication spreads superior and inferior.
Offered Qutenza but they wanted injections
