40 mL of 0.75% is a lot of local, I don't care how fat the patient is.
u/s guided axillary + musculocutaneous. I use 0.5% bupiv with epi (I should probably stop using epi), 30 mL total. Old school. I like it because it's easy (u/s views are reliably easy to obtain), safe (no chance of PTX or phrenic injury), and highly effective for hand and wrist procedures.
Getting a hand surgeon at our place come July.
What's everybody's "go to" block for hand surgery and why?
No supplemental GA-block is the sole anesthetic.
U/S guided blocks are the bomb.
If you want me to comment on "old school" blocks for those centers without U/S let me know. Some of us know how to get by with just a NS and still do thousands of hand/elbow cases successfully. That said, the modern era of U/S has transformed the skills required to do these blocks to the level of a CRNA.
For folks who have done alot of u/s blocks for major hand surgery:
1. In your experience, How often, even with hitting the corner pocket appropriately and using an appropriate dose and volume does the supraclavicular fail to provide surgical anesthesia?
2. How often is tourniquet pain an issue for ax blocks with appropriate hitting the intercostobrachial and musculocutaneous nerves?
3. Any general comments about pros and cons of axillary vs infraclavicular approach that you wish to share would be appreciated.
1. In my own hands about 10% failure rate of surgical anesthesia in the ulnar region with SCB. I haven't tried fixing this as infraclav works so well for me and is an easier block. The only time I like supraclav is when the patient has a pretty fresh fracture and cant lift their arm above their head. Thats where the supraclav would be a lot better. The other thing I like about infraclav is that I never get the phrenic in a clinically noticable fashion. With high volume supraclav you will get a phrenic block some of the time.
2. Don't do axillary blocks much since started doing infraclav.
3. Only advantage I see in doing axillary over infraclav is in the morbidly obese and the infraclav is to deep. Have to be pretty fat for that. If they have their arm up it flattens that area out.
I have really good reimbursement rates, so this is not true for every place but I get about $800 for a brachial plexus block and about $1300 for bracial plexus catheter. Medicare rates are less than 10% of that.
The overall theme I got from the conference was that regional anesthesia is the wild west, there are no set standard and a lot of unknowns. Just like with all of medicine, once we start gathering data and using different techniques more and more, recommendations change.
The main benefit of infra vs supraclavicular is no phrenic nerve involvement w infra. That being said I usually do supra's. Just my preference. I find supra's to be a much quicker superficial block. I usually do infra's when there is abnormal anatomy or a central line sitting above the clavicle. I do not stim either since I am doing them with ultrasound. I have never used additives. Usually just 0.5% ropi, but with high volumes = 30-40mls, lasting 14-20hrs. I am interested in trying BLADES recommended use of decadron to extend my block duration.
We don't see much hand surgery over here. Surgeons dont want locks for Carpal tunnels. Are people doing blocks for trigger finger releases or de quervains? Seems like local infiltration works great. I'm convincing a lot of the surgeons to let me do a block for wrist fractures. What other cases are you blocking? I thought about blocking AV fistulas but since there most of these will be sole anesthetic, it would be for fun/practice only (definitely not for reimbursement).
Are you going to be doing any CPNB? I don't have much CPNB experience, but ppl say that a supraclav catheter is more prone to falling out and an axillary catheter may get incomplete coverage, leaving the infraclav catheter as your best bet.
I know you put an infraclav catheter deep to the artery, but where do you place a supraclav catheter? In the corner pocket? Or can you just get a hand twitch and place it posterolateral to the middle trunk?