dr doze

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Getting a hand surgeon at our place come July.
What's everybody's "go to" block for hand surgery and why?

(approach+drug(s)+volume)

No supplemental GA-block is the sole anesthetic.
 

ProwlerturnGas

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US guided supraclavicular single shot, 40 ml 0.5% or 0.75% Ropivicaine. Sets up fast and no GA required. And easy as pie
 

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The only time I do a block without GA is when the pt refuses to have surgery otherwise. 1) You have to deal with TQT pain 2) you have to delay surgical incision until surgical anesthesia kicks in 3) you can't bill the block as a separate procedure for postop pain only 4) if your block fails, you delay the surgeon even more as you try to redo or supplement (as opposed to redoing the block after wakeup)

If you salaried and there is a block team that can block the patient well in advance, then you are in academics and the added pressure of a block without GA is a good learning experience. Otherwise, in pp, block the pt and put them to sleep - bill more, delay less. 99% of pts don't want to be awake.

That said, 1,2, or 3 injection infraclav is a great block, except in some fatties where it's real deep, then I turn to supraclav (not always easy to get to corner pocket) or axillary (need to do a wheal for T2 and TQT pain). I love doing distal blocks but I don't get much chance to do them (ulnar above elbow for ORIF pinky).
 
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Oggg

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Never used 0.75%ropiv before. How fast is it? 20min til you can cut? 0.5%ropiv is pretty slow if your surgeon is fast.
 

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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.
 

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Ultrasound guided infraclavicular block. 30ml of whatever local you want (I use Ropi 0.5% with Epi 1:400k).
 

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Hand surgery I do axillary blocks, I don't always get the Musculocutaneous unless the incision will extend in that region, we always block T2 (cuff block) for the tourniquet. Solutions depend on my attendings but mostly also if the pt is going to sleep or not. Some like to bill as a general case and the block for post op pain, so we'll use an lma or tube them then I'll use all bupivicaine (0.5% without epi 40ml, plus another 4-6ml for the cuff block) and I'll run them on very little gas. If we want our block to set in quicker then we'll do 50/50 mix of 2%lido with 0.5% bupi, or 1.5% Mepivicaine and 0.5% Bupivicaine 50/50mix, Volume is almost always 40ml sometimes 30ml in a really skinny pt, then we'll either run a propofol drip or give them some versed usually 4 to 6mg. For pinky surgery I've done just an ulnar block just above the wrist I don't remember the volume that we used I think it was like 10 or 15ml. I've had co-residents do median nerve block right bellow the elbow for carpal tunnel releases and that worked great. We don't have Ropivicaine in our hospital, or if we do it's hidden somewhere, so we don't use it.

All these blocks now take about 10-15min, that's with set up and drawing everything up. So really no delay a lot of times I'll just do them with a senior resident present. But honestly once you're comfortable getting the needle in view all blocks are very fast and easy to do, unless the pt is super obese or the anatomy is weird, which happens every now and then.
 

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40 mL of 0.75% is a lot of local, I don't care how fat the patient is.

I use 30 mls of 0.5% Rop and I'm 100% for a SURGICAL ANESTHETIC so far. 15mls will give you a great post op pain block and spare the phrenic nerve but propofol is required.

Volume over 25 mls will BLOCK the phrenic nerve when doing a Supraclavicular block quite frequently (50% or greater).
 
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BLADEMDA

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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.
Yes, works well but takes longer than than a single shot block (Supra or ICB). Again, NO EPI added if I use U/S. My volume for U/S guided axillary blocks is 5 ml per nerve. If I decide to skip a particular nerve then I increase the volume so it spreads around real well.

Honestly, a good transarterial axillary block with 40 mls of 1.5% Mepi with epi 1:400,000 still works like a charm and is very fast to perform.

If the MC nerve needs to be blocked then add the use of a NS and locate the nerve in the belly of the biceps muscle or up high in coracobrachialis.
 
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BLADEMDA

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Getting a hand surgeon at our place come July.
What's everybody's "go to" block for hand surgery and why?

(approach+drug(s)+volume)

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.:eek:
 

ProwlerturnGas

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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.:eek:

I too trained solely with NS. Picked up US guided blocks afterward. Do dig the US!

IF I am worried about knocking out the phrenic, I skip the supraclavicular route and go infraclavicular or axillary. Should have been more careful with typing....when using 0.75% Ropi, I dial down the volume, more like 25-30 ml.
 

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Sole anesthetic: I'll do 15 ml of 2% lidocaine followed by 20 mL of 0.5% Ropivicaine for post op analgesia.

I rarely do a block for sole anesthetia though so usually it's just 0.5% ropivicaine and a LMA.

drccw
 

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If a quick short case bier with 30f. 5% lidocaine and 30 of tordol. Tourniquet placed on forearm.
 
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I do 8-10 hand cases every Tuesday. Anywhere from longer repairs to carpal tunnel. I have a surgeon who does not want to supplement with any local and does not want general on the shorter cases. Since Bier blocks have a fair amount of sedation needed with some patients, I took to doing US infraclaviculars on all her cases.

For carpal tunnels and such just use 2% lido (or 1.5% mepiv with the recent shortage) X 20-25ccs. Sets up in no time and lasts only about 2-4 hours. For longer, more stimulating cases I use bupiv with decadron. Keeps them happy until the next day.

Some guys swear by the supraclav "spinal of the arm", but I got enough ulnar sparing (at least 10% of the time) even getting the corner pocket, that I went to the infraclav which gets eveything I want including the touriquet coverage. People worry about the lung, but if you look medial enough, you can see the lung and then just head lateral until its out of your way. This block has worked great for me where the rubber meets the road on fast paced hand days. Patients really like it too. They don't like being numb for 24 hours for a carpal tunnel. It'd be easier if she would just use local, but she says it messes up her anatomy. Whatever..
 

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supraclav us guided 35-40 cc local, I usually use 1/2 1.5% mepiv and 1/2 0.5 ropiv. Corner pocket local placement is key to get the hand. The first couple of times I did this block I was putting the local at the obvious visualized nerve bundles and I missed the hand. No problems since. If I don't have US available (like at our surgery center) I do stim ax block with musculocutaneous. I have not needed any additional anesthetic for the patients that did not want any. Most of the patients I block like this do not want to go to sleep. Otherwise I just pop in an lma and let the surgeon put in some local.
 

dr doze

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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.
 

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Just wondering, when documented and billed properly, what's a typical reimbursement that you guys see for ultrasound guided single shot blocks for post-op pain?
 

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Reg Anesth Pain Med. 2009 Jul-Aug;34(4):366-71.
A prospective, randomized comparison between ultrasound-guided supraclavicular, infraclavicular, and axillary brachial plexus blocks.

Tran de QH, Russo G, Muñoz L, Zaouter C, Finlayson RJ.
Source

Department of Anesthesia, Montreal General Hospital, 1650 Ave Cedar, D10-144 Montreal, Quebec H3G-1A4, Canada. [email protected]

Abstract

BACKGROUND:

This prospective, randomized, observer-blinded study compared ultrasound-guided supraclavicular (SCB), infraclavicular (ICB), and axillary (AXB) brachial plexus blocks for upper extremity surgery of the elbow, forearm, wrist, and hand.
METHODS:

One hundred twenty patients were randomly allocated to receive an ultrasound-guided SCB (n = 40), ICB (n = 40), or AXB (n = 40). Performance time (defined as the sum of imaging and needling times) and the number of needle passes were recorded during the performance of the block. Subsequently, a blinded observer recorded the onset time, block-related pain scores, success rate (surgical anesthesia), and the incidence of complications. The main outcome variable was the total anesthesia-related time, defined as the sum of performance and onset times.
RESULTS:

No differences were observed between the 3 groups in terms of total anesthesia-related time (23.1-25.5 mins), success rate (95%-97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with the supraclavicular and infraclavicular approaches, ultrasound-guided AXBs required a higher number of needle passes (6.1 [SD, 2.0] vs 2.0-2.6 [SD, 1.1-1.8]; both P < or = 0.001), a longer needling time (7.4 mins [SD, 2.2 mins] vs 4.9-5.5 mins [SD, 1.9-4.2 mins]; both P < or = 0.016), and a longer performance time (8.5 mins [SD, 2.3 mins] vs 6.0-6.2 mins [SD, 2.1-4.5 mins]; both P < or = 0.008). Supraclavicular blocks resulted in a higher rate of Horner syndrome (37.5% vs 0%-5%; both P < 0.001).
CONCLUSION:

Adjunctive ultrasonography results in similar success rates, total anesthesia-related times, and block-related pain scores for the SCB, ICB, and AXB.
 

BLADEMDA

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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. SCB is still a VOLUME block for SURGICAL ANESTHESIA. My experience agrees with the literature that a minimum of 30 mls of local is needed up to 40 mls. I use 30 mls for SURGICAL BLOCKS but the evidence points to greater success with 35-40 mls.
My failure rate is ZERO for post op pain relief and probably 1-2% for surgical blocks.
This is a reliable block when sufficient volume is utilized and/or a NS is added if the nerves are not visualized. Take a look at his study (there are more) showing the failure rate increases when a NS is NOT utilized and the nerve bundles can't be visualized:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872833/pdf/kjae-58-267.pdf

The quoted failure rate with a distal twitch (NS), U/S technique (corner pocket) and sufficient volume (no less than 30 mls) is less than 2% (surgical block). Post Op Pain relief is 99% or better when utilizing all 3 listed above.

2. I get good tourniquet coverage for about 60-90 minutes with a properly performed Axillary block. After 90 minutes the pain from the tourniquet becomes a factor but I have propofol for that.

3. All Brachial Plexus blocks are good. What you need is practice, a good U/S machine and time to do the block. I like SCB because they are really fast, work well and last 24 hours (with Decadron added) for post op pain relief.
 
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BLADEMDA

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One size does not fit all: Proposal of an algorithm for the practice of ultrasonography in combination with nerve stimulation for peripheral nerve blockade

  • Hervé Bouaziz
  • [Denis Jochum], [Attila Bondar], [Laurent Delaunay], [Michael Egan], [Hervé Bouaziz]
Several articles have been published recently comparing the use of ultrasound (US) to that of peripheral stimulator (PNS) as nerve blocking techniques. We have read the meta-analysis by Abrahams et al. of randomized controlled trials, which suggests the greater efficacy of US compared
More... Several articles have been published recently comparing the use of ultrasound (US) to that of peripheral stimulator (PNS) as nerve blocking techniques. We have read the meta-analysis by Abrahams et al. of randomized controlled trials, which suggests the greater efficacy of US compared to PNS [1]. Though there are many interesting points to the meta- analysis, Abrahams acknowledges in Appendix A of his review and in the subsequent correspondence, that of the 9 studies used, 3 used an inappropriate motor response as an endpoint and others opted for too high a minimal stimulating current [1]. These practices greatly reduced the effectiveness of nerve blocks using PNS. Perlas et al. for example described a 40% failure for popliteal block [1]. We would suggest that on balance, it is neither necessary nor desirable to persist in attempts to establish the superiority of one technique over the other and would rather encourage the view that there are advantages as well as limitations pertaining to both. Consideration therefore should be given to a practice which is based on how both PNS and US approaches might be complementary rather than choosing one to the exclusion of the other. We submit that the algorithm we describe is a practical way to combine the two approaches and should result in a more favourable risk-benefit ratio for nerve localization.
In a series of steps as illustrated in the algorithm, the first (and essential) is to obtain adequate training in both techniques [2]. In accordance with best practice, the procedure is performed on an awake or lightly sedated patient in order to maintain continuous verbal contact [3]. A sterile technique is mandatory. An initial ultrasound scan of the target anatomical area must be undertaken [4]. The scanning should be systematic and should cover a large area in order to accurately identify the anatomical components, particularly the neurovascular structures. The initial aim is to plan the needle trajectory and develop a strategy to optimise performance of the block. Whether an in-plane or out-of-plane technique is used it is essential that the full extent of the needle be visualized. Meanwhile the nerve stimulator should be set at 1 mA current intensity and 0.1 ms for the impulse duration. Nerve stimulation has a high specificity and low sensitivity [5] and it should always be kept in mind that in case of needle to nerve contact, it is still possible to increase current intensity without eliciting a motor or sensory response.
During the procedure the needle tip position can be confirmed by hydrolocalization. This consists of repetitive injections of a small volume (usually less than 1 ml) of either the local anaesthetic itself, saline or dextrose 5% water (D5W). We recommend the use of D5W or saline as safer during needle positioning, when the needle tip may contact the nerve(s). Gentili et al. has shown in an experimental study that no neural damage occurred after saline injection, even if it was administered intrafascicularly [6]. D5W is preferred as it is a nonionic solution and in contrast to saline it potentiates the electrical field for the nerve stimulator [7].
Priority should be given to US, when the quality of the image is good and the anatomical structures can be easily identified. A tangential rather than a direct approach will provide optimal spread of the local anaesthetic and should therefore be chosen. In the tangential approach, when the needle is positioned slightly beyond the nerve (in order to obtain a circumferential spread of local anaesthetic) the minimum current intensity will be inevitably increased. If the quality of the image is poor, nerve stimulation assumes greater importance. In both cases, finding the minimum stimulating current intensity is essential [3] as it indicates the distance between the needle tip and the nerve (more precisely, the nearest nerve fascicle) as well as providing functional information.
Strict adherence to safe practice should be maintained [3] and as with any regional technique it is essential to aspirate before injecting the solution and be aware that US images may give a false sense of security. Manoeuvres of the probe such as applying and then releasing pressure on the tissues can localise venous structures and define the relationship of the needle to the vein. While the width of the US beam is in the order of 1mm, it is essential to position the US field exactly over the needle tip to allow visualization of the first millilitre of hypoechoic fluid injected [4]. Nerve stimulators, e.g. Stimuplex HNS 12 (B Braun), that display the electrical impedance on their screen provide valuable information and should be used [8]. At a constant stimulating current intensity, any modification of the electrical impedance observed may be indicative of pre-injection intraneural needle placement. Absence of variation or a mild increase in electrical impedance during the injection of a few millilitres of D5W indicates intravascular needle position [9]. Extrafascicular injection should be of low resistance and painless. Whether needle repositioning is required depends on the pattern of fluid spread seen on the US image. An optimal spread, in contact with and circumferential to the nerve will permit a reduced injection volume of local anaesthetic, provided that it is dispersed along the nerve. When this is not the case, the needle should be repositioned.
The overall aim should be to inject the local anaesthetic at the correct site, to minimise the dose while administering an adequate volume of solution. Throughout the procedure the operator should continuously assess the advantages and limitations of both techniques to obtain the most favourable risk-benefit ratio for the patient. In our view, it is necessary to combine techniques using a rigorous procedure for the optimum result. The algorithm we propose may be simplified and individualized according to preference but it should be kept in mind that each step removed is a loss of potentially useful information.
References: 1. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta- analysis of randomized controlled trials. Br J Anaesth 2009;102:408-17. 2. Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak-Nielsen ZJ, Ivani G. The American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy Joint Committee Recommendations for Education and Training in Ultrasound-Guided Regional Anesthesia. Reg Anesth Pain Med 2009;34:40- 46. 3. Les blocs périphériques des membres chez l’adulte. Recommandations pour la pratique clinique. RPC publiées par la SFAR. http://sfar.org/t/spip.php?article184 (Mis en ligne le 2 mars 2003). 4. Brull R, Perlas A, Cheng PH, Chan VW. Minimizing the risk of intravascular injection during ultrasound-guided peripheral nerve blockade [Letter]. Anesthesiology 2008;109:1142. 5. Perlas A, Niazi A, McCartney C, Chan V, Xu D, Abbas S. The sensitivity of motor response to nerve stimulation and paresthesia for nerve localization as evaluated by ultrasound. Reg Anesth Pain Med 2006;31:445-50. 6. Gentili F, Hudson A, Kline DG, Hunter D. Peripheral nerve injection injury: An experimental study. Neurosurgery 1979;4:244-53. 7. Tsui BC, Kropelin B, Ganapathy S, Finucane B. Dextrose 5% in water: fluid medium for maintening electrical stimulation of peripheral nerves during stimulating catheter placement. Acta Anaesthesiol Scand 2005;49:1562-5. 8. Jochum D, Iohom G, Diarra DP, Loughnane F, Dupré LJ, Bouaziz H. An objective assessment of nerve stimulators used for peripheral nerve blockade. Anaesthesia 2006;61:557- 64. 9. Tsui BCH, Chin JH. Electrical impedance to warn of intravascular needle placement. Reg Anesth Pain Med 2008;32:A-51.
*****(Authors request Algorithm to be attached here)****






Published August 7, 2009
 
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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.
 

dhb

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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.
:wow:
 

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BLADEMDA

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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.
1. Add a NS to the SCB and get a distal twitch to the wrist or fingers. The stimulation only needs to be 0.9 or less provided you put the needle in the corner pocket. This will improve your success to 95% or better.

http://www.ncbi.nlm.nih.gov/pubmed/20532055

http://www.ncbi.nlm.nih.gov/pubmed/15041619

2. Axillary blocks are a pain compared to a SCB or ICB but i encourage you to do them every now and then to maintain proficiency.

3. The SCB is easy on an obese patient and is my "go to" block. Success rate is just as good as thin patients if using u/s.

http://www.ncbi.nlm.nih.gov/pubmed/16551933

Medicare rates for blocks suck.
 
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Just came form a regional conference that's annually sponsored by my residency program. Dr. Hadzic NYSORA president was there and I had a chance to talk to him. Basically he didn't have a preference about what block to do for hand surgery, his advice was in terms of how the blocks are done. Basically what he does is use both U/S and NS for all his blocks. He sets the NS to 0.5mA and leaves it alone and uses the U/S to direct his needle to what he thinks are the nerves he wants to target, once he achieves a motor response he pulls back until he doesn't have the response and then injects. He does this to avoid intraneural injections and quoted a study that showed that a motor response of 0.5 or less when looking at better imaging of the nerve had a high percentage of needles being within the epineurium. He also looks at the force needed to inject the solution. I forget the amount of newtons it shouldn't exceed but what he said is basically you can fill your syringe partly with air and if you're compressing the air volume by more than 50% then you're using too much force to inject the solution and your needle might be intraneural. He also mentioned a study or two in regards to intraneural injections and basically states that there should be better terminology and that in bigger distal nerves most of the time when you're within the epineurium you're still in the interfascicular epineurium and most likely not within the perineurium.

As for additives the only one worth while is epinephrine to increase duration of action, all others only have anecdotal evidence and he doesn't use anything else in his blocks.


Another expert at the conference said he almost never does axillary blocks, only when a resident wants to do them, just because infraclavicular blocks are easier to do and work just as well if not better. For obese patients where these roots might be very deep and not well visualized his advice was just to find the subclavian artery and inject half your local volume at the 4/5 o'clock position and the other half at the 7/8 o'clock position.


Even though this is not hand surgery specific thought I'd share this info.

And for billing people get reimbursed anywhere from 8 to 12 units per block depending on the type of block.
 

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Hadzic is a Regional Guru and his technique is sound. However, has he tried increasing his stimulation threshold to 0.6 or 0.9 for additional safety when using U/S? My experience is 0.6-0.9 is more than adequate for stimulation provided you can see the nerve complex/roots/trunks on U/S.

The comment about pressure during injection is a wise one. I'd rather inject my own local when possible to maker certain the pressure isn't excessive. Over time you get a good feel for the right injection pressure.

Hadzic is wrong about the "additive" comments. I don't use EPI in my blocks (for additional safety) but add Decadron to prolong the analgesia. It works and has literature behind it. For now, Decadron is added to local for non diabetics and no pre-exiting neurological diseases/neuropathy.


Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine http://bja.oxfordjournals.org/content/107/3/446

http://www.ncbi.nlm.nih.gov/pubmed/22379567
 
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For those who think the academics know everything they don't. When I finished training from a top Residency program years ago the gurus said the following:

1. Axillary blocks don't work well for elbow surgery- Wrong
2. ISB can't be used for hand surgery- Wrong
3. You need 40 mls of local to do an ISB- Wrong

Hadzic is a guru and his techniques are sound. But, he isn't right about everything because the body of knowledge is incomplete.
 

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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.
 
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BLADEMDA

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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.
So if it is the wild West now what was it 20 years ago?:)
 

secoy

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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.
 

Oggg

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Interesting article about the MC nerve coming off proximal to the infraclav site. I haven't noticed a missed MCN after infraclav, but my n is small. Anyone else see this?
 

BLADEMDA

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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.
Are you doing multiple injections for your INfraclavicular blocks? Do you go right for the posterior cord at 600 then the lateral then the medial? With 40 mls I imagine a single injection at 600 woud work fine. In obese patients are you using the big, low freq curved probe because depth is 6cm or more?
 

secoy

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Like you said with 40mls you can routinely aim for 6 o'clock on the artery and get good spread with a single injection. That said, if spread looks inadequate I will readjust my needle trajectory to ensure complete spread.

In my current practice, which is a tiny community hospital, we do not have access to the curvlinear probe. I have used it before many times for obese patients and find that it works excellent. Currently we have one probe the L38xi for a sonosite s-nerve. Its rated up to 9cm but of coursse the screen is too narrow at that setting. I can reliably see 6cm well with this probe. If someone is obese + large breasts, I usually just do a supraclavicular.
 

Oggg

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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).
 

dr doze

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I believe that we will be doing a fair amout of arthroplasties. I suspect alot of rheumatoid patients.
 

RussianJoo

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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).
since I am a resident and work in a teaching hospital we block everything or at least try to. anything in the upper extremity will get a block unless the surgeon specifically says no a head of time or it's just excision of a small superficial mass. For AV fistulas we do a supercalvicular block then just use 2 to 4 mg of Versed for sedation, that's all those pt's usually need.
 

Oggg

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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.
 

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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 tunnel supraclavs, and don't generally have problems with them falling out, at least for several days, on patients moving about and going to PT regularly.
 

Oggg

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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?
 

dhb

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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?
Corner pocket
 

psychbender

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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?
I've pretty much always put them in the corner pocket, but even with tunnelling, injecting air to see the tip of the catheter on U/S, and securing the crap out of it, who knows where the end really ends up after a while?
 
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