U/s guided caudal?

[deleted59964]

Anyone routinely do these for kids?
Landmark has a great safety record, and is quick.
While I expect the efficacy of SDN inserted caudals is 100-110%, the literature suggests it is surprisingly low

I’m considering trying u/s ...
Thoughts?

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[deleted59964]

 

[DrZzZz]

Anyone routinely do these for kids?
Landmark has a great safety record, and is quick.
While I expect the efficacy of SDN inserted caudals is 100-110%, the literature suggests it is surprisingly low

I’m considering trying u/s ...
Thoughts?

Had one attending in training that loved using US. And he was one of the most seasoned pedi guys we had. Haven't done a caudal since residency. But if I had to, I probably only use it as a backup for a troublesome caudal (think bigger, fatter kid with tougher landmarks). It's a good adjunct, throw on color flow as you inject to confirm placement. But I only see it as an adjunct personally.

 

[deleted592694]

Fellow in-training here; one of the few attendings here that teaches U/S-guided caudals uses it for teaching purposes or as an adjunct for difficult caudals only, stating that for the vast majority of patients, the landmark technique is just fine and more efficient. We do use it routinely to help guide us during placement of caudal catheters, however.

 

[dhb]

Haven't done one in 10 years but yeah you could probably use US, but then if you had a machine why would you not do a TAP?

 

[deleted162650]

Haven't done one in 10 years but yeah you could probably use US, but then if you had a machine why would you not do a TAP?

‘Cuz TAPs don’t do much for uro cases.

 

[deleted59964]

caudal = epidural >> TAP

 

[dhb]

‘Cuz TAPs don’t do much for uro cases.

D block

 

[dhb]

caudal = epidural >> TAP

Dislike : single shot TAP >>> 6h caudal

 

[Hoya11]

‘Cuz TAPs don’t do much for uro cases.

or any case

 

[somedumbDO]

I use it for difficult caudals where I can’t get that”feel” of the space, rescue my partners that have failed a couple of times and have injected sub q w fluid and can’t feel landmarks or if they have private insurance which is rare here less than 20% still quicker and easier using landmark.

 

[dhb]

or any case

When you're not good at something the results are often poor

 

[Hoya11]

When you're not good at something the results are often poor

When your drinking the kool-aid, everything seems like a successful intervention. I dont believe TAPs are clinically significant. If they didnt bill so well they would never be done.

 

[dhb]

When your drinking the kool-aid, everything seems like a successful intervention. I dont believe TAPs are clinically significant. If they didnt bill so well they would never be done.

That's funny: in Europe you can't bill for them, maybe that's why they work.
Very often i do cases with a TAP and no other pain meds per and post-op, so maybe they don't work, but they don't work fine for me.

Habe you ever done a TAP on a patient post op after an iliac bone graft harvest that goes from writhing pain to asleep in 5min?
Have you ever done an ESB on a rib fracture patient that thanked you profusely 10min later? I have...

 

[nimbus]

When your drinking the kool-aid, everything seems like a successful intervention. I dont believe TAPs are clinically significant. If they didnt bill so well they would never be done.

It’s not uncommon in my experience to have laparotomy patients who get 100mcg fentanyl at the beginning of a procedure plus an asleep TAP block at the end who need no other pain meds until POD #1. We have several surgeons who make a point of asking for them because they do indeed work. They aren’t asking for it in order to slow down their own lineups

 

[deleted592694]

I would rather trust the surgeon and PACU/floor nurses whose patients complain less with respect to pain after TAP blocks than the ivory tower regional 'expert' who once straight up told me "TAPs don't work because such and such article says so."

 

[DoctwoB]

Surgeon weighing in. All I can say it’s amazing what good anesthesia can do. Our Prostates and even open cystectomies are almost all completely narc free. I couldn’t tel you if it’s the TAP, the ketamine, the Preop meds, limiting the volatile, or all of the above, but the end result is a qualitative leap in pain control to when I started residency 6-7 years ago. Anecdotally at one point in that journey we switched from paraveetebrals to TAPs and didn’t notice much of a difference.

 

[Laryngophed]

Surgeon weighing in. All I can say it’s amazing what good anesthesia can do. Our Prostates and even open cystectomies are almost all completely narc free. I couldn’t tel you if it’s the TAP, the ketamine, the Preop meds, limiting the volatile, or all of the above, but the end result is a qualitative leap in pain control to when I started residency 6-7 years ago. Anecdotally at one point in that journey we switched from paraveetebrals to TAPs and didn’t notice much of a difference.

Why no thoracic epidural?

 

[dhb]

Why no thoracic epidural?

Because it's just not superior for these cases

 

[Hoya11]

Because it's just not superior for these cases

Did you consider essential oils?

 

[Hoya11]

It’s not uncommon in my experience to have laparotomy patients who get 100mcg fentanyl at the beginning of a procedure plus an asleep TAP block at the end who need no other pain meds until POD #1. We have several surgeons who make a point of asking for them because they do indeed work. They aren’t asking for it in order to slow down their own lineups

Surgeons ask for ridiculous things.

Things that IMO dont work (or dont work enough to be worth it):

Lido infusions
Mag infusions
Ketamine infusions
Tissue blocks (TAP, Paravertebral)
Remifentanil
Facet Blocks
Sympathetic plexus blocks
Exparel
Saphenous nerve block (just do a femoral)

Just my opinion. Sure I have done all of them to please the surgeon/referring doc, but IMO not helpful/superior to current standard and I dont like doing it.

You can do a case with lots and lots of different stuff to avoid a little opiate. Why? If you really think you are making a difference with this stuff all I have to say is agree to disagree and that maybe your perception of a successful intervention is different than mine, it wouldnt be the first time for me. But just because I dont believe that saphenous nerve block with exparel is the bees knees, doesnt make me suck at doing it. My perception of success if just as valid as yours, and doesnt just echo whatever is trendy right now or what the surgeons are saying..

I've seen lots and lots of cases where TAP blocks were given by various providers , surgeons, experienced anesthesia docs, whoever.. tons of pain.. where does it hurt? "right here" - indicating somatic pain still present. Maybe it works or has an impact some small percentage of the time at best, and remains in my category of not worth it, but if you think that YOU doing it is the difference, disagree.. much more likely your perception of success/superiority,

the iliac bone guy just needed any kind of local infiltration or some narcotic god forbid
and the other guy needed an epidural

 

[deleted59964]

Surgeons ask for ridiculous things.

Things that IMO dont work (or dont work enough to be worth it):

Lido infusions
Mag infusions
Ketamine infusions
Tissue blocks (TAP, Paravertebral)
Remifentanil
Facet Blocks
Sympathetic plexus blocks
Exparel
Saphenous nerve block (just do a femoral)

Just my opinion. Sure I have done all of them to please the surgeon/referring doc, but IMO not helpful/superior to current standard and I dont like doing it.

You can do a case with lots and lots of different stuff to avoid a little opiate. Why? If you really think you are making a difference with this stuff all I have to say is agree to disagree and that maybe your perception of a successful intervention is different than mine, it wouldnt be the first time for me. But just because I dont believe that saphenous nerve block with exparel is the bees knees, doesnt make me suck at doing it. My perception of success if just as valid as yours, and doesnt just echo whatever is trendy right now or what the surgeons are saying..

I've seen lots and lots of cases where TAP blocks were given by various providers , surgeons, experienced anesthesia docs, whoever.. tons of pain.. where does it hurt? "right here" - indicating somatic pain still present. Maybe it works or has an impact some small percentage of the time at best, and remains in my category of not worth it, but if you think that YOU doing it is the difference, disagree.. much more likely your perception of success/superiority,

the iliac bone guy just needed any kind of local infiltration or some narcotic god forbid
and the other guy needed an epidural

not sure what you mean about ketamine infusions and remifentanil "doesn't work" ... they are very potent agents. maybe they don't achieve what you hoped they would?

paravertebrals I also think work (as do erector spinae) when you put the local in the right spot.

the rest of your list I agree with ... I think lido infusions and mag infusions are witch craft.