Wrist block for carpal tunnel

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Simba1711

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Been doing a lot of wrist blocks for carpal tunnel surgery. In residency I would just do a brachial plexus block which is overkill. For carpel tunnel surgery do you have to block the median and ulnar nerve? That’s what hadzic recommends a lot of my colleagues just do a median nerve block and patients do fine. Both options also do a circumferential subq injection at wrist crease to block terminal branches. Curious what people in this forum do ?
 
Simba1711 said:
Been doing a lot of wrist blocks for carpal tunnel surgery. In residency I would just do a brachial plexus block which is overkill. For carpel tunnel surgery do you have to block the median and ulnar nerve? That’s what hadzic recommends a lot of my colleagues just do a median nerve block and patients do fine. Both options also do a circumferential subq injection at wrist crease to block terminal branches. Curious what people in this forum do ?
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Never done any block for carpal tunnel. Surgeon always just does local.
 
It depends on the approach and the quality of your surgeon. Do they do endoscopic, or open? Are they fast, or slow?
I've worked with all types, but right now I have a hand surgeon who does all endoscopic CTR but requests mac and then does his own crappy "block" that doesn't usually work well. He then gets annoyed when he's jamming the endoscope in and they are writhing and screaming, even with heavy mac.
You aren't alone.
 
Local by surgeon with MAC. If surgeon is good and open surgery then it should be a 15 min ordeal and no biggie.

If surgeon not great then do a Baer block, easiest and quickest, safer than doing a supraclav in my opinion, I would want this if I was getting the surgery.
 
In residency they are all local no sedation, so I did none.

in fellowship, I did radial sparing axillary blocks. Then I went to practices where it was all local by surgeon which was fine.

Then I went to a place that was a combo of bier blocks and generals for endoscopic (surgeon dept) and local/MAC.
 
I think I would prefer the surgeon just do local too. They get annoyed if the patient moves at all and they want short acting local so the patient moves their fingers in pacu. I don’t get paid extra for doing the block since it’s primary anesthetic anyway
 
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Yes some cases are done local only but with good patient selection. You don't need to do general for endoscopic, bier blocks work just fine for those too.
 
Mirroring others here, surgeon states that his local would distort the anatomy for endoscopic approach. So painfully I had to do a bier block, with basically a room air general (aka heavy MAC). So it felt like I was doing two anesthetics, because the Bier block never seems to be 100%, plus the patients usually "don't want to know a thing." I would be happy to never do another bier block again.
 
LivetoTell said:
Mirroring others here, surgeon states that his local would distort the anatomy for endoscopic approach. So painfully I had to do a bier block, with basically a room air general (aka heavy MAC). So it felt like I was doing two anesthetics, because the Bier block never seems to be 100%, plus the patients usually "don't want to know a thing." I would be happy to never do another bier block again.
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Bier block works well in my opinion, maybe some tourniquet discomfort so you’ll have to use a double tourniquet. What do you have again big MAC? Also, why are you on room air??
 
LivetoTell said:
Mirroring others here, surgeon states that his local would distort the anatomy for endoscopic approach. So painfully I had to do a bier block, with basically a room air general (aka heavy MAC). So it felt like I was doing two anesthetics, because the Bier block never seems to be 100%, plus the patients usually "don't want to know a thing." I would be happy to never do another bier block again.
Click to expand...

One thing that I've found helps is to keep the tourniquet as distal as possible and to have the nurse hold the patient's wrist tightly just proximal to the surgical site. I vary the dose based on arm size, usually 20-30 cc of lido 0.5%.
 
Simba1711 said:
I think I would prefer the surgeon just do local too. They get annoyed if the patient moves at all and they want short acting local so the patient moves their fingers in pacu. I don’t get paid extra for doing the block since it’s primary anesthetic anyway
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What local is wearing off so quickly? And why are they going to pacu in the first place?
 
They’ll ask us to do wrist block or brachial plexus block ( Supra infra or axillary ) with Mepiviaine or lidocaine. Will freak out if we use bupi. We’ll give sedation or do general.

Arch Guillotti said:
What local is wearing off so quickly? And why are they going to pacu in the first place?
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I’ve never done bier block in residency. I am pretty sure I am not alone….

I suppose our hand surgeons are just good in retrospect. I usually give prop, they inject local, sit/chart for rest of the time.

I’ve had a few cases even with endoscopic carpel tunnel that was done the same way…. At the end, surgeon was like,
“oh, usually I prefer general…..”
It was a general, and patient tolerated well. Thank you.
 
This is an example of overthinking a non existing problem!
Why on earth would one need a "wrist block" to do a simple procedure that is basically snipping a ligament directly under the skin???
If the orthopod does not know how to inject local anesthetic then stick in an LMA and let them surgurize!
 
Yeah I agree with you. Surgeon wants sedation even though it’s actually general without an airway cuz it looks better on the chart.

Unfortunately as the new guy in the group I don’t want to cause any waves or change the culture that is already set.
 
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coffeebythelake said:
For the hand guys, we do Bier block or MAC with surgeon administered local

Apparently every once in a while a neurosurgeon does a carpal tunnel surgery and they demand general anesthesia 🙄
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I bet they call in neuromonitoring with motors too! Amiright or Amiright?
 
coffeebythelake said:
For the hand guys, we do Bier block or MAC with surgeon administered local

Apparently every once in a while a neurosurgeon does a carpal tunnel surgery and they demand general anesthesia 🙄
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I didn’t know that was a thing until recently. That they do carpal tunnel too?
 
IMGASMD said:
I didn’t know that was a thing until recently. That they do carpal tunnel too?
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I was told years ago (40+) that carpal tunnels and carotid endarterectomies were primarily neurosurgical procedures. Emory used to have a neuro guy that would line up carpal tunnels all day long one or two days a month
 
IMGASMD said:
I’ve never done bier block in residency. I am pretty sure I am not alone….

I suppose our hand surgeons are just good in retrospect. I usually give prop, they inject local, sit/chart for rest of the time.

I’ve had a few cases even with endoscopic carpel tunnel that was done the same way…. At the end, surgeon was like,
“oh, usually I prefer general…..”
It was a general, and patient tolerated well. Thank you.
Click to expand...

The preop nurse places two ivs and you inject local on the side they're working on
 
GassYous said:
I only use one tourniquet

And our lido is a huge 50 cc bottle so it's hard to confuse with anything else.
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We use 0.5% plain lido in 50 cc bottles also. But I've heard bicarb being used inadvertently. You can imagine what happened

Double tourniquet system is recommended for bier blocks, as an additional safeguard against malfunction (rare) but also to allow extension of block time (more common)
 
coffeebythelake said:
We use 0.5% plain lido in 50 cc bottles also. But I've heard bicarb being used inadvertently. You can imagine what happened

Double tourniquet system is recommended for bier blocks, as an additional safeguard against malfunction (rare) but also to allow extension of block time (more common)
Click to expand...

You can drop the tourniquet after 10 minutes without any problems
What's the difference between 100 mg of lido in the iv for induction or 100 mg of lido in the iv for bb
 
GassYous said:
You can drop the tourniquet after 10 minutes without any problems
What's the difference between 100 mg of lido in the iv for induction or 100 mg of lido in the iv for bb
Click to expand...

The double tourniquet is to extend block time not to shorten it. When patient starts having tourniquet pain you would inflate the distal and deflate the proximal.

50 cc of 0.5% lidocaine is 250 mg which is not a small dose especially for a small patient. We often dose < 4 mg/kg for these bier blocks. If the patient is 50 kg that is near 200 mg lidocaine. Don't tell me you would normally push this dose by regular IV. I wouldn't normally do more than 1.5 mg /kg IV.

10 min and then dropping the tourniquet is pushing it imo. I think most would recommend waiting 20 min.

Bier blocks are safe but they aren't risk free
 
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40-50 cc of lido 0.5%. So yes dose is 200-250 mg, so for safety typically need tourniquet your at least 15 mins.
 
Blockit said:
Well, it *is* a nerve......
😎
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Yeah, and it takes an hour with our Neurosurgeon on the one he does once every few years, even though he's very good and quick on crani and spine cases. Why a neurosurgeon would do those cases to begin with is beyond me. Leave it to the hand guys, but a nerve is a nerve...
 
“Hey, Anesthesia! Do me a favor and inject some local, right by the nerves, in this area I’m about to start cutting around.”—Sincerely, your Surgeon, your surgeon’s defense attorney, and your surgeon’s malpractice insurer
 
DirtDocMD said:
“Hey, Anesthesia! Do me a favor and inject some local, right by the nerves, in this area I’m about to start cutting around.”—Sincerely, your Surgeon, your surgeon’s defense attorney, and your surgeon’s malpractice insurer
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I have worked with ridiculous surgeons who request a brachial plexus block but can‘t understand why anyone would do a selective nerve block.
 
DirtDocMD said:
“Hey, Anesthesia! Do me a favor and inject some local, right by the nerves, in this area I’m about to start cutting around.”—Sincerely, your Surgeon, your surgeon’s defense attorney, and your surgeon’s malpractice insurer
Click to expand...

Exactly. Do an unnecessary block for a not-painful surgery for a patient with pre-existing median neuropathy that may worsen after surgery. Sounds super smart. Nothing could possibly go wrong.
 
Maz777 said:
Exactly. Do an unnecessary block for a not-painful surgery for a patient with pre-existing median neuropathy that may worsen after surgery. Sounds super smart. Nothing could possibly go wrong.
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Smart for the surgeon. Spread the risk and the blame.
 
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