Popliteal block

[fakin' the funk]

The volumes for blocks vary wildly. I typically use 15ml for an interscalene block but one of my colleagues uses 50ml. BTW thanks for the excellent ultrasound images posted here.

FIFTY?! How does one even fit 50ml of anything into the neck without it looking like a subcutaneous golfball.

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[fakin' the funk]

Which other nerves are tolerant to intraneural injections and which blocks do I have to be extra careful

My my, quite inquisitive, aren't we?

 

[BLADEMDA]

Which other nerves are tolerant to intraneural injections and which blocks do I have to be extra careful

Sciatic/Popliteal nerve blocks are the "most tolerant" of an intraneural injection followed by the Femoral nerve where sloppy technique rarely leads to any complications.

I can say that the Interscalene block is probably the one with most number of complications per the literature so you need to be extra careful.

 

[Aether2000]

That was my thought when I saw it being done. There is no doubt there is epidural spread with lateral epidural space involvement, phrenic nerve block, vertebral artery branches, and posterior primary rami branches of C3-C7. It does work, but OMG!

 

[pgg]

Which other nerves are tolerant to intraneural injections and which blocks do I have to be extra careful

?

The ones that go to the teeth more tolerant of getting rattled with a laryngoscope, of course.

 

[deleted682700]

http://www.anesthesiologynews.com/R...al-Legal-Protection-Strategies/32991/ses=ogst

Nice review here. Summary. Nerve injuries are rare, 2 in a thousand to ten thousand blocks. No definite evidence that ultrasound or parenthesis or stimulation technique are better in reducing that risk. The nerve injury may be surgical.

Of course would not inject if the patient has severe pain or paresthesia. Under ultrasound would not inject intraneural if you know what to look for. Avoid epi containing local anesthetic solutions particular in diabetics.

Informed consent, focused neuro exam before, keeping a verbal communication at the time of injection.
Document to avoid legal headache.

 

[GA8314]

I usually go as high up as possible to see Sciatic, but if I can only view (for whatever reason) at CP and Tibial which are close together, then I'll assume spill over and may use a bit more volume (lie 5ml more).

 

[sevoflurane]

I usually go as high up as possible to see Sciatic, but if I can only view (for whatever reason) at CP and Tibial which are close together, then I'll assume spill over and may use a bit more volume (lie 5ml more).

If I am doing lower extremity (ankle), I def. don't mind getting CP/PT together because there will be more neuronal surface to inject around and therefore onset will be faster. For sciatic catheters, I steer the needle between the CP/PT and leave the catheter sandwiched in between.
Don't get me wrong... getting a nice doughnut around a sciatic nerve is great, but if you have a quick case it may not set up in time for pacu. I find that in those cases that increasing the surface area the Local is exposed to (ie at the bifurcation), the block sets up faster. My 2 cents.

 

[facted]

I always go right at the bifurcation and have never had an issue. Block sets up quick as well. I like going there as opposed to at the sciatic because I can more definitively exclude intraneural injection and it gives you a nice landing spot in the common sheath, but between the sheaths of the two individual nerves. See the paper from RAPM that I posted above for the evidence behind this approach.

 

[Arch Guillotti]

Don't get me wrong... getting a nice doughnut around a sciatic nerve is great, but if you have a quick case it may not set up in time for pacu.

What kind of local anesthetic are you using? I do popliteal blocks right before the case and get a block that is adequate for surgical anesthesia.

 

[sevoflurane]

What kind of local anesthetic are you using? I do popliteal blocks right before the case and get a block that is adequate for surgical anesthesia.

Surgical anesthesia right after a popliteal block...as in an awake patient?
I always use bupi for my LE blocks.
It takes some time to set up for "surgical anethesia" especially if you are going after osteotomes.