Regional Anesthesia: A Case Example

[jetproppilot]

Heres a great case, dudes/dudettes:

One of our ortho studs had five cases yesterday, the first being an ACL repair on a 31 year old healthy dude who popped his ACL on his first slope in Vail in February.

Patient in the holding area at 0640. Gave him midazolam 4mg and did the fem/sciatic blocks (bupiv .5% with epi, 30ml each site.). Done at 0655. Into the OR at 0710. Propofol 150 mg, LMA #4, sevo at 2% until after incision, then was able to back it down to .6% for the duration of the case, which took about an hour and 45 minutes. Gas off, LMA out. He was in recovery for 30 minutes, then back to day surgery long enough to get crutches, and he was out the door. I called him at 6pm and he was just starting to have a twinge of posterior knee pain.

What are the salient parts of this case? Its funny, when you first start anesthesia you're thinking about what cool drugs you can give, and the longer you do it, you try and figure out what you can withhold. WE GAVE NO OPIODS TO ACL DUDE! None. Nodda. Keep in mind if your blocks are good, you'll have great surgical-site analgesia, so actually the LMA/sevo was probably overkill. Our next step is to do these cases with just a propofol or precedex infusion and a nasal cannula. Not having to give opiods and being able to run justa whiff of volatile agent meant this dude woke up crisp with no post-op nausea, and no pain. The key is to tell them before they leave that the blocks will last 12-24 hours, but at the first hint of pain to pop a couple percocets.

I called him at home around 6pm and he said he stopped at Subway on the way home and picked up a sandwich/chips/drink, and ate it without problems.

No opiods and minimal agent leads to minimal chance of post-op nausea, urinary retention, etc, minimal PACU stay, and a happy patient and surgeon. Become deft at regional techniques, dudes/dudettes.

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[4th year]

I never thought of regional anethesia as a method of decreasing incidence of post-op n/v via no opiods. Awsome idea and good case. Thank you.

 

[jem04]

The only thing you may miss (without the sevo) would be the obturator which could be important for tourniquet pain. We will often add a spinal to the above technique (which of course does increase prep time a bit and could impact PACU stay if you don't time it right). We have also been sending appropriate people home with femoral catheters and disposable infusion pumps. I agree regional is awesome.

 

[MDEntropy]

Thanks for the case Jet.

Jem with 30 ml in a femoral block, you should, theoretically, get the obturator and the lat fem cutaneous, no? (3 in 1?). Also, it is hard for me to see ADDING a spinal to a fem/sciatic block combo but you are saying this is being done at a place advanced enough to be sending people home with peripheral nerve block catheters? Doesn't that (the spinal) seem like overkill?

Jet,

What approach did you use for the sciatic block? I am just curious.

What about the choice of local anesthetic? If you are going to give such a large dose of bupiv, have you considered ropiv as an alternative (more costly of course). Or what about using tetracaine and possibly leaving the patient will be pain free until the next morning?

Did you use anything that you didn't mention - not that you would need to, I am just curious (e.g. lidocaine, nitrous, toradol, decadron)?

How often do you call your post-op patients at home?

Would you mine itemizing how much you can bill for that case? I imagine it would be something like:
Fem/Sciatic Block - x units (maybe 8)
GA with LMA for ACL - y units for start up (maybe 3)
1.75 hours of OR ( 7 units for seven 15 minute intervals)
So maybe it comes out to 18 units - and you would expect maybe $50 per unit for a total of $900. I may be way off here but I am just trying to understand how it works.

Thanks for your posts

 

[jetproppilot]

Thanks for the case Jet.

Jem with 30 ml in a femoral block, you should, theoretically, get the obturator and the lat fem cutaneous, no? (3 in 1?). Also, it is hard for me to see ADDING a spinal to a fem/sciatic block combo but you are saying this is being done at a place advanced enough to be sending people home with peripheral nerve block catheters? Doesn't that (the spinal) seem like overkill?

Jet,

What approach did you use for the sciatic block? I am just curious.

What about the choice of local anesthetic? If you are going to give such a large dose of bupiv, have you considered ropiv as an alternative (more costly of course). Or what about using tetracaine and possibly leaving the patient will be pain free until the next morning?

Did you use anything that you didn't mention - not that you would need to, I am just curious (e.g. lidocaine, nitrous, toradol, decadron)?

How often do you call your post-op patients at home?

Would you mine itemizing how much you can bill for that case? I imagine it would be something like:
Fem/Sciatic Block - x units (maybe 8)
GA with LMA for ACL - y units for start up (maybe 3)
1.75 hours of OR ( 7 units for seven 15 minute intervals)
So maybe it comes out to 18 units - and you would expect maybe $50 per unit for a total of $900. I may be way off here but I am just trying to understand how it works.

Thanks for your posts

Wuddup Entropy,

I use the posterior approach of Labat, using the PSIS, greater trochanter, draw a line, bisect the line, drop down 5 cm, insert the needle there. Thats the technique I learned and I know it well. BUT, I'd like to learn another less laborious technique, cuz it takes time to flip the patient lateral after the femoral block, find your landmarks, mark the midpoint, blah blah blah. But hey, it works until I can learn a better way.

We didnt use anything I didnt mention: no N2O, lidocaine, ketorolac, or decadron. Just midazolam, propofol, and a wiff of sevo.

I use bupiv because its the longest acting thing we have. I don't think ropiv would give me anything better than the bupiv, but tetracaine is an interesting suggestion- I'll have to look into that.

I like calling patients at home if I've performed something I think is innovative, just to get feedback. If you dont talk to the patient, you don't know if what you utilized really made a difference, right? If the feedback I get isnt good, I'll tweek the anesthetic. So far, all of our ACL patients have been very satisfied. The ones that are really happy are the ones that had a straight general for their first ACL, and endured the post op pain, N/V, etc; then you perform the regional stuff and they see...no, they FEEL...the contrast....and the superiority, of the regional blocks. Being able to eat a Subway sandwich on your way home from your ACL surgery speaks volumes, don't you think?

Your monetary estimates are pretty accurate, except we charge $58.00 a unit.

My humble opinion is that adding a spinal kinda kills the reasons why one does the fem/sciatics. A young patient post-op with a spinal will have a high incidence of urinary retention, and they won't be able to ambulate on crutches within an hour of the end of the surgery, so they'll be hanging out in PACU or day surgery until the spinal wears off. Doing just the fem/sciatic leaves the operative leg dead for 12-24 hours, but everything else works- namely the bladder and the non-operative leg, enabling the dude to jet outta day surgery an hour later and stop at Subway on the way home, and take a wizz when they reach their home bathroom.

 

[jem04]

Thanks for the case Jet.

Jem with 30 ml in a femoral block, you should, theoretically, get the obturator and the lat fem cutaneous, no? (3 in 1?). Also, it is hard for me to see ADDING a spinal to a fem/sciatic block combo but you are saying this is being done at a place advanced enough to be sending people home with peripheral nerve block catheters? Doesn't that (the spinal) seem like overkill?

I should clarify--- the technique that I described is what we are doing for total knees, not for ACL or other repairs. Also, the classically described 3 in 1 block may not be adequate for obturator coverage (although prob. >50% of pt.'s don't have cutaneous input from it anyway).

I also usually use the Labat approach for single-shot sciatic and the Raj for catheters unless the pt. can't be turned easily in which case the anterior approach is effective (although I think it is more difficult).

Here's one abstract about obturator coverage:
Anesth Analg. 2002 Feb;94(2):445-9, table of contents. Related Articles, Links


An evaluation of the cutaneous distribution after obturator nerve block.

Bouaziz H, Vial F, Jochum D, Macalou D, Heck M, Meuret P, Braun M, Laxenaire MC.

Department of Anesthesiology and Intensive Care, Hopital Central, Nancy, France. [email protected]

In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.

 

[jetproppilot]

Thanks for the case Jet.

Jem with 30 ml in a femoral block, you should, theoretically, get the obturator and the lat fem cutaneous, no? (3 in 1?). Also, it is hard for me to see ADDING a spinal to a fem/sciatic block combo but you are saying this is being done at a place advanced enough to be sending people home with peripheral nerve block catheters? Doesn't that (the spinal) seem like overkill?

I should clarify--- the technique that I described is what we are doing for total knees, not for ACL or other repairs. Also, the classically described 3 in 1 block may not be adequate for obturator coverage (although prob. >50% of pt.'s don't have cutaneous input from it anyway).

I also usually use the Labat approach for single-shot sciatic and the Raj for catheters unless the pt. can't be turned easily in which case the anterior approach is effective (although I think it is more difficult).

Here's one abstract about obturator coverage:
Anesth Analg. 2002 Feb;94(2):445-9, table of contents. Related Articles, Links


An evaluation of the cutaneous distribution after obturator nerve block.

Bouaziz H, Vial F, Jochum D, Macalou D, Heck M, Meuret P, Braun M, Laxenaire MC.

Department of Anesthesiology and Intensive Care, Hopital Central, Nancy, France. [email protected]

In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.

Nice post.

 

[militarymd]

Your monetary estimates are pretty accurate, except we charge $58.00 a unit.

How much do you get paid per unit?

Where I'm located, if you use regional as part of your anesthetic, you cannot bill for any additonal units....it is just part of the anesthetic...and we get paid only 45 per unit...I'm not sure how much per unit we bill.

If I use regional for post op pain management because of medical indication (failure of medical therapy, severe OSA, etc...) then we can bill/get paid for regional anesthesia...

By the way 300 mg of bupivicane seems like really pushing the envelope. I had a patient seize after 200 mg of bupi (65 kg patient) ....about 20 minutes after the block as placed....treated with 25mg of STP....patient seized again in 5 minutes...treated again with 50 mg of STP....patient seized again in 5 minutes...induced GA, and pray that the QRS interval doesn't widen.

Our orthopedic surgeons do ACLs in about an hour....regional is really over kill for us for post op pain control.

 

[jetproppilot]

How much do you get paid per unit?

Where I'm located, if you use regional as part of your anesthetic, you cannot bill for any additonal units....it is just part of the anesthetic...and we get paid only 45 per unit...I'm not sure how much per unit we bill.

If I use regional for post op pain management because of medical indication (failure of medical therapy, severe OSA, etc...) then we can bill/get paid for regional anesthesia...

By the way 300 mg of bupivicane seems like really pushing the envelope. I had a patient seize after 200 mg of bupi (65 kg patient) ....about 20 minutes after the block as placed....treated with 25mg of STP....patient seized again in 5 minutes...treated again with 50 mg of STP....patient seized again in 5 minutes...induced GA, and pray that the QRS interval doesn't widen.

Our orthopedic surgeons do ACLs in about an hour....regional is really over kill for us for post op pain control.

Overkill for post op pain control? Ever had a GA only for ACL replacement, Dude? I strongly disagree. Just watch an ACL after a strict general in the PACU, then watch an ACL in the PACU with fem-sciatic blocks placed pre-operatively. Absolutely no comparison. Pre-emptive analgesia theory predicts less post-operative opiod requirement following a regional anesthetic, with resultant
less post-op opiod use sequalae. In order to justify the extra workload imposed on myself by preoperative regional, I've called many, many day surgery patients at home the night of the surgery, both total general and combined GA-regional. Absolutely, positively, no comparison in post-op performance when they reach their residence. Less pain, less post-op N/V, less urinary retention incidence.
I've had one seizure in eight years of private practice, immediately following 30mL .5% bupiv interscalene block. Valium 10mg IV; no more seizures. I think benzodiazepam efficacy is higher than barbiturates in seizure ablation subsequent to local anesthetic administration. Just my humble opinion. Have never had a seizure following fem/sciatic blocks.
I disagree with your statement "If I use regional for post-op pain management...". I think this is where alot of clinicians miss the boat with regional anesthesia. Why not place the blocks BEFORE the case and exploit the analgesia intraoperatively? Like I said in my post, the blocks enable us to use zero opiods and minimal volatile anesthetic. Mind as well place them before. The patient benefits alot more.
Additionally,I think changing one's entire practice based on one bad situation is shorting yourself. Do anesthesia long enough, and something, some time will go awry.
And money is not the motivating factor with me and regional anesthesia utilization. Efficiency and patient/surgeon/personal satisfaction are, in that order. What is the workload of your PACU nurses with a GA only ACL? How much stuff do they have to give the patient in the PACU to make them comfortable, and how much anti-emetic do they have to give after all the opiods? Our PACU nurses check in the post-op ACL, watch them for 15-30 minutes, giv'em a Sprite to drink, then call the transporter to get them to day surgery. Rarely are rescue opiods/anti-emetics needed.

 

[jetproppilot]

How much do you get paid per unit?

Where I'm located, if you use regional as part of your anesthetic, you cannot bill for any additonal units....it is just part of the anesthetic...and we get paid only 45 per unit...I'm not sure how much per unit we bill.

If I use regional for post op pain management because of medical indication (failure of medical therapy, severe OSA, etc...) then we can bill/get paid for regional anesthesia...

By the way 300 mg of bupivicane seems like really pushing the envelope. I had a patient seize after 200 mg of bupi (65 kg patient) ....about 20 minutes after the block as placed....treated with 25mg of STP....patient seized again in 5 minutes...treated again with 50 mg of STP....patient seized again in 5 minutes...induced GA, and pray that the QRS interval doesn't widen.

Our orthopedic surgeons do ACLs in about an hour....regional is really over kill for us for post op pain control.

Just read your post again, and I think what you were implying is that because your surgeons do an ACL in an hour that regional is overkill. The incisions and osseous manipulation/trauma are pretty much the same in a one hour case vs. a 1hr 45 minute case, don't you think? 45 minutes more of operative time is not going to have any impact on post-op pain. Same procedure, same incisions. And again, alot of the advantages are realized by the patient after they leave the hospital, independent of intra-operative length of time.

 

[militarymd]

Difference in practice and opinion. My prior practice, we would do a number cases with just blocks...fem/sciatic...for just scopes...we would just do the block and send the patient down to the ortho clinic without any anesthesia baby sitters, so I know all about the benefits that you get from doing just regional.

My current practice, just about 100% GA. Part of this is insurance dependent. They won't pay for the block, unless there is a medical indication for it ....post op pain control not able to be managed medically.

You are absolutely correct that in the first 24 hours, there is less pain. Look at it at 48 hours....no difference.

A lot of the literature looking at regional anesthesia uses endpoints like "opiod sparing" effect. Well, our orthopedic surgeons really don't mind prescibing opiods, and the patients don't seem to suffer.

Sure, they are a little more uncomfortable in the PACU and the first 24 hours, but at 48 hours...no difference.

How about my first question? How much per unit do you get reimbursed?

 

[militarymd]

Just read your post again, and I think what you were implying is that because your surgeons do an ACL in an hour that regional is overkill. The incisions and osseous manipulation/trauma are pretty much the same in a one hour case vs. a 1hr 45 minute case, don't you think? 45 minutes more of operative time is not going to have any impact on post-op pain. Same procedure, same incisions. And again, alot of the advantages are realized by the patient after they leave the hospital, independent of intra-operative length of time.

Has it been studied? I haven't looked at the literature for that specific question, but from my observation, it does seem that length of time under surgical manipulation does affect severity of post op pain.

Back in 1997, I worked with one Ortho guy who took on average 8+ hours for ACLs with 2 + hours of TQ time...on and off obviously...I had to keep reminding him, and now I work with surgeons that finish in an hour. I always post op check all of my patients the next day.....there is definitely a difference.

Back in 1997, I felt a need to and actually put epidurals in for post op pain, now the patients all look like they just had knee scopes...

I assume that your ortho guys do their ACLs arthroscopically ...right?

 

[militarymd]

Additionally,I think changing one's entire practice based on one bad situation is shorting yourself. Do anesthesia long enough, and something, some time will go awry.

I would rather have 100% of my patients complain of PONV, then have 1 patient suffer cardiac arrest from bupivicain toxicity.

I had a colleague (he's fellowship trained Peds guy..15 + years of practice after training) who performed a caudal on a 6 week old for BIHR (1cc/kg 0.25 marcaine)...15 minutes later, he was doing chest compressions. Kiddo did fine, but he had to explain to the parents why the caudal was such a great idea again after the surgery.....he was rethinking regional and its benefits.

Look what happened to 0.75% bupivicaine ....all because of 8? pregnant women nation wide?

 

[jetproppilot]

I would rather have 100% of my patients complain of PONV, then have 1 patient suffer cardiac arrest from bupivicain toxicity.

I had a colleague (he's fellowship trained Peds guy..15 + years of practice after training) who performed a caudal on a 6 week old for BIHR (1cc/kg 0.25 marcaine)...15 minutes later, he was doing chest compressions. Kiddo did fine, but he had to explain to the parents why the caudal was such a great idea again after the surgery.....he was rethinking regional and its benefits.

Look what happened to 0.75% bupivicaine ....all because of 8? pregnant women nation wide?

So did the dude stopped doing caudals on all his patients?
We had a child when I was a resident code on the way to the PACU at a childrens-only hospital secondary to hypoventilation from post-extubation opiod administration. So what are we gonna do? Ban post-extubation opiod administration on the 15 thousand annual case load patients? Pedi-anesthesiolgist staff dude handled it like he was doing a crossword-established aggressive ventilation, chest compressions, atropine, kid comes back, pedi-MD dude goes back to his next job. I can still hear his words like it was yesterday:
"Bill, great example here- don't forget chest compressions so the medicine circulates..."
Don't get me wrong, dude. I see your point. But banning regional anesthesia because of a few morbidities when you're talking about hundreds of thousands of regionals performed annually, I just don't get it. If everyone followed that train of thought, heart surgeons, with their 2% mortality with a top of the line surgeon, would quit and go to work at Taco Bell.

 

[jetproppilot]

I would rather have 100% of my patients complain of PONV, then have 1 patient suffer cardiac arrest from bupivicain toxicity.

I had a colleague (he's fellowship trained Peds guy..15 + years of practice after training) who performed a caudal on a 6 week old for BIHR (1cc/kg 0.25 marcaine)...15 minutes later, he was doing chest compressions. Kiddo did fine, but he had to explain to the parents why the caudal was such a great idea again after the surgery.....he was rethinking regional and its benefits.

Look what happened to 0.75% bupivicaine ....all because of 8? pregnant women nation wide?

Alright, I'll stop. I respect your stance, bro. I've been doing this long enough to know theres about 20 ways to do any specific case. You're right, just a different practice style. But because of my training and matriculation into a practice that used alot of regional, I'm inclined towards the regional end. It'd be MUCH easier for me to put everyone to sleep. Hell, I could sleep 30 minutes more every day.
I'll have to check with the billing office, but I think we charge $58.00 a unit. 40 a unit sounds low to me. I know in Vegas they're in the high 60s. Sounds like you may wanna consider raising your rates, regardless of where you live.

And as a side note, I guess you're in the military. Thanks for all you do. I couldnt live the care free life I live without you guys.

 

[jetproppilot]

Has it been studied? I haven't looked at the literature for that specific question, but from my observation, it does seem that length of time under surgical manipulation does affect severity of post op pain.

Back in 1997, I worked with one Ortho guy who took on average 8+ hours for ACLs with 2 + hours of TQ time...on and off obviously...I had to keep reminding him, and now I work with surgeons that finish in an hour. I always post op check all of my patients the next day.....there is definitely a difference.

Back in 1997, I felt a need to and actually put epidurals in for post op pain, now the patients all look like they just had knee scopes...

I assume that your ortho guys do their ACLs arthroscopically ...right?

Ortho is a big player at our hospital. Some dudes do ACLs with scopes, some dont.

EIGHT hours for an ACL? OK dude, you and I could probably do an ACL in 8 hours using the Orthopedics For Dummies text. I don't think that can be used in defense when talking about times, say a 1 hour case compared to a 2 hour case. The post op pain in an 8 hour ACL patient was probably from the fascial elements coming together in the healing process.

 

[MDEntropy]

I should clarify--- the technique that I described is what we are doing for total knees, not for ACL or other repairs. Also, the classically described 3 in 1 block may not be adequate for obturator coverage (although prob. >50% of pt.'s don't have cutaneous input from it anyway).

So, am I reading from your (partially quoted) post that the tourniquet pain (which you mentioned in your first post in this thread) is due not to cutaneous innervation but muscular innervation? That is, you may block medial sensation but if you still have adductor strength you will get tourniquet pain? I don't see that from the abstract, but I think that is the point you are making - correct? I certainly didn't know that. Is that what you're saying?

I still have to say I think the spinal is overkill though? But you don't see it this way, so please tell me why you think a spinal is necessary for a total knee if you have done a fem/sciatic? I would love to hear your reasoning.

 

[jetproppilot]

So, am I reading from your (partially quoted) post that the tourniquet pain (which you mentioned in your first post in this thread) is due not to cutaneous innervation but muscular innervation? That is, you may block medial sensation but if you still have adductor strength you will get tourniquet pain? I don't see that from the abstract, but I think that is the point you are making - correct? I certainly didn't know that. Is that what you're saying?

I still have to say I think the spinal is overkill though? But you don't see it this way, so please tell me why you think a spinal is necessary for a total knee if you have done a fem/sciatic? I would love to hear your reasoning.

OK Dudes/Dudettes, take notes here- this is an invaluable asset of the internet and the subsequent creation of SDN- now MDAs, CRNAs, AAs, med students, residents, housewives, and bookies..from the USA, Columbia, Ireland, or wherever..can interact and exchange opinions... MDEntropy is inquisitive about a technical aspect of the dude's post...and scientific replies will follow...thats the beauty of this site...I don't think alot of the viewers realize that ten years ago this **** wasnt possible! Exploit this valuable asset, Grasshoppas...........

 

[militarymd]

So did the dude stopped doing caudals on all his patients?

I think you're missing my point. If we do enough of anything, we'll get complications. God knows, I've had my share of every type of complications related to putting people to sleep.

I'm just point out that by doing combined techniques, you're buying the complications of both techniques while the benefits are ....depending on who is looking ....not that great. Our ortho guys really don't care about the benefits that you talk about. They specifically ask for no blocks. Most of our surgeons get 2 rooms, so delay in case starts is not an issue. They don't see the benefits.....a little pain vs no pain at 24 hours....no difference at 48 hours.

I'm also an intensivist....and when I'm in the ICU, the benefits derived from regional anesthesia for post op patients there are zip.

We charge 80 per unit but get reimbursed 45 or 44. Do you get reimbursed the full amount that you charge?

Also, do you get to bill separately for your blocks when you also put them to sleep? We can't do that. Only for medically indicated blocks, and after surgery is done and patient has recovered from GA.

 

[jetproppilot]

Heres a great case, dudes/dudettes:

One of our ortho studs had five cases yesterday, the first being an ACL repair on a 31 year old healthy dude who popped his ACL on his first slope in Vail in February.

Patient in the holding area at 0640. Gave him midazolam 4mg and did the fem/sciatic blocks (bupiv .5% with epi, 30ml each site.). Done at 0655. Into the OR at 0710. Propofol 150 mg, LMA #4, sevo at 2% until after incision, then was able to back it down to .6% for the duration of the case, which took about an hour and 45 minutes. Gas off, LMA out. He was in recovery for 30 minutes, then back to day surgery long enough to get crutches, and he was out the door. I called him at 6pm and he was just starting to have a twinge of posterior knee pain.

What are the salient parts of this case? Its funny, when you first start anesthesia you're thinking about what cool drugs you can give, and the longer you do it, you try and figure out what you can withhold. WE GAVE NO OPIODS TO ACL DUDE! None. Nodda. Keep in mind if your blocks are good, you'll have great surgical-site analgesia, so actually the LMA/sevo was probably overkill. Our next step is to do these cases with just a propofol or precedex infusion and a nasal cannula. Not having to give opiods and being able to run justa whiff of volatile agent meant this dude woke up crisp with no post-op nausea, and no pain. The key is to tell them before they leave that the blocks will last 12-24 hours, but at the first hint of pain to pop a couple percocets.

I called him at home around 6pm and he said he stopped at Subway on the way home and picked up a sandwich/chips/drink, and ate it without problems.

No opiods and minimal agent leads to minimal chance of post-op nausea, urinary retention, etc, minimal PACU stay, and a happy patient and surgeon. Become deft at regional techniques, dudes/dudettes.

WHOA!!!

Great thread, being ascended.

Like VH1 Behind The Music.

Read and learn.

And question.

 

[jetproppilot]

Heres a great case, dudes/dudettes:

One of our ortho studs had five cases yesterday, the first being an ACL repair on a 31 year old healthy dude who popped his ACL on his first slope in Vail in February.

Patient in the holding area at 0640. Gave him midazolam 4mg and did the fem/sciatic blocks (bupiv .5% with epi, 30ml each site.). Done at 0655. Into the OR at 0710. Propofol 150 mg, LMA #4, sevo at 2% until after incision, then was able to back it down to .6% for the duration of the case, which took about an hour and 45 minutes. Gas off, LMA out. He was in recovery for 30 minutes, then back to day surgery long enough to get crutches, and he was out the door. I called him at 6pm and he was just starting to have a twinge of posterior knee pain.

What are the salient parts of this case? Its funny, when you first start anesthesia you're thinking about what cool drugs you can give, and the longer you do it, you try and figure out what you can withhold. WE GAVE NO OPIODS TO ACL DUDE! None. Nodda. Keep in mind if your blocks are good, you'll have great surgical-site analgesia, so actually the LMA/sevo was probably overkill. Our next step is to do these cases with just a propofol or precedex infusion and a nasal cannula. Not having to give opiods and being able to run justa whiff of volatile agent meant this dude woke up crisp with no post-op nausea, and no pain. The key is to tell them before they leave that the blocks will last 12-24 hours, but at the first hint of pain to pop a couple percocets.

I called him at home around 6pm and he said he stopped at Subway on the way home and picked up a sandwich/chips/drink, and ate it without problems.

No opiods and minimal agent leads to minimal chance of post-op nausea, urinary retention, etc, minimal PACU stay, and a happy patient and surgeon. Become deft at regional techniques, dudes/dudettes.

....

 

[Aether2000]

Interesting thread, but it has nothing to do with pain medicine. It is a great regional anesthesia thread, but we the practitioners of pain medicine do not do regional blocks of the sciatic or femoral nerves since the relief from painful syndromes is so short, regional blocks have little value.