| Frequently Asked Questions |
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| Category #24 - Micellaneous RA and Ortho topics |
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Do you see muscular pain after your blocks?
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Typically, we do not. However, many of our patients still have access to other forms of analgesia besides their peripheral nerve block, and their use likely masks any muscular pains. Interestingly though, it is this exact reason why we developed our approach to the continuous cervical paravertebral block (Reg Anesth Pain Med 2001; 26: 68; Reg Anesth Pain Med 2003; 28: 241 - 4; Reg Anesth Pain Med 2003; 28: 406 - 13).
In a pilot study of 48 patients they all had posterior approaches to the roots of the brachial plexus and experienced no surgical pain, but demanded the painful catheter in their neck be removed. The extensor muscles of the neck are exquisitely tender in most humans. By performing this block in the window between the levator scapula and trapezius muscles, the neck pain seen with this block has largely been eliminated.
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What do you do if you have a negative Raj test?
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The Raj test indicates that at the moment the first mL of local anesthetic (or other solution) exits the catheter or needle, the current density is being dissipated from its tip. This signifies that the tip was indeed in close proximity to the nerve at the time of injection. This test was initially proposed by Raj as a means to ensure needle tip proximity to nerves with uninsulated needles. When using uninsulated needles, it is possible to have the needle tip several cm away from the nerve, yet still stimulate the nerve through the side of the needle. This test thus became important to establish whether or not the needle tip, and subsequently the local anesthetic, was near the nerve. With the use of insulated needles and catheters that have only a small exposed conductive tip, this test is less important. If we are able to stimulate the nerve at a low current, we know the local anesthetic will reach the nerve. Despite its diminished importance, we use the Raj test as a further means to guarantee our proper needle or catheter position. Therefore, a negative Raj test must mean that either the local anesthetic did not exit the catheter tip; the solution injected is a conductor of electrical current (water), or most likely that the tip moved in relation to the nerve at the time of injection. An intravenous catheter next to a nerve can still stimulate the nerve, but the Raj test will be negative.
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Where can I read, or even better still, see how to do these blocks?
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We have two new productions that you can order from http://RAEducation.com: "The Primer of Regional Anesthesia Anatomy" (which is a DVD and textbook); and "Orthopaedic Anesthesia: All the Blocks and Anesthetic Anatomy". (The latter is a DVD). Individual blocks can be downloaded from http://www.RAEducation.com
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Anesthetic anatomy is so different from surgical anatomy. Can you direct me to a good publication that deals with anesthetic anatomy?
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We have two new productions that you can order from http://RAEducation.com: "The Primer of Regional Anesthesia Anatomy" (which is a DVD and textbook); and "Orthopaedic Anesthesia: All the Blocks and Anesthetic Anatomy". (The latter is a DVD). Individual blocks can be downloaded from http://RAEducation.com.
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How can we arrange regional anesthesia workshops in our area?
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Please visit the website http://RAEducation.com and http://uianesthesia.com/rasci.
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Is there any relationship between epidural block and Epstein-Barr viral infection?
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I have no idea of the relationship with EB and epidural, but my instincts tell me to stay away from the epidural space for a while after such an infection. I would suggest sympathetic blocks to start off with then continuous low concentration low volume continuous sciatic block. I don't think the EB infection is her problem, I think the CRPS will bug her (and you) for some time to come.
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How can I learn more of continuous nerve blocks at the patient's home?
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We have just produced a booklet "CPNB at Home". This has all the protocols and how to set it up in it. You can download it free of charge from http://RAEducation.com. Go to Tutorials and see # 10.
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How can I get hold of your protocols for home-going catheters?
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| We have just produced a booklet "CPNB at Home". This has all the protocols and how to set it up in it. You can download it free of charge from http://RAEducation.com. Go to Tutorials and see # 10.
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Is there anywhere that patients can read about regional anesthesia?
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We have just produced a booklet "Understanding Nerve blocks". This has all the blocks, for what surgery and what to be careful of. You can get it at http://RAEducation.com. This booklet is especially valuable for nurses, physical therapists and other professionals like family physicians.
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I have just been appointed as Chief of Anesthesia at a busy and expanding ortho surgery center. I and another staff anesthesiologist who has attended your workshop in Iowa, are interested in increasing the amount of regional anesthesia performed here. In particular, our surgeons and we are interested in home catheter techniques for both upper and lower extremity surgery. I was wondering if you could share any protocols, patient information about these techniques, post-op discharge instructions, frequency of patient contact at home, etc.
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I believe this issue is very important and I also believe that a huge number of institutions are speeding into this without enough thought. I was one of them. At the Cape Shoulder Institute we did 4700 interscalene catheters and sent 2000 + of them home on the day of surgery. We attracted medico-legal attention 4 times and all four of these were associated with the removal of the catheter. So, in my opinion, a trained professional should remove catheters, but many others do not share this view.
Having said that, please find our planning how we are tackling this problem in our booklet CPNB's at home available at http://RAEducation.com (Tutorials # 10). You can also get a patient information booklet at the same source. You can adapt and adopt these to your practice if you so wish.
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Do you use cervical epidural anesthesia for CEA surgery?
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I have no experience of that and I do not know of anybody who has. I would think it is overkill. We have used high cervical paravertebral blocks (C3/4) performed similar to low cervical paravertebral blocks (See Boezaart et al. Reg Anesth Pain Med 2003; 28: 241 - 244). These work very well and take the danger of injury to the vertebral artery out of the equation. With high cervical epidural block, the phrenics will both be threatened. Please see Buchheit et al. Reg Anesth Pain Med 2000; 25: 313 - 317 for a good reference on cervical epidural block.
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Where are blocks performed at the University of Iowa Hospitals?
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We have designated block areas in our ambulatory center, as well as in the chronic pain clinic. Both of these areas are in close proximity to the operating suites.
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Who does these blocks?
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Anesthesiologists (faculty and resident) that are assigned to the particular case do the blocks. We have a dedicated junior resident who rotates through regional anesthesia for a two-week period. This resident studies anatomy on our pre-dissected plastinated cadaver during this time and provides the ongoing anesthetic, while the faculty and resident perform the block on the next patient. We like to be very sure that the block is perfect before we take the patient into the OR. We like to place the first two blocks of the list before the list starts in the ASC. That way we can do the third block during the changeover between numbers one and two. Number two will then be well set-up and number three will have the time taken for number two to set-up. Similarly we like to do number four in the turnover time between two and three. We have no problems doing cases under light general anesthesia when indicated. A favorite sedation is a meperidine and midazolam combination in combination with a solid block.
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