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  • Case presentation- Ulnar nerve decompression



    66 year old male scheduled for Ulnar nerve decompression/ CTR.

    PMH:
    HTN
    GERD
    OSA
    tonsillar cancer
    Cancer base of tongue/ radiation and radical neck dissection

    PSH:
    Microlaryngoscopy w biopsies (done under deep sedation with pt SV)
    Removal of mass, base of tongue (DL X2 /second one was with glidescope view of cords, unable to pass tube...used fiberoptic scope to assist passage)

    Bilateral radical neck dissection with reconstruction using free flaps, trach

    Closure of trach

    So, you have gotten your assignments for the next day and have this history on one of your patients. What is your plan? What questions do you have?
    This article was originally published in forum thread: Case presentation- students weigh in started by nurserebecca View original post
    Comments 22 Comments
    1. nurserebecca's Avatar
      nurserebecca -
      Quote Originally Posted by ABCRn View Post
      Finish assessment- allergies? What medications currently taking and which ones today, reaction to past anesthestic, NPO status, labs, ROS. I would like to do this with regional anesthesia and light sedation but the question is can patient undergo block, will patient accept block and what is my plan to secure the airway in the event of catastrophe - I would want to see past anesthesia records with the understanding that airway can be completely different tomorrow. With anatomy have to assume that LMA may not seat (and if GERD is uncontrolled this is not an option), that masking pt with OSA and radiation to tissue of neck/scar tissue is going to make mask ventilation difficult and have high risk of loss of control of airway. I'm thinking awake fiberoptic intubation if we need to do GETA with extubation of patient fully awake. Crich kit and difficult airway cart in room. If regional case, again difficult airway cart and fiberoptic scope in room...that's all I can think of for now (Friday)....
      Good thinking
    1. nurserebecca's Avatar
      nurserebecca -
      Any concerns about free flaps?
    1. nurserebecca's Avatar
      nurserebecca -
      Hmmm, I have never done a bier block for any procedures above the wrist. Have you? Unfortunately, we do not have a bier block tourniquet.
    1. Shane's Avatar
      Shane -
      Quote Originally Posted by ckh23 View Post
      To add on, this airway sounds like it could be a disaster and possibly already has tracheal stenosis. I would be think a bier block would be the safest option without getting involved with airway and avoid possible intra-vascular injection with regional.
      A Bier block? I would never trust it for anything more than a quick hand case that can be supplemented with local if needed. I would do an chose an infraclavicular block.
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by nurserebecca View Post
      Hmmm, I have never done a bier block for any procedures above the wrist. Have you? Unfortunately, we do not have a bier block tourniquet.
      I've done Bier blocks for these exact cases on multiple occasions, and have never had a problem. It does depend a little on the surgeon and how high up the upper arm they carry the ulnar nerve incision. You have to make sure to get the cuff as high into the axilla as possible, and use the smallest tourniquet you can. I routinely get a solid 60 -90 minutes from Bier blocks. I think they are getting to be a lost art and an under-appreciated technique.
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by ckh23 View Post
      To add on, this airway sounds like it could be a disaster and possibly already has tracheal stenosis. I would be think a bier block would be the safest option without getting involved with airway and avoid possible intra-vascular injection with regional.
      Not to bust your nuts, but where do you inject the local when doing a Bier block?
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by nurserebecca View Post
      Unfortunately, we do not have a bier block tourniquet.
      I guess I'm not aware of a specifically labeled bier block tourniquet, but a bier block tourniquet is not needed. you can supplement with manual BP cuff and IV tourniquet, two IV tourniquets (poorest of the poor man's techniques), or two automatic compression tourniquets.
    1. ckh23's Avatar
      ckh23 -
      Quote Originally Posted by pdsr View Post
      Not to bust your nuts, but where do you inject the local when doing a Bier block?
      I know you are injecting the lido into an IV. My thinking was an inadvertent vascular injection during regional with a different local could lead down a bad road of needing to secure a difficult airway in an emergency.
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by nurserebecca View Post
      Hmmm, I have never done a bier block for any procedures above the wrist. Have you? Unfortunately, we do not have a bier block tourniquet.
      We don't have one either. ... we just use the regular ortho tourniquet... Granted our bier block cases last 20 min.


      ........

      I'm not sure about a nerve block like an infraclavicular... If there was any damage post op the block would be the scape goat
      Although granted an EMG could figure that out.
      Sent from my Nexus 4 using Tapatalk
    1. Shane's Avatar
      Shane -
      I'm not sure about a nerve block like an infraclavicular... If there was any damage post op the block would be the scape goat
      Although granted an EMG could figure that out.
      Sent from my Nexus 4 using Tapatalk[/QUOTE]

      I don't buy the argument of not doing a PNB because of the chance of nerve injury. The chance of any substantial nerve injury is extremely rare. We probably do over 1500 PNBs a year as a group and get an occasional call every few months with a complaint of paresthesia.
    1. RAYMAN's Avatar
      RAYMAN -
      Any reason you can't use a LMA?
    1. BuckeyeRN's Avatar
      BuckeyeRN -
      Quote Originally Posted by RAYMAN View Post
      Any reason you can't use a LMA?
      Depending on the severity of the GERD and also my concern about being able to mask the patient secondarily to the other neck surgeries/radiation would be my argument about not going that route. The patient's I have seen s/p neck/throat CA with radical necks and radiation were not pretty airways.

      I have not done a bier block for something above the wrist/distal forearm but would definitely be an option. Otherwise my thoughts are either supraclavicular or axillary block. If GA must be done then its going to be an awake FOI and my primary recipe for that is precedex and some lidocaine spray.

      From previous record, what size tube passed and make sure that size ETT will fit on whatever FO scope you have in the room. (Don't ask how I found this tidbit out)
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by BuckeyeRN View Post
      Depending on the severity of the GERD and also my concern about being able to mask the patient secondarily to the other neck surgeries/radiation would be my argument about not going that route. The patient's I have seen s/p neck/throat CA with radical necks and radiation were not pretty airways.

      I have not done a bier block for something above the wrist/distal forearm but would definitely be an option. Otherwise my thoughts are either supraclavicular or axillary block. If GA must be done then its going to be an awake FOI and my primary recipe for that is precedex and some lidocaine spray.

      From previous record, what size tube passed and make sure that size ETT will fit on whatever FO scope you have in the room. (Don't ask how I found this tidbit out)
      You can do a Bier Block fairly easily, even for things up to the elbow. Just raise the arm and inject with it in the raised pisition, thus making the elbow area the dependent position(not saying it will be the best choice, but you can easily do it).

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. bettermj's Avatar
      bettermj -
      Bier Block. Supplemental O2/N2O w nc, versed, fent.

      Have backup AW issues at hand (OAW, lma, oetts, etc).

      And like mentioned above, there are numerous ways to do the BB.
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      If I couldn't do regional, I think an awake fiber optic would be indicated on account of possible difficult intubation and aspiration risk.
    1. nurserebecca's Avatar
      nurserebecca -
      Part II. So I see the patient preop. Airway exam, MP III, Mouth opening 2FB, I look in the mouth and his uvula is deviated to the left (patient's right). Tongue looks normal. He is Edentulous, but his gum and intraoral tissue looks very friable. His neck is indurated and red with bilateral scars. I ask him if he knows which side of his neck/chest that they "hooked up" the vessels of his free flap, he doesn't know. I notice that he has a portacath on the right and can trace the catheter up over his clavicle.

      GERD is controlled on meds, and patient has had feeding tube placed because of dysphagia. He denies any buildup of secretions or choking, he can lay flat.

      I get the ultrasound to look at his anatomy, and do not find any apparent pedicle flap inserted on the operative side in the supraclavicular area.

      I decide to do a supraclavicular block and have the surgeon add local for the CTR. My backup plan is #1 NPA inserted and deep sedation/ general with TIVA. #2 attempt LMA placement #3 glide scope with fiber optic to manipulate ETT .
    1. squeezingthebag's Avatar
      squeezingthebag -
      Quote Originally Posted by bettermj View Post
      Bier Block. Supplemental O2/N2O w nc, versed, fent.

      Have backup AW issues at hand (OAW, lma, oetts, etc).

      And like mentioned above, there are numerous ways to do the BB.
      Do you use nitrous via NC often? Never have but I'm intrigued. What kind of cases? Do you just use that little circuit adapter thing that comes in the NC bag?
    1. JoshCRNA's Avatar
      JoshCRNA -
      Quote Originally Posted by squeezingthebag View Post
      Do you use nitrous via NC often? Never have but I'm intrigued. What kind of cases? Do you just use that little circuit adapter thing that comes in the NC bag?
      It's worked well for me in the past. Probably a bit more effective with a simple FM for a higher inspired % N2O.

      Actually saved a deep MAC I did recently for a ganglion cyst that turned out to be something else, and our single TQ bier block at 45 minutes or so resulted in our patient moving the operative arm quite a bit despite midazolam/fent/prop/ketamine. Threw on some nitrous and the patient finished the last 20 minutes or so without a single problem.

      Don't know how effective it is but I will take the suction tubing and set it under the drapes and close to the mask in hopes of reducing polluting the OR to some extent.
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by nurserebecca View Post
      Part II. So I see the patient preop. Airway exam, MP III, Mouth opening 2FB, I look in the mouth and his uvula is deviated to the left (patient's right). Tongue looks normal. He is Edentulous, but his gum and intraoral tissue looks very friable. His neck is indurated and red with bilateral scars. I ask him if he knows which side of his neck/chest that they "hooked up" the vessels of his free flap, he doesn't know. I notice that he has a portacath on the right and can trace the catheter up over his clavicle.

      GERD is controlled on meds, and patient has had feeding tube placed because of dysphagia. He denies any buildup of secretions or choking, he can lay flat.

      I get the ultrasound to look at his anatomy, and do not find any apparent pedicle flap inserted on the operative side in the supraclavicular area.

      I decide to do a supraclavicular block and have the surgeon add local for the CTR. My backup plan is #1 NPA inserted and deep sedation/ general with TIVA. #2 attempt LMA placement #3 glide scope with fiber optic to manipulate ETT .
      Nice
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by Shane View Post

      I don't buy the argument of not doing a PNB because of the chance of nerve injury. The chance of any substantial nerve injury is extremely rare. We probably do over 1500 PNBs a year as a group and get an occasional call every few months with a complaint of paresthesia.

      Yeah you and I know the risk is vanishingly small, but to an ortho surgeon the nerve injury is caused by the block 100% of the time, even if it was something like an ulnar nerve transposition. I like the idea of a beir block.


      Sent from my Nexus 4 using Tapatalk