General, Spinal, blocks, oh my 411 please

  1. I work on an orthopedic floor and am still feeling inadequate understanding the different anesthesia used and the implications for me as a nurse taking care of a pt the first 24 hours after surgery. We use generals, spinals, and intrethecals on our floor and then they've been using an adductor?? block. Don't understand exactly what that means. Honest I don't think all the other nurses really do either. I know generals they are put under and have some type of airway. Intrathecals I know that they're vitals are closely monitored for 24 hours and narcotic administration is discouraged. What I don't understand is how to know when blocks should wear off? Implications for pain management regarding the different anesthesia and implications on assessment findings I should/or should not expect from one anesthesia versus another. At the moment I kind of assess everyone the same, watch vitals closely, neurovascular checks, and address pain as it is reported. I'd like to be able to skim the post op anesthesia report if I don't get details in report and have a better clue what the info in thier reports means to me in caring for the patient. Mostly pain management implications. Also we have been using Exparel recently and the other nurses will say they used an abductor/adductor (sorry I'd have to get a chart open) block. From what I can tell from reading that has nothing to do with anything except the location of the block? I think what they should be sharing is the medication in the block because I would think one medication would be different than another. I also don't really understand why one is better than an other, why they choose one over another other than maybe pt history, but not got a firm understanding on this. Just feeling very inadequate in this area and keep trying to read on this, but just not finding great resources to answer the questions I have. Any links, info, books, podcasts, etc or just your personal two cents would be greatly appreciated.
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  2. 15 Comments

  3. by   offlabel
    An adductor canal block...

    The Adductor canal block - YouTube
  4. by   tsm007
    Quote from offlabel
    An adductor canal block...

    The Adductor canal block - YouTube
    That was helpful. Question though when an adductor block is used what kind of anesthesia usually goes with it to put them to sleep while the procedure is done?
  5. by   offlabel
    Quote from tsm007
    That was helpful. Question though when an adductor block is used what kind of anesthesia usually goes with it to put them to sleep while the procedure is done?

    Very generally if a peripheral n. block is going to be used by the surgeon for post op analgesia, it is for a knee procedure (i.e. ACL, TKA) and it is most usually done with a spinal or general anesthetic. ACB's are sometimes favored because some people think it allows early ambulation after surgery but others will say that the motor block you get with using a femoral n. block instead is a good trade off for the superior post op analgesia.

    A lot comes down to the procedure and the surgeon doing it. Bottom line is that a FNB or ACB is for post op analgesia, not intraop anesthesia, generally speaking. There isn't enough coverage in these blocks for the surgery itself so a spinal or general is needed for that.
  6. by   RainMom
    The meds used for the block are largely preference of the anesthesiologist. Most of ours use bupivicaine (Exparel) with maybe epinephrine & I know one that also adds dexamethasone. Really, I don't think you need to worry about exactly what was in the block cocktail, just its effectiveness.

    Most blocks in my experience are mostly worn off in 12-24 hrs. It can vary depending on who performed it & differences in pt anatomy. I've had pts come into PACU in 10/10 pain even after a block & others I cared for on the floor that continued to have mild numbness for over 24 hrs.
  7. by   tsm007
    Quote from RainMom
    The meds used for the block are largely preference of the anesthesiologist. Most of ours use bupivicaine (Exparel) with maybe epinephrine & I know one that also adds dexamethasone. Really, I don't think you need to worry about exactly what was in the block cocktail, just its effectiveness.

    Most blocks in my experience are mostly worn off in 12-24 hrs. It can vary depending on who performed it & differences in pt anatomy. I've had pts come into PACU in 10/10 pain even after a block & others I cared for on the floor that continued to have mild numbness for over 24 hrs.
    Yes, this is what I'm looking for. They just switched to Exparel and I think that it is not as great as they are hoping it to be. People are moving faster, but I'm having trouble anticipating pain needs with it.

    Also not quite sure why intrathecals are monitored so much more closely. Going to keep reading. I am big on understanding why things happen and most of the nurses I work with don't seem to care about the why of things. Understanding pharmacology, mechanism of action, and pathophysiology just puts the pieces together better for me. Thanks for the info and appreciate the comments.
  8. by   offlabel
    Quote from RainMom
    The meds used for the block are largely preference of the anesthesiologist. Most of ours use bupivicaine (Exparel) with maybe epinephrine & I know one that also adds dexamethasone. Really, I don't think you need to worry about exactly what was in the block cocktail, just its effectiveness.
    Well, that's the thing...what is in the "cocktail" determines the length of the block. Knowing this can help anticipate a window for when the patient will begin to hurt. Plain bupivacaine < bupiv c decadron = Exparel < PNB + catheter. Lousy block with whatever = pain. Talk to your anesthesia departments to get an idea of analgesia window for each kind of block.

    These are good questions because when a block wears off, it wears off and it hurts like hell. Starting PO's within that window is excellent nursing care.
  9. by   tsm007
    Quote from offlabel
    Well, that's the thing...what is in the "cocktail" determines the length of the block. Knowing this can help anticipate a window for when the patient will begin to hurt. Plain bupivacaine < bupiv c decadron = Exparel < PNB + catheter. Lousy block with whatever = pain. Talk to your anesthesia departments to get an idea of analgesia window for each kind of block.
    Since I work nights I pretty much never see our anesthesia people. But next time I see one I'm going to pick one of their brains.

    These are good questions because when a block wears off, it wears off and it hurts like hell. Starting PO's within that window is excellent nursing care.
    Yes, this! With them switching blocks recently I am getting different thoughts from different nurses and honestly not sure that any of them really know.
  10. by   tsm007
    Boy, I feel like a dummy. Okay, I watched this youtube video. Anesthesia options for knee surgery It was made for patients, but extremely helpful to me.

    I realize why I've been so confused. I'm mixing up the 'anesthesia' with the 'sedation'. Now this is all making so much more sense. I still have more reading/video watching to do, but this was an aha moment for me. Thank you for your help.
  11. by   tsm007
    Last question, I have been reading and searching, but lost here. What the heck is the difference between intrathecal and spinal? My searching is getting me nowhere on this.
  12. by   Bluebolt
    Quote from tsm007
    Last question, I have been reading and searching, but lost here. What the heck is the difference between intrathecal and spinal? My searching is getting me nowhere on this.
    Intrathecal and Spinal are two different terms to say the same thing. Intrathecal means they are injecting the local (or whatever) into the arachnoid space which lies right on top of the pia mater. If you went deeper than that you'd be in the spinal cord, causing damage. When people say "spinal" that's the space they are injecting the meds.

    Maybe you're trying to define the difference between spinal and epidural? The dura lies on top of the arachnoid space where we mentioned injecting "spinal" anesthesia. If you go one layer further out from the dura you enter this larger space called the epidural space. It's sandwiched posteriorly by the ligamentum flavum (named after that rapper Flava Flav I think) and this space is where and an epidural catheter is threaded and dosed. I've been told those are allowed to stay in for 24-48 hours for prolonged pain relief. Don't ask me about baracity and all that because I'll tell you just head on to CRNA school.

    Just did a case yesterday where we had a total knee arthroscopy and femoral nerve block was done. The surgeon didn't want any further block done beyond that because he likes getting his patients up moving post op quickly. General anesthesia was used for the procedure. Ropivacaine was the local of choice. Do I remember the PKA, no, probably not.
  13. by   tsm007
    Quote from Bluebolt
    Intrathecal and Spinal are two different terms to say the same thing. Intrathecal means they are injecting the local (or whatever) into the arachnoid space which lies right on top of the pia mater. If you went deeper than that you'd be in the spinal cord, causing damage. When people say "spinal" that's the space they are injecting the meds.

    Maybe you're trying to define the difference between spinal and epidural? The dura lies on top of the arachnoid space where we mentioned injecting "spinal" anesthesia. If you go one layer further out from the dura you enter this larger space called the epidural space. It's sandwiched posteriorly by the ligamentum flavum (named after that rapper Flava Flav I think) and this space is where and an epidural catheter is threaded and dosed. I've been told those are allowed to stay in for 24-48 hours for prolonged pain relief. Don't ask me about baracity and all that because I'll tell you just head on to CRNA school.

    Just did a case yesterday where we had a total knee arthroscopy and femoral nerve block was done. The surgeon didn't want any further block done beyond that because he likes getting his patients up moving post op quickly. General anesthesia was used for the procedure. Ropivacaine was the local of choice. Do I remember the PKA, no, probably not.
    Well maybe that's it. I see "intrathecal precautions" on our floor, but you know I think you may be right. I am going to start reading all the anesthesia notes and comparing it to what I hear in report and see if that this is just one in the same and I'm making it harder than what I need to be.
  14. by   tsm007
    Quote from Bluebolt
    Intrathecal and Spinal are two different terms to say the same thing. Intrathecal means they are injecting the local (or whatever) into the arachnoid space which lies right on top of the pia mater. If you went deeper than that you'd be in the spinal cord, causing damage. When people say "spinal" that's the space they are injecting the meds.

    Maybe you're trying to define the difference between spinal and epidural? The dura lies on top of the arachnoid space where we mentioned injecting "spinal" anesthesia. If you go one layer further out from the dura you enter this larger space called the epidural space. It's sandwiched posteriorly by the ligamentum flavum (named after that rapper Flava Flav I think) and this space is where and an epidural catheter is threaded and dosed. I've been told those are allowed to stay in for 24-48 hours for prolonged pain relief. Don't ask me about baracity and all that because I'll tell you just head on to CRNA school.

    Just did a case yesterday where we had a total knee arthroscopy and femoral nerve block was done. The surgeon didn't want any further block done beyond that because he likes getting his patients up moving post op quickly. General anesthesia was used for the procedure. Ropivacaine was the local of choice. Do I remember the PKA, no, probably not.
    Okay, I *think* I may have found the problem. I think the nurses I work with may just not be using precise terminology and that's why I am confused. Maybe???

    I found this article

    Spinal anesthesia should be performed using only local anesthetics, as intrathecal opioids increase the risk of urinary retention, pruritus, and respiratory depression19 unless low doses (less than 200 µg) are used, and may not have superior analgesic efficacy compared with LIA in TKA
    I think what they may be referring to is intrathecal OPIOIDS vs local anesthetic being used in the spinal. I think. I'm going to do some chart digging in the next few weeks but I think this is why I am seeing some people having "spinals" in report, but not on "intrathecal" precautions.

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