Видео

Typically we don't ablate these at the mid-thigh. The infra-patellar branch of the saphenous is often ablated (or treated with cryo-analgesia) on the medial side of the knee joint. I'd be concerned about ablating the nerve to vastus medialis...while it doesn't seem to contribute much to gross motor power in postop patients for a few days, I wouldn't want to knock it out for several months. Thanks for watching!

Thanks for watching!

@@regionalanesthesiology I’m quite experienced and comfortable with the “standard” blocks, and place multiple blocks daily, but I had never before placed IPACK. I looked at multiple IPACK videos. To me, your video seemed clearest and safest. It resonated with me. Soooo-after informed consent-in which I explained the previous information to the patient-and patient requested block-For postop pain, I used your video to place an IPACK in addition to an adductor canal block. The patient was thrilled. Said it’s the first time pain-free since knee injury! Today-patient still happy he had the block. I added dexamethasone and stayed low dose as you recommended and all is well. Thank you!

There are certainly different ways to get the same result. We do genicular blocks because it’s an image-guided, consistent, reproducible way to block those nerves at the knee, and we get excellent results. Obviously we take care to use aseptic technique. Surgeons infiltrating blindly is…just ok. It’s notoriously inconsistent, is operator-dependent, and they frequently miss things. I do appreciate that some centers get good results combining approaches as you suggest. I’m quite biased, but my personal take is let the surgeons cut bone, and leave the analgesia and local anesthetic use to the experts. 😊

@@regionalanesthesiologyIm very pleased for your answer. Im from germany and follow you intensively and appreciate your take on the subject. your participation in the pajunk videos were very stimulating and most of the information that i share with residents derive from your knowledge. maybe one time we meet to share our passion for regional anesthesia. BUT unfortunately surgeons are a very sensitive kind and endoprothetic infections renders most operators superstitious to practices on the operating field. i dont have the capacities or backup to provide studies which compares combined focused genicular blocks by surgeons in combination with NVM and Saphenus nerve blocks respecting toxic LA levels. Maybe you re bringing insight inti this in the future. i d be very interested ☺️

O plano anestésico dependerá do procedimento cirúrgico que você fará. Normalmente combinamos anestesia geral com bloqueios nervosos para manter os pacientes o mais confortáveis ​​possível

Eu perguntaria ao seu anestesista se é apropriado

Nope, if you keep the needle sterile you can prep the skin on both sides and use the same needle for both. Thanks for watching!

Thanks very much for watching!

Glad it was helpful, thanks for watching!

Yes, I think that's a great way to do it. It's pretty quick to do so you're not going to take up a lot of surgical time, and it avoids the discomfort of needling the periosteum while awake. Thanks for watching!

Thanks for watching!

Thanks for watching!

Thank you, more to come!

Thanks for the comment. Yes, agree, something to watch for. The inferior epigastric vessels are surprisingly large (and therefore at risk) but can be missed on ultrasound. I always turn on the color Doppler to double-check before inserting the needle.

Thanks so much!

I use them once spinal anesthesia has been applied or just before taking the patient to PACU; if under GA just after intubation or before waking up the patient, it all depends of how much time the surgeon leaves me alone doing my job; so far haven't have no single "ouch" from that many punctures.

Thanks for the questions--yes, it can be a number of pokes. The geniculars especially can be a little uncomfortable when the needle hits the periosteum, but a little sedation/analgesia goes a long way. I personally like to do my spinal FIRST in preop, then immediately do the adductor, ipack and genics (I'm also now doing anterior femoral cutaneous nerve blocks too for the skin). The whole thing (spinal plus blocks) can be done in less than 10-15 min once you're up to speed, and well tolerated after the spinal goes in. We had to get our preop nurses comfortable with the idea of a patient getting a spinal out of the OR, but were able to show them it's safe and effective. Good luck!

Start on what you think is the midline with the probe in the saggital orientation. You’re looking for the spinous process as you see the images in this video. Once you find the spinous process, rotate your probe 90 degrees and tilt slightly superior, or adjust slightly superior. That’ll show you the “bat sign”

You're not alone...it's sometimes tricky. Play with the tilt of the probe--try angling it slightly towards the head and then slide up or down several millimeters. Also, those spaces also get smaller as we age and the discs compress. While you're getting used to the technique, try scanning younger people to get used to their juicy anatomy, then as you get more confident you'll be better with the oldies. I brought my teenage kids in on a weekend and scanned their backs and it was amazingly different (and rewarding!). Good luck!