How to Choose Local Anesthetics for Nerve Blocks - Crash course with Dr. Hadzic

[@nysoravideo]

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[@serhatsoylu2880]

As an anesthesiologist, pharmacology of the drugs which we use in daily practice is one of the most important part of our job. But it is sooo boring to read and learn. I always forget which drug has which type of pharmacologic action. When i watch this video i became more confident about local anesthestics. This video shows us how we could use basic science knowledge in our daily practice. Thanks Dr Hadzic..

[@MegaPoliyo]

In the UK you have to pass exams so you know this stuff or leave the career.

[@serman51]

@@MegaPoliyo that is called memorizing the knowledge to be able to pass the exam. Try to remember pharmacokinetics of the local anesthetics or any other drug 5-10 years after passing those exams.

[@DRBLUESNYC]

@@serman51 Indeed - cramming and memorizing are two different things. This is why I mention "street-wise approach" - or pragmatic knowledge that is immediately applicable to clinical practice, not only exams. Greetings to all

[@MegaPoliyo]

@@serman51 im pretty sure anyone with the FRCA can recall all of this info but I know that the UK exams are notoriously some of the hardest anaesthesiology exams in the world. Plus our training is 9 years compared to the American 4. So it makes sense. But still, I'm surprised, this feels like something a first year would be learning but the comments seem filled with experienced people... Perhaps it's because regional is relatively new so the newer trainees see this as standard stuff whereas some of the older more experienced guys have long since forgotten this. Either way it's a quality video.

[@brandonmadsen9997]

@@MegaPoliyo 9 years? are you including medical school as well? if so, then the American training schedule is 8 years. Are fellowship years following residency in the UK as well? Roughly 50% of American anesthesia grads do a fellowship year, so in that case they too would be training 9 years.

[@alcruz8094]

Amazing. Thirty years in anesthesiology and I´ve never seen an explanation so clear. Congratulations.

[@DRBLUESNYC]

Street-smart approach!

[@DRBLUESNYC]

Super happy to hear that these efforts are useful! Best regards

[@thepowerofpositivity8075]

For all anesthesia providers: Just as any fields, if you don’t use it you loose it! So if you don’t use neuraxial anesthesia and peripheral nerve blocks frequently in your practice, this is a good review of local anesthetics. Cheers :)

[@shielas5903]

i love NYSORA!!! It helped me through CRNA school and now I'm working and watching your videos. thank you so much Dr. Hadzic!!! Godsent!

[@nysoravideo]

Wonderful! Happy to help!

[@nysoravideo]

Thank you Shiela! Glad you like the video. Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up - let's share our clinical experience!

[@MrAnakindra]

Good presentation. The online thing is that the real length of the blocks is realistically much shorter. Patientens are gonna start feeling some pain after 3-4h, if we take Ropivacaine as an example. The described length of action for individual anesthetics is based on their elimination time (2 - 3 half-value times), but the clinical effect starts to diminish much earlier.

[@sherrydawson6253]

Just found u some iis over my head but watched it twice. I'm just a former nurse but always learning! Thank u.

[@DRBLUESNYC]

Thank you for your feedback. Awesome!

[@scottrobinson2678]

This corresponds well with my practice of over 35 years. A couple of features not mentioned here are the relative motor vs sensory blockade (for most long lasting blocks, we only want sensory blockade). Also, near toxicity of LA given in high concentration. For most upper extremity surgery I prefer Lidocaine 1.5% for speed of onset and density of block (usually mixing in a small amount of HCO3 not mentioned). For these cases, I do not want prolonged motor blockade especially if the patient is going home. In a resident situation, I found it very difficult to convince the ortho residents to infiltrate their wounds with bupivacaine on closure. Thanks Dr. Hadzic. I've had to explain the dilution effect of mixes to most residents and many surgical attendings.

[@nysoravideo]

Hey Scott Robinson! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works 4 you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!

[@stefanofresilli2749]

I write for comparison with colleagues, in our centre we often use a mixture of local anaesthetics, with low concentrations of long acting anaesthetics (e.g. ropivacain 0.15%) with high concentration of short acting anaesthetics (e.g. 1.5% mepivacain) to ensure a shot acting motor blockade with a long acting sensory blockade, do you agree with this approach, do you do similar things in your hospital?

[@joseramoncabanas]

Excellent practical recomendations! It´s a pleasure watching these amazing videos where we can review the principal aspects of anesthetic drugs. But we have to consider four different aspects: 1. Medical level depending in high and low-income countries. 2. Operator factor. Sometimes you don´t really know how long is going to be the surgery, depending on the doctor. 3. Take care of toxicity doses. We forget it too frequently. 4. Be ready for an alternative anesthetic plan (Plan A, Plan B, ....) and a rescue anesthetic plan. Thanks a lot!

[@DRBLUESNYC]

Both of your comments are 100% correct! Thank you and greetings.

[@chris002able]

Put your teleprompter above the camera for a better look. Favorite video by content though!

[@JamesSims]

I am scheduled for this surgery in five days. Listening to your explanations was completely accessible to me. I now understand a whole lot more than I ever have and it sounds as though your choice of anesthesia is what I am going to request. I also would love to “look over the surgeons shoulder“ to better understand what is going on inside of my body. Thank you for your concise and explicit knowledge sharing!

[@nysoravideo]

Thank you for sharing James and thanks for watching!

[@gdhhayes2129]

I'm here a year later for the same reason; upcoming surgery. I feel so much better about it as I'm becoming empowered by knowledge and recognizing my choices.

[@asociacionveterinariabasat8054]

Excellent speech, hats off!

[@nysoravideo]

Thank you for your feedback!

[@carlos12485]

Im a veterinarian and I work with horses and so many times we used to use lidocaine to block nerves on their forelimb and handlimb and I love your video if you could add subtitles that would be incredible because I dont have the 100% of the english. Anyway very godo video.

[@nysoravideo]

Hi Carlos12485, thank you for your comment. We invite you to download the NYSORA Veterinary RA app. There you will find all the tips and tricks of the Nerve Blocks performed in animals. Here is the link: Android: play.google.com/store/apps/details?id=com.nysoravet.app iOS: apps.apple.com/tr/app/nysora-vet-ra/id1573219253 Instagram: instagram.com/vet_anesthesia/?

[@mirmahmud1438]

Thank you very much sir for your extraordinary presentation about LA which was very complicated to me before your presentation..hope to get more like this..

[@DRBLUESNYC]

Great, thanks for the feedabck

[@장대양봉-y7k]

Thank you for the excellent presentation

[@nysoravideo]

Glad it was helpful!

[@gasparborism]

What are you thoughts about ropivacaine 2% and 7,5%?

[@DRBLUESNYC]

The highest % of ropivacaine commercially available is 1%. The same for bupivacaine - 0.5% is the highest (there are higher concentrations for spinal anesthesia, though). Best regards

[@zulzulkifli2461]

He probably means 0.2% and 0.75%...dr.hadzic....

[@davidbernstein3514]

wondering how you chose to dismiss decadron as a useful additive to 0.5% bupiv blocks? that data is pretty good, certainly better quality data then Experel?

[@MegaPoliyo]

Shares in experel

[@DRBLUESNYC]

Hi David. Dexamethasone perineurally is in our opinion - simply systemic effect, like an IM or IV injection. Here’s data that I trust: Br J Anaesth. 2013 Sep;111(3):445-52. There are other publications that do show some variable and inconsistent benefit, but you need to make up your own mind based on the available data that you trust. In any event - if dexamethasone indeed can cause/prolong nerve blocks, clinicians would be using it instead of local anesthetics as well. This is not the case, and there are no steroid-specific receptors or mechanism of action that is logical. Therefore, our understanding is - systemic benefit. EXPAREL. Every study that compared Exparel vs Placebo documented sustained benefit up to 72 hours (femoral block: Anesthesiology. 2016 Jun;124(6):1372-83, interscalene: Pain Med. 2020 Feb 1;21(2):387-400, epidural: Reg Anesth Pain Med. 2012 Nov-Dec;37(6):616-22). Its pharmacokinetics are also consistent with the data on pain/sensory block duration as well (Clin Drug Investig. 2013 Feb;33(2):109-15). I also experienced EXPAREL effect as a patient, an interesting experience that attests to its efficacy when used properly. Greetings from NYSORA!

[@dbash3428]

@@DRBLUESNYC Thank you for all that you do and making these great educational videos. I think the keyword in your response that should be highlighted is PLACEBO. That tells us that exparel is better than nothing/ injecting saline around a nerve. As I’m sure you are aware the Feb 2021 Anesthesiology journal had a meta-analysis concluded that exparel had a “clinically unimportant improvement in the AUC of postop- erative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and func- tional outcomes. High-quality evidence does not support the use of peri- neural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.”

[@DRBLUESNYC]

@@dbash3428 Hi Bash. Indeed - PLACEBO. But that is the FDA standard for approval of new drugs. And yes, the Meta-analysis did conclude "clinically unimportant improvement". However, the meta-analysis also included data from the clinical registries that have not been published and have not met the peer-review rigors. In fact, in one of our next videos - soon - we will explain the Exparel saga and break down the misconceptions about this formulation of bupivacaine.

[@lucasarnold1399]

Great presentation, good work. Thank you for your effort

[@nysoravideo]

Glad you liked it!

[@mohammadnoufal4723]

Could you discuss Local anesthesia choice for spinal and epidural ?

[@DRBLUESNYC]

Will do in one of our future videos. Greetings

[@ariakowsarian9057]

Amazing presentation, very practical and useful

[@nysoravideo]

Glad it was helpful!

[@sufyanbaradia1534]

Amazing presentation… Can we use lidocaine 1-2% for spinal anesthesia ?

[@Chacha-rb6ir]

Thumb’s up for you, thank you so much.

[@nysoravideo]

Glad it helped!

[@chaitanyasejekan482]

Excellent and sweet presentation sir I always love to see your videos which is more informative and learn new things 🙏🙏🙏

[@nysoravideo]

Thank you for your kind feedback!

[@iaposner]

Great presentation, thank you for this. Question: So adding dexamethasone is not an option to prolong nerve blocks?

[@MegaPoliyo]

Doesn't prolong the block but the antiinflammatory action will reduce localised inflammation and reduce subsequent sensitisation so you will reduce chronic pain and reduce the intensity of post block pain but not the block itself.

[@iaposner]

@@MegaPoliyo Understood, thank you.

[@DRBLUESNYC]

It is, But it's effect is systemic only, so easier to administer IV, rather than mixing with local anesthetics. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, Carlier S, Missant C, Van de Velde M. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth. 2013 Sep;111(3):445-52. doi: 10.1093/bja/aet109. Epub 2013 Apr 15. PMID: 23587875.

[@sabihashaikh6180]

That was clear and comprehensive.thanks

[@nysoravideo]

Thank you Sabiha Shaikh! Glad it is helpful. Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up very soon! Cheers!

[@TheGeezzer]

Very painless explanation, thank you.

[@simerpaulmariano9231]

Thank you..

[@johnkidd1694]

NYSORA stuff is some of the most useful educational material out there.

[@nysoravideo]

Hi John, Thank you for your comment. Make sure you watch the latest releases as well. Greetings from NYSORA!

[@Genn3k]

Is there a difference in the quality (sensitive or motor) of the nerve block between Lidocaïne 2% et Mépivacaïne 1,5% ? Do you have an explanation why most of the time, this is the Mepivacaïne whish is used and not the lidocaïne ? Thanks a lot for your videos and your answers. Best regards from Paris

[@robertonardi9340]

Dr, is there any relation with the volume of AL and the block duration? Thanks

[@botiyowmohamed1959]

Thank you Dr

[@nysoravideo]

Very welcome!

[@mapro24]

Gracias!

[@docanamika510]

Thankyou sir 🙏🏻well explained

[@nysoravideo]

Always welcome!

[@АнараАжикеева-ф1и]

Thank you very much ❤

[@nysoravideo]

You're welcome 😊

[@Abu-cy7jp]

Thanks sir

[@Bushehri1]

Incredible as always Doctor Hadzec! ❤, An Essential and easy explanation for Anesthetic, the illustrations looks like netter's 👍,please in Toxicity each X will be how much in percentage means % ? and what was the A- 100mM means too at 4:00 minutes please? Thank a lot for the lecture 🙏

[@cristobalroig]

hello can you ddo one chapter on Pudendal neuralgic block nerve please

[@nysoravideo]

Hi Cristobal! Thank you. This is a great suggestion, we will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best regards from NYSORA!!

[@WAFIKAMIN1]

Thanks a lot dear

[@rashidjumamohamed3437]

Thank u so much

[@nysoravideo]

Most welcome 😊

[@joestevenson5568]

"These are the ONLY local anaesthetics relevant to clinical practice" Cocaine, Prilocaine and Articaine getting snubbed hard

[@surabhistories]

Please make a video on dexmed as additive

[@nysoravideo]

Hi Surabhi! Noted!

[@jch6240]

The best crystal clear presentation about LA ever .

[@nysoravideo]

Glad you liked it!

[@iaposner]

Again thank you for your great presentation. I have a question, if you to get a faster onset and a longer sustained block, how to proceed when doing a single needle block (no catheter). Should you not still mix early onset med with longer duration med?

[@nysoravideo]

Hey Israel Posner! Yes - you can mix, but better yet - simply increase the concentration of the local anesthetic. An example - instead of mixing ropivacaine 1% and lidocaine 2% - use 1% ropivacaine; the onset will be similar to the mixture, if note faster. And thank you for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!

[@hammoudalesbonsplans1522]

Excellent presentation , in my opinion Lidocaine 2% is more faster than Bupivacaine 0,5% because of PKA lower in Lidocaine . For mixing LA i dont use that in the same preparation ( but possible in different sites ) cause toxicity of LA is additive . I use Dexamethasone IV to prolong effect of LA and sometimes Clonidine in nerve . What do you think Professor?

[@nihadk8393]

What is your opinion on using fentanyl alongside Bupivacaine, I've done it a few times, and noticed a very fast onset, but BP drops way faster (in case the patient didn't receive enough saline) .

[@devendarjain7037]

Hi Dr Hadzic, what about the use of dexmedetomidine as an additive, seems to definitely prolong the block by 4-6 hours?

[@hoho7378]

Thanks!

[@cristobalroig]

what is the effect pf mixing Lidocaine with some steriods in nerve block

[@st0rmscap3]

Hi Dr Hadzic, thanks for the very informative video on LAs. Would want to ask if high concentration Ropivacaine eg at 0.75-1% potentially neurotoxic? And therefore should be avoided?

[@Andrew-cm5tc]

I know he discussed mixing lidocaine with other local anesthetics. I would like to add that you can't do that with Exparel. From their website it says "If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL."

[@nysoravideo]

Hey Andrew! That is great also. Thank you for sharing! B-safe!

[@jonatasmadeira8652]

Any room to use 0.5% of hyperbaric bupivacaine to nerve block?

[@AshishGupta-cy1dt]

Sir what's the ratio of drugs in a mixture of bupivacaine and liposomal bupivacaine

[@casualchris]

Why mix sodium bicarb with lido w epi?

[@granrappanotyouraveragemoe2682]

Thanks👍🏾

[@smlesmle7800]

I use artinibsa 4% there is fog in the operation of the bulhorn ( lip lift) the sture opens could it be because the percentage is too high?

[@morleychallenged]

I had mitral-valve surgery 5 years ago. I quit smoking then. I cancelled dental surgery and heart surgery because of low diastolic pressure. I was afraid of Anesthesio ruining the outcome. I'm okay now.

[@morleychallenged]

Before that, Sodium pentothal, nitrous oxide and almost anything until now. Any comments?

[@nysoravideo]

Dear Morley! Thank you for watching our channel. However it is difficult to give medical recommendation based on the short information you have provided. We are unable to do this in this on this platform. We would strongly recommend you contact your doctor for further management. Nysora Team!

[@morleychallenged]

@@nysoravideo It's okay. I'm the grandson of a WW2 surgeon. I can get down the road a little bit farther.

[@ovidiumihai2904]

I would reconsider the duration time of 2% lido as 4h is a bit of an overstatement. also, I think is importat to state if its with or without epi or other adjuvants. Please do tell me if I am wrong, as a matter of fact Im in training and having a bit of o hard time coming to narrow down an exact period of duration for these anesthetics ... :)

[@chle4658]

does Epinephrine provide a lower toxicity then?

[@samuelabreu7599]

❤️ Levobupivacaine❤️

[@wansangoh4951]

Will you be able to do one for numbing cream as some patients cannot find one that work on them?

[@ryannau1756]

Anyone using exparel for Peng blocks?

[@nysoravideo]

Hey Ryan Nau! Not seen anything published all written up on this. However this is definitely great application for Exparel. Greetings from NYSORA!!

[@KishoreRajput32]

Hi sir, amazing vlog... Sir... Establish a Certificate Regional Anaesthesia online course.

[@nysoravideo]

Hi Kishor Kumar! European Society of Anesthesiologists provides EDRA diploma. Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!

[@10203040506070809051]

The concentration of local anesthetics in a mixture gets added up and the final concentration of the solution will be average of their concentration value, so adding 10 ml of 2% lidocaine to 10ml of 0.5 % Bupivacaine makes the final concentration of the solution ,1.25%, the solutions cant be considered as diluting each other

[@02hreblue30]

you completely contradicted yourself. You proved that the concentration is diluted

[@xoranginho]

Makes no sense

[@MarcPaganCohen]

My "3 day duration Interscalene brachial plexus block" given for shoulder replacement surgery has lasted ..... 4 weeks, and counting. Problem? Kidding, but not. Operative arm is paralyzed and numb from shoulder to wrist. A good sign, although hand numb too, have 5% grip strength and some movement of each finger. As a layman, I see 3 possible causes of nerve injury 1 Physical damage with needle during nerve block. Unlikely, due to ultra sound guidance 2 Bad batch of a nerve block med, or meds 3 Physical damage during surgery.

[@MegaPoliyo]

Definitely a problem! You've got a damaged brachial plexus. I would go straight back to my surgeon ask for an MRI and maybe a neurology consult. It's not going to be option 2. That's not really a thing.

[@pastormiriamgakori847]

Kindly somebody help me am dying of pain due to glossopharyngeal neuralgia, can't afford treatment and wondering whether this is afford in my country kenya Africa

[@90sToddler]

You probably just got corticosteroids

[@MarcPaganCohen]

@@90sToddler Yep, a massive dose of steroids for 10 days, prescribed by a neurologist. It didn't hurt, but in my unscientific sample size of one opinion....time was the best medicine that enabled the area to reduce swelling/heal.

[@anemon8333]

You don't have prilokain and artikain in here :/

[@vapordoc]

I think he gets some stuff wrong here. I would cross reference some of his statements i.e. that the amine part determines onset and that the ring part determines duration and potency. Theres a few other things he glosses over that i think are incorrect.

[@grekiki]

What does 10% concentration mean in drugs? Is it by volume, by weight? Wondering how the presenter got 10mg/ml from 1% value

[@marianosantopinto]

I still think it has always to do with chemistry and physics

[@taniaadams6501]

I don't understand why I'm a target

[@Chocoecstasy]

Spelling of spread 😂

[@marekkram5608]

Tell me the truth Is there Graphen-Oxide in this ? Now tell me the truth ???

[@nysoravideo]

We're sorry to hear that! We like to support a holistic approach to medicine, and while most of our content relies on science and technique, we do occasionally share how we go about the other aspects in our industry. We understand if it's not for you, and hope you'll stay tuned for what else we have to share in the future! Greetings from NYSORA.

[@wafaibrahim369]

Thanks you 💖💖💖💖💖💖

[@nysoravideo]

Welcome 😊