PNBschool

12/30/2025

3 ultrasound basics that immediately improve your block quality. Do these 3 things before you even think about picking up a block needle.

1️⃣ Set the correct depth
If your target is too deep, you lose resolution. Too shallow, and anatomy is cut off. Adjust depth so the nerve and surrounding structures fill the screen—precision starts with framing.

2️⃣ Optimize gain (not just brightness)
Over-gained images hide needle and tissue planes. Under-gained images miss subtle fascial layers. Balance overall gain so nerves, vessels, and fascia are clearly differentiated without washout. Make the darks darker and the lights lighter….(vascular structures are dark, bone/fascia are light)

3️⃣ Choose the right transducer
High-frequency linear probes for superficial targets. Lower-frequency or curvilinear probes for deeper structures. The wrong probe makes even good technique look bad.

Small adjustments. Big difference in image quality, needle visualization, and block success.

12/29/2025

You need to see it to block it.

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12/29/2025

Making Regional Anesthesia Easy Is a Cultural Decision

Every hospital says it values patient outcomes.
Fewer are willing to redesign culture to support them.

A strong regional anesthesia program is not built on individual skill alone.
It is built on intentional simplicity.

Hospitals that succeed with regional anesthesia do a few things exceptionally well:
• They standardize block selection instead of leaving it to personal preference
• They normalize education, not just for anesthesiologists, but for surgeons, nursing, and perioperative staff
• They remove mystique and variability from regional techniques
• They expect blocks as part of the perioperative plan—not as an optional add-on

When regional anesthesia becomes routine:
• Adoption increases
• Reliability improves
• Risk decreases
• Patient experience becomes predictable

The most effective programs I see are not the most complex.
They are the most aligned.

Making regional anesthesia easy is not about “dumbing it down.”
It is about designing systems that allow teams to perform at a high level—consistently.

That is culture by design.

12/28/2025

AI Fails lol

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12/24/2025

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12/24/2025

Merry Christmas from PNBschool.

While the world slows down, anesthesia professionals remain focused on what matters most—keeping patients safe, comfortable, and stable, even on holidays.

To everyone covering call, staffing ORs, PACUs, ICUs, and OB units this season: your work does not go unnoticed.

Wishing you a peaceful holiday, smooth cases, and a well-deserved moment of rest with family and friends.

— PNBschool

12/22/2025

BOOST YOUR BLOCK 💉 | Local Anesthetic Additives That Matter

When used thoughtfully, additives can meaningfully improve the quality, safety, and duration of peripheral nerve blocks. Three of the most commonly used—and best studied—options are epinephrine, dexamethasone (Decadron), and dexmedetomidine.

Why add them?
• Enhanced analgesia
• Prolonged block duration
• Improved safety and reliability

Epinephrine
• Acts as a vasoconstrictor → slows systemic absorption
• Improves block density and duration
• Serves as an early intravascular injection marker
➡️ Optimal dose: ~5 mcg/mL (1:200,000) in the local anesthetic solution balances efficacy with safety and minimizes ischemic risk.

Dexamethasone (Decadron)
• Significantly prolongs sensory block duration
• Reduces rebound pain and opioid consumption
• Can be administered perineural OR concomitant IV, with multiple studies showing similar duration benefits between routes
➡️ Common dose: 4–10 mg IV or perineural

Dexmedetomidine
• Alpha-2 agonist that prolongs block duration and improves analgesic quality
• Dose-dependent effects—lower doses reduce risk of bradycardia and hypotension
➡️ Typical perineural dose: 25–50 mcg

As always, dosing, patient selection, and institutional policies matter—but when used appropriately, these additives can meaningfully elevate regional anesthesia outcomes.

Do you use any of these in your practice or are you a purist? Let us know in the comments.

References
1. Neal JM et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Reg Anesth Pain Med. 2018.
2. Kirkham KR et al. Perineural vs intravenous dexamethasone for peripheral nerve blocks. Br J Anaesth. 2018.
3. Desmet M et al. IV dexamethasone prolongs peripheral nerve block duration. Anesthesiology. 2013.
4. Abdallah FW et al. Dexmedetomidine as an adjuvant in peripheral nerve blocks. Br J Anaesth. 2016.
5. Liu SS et al. Epinephrine in regional anesthesia: benefits and risks. Anesth Analg. 1995.

12/17/2025

For years I’ve been preaching what the evidence now formally supports: fascial plane blocks work — especially TAP and re**us sheath blocks for abdominal surgery. From enhanced recovery protocols to real-world OR and PACU outcomes, these blocks reliably reduce postoperative pain and opioid requirements after minimally invasive and open abdominal procedures. 

What many are now calling a “trend” has been part of high-value analgesia for years — guided, reproducible, and extremely effective when performed correctly. TAP and re**us blocks aren’t just nice to have, they are core tools in multimodal pain management that improve patient comfort and recovery trajectories.

If you’re not yet incorporating fascial plane blocks into your abdominal surgical analgesia pathways, the data — and now practice guidelines — say it’s time to rethink your approach.

Please share for your followers. Have questions about TAP or Re**us Sheath Blocks, dmmm me e or ask in the comments.

12/16/2025

The PENG block alone is not very analgesic. While it effectively targets the articular branches innervating the anterior hip capsule, it provides limited cutaneous coverage and does not address lateral thigh or skin incision pain—leaving patients with incomplete analgesia if used in isolation.

That’s where the LFCN block comes in.

By combining PENG + LFCN, you address:
• Deep anterior hip capsule pain
• Lateral thigh cutaneous sensation
• Improved peri-incisional analgesia
• Minimal motor blockade
• Better early mobilization

This pairing is especially useful for hip fracture surgery, THA (yes, both anterior and posterior lateral approach if performed correctly), and hip arthroscopy, where motor-sparing analgesia matters.

Think anatomy. Think coverage.
Single blocks rarely do it all.

—
Follow for practical, anatomy-based regional anesthesia education.

12/10/2025

Epinephrine as an Intravascular Marker: What’s the Minimum Effective Dose?

When epinephrine is added to local anesthetic, it can act as a physiologic safety marker—helping identify an unintentional intravascular injection during peripheral nerve blocks.

Minimum Effective Concentration

The smallest reliably effective dose for detecting intravascular injection is:

👉 5 mcg/mL (1:200,000)

This concentration produces consistent, measurable changes in heart rate and blood pressure when injected intravascularly.

⸻

What Physiologic Response Should You See?

With a 5 mcg/mL concentration, an intravascular test dose typically produces:
• HR increase ≥ 10 beats per minute, OR
• SBP increase ≥ 15 mmHg within ~30–60 seconds

These responses are well-documented in both neuraxial and regional anesthesia literature and apply across a wide patient population except those chronically on beta blockers (blunted response).

⸻

Why Not Use a Higher Dose?

Higher concentrations (e.g., 1:100,000) do NOT meaningfully improve detection but CAN increase risk of:
• Transient hypertension
• Tachyarrhythmias
• Patient discomfort
• Unnecessary sympathetic stimulation

Thus, 1:200,000 (5 mcg/mL) remains the sweet spot for safety + sensitivity.

⸻

When to Use Epinephrine as a Marker

✔️ During catheter insertion
✔️ During deep blocks near vascular structures
✔️ When injecting incrementally during high-volume blocks
✔️ In cases where LAST risk is elevated

⸻

When NOT to Rely on Epinephrine Response

⚠️ Patients on beta-blockers
⚠️ Elderly or severely ill patients with limited autonomic reserve
⚠️ Pediatric patients—HR responses vary
⚠️ Severe cardiac disease

In these cases, physiologic response may be attenuated or absent, decreasing test dose reliability.

⸻

Bottom Line

You only need 5 mcg/mL of epinephrine to serve as an effective intravascular marker during ultrasound-guided regional anesthesia.
It is one of the simplest ways to enhance safety—when used thoughtfully and in the right patient.

12/08/2025

Regional Anesthetic Additives: EPINEPHRINE ⚡️

When, Where, and Why to Use It in Your Local Anesthetic Solution

WHY add epinephrine?
• Prolongs block duration by reducing vascular absorption
• Improves block density with certain intermediate-acting anesthetics
• Acts as an intravascular marker—rapid ↑HR/↑BP during test dose
• Reduces peak plasma levels, improving safety margin

⸻

WHEN is epi useful?
• When you want better surgical anesthesia for short-to-moderate cases
• When you need a safety marker during high-risk injections
• When working in highly vascular areas where systemic uptake is a concern

⸻

WHERE is epi appropriate?
• Most peripheral extremity blocks (upper & lower extremity)
• Fascial plane blocks where vascularity may limit duration
• Superficial blocks where absorption is typically faster

⸻

Indications

✔️ Enhance duration of intermediate-acting local anesthetics
✔️ Improve block density for surgical anesthesia
✔️ Provide physiologic intravascular test dose
✔️ Reduce systemic absorption in vascular regions

⸻

Contraindications

⚠️ End-artery territories (digits, p***s, nose, ears)
⚠️ Patients with severe cardiac disease, arrhythmias, or unstable hypertension
⚠️ Peripheral vascular disease where vasoconstriction may worsen ischemia
⚠️ Patients on MAO inhibitors or TCAs—potentiated adrenergic response
⚠️ Situations requiring reliable nerve blood flow (e.g., severe neuropathy)

Is epi an always, sometimes or never for regional techniques? Answer in the comments

Please share for your followers. Thanks for reading.

12/02/2025

🩺 LAST: Recognize It. Treat It. Prevent It.
Local Anesthetic Systemic Toxicity remains one of the most time-critical emergencies in regional anesthesia.

Know the early signs:
• Perioral numbness
• Metallic taste
• Tinnitus
• Agitation → Seizures
• Sudden drop in BP/HR or wide-complex arrhythmias

Immediate steps:
1️⃣ Stop injecting
2️⃣ Call for help
3️⃣ Airway + oxygenation
4️⃣ 20% Lipid Emulsion (bolus + infusion)
5️⃣ Avoid: propofol for cardiac arrest, vasopressin, Ca-channel blockers, beta blockers
6️⃣ Treat seizures (benzodiazepines preferred)

Prevention:
• Use ultrasound
• Incremental injections
• Aspirate every time
• Know max dosing
• Always have lipid emulsion available

Regional isn’t dangerous — being unprepared is.