PNBschool

01/28/2026

Perioperative Bblocker Use

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01/28/2026

Regional Anesthesia…what has actually changed in the last 5 years.

⚠️ Block Adjuncts: Benefit vs Risk
Longer blocks matter — safety matters more.
Perineural dexmedetomidine prolongs duration but increases bradycardia, hypotension, and sedation.
IV dexamethasone offers similar prolongation with a cleaner safety profile.

🩻 Ultrasound ≠ Immunity
Ultrasound reduces risk — it doesn’t eliminate it.
LAST and nerve injury still occur.
Needle tip control, full scans, aspiration, and epinephrine markers still matter.

🏥 RA = ERAS Infrastructure
Regional anesthesia is no longer optional.
Less opioids, less PONV, faster mobilization, earlier discharge.

🤖 The Quiet Shift: Data + AI
How regional anesthesia is taught is changing.
AI-assisted ultrasound, automated anatomy recognition, and real-data simulation are the next frontier.

©️ PNBschool — We make regional anesthesia easy.

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01/27/2026

All THA pain obviously isn’t deep — it’s SKIN.
And that’s exactly why the LFCN + PENG combo works so well.

When the LFCN block is performed at the right level, it reliably covers the skin incision for both anterior and posterior hip approaches — while the PENG handles the deep articular pain.

Why this combo is 🔑 for Total Hip Arthroplasty:
• PENG → anterior hip capsule & deep pain
• LFCN → incision + superficial sensory pain
• Minimal motor weakness
• Cleaner PACU wake-ups
• Better early mobility

Miss the level on the LFCN and you miss the incision.
Hit it correctly and the coverage is money. A very under rated block overall.

We make regional anesthesia easy.

01/22/2026

Perioperative Beta-Blockers: Cardiac Safety First — Analgesic Adjunct Second

Perioperative beta-blockers remain a cornerstone of cardiac risk management, with strong evidence supporting continuation in patients on chronic therapy and avoidance of same-day initiation. When used appropriately, they improve hemodynamic stability and reduce myocardial stress.

Less commonly appreciated is their adjunctive role in multimodal analgesia. Short-acting agents such as esmolol attenuate sympathetic outflow and central sensitization, reducing postoperative pain amplification and opioid requirements — without acting as opioids or sedatives. This effect is mediated through modulation of stress pathways, including downstream influence on substance P–related nociceptive signaling, rather than direct nociceptor blockade.

Importantly:
• Beta-blockers should not be initiated solely for pain control
• Analgesic benefit is adjunctive, not primary
• Careful titration is essential to avoid hypotension, bradycardia, and masked hypovolemia

Within ERAS pathways, beta-blockers can complement regional anesthesia, non-opioid analgesics, and opioid-sparing strategies by improving physiologic stability, decreasing stress responses, and supporting faster recovery with fewer opioid-related adverse effects.

Key takeaway:
Use beta-blockers for the right indication, at the right time, in the right patient — and recognize their role as a supporting player in modern, evidence-based perioperative pain management.

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Selected References
• Kehlet H, Dahl JB. The stress response to surgery: release mechanisms and clinical implications. Anesth Analg. 1993.
• Chia YY et al. Perioperative esmolol infusion reduces postoperative pain and opioid consumption. Anest

01/19/2026

One of the biggest myths in regional anesthesia is that you “just need more ultrasound time.” The reality? Efficiency follows a predictable learning curve.

Most clinicians struggle not because they’re bad — but because they’re training without structure.

Here’s what the data consistently shows 👇
• Image acquisition takes ~20–40 supervised scans before it feels natural
• Needle visualization often lags behind anatomy (and frustrates everyone)
• True efficiency doesn’t show up until >20 well-executed blocks
• Catheters and advanced techniques demand intentional reps, not luck

🚫 Random scanning
🚫 Rushing to the needle
🚫 Skipping pre-scan optimization

✅ Deliberate practice
✅ Pre-scan before every needle
✅ In-plane mastery first
✅ Ergonomics + machine setup
✅ Simulation & repetition

This is exactly why some providers “plateau” — and others accelerate.

Efficiency isn’t talent. It’s training design.

If you want regional anesthesia to feel easy, predictable, and fast — you need to respect the curve.

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01/16/2026

Combined Spinal-Epidural (CSE): Why Use Both?

The combined spinal-epidural (CSE) technique gives you the best of both worlds—the rapid, dense onset of a spinal with the flexibility and durability of an epidural.

Why choose CSE?
• ⚡ Immediate, reliable anesthesia from the spinal—no waiting, no patchy onset
• 🎚️ Titration and extension via the epidural catheter for longer cases
• 🔁 Postoperative or labor analgesia without re-dosing intrathecal medication
• 📉 Lower intrathecal dose → improved hemodynamic stability
• 🛠️ Built-in backup if surgical time or block height needs change

How does it compare?
• Spinal alone → fast and dense, but fixed duration
• Epidural alone → adjustable, but slower onset and less predictable spread
• CSE → rapid onset plus flexibility and longevity

When CSE really shines
✔️ Cesarean delivery
✔️ Unpredictable case length
✔️ Situations where postoperative analgesia matters

One technique. Two advantages. Maximum control.

01/16/2026

Combined Spinal-Epidural (CSE): Why Use Both?

The combined spinal-epidural (CSE) technique gives you the best of both worlds—the rapid, dense onset of a spinal with the flexibility and durability of an epidural.

Why choose CSE?
• ⚡ Immediate, reliable anesthesia from the spinal—no waiting, no patchy onset
• 🎚️ Titration and extension via the epidural catheter for longer cases
• 🔁 Postoperative or labor analgesia without re-dosing intrathecal medication
• 📉 Lower intrathecal dose → improved hemodynamic stability
• 🛠️ Built-in backup if surgical time or block height needs change

How does it compare?
• Spinal alone → fast and dense, but fixed duration
• Epidural alone → adjustable, but slower onset and less predictable spread
• CSE → rapid onset plus flexibility and longevity

When CSE really shines
✔️ Cesarean delivery
✔️ Unpredictable case length
✔️ Situations where postoperative analgesia matters

One technique. Two advantages. Maximum control.

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01/14/2026

PENG blocks in anterior total hip arthroplasty can help reduce hospital length of stay, but…….

By targeting the anterior hip capsule, the PENG block may help decrease length of stay in the hospital but they did not show to reduce overall opioid use.

The PENG block should not be considered a complete solution for postoperative pain relief for anterior total hip arthroplasty.

Anterior THA involves significant cutaneous and lateral thigh pain, which the PENG block does not address. Adding a lateral femoral cutaneous nerve (LFCN) block targets this missing component, providing another layer of analgesia that improves patient comfort—especially during early ambulation.

The takeaway:
PENG blocks work best as an adjunct, not in isolation. Combining a PENG block for deep anterior capsular pain with an LFCN block for superficial incision pain creates a more complete analgesic strategy—one that supports ERAS pathways and safe, earlier discharge.

Follow for evidence-based regional anesthesia that actually translates to better outcomes.

hip arthroplasty

01/13/2026

Extubation is a decision, not a reflex.

Objective recovery, adequate ventilation, and airway protection must align.

If criteria aren’t met, remaining intubated and transferring to PACU/ICU for continued ventilation and pacification is a safe, appropriate option—not a failure. A secure airway is always safe.

Ever try a Jackson Reese circuit?

Measure neuromuscular recovery. Delay when needed. Patient safety first.

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01/09/2026

Femoral Triangle vs Adductor Canal
What are you actually blocking?

One of the most common misunderstandings in lower-extremity regional anesthesia is treating the femoral triangle block and the adductor canal block as binary, nerve-specific techniques. In reality, these injections exist on an anatomic continuum.

Femoral Triangle Injection
• Targets femoral nerve branches, including the saphenous nerve and nerve to vastus medialis
• Produces reliable analgesia, but motor involvement is dose- and location-dependent
• Proximal spread and higher volumes may increase quadriceps weakness

Adductor Canal Injection
• Primarily targets the saphenous nerve, inconsistently the nerve to vastus medialis, and articular branches to the knee
• Designed to balance analgesia with preserved function
• Excessive volume or proximal injection may often convert this into a functional femoral triangle block

Key Takeaway: Volume Matters
They are fascial plane injections with3
• Larger volumes (≥15–20 mL)

➡️ may be motor involvement regardless of what the block is “called” if large volumes are used.

Clinical Pearl
If your “adductor canal block” causes quadriceps weakness, the issue is rarely the name of the block — its volume spread, total volume, and location.

Regional anesthesia outcomes are driven by anatomy + technique, not labels.

Follow PNBschool for practical, anatomy-driven regional anesthesia education that translates directly to better patient outcomes.

01/08/2026

How are things going up there?

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01/08/2026

How well do you really know interscalene block anatomy?

Take a look at this ultrasound image and quiz yourself before scrolling 👇

Question:
Which structure are you targeting for an effective interscalene block for a straight forward rotator cuff repair?

A️⃣ C6 nerve roots
B️⃣ Superior trunk
C️⃣ C8 nerve root
D️⃣ Phrenic Nerve

Key anatomy to identify before you inject:
• Anterior scalene
• Middle scalene
• Brachial plexus nerve roots
• Carotid artery & IJV (medial—danger zone)
• Any other vascular structures

💡 Pearl: Most “failed” ISBs are anatomy failures, not needle failures. If you can’t confidently identify the roots or before inserting the needle, stop and rescan.

⬇️ Drop your answer in the comments
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⬇️ Follow for daily regional anesthesia education