Femoral and sciatic nerve block for hindfoot and ankle surgery

Background

The use of regional anesthesia, such as ankle block or sciatic nerve block, has gained in popularity due to considerations of patient comfort and safety in foot and ankle surgery. However, if the operation extends above the midfoot or if a thigh tourniquet is required, general or spinal anesthesia is needed. The authors aimed to determine by prospective study whether a ‘double block’, involving femoral and sciatic nerve blocks, is advantageous under such conditions.

Materials and methods

The effectiveness of a preoperative double block was prospectively evaluated in 26 consecutive patients undergoing a variety of foot and ankle procedures, compared with 32 patients with sciatic nerve block alone. Time of analgesia onset, length of block coverage, and complications were noted. Degree of pain was measured using VAS (Visual Analog Scale) scores at the operation, just after surgery, and at 2 h, 1 day, and 2 days after surgery.

Results

The surgical procedures performed under double block were ankle arthroscopy and medial ankle ligament reconstruction, and Achilles tendon repair, and the following conditions were treated; surgery for medial ankle fracture, ankle fusion, subtalar fusion, and surgery for hindfoot diseases, such as, talocalcaneal coalition. The average time required to analgesia onset was 63 min for a double block and 61 min for sciatic nerve block alone. Analgesia time lasted 12.0 h for a double block and 12.4 h for sciatic nerve block alone. Average VAS scores at the operation and immediately after the operation were 0.03 (range 0–1) and 0.16 (range 0–2) for sciatic nerve block, and 0.35 (range, 0–4), 0.31 (range 0–2) for double block. Average VAS scores at 2 h, 1 day, and 2 days postoperatively were 0.28 (range, 0–2), 2.16 (range 0–6), and 1.63 (range 0–5) for sciatic nerve block, and 0.42 (range 0–5), 2.27 (range 0–7), and 1.72 (range 0–8), respectively, for double block.

Conclusion

The results of this prospective study suggest that double block provides good surgical anesthesia and good postoperative pain control for hindfoot and ankle surgery.     

Case report: Sequential bilateral upper extremity intravenous regional anesthesia with chloroprocaine

Purpose

This case report describes the novel use of sequential bilateral upper extremity intravenous regional anesthesia with 2-chloroprocaine for bilateral endoscopic carpal tunnel decompression.

Clinical features

A 49-yr-old female, American Society of Anesthesiologists physical status I, presented for outpatient bilateral carpal tunnel release. Sequential bilateral intravenous regional anesthesia was performed with 0.5% 2-chloroprocaine 30 mL per arm using a double upper arm tourniquet. Intraoperative sedation consisted of midazolam and fentanyl. Tourniquet times for the right and left arms were 28 and 19 min, respectively. After deflation of each tourniquet, mild limb twitching occurred but resolved immediately after administration of intravenous midazolam. The patient made a rapid recovery, and she was discharged home uneventfully.

Conclusions

Bilateral sequential intravenous regional anesthesia with 2-chloroprocaine is effective for upper extremity surgery of short duration. Recommendations to minimize the risk of local anesthetic toxicity are reviewed.     

Contralateral local anesthetic spread from an outpatient interscalene catheter

Purpose

Ambulatory continuous infusions have been associated with improved analgesia and few serious complications. This report describes an unusual case of a patient with a continuous interscalene nerve block who developed a contralateral upper extremity sensory block. The complication did not occur until postoperative day two while the patient was at home.

Clinical features

A 56-yr-old woman had a continuous interscalene catheter placed for arthroscopic lysis of adhesions of her shoulder. The insertion needle was initially injected with 0.5% ropivacaine 25 mL (1:400,000 epinephrine), producing a unilateral interscalene block. Postoperatively, the patient was started on a continuous interscalene infusion of 0.2% ropivacaine at 8 mL·hr^?1 via a disposable infusion pump. The next day, the patient had a unilateral brachial plexus block and an associated Horner’s syndrome and was discharged home with the infusion. On the morning of the second postoperative day, the patient developed ipsilateral and contralateral Horner’s syndrome with associated numbness in both shoulders. The catheter was removed and symptoms resolved four hours later.

Conclusions

Ambulatory continuous infusions are typically associated with few serious complications and a favourable safety profile. This case demonstrates that unexpected complications can still occur even after days of normal operation. Based on our previous experience, we believe this to be a rare but potentially serious event that requires awareness by those discharging patients with continuous infusions of local anesthetics.     

Reversal of high spinal anesthesia with cerebrospinal lavage after inadvertent intrathecal injection of local anesthetic in an obstetric patient

Purpose

High or total spinal anesthesia commonly results from accidental placement of an epidural catheter in the intrathecal space with subsequent injection of excessive volumes of local anesthetic. Cerebrospinal lavage has been shown to be effective at reversing the effects of high/total spinal anesthesia but is rarely considered in obstetric cases. Here, we describe the use of cerebrospinal lavage to prevent potential complications from high/total spinal anesthesia after unintentional placement of an intrathecal catheter in a labouring obstetric patient.

Clinical features

A 34-yr-old female presented to the labour and delivery unit in active labour. Epidural anesthesia was initiated, and after the first bolus dose, the patient experienced lower extremity motor block and shortness of breath. A high spinal was confirmed, and cerebrospinal lavage was performed. In total, 40 mL of cerebrospinal fluid (CSF) were exchanged for an equal volume of normal saline. The patient’s breathing difficulties and motor block resolved quickly, and a new epidural catheter was placed after removal of the spinal catheter. Pain control was effective, and the patient delivered a healthy baby.

Conclusion

We show that exchange of CSF for normal saline can be used successfully to manage a high spinal in an obstetric patient. Our results suggest that CSF lavage could potentially be an important and helpful adjunct to the conventional supportive management of obstetric patients in the event of inadvertent high or total spinal anesthesia.     

Prospective non-randomized comparison of open versus laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair under different anesthetic methods

Purpose

To compare prospectively open vs. laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair performed under different anesthetic methods.

Methods

A total of 175 patients scheduled for unilateral inguinal hernia repair were assigned to one of the following groups: (i) open repair under local anesthesia, (ii) open repair under regional anesthesia, (iii) open repair under general anesthesia, and (iv) TAPP under regional anesthesia. Immediate postoperative pain was the main outcome measured. Short- and long-term complications and the degree of patient satisfaction were also assessed.

Results

Transabdominal preperitoneal repair under regional anesthesia yielded the lowest pain scores, whereas open repair under general anesthesia yielded the highest pain scores (P < 0.05). Open repair under local or general anesthesia had a lower urinary retention incidence than the spinal groups (P < 0.05). Chronic pain incidence was lower for the TAPP group (P 0.003). There were no differences in other short- and long-term complications.

Conclusion

Transabdominal preperitoneal repair under spinal anesthesia proved superior to open repair performed under different types of anesthesia in terms of immediate (24-h) postoperative pain. The method of anesthesia might have contributed more to this favorable outcome than the surgical technique itself, but at the cost of a high urinary retention incidence. The incidence of chronic pain was lower after TAPP repair.     

Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: a case series

Purpose

The saphenous nerve, a branch of the femoral nerve, is a pure sensory nerve that supplies the anteromedial aspect of the lower leg from the knee to the foot. There is limited evidence of the effectiveness of ultrasound-guided techniques to block the saphenous nerve. We therefore undertook a retrospective case series to investigate the efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block.

Methods

During a four-month period, all patients receiving a subsartorial saphenous nerve block for lower extremity surgery at our institution had their medical records reviewed. Patient demographics and data were recorded, including block characteristics, intraoperative anesthetic management, pre-block, post-block, and postoperative pain scores, as well as postoperative analgesic dosing. Preoperative block success was defined by minimal intraoperative analgesic administration and a pain score of 0 in the postanesthesia care unit not requiring analgesic supplementation. Postoperative block success was defined by reduction of pain score to 0 without need for additional analgesic dosing.

Results

Thirty-nine consecutive patients were identified as receiving an ultrasound-guided subsartorial saphenous nerve block. Overall, this ultrasound-guided technique was found to have a 77% success rate.

Conclusion

This case series shows that an ultrasound-guided subsartorial approach to saphenous nerve blockade is a moderately effective means to anesthetize the anteromedial lower extremity. The success rate is based on stringent criteria with an endpoint of postoperative analgesia. A randomized prospective study would provide a more definitive answer regarding the efficacy of this technique for surgical anesthesia.     

Factors affecting recovery and discharge following ambulatory surgery

Purpose

Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia.

Source

A search was performed in the Cochrane Central Registerfor Controlled Trials, MEDLINE®, EMBASE®, CINAHL, and PsycINFO, to review factors delaying discharge following ambulatory surgery. The following subject headings were used: “ambulatory surgery, discharge, recovery, car driving, escort, transport, fast tracking, patient discharge, recovery, transportation of patients, hospital discharge, recovery room, patient transport, hospital discharge, recovery room, anesthetic recovery, patient transport, ambulatory surgical procedures, patient discharge, recovery of function, automobile driving, patient escort service, recovery room”. Using the same search engines, the following keywords were used: “fast tracking, recovery, and discharge”.

Principal findings

The current literature supports that discharge scoring systems may be useful to guide discharge following ambulatory surgery. While fast-tracking has become common in some centres, further studies are required to justify more routine implementation of this practice in the management of patients undergoing ambulatory surgery. Patients at low risk for urinary retention can be discharged home without voiding. Patients should not drive until at least 24 hr postoperatively.

Conclusions

Ensuring rapid postoperative recovery and safe discharge following ambulatory surgery are important components of the ambulatory surgical program. A clearly defined process should be established for each ambulatory surgical unit to ensure the safe and timely discharge of patients after anesthesia, in accordance with current best evidence.     

Patientenerwartungen vor elektiver Leistenhernienoperation

Introduction

The pressure to save costs will lead to an increased use of outpatient facilities for inguinal hernia repair. Little is known about patients’ expectations concerning inguinal hernia repair and the implication for ambulatory surgery.

Methods

In a prospective study, 156 patients with unilateral hernia were questioned about their expectations concerning the upcoming surgery. They were asked to evaluate different aspects using a visual analogue scale, to answer questions in an essay style, and to name the five most important aspects of surgery.

Results

The five most important aspects were recurrence rate, personal contact with the physician, postoperative pain management, recovery time, and the medical facilities. The possibility for outpatient surgery and for local anesthesia seemed to be most important to young, professionally active patients (<30 years), whereas older patients were more concerned about insufficient postoperative recovery at home and surgical complications.

Conclusions

If patients’ expectations are considered, outpatient inguinal hernia repair will favor surgical techniques under local anesthesia with mesh implantation. Postoperative patient care will have to include intensified patient information, adequate pain management, and well-organized home recovery.     

Alternative site for median nerve blockade allowing early functional rehabilitation after hand surgery

Purpose

In this report we describe an alternative approach to catheter placement for continuous selective median nerve blockade. It spared the finger movements and therefore allowed early postoperative rehabilitation in a patient who underwent surgical repair of the index finger flexor tendon.

Clinical features

A patient with a complicated history of traumatic index finger flexor tendon rupture, surgical repair, failed rehabilitation due to poor postoperative pain control, adhesion formation, and subsequent rerupture due to tenolysis was admitted for reconstructive surgery. This time, a continuous regional block was used. Although the insertion of a catheter at the wrist level would have spared the anterior interosseous branch of the median nerve and preserved finger movements, a more distant site had to be chosen to avoid proximity to the surgical wound. Therefore, under combined ultrasonography and neurostimulation guidance, the catheter was inserted in the proximal one-third of the patient??s forearm distal to the branching-off point of the anterior interosseous nerve. Continuous ropivacaine infusion was initiated and maintained until being stopped on the afternoon of the third postoperative day, providing good analgesia without interfering with postoperative physiotherapy, which was successfully completed during this hospitalization.

Conclusion

Placement of a catheter for continuous median nerve blockade in the proximal one-third of the forearm for effective postoperative pain-free rehabilitation after hand surgery should be considered in cases in which the surgical incision extends toward the patient??s wrist. The block site can be readily identified by a combined use of ultrasonography and neurostimulation guidance.     

Ultrasound-guided regional anesthesia for upper limb surgery

Purpose

The purpose of this module is to review the main ultrasound-guided approaches used for regional anesthesia of the upper limb.

Principal findings

The anatomical configuration of the upper limb, with nerves often bundled around an artery, makes regional anesthesia of the arm both accessible and reliable. In-depth knowledge of upper limb anatomy is required to match the blocked territory with the surgical area. The interscalene block is the approach most commonly used for shoulder surgery. Supraclavicular, infraclavicular, and axillary blocks are indicated for elbow and forearm surgery. Puncture techniques have evolved dramatically with ultrasound guidance. Instead of targeting the nerves directly, it is now recommended to look for diffusion areas. Typically, local anesthetics are deposited around vessels, often as a single injection. Phrenic nerve block can occur with the interscalene and supraclavicular approaches. Ulnar nerve blockade is almost never achieved with the interscalene approach and not always present with a supraclavicular block. If ultrasound guidance is used, the risk for pneumothorax with a supraclavicular approach is reduced significantly. Nerve damage and vascular puncture are possible with all approaches. If an axillary approach is chosen, the consequences of vascular puncture can be minimized because this site is compressible.

Conclusions

Upper limb regional anesthesia has gained in popularity because of its effectiveness and the safety profile associated with ultrasound-guided techniques.     

Case series: ultrasound-guided supraclavicular block using a curvilinear probe in 104 day-case hand surgery patients

Purpose

To report our experiences regarding the implementation of a combined ultrasound and nerve stimulation guidance technique for supraclavicular blockade in day-case hand surgery patients at our institution.

Clinical features

We retrospectively reviewed 104 patient charts from the first 6 months of our clinical practice of using this block approach for upper extremity surgery. Block success, completion and recovery time, post-block analgesia requirement, acute complication rate, and duration of hospital stay were evaluated and categorized based on the practitioner who performed the block (fellow/staff anesthesiologists and residents), as well as the body mass index of the patient (when available). During the performance of each block, the brachial plexus was viewed using a curvilinear probe, and the needle was advanced in-plane in an anterolateral-to-posteromedial direction. The plexus, needle, and spread of local anesthetic could be clearly visualized in each case. Surgical regional anesthesia was achieved in 94.2% of blocks. The block was the sole method of postoperative analgesia in 85.6% of patients, and the overall block completion time was 20.2 ± 9.2 min. There were no occurrences of clinical pneumothorax during the study period.

Conclusions

We report our successful experience using ultrasound guidance and nerve stimulation during supraclavicular blockade. The curvilinear probe enables a large field of view, adequate resolution in larger patients, and excellent needle visibility that allows access to the plexus while avoiding the pleura and subclavian artery.     

The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management

Background

The incidence of neurologic complications from foot and ankle surgery utilizing regional anesthesia is not well established.

Questions/Purposes

The purpose of this study was to prospectively determine the incidence of neurologic and peripheral nerve block (PNB) site complications on a busy foot and ankle service that utilizes ankle blocks (ABs) and popliteal blocks (POPs).

Patients and Methods

This prospective observational study included patients undergoing foot and ankle surgery with ABs or POPs. Block choice was determined by surgeon’s preference. Patients were assessed for complications during postoperative visits at 2, 6, and 12 weeks. The relation of each complication to the block was scored by a surgeon and anesthesiologist.

Results

From October 2012 to October 2014, 2516 patients underwent 2704 surgeries. There were 195 complications (7.2%) considered neurologic or at the PNB site. The incidence of serious complications was 0.7%. A higher complication rate was reported for POPs (8.8%) than for ABs (2.5%). However, when analysis was limited to forefoot surgery, this difference was not significant. Dexamethasone use was associated with increased complications for POPs. Only 5 of the 195 total complications, and 2 of 20 serious complications, were deemed to have been likely caused by the block by both the surgeon and anesthesiologist reviewer.

Conclusions

The incidences of neurologic or block-related complications and serious complications were 7.2 and 0.7%, respectively, most without a clear surgical vs. nerve block etiology. The higher complication rate for POPs using perineural dexamethasone should be interpreted cautiously in light of the lack of randomization and likely confounders.

     

Can Regional Anesthesia and Analgesia Prolong Cancer Survival After Orthopaedic Oncologic Surgery?

Background

The perioperative period of major oncologic surgery is characterized by immunosuppression, angiogenesis, and an increased load of circulating malignant cells. It is a window period in which cancer cells may seed, invade, and proliferate. Thus, it has been hypothesized that the use of regional anesthesia with the goal of reducing surgical stress and opioid and volatile anesthetic consumption would avoid perioperative immune suppression and angiogenesis and ultimately cancer recurrence.

Questions/purposes

We performed a systematic review of the literature on the use of regional anesthesia and postoperative analgesia to improve cancer-related survival after oncologic surgery. Our primary topic of interest is survival after orthopaedic oncologic surgery, but because that literature is limited, we also have systematically reviewed the question of survival after breast, gastrointestinal, and genitourologic cancers.

Methods

We searched the PubMed and Embase databases with the search terms: “anesthesia and analgesia”, “local neoplasm recurrence”, “cancer recurrence”, “loco-regional neoplasm recurrence”, “disease-free survival”, and “cumulative survival rates”. Our initial search of the two databases provided 836 studies of which 693 were rejected. Of the remaining 143 studies, only 13 articles qualified for inclusion in this systematic review, based on defined inclusion criteria. All these studies had retrospective design. Due to the high heterogeneity among the identified studies and the complete absence of randomized controlled trials from the literature on this topic, the results of a meta-analysis would be heavily confounded; hence, we instead performed a systematic review of the literature.

Results

No eligible studies addressed the question of whether regional anesthesia and analgesia have an impact on survival after musculoskeletal cancer surgery. Only one relevant clinical study was identified on regional breast cancer survival; it suggested a benefit. The literature on gastrointestinal and genitourinary surgery was larger but mixed, although some preliminary studies do suggest a benefit of regional anesthesia on survival after oncologic surgery in those patient populations.

Conclusions

Although basic science studies suggest a potential benefit of regional anesthesia and stress response reduction in cancer formation, we found little clinical evidence to support the theory that regional anesthesia and analgesia improve overall patient survival after oncologic surgery.     

Urologische Operationen in Analgosedierung und Lokalanästhesie

Objective

Analogosedation and local anesthesia, including regional nerve blocks are used for endoscopic diagnostic or radiological and ultrasound-guided procedures in which the patient should not move or has to be free of pain. We retrospectively analyzed patient satisfaction, complications and the risk of urological interventions with analgosedation and/or local anesthesia between 2008 and 2012.

Material and methods

In total 21,690 urological patients underwent surgical treatment at the Department of Urology of the University Hospital of Essen between 2008 and 2012 and3,327 of these cases were performed by urologists with the patient under analogosedation (n?=?1484) and local anesthesia (n?=?1843). In total 13 surgical and endoscopic procedures were separately analyzed and evaluated for safety and practicability.

Results

In five cases (0.15?%) the procedures with analgosedation or local anesthesia were interrupted because of agitation (n?=?3) and in one case the transurethal resection was stopped due to a large bladder tumor. One patient suffered anaphylactic shock after preoperative intravenous application of cefuroxim 1.5 g. After cardiopulmonary resuscitation and a short stay on the intensive care unit the patient was discharged after 2 days.

Conclusions

Local anesthesia and analgosedation should be performed by urologists for minor surgery, endoscopic procedures and radiological or ultrasound-guided treatment. For safety reasons there should always be a second medical doctor present for assistance. Analgesia with deep sedation or loss of defensive reflexes should be administered by anesthesiologists.     

Ultrasound-guided perineural steroid injection to treat intractable pain due to sciatic nerve injury

Purpose

Sciatic neuropathy is a rare but serious complication of cardiac surgery. Neuropathic pain following nerve injury can be severely debilitating and largely resistant to treatment. We present a case of this complication where ultrasound-guided perineural steroid injection at the site of the sciatic nerve injury provided excellent pain relief and facilitated subsequent rehabilitation.

Clinical features

A 17-yr-old boy developed bilateral sciatic neuropathy after a nine-hour cardiac surgical procedure in the supine position, resulting in debilitating dysesthesia refractory to neuropathic pain therapies and leading to severe functional limitation. With magnetic resonance imaging of the lower extremities, the location of the lesion was determined to be from the level of the superior gemellus to the level of the quadratus femoris. An ultrasound-guided injection of triamcinolone 20 mg and lidocaine 40 mg around both sciatic nerves at the level of the lesion was administered two months after the surgery, and the pain score (rated on a scale 0-10) at rest decreased from 9-10 to 1 two weeks after the injection.

Conclusions

There are a limited number of reports in the literature on sciatic nerve injuries associated with cardiac surgery. This case illustrates the efficacy of ultrasound-guided steroid injection around sciatic nerves at the level of superior gemellus in treating our patient’s neuropathic pain.     

Amputation of a lower extremity after severe trauma

Objective

Serious lower extremity injuries sometimes warrant emergency amputation. The goal of amputation in polytrauma patients is to increase chances of survival, while the goal of amputation in a single limb injury is to prevent further complications, e.g., infection, septic shock.

Indications

Rescue from life-threatening lower extremity bleeding in a critically injured patient. Severe injury of a lower extremity: crushed, burned, frozen, advanced infection.

Contraindications

Patient refusal.

Surgical technique

Supine position, determination of resection border, skin incision, identification of nerves and blood vessels, osteotomy, vessel ligation, separation of blood vessels and nerves, final removal of tissue with amputation knife, disposal of amputated extremity, skin closure.

Postoperative management

Wound care, careful compression wraps beginning on postoperative day?7, early prosthesis fitting, mental health care consultation.

Results

From January 2008 until October 2010, 115?lower extremities were amputated at the BG Trauma Clinic in Ludwigshafen, Germany. A total of 42?amputations were posttraumatic and were performed in the clinic for trauma surgery and orthopedics. There were a total of 18?foot and toe amputations, 16?lower leg amputations, 5?knee amputations, and 3?above knee amputations. Comparison of the groups is difficult due to the varying mechanisms of injury and locations of amputation. Therapeutic decisions regarding emergency amputation are made with careful consideration of the patient.     

The effects of single-dose intravenous dexmedetomidine on hyperbaric bupivacaine spinal anesthesia

Purpose

Dexmedetomidine, a selective α2-adrenoceptor agonist, has analgesic and sedative effects. The purpose of this study was to investigate the effects of small, single-dose intravenous dexmedetomidine administration after hyperbaric bupivacaine spinal anesthesia.

Methods

Sixty adult patients classified as American Society of Anesthesiologists physical status 1 or 2 and scheduled for lower extremity surgery under spinal anesthesia were studied. Patients were randomly assigned to one of three groups and administered hyperbaric intrathecal bupivacaine 12 mg. 5 min after spinal anesthesia, patients in groups 1, 2, and 3 received normal saline 10 ml, dexmedetomidine 0.25 μg/kg, and dexmedetomidine 0.5 μg/kg, respectively, over 10-min intravenous administration. The onset time, maximum block level, two-dermatome sensory regression time, duration of motor and sensory anesthesia, and side effects were assessed.

Results

The two-dermatome sensory regression time was significantly increased in groups 2 and 3. The duration of motor and sensory anesthesia was significantly increased in group 3. Onset time, maximum block level, level of sedation, and incidence of hypotension and treatment-needed bradycardia were no different among the groups.

Conclusion

Single-dose intravenous dexmedetomidine 0.25–0.5 μg/kg, administered 5 min after intrathecal injection of hyperbaric bupivacaine, improved the duration of spinal anesthesia without significant side effects. This method may be useful for increasing the duration of spinal anesthesia, even after intrathecal injection of local anesthetics.