Ultrasound-guided femoral and sciatic nerve blocks combined with sedoanalgesia versus spinal anesthesia in total knee arthroplasty

Ultrasound-guided femoral and sciatic nerve block as an option for below-knee amputation in an elderly patient: A case report

Peripheral nerve blocks can be a very safe option in elderlypatients with multiple comorbidities where spinal or general anesthesia may be associated with increased risks. We present a 67 years male taking antiplatelet drugs with deranged coagulation profile with bilateral pneumonia with diabetic foot with wet gangrene planned for emergency below knee amputation under ultrasound guided femoral and sciatic nerve block.

A Prospective Comparative Study Between Ultrasound-Guided Combined Sciatic-Femoral Nerve Block Versus Spinal Anesthesia for the Patients Undergoing Elective Below-Knee Surgeries

Introduction

The scope of anesthesia has shifted from general anesthesia (GA) and spinal anesthesia (SA) for below-knee surgery to peripheral nerve blocks (PNB). Combined sciatic-femoral nerve block (SFNB) with ultrasound (USG) guidance can be a better format for use. 

Objectives

The primary objectives were to compare the duration of onset of sensory and motor blockade, total duration of sensory and motor blockade, and time of first analgesic requirement between both groups.

Methods

A prospective, randomized comparative study was carried out at a tertiary care teaching hospital in Odisha, India, from April 2019 to April 2021 in the Department of Anaesthesiology. Patients admitted for elective below-knee surgeries with American Society of Anesthesiology (ASA) grade II or less were divided into two groups (Group A receiving USG-guided SFNB and group B receiving SA) by computer-generated sampling. The block randomization method was used to ensure equal samples in both groups. Data collection was done using the Magpi software (Magpi, Inc., Washington, D.C., United States) on android-based mobile phones. Data were analyzed using Stata Statistical Software: Release 12 (2011; StrataCorp LP, College Station, Texas, United States) for analysis. Relevant statistical tests were used to compare the results between the groups (independent sample t-test or Wilcoxson signed-rank test). Repeated measures ANOVA (RM-ANOVA) was used to check the hemodynamic stability within the groups.

Results

Thirty-seven subjects were enrolled in each arm (Group A and Group B). Baseline parameters in both groups were comparable. The most common indication among the study subjects was single or multiple meta-tarsal fractures (20, 27.0%) followed by malleolus (15, 20.3%) and calcaneum fractures (13, 17.6%). Most of the study subjects were from ASA grade I (around 80%). The time of onset of sensory and motor block was found to be more for USG-guided SFNB (8.08±2.11 minutes and 11.35±1.84 minutes, respectively) as compared to the SA group (3.03±0.50 minutes and 4.89±0.52 minutes, respectively) (p<0.001). Total anesthesia and time to first analgesic requirement were, however, more in USG-guided SFNB (349.43±53.49 minutes and 339.73±54.24 minutes, respectively) as compared to the SA group (137.30±34.21 minutes and 137.30±34.21 minutes, respectively) (p<0.001). The mean time to first urination in USG-guided SFNB (178.92±20.92) was significantly less (p<0.001) compared to the SA group (419.19±40.30).

There were no adverse events (0%) in USG-guided SFNB while 64.9% of the subjects in the SA group experienced adverse events (p<0.001). The most common adverse events were nausea/vomiting and hypotension (around 50% for both). Hemodynamic stability was present in both the groups of anesthesia subjects, though fluctuations in blood pressure may be seen more frequently in cases of SA. All the subjects in both the groups had achieved a Bromage score of 3 universally. The grand mean score of pain by SA (2.347±0.044) was more (p<0.001) in comparison to that in subjects with USG-guided SFNB (1.961±0.073) and this was significant in both the groups. The mean increase in pain score at 24 hours in comparison to baseline was, however, significantly more (p<0.05) in the SA group (1.784±0.111) in comparison to those receiving USG-guided SFNB (1.324±0.190).

Conclusion

USG-guided SFNB is a better option for below-knee surgeries as compared to SA.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Peripheral Nerve Block Versus Spinal Anesthesia for Total Knee Replacement in Elderly Patients

Introduction: Spinal anesthesia and peripheral nerve block anesthesia are used in total knee replacement. The main aim of the study was to examine whether peripheral nerve block anesthesia would provide a more stable hemodynamic profile and analgesic effect in elderly patients undergoing total knee replacement, as compared to spinal anesthesia.

Methods: This is a single-center case-control trial, with patients from our prospectively followed registry. The patients were divided into two groups, those with peripheral nerve block anesthesia and spinal anesthesia. Propensity score analysis was performed in 1:1 ratio. The primary outcome was analgesia with total analgesic effect and the secondary outcome was intraoperative hemodynamic status.

Results: The patients in peripheral nerve block anesthesia group had a longer length of analgesia (606.19±219.35 vs 359.48±106.82, P<0.01) and pain scores during 24h and 48h after the surgery were lower in the same group of patients (3.21±1.74 vs 5.02±2.23, P=0.037; 3.03±1.57 vs 5.67±2.51, P=0.028). Spinal anesthesia group had a larger number of patients with significant hypotension (3.84% vs 15.38%, P=0.01), as well as a larger number of patients who received vasopressors (0% vs 9.61%, P<0.01).

Conclusion: Both anesthesia methods demonstrated sufficient analgesic efficacy in total knee replacement, although there was less pain severity and longer analgesic effect of peripheral nerve block anesthesia in patients who were 60 years old or older. Spinal anesthesia showed a significantly higher degree of hypotension than in those patients receivingperipheral nerve block anesthesia.

Comparison of the Combined Femoral and Lateral Femoral Cutaneous Nerve Block Plus Popliteal Block with Spinal Anesthesia for Thigh Tourniquet Pain During Foot or Ankle Surgery: A Randomized Clinical Trial

Background

A pneumatic thigh tourniquet is routinely used during lower-extremity orthopedic surgeries to provide a bloodless field. When using peripheral nerve blocks, tourniquet-related thigh pain and discomfort limit their routine use as an anesthetic method.

Objectives

The aim of the present prospective, randomized study was to compare the efficacy of combined femoral nerve/lateral femoral cutaneous nerve block technique and spinal anesthesia on intraoperative thigh tourniquet pain.

Methods

We studied 60 American Society of Anesthesiologists physical status I-II patients scheduled for orthopedic surgery on the foot or ankle using a pneumatic thigh tourniquet. They were randomly divided into two equal groups. The peripheral nerve block group received a combined popliteal, femoral, and lateral femoral cutaneous nerve block under ultrasound-guidance. In both groups, the level of sensory blockade was determined by the pinprick test. The block performance time, anesthetic effect time, intraoperative tourniquet pain scores, the amount of fentanyl and ketamine, surgery duration, and patient’s satisfaction were recorded.

Results

The patients’ characteristics were comparable in the two groups. The mean duration of block performance and anesthetic effect, intraoperative tourniquet pain scores, and the amount of intravenous analgesics in the peripheral nerve block group were significantly greater than those in the spinal anesthesia group. Patient satisfaction was similar in both groups.

Conclusions

Spinal anesthesia is significantly more effective than the peripheral nerve block method in reducing thigh tourniquet pain. A combined femoral and lateral femoral cutaneous nerve block with popliteal block can improve thigh tourniquet tolerance if supplemented with intravenous analgesics.

Sciatic obturator femoral technique versus spinal anaesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator. A randomised trial

Background

Peripheral nerve block is preferable for lower extremity surgery because it sufficiently blocks pain pathways at different levels providing excellent anaesthesia at the site of surgery. We designed this study to compare the efficacy and safety of SOFT block (sciatic-obturator-femoral technique) compared with spinal anaesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator.

Methods

One hundred and seven patients ASA I, II scheduled for fixation of open tibial fractures using Ilizarov external fixator. The patients were randomly allocated to receive either spinal anaesthesia or SOFT block. In spinal anaesthesia group, patients received spinal anaesthesia with hyperbaric bupivacaine 0.5% (7. 5-10mg). In SOFT group, patients received SOFT block with bupivacaine 0.25%. Primary endpoint included the duration of analgesia. The secondary endpoints included patient satisfaction scores, visual analogue scores, incidence of adverse events as vomiting, systemic toxicity from local anaesthetic drug and time to first effect of the techniques.

Results

The duration of SOFT block and time to first analgesic dose in SOFT group was significantly longer (p < 0.001). There was no significant difference between the study groups regarding satisfaction scores, the incidence of cardiovascular collapse, seizures and paraesthesia. Pain scores were significantly lower in SOFT group at 3,6,12 h postoperative (p < 0.001). The time to the first effect was significantly longer in SOFT group (p < 0.001).

Conclusion

SOFT is a feasible technique of local anaesthesia for control of postoperative pain with unremarkable adverse events compared with spinal anaesthesia, in patients undergoing fixation of tibial fractures using Ilizarov external fixator.

Trial registration

This trial was retrospectively registered at ClinicalTrials.gov. registry number: NCT03450798 on February 20, 2018.

Lateral Supratrochanteric Approach to Sciatic and Femoral Nerve Blocks in Children: A Feasibility Study

Background

Sciatic and femoral nerve blocks (SNB and FNB) result in effective lower limb analgesia. Classical SNB and FNB require patient repositioning which can cause pain and discomfort. Alternative approaches to sciatic and femoral nerve blocks in supine patients can be useful.

Materials and Methods

Neurostimulator-guided SNB and FNB from the lateral supratrochanteric approach were performed. Local anesthetic spread in SNB and FNB after radiographic opacification was analyzed. Time and number of attempts to perform blocks, needle depth, and clinical efficacy were assessed.

Results

Mean needle passes number and procedure time for SNB were 2.5 ± 0.3 and 2.4 ± 0.2 min, respectively. Mean needle passes number and procedure time for FNB were 2.7 ± 0.27 and 2.59 ± 0.23 min, respectively. Mean skin to nerve distance was 9.1 ± 0.45 cm for SNB and 8.8 ± 0.5 cm for FNB. Radiographic opacification of SNB showed local anesthetic spread close to the sacrum and involvement of sacral plexus nerve roots. Spread of local anesthetic in FNB was typical. Intraoperative fentanyl administration was required in 2 patients (9.5%) with mean dose 1.8 ± 0.2 mcg/kg. Mean postoperative pain score was 0.34 ± 0.08 of 10.

Conclusion

The lateral supratrochanteric approach to SNB and FNB in children can be an effective lower limb analgesic technique in supine patients. The trial is registered with ISRCTN70969666.

Lower limb surgeries under combined femoral and sciatic nerve block

Introduction:

Peripheral nerve blocks are gaining popularity for many infraumblical surgeries with the development of new techniques such as ultrasound and peripheral nerve stimulator. It provides stable hemodynamic, better, and prolonged postoperative analgesia. This study was carried out to see the effectiveness of combined femoral and sciatic nerve block with ropivacaine alone and by adding fentanyl.

Materials and Methods:

The study was carried out on 100 patients scheduled for lower limb surgeries and were randomly divided into two groups of 50 each. In Group A, patients received 20 ml of 0.5% ropivacaine for femoral nerve block and same dose for sciatic nerve block and in Group B, 25 μg fentanyl was added each for femoral nerve and sciatic nerve block along with ropivacaine. All hemodynamic parameters, onset and duration of sensory and motor blocks were noted. The patient characteristics were analyzed using the “Chi-square tests” and the intergroup comparison of the parametric data was carried out using the unpaired t-test using software IBM SPSS 17.0.

Results:

Combined femoral and sciatic nerve block provide longer duration of postoperative analgesia of about 12–13 h. All the above-mentioned parameters were statistically non-significant.

Conclusion:

Hence in this study, onset and duration of sensory and motor block was comparable in both groups. However postoperative analgesia was prolonged as compared to neuraxial blockade without any hemodynamic instability.