Effects of Ultrasound-Guided Lower Extremity Nerve Blocks for Below-Knee Procedures in the Emergency Department of a Tertiary Care Hospital, Central Gujarat

Background and objectives Ultrasound-guided femoral and popliteal sciatic nerve blocks are useful adjuncts for many below-knee procedures like debridement, amputation, etc. The objectives of the study were to find the efficacy and feasibility of the ultrasound-guided combined femoral and popliteal sciatic nerve block for below-knee procedures in the Emergency Medicine Department (ED). Methodology This prospective clinical study was carried out over three months in ED. A total of 30 patients undergoing below-knee procedures were included in the study. Femoral and popliteal sciatic nerve blocks were administered to each patient using the high-frequency linear ultrasound probe by emergency physicians trained in ultrasound. The effect of blocks, amount of local anesthetic (LA) used, duration of the procedure, and post-block analgesia were recorded. Patients were monitored for possible complications, if any. Data were entered and analyzed using a Microsoft Excel worksheet. Results The average volume of LAs required was around 34.5 cc for both blocks combined. No complications like vascular puncture or nerve injury were reported during the study. The time taken to complete the procedure was around 33 minutes, and the average time to achieve sensory block was around 9 minutes after completing the procedure. Conclusions An ultrasound-guided combined femoral and popliteal sciatic nerve block is an effective and feasible procedure and thus should be considered in ED for below-knee procedures.

Dexamethasone Addition to Popliteal Nerve Blocks: Effects on Duration of Analgesia and Incidence of Postoperative Nerve Complication

Background. The purpose of this prospective, double-blinded randomized control pilot study was to evaluate the effect of adjunctive dexamethasone on analgesia duration and the incidence of postoperative neuropathic complication. Peripheral nerve blocks are an effective adjunct to decrease postoperative pain in foot and ankle surgery, and any possible modalities to augment their efficacy is of clinical utility. Methods. Patients were randomly assigned to a control group (n = 25) receiving nerve blocks of bupivacaine and epinephrine or an experimental group (n = 24) with an adjunctive 8 mg dexamethasone. The patients, surgeons, and anesthesiologists were all blinded to allocation. Patients had a minimum 1 year postoperative follow-up. Results. Forty-nine patients completed the protocol. There was no statistically significant difference in analgesia duration (P = .38) or postoperative neuropathic complication incidence (P = .67) between the 2 groups. Conclusions. The addition of dexamethasone to popliteal nerve blocks does not appear to affect analgesia duration or incidence of postoperative neuropathic complications. However, our study was underpowered, and we recommend a larger scale prospective study for validation.Levels of Evidence: Level II: Prospective, randomized control pilot study.

Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair

The use of regional anesthetic techniques in the peri-operative period has increased as a means to improve analgesia and patient outcomes. Traditionally, various local anesthetics are used and addition of adjuncts such as epinephrine, clonidine, and dexamethasone has shown to prolong the block effect. There has been ongoing research to support the prolongation of a regional block with the addition of dexamethasone and dexmedetomidine (Dex-Dex), providing analgesia for multiple days. We present a case of a 35-year-old female who underwent an Achilles tendon repair with an adductor/popliteal nerve block. Both dexmedetomidine and dexamethasone were added to the local anesthetic mixture with substantial postoperative analgesic control. The patient also did not require any supplemental opioid medication. This case emphasizes the proposed synergistic effect of dexmedetomidine and dexamethasone when added to the local anesthesia injectate for lower extremity peripheral nerve blocks.

Comparison of the effects of remifentanil-based general anesthesia and popliteal nerve block on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation: A retrospective observational study

Diabetic foot ulcer is the most common cause of diabetes-associated nontraumatic lower extremity amputation. Most patients who undergo lower extremity amputation for a diabetic foot have had diabetes for a long time and suffer from multiorgan disorder; thus, it can be a challenge to ensure sufficient anesthetic and analgesic effects while maintaining stable hemodynamics. Recently, peripheral nerve block has gained popularity owing to its attenuating effects of systemic concerns. This retrospective observational study aimed to compare the effects of remifentanil-based general anesthesia (GEA) and popliteal nerve block (PNB) on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation.A total of 59 consecutive patients with a diabetic foot who underwent distal foot amputation between January 2012 and May 2014 were retrospectively reviewed. Patients received remifentanil-based GEA (GEA group, n = 32) or PNB (PNB group, n = 27). The primary outcomes were to evaluate postoperative analgesic effects and perioperative hemodynamics. Also, postoperative pulmonary complications and 6-month mortality were assessed as secondary outcomes.Significant differences in pain scores using numeric rating scale were observed between the groups in a linear mixed model analysis (PGroup×Time = 0.044). Even after post hoc analysis with the Bonferroni correction, the numeric rating scale scores were significantly lower in the PNB group. Furthermore, patients in the PNB group required less pethidine during the first 6 hours after surgery (27 ± 28 vs 9 ± 18 mg; P = 0.013). The GEA group had a lower mean blood pressure (Bonferroni-corrected P < 0.01), despite receiving more ephedrine (P < 0.001). Significantly more patients in the GEA group suffered from postoperative pneumonia and required the management in intensive care unit (P = 0.030 and 0.038, respectively). However, the groups did not differ in terms of 6-month mortality.This study demonstrated that compared with remifentanil-based GEA, PNB might be a favorable option for diabetic patients undergoing distal foot amputation, despite the lack of significant mortality benefits, as PNB was associated with improved postoperative analgesia, hemodynamic stability, and a low incidence of pulmonary complications during the immediate postoperative period, especially in high-risk patients.