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Home , August Bier, Femoral nerve, Femoral nerve block, Local anesthesia

Femoral Blocks

Julie Ronnebaum, DPT, GCS, CEEAA Objectives  1. Become familiar with the evolution of peripheral nerve blocks.  2. Describe the advantages and disadvantages of femoral nerve blocks  3. Identify up-to-date information on the use of femoral .  4. Recognize future implications. History of  The use of anesthetics began over 160 years ago. General Anesthesia  In 1845, Horace Wells used nitrous oxide gas during a tooth extraction

 1st- public introduction of general anesthesia October 16, 1846.  Known as “Ether Day” ( William Morton)  In front of audience at Massachusetts General Hospital

 First reporte d deat h in 1847 due to t he et her

 Other complications  Inttouctoroduction to eteteher was ppoogerolonged  for hours to days after

Schatsky, 1995, Hardy, 2001 History of Anesthesia  In 1874, morphine introduced as a killer.  In 1884, August Freund discovers cyclopropane for surgery  Problem is it is very flammable  In 1898, heroin was introduced for the addiction to morphine  In 1923 Arno Luckhardt administered ethylene oxygen for an anesthetic

History of Anesthesia Society History of Anesthesia  Alternatives to general anesthesia

 In the 1800’s used by the Incas and Conquistadors

 1845, Sir Francis Rynd applied a morphine directly to the nerve to relieve intractable neuralgg(ia. ( first recorded nerve block )  Delivered it by gravity into a cannula

 In 1855, Alexander Wood is a glass syringe to deliver the for a nerve block. ( also known as regg)ional anesthesia)

 In 1868 a Peruvian surgeon discovered that if you inject cocaine into the skin it numbed it.

 In 1884, Karl Koller discovered cocaine could be used to anesthetized the eye of a frog.

History of Anesthesia Society History of Anesthesia

 In 1885, James Corning introduced cocaine for spinal analgesia (dog)  In 1898, August Bier administered spinal analgesia on humans.  In 1900 first spinal analgesia for vaginal delivery  In 1903, Ernest Fourneau introduced first synthetic ( Amylocain)  In 1946, Paul AbAnsbro itintrod uced a con tinuous nerve blkblock  In 1965, Bupivacaine is first marketed as a pain reliever  In 1999, first reviews are published using the use for nerve blocks.

History of Anesthesia Society Regional Anesthesia  Local anesthetic induced blockade of peripheral or spinal nerve impulses from a targeted body part with preserved level of consciousness

http://medical-dictionary Types of Regional Anesthesia  local anesthetic (Bier block)  spinal, epidural  Peripheral nerve blocks ( PNB)  Truncal ( paravertebral, TAP blocks)  Plexus (brachial plexus, )  Distal ( femoral, sciatic) Peripheral Nerve Blocks Advantages  Can combine the regional anesthetic with light general anesthetic.  Decrease in post operative nausea and vomiting, delirium and respiratory depression.  All with the goal of a decreased  length of stay in the hospital.  Decreased narcotic requirements after surgery  Earlier return of bowel function  Improved pain scores within first 24 hours Disadvantages  Variable duration  Failed blocks  Intraoperative awareness and discomfort  Sustained Motor blockade  Rare serious complications Contraindications  Excessive  On anticoagulants  Preexisting nerve injury  Infection Relationship to Physical Therapy  Allows for earlier mobilization status post total arthroscopic surgery. ( Capdevila,2005)  Earlier mobilization improves short and long term functional outcomes ( Atkinson, 2008) Complication of Peripheral Nerve Bloc ks  Local anesthetic toxicity  Bleeding/hematoma  Infection (Neuburger , 2007)  Nerve injury ( transient paralysis 1-3%) ( Capdevila, 2005)  Permanent injury 1/10,000 Specific kinds of blocks  Brachial plexus  Interscalene block  Supraclavicular block  Axillary block

 Lower extremity  Lumbar plexus  and block  block: anterior, gluteal and popliteal

 Truncal  Paravertebral block  Transverse abdominus plane (TAP) block Femoral Nerve Block for TKA  Used for postoperative pain relief of the or .  Most commonly with ACL repairs and total knee arthroplasties

http://www.google.com/imgres?q=pictures+of+femoral+nerve+block&hl=en&sa=X&rlz=1W1AURU_enUS499& biw=1680&bih=795&tbm=isch&prmd=imvns&tbnid=6pqjRM7R44VliM

http://en.wikipedia.org/wiki/File:Fermoral_nerve_block.jpg Motor and cutaneous distribution

http://www.ifna-int.org/ifna/e107_files/downloads/lectures/H17Femoral.pdf with Femoral Nerve Block

Medication On set Anesthesia (hrs) Analgesia (hrs)  3% 2-Bupivacaine (Allen,10-15 1998) 1 2 (+HCO3) Ropivicaine (Morin, 2005) 3% 2- chloroprocaine 10-15 1.5-2 2-3 (+HCO3+Lidocaine epi) (Macalou, 2004) 1.5% Mepivacaine 15-20 2-3 3-5 (+HCO2) 1.5% Mepivacaine 15-20 2-5 3-8 (+HCO2+ epi)

2% lidocaine 10-20 2-5 3-8 0.5% ropivacaine 15-30 4-8 5-12 0.75% ropivacaine 10-15 5-10 6-24 0.5 Bupivacaine 15-30 5-15 6-30

NYSORA Application  Do patients that undergo a total knee arthroplasty, and receive the Femoral Nerve block, perform better than those who have had traditional methods of pain control? Pain

Reference Journal Block #pt Outcomes Results

Allen et. al, 1998 Anesthesia and FNB, FNB + SNB 36 VAS, morphine The FSNB group had Analgesia consumption, side decreased pain scores effects only on POD 1 McNamee et al, 2001 ACTA SSFNB+Sciatic, SSFNB 50 VAS, activity, Morphine Anaesthesiologica +Sciatic + PCA morphine consumption was Scandinavica consumption significantly reduced in SSFNB + Sciatic SSFNB + sciatic + PCA Macalou et.al, 2004 Anesthesia and SSFNB, PCA 57 VAS, morphine Pain rating were the Anlgesia consumption, side same for all groups, effects pain was experienced in back of knee Pham Dang et.al, Regional Anesthesia FNB, FNB + SNB 28 Amplitude of knee Pain scores at rest 2005 and PPiain MMdiiedicine flex ion, sideeffec tswere siifitlignificantly higher in the FNB group compared to the FSNB group. This difference disappeared after 36 hours after surgery. The FSNB group consumed 81% less morphine compared to the FNB group. Pain continued Reference Journal Block #pt Outcomes Results

Morin et al, 2005 Regional Anesthesia FNB, FNB + SNB, PNB 90 Morphine Postoperative and Pain Medicine consumption, pain morphine scores, maximal consumption during bending and extending 48 hours was of the knee, walking significantly lower in distance the FSNB group than in the FNB group. Postoperative pain scores were not different Good et. al. ,2007 American Journal of SSFNB , PCA 42 VAS, side effects, SSFNB consumed less Orthopedics morphine morphine and pain consumption ratings remained the same for both groups Hung et. al, 2009 The Journal of FNB, FNB + SNB 88 VAS, morphine The FSNB group had Arthlhroplasty consumption lower pain scores on the day of surgery both there was no difference on POD 1 and 2. The FSNB group used significantly less PCA morphine compared to the FNB and control group Kadic, et al, 2009 ACTA CFNB, PCA 53 VAS, morphine CFNB hdhad less pain Anaesthesiologica consumption, side and nausea. Scandinavica effects Range of motion

Reference Journal Block #pt Outcomes Results

Singelyn et al, 1998 Anesthesia and PCA, CFNB+ SNB, EPI 45 VAS, Knee flexion, Significantly better Analgesia side effects, length of knee flexion, stay ambulation distance up to 6 weeks post op, at 3 months no difference Wang et al, 2002 Regional Anesthesia SSFNB vs placebo 30 VAS, knee range of Knee range of motion and Pain Medicine motion, length of at discharge was not stay in hospital statistically different, length of stay shorter for blocks NiNngai, et al, 2007 The JlJournal of PCA, low FNB (. 15%) 60 VAS, range of motion, FNB had better range Arthroplasty and high (.2%) dose morphine use. of motion initially FNB Kadic, et al, 2009 ACTA CFNB, PCA 53 VAS, morphine Better knee range of Anaesthesiologica consumption, side motion in first 6 days, Scandinavica effects after 3 months the same. Fetherston,et al, 2011 Journal of Orthopedic PCA, CFNB 53 Pain, range of motion, FNB had lower range surgery and Research TUG of motion than PCA Functional recovery  At 6 months, gait distance was the same for all groups (Kadic, 2009)  The TUG times were better for th e PCA group as compare d to the CFNB group.  Men prepared better than the women.( Fetherston, 2011)

 1.6% of 1018 patients had fallen within 48 hours after surgery had a nerve block. ((,)Sharma, 2010)  Lower extremity nerve blocks result in decreased leg stiffness and lateral instability, which may lead to difficulty with pivoting maneuvers. ( Muraskin, 2007)  Demonstrated there is a causal relationship between CPNB and the risk of falling after knee and hip arthroplasty.( Ilfed, 2010) Sensation and motor recovery

 Prolonged nerve blockade can last up to 30 hours ( Hadzic et al 2004, Seldlander et al 1988)  Prolonged sensory deprivation up to 1 year after surgery. ( Sharma, 2010) Summary of literature  Pain scores at rest  At 24 hours, majority of patients with CFNB exhibited less pain than those that received a PCA.  At 48 hours, no significant differences between groups.

 Pain with activity  At 24 hours, all blocks had less pain than PCA.  At 48 hours, those who received the sciatic block had better pain scores.

 Knee range of motion  There were no significant differences at discharge in knee range of motion scores for all groups What are the clinicians saying? Case Study  The patient was an 88 year old male diagnosed with osteoarthritis of t he le ft knee. This pati ent und erwent a le ft TKA an d rece ive d a CFNB with Ropivacaine. The patient received physical therapy via the standard joint camp protocol, startinggy on postoperative day 1.

Ronnebaum, 2012 Joint Camp Exercises

Table #2 Total Knee Arthroscopy Exercises

Postoperative Day Exercises 1. Independent with gluteal sets Day 1 2. Minimum assistance needed to perform ankle dorsiflexion, plantar flexion and heel PM slides. 3. Maximum assistance needed to perform straight leg raise (SLR), short arch quad (SAQ) and long arch quads (LAQ). Patient was unable to perform a quad set. Patient performed 10 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps and heel slides. Day 2 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad AM set. Patient performed 15 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps and heel slides Day 2 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad PM set. Patient performed 15 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps an heel slides. Day 3 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad AM set. Patient performed 15 repetitions of each exercise in semi reclined position .

Ronnebaum, 2012 Functional Outcomes

Table 3: Functional Outcome Progression During the Inpatient Stay Table 3: Functional Outcome Progression During the Inpatient Stay Functional Postoperative Day Postoperative Day Postoperative Day Postoperative Day Functional Outcomes #1 afternoon #2 morning # 2 afternoon #3 morning Outcomes Ambulation assist Minimal Contact guard Contact guard Contact guard Ambulation assist assistance assist assist assist Ambulation Standard walker Wheeled walker Wheeled walker Wheeled walker Ambulation device device Ambulation 60 feet 150 feet 150 feet 150 feet Ambulation Distance Distance Ambulation Step to gait Step to gait with Step to gait Step through gait Ambulation Pattern verbal cues to step Pattern fthitthfurther into the walker Pain (Visual 8743Pain (Visual Analog Scale) Analog Scale) Range of Flexion 94 NA Flexion 90 Flexion 90 Range of motion(degrees) Extension -10 Extension -6 Extension -6 motion(degrees)

Ronnebaum, 2012 Conclusions  The continuous femoral nerve block did prevent the side effects found with the traditional methods of pain relief.  At discharge patient was unable to perform independent SLR and SAQ.  Patient did achieve 90 degrees of knee flexion by discharge but had -6 degg.rees of extension.  The patient went home with knee immobilizer secondary to quadriceps weakness.  Patient was referred to OPT PT secondary to quadriceps weakness.

Ronnebaum, 2012 Future studies  Examine the spike in pain rating 16-28 hours after surgery

 Examine prolonged quadriceps weakness

 Examine the effects of infiltration techniques as compared the PCA and nerve bloc ks. References  Singelyn FJ, Deyaert M, Joris D, et al. Effects of IV patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998;87:88–92.  Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay total knee replacement. Reg Anesth Pain Med 2002;27:139–44.  Sharma, S, et al Complications of femoral nerve block for total knee arthoplasty. Clinical Orthopedics and related research. 2010. 468: 135-140.  McNamee, et al. Total knee replacement: a comparison of ropivacaine and bupivacaine in combined femoral and sciatic block. Acta Anaestheiola Scandiavia. 2001. 45: 477-481.  Selander, D. Nerve toxicity of local anesthetics. and regional blockade. In: Lofstrom J, Sjostrand U,,, editors. Amsterdam, Elsevier Science Publisher ;1988: 77.  Hadzic, A et al New York School of Regional Anesthesia. Peripheral nerve blocks, principles and practice. New York: McGraw-Hill: 2004:62.  Muraskin et al, Falls associated with lower extremity nerve block: a pilot investigation. Regional Anesthesia in Pain Medicine. 2007. 32(1); 67-72.  Illfed, B et al. The Association between lower extremity continuous nerve blocks and patient falls after knee and hip arthroplasty. Anesthesia and Analgesia, 2010. 10(10) 1-3.  Schatski, SC Ether Day. American Journal of Radiology. 1995. 165:560.  Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD: Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg 1998; 87:93–7  Macalou D, Trueck S, Meuret P, Heck M, Vial F, OuologuemS, Capdevila X, Virion JM, Bouaziz H: Postoperative analgesia after total knee replacement: The effect of an block added to the femoral 3-in-1 nerve block. Anesth Analg 2004; 99:251– 4  McNamee DA, Convery PN, Milligan KR: Total knee replacement: A comparison of ropivacaine and bupi vacai ne in combi ned femoral and sci ati c bloc k. Ac ta AthilAnaesthesiol Scand 2001; 45: 477– 81  Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B: A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg 2006;102:1240 – 6  Ka dic L, Boonst ra MC, De Waal Mal efijt MC, Lak o SJ, J Van EdEgmond J, Dri essen JJ: Con tinuous femora l nerve block after total knee arthroplasty? Acta Anaesthesiol Scand 2009; 53:914 –20  Morin AM, Kratz CD, Eberhart LH, Dinges G, Heider E, Schwarz  N, Eisenhardt G, Geldner G, Wulf H: Postoperative analgesia and recovery after total-knee replacement: Compar ison o f a con tinuous pos ter ior lum bar p lexus (psoas compar tmen t) bloc k, a con tinuous femora l nerve block, and the combination of a continuous femoral and . Reg Anesth Pain Med 2005; 30:434–4  Good RP, Snedden MH, Schieber FC, Polachek A: Effects of a preoperative femoral nerve block on and rehabilitation after total knee arthroplasty. Am J Orthop 2007; 36:554 –7  Capdevila X et al , Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. . 2005;103(5):1035.  Neuburger M et al., Inflammation and infection complications of 2285 perineural catheters: a prospective study. Acta Anaesthlhesiol Scand. 2007;51(1):108.  Ronnebaum, J. Acute Care Outcomes Status Post Total Knee Arthroplasty with Continuous Femoral Nerve Block. Journal of Acute Care Physical Therapy. 3(1)2012:149-156.  Weber, A., Fournier, R., Van Gessel, E. et al. (2002)Sciatic nerve block and the improvement of femoral nerve block analgesia after total knee replacement. Journal of Anaestheology 19: 832-850.