Anesth Pain Med 2011; 6: 270～274 ￭Case Report￭ Femoral and sciatic nerve blocks for total knee replacement in an obese patient with a previous history of failed endotracheal intubation −A case report− Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea Jong Hae Kim, Woon Seok Roh, Jin Yong Jung, Seok Young Song, Jung Eun Kim, and Baek Jin Kim Peripheral nerve block has frequently been used as an alternative are situations in which spinal or epidural anesthesia cannot be to epidural analgesia for postoperative pain control in patients conducted, such as coagulation disturbances, sepsis, local undergoing total knee replacement. However, there are few reports infection, immune deficiency, severe spinal deformity, severe demonstrating that the combination of femoral and sciatic nerve blocks (FSNBs) can provide adequate analgesia and muscle decompensated hypovolemia and shock. Moreover, factors relaxation during total knee replacement. We experienced a case associated with technically difficult neuraxial blocks influence of successful FSNBs for a total knee replacement in a 66 year-old the anesthesiologist’s decision to perform the procedure [1]. In female patient who had a previous cancelled surgery due to a failed tracheal intubation followed by a difficult mask ventilation for 50 these cases, peripheral nerve block can provide a good solution minutes, 3 days before these blocks. FSNBs were performed with for operations on a lower extremity. The combination of 50 ml of 1.5% mepivacaine because she had conditions precluding femoral and sciatic nerve blocks (FSNBs) has frequently been neuraxial blocks including a long distance from the skin to the used for postoperative pain control after total knee replacement epidural space related to a high body mass index and nonpalpable lumbar spinous processes. This case suggests that FSNBs can [2]. However, there are few reports demonstrating that FSNBs provide a good alternative anesthetic method for total knee can provide an adequate anesthesia during a total knee replacement. (Anesth Pain Med 2011; 6: 270∼274) replacement. We experienced a case of successful FSNBs for a total knee replacement in a 66 year-old female patient who Key Words: Femoral nerve, Intubation, Nerve block, Sciatic nerve, had a history of failed tracheal intubation and conditions Total knee replacement. precluding neuraxial blocks. CASE REPORT Spinal or epidural anesthesia has gained widespread acceptance for surgery involving the lower extremities. In the A 66 year-old female (height 150 cm, weight 84 kg) was presence of an increased risk of perioperative pulmonary scheduled for elective total knee replacement. She had been compromise, such as in patients with respiratory impairment or treated with methyprednisolone and methotrexate for degenerative features suggestive of a difficult airway after induction of osteoarthritis and rheumatoid arthritis for 3 years, and with general anesthesia, spinal or epidural anesthesia might confer antihypertensive medications including aspirin 100 mg once a some management and outcome advantages. On occasion, there day for hypertension for 5 years. One year ago, total knee replacement was canceled due to underlying conditions involving Received: February 21, 2011. heart and kidney, anemia and other problems in a local private Revised: March 4, 2011. Accepted: April 1, 2011. hospital and then she was transferred to our institution for Corresponding author: Woon Seok Roh, M.D., Department of better management of the problems. After appropriate management Anesthesiology and Pain Medicine, School of Medicine, Catholic of the clinical problems, an elective total knee replacement University of Daegu, 3056-6, Daemyeong 4-dong, Nam-gu, Daegu 705-718, Korea. Tel: 82-53-650-4504, Fax: 82-53-650-4517, E-mail: was scheduled. Preoperative laboratory tests showed hemoglobin [email protected] 8.5 g/dl, total white blood cell count 16,500 cells/mm3, platelet 270 Jong Hae Kim, et al：Peripheral nerve block and total knee replacement 271 Fig. 1. Preoperative chest radiograph shows mild pulmonary edema, left Fig. 3. Preoperative lumbar spine lateral radiograph demonstrates pleural effusion and destructive pulmonary tuberculosis in atelectasis distance from skin to epidural space is approximately 97.8 mm. involving left upper lobe. block in electrocardiogram. However, the pulmonary function test revealed moderate obstructive lung defect with 0.93 liters of forced expiratory volume in one second and decrease in flow rate at peak flow and flow at 50% and 75% of the flow volume curve, and mild pulmonary edema, left pleural effusion and destructive pulmonary tuberculosis in atelectasis involving left upper lobe were visualized on preoperative chest radiograph (Fig. 1). She also had a history of dyspnea on exertion for 3 years. In addition, she came to be diagnosed with chronic renal failure due to hypertensive nephropathy during this admission. Examination of her upper airway revealed that soft palate and uvula were easily visualized and she was assigned to Mallampati class II. Flexion and extension of the cervical spine appeared to be reasonably well preserved. Her lumbar interspinous space could not be palpated due to excess body Fig. 2. Preoperative lumbar spine anteroposterior radiograph shows trunk fat. She complained of intermittent low back pain, but osteophytes and no remarkably narrowed interlaminar space in the lower plain radiographs of the lumbar spine showed no particular lumbar vertebrae. bony abnormalities except osteophytes (Fig. 2 and 3). After reviewing the risks of the various forms of anesthesia, general count 106,000/mm3 and blood urea nitrogen 37.5 mg/dl, anesthesia was planned. creatinine 2.7 mg/dl, prothrombin time 11.9 seconds, activated Premedication consisted of intramuscular glycopyrrolate 0.1 partial thromboplatin time 34.4 seconds and bleeding time and mg 30 minutes before surgery. Electrocadiogram, pulse oxime- clotting time in the normal range. Pancytopenia resulting from try and blood pressure cuff were applied for intraoperative moni- disease modifying antirheumatic drugs was resolved following toring. Alveolar denitrogenation was performed with the patient their cessation, but the anemia still persisted. Preoperative vital breathing 100% oxygen through a nonrebreather mask. Anes- signs were blood pressure 120/80 mmHg and heart rate 60 thesia was induced with intravenous propofol 80 mg combined beats per minute. Transthoracic echocardiography and coronary with continuous infusion of remifentanil 0.3 μg/kg/min. After angiography were found to be normal with right bundle branch achieving unconsciousness, intravenous rocuronium 85 mg was 272 Anesth Pain Med Vol. 6, No. 3, 2011 Three days after the event, FSNBs was planned for the total knee replacement. On arrival in the operating room, monitoring of noninvasive blood pressure, electrocardiogram and SpO2 was instituted. Then, femoral nerve block was performed lateral to the femoral artery immediately below the inguinal ligament. Successful location was indicated by contraction of the quadriceps femoris muscle with an initial current of 1 mA at 1 Hz and continuous contraction at 0.5 mA at 1 Hz using Ⓡ Stimuplex A 150 mm needle (Braun Medical, Melsungen, Germany). After negative aspiration, 25 ml of 1.5% mepiva- caine were injected. The sciatic nerve block was based on Fig. 4. This photograph shows the obese patient after femoral and sciatic Labat’s technique. In the lateral decubitus position (Sim’s nerve blocks. position), the same needle used for the femoral nerve block was inserted at a right angle to all cutaneous planes at administered. Suddenly, mask ventilation became impossible the caudal end of 3−5 cm line originating from, and and immediate endotracheal intubation was attempted. Laryngo- perpendicular to, the middle of a line that intersects the greater scopy revealed a grade 4 Cormack and Lehane view and trochanter posterior to the iliac spine. The sciatic nerve was another attempt of endotracheal intubation also failed. The identified with the help of a nerve stimulator using a stimulus consecutive attempts using a light wand, fiberoptic bronchoscope, of 1 mA at 1 Hz, while contractions of the gastrocnemius (foot laryngeal mask airway were in vain. However, saturation of plantar flexion) indicated proximity to the sciatic nerve and the peripheral oxygen (SpO2) was maintained above 95% with a needle was introduced until muscle twitches were elicited with two-handed technique despite failed intubation and difficult currents of 0.5 mA at 1 Hz. After negative aspiration, 25 ml positive pressure ventilation. After discussion of 20 minute-long of 1.5% mepivacaine were injected. Patients were then returned preoperative episodes with the surgeon, it was decided to to a supine position (Fig. 4). Radial artery catheterization and cancel the surgery. To reverse neuromuscular blockade, 20 mg subclavian central venous catheterization were performed for of pyridostigmine with 0.4 mg of glycoppyrolate was used continuous arterial pressure monitoring and central venous intravenously. Recovery of spontaneous respiration and conscious- pressure monitoring, respectively. The patient felt no pain at ness was not achieved in spite of 15 minutes of additional the incision site when pinch was applied just before the positive pressure ventilation with a two-hand technique, during operation. The operation had been uneventful since and took which arterial catheterization was