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Ultrasound-Guided Femoral Nerve, Femoral Branch of Genitofemoral

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Ultrasound-Guided Femoral Nerve, Femoral Branch of Genitofemoral Anesth Pain Med 2013; 8: 222-225 ￭Case Report￭ Ultrasound-guided femoral nerve, femoral branch of genitofemoral nerve and sciatic nerve block for femoro-popliteal or tibial arterial bypass surgery on patients with cardiac dysfunction -Report of two cases- Departments of Anesthesiology and Pain Medicine, *General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Burn Young Heo, Mi Sook Gwak, Jae Woong Jung, Eun Jung Oh, Soo Joo Choi, Sangmin Maria Lee, and Young Wook Kim* We report two cases of high-risked patients with cardiac dysfunction systemic disorders, and are at high risk for perioperative undergoing femoro-popliteal or tibial arterial bypass surgery anes- complications [1]. Although lower limb revascurarization sur- thetized by ultrasound guided peripheral nerve blocks; femoral gery is commonly conducted under general or central neuraxial nerve, femoral branch of genitofemoral nerve and sciatic nerve block. We used an anesthetic solution consisting of 0.375% ropiva- anesthesia, peripheral regional anesthesia could be a good caine with epinephrine. We provided sufficient surgical anesthesia. alternative, especially in patients with high risk cardiac These nerve blockades provided stable intraoperative and post- dysfunction [2]. We report two cases of high-risked patients operative hemodynamic status, which is valuable knowledge from the perspective of postoperative pain control as well as satisfaction with cardiac dysfunction undergoing femoro-popliteal or tibial of both patients and surgeons. We believe that femorosciatic nerve arterial bypass surgery anesthetized by ultrasound guided block with concurrent femoral branch block of genitofemoral nerve peripheral nerve blocks; femoral nerve, femoral branch of could be an excellent anesthetic choice for patients receiving genitofemoral nerve and sciatic nerve block. femoro-popliteal or tibial arterial bypass surgery, especially in patients with cardiac dysfunction. (Anesth Pain Med 2013; 8: 222 First patient had generalized myocardial hypokinesia with -225) total occlusion in left internal carotid artery. Also he had cerebral infarction history and was taking anticoagulants. The Key Words: Femoral nerve, Nerve block, Peripheral vascular second patient had hypertensive cardiomyopathy with aortic disease, Regional anesthesia, Sciatic nerve, Ultrasonography. regurgitation, atrial fibrillation, mild congestive heart failure resulting in decreased left ventricle (LV) systolic function and regional wall motion abnormality. Additionally chronic obstruc- Patients undergoing lower extremity vascular surgery present tive lung disease, and azotemia. This patient also had been a dilemma to the anesthesia provider. Most of the patients taking anticoagulants. Both patients seemed to be at high risk may have severe coronary artery disease (CAD) with other for general or central neuraxial anesthesia. But we achieved successful anesthesia through peripheral nerve blocks. Com- Received: April 17, 2013. bined femoral and sciatic nerve block with concurrent femoral Revised: 1st, May 13, 2013; 2nd, May 29, 2013. branch block of genitofemoral nerve may be considered as an Accepted: June 19, 2013. Corresponding author: Mi Sook Gwak, M.D., Ph.D., Department of alternative safe anesthetic technique for femoro-popliteal or Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyun- tibial arterial bypass surgery in patients with high-risk cardiac kwan University School of Medicine, 50, Irwon-dong, Gangnam-gu, Seoul dysfunction and taking anticoagulants. 135-710, Korea. Tel: 82-2-3410-2470, Fax: 82-2-3410-0361, E-mail: [email protected] It was presented The 89th Annual Scientific Meeting of the Korean Society of Anesthesiologists, November 2012, Kim Dae Jung Convention Center, Gwangju, Korea. 222 Burn Young Heo, et al：Peripheral nerve block for lower limb bypass surgery 223 at a frequency of 1 Hz using electrical nerve stimulator TM Ⓡ CASE REPORTS (EZstim II, Model ES400; Life-Tech , Stafford, TX, USA). Femoral branch block of genitofemoral nerve was performed with 10 ml of 0.375% ropivacaine, injected between the fascia Case 1 lata and fascia iliaca, above the femoral nerve, under ultra- A 71 year-old man (175 cm, 71 kg) suffering from diabetes sound guidance. and hypertension was scheduled for bypass surgery between The patient was repositioned laterally to perform sciatic right common femoral artery and posterior tibial artery. Duplex nerve block (SNB) with the modified Labat technique ultrasonography showed severe wall calcification inside the (subgluteal approach) [3]. With the affected hip and knees right external iliac artery, and total occlusion of the right flexed, the sciatic nerve was scanned using a low-frequency (5 superficial femoral artery and right popliteal artery. The patient –2 MHz) C60X curved array transducer (SonoSite, Bothell, had right hemiparesis due to cerebral infarction that occurred Washington, USA). Using the same nerve block needle with by following spine surgery due to spinal stenosis 9 years ago. real-time ultrasound guidance, after observing a positive motor The patient also had a history of enterohemorrhage 2 months response (dorsiflexion or plantar flexion) of the foot, 25 ml of previously. Because of the cerebral infarction the patient was 0.375% ropivacaine with epinephrine was injected for sensory taking aspirin. Consequently, international normalized ratio nerve block. Sensory nerve block was checked using the pin (INR) of prothrombin time was elevated to 1.12 (normal range, prick method. Complete anesthesia that was adequate for 0.90–1.10). Echocardiography showed moderate LV systolic surgery developed within 30 minutes after the nerve block. For dysfunction, ejection fraction 35%, left atrial enlargement, intraoperative sedation, remifentanil (0.03–0.05 μg/kg/min) and dilated left ventricle cavity, and a regional wall motion propofol (15–20 μg/kg/min) were infused continuously during abnormality consisting of hypokinesia and akinesia on the the surgery. The surgery took 5 hours and the patient’s vital inferior and septal walls. Brain magnetic resonance imaging signs were stable. The skin incision extended from inguinal and carotid ultrasonography revealed total occlusion of left area to ankle level. The operating environment was excellent. internal carotid artery and 40–50% stenosis of right common At the end of the surgery, fentanyl was infused intravenously carotid artery. Preoperatively, the patient was consulted to a by patient-controlled analgesia devices : fentanyl infusion, 10 neurologist about the high possibility of cerebral infarction. μg/hr ; bolus , 10 μg; and lockout time, 15 min. The patient Recommendations were careful management of blood pressure was moved to the recovery room. Complete motor and sensory and cardiac rhythm. Also, the attending cardiologist provided recovery appeared after 8 hours of the nerve block. Pain was advice concerning the moderate to high risk of congestive assessed with a numeric rating scale (NRS). If the NRS score heart failure. Considering the patient’s overall condition, we for pain was 5 or more, morphine sulfate was administered decided to proceed with the surgery under peripheral nerve additionally. The patient received additional intravenous block using femoro-sciatic nerve block in conjunction with morphine sulfate after 35 hours from the nerve block. The femoral branch block of genitofemoral nerve. overall effectiveness of pain relief was very good. After standard monitoring (electrocardiogram, pulse oximetry, Case 2 noninvasive blood pressure), 5 L/min O2 was delivered via facial mask and the arterial line was placed on the right radial A 73-year-old man (176 cm, 65 kg) underwent above knee artery. In the supine position, femoral nerve block was femoropopliteal bypass surgery with a polytetrafluoroethylene performed with guidance of a M-turbo ultrasound with a graft due to left superficial femoral artery occlusion. The model L38X 10-5 MHz 25 mm high-frequency linear array patient had hypertensive cardiomyopathy with moderate aortic transducer (SonoSite, Bothell, Washington, USA) using an regurgitation, chronic atrial fibrillation, chronic obstructive lung insulated nerve block needle (21G, 100 mm; SonoPlex Stim disease, and mild azotemia. Carotid ultrasound showed right Ⓡ cannula; PAJUNK GmbH, Medizintechnologie, Geisingen, internal carotid artery with −70% stenosis. Furthermore Germany). A local anesthetic solution consisting of 25 ml of echocardiography showed mild congestive heart failure, decrea- 0.375% ropivacaine with epinephrine 1 : 200,000 was injected, sed LV systolic function, and regional wall motion abnor- during quadriceps femoris muscle twitching were elicited (i.e., mality. The patient was taking anticoagulants, aspirin, and cephalad knee cap movement) on 0.5 mA impulses delivered warfarin. Preoperative prothrombin time was prolonged and 224 Anesth Pain Med Vol. 8, No. 4, 2013 Fig. 1. Femoral nerve block, ultrasound image. Femoral nerve is located lateral and somewhat posterior to the femoral artery. FA: femoral artery, Fig. 3. Ultrasound image of sciatic nerve block. Sciatic nerve becomes FN: femoral nerve, LA: local anesthetics. apparent after injection. SN: sciatic nerve, LA: local anesthetics, GMM: Gluteus maximus muscle. left ventricle systolic dysfunction complicating perioperative management [1]. In patients with coronary artery disease it is suggested to delay the non-cardiac surgery after having coronary artery bypass grafting
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