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 surgery or percutaneous transluminal coronary angioplasty to decrease the risk of cardiac complication [4]. Mangano [5] reported that 5–15% of all patients with peripheral artery occlusive disease also demonstrate perioperative acute myocardial infarction, with a postoperative mortality rate of 2–15%. Some of these perioperative complications may be related to the choice of anesthetic used. Additionally, concomitant anticoagulant medi- cation results hesitancy regarding anesthetic decision. Certainly, above knee femoropopliteal bypass can be
Fig. 2. Femoral branch block of genitofemoral nerve. The needle is tolerable under lidocaine local anesthesia with systemic seda- advanced between fascia lata and fascia iliaca. FA: femoral artery, FN: tion [6]. In such cases, eligibility criteria are limited to a femoral nerve, GF: genitofemoral nerve. non-obese thigh and an above knee popliteal segment of at least 10 cm. However, in our cases, the site of skin incision INR was 1.81 (0.90–1.10). Femoral nerve, femoral branch of extended widely throughout the leg, from the inguinal area to genitofemoral nerve, and sciatic nerve blocks were performed the ankle level, and the procedure involved deep tissues. for surgical anesthesia (Fig. 1–3). Nerve block technique and Moreover, protracted surgery of over 3 hours was expected. local anesthetics were used, as in case 1. The surgery took 3 Therefore, we required more potent and certain anesthetic level hours without any unwanted events. And the patient recovered to provide an adequate surgical environment, including the well. inguinal area. Therefore, we decided to anesthetize with peripheral nerve block technique. DISCUSSION Lumbar plexus block in conjunction with SNB can be initially considered for the surgery [7]. Basagan-Mogol et al. Patients with peripheral arterial disease usually have a high [8] reported femoropopliteal bypass surgery in a high-risk incidence of significant coronary artery disease, and consequent patient under combination of nerve blocks on psoas compart- Burn Young Heo, et al：Peripheral nerve block for lower limb bypass surgery 225 ment, sciatic nerve, and T12-L1 paravertebral. However, most vascular disorder patients take anticoagulants. Lumbar plexus REFERENCES block can cause complications including epidural or spinal extension of the block, intravenous local anesthetic infection, 1. Longnecker DE. Anesthesiology. 2nd ed. New York, McGraw-Hill bleeding, and retroperitoneal hematoma [9,10]. In addition, Professional. 2012, p 1009. 2. Yazigi A, Madi-Gebara S, Haddad F, Hayeck G, Tabet G. patients with a spine operation history or implanted hardware Combined sciatic and femoral nerve blocks for infrainguinal of the spine may disturb the ultrasound image [11]. Besides, arterial bypass surgery: a case series. J Cardiothorac Vasc Anesth femoral nerve block is more simple and easy to perform than 2005; 19: 220-1. lumbar plexus block. 3. Di Benedetto P, Casati A, Bertini L, Fanelli G. Posterior subgluteal There were several reports about femoro-sciatic nerve block approach to block the sciatic nerve: description of the technique as a postoperative analgesia after knee surgery, as well as and initial clinical experiences. Eur J Anaesthesiol 2002; 19: 682-6. anesthesia for total knee replacement arthroplasty and outpatient 4. Han JI. Perioperative risk of non-cardiac surgery in coronary artery knee arthroscopy or lower limb amputation below the knee disease patients. Anesth Pain Med 2007; 2: 55-60. [12]. Also, femorosciatic nerve block has been introduced for 5. Mangano DT. Perioperative cardiac morbidity. Anesthesiology infra-inguinal artery bypass grafts [2,13,14]. A previous study 1990; 72: 153-84. of 506 legs in 307 patients reported that ultrasound guided 6. Lumsden AB, Weiss V, Pitts M, MacDonald MJ, Surowiec SM, femorosciatic nerve block may provide considerable reduction Ofenloch JC. Local anesthesia for above knee femoropopliteal bypass: an alternative technique to endoluminal bypass grafting. of pain during endovenous laser ablation and other treatments, Cardiovasc Surg 1998; 6: 262-7. such as ambulatory phlebectomy and foam sclerotherapy in 7. Asakura Y, Kandatsu N, Kato N, Sato Y, Fujiwara Y, Komatsu patients with lower extremity superficial venous insufficiency T. Ultra-sound guided sciatic nerve block combined with lumbar [15]. But, in our cases, skin incision was considerably long plexus block for infra-inguinal artery bypass graft surgery. Acta and could be made throughout the leg, somewhat above the Anaesthesiol Scand 2008; 52: 721-2. 8. Basagan-Mogol E, Turker G, Yilmaz M, Goren S. Combination inguinal ligament. Furthermore, the operative procedure invaded of a psoas compartment, sciatic nerve, and T12-L1 paravertebral deep tissues, either friable artery, compared to endovenous blocks for femoropopliteal bypass surgery in a high-risk patient. laser ablation. Therefore, we required more potent and certain J Cardiothorac Vasc Anesth 2008; 22: 337-9. anesthetic level including the inguinal area. We performed 9. Pousman RM, Mansoor Z, Sciard D. Total spinal anesthetic after combined nerve block technique involving the femoral nerve, continuous posterior lumbar plexus block. Anesthesiology 2003; femoral branch of genitofemoral nerve, and sciatic nerve block. 98: 1281-2. 10.Huet O, Eyrolle LJ, Mazoit JX, Ozier YM. Cardiac arrest after To our knowledge, the present cases are the first to report injection of ropivacaine for posterior lumbar plexus blockade. the use of femorosciatic nerve block and femoral branch block Anesthesiology 2003; 99: 1451-3. of genitofemoral nerve for the purpose of surgical anesthesia 11. Chin KJ, Perlas A. Ultrasonography of the lumbar spine for during lower extremity revascularization surgery. We obtained neuraxial and lumbar plexus blocks. Curr Opin Anaesthesiol 2011; sufficient anesthetic level. In lower limb vascular surgeries, 24: 567-72. 12. Kocum A, Turkoz A, Bozdogan N, Caliskan E, Eker EH, Arslan patients with high perioperative risk for whom general/neuraxial G. Femoral and sciatic nerve block with 0.25% bupivacaine for anesthesia are thought to be of danger can be anesthetized surgical management of diabetic foot syndrome: an anesthetic successfully by this combination of nerve block. These nerve technique for high-risk patients with diabetic nephropathy. J Clin blocks can also provide sufficient analgesia, and stable Anesth 2010; 22: 363-6. intraoperative and postoperative hemodynamic status. This 13. Segura E, Figueiredo D. Peripheral nerve block for infrainguinal knowledge is valuable from the perspective of postoperative arterial bypass surgery. Rev Esp Anestesiol Reanim 2009; 56: 52-3. pain control as well as patients and surgeon satisfaction. We 14. Giordano JM, Morales GA, Trout HH 3rd, DePalma RG. Regional think that this approach could be an excellent anesthetic nerve block for femoropopliteal and tibial arterial reconstructions. choice, especially in high-risk patients who receive femoro-pop- J Vasc Surg 1986; 4: 351-4. liteal or tibial arterial bypass surgery. 15. Yilmaz S, Ceken K, Alimoglu E, Sindel T. US-guided femoral and sciatic nerve blocks for analgesia during endovenous laser ablation. Cardiovasc Intervent Radiol 2013; 36: 150-7.