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Pheral nerve blocks for ostheosynthesis of pertrochanteric femur fracture
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98. Pheral nerve blocks for ostheosynthesis of pertrochanteric femur fracture Vieta, C, Domingo T, Mayoral V, Koo M, Viscosillas, Montero A [email protected] Department of Anesthesiology. Hospital Universitari de Bellvitge. Barcelona, Spain Feixa Llarga s/n 08907 L’Hospitalet de Llobregat, Barcelona, Spain Taxdirt n° 1-3 -5 08025 Barcelona Josep Tarradellas n° 17 08232 Viladecavalls, Barcelona, Spain Introduction: Osteosynthesis of pertrochanteric femur fracture is the most common procedure on orthopedic emergency surgery on aged patients. It usually consists on fracture reduction and 135° plate-screw fixation. Spinal block is the most used anesthetic technique. We propose as an alternative a femoral and a femorocutaneous block combined with a parasacral block of the sciatic nerve (Mansour). Femoral, sciatic and obturator nerve innervate the femoral diaphysis. The inferior gluteal nerve is related to sensitivity on the trochanteric massif. Femorocutaneous nerve gives sensitive innervation to the incision zone except to the most proximal incision part (Iliohypogastric nerve or subcostal nerve). Patients and methods: Twenty-three patients (5 Male, 18 Female) undergoing surgery for pertrochanteric fracture were included. The rang of age varied between 53 and 92 years. ASA clasification status ⱖ 3 were 17. All patients were administered iron sacharate intravenously (Venofer®) dosage: 200 mgr/48h. Usual intraoperative monitoring was NIBP, ECG and pulse oxymetry. Oxygen therapy by nasal prongs. Firstly, we proceeded with the femoral block using Winnie’s technique. After a motor response of patella movement at 0.5 mA (2 Hz), we administered 15 mL of 0.5% ropivacaine. We performed the femorocutaneous nerve block (5 mL of 0.5% ropivacaine). After placing the patient in a lateral decubitus position we performed a sciatic nerve block using a Mansour’s technique. After obtaining a distal response and a negative aspiration test, we injected 20 mL of 1.5% mepivacaine. To reduce sedation dosage, we proceeded to block the contralateral obturator nerve (inguinal approach) with 50 mm neurostimulation needle (5 mL of 1% mepivacaine). Propofol 0.1 - 0.2 mg/kg/h was used to ensure confort to the patient. Recovery room: paracetamol 1g/8 h IV and methamizol 2 g/8 h IV was administered. Results: In all cases we obtained an excellent hemodynamic stability (there were not more than 30 mm Hg decrease on mean blood pressure). There was no anesthetic technique failure and no signs of local anesthetics toxicity were reported. VAS scores were 0 at the recovery room and during the next 24 hours after surgery. Conclusion: Unilateral and peripheral block of the low extremity gives a great haemodynamic. Mansour’s parasacral block allows blocking both sciatic and inferior gluteal nerves and frequently the obturator nerve, too (all cases presented sensitive block). This combination permits an acceptable dose of local anesthetic giving long standing postoperative analgesia.
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Peripheral Nerve Blocks
57
106. Novel approach for sciatic nerve block: clinical study Alpaslan Apan, Filiz Sari, Aysun Uz, Saziye Sahin [email protected] Kirikkale University Faculty of Medicine Dep. of Anaesthesiology*, Ankara University Faculty of Medicine Dep. of Anatomy®, Saglik Cad. 71100 Kirikkale, Turkey Urankent THK Bloklari E-2 Blok No: 15 Demetevler Ankara, Turkey Background and Goal of study: The classical approach to sciatic nerve (SN) block is not useful in patients with limited hip flexion (1). We aimed to assess the clinical effectiveness of surface landmarks obtained from previous anatomic study (2). Materials and methods: The study was conducted in 50 healthy informed adult patients undergoing lower extremity surgery, after approved from local ethics committee. Patients were randomly assigned into two equal groups and sciatic nerve blocks were performed using Labat’s technique (Group L) or novel approach (Group N). To define novel technique, a line was drawn between posterior superior iliac spine (PSIS) to ischial tuberose (IT) and 8 cm from PSIS (A) and 2 cm lateral to IT (B) were marked. A slightly concave line from A to B was considered surface projections of sciatic nerve and 5 cm from A was considered as needle insertion point (C). The stimulating needle was inserted perpendicularly to the operating table. Ropivacaine 7.5% 20 ml solution was administered with gentle aspirations after ankle dorsiflexion or eversion was observed under 0.5 mAmp stimuli. The quality of block was determined as good (no supplemental anaesthetic was required), satisfactory (IV or local supplementation was required) and failed (necessity of general anaesthesia). Results and discussion: There was no difference between number of attempt to find out sciatic nerve (Group L: 1.68 ⫾ 0.71, Group N: 1.57 ⫾ 0.59, p⫽ 0.487). Also, there was no significant difference between success rates (Group L: 13 / 10 / 2, Group N: 17 / 7 / 1 for good, satisfactory and failed cases, respectively). Conclusion: This study suggests new and alternative landmarks for determining the surface projections of sciatic nerve in a line rather than describing points for needle insertion. The alternative approach that determined in this study provides flexibility to the anaesthetist and seems to be reliable especially in patients in limited positioning.
References: 1. van Staa TP, et al. Bone 2001; 29: 517-22. 2. Apan A, et al. EJA 21, Supp 32: A-452.
Key Words: Regional anaesthesia, nerve block, sciatic nerve.
98. Pheral nerve blocks for ostheosynthesis of pertrochanteric femur fracture Vieta, C, Domingo T, Mayoral V, Koo M, Viscosillas, Montero A [email protected] Department of Anesthesiology. Hospital Universitari de Bellvitge. Barcelona, Spain Feixa Llarga s/n 08907 L’Hospitalet de Llobregat, Barcelona, Spain Taxdirt n° 1-3 -5 08025 Barcelona Josep Tarradellas n° 17 08232 Viladecavalls, Barcelona, Spain Introduction: Osteosynthesis of pertrochanteric femur fracture is the most common procedure on orthopedic emergency surgery on aged patients. It usually consists on fracture reduction and 135° plate-screw fixation. Spinal block is the most used anesthetic technique. We propose as an alternative a femoral and a femorocutaneous block combined with a parasacral block of the sciatic nerve (Mansour). Femoral, sciatic and obturator nerve innervate the femoral diaphysis. The inferior gluteal nerve is related to sensitivity on the trochanteric massif. Femorocutaneous nerve gives sensitive innervation to the incision zone except to the most proximal incision part (Iliohypogastric nerve or subcostal nerve). Patients and methods: Twenty-three patients (5 Male, 18 Female) undergoing surgery for pertrochanteric fracture were included. The rang of age varied between 53 and 92 years. ASA clasification status ⱖ 3 were 17. All patients were administered iron sacharate intravenously (Venofer®) dosage: 200 mgr/48h. Usual intraoperative monitoring was NIBP, ECG and pulse oxymetry. Oxygen therapy by nasal prongs. Firstly, we proceeded with the femoral block using Winnie’s technique. After a motor response of patella movement at 0.5 mA (2 Hz), we administered 15 mL of 0.5% ropivacaine. We performed the femorocutaneous nerve block (5 mL of 0.5% ropivacaine). After placing the patient in a lateral decubitus position we performed a sciatic nerve block using a Mansour’s technique. After obtaining a distal response and a negative aspiration test, we injected 20 mL of 1.5% mepivacaine. To reduce sedation dosage, we proceeded to block the contralateral obturator nerve (inguinal approach) with 50 mm neurostimulation needle (5 mL of 1% mepivacaine). Propofol 0.1 - 0.2 mg/kg/h was used to ensure confort to the patient. Recovery room: paracetamol 1g/8 h IV and methamizol 2 g/8 h IV was administered. Results: In all cases we obtained an excellent hemodynamic stability (there were not more than 30 mm Hg decrease on mean blood pressure). There was no anesthetic technique failure and no signs of local anesthetics toxicity were reported. VAS scores were 0 at the recovery room and during the next 24 hours after surgery. Conclusion: Unilateral and peripheral block of the low extremity gives a great haemodynamic. Mansour’s parasacral block allows blocking both sciatic and inferior gluteal nerves and frequently the obturator nerve, too (all cases presented sensitive block). This combination permits an acceptable dose of local anesthetic giving long standing postoperative analgesia.
•
Peripheral Nerve Blocks
57
106. Novel approach for sciatic nerve block: clinical study Alpaslan Apan, Filiz Sari, Aysun Uz, Saziye Sahin [email protected] Kirikkale University Faculty of Medicine Dep. of Anaesthesiology*, Ankara University Faculty of Medicine Dep. of Anatomy®, Saglik Cad. 71100 Kirikkale, Turkey Urankent THK Bloklari E-2 Blok No: 15 Demetevler Ankara, Turkey Background and Goal of study: The classical approach to sciatic nerve (SN) block is not useful in patients with limited hip flexion (1). We aimed to assess the clinical effectiveness of surface landmarks obtained from previous anatomic study (2). Materials and methods: The study was conducted in 50 healthy informed adult patients undergoing lower extremity surgery, after approved from local ethics committee. Patients were randomly assigned into two equal groups and sciatic nerve blocks were performed using Labat’s technique (Group L) or novel approach (Group N). To define novel technique, a line was drawn between posterior superior iliac spine (PSIS) to ischial tuberose (IT) and 8 cm from PSIS (A) and 2 cm lateral to IT (B) were marked. A slightly concave line from A to B was considered surface projections of sciatic nerve and 5 cm from A was considered as needle insertion point (C). The stimulating needle was inserted perpendicularly to the operating table. Ropivacaine 7.5% 20 ml solution was administered with gentle aspirations after ankle dorsiflexion or eversion was observed under 0.5 mAmp stimuli. The quality of block was determined as good (no supplemental anaesthetic was required), satisfactory (IV or local supplementation was required) and failed (necessity of general anaesthesia). Results and discussion: There was no difference between number of attempt to find out sciatic nerve (Group L: 1.68 ⫾ 0.71, Group N: 1.57 ⫾ 0.59, p⫽ 0.487). Also, there was no significant difference between success rates (Group L: 13 / 10 / 2, Group N: 17 / 7 / 1 for good, satisfactory and failed cases, respectively). Conclusion: This study suggests new and alternative landmarks for determining the surface projections of sciatic nerve in a line rather than describing points for needle insertion. The alternative approach that determined in this study provides flexibility to the anaesthetist and seems to be reliable especially in patients in limited positioning.
References: 1. van Staa TP, et al. Bone 2001; 29: 517-22. 2. Apan A, et al. EJA 21, Supp 32: A-452.
Key Words: Regional anaesthesia, nerve block, sciatic nerve.