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126: Combined Sciatic-Femoral Nerve Block in a Patient With Progressive Systemic Sclerosis
104
Posters
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Peripheral Nerve Blocks
70. Evaluation of the incidence of intravascular needle placement for single shot lumbar plexus blockade
126. Combined sciatic-femoral nerve block in a patient with progressive systemic sclerosis
M. Crowley1, P. Asif2, G. D’Souza1 1John Radcliffe Hospital, Nuffield Department of Anaesthesia, Oxford, UK, 2Russells Hall Hospital, Deapartment of Anaesthesia, Dudley, UK
B. Gokce Ceylan, S. Sari, O. Ozorak, L. Yavuz, F. Eroglu Suleyman Demirel University, Medical Faculty, Department of Anaesthesiology and Reanimation, Isparta, Turkey
Background: Intravascular needle placement is a worrying possibility for anaesthetists when providing both central and peripheral nerve blockade.
Objective: Progressive systemic sclerosis (PSS) is a multisystem disorder characterized chiefly by fibrosis of blood vessels, skin, musculoskeletal system, and visceral organs. Pathogenesis of PSS involves microvascular insult and a secondary overproduction and accumulation of collagen, activation of immunologic mechanisms, and increased fibroblast activation and proliferation. Patients with progressive systemic sclerosis can pose a significant challenge for the anesthesiologist (1).
Typically a large volume (20 to 30 mls) of concentrated local anaesthetic is used for lumbar plexus blockade which could result in neuro or cardiac toxicity for the patient if subsequent local anaesthetic is administered intra-vascularly. Methods: We performed a prospective study looking at 40 consecutive single shot lumbar plexus blocks performed in one centre by the same experienced anaesthetist. These blocks were performed when clinically indicated on patients for lower limb surgery. Our main aim was to evaluate the incidence of intravascular needle placement when performing single shot lumbar plexus blockade. A 100 mm stimiplex needle was inserted at an L 3/4 level using a posterior landmark guided technique. Before local anaesthetic injection into the psoas muscle the syringe was aspirated looking for the presence of blood. This was also performed regularly after every 5 mls of injectate. Results: The lumbar plexus were successfully located in 39 of 40 patients using a peripheral nerve stimulator technique. In two cases fresh blood was aspirated indicating intravascular placement of the needle tip. During one of these two cases a previous negative aspiration result had been found and 5 mls of local anaesthetic had been injected. Conclusions: We found that the incidence of inadvertent intravascular needle placement for single shot lumbar plexus blockade to be in the region of five per cent. A previous negative aspiration result does not indicate continued suitable needle tip placement and this supports the use of regular needle aspiration technique to confirm its correct position.
Case: Foot amputation under ankle was planned for a 63 year-old woman, 130-cm in height, weighing 22-kg with a history of systemic sclerosis for the treatment of progressive digital necrosis associated with Reynaud’s phenomenon. General anesthesia was not planned due to reduced mandibular mobility and oral narrowing. The sciatic and femoral nerve blocks were performed with the aid of a nerve stimulator (Stimuplex DigRc) and nerve stimulating needles (StimuplexA, Braun) with a total dose of 30 ml of 0.5% levobupivacaine. The monitored parameters were stable and the patient was pain free and comfortable throughout the surgery. Conclusion: Peripheral nerve block anesthesia offers many clinical advantages that contribute to both an improved patient outcome and lower overall healthcare costs. Late and severe systemic sclerosis presents with cardiac, pulmonary, and renal manifestations. Though there are no specific contraindications to the use of any type of anesthetic; peripheral techniques may be successfully utilized in proper cases.
Reference 1. Roberts JG, Sabar R, Gianoli JA, Kaye AD. Progressive systemic sclerosis: clinical manifestations and anesthetic considerations. J Clin Anesth. 2002; 14:474-7.
Posters
•
Peripheral Nerve Blocks
70. Evaluation of the incidence of intravascular needle placement for single shot lumbar plexus blockade
126. Combined sciatic-femoral nerve block in a patient with progressive systemic sclerosis
M. Crowley1, P. Asif2, G. D’Souza1 1John Radcliffe Hospital, Nuffield Department of Anaesthesia, Oxford, UK, 2Russells Hall Hospital, Deapartment of Anaesthesia, Dudley, UK
B. Gokce Ceylan, S. Sari, O. Ozorak, L. Yavuz, F. Eroglu Suleyman Demirel University, Medical Faculty, Department of Anaesthesiology and Reanimation, Isparta, Turkey
Background: Intravascular needle placement is a worrying possibility for anaesthetists when providing both central and peripheral nerve blockade.
Objective: Progressive systemic sclerosis (PSS) is a multisystem disorder characterized chiefly by fibrosis of blood vessels, skin, musculoskeletal system, and visceral organs. Pathogenesis of PSS involves microvascular insult and a secondary overproduction and accumulation of collagen, activation of immunologic mechanisms, and increased fibroblast activation and proliferation. Patients with progressive systemic sclerosis can pose a significant challenge for the anesthesiologist (1).
Typically a large volume (20 to 30 mls) of concentrated local anaesthetic is used for lumbar plexus blockade which could result in neuro or cardiac toxicity for the patient if subsequent local anaesthetic is administered intra-vascularly. Methods: We performed a prospective study looking at 40 consecutive single shot lumbar plexus blocks performed in one centre by the same experienced anaesthetist. These blocks were performed when clinically indicated on patients for lower limb surgery. Our main aim was to evaluate the incidence of intravascular needle placement when performing single shot lumbar plexus blockade. A 100 mm stimiplex needle was inserted at an L 3/4 level using a posterior landmark guided technique. Before local anaesthetic injection into the psoas muscle the syringe was aspirated looking for the presence of blood. This was also performed regularly after every 5 mls of injectate. Results: The lumbar plexus were successfully located in 39 of 40 patients using a peripheral nerve stimulator technique. In two cases fresh blood was aspirated indicating intravascular placement of the needle tip. During one of these two cases a previous negative aspiration result had been found and 5 mls of local anaesthetic had been injected. Conclusions: We found that the incidence of inadvertent intravascular needle placement for single shot lumbar plexus blockade to be in the region of five per cent. A previous negative aspiration result does not indicate continued suitable needle tip placement and this supports the use of regular needle aspiration technique to confirm its correct position.
Case: Foot amputation under ankle was planned for a 63 year-old woman, 130-cm in height, weighing 22-kg with a history of systemic sclerosis for the treatment of progressive digital necrosis associated with Reynaud’s phenomenon. General anesthesia was not planned due to reduced mandibular mobility and oral narrowing. The sciatic and femoral nerve blocks were performed with the aid of a nerve stimulator (Stimuplex DigRc) and nerve stimulating needles (StimuplexA, Braun) with a total dose of 30 ml of 0.5% levobupivacaine. The monitored parameters were stable and the patient was pain free and comfortable throughout the surgery. Conclusion: Peripheral nerve block anesthesia offers many clinical advantages that contribute to both an improved patient outcome and lower overall healthcare costs. Late and severe systemic sclerosis presents with cardiac, pulmonary, and renal manifestations. Though there are no specific contraindications to the use of any type of anesthetic; peripheral techniques may be successfully utilized in proper cases.
Reference 1. Roberts JG, Sabar R, Gianoli JA, Kaye AD. Progressive systemic sclerosis: clinical manifestations and anesthetic considerations. J Clin Anesth. 2002; 14:474-7.