- Email: [email protected]
Combined sciatic and femoral nerve blocks for infrainguinal arterial bypass surgery: A case series
Combined Sciatic and Femoral Nerve Blocks for Infrainguinal Arterial Bypass Surgery: A Case Series Alexander Yazigi, MD,* Samia Madi-Gebara, MD,* Fadia Haddad, MD,* Gemma Hayeck, MD,* and Georges Tabet, MD†
I
NFRAINGUINAL ARTERIAL BYPASS surgery for lowerlimb revascularization has increased in the past years.1 Most vascular surgical patients have advanced atherosclerotic disease and a variety of medical problems complicating the perioperative management.2,3 The type of anesthesia influences surgical stress response as well as intraoperative hemodynamic changes and may have an impact on perioperative complications. Lower-limb arterial bypass surgery is usually performed under general, spinal, or epidural anesthesia. A combined sciatic and femoral nerve block is a peripheral regional anesthesia technique indicated for surgical procedures involving the lower extremity.4 However, the use of this anesthetic technique for lower-limb revascularization has been rarely reported in the literature.5 A case series of patients who had infrainguinal arterial bypass surgery under combined sciatic and femoral nerve blocks is presented. METHODS The study group consisted of consenting patients scheduled for elective lower-extremity vascular surgery between January and December 2003. Procedures included only arterial grafting distal to the inguinal ligament. Patients were excluded from the study if they had a history of an allergic reaction to a local anesthetic. On the morning of surgery, patients received their chronic medications. Premedication consisted of oral hydroxyzine, 1 mg/kg. Intraoperative monitoring was performed with continuous electrocardiography, radial artery catheter, and pulse oximetry. Electrocardiographic monitoring was performed with a multilead system dual-channel oscilloscope (Datex-Ohmeda S/5, Helsinki, Finland) with computerized ST-segment analysis. Regional anesthesia by combined femoral and sciatic nerve blocks was performed with isobaric bupivacaine 0.375%. A femoral nerve block was performed by using the following technique described by Winnie et al6: the patient was placed in supine position, a line was drawn between the anterior superior iliac spine and the pubic tubercle to identify the inguinal ligament, the femoral artery was marked, an insulated 22-G 50-mm short-bevel needle was advanced lateral to the artery, and the femoral nerve was located by a nerve stimulator and blocked by 20 mL of the bupivacaine solution. Sciatic nerve block was performed using the following approach described by Labat7: the patient was positioned laterally, a line was drawn to connect the posterior superior iliac spine to the greater trochanter of the femur, a perpendicular was drawn bisecting the line and extending 5 cm caudally, an insulated 22-G 100-mm short-bevel needle was advanced at this level, and the sciatic nerve was located by a nerve stimulator and
From the Departments of *Anesthesia and Intensive Care and †Cardio-vascular and Thoracic Surgery, Hotel-Dieu de France Hospital, Saint Joseph University, School of Medicine, Beirut, Lebanon. Address reprint requests to Alexandre Yazigi, MD, Department of Anesthesia and Intensive Care, Hotel-Dieu de France Hospital, Alfred Naccach Street, Beirut, Lebanon. E-mail: [email protected] © 2005 Elsevier Inc. All rights reserved. 1053-0770/05/1902-0018$30.00/0 doi:10.1053/j.jvca.2005.01.002 Key words: peripheral vascular surgery, regional anesthesia, nerve block 220
blocked by 20 mL of the bupivacaine solution. Patients were kept on spontaneous breathing with oxygen delivered through a face mask. Regional anesthesia was supplemented with intravenous midazolam to maintain conscious sedation. All patients had infrainguinal arterial bypass surgery using an in situ saphenous vein. Postoperatively, patients were admitted to the intensive care unit for 24 to 48 hours. Intravenous patient-controlled analgesia with morphine was used for 72 hours. Demographic data, preoperative medications, and medical and surgical history were obtained from the patients and the medical record. Recording of hemodynamic parameters and of significant ST-segment deviations was started at anesthesia induction and stopped after patients were discharged from the operating room. The incidence of intraoperative vasoactive drugs requirement was noted. Postoperatively, patients were followed up daily until discharge for the presence of cardiac morbidity including angina pectoris, myocardial infarction, congestive heart failure, ventricular arrhythmia, or sudden cardiac arrest. Neurologic, respiratory, and infectious complications were also assessed. Perioperative mortality and graft occlusion within 30 days were noted. RESULTS
Twenty-five patients were enrolled in this case series. Combined sciatic and femoral nerve blocks were adequate for surgical procedures, and there was no shift from peripheral regional anesthesia to general anesthesia. No patient experienced any symptoms or signs of local anesthetic toxicity, nerve injury, or hematoma related to regional anesthesia. Demographic, medical, and surgical data are presented in Table 1. Preoperative baseline heart rate, arterial systolic and diastolic pressures, and their highest and lowest values recorded intraoperatively are presented in Table 2. One patient presented 2 episodes of intraoperative ST-segment depression of a magnitude of 1.5 mm and total duration of 6 minutes. Two patients required small doses of ephedrine (6 and 9 mg) during surgery. Postoperatively, there was 1 case of ventricular tachycardia that responded to cardioversion, 2 cases of wound infection, and 1 case of graft occlusion that required a new surgical procedure. No perioperative mortality was noted. DISCUSSION
This case series shows that a combined femoral and sciatic nerve block is an adequate anesthetic technique for infrainguinal arterial bypass surgery. It provides intraoperative hemodynamic stability and an acceptable postoperative course for a patient population known to have multiple risk factors. Peripheral regional anesthesia was described for some lowerlimb vascular procedures such as saphenous vein stripping8 and below-knee debridement.9 However, combined femoral and sciatic nerve blocks for infrainguinal arterial bypass in highrisk patients were rarely reported. Mackay et al,5 in a retrospective study, described the use of combined sciatic and femoral nerve blocks in a group of 46 patients undergoing urgent lower-limb revascularization, with very acceptable postoperative morbidity and mortality rates.5 The present case series confirms these results. Neuraxial and peripheral regional anesthesia techniques provide
Journal of Cardiothoracic and Vascular Anesthesia, Vol 19, No 2 (April), 2005: pp 220-221
SCIATIC AND FEMORAL NERVE BLOCKS
221
Table 1. Patients’ Demographic, Medical, and Surgical Data Age (y) Males (n) Diabetes (n) Hypercholesterolemia (n) Currently smoking (n) Hypertension (n) History of angina (n) Previous MI (n) Previous CABG or PTCA (n) Antianginal medications (n) Congestive heart failure (n) Surgical time (min) Femoral-popliteal bypass (n) Femoral-distal bypass (n)
70 ⫾ 7 16 18 8 19 18 15 7 7 17 5 185 ⫾ 45 9 16
Table 2. Baseline and Intraoperative Maximal Hemodynamic Changes Baseline SAP Baseline DAP Baseline HR Highest SAP Highest DAP Lowest SAP Lowest DAP Highest HR Lowest HR
NOTE. All data are presented as number of patients except for age and surgical time. Abbreviations: MI, myocardial infarction; CABG, coronary artery bypass graft; PTCA, percutaneous transluminal coronary angioplasty.
blockade of the stress response to surgery, avoidance of hyperdynamic responses to light general anesthesia, and reduce the risk of postoperative respiratory complications.10 Spinal and epidural anesthesia are, however, associated with a risk of hypotension and of epidural hematoma because of heparin administration during vascular surgery.11 The expected advantages of peripheral regional anesthesia in lower-limb vascular surgery should be confirmed by large clinical trials. Such trials should evaluate the postoperative morbidity and mortality of patients operated upon under sciatic and femoral nerve blocks versus general or epidural anesthesia.
131 ⫾ 14 74 ⫾ 9 73 ⫾ 11 160 ⫾ 24 85 ⫾ 14 117 ⫾ 22 61 ⫾ 12 86 ⫾ 14 67 ⫾ 11
NOTE. Values are expressed in mmHg for blood pressures and in beats per minute for heart rate. Data are presented as mean values and standard deviation. Abbreviations: SAP, systolic arterial pressure; DAP, diastolic arterial pressure; HR, heart rate.
Several studies have compared the impact of general, spinal, and epidural anesthesia on postoperative complications after lowerlimb vascular surgery.12-16 The cumulative results of these trials showed that the incidence of postoperative cardiovascular morbidity and mortality is similar, regardless of whether the patient received general, spinal, or epidural anesthesia. In conclusion, a combined sciatic and femoral nerve block is an adequate anesthetic technique for infrainguinal arterial bypass surgery. It may be an alternative to general and epidural anesthesia for lower-limb revascularization. Further studies are needed to evaluate the impact of peripheral regional anesthesia on perioperative morbidity and mortality and on vascular graft patency.
REFERENCES 1. Sayers RD, Thompson MM, Varty K, et al: Changing trends in the management of lower-limb ischaemia: A 17-year review. Br J Surg 80:1269-1273, 1993 2. Hertzer NR: Basic data concerning associated coronary disease in peripheral vascular patients. Ann Vasc Surg 1:616-620, 1987 3. L’Italien GJ, Cambria RP, Cutler BS, et al: Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures. J Vasc Surg 21:935-944, 1995 4. Wedel DJ: Nerve blocks, in Miller RD (ed): Anesthesia (ed 4). New York, NY, Churchill Livingstone, 1994, pp 1535-1564 5. Mackay CA, Razik W, Simms MH: Local anaesthetic for lowerlimb revascularization in high-risk patients. Br J Surg 84:1096-1098, 1997 6. Winnie AP, Ramamurthy S, Durrani Z: The inguinal paravascular technique of lumbar plexus anesthesia: The “3-in-1” block. Anesth Analg 52:989-996, 1973 7. Labat G: Labat’s Regional Anesthesia: Its Techniques and Clinical Applications (ed 4). St. Louis, MO, Warren H. Green, 1985 8. Vloka JD, Hadzic A, Mulcare R, et al: Combined popliteal and posterior cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: An alternative to spinal anesthesia. J Clin Anesth 9:618-622, 1997 9. Davies MJ, McGlade DP: One hundred sciatic nerve blocks: a comparison of localisation techniques. Anaesth Intensive Care 21:76-78, 1993
10. Ellis JE, Klock PA, Klafta JM, et al: Choice of anesthesia and intraoperative monitoring for lower extremity revascularization. Surg Clin North Am 75:665-678, 1995 11. Martinez-Palli G, Sala-Blanch X, Salvado E, et al: Epidural hematoma after epidural anesthesia in a patient with peripheral vascular disease. Case report. Reg Anesth 21:342-346, 1996 12. Bode RH, Lewis KP, Zarich SW, et al: Cardiac outcome after peripheral vascular surgery: Comparison of general and regional anesthesia. Anesthesiology 84:3-13, 1996 13. Christopherson R, Beattie C, Frank SM, et al: Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 79:422-434, 1993 14. Rivers SP, Scher LA, Sheehan E, et al: Epidural versus general anesthesia for infrainguinal arterial reconstruction. J Vasc Surg 14:764770, 1991 15. Cook PT, Davies MJ, Cronin KD, et al: A prospective randomized trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. Anaesth Intensive Care 14:373-380, 1986 16. Damask MC, Weissman C, Todd G: General versus epidural anesthesia for femoral-popliteal bypass surgery. J Clin Anesth 2:71-75, 1990
I
NFRAINGUINAL ARTERIAL BYPASS surgery for lowerlimb revascularization has increased in the past years.1 Most vascular surgical patients have advanced atherosclerotic disease and a variety of medical problems complicating the perioperative management.2,3 The type of anesthesia influences surgical stress response as well as intraoperative hemodynamic changes and may have an impact on perioperative complications. Lower-limb arterial bypass surgery is usually performed under general, spinal, or epidural anesthesia. A combined sciatic and femoral nerve block is a peripheral regional anesthesia technique indicated for surgical procedures involving the lower extremity.4 However, the use of this anesthetic technique for lower-limb revascularization has been rarely reported in the literature.5 A case series of patients who had infrainguinal arterial bypass surgery under combined sciatic and femoral nerve blocks is presented. METHODS The study group consisted of consenting patients scheduled for elective lower-extremity vascular surgery between January and December 2003. Procedures included only arterial grafting distal to the inguinal ligament. Patients were excluded from the study if they had a history of an allergic reaction to a local anesthetic. On the morning of surgery, patients received their chronic medications. Premedication consisted of oral hydroxyzine, 1 mg/kg. Intraoperative monitoring was performed with continuous electrocardiography, radial artery catheter, and pulse oximetry. Electrocardiographic monitoring was performed with a multilead system dual-channel oscilloscope (Datex-Ohmeda S/5, Helsinki, Finland) with computerized ST-segment analysis. Regional anesthesia by combined femoral and sciatic nerve blocks was performed with isobaric bupivacaine 0.375%. A femoral nerve block was performed by using the following technique described by Winnie et al6: the patient was placed in supine position, a line was drawn between the anterior superior iliac spine and the pubic tubercle to identify the inguinal ligament, the femoral artery was marked, an insulated 22-G 50-mm short-bevel needle was advanced lateral to the artery, and the femoral nerve was located by a nerve stimulator and blocked by 20 mL of the bupivacaine solution. Sciatic nerve block was performed using the following approach described by Labat7: the patient was positioned laterally, a line was drawn to connect the posterior superior iliac spine to the greater trochanter of the femur, a perpendicular was drawn bisecting the line and extending 5 cm caudally, an insulated 22-G 100-mm short-bevel needle was advanced at this level, and the sciatic nerve was located by a nerve stimulator and
From the Departments of *Anesthesia and Intensive Care and †Cardio-vascular and Thoracic Surgery, Hotel-Dieu de France Hospital, Saint Joseph University, School of Medicine, Beirut, Lebanon. Address reprint requests to Alexandre Yazigi, MD, Department of Anesthesia and Intensive Care, Hotel-Dieu de France Hospital, Alfred Naccach Street, Beirut, Lebanon. E-mail: [email protected] © 2005 Elsevier Inc. All rights reserved. 1053-0770/05/1902-0018$30.00/0 doi:10.1053/j.jvca.2005.01.002 Key words: peripheral vascular surgery, regional anesthesia, nerve block 220
blocked by 20 mL of the bupivacaine solution. Patients were kept on spontaneous breathing with oxygen delivered through a face mask. Regional anesthesia was supplemented with intravenous midazolam to maintain conscious sedation. All patients had infrainguinal arterial bypass surgery using an in situ saphenous vein. Postoperatively, patients were admitted to the intensive care unit for 24 to 48 hours. Intravenous patient-controlled analgesia with morphine was used for 72 hours. Demographic data, preoperative medications, and medical and surgical history were obtained from the patients and the medical record. Recording of hemodynamic parameters and of significant ST-segment deviations was started at anesthesia induction and stopped after patients were discharged from the operating room. The incidence of intraoperative vasoactive drugs requirement was noted. Postoperatively, patients were followed up daily until discharge for the presence of cardiac morbidity including angina pectoris, myocardial infarction, congestive heart failure, ventricular arrhythmia, or sudden cardiac arrest. Neurologic, respiratory, and infectious complications were also assessed. Perioperative mortality and graft occlusion within 30 days were noted. RESULTS
Twenty-five patients were enrolled in this case series. Combined sciatic and femoral nerve blocks were adequate for surgical procedures, and there was no shift from peripheral regional anesthesia to general anesthesia. No patient experienced any symptoms or signs of local anesthetic toxicity, nerve injury, or hematoma related to regional anesthesia. Demographic, medical, and surgical data are presented in Table 1. Preoperative baseline heart rate, arterial systolic and diastolic pressures, and their highest and lowest values recorded intraoperatively are presented in Table 2. One patient presented 2 episodes of intraoperative ST-segment depression of a magnitude of 1.5 mm and total duration of 6 minutes. Two patients required small doses of ephedrine (6 and 9 mg) during surgery. Postoperatively, there was 1 case of ventricular tachycardia that responded to cardioversion, 2 cases of wound infection, and 1 case of graft occlusion that required a new surgical procedure. No perioperative mortality was noted. DISCUSSION
This case series shows that a combined femoral and sciatic nerve block is an adequate anesthetic technique for infrainguinal arterial bypass surgery. It provides intraoperative hemodynamic stability and an acceptable postoperative course for a patient population known to have multiple risk factors. Peripheral regional anesthesia was described for some lowerlimb vascular procedures such as saphenous vein stripping8 and below-knee debridement.9 However, combined femoral and sciatic nerve blocks for infrainguinal arterial bypass in highrisk patients were rarely reported. Mackay et al,5 in a retrospective study, described the use of combined sciatic and femoral nerve blocks in a group of 46 patients undergoing urgent lower-limb revascularization, with very acceptable postoperative morbidity and mortality rates.5 The present case series confirms these results. Neuraxial and peripheral regional anesthesia techniques provide
Journal of Cardiothoracic and Vascular Anesthesia, Vol 19, No 2 (April), 2005: pp 220-221
SCIATIC AND FEMORAL NERVE BLOCKS
221
Table 1. Patients’ Demographic, Medical, and Surgical Data Age (y) Males (n) Diabetes (n) Hypercholesterolemia (n) Currently smoking (n) Hypertension (n) History of angina (n) Previous MI (n) Previous CABG or PTCA (n) Antianginal medications (n) Congestive heart failure (n) Surgical time (min) Femoral-popliteal bypass (n) Femoral-distal bypass (n)
70 ⫾ 7 16 18 8 19 18 15 7 7 17 5 185 ⫾ 45 9 16
Table 2. Baseline and Intraoperative Maximal Hemodynamic Changes Baseline SAP Baseline DAP Baseline HR Highest SAP Highest DAP Lowest SAP Lowest DAP Highest HR Lowest HR
NOTE. All data are presented as number of patients except for age and surgical time. Abbreviations: MI, myocardial infarction; CABG, coronary artery bypass graft; PTCA, percutaneous transluminal coronary angioplasty.
blockade of the stress response to surgery, avoidance of hyperdynamic responses to light general anesthesia, and reduce the risk of postoperative respiratory complications.10 Spinal and epidural anesthesia are, however, associated with a risk of hypotension and of epidural hematoma because of heparin administration during vascular surgery.11 The expected advantages of peripheral regional anesthesia in lower-limb vascular surgery should be confirmed by large clinical trials. Such trials should evaluate the postoperative morbidity and mortality of patients operated upon under sciatic and femoral nerve blocks versus general or epidural anesthesia.
131 ⫾ 14 74 ⫾ 9 73 ⫾ 11 160 ⫾ 24 85 ⫾ 14 117 ⫾ 22 61 ⫾ 12 86 ⫾ 14 67 ⫾ 11
NOTE. Values are expressed in mmHg for blood pressures and in beats per minute for heart rate. Data are presented as mean values and standard deviation. Abbreviations: SAP, systolic arterial pressure; DAP, diastolic arterial pressure; HR, heart rate.
Several studies have compared the impact of general, spinal, and epidural anesthesia on postoperative complications after lowerlimb vascular surgery.12-16 The cumulative results of these trials showed that the incidence of postoperative cardiovascular morbidity and mortality is similar, regardless of whether the patient received general, spinal, or epidural anesthesia. In conclusion, a combined sciatic and femoral nerve block is an adequate anesthetic technique for infrainguinal arterial bypass surgery. It may be an alternative to general and epidural anesthesia for lower-limb revascularization. Further studies are needed to evaluate the impact of peripheral regional anesthesia on perioperative morbidity and mortality and on vascular graft patency.
REFERENCES 1. Sayers RD, Thompson MM, Varty K, et al: Changing trends in the management of lower-limb ischaemia: A 17-year review. Br J Surg 80:1269-1273, 1993 2. Hertzer NR: Basic data concerning associated coronary disease in peripheral vascular patients. Ann Vasc Surg 1:616-620, 1987 3. L’Italien GJ, Cambria RP, Cutler BS, et al: Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures. J Vasc Surg 21:935-944, 1995 4. Wedel DJ: Nerve blocks, in Miller RD (ed): Anesthesia (ed 4). New York, NY, Churchill Livingstone, 1994, pp 1535-1564 5. Mackay CA, Razik W, Simms MH: Local anaesthetic for lowerlimb revascularization in high-risk patients. Br J Surg 84:1096-1098, 1997 6. Winnie AP, Ramamurthy S, Durrani Z: The inguinal paravascular technique of lumbar plexus anesthesia: The “3-in-1” block. Anesth Analg 52:989-996, 1973 7. Labat G: Labat’s Regional Anesthesia: Its Techniques and Clinical Applications (ed 4). St. Louis, MO, Warren H. Green, 1985 8. Vloka JD, Hadzic A, Mulcare R, et al: Combined popliteal and posterior cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: An alternative to spinal anesthesia. J Clin Anesth 9:618-622, 1997 9. Davies MJ, McGlade DP: One hundred sciatic nerve blocks: a comparison of localisation techniques. Anaesth Intensive Care 21:76-78, 1993
10. Ellis JE, Klock PA, Klafta JM, et al: Choice of anesthesia and intraoperative monitoring for lower extremity revascularization. Surg Clin North Am 75:665-678, 1995 11. Martinez-Palli G, Sala-Blanch X, Salvado E, et al: Epidural hematoma after epidural anesthesia in a patient with peripheral vascular disease. Case report. Reg Anesth 21:342-346, 1996 12. Bode RH, Lewis KP, Zarich SW, et al: Cardiac outcome after peripheral vascular surgery: Comparison of general and regional anesthesia. Anesthesiology 84:3-13, 1996 13. Christopherson R, Beattie C, Frank SM, et al: Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 79:422-434, 1993 14. Rivers SP, Scher LA, Sheehan E, et al: Epidural versus general anesthesia for infrainguinal arterial reconstruction. J Vasc Surg 14:764770, 1991 15. Cook PT, Davies MJ, Cronin KD, et al: A prospective randomized trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. Anaesth Intensive Care 14:373-380, 1986 16. Damask MC, Weissman C, Todd G: General versus epidural anesthesia for femoral-popliteal bypass surgery. J Clin Anesth 2:71-75, 1990