Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: A case report and description of a catheter technique†

Single fascia iliaca compartment block for post-hip fracture pain relief

Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37-96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block's efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.

Assessment and treatment of postoperative pain in older adults

Hospitals are experiencing an increase in surgical procedures aimed at improving function and quality of life for elders. However, recent reports of pain management practices of elder patients show that pain is underassessed and undertreated. High postoperative pain intensities have been associated with delayed ambulation, postoperative pulmonary complications, increased hospital length of stay, long-term functional impairment, and chronic pain syndromes in this age group. Aggressive pain control is needed, but challenges in assessing and treating pain in older adults make this difficult. The purpose of this article is to review strategies for assessing and treating postoperative pain in older adults. Attention is given to the challenges associated with mental and physical impairments experienced by elders and a review of assessment and pharmacologic and nonpharmacologic strategies are included.

Bilateral continuous 3-in-1 nerve blockade for postoperative pain relief after bilateral femoral shaft surgery

We tested the effectiveness of bilateral continuous paravascular femoral nerve blocks in a patient following bilateral femoral shaft surgery in whom other analgesic regimens were considered contraindicated or of limited effectiveness. Bilateral continuous femoral paravascular nerve blocks were performed using a previously described technique. General anesthesia was subsequently used to facilitate surgery, which was a bilateral osteosynthesis using dynamic hip screws for osteolytic metastases of the proximal extremities of both femurs. A continuous infusion of lidocaine, morphine, and clonidine was established in both femoral catheters preoperatively and used postoperatively as the principle source of analgesia. Radiographic contrast was used to document the position of both catheters and to document the spread of injectate. Visual analog scale (VAS) pain scores were recorded in the recovery room and at 4, 16, 24, 48, and 72 hours postoperatively. Plasma lidocaine levels were determined by gas chromatography at 4, 16, and 48 hours postoperatively. Sensory assessment in the distribution of the femoral, lateral cutaneous, and obturator nerves was performed to confirm the presence of sensory blockade. We successfully provided analgesia with bilateral continuous femoral paravascular nerve blocks. Pain scores at rest were consistently rated good to excellent (VAS < 20 mm). Evidence of sensory conduction block was present throughout the infusion. Plasma concentrations of lidocaine were consistently below toxic levels (1.35 to 1.65 micrograms/ml). Radiographic contrast studies failed to demonstrate movement of contrast to the level of the lumbar plexus. Bilateral continuous femoral paravascular nerve blocks can be used to provide effective and safe analgesia in patients requiring aggressive analgesia in whom other techniques may be contraindicated.