Combined sciatic and femoral nerve blocks for infrainguinal arterial bypass surgery: A case series

Editor's Choice - Regional Versus General Anaesthesia in Peripheral Vascular Surgery: a Propensity Score Matched Nationwide Cohort Study of 17 359 Procedures in Denmark

OBJECTIVE

Cardiopulmonary comorbidity is common in vascular surgery. General anaesthesia (GA) may impair perfusion and induce respiratory depression. Regional anaesthesia (RA), including neuraxial or peripheral nerve blocks, may therefore be associated with a better outcome.

METHODS

This was a nationwide retrospective cohort study. All open inguinal and infra-inguinal arterial surgical reconstructions from 2005 to 2017 were included. Data were extracted from national registries. Multivariable linear and logistic regression models and propensity score matching were used. The propensity score was derived by developing a model that predicted the probability that a given patient would receive GA based on age, comorbidity, anticoagulant medication, procedure type, and the urgency of surgery. Matching was performed in four groups based on American Society of Anesthesiologists' score I - II, score III - V, and gender. Outcome parameters included surgical and general complications (bleeding, thrombosis/embolus, cardiac, pulmonary, renal, cerebral, and >3 days intensive care therapy), length of stay, and 30 day mortality, hypothesising a better outcome after RA.

RESULTS

There were 10 509 procedures in the GA group and 6 850 in the RA group. After propensity score matching, 6 267 procedures were included in each group. Surgical and general complications were significantly more common after GA in both matched (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001) and unmatched analyses (3.8 vs. 2.5%, p < .001 and 6.5 vs. 4.2%, p < .001). The 30 day mortality rate was significantly higher after GA, in matched and un matched analyses (3.1 vs. 2.4%, p = .019 and 4.1 vs. 2.4%, p < .001). There was no difference in length of stay.

CONCLUSION

RA may be associated with a better outcome, compared with GA, after open inguinal and infra-inguinal peripheral vascular surgery. In the clinical context when RA is not feasible, GA can still be considered safe.

Effects of adding a combined femoral and sciatic nerve block with levobupivacaine and clonidine to general anaesthesia in femoropopliteal bypass surgery: A randomised, double-blind, controlled trial

BACKGROUND

Adding a regional block to general anaesthesia can prevent postoperative pain and improve peripheral circulation.

OBJECTIVE

To seek improved postoperative analgesia and care due to a long-acting combined femoral and sciatic nerve block in patients undergoing femoropopliteal bypass surgery.

DESIGN

A randomised, double-blind, controlled trial.

SETTING

Vascular surgery unit of a French university hospital.

PATIENTS

Forty-four adults scheduled for bypass surgery under general anaesthesia.

INTERVENTION

Patients were allocated to receive either an active nerve block with 20 ml of 0.375% levobupivacaine and clonidine 0.5 μg kg, or a simulated (sham) block only, but with local anaesthesia of the skin, before general anaesthesia. General anaesthesia was standardised with propofol, then sevoflurane and sufentanil adjusted according to clinical need. Postoperative analgesia was standardised with paracetamol 1 g every 6 h, and intravenous morphine, initially titrated in the postanaesthesia care unit and then patient-controlled. Oral analgesics were repeated up to day 3.

MAIN OUTCOME MEASURES

The primary outcome was morphine consumption during the first 24 postoperative hours. In a subgroup of postoperative patients distal tissue oxygen saturation was recorded at the lateral side of the blocked calf.

RESULTS

Patients in the active group received less intra-operative sufentanil (median dose 25 vs. 41 μg), needed less morphine during the first 24 h (15 vs. 27 mg) and 72 (20 vs. 35 mg) postoperative hours, than in the control group. They also had less pain on movement, but pain at rest, the tissue oxygen saturation and other rehabilitation outcomes were unaffected by the treatment. Tolerance outcomes were also similar between groups.

CONCLUSION

Combining the two regional blocks improves the quality of postoperative care in this frail population, probably by reducing the amount of peri-operative opioid.

TRIAL REGISTRATION

ClinicalTrials.gov (ref. NCT01785693).

Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

A case report: the use of ultrasound guided peripheral nerve block during above knee amputation in a severely cardiovascular compromised patient who required continuous anticoagulation

RATIONALE

Although lower-extremity surgeries are mainly performed under general or central neuraxial anesthesia, ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and present with poor cardiovascular conditions.

PATIENTS CONCERNS

The patient required continuous anticoagulation treatment due to the high risk of thromboembolism and poor cardiovascular conditions.

DIAGNOSES

The patient required lower-extremity amputation due to atherosclerotic and thromboembolic obstruction.

INTERVENTIONS

We decided to progress the operation under peripheral nerve block. The sciatic, femoral, lateral femoral cutaneous nerve and anterior branch of the obturator nerve were blocked under ultrasound guidance. Sixty ml of a local anesthetic (equal mix of 1% lidocaine and 0.375% ropivacaine) was administered for the block.

OUTCOMES

Sufficient sensory block at the area of amputation was obtained, and the patient's vital signs were stable throughout surgery.

LESSONS

Ultrasound-guided peripheral nerve block can be an excellent anesthetic technique for patients receiving radical surgery at the proximal lower extremities, especially patients who are critically ill and considered high risk.

Use of Femoral and Sciatic Nerve Block Combination in Severe Emphysematous Lung Disease for Femoral Popliteal Arterial Bypass Surgery

Regional anesthesia is a widely used anesthesia technique for high-risk patients with severe vascular or pulmonary diseases in which general anesthesia is considered harmful and should be avoided. In this case, we present the use of femoral-sciatic nerve block combination for a 65-year-old, ASA IV, male patient who had severe emphysematous lung disease and was planned for a right femoral-popliteal arterial bypass surgery. He had severe pulmonary disease, hypertension, peripheral vascular disease, and was on clopidogrel treatment. Due to his existing comorbidities, regional anesthesia was considered the right method. The combination of femoral and sciatic nerve block was successfully used for the operation, which lasted for one hour and fifty minutes under sedation, and was continuously supplied with a propofol infusion. The patient was safely discharged to the surgical ward with no pain. The femoral block and sciatic block combination is described as one of the most useful, and at the same time, the most ignored anesthetic method. This technique is considered a standard technique and is often taught early in training; however, its use seems to be underestimated as there are only a few cases documented in Turkey. The aim of this case is to serve as a reminder of its significant value in patients who are not appropriate for general anesthesia and neuraxial blocks.

Recent Progress of Bypass Surgery to the Dialysis-Dependent Patients with Critical Limb Ischemia

According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in the United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting. (This is a translation of Jpn J Vasc Surg 2017; 26: 33–39.)

Regional anesthesia for vascular surgery

Patients presenting for vascular surgery present a challenge to anesthesiologists because of their severe systemic comorbidities. Regional anesthesia has been used as a primary anesthetic technique for many vascular procedures to avoid the cardiovascular and pulmonary perturbations associated with general anesthesia. In this article the use of regional anesthesia for carotid endarterectomy, open and endovascular abdominal aortic aneurysm repair, infrainguinal arterial bypass, lower extremity amputation, and arteriovenous fistula formation is described. A focus is placed on reviewing the literature comparing anesthetic techniques, with brief descriptions of the techniques themselves.

Regional anesthesia for vascular surgery

Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.

Neuroaxis block compared to general anesthesia for revascularization of the lower limbs in the elderly. A systematic review with metanalysis of randomized clinical studies

BACKGROUND AND OBJECTIVES

Currently, it is controversial on whether neuroaxis block (NB) is more effective than general anesthesia (GA) in elderly individuals undergoing non-cardiac surgeries. The objective of this study was to determine the efficiency of NB in comparison to GA for revascularization of the lower limbs (RLL) in the elderly.

METHODS

A search of the following data base was conducted: MEDLINE (1955 to 2007), CINHAL (1982 to 2007), EMBASE (1980 to 2007), LILACS (1982 to 2007), and ISI (1945 to 2007). Two investigators undertook an independent analysis of the studies published to identify randomized clinical trials (RCTs) comparing NB with GA for RLL. The full text of the RCTs that fulfill the inclusion criteria was analyzed. Disagreements were analyzed in consensus meetings. The software Review Manager was used for the Metanalysis by means of odds ratio with a confidence interval of 95%.

RESULTS

Three studies involving 465 patients were selected. Metanalysis of the following parameters did not show statistically significant differences: mortality (OR: 0.90; CI 95%: 0.30-2.73; p = 0.85 for spinal anesthesia; OR: 1.30, CI 95%: 0.38-4.48, p = 0.68, for epidural block); myocardial infarction (OR: 1.38, CI 95%: 0.29-6.46, p = 0.68); and rate of lower limb amputation (OR: 0.81, CI 95%: 0.30-2.19, p = 0.68, for spinal block; OR: 0.70, CI 95%: 0.24-2.07, p = 0.52 for epidural block). A statistically significant difference was observed for pneumonia (OR: 0.37, CI 95%: 0.15-0.89, p = 0.03); however, clinical heterogeneity was present.

CONCLUSIONS

This metanalysis did not generate enough evidence to demonstrate that NB is more efficient, equivalent, or less efficient than GA for RLL in the elderly.