Artroscopía de rodilla bajo bloqueos de nervios femoral y ciático en paciente COVID-19 con artritis séptica. Reporte de caso / Knee arthroscopy under femoral and sciatic nerve blocks in a COVID-19 patient with septic arthritis. A case report

Since the start of the COVID-19 pandemic, several anesthetic societies have generated clinical recommendations for the perioperative management of these patients, including the Chilean Society of Anesthesiology. Among these recommendations, the advantages of regional anesthesia have been highlighted. In this article, we report and discuss the case of a 59-year-old patient with diabetes mellitus II, Chronic Arterial Hypertension, Gout, and Stage IV Chronic Renal Failure admitted with a multifocal septic condition characterized by suppurative collections including a large subcutaneous lumbar abscess recently drained. The patient evolved with left knee septic arthritis and was scheduled for arthroscopic irrigation and debridement. As per protocol a SARS-COV2 PCR was tested and resulted positive. It was decided to proceed to surgery under anesthetic ultrasound-guided femoral and sciatic nerve blocks using an adrenalized (2.5 ug/mL) solution of 0.33% Levobupivacaine- 0.66% Lidocaine (15 mL each). Fifteen minutes later, the knee was mobilized passively without pain. Surgery started after 30 minutes. The surgical and anesthetic conditions were described as adequate by the surgeon and the patient, respectively. The postoperative evolution was satisfactory without presenting respiratory symptoms and the patient was discharged 17 days after under oral antibiotic treatment.

Desde el comienzo de la pandemia de COviD-19, varias sociedades de anestesia han generado recomendaciones clínicas para el tratamiento perioperatorio de estos pacientes, incluida la Sociedad Chilena de Anestesiología. Entre estas recomendaciones, se han destacado las ventajas de la anestesia regional. En este artículo, reportamos y discutimos el caso de un paciente de 59 años con diabetes mellitus tipo 2, hipertensión arterial, gota e insuficiencia renal crónica en etapa IV, admitido por una sepsis multifocal caracterizada por colecciones supurativas que incluyen un gran absceso lumbar subcutáneo drenado recientemente. El paciente evolucionó con artritis séptica de rodilla requiriendo de una exploración y aseo artroscópico. Por protocolo perioperatorio COviD-19, se solicitó PCR para SARS-COv2 con un resultado positivo. Se decidió proceder a la cirugía bajo bloqueos anestésicos guiados por ultrasonido de nervios femoral y ciático utilizando una solución adrenalizada (2,5 ug/mL) de levobupivacaína al 0,33% lidocaína al 0,66% (15 mL en cada uno). Quince minutos después, la rodilla se movilizó pasivamente sin dolor. La cirugía se inició tras media hora empleando una ligera sedación con propofol. Las condiciones quirúrgicas y anestésicas fueron descritas como adecuadas por el cirujano y el paciente. Este último evolucionó favorablemente, sin síntomas respiratorios y fue dado de alta 17 días después con tratamiento antibiótico oral.

Efecto analgésico del bloqueo PENG (grupo de nervios pericapsulares) en pacientes con fractura de cadera / Analgesic effect of the PENG BLOCK (pericapsular nervous group) in patients with hip fracture

Ultrasound regional blockade emerged that blocks the branches of the femoral nerve, obturator and accessory obturator that innervate the anterior hip capsule, the PENG block (group of pericapsular nerves), which by its Recent description does not have enough evidence in medical practice. To verify the analgesic effect of the PENG block in patients with hip fracture and its analgesic permanence during the first 10 hours after the block in patients admitted with a diagnosis of hip fracture, at the General Interzonal Hospital of Acute "Dr Oscar E Alende "From Mar del Plata, Argentina, in the months of May to November 2019. A prospective descriptive observational study was carried out with a total of 53 patients, hospitalized patients with a diagnosis of hip fracture, with standardized intravenous analgesic scheme and who have not yet undergone hip surgery. Pain was evaluated with the EVA scale (visual analog scale) prior to the blockage, and then at 30 min and 10 hours after the blockade, 15 ml of 1% lidocaine and 15 ml of bupivacaine at 0 were used. 25%, convex or linear ultrasound probe according to patient weight and 100 mm needle. In order to reproduce and evaluate the pain, the patients had a 30º flexion of the hip. Prior to the blockade, 66% of the patients had severe pain and 34% moderate pain, none presented mild pain or absence, both at thirty minutes and ten hours after the blockade, no patient presented severe pain and all patients presented analgesia with a decrease in more than three points on the VAS scale, in some cases reaching a decrease of 10 points on that scale. The PENG block is a regional anesthesia technique that provides very good analgesia to patients with hip fractures, therefore, it is an excellent saving strategy for systemic analgesics. Knowing the analgesia provided by the blockade at 30 min and at 10 h, it could be performed both in the preoperative period for the transfer and mobilization of the patient, as well as in the postoperative period, which could save the use of opioids and decrease hospital stay.

INTRODUCCIÓN La fractura de cadera es una emergencia ortopédica común en ancianos asociada a gran morbimortalidad, una adecuada analgesia regional perioperatoria determina un ahorro en el uso de analgésicos sistémicos. Recientemente, en el año 2018, surgió un nuevo bloqueo regional ecoguiado muy prometedor que bloquea las ramas del nervio femoral, obturador y obturador accesorio que inervan la capsula anterior de la cadera, el bloqueo PENG (grupo de nervios pericapsulares), el cual por su reciente descripción no cuenta con la suficiente evidencia en la práctica médica. OBJETIVOS: Comprobar el efecto analgésico del bloqueo PENG en pacientes con fractura de cadera y su permanencia analgésica durante las 10 primeras horas posteriores al bloqueo en los pacientes internados con diagnóstico de fractura de cadera, en el Hospital Interzonal General de Agudos "Dr. Oscar E Alende" de Mar del Plata, Argentina, en los meses de mayo a noviembre del 2019. MATERIALES Y MÉTODOS: Se realizó un estudio observacional descriptivo prospectivo con un total de 53 pacientes, se incluyeron pacientes internados con diagnóstico de fractura de cadera, con esquema analgésico endovenoso estandarizado y que aún no hayan sido sometido a cirugía de cadera. Se evaluó el dolor con la escala EVA (escala análoga visual) previo al bloqueo, y luego a los 30 min y a las 10 Hs de haber realizado el bloqueo, para este se utilizaron 15 ml lidocaína 1% y 15 ml de bupivacaína al 0,25%, sonda ecográfica convexa o lineal según el peso del paciente y aguja 100 mm. Para reproducir y evaluar el dolor se les realizo a los pacientes una flexión de 30º de la cadera. RESULTADOS: Previo al bloqueo el 66% de los pacientes tuvieron dolor severo y 34% dolor moderado, ninguno presentaba dolor leve o ausencia del mismo, tanto a los treinta minutos como a las diez horas posteriores al bloqueo ningún paciente presento dolor severo y todos los pacientes presentaron analgesia con una disminución en más de tres puntos en la escala de EVA, llegando en algunos casos a una disminución de 10 puntos de dicha escala. CONCLUSIONES: El bloqueo PENG es una técnica de anestesia regional que brinda muy buena analgesia a los pacientes con fractura de cadera, por consiguiente, es una excelente estrategia ahorradora de analgésicos sistémicos. Conociendo la analgesia que brinda el bloqueo a los 30 min y a las 10 h de realizado, se podría realizar dicho bloqueo tanto en el preoperatorio para el traslado y movilización del paciente, como en el post-operatorio, lo que podría ahorrar el uso de opioides y disminuir la estancia hospitalaria.

Effect of Combined Single-Injection Femoral Nerve Block and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Replacement

PURPOSE: Total knee replacement is one of the most painful orthopedic procedures, and effective pain relief is essential for early mobility and discharge from hospital. The aim of this study was to evaluate whether addition of single-injection femoral nerve block to epidural analgesia would provide better postoperative pain control, compared to epidural analgesia alone, after total knee replacement. MATERIALS AND METHODS: Thirty-eight patients received a single-injection femoral nerve block with 0.25% levobupivacaine (30 mL) combined with epidural analgesia (femoral nerve block group) and 40 patients received epidural analgesia alone (control group). Pain intensity and volume of patient-controlled epidural analgesia medication and rescue analgesic requirements were measured in the first 48 hours after surgery at three time periods; 0-6 hours, 6-24 hours, and 24-48 hours. Also, side effects such as nausea, vomiting, and pruritus were evaluated. RESULTS: Median visual analog scale at rest and movement was significantly lower until 48 hours in the femoral nerve block group. Patient-controlled epidural analgesia volume was significantly lower throughout the study period, however, rescue analgesia requirements were significantly lower only up to 6 hours in the femoral nerve block group. The incidences of nausea and vomiting and rescue antiemetic requirement were significantly lower in the femoral nerve block group up to 6 hours. CONCLUSION: The combination of femoral nerve block with epidural analgesia is an effective pain management regimen in patients undergoing unilateral total knee replacement.

Postoperative analgesia for total knee replacement: comparing between pre-and postoperative "3-in-1" femoral nerve block.

BACKGROUND: Total Knee Replacement (TKR) produces severe postoperative pain. Pre- and postoperative single-shot "3-in-1" Femoral Nerve Block (FNB) were reported to improve analgesia and reduce morphine consumption post TKR. OBJECTIVE: To find out the most beneficial time for injection of single shot "3-in-1" FNB for TKR between preoperative and postoperative in a prospective controlled trial. MATERIAL AND METHOD: In a Randomized, double-blind Controlled Trial (RCT), 48 patients undergoing TKR received either pre- or postoperative "3-in-1" FNB using 30 mL of bupivacaine 0.25% after a standardized general anesthesia. Morphine consumption, Numeric Pain-Rating Scale (NPRS) at rest and during movement, tension in the back of the knee, nausea/vomiting, pruritus, sedation, and respiratory depression at 1, 4, 24 and 48 hr after TKR were compared RESULTS: There were no significant differences in 48-hr morphine consumption [46.5 (20.0) vs 45.0 (23.6) mg, p = 0.809], NPRS both at rest and during movement, tension in the back of knee, nausea/vomiting, pruritus, sedation, and respiratory depression at any time during 48-hr postoperative TKR between groups. CONCLUSION: Preoperative single-shot "3-in-1" FNB using 30 mL of bupivacaine 0.25% is not better than postoperative single-shot "3-in-1" FNB using the same drug in postoperative pain and morphine reduction in patients undergoing elective TKR under general anesthesia.

Femoral nerve block versus spinal anesthesia for lower limb peripheral vascular surgery

Perioperative cardiac complications occur in 4% to 6% of patients undergoing infrainguinal revascularization under general, spinal, or epidural anesthesia. The risk may be even greater in patients whose cardiac disease cannot be fully evaluated or treated before urgent limb salvage operations. Prompted by these considerations, we investigated the feasibility and results of using femoral nerve block with infiltration of the genito4femoral nerve branches in these high-risk patients. Forty peripheral vascular reconstruction of lower limbs were performed under either spinal anesthesia [20 patients] or femoral nerve block with infiltration of genito-femoral nerve branches supplemented with local infiltration at the site of dissection as needed [20 patients]. All patients had arterial lines. Arterial blood pressure and electrocardiographic monitoring was continued during surgery, in PACU and in the intensive care units. Operations included femoral-femoral, femoral-popliteal bypass grafting and thrombectomy. The intra-operative events showed that the mean time needed to perform the block and dose of analgesics and sedatives needed during surgery was greater in group I [FNB,] compared to group II [P=0.01*, P0.029*, P0.039*], however, the time needed to start surgery was shorter in group I than in group II [P=0. 039]. There were no block failures in either group, but local infiltration in the area of the dissection with 2 ml [range 1-5 ml] of 1% lidocaine was required in 4 [20%] patients in FNB group vs none in the spinal group. The recovery times showed that the nerve block resolution and time to micturition was longer [P0. 0001 [p=0.0001*, p=0.00032*] in the Spinal group [group II] as compared with patients receiving femoral nerve blockade [group I]. Moreover, the incidence of pain requiring analgesics in PACU and postoperative complications was higher in group II than in group I [P0.021*, p0.0028*]. lower limb vascular reconstruction can be done under local anesthesia [femoral nerve block with infiltration of genitor-femoral nerve branches] with acceptable complication rates specially in patients with high-risk diseases

Analgesia Pós-operatória com bloqueio do plexo lombar: comparacäo entre as técnicas com cateter e com estimulaçäo do nervo femoral / Postoperative analgesia with paravascular lumbar plexus block: comparasion between femoral nerve stimulation and catheter techniques

Justificativa e Objetivos: Winnie e col descreveram a técnica do bloqueio do nervo lateral cutâneo da coxa, femoral e obturador através de injeçäo única de anestésico local no conduto fascial muscular englobando o nervo femoral. O objetivo deste estudo foi avaliar a eficácia da injeçäo única de bupivacaína 0,25 por cento através do bloqueio "3 em 1" identificado pelo estimulador de nervos periféricos ou pela perda da resistência à punçäo, na analgesia pós-operatória de 100 pacientes de cirurgia ortopédicas submetidos à raquianestesia. Método: Cem pacientes escalados para cirurgia ortopédicas sob raquianestesia receberam o bloqueio "3 em 1" de acordo com a técnica de Winnie, identificando o nervo femoral com estimulador de nervos periféricos ou através do teste da perda da resistência, para analgesia pós-operatória de 100 pacientes de cirurgia ortopédicas sob raquianestesia receberam o bloqueio "3 em 1" de acordo com a técnica de Winnie, identificando o nervo femoral com estimulador de nervos periféricos ou através do teste da perda da resistência, para analgesia pós-operatória, sendo injetados 40 ml de bupivacaína 0,25 por cento sem epinefrina. Foi avaliado o bloqueio nos nervos lateral cutâneo, femoral e obturador às 4, 8, 12, 16, 20 e 24 horas. A quantidade de opióides administrada em cada paciente foi anotada nas primeiras 24 horas. Em alguns pacientes foi avaliada a dispersäo do anestésico através de estudo radiográfico com contraste iodado näo iônico. Resultados: O bloqueio "3 em 1" foi obtido em 93 por cento dos pacientes. Näo ocorreu diferença significativa na incidência dos bloqueios nos três nervos durante as primeiras 24 horas. O tempo médio de analgesia foi significativamente maior com o cateter (17,64 horas) quando comparado com o estimulador de nervos (14,06 horas). O bloqueio reduziu a quantidade de opióides administrados após a cirurgia, sendo que 43 por cento dos pacientes näo necessitaram de complementaçäo analgésica no pós-operatório. Näo ocorreu diferença na necessidade de doses complementares de analgésicos nos dois grupos nas primeiras 24 horas. Näo foram observados sinais e sintomas clínicos de toxicidade da bupivacaína nem seqüelas associadas ao bloqueio dos nervos. A dispersäo do anestésico no estudo radiográfico foi praticamente a mesma com ambas as formas de bloqueio

Bloqueio contínuo do plexo lombar via compartimento ilíaco, combinado com bloqueio contínuo do nervo femoral em trauma grave de membro inferior: relato de caso / Continuous iliac compartment block of lumbar plexus combined with continuous femoral block in severe trauma of the lower limb: case report

Justificativa e Objetivos: Anestesia regional com anestésico local isoladamente ou com opióide, proporciona analgesia eficaz e segura durante a cirurgia, podendo proporcionar analgesia no período pós-operatório imediato. O Objetivo deste relato é apresentar um caso de um paciente com grave fratura exposta de joelho, associada a lesäo de artéria poplíitea, em que foi realizado bloqueio contínuo do plexo lombar esquerdo combinado com bloqeuio contínuo do nervo femoral direito. Relato de caos: P aciente masculino, 27 anos, 67 kg, estômago cheio, com fratura exposta do joelho esquerdo e lesäo da artéria poplítea, apresentava-se com sede, sudorese, palidez, PA de 110/65 mmHg, FC de 83 bpm e com o pé esquerso frio e isquêmico. FOi feito o bloqueio do plexo lombar por via compartimental ilíaca esquerda e bloqueio do nervo femoral com cateter na bainha perifemoral na regiäo inguinal direita, para retirada da veia safena e possível enxerto. Para o bloqueio do plexo lombar foi utilizado 40 ml de uma soluçäo de bupivacaína 0,25 por cento com adrenalina (1:200.000) e para o bloqueio contínuo do plexo lombar foi utilizado para analgesia pós-operatória pelo período de 12 dias. Coclusöes: A associaçäo do bloqueio contínuo do plexo lombar por via compartimental ilíaca esquerda e do bloqueio do nervo femoral direito foram eficazes para os procedimentos propostos. O bloqueio contínuo do plexo lombar proporcionou analgesia prolongada no pós-operatório, inclusive permitindo manipulacäo da regiäo operada por ocasiäo de trocas de curativos

Meralgia paraesthetica.

Forty-four patients of meralgia paraesthetica presented with combination of symptoms mainly of numbness with loss of superficial sensation on the anterolateral aspect of a thigh were selected for the study. They responded well to local infiltration of hydrocortisone acetate and lignocaine hydrochloride which not only helped in diagnosis but also prevented the recurrence of symptoms in majority of cases.