Ambulatory surgery for multi-ligament knee reconstruction with continuous dual catheter peripheral nerve blockade

Abstract

Purpose: Major reconstructive surgery of the knee traditionally requires an extended hospital stay for pain management. Continuous peripheral nerve blockade is an alternative method of pain control but is seldom used in the ambulatory setting. This case illustrates the use of lumbar plexus and sciatic nerve peripheral catheters for major knee surgery using intermittent bolus dosing for outpatient analgesia.Clinical features: A 20-yr-old male presented for multi-ligamentous knee reconstruction (posterior collateral ligament and revision anterior collateral ligament and lateral collateral ligament). Anesthesia was managed with a lumbar plexus and a sciatic nerve peripheral catheter and a light general anesthetic. Post-operative analgesia was provided with a 12-hr infusion of 0.2% ropivacaine in an over night recovery care centre. Subsequent catheter dosing was performed as an outpatient, twice a day using 0.2% ropivacaine, 10 ml in each catheter (four injections total). This provided 96 hr of analgesia and low supplemental opioid use. Conclusion:The use of a lumbar plexus and sciatic nerve peripheral catheter offered an alternative to conventional pain control that worked well in the ambulatory setting. By providing prolonged unilateral lower limb analgesia, extensive knee surgery was performed that would normally require a hospital stay for pain control. Using a bolus dosing method the risk of local anesthetic complications occurring outside of the hospital with a continuous infusion was minimized. AJOR reconstructive surgery of the knee traditionally requires an extended hospital stay for pain management. Surgery such as total knee arthroplasty or multi-ligament reconstruction (as opposed to single anterior cruciate ligament repair) often involves a large incision, substantial soft tissue dissection and multiple osteotomies. As a result patients frequently require large doses of post-operative iv narcotics or continuous epidural analgesia. The care required to manage these modalities usually makes early hospital discharge difficult and prohibits performing this surgery on an ambulatory basis.Continuous peripheral nerve blockade (CPNB) is an alternative technique that can provide prolonged REGIONAL ANESTHESIA A N D P A I N

Regional anaesthesia in day‐stay and short‐stay surgery

“…In addition to the intra‐operative management of these patients, postoperative pain control is essential to facilitate rehabilitation after lower extremity surgery. Techniques such as neuraxial blockade [27, 28], intra‐articular opioids with and without local anaesthetics [27–29], single injection or continuous perineural infusion [30–32], and systemic opioids, all have individual advantages and disadvantages.…”

Ultrasound-guided psoas compartment block and general anesthesia for arthroscopic knee surgery: a case report

“…[18][19][20][21] Central neuraxial blocks and general anesthesia provide effective anesthesia, however neuraxial blocks cause nausea/emesis, urinary retention, post-dural puncture, hemodynamic changes, motor weakness in the lower extremity and on the other hand general anesthesia is reported with high postoperative pain scores, and low satisfaction ratings. [4,12] However, peripheral nerve blocks have advantages of providing limb-specific anesthesia/analgesia without extended muscle weakness, allowing early ambulation, enabling effective physiotherapy and early discharge. [4,22,23] Although femoral nerve block is easy to perform, the obturator and lateral femoral cutaneous nerves are not consistently blocked with this technique.…”

“…[1][2][3][4] It provides the blockade of the femoral, obturator and lateral cutaneous nerves of the thigh with a single injection. [3][4][5] Therefore, it may be used for anesthesia and analgesia of anterior, medial, and lateral procedures of the thigh such as skin grafts and femoral osteotomy, total knee replacement, [6] total hip replacement, [7,8] hip fractures, [9,10] knee arthroscopy, [11] anterior and posterior cruciate ligament reconstructions [12] and chronic hip pain. [13] The PCB technique is traditionally performed using surface anatomical landmarks and observing quadriceps muscle contraction to peripheral nerve stimulation.…”

Anterior sciatic nerve block – new landmarks and clinical experience

“…Although sciatic and femoral nerve blocks are excellent adjuncts to anesthesia and postoperative analgesia for operations of the lower extremities such as total knee replacement, sciatic nerve blocks are underused compared to other anesthetic techniques (1–6). However, the usefulness of sciatic nerve blocks has been recently challenged (2).…”

“…They are used not only for pain management but also in combination with general anesthesia to maintain stable hemodynamic conditions (1). The sciatic nerve block may be used for nearly all operations of the lower extremity, either as single block or preferably in combination with a femoral nerve block (2–6). The blockage can be achieved using different techniques.…”