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Foot gangrene in a 69 year old, 156 cm, 90 kg with a long history of DM. Scheduled surgery is wound debridement. The patient is hemodynamically stable. Relevant medications include insulin, and low-molecular-weight heparin (stopped 48 hours ago). Airway assessement is MP 2. What is the best anesthetic choice for this patient/operation:
Spinal anesthesia
Popliteal Block
Ankle Block
General
Tourniquet pain is one of the most common reasons why peripheral nerve blocks for distal surgery can not be used as a single anesthesia modality. For instance, for foot surgery, Tourniquet can be applied below the knee, but some surgeons are uncomfortable with this. For foot surgery, we often use Long-Acting local anesthetic for ANKLE or POPLTEAL block (e.g. ropivacaine, bupivacaine), and shorter-acting local anesthetic for FEMORAL block (e.g. lidocaine) – for tourniquet pain. THis way, the analgesic block for Tourniquet resolves quickly after surgery, leaving the long-acting pop or ankle block for postop analgesia. With this strategy and intraoperative sedation, Tourniquet pain is tolerated up to 45 minutes by most patients. How does every else treats the Tourniquet pain intraoperatively or what are the strategies to enable nerve blocks as a sole anesthesia technique when high Tourniquet is used?
A 50-year-old patient without comorbidities underwent Whipple surgery, postoperative analgesia was provided by an epidural catheter that we placed at the level of L2/L3 and tread it 6 cm.
We ordinated a bolus of 20 ml 0,1% Levobupivacaine and 50 µg Fentanyl every 6 hours.
The patient was without any pain and we started the ERAS protocol on the first day. After three days, we removed the catheter and continued around the clock analgesia with paracetamol and NSAID.
Would you provide analgesia in some other way?
This study is very interesting: https://pubmed.ncbi.nlm.nih.gov/30635497/
It suggests costoclavicular has equivalent analgesia to ISC block. I have never tried it to shoulder surgery. Has anyone of you tried?
