Femoral Nerve Blocks Julie Ronnebaum, DPT, GCS, CEEAA

Objectives  1. Become familiar with the evolution of peripheral nerve

blocks.  2. Describe the advantages and disadvantages of femoral nerve blocks  3. Identify up-to-date information on the use of femoral nerve block..  4. Recognize future implications.

History of Anesthesia  The use of anesthetics began over 160 years ago.

General Anesthesia  In 1845, Horace Wells used nitrous oxide gas during a tooth extraction  1st- public introduction of general anesthesia October 16 16, 1846. 1846  Known as “Ether Day” ( William Morton)  In front of audience at Massachusetts General Hospital  First Fi reportedd ddeathh iin 1847 ddue to the h ether h  Other complications  Introduction t o uct o to ether et e was prolonged p o o ge  Vomiting for hours to days after surgery Schatsky 1995, Schatsky, 1995 Hardy Hardy, 2001

History of Anesthesia  In 1874, morphine introduced as a pain killer.  In 1884, 1884 August Freund discovers disco ers cyclopropane c clopropane for surger surgery  Problem is it is very flammable

 In 1898, heroin was introduced for the addiction to morphine  In 1923 Arno Luckhardt administered ethylene oxygen for an anesthetic

History of Anesthesia Society

History of Anesthesia  Alternatives to general anesthesia  In the 1800’s Cocaine used by the Incas and Conquistadors  1845, Sir Francis Rynd applied a morphine solution directly to the nerve to relieve

intractable neuralgia. g ( first recorded nerve block))  Delivered it by gravity into a cannula

 In 1855, Alexander Wood is a glass syringe to deliver the medication for a nerve block. (

also known as regional g anesthesia))

 In 1868 a Peruvian surgeon discovered that if you inject cocaine into the skin it numbed

it.

 In 1884, Karl Koller discovered cocaine could be used to anesthetized the eye of a frog.

History of Anesthesia Society

History of Anesthesia  In 1885, James Corning introduced cocaine for spinal analgesia (dog)  In 1898, August Bier administered spinal analgesia on humans.  In 1900 first spinal analgesia for vaginal delivery  In 1903, Ernest Fourneau introduced first synthetic local anesthetic (

Amylocain)  In I 1946, 1946 Paul P l Ansbro A b introduced i t d d a continuous ti nerve bl blockk  In 1965, Bupivacaine is first marketed as a pain reliever  In 1999, first reviews are published using the use for nerve blocks.

History of Anesthesia Society

Regional Anesthesia  Local anesthetic induced blockade of peripheral or spinal

nerve impulses from a targeted body part with preserved level of consciousness

http://medical-dictionary

Types of Regional Anesthesia  local anesthetic (Bier block)  spinal, epidural  Peripheral nerve blocks ( PNB)  Truncal ( paravertebral, TAP blocks)  Plexus (brachial plexus, lumbar plexus)  Distal ( femoral, femoral sciatic)

Peripheral Nerve Blocks

Advantages  Can combine the regional anesthetic with light general

anesthetic.  Decrease in post operative nausea and vomiting, delirium and respiratory depression. depression  All with the goal of a decreased  length of stay in the hospital. hospital  Decreased narcotic requirements after surgery  Earlier return of bowel function  Improved pain scores within first 24 hours

Disadvantages  Variable duration  Failed blocks  Intraoperative awareness and discomfort  Sustained Motor blockade  Rare serious complications

Contraindications  Excessive sedation  On anticoagulants  Preexisting nerve injury  Infection

Relationship to Physical Therapy  Allows for earlier mobilization status post total arthroscopic

surgery. ( Capdevila,2005)  Earlier mobilization improves short and long term functional outcomes ( Atkinson, Atki 2008)

Complication of Peripheral Nerve Bl k Blocks  Local anesthetic toxicity  Bleeding/hematoma  Infection (Neuburger , 2007)  Nerve injury ( transient paralysis 1-3%) ( Capdevila, 2005)  Permanent injury 1/10,000

Specific kinds of blocks  Brachial plexus

 Interscalene block  Supraclavicular block  Axillary block

 Lower extremity

 Lumbar plexus  Femoral nerve block and saphenous nerve block  Sciatic nerve block: anterior, gluteal and popliteal

 Truncal

 Paravertebral block  Transverse abdominus plane (TAP) block

Femoral Nerve Block for TKA  Used for postoperative pain relief of the thigh or knee.  Most commonly with ACL repairs and total knee arthroplasties

http://www.google.com/imgres?q=pictures+of+femoral+nerve+block&hl=en&sa=X&rlz=1W1AURU_enUS499& biw=1680&bih=795&tbm=isch&prmd=imvns&tbnid=6pqjRM7R44VliM

http://en.wikipedia.org/wiki/File:Fermoral_nerve_block.jpg

Injection

Motor and cutaneous distribution

http://www.ifna-int.org/ifna/e107_files/downloads/lectures/H17Femoral.pdf

Medications with Femoral Nerve Block Medication

On set

Anesthesia (hrs)

 Bupivacaine (Allen, 1998) 1 10-15

p 3% 2- chloroprocaine (+HCO3)  Ropivicaine

(Morin, 2005) 10-15 3% 2- chloroprocaine  Lidocaine (Macalou, 2004) (+HCO3+ epi)

Analgesia (hrs) 2

1.5-2

2-3

1.5% Mepivacaine (+HCO2)

15-20

2-3

3-5

1.5% Mepivacaine p (+HCO2+ epi)

15-20

2-5

3-8

2% lidocaine

10-20

2-5

3-8

0.5% ropivacaine

15-30

4-8

5-12

0.75% ropivacaine

10-15

5-10

6-24

0 5 Bupivacaine 0.5

15-30 15 30

55-15 15

66-30 30 NYSORA

Application  Do patients that undergo a total knee arthroplasty, and

receive the Femoral Nerve block, perform better than those who have had traditional methods of pain control?

Pain Reference

Journal Journal 

Block

#pt

Outcomes

Results

Allen et. al, 1998

Anesthesia and  Analgesia

FNB, FNB + SNB

36

The FSNB group had  decreased pain scores  only on POD 1

McNamee et al, 2001

ACTA  Anaesthesiologica Scandinavica

SSFNB+Sciatic, SSFNB  +Sciatic + PCA

50

VAS, morphine  consumption, side effects VAS, activity,  morphine  consumption

Macalou et.al, 2004

Anesthesia and  Anlgesia

SSFNB, PCA

57

VAS, morphine  consumption, side  effects

Pain rating were the  same for all groups,  pain was  experienced in back  of knee

Pham Dang et.al,  2005

Regional Anesthesia  and Pain Medicine d P i M di i

FNB, FNB + SNB

28

Amplitude of knee  fl i flexion, side id effects ff t

Pain scores at rest  were significantly  i ifi tl higher in the FNB  group compared to  the FSNB group.  This  difference  disappeared after 36 disappeared after 36  hours after surgery.   The FSNB group  consumed 81% less  morphine compared  to the FNB group to the FNB group. 

Morphine Morphine  consumption was  significantly reduced  in SSFNB + Sciatic  SSFNB + sciatic + PCA

Pain continued Reference

Journal 

Block

#pt

Outcomes

Results

Morin et al, 2005

Regional Anesthesia  and Pain Medicine

FNB, FNB + SNB, PNB

90

Morphine  consumption, pain  scores, maximal  bending and extending  of the knee, walking  distance

Postoperative  morphine  consumption during  48 hours was  significantly lower in  the FSNB group than  in the FNB group.   Postoperative pain  scores were not  different

Good et. al. ,2007

American Journal of  Orthopedics

SSFNB , PCA

42

VAS, side effects,  morphine  consumption 

SSFNB consumed less  morphine and pain  ratings remained the  same for both groups

Hung et. al, 2009

The Journal of  Arthroplasty h l

FNB, FNB + SNB

88

VAS, morphine  consumption

The FSNB group had  l lower pain scores on  the day of surgery  both there was no  difference on POD 1  and 2.  The FSNB  group used  d significantly less PCA  morphine compared  to the FNB and control  group

Kadic et al 2009 Kadic, et al, 2009

ACTA  ACTA Anaesthesiologica Scandinavica

CFNB PCA CFNB, PCA

53

VAS, morphine  VAS morphine consumption, side  effects

CFNB had less h d l pain  and nausea.

Range of motion Reference

Journal 

Block

#pt

Outcomes

Results

Singelyn et al, 1998 et al 1998

Anesthesia and Anesthesia and  Analgesia

PCA CFNB+ SNB, EPI PCA, CFNB+ SNB EPI

45

VAS, Knee flexion,  VAS Knee flexion side effects, length of  stay

Significantly better  Significantly better knee flexion,  ambulation distance  up to 6 weeks post  op, at 3 months no  difference

Wang et al, 2002

Regional Anesthesia  and Pain Medicine

SSFNB vs placebo

30

VAS, knee range of  motion, length of  stay in hospital

Knee range of motion  at discharge was not  statistically different,  length of stay shorter  for blocks

N i t l 2007 Nngai, et al, 2007

The Journal of  Th J l f Arthroplasty

60

VAS, range of motion,  VAS f ti morphine use.

FNB had better range  of motion initially

Kadic, et al, 2009

ACTA  Anaesthesiologica Scandinavica

PCA, low FNB (.15%)  PCA l FNB ( 15%) and high (.2%) dose  FNB CFNB, PCA

53

VAS, morphine  consumption, side  effects

Better knee range of  motion in first 6 days,  after 3 months the after 3 months the  same.

Fetherston,et al, 2011

Journal of Orthopedic  surgery and Research

PCA, CFNB

53

Pain, range of motion,  TUG

FNB had lower range  of motion than PCA

Functional recovery  At 6 months, gait distance was the same for all groups (Kadic, 2009)  The Th TUG times were better b for f the h PCA group as comparedd to

the CFNB group.

 Men prepared better than the women.( Fetherston, 2011)

 1.6% of 1018 patients had fallen within 48 hours after surgery had a nerve block. ((Sharma,, 2010))  Lower extremity nerve blocks result in decreased leg stiffness and

lateral instability, which may lead to difficulty with pivoting maneuvers ( Muraskin, maneuvers. Muraskin 2007)  Demonstrated there is a causal relationship between CPNB and the risk of falling after knee and hip arthroplasty.( Ilfed, 2010)

Sensation and motor recovery  Prolonged nerve blockade can last up to 30 hours ( Hadzic et al 2004, Selander l d et all 1988)

 Prolonged sensory deprivation up to 1 year after surgery. Sharma, 2010))

(

Summary of literature  Pain scores at rest

 At 24 hours, hours majority of patients with CFNB exhibited less pain than

those that received a PCA.  At 48 hours, no significant differences between groups.  Pain with activity

 At 24 hours, all blocks had less pain than PCA.  At 48 hours hours, those who received the sciatic block had better pain

scores.

 Knee range g of motion

 There were no significant differences at discharge in knee range of

motion scores for all groups

What are the clinicians saying?

Case Study  The patient was an 88 year old male diagnosed with osteoarthritis

off the h lleft f kknee. Thi This patient i underwent d a lleft f TKA andd received i da CFNB with Ropivacaine. The patient received physical therapy via the standard joint camp protocol, startingg on postoperative dayy 1.

Ronnebaum,, 2012

Joint Camp Exercises Table #2 Total Knee Arthroscopy Exercises Postoperative Day Day 1 PM

Day 2 AM Day 2 PM Day 3 AM

Exercises 1. Independent with gluteal sets 2. Minimum assistance needed to perform ankle dorsiflexion, plantar flexion and heel slides. 3 Maximum assistance needed to perform straight leg raise (SLR) 3. (SLR), short arch quad (SAQ) and long arch quads (LAQ). Patient was unable to perform a quad set. Patient performed 10 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps and heel slides. 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad set. Patient performed 15 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps and heel slides 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad set. Patient performed 15 repetitions of each exercise in semi reclined position. 1. Independent with gluteal sets, ankle pumps an heel slides. 2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad set. Patient performed 15 repetitions of each exercise in semi reclined position. position Ronnebaum, 2012

Functional Outcomes Table 3: Functional Outcome Progression During the Inpatient Stay

Functional Outcomes Ambulation assist Ambulation device Ambulation Distance Ambulation Pattern

Pain (Visual Analog Scale) Range of motion(degrees)

Postoperative Day #1 afternoon Minimal assistance Standard walker

Postoperative Day #2 morning Contact guard assist Wheeled walker

Postoperative Day # 2 afternoon Contact guard assist Wheeled walker

Postoperative Day #3 morning Contact guard assist Wheeled walker

60 feet

150 feet

150 feet

150 feet

Step to gait

Step to gait with verbal cues to step f th into further i t the th walker 7

Step to gait

Step through gait

4

3

NA

Flexion 90 Extension -6

Flexion 90 Extension -6

8 Flexion 94 Extension -10

Table 3: Functional Outcome Progression During the Inpatient Stay Functional Outcomes Ambulation assist Ambulation device Ambulation Distance Ambulation Pattern

Pain (Visual Analog Scale) Range of motion(degrees) Ronnebaum, 2012

Conclusions  The continuous femoral nerve block did prevent the side    

effects found with the traditional methods of pain relief. At discharge patient was unable to perform independent SLR and SAQ. SAQ Patient did achieve 90 degrees of knee flexion by discharge but had -6 degrees g of extension.. The patient went home with knee immobilizer secondary to quadriceps weakness. Patient was referred to OPT PT secondary to quadriceps weakness. Ronnebaum, 2012

Future studies  Examine the spike in pain rating 16-28 hours after surgery  Examine prolonged quadriceps weakness  Examine the effects of infiltration techniques as compared

th PCA andd nerve bl the blocks. k

References 

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Singelyn FJ, Deyaert M, Joris D, et al. Effects of IV patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. arthroplasty Anesth Analg 1998;87:88–92. 1998;87:88 92 Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay total knee replacement. Reg Anesth Pain Med 2002;27:139–44. Sharma, S, et al Complications of femoral nerve block for total knee arthoplasty. Clinical Orthopedics and related research research. 2010 2010. 468: 135-140 135 140. McNamee, et al. Total knee replacement: a comparison of ropivacaine and bupivacaine in combined femoral and sciatic block. Acta Anaestheiola Scandiavia. 2001. 45: 477-481. Selander, D. Nerve toxicity of local anesthetics. Local anesthesia and regional blockade. In: Lofstrom J, Sjostrand j U,, editors. Amsterdam,, Elsevier Science Publisher;1988: ; 77. Hadzic, A et al New York School of Regional Anesthesia. Peripheral nerve blocks, principles and practice. New York: McGraw-Hill: 2004:62. Muraskin et al, Falls associated with lower extremity nerve block: a pilot investigation. Regional Anesthesia in Pain Medicine. 2007. 32(1); 67-72. Illfed, B et al. The Association between lower extremity continuous nerve blocks and patient falls after knee and hip arthroplasty. Anesthesia and Analgesia, 2010. 10(10) 1-3. Schatski, SC Ether Day. American Journal of Radiology. 1995. 165:560.

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Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD: Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg 1998; 87:93–7 Macalou D, Trueck S, Meuret P, Heck M, Vial F, OuologuemS, Capdevila X, Virion JM, Bouaziz H: Postoperative analgesia after total knee replacement: The effect of an obturator nerve block added to the femoral 3-in-1 nerve block. Anesth Analg 2004; 99:251– 4 McNamee DA, Convery PN, Milligan KR: Total knee replacement: A comparison of ropivacaine and b i bupivacaine i in i combined bi d femoral f l andd sciatic i ti block. bl k Acta A t Anaesthesiol A th i l Scand S d 2001; 2001 45 45:477– 477 81 Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B: A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg 2006;102:1240 – 6 K di LL, Boonstra Kadic B t MC, MC De D Waal W l Malefijt M l fijt MC, MC Lako L k SJ SJ, J Van V Egmond E d J, J Driessen Di JJ: JJ C Continuous ti ffemorall nerve block after total knee arthroplasty? Acta Anaesthesiol Scand 2009; 53:914 –20 Morin AM, Kratz CD, Eberhart LH, Dinges G, Heider E, Schwarz N, Eisenhardt G, Geldner G, Wulf H: Postoperative analgesia and recovery after total-knee replacement: C Comparison i off a continuous ti posterior t i llumbar b plexus l ((psoas compartment) t t) bl block, k a continuous ti ffemorall nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg Anesth Pain Med 2005; 30:434–4 Good RP, Snedden MH, Schieber FC, Polachek A: Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty. Am J Orthop 2007; 36:554 –77

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Capdevila X et al , Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology. 2005;103(5):1035.

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Neuburger M et al., Inflammation and infection complications of 2285 perineural catheters: a prospective study. Acta Anaesthesiol h l Scand. d 2007;51(1):108.

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Ronnebaum, J. Acute Care Outcomes Status Post Total Knee Arthroplasty with Continuous Femoral Nerve Block. Journal of Acute Care Physical Therapy. 3(1)2012:149-156.

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Weber, A., Fournier, R., Van Gessel, E. et al. (2002)Sciatic nerve block and the improvement of femoral nerve block analgesia after total knee replacement. Journal of Anaestheology 19: 832-850.