Technology and product update Sciatic nerve block: A useful procedure for diabetic foot surgery


Figure 2. The saphenous nerve is block by injecting a subcutaneous wall from the tuberositas tibia [1] to the medial caput of the gastrocnemius muscle [2].


requiring surgery to manage diabetic foot disease. The following case reports illustrate the benefits of peripheral nerve blocks in this patient group.


the block are related to the type of local anaesthetic used; lidocaine blocks have a fast onset and last from 2 to 3 hours, while ropivacaine blocks have a slower onset but regularly last >10 hours.[5]


It is therefore


suggested that lidocaine and ropivacaine be combined to achieve both fast onset and a long duration. With a sufficient block, additional postoperative pain control can usually be dispensed with. Using this block technique does not impair the patient’s protective reflexes (e.g. coughing, swallowing), meaning that there is no need for postoperative fastening and, for this reason, may make inpatient glycaemic control more manageable.


CASE STUDIES As outlined before, diabetic patients regularly suffer from severe comorbidities, which contribute to a high risk profile according to American Society of Anesthesiologists patient classification status III (severe systemic disease – i.e. definite functional impairment [e.g. diabetes and angina with relatively stable disease, but requiring therapy]) or IV (severe systemic disease that is a constant threat to life [e.g. diabetes and angina and chronic heart failure; patient has dyspnea on mild exertion and chest pain]).[6] Hence, surgical procedures to manage diabetic foot disease should be undertaken with a careful consideration of the anaesthetic techniques available. Regrettably, there is a widely held belief – among both patients and healthcare professionals – that all surgical procedures require general anaesthesia. In the authors’ practice, the nerve block anaesthesia described above has proven a useful addition to the management of some patients


Case 1 A 72-year-old man was scheduled for below- knee amputation due to infected diabetic foot ulceration. The patient had long- standing insulin-dependent diabetes (IDDM), renal insufficiency and severe coronary artery disease. He had a history of myocardial infarction during a femoro–popliteal bypass surgery, which led to intraoperative cardiopulmonary resuscitation. Given the patient’s history general anaesthesia was not recommended. Due to absolute arrhythmia associated with atrial fibrillation, he was anticoagulated with high-dose enoxaparin and therefore spinal anaesthesia was contraindicated. Following discussion, the patient


consented to regional anaesthesia and the authors’ team blocked the sciatic and the saphenous nerve as described above. Beside light sedation with 0.5 mg of midazolame he received no other systemic substance. The surgery was uneventful with a heart


rate between 60 and 80 beats/min and a noninvasive blood pressure of 130/60 mmHg throughout. Postoperatively the patient was transferred to his normal ward to take lunch. At 1-year follow-up the patient was doing well, with no major documented events.


Case 2 A 77-year-old man with a history of long- standing IDDM, renal insufficiency and arterial hypertension, was scheduled for forefoot amputation due to infected diabetic foot ulceration. The patient’s left ventricular ejection fraction was significantly reduced (15%). Spinal anaesthesia (with possibly deleterious preload reduction) and general anaesthesia (with possibly hazardous positive-pressure ventilation) seemed unfavourable interventions. The patient consented to a regional anaesthesia and the authors’ team undertook the block described previously. Again, beside moderate intravenous sedation during the blocking procedure with midazolame and sufentanil (1 mg and 0.01 mg, respectively) no additional systemic medication was required. Surgery was uneventful, heart-rate ranged between 75 and 85 beats/min; blood pressure was stable at 130/80 mmHg.


Wounds International Vol 5 | Issue 2 | ©Wounds International 2014 | www.woundsinternational.com 29


“Surgical procedures to manage diabetic foot disease should be undertaken with a careful consideration of the anaesthetic techniques available.”


Technology update


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