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


Following the amputation, the patient was


“The authors’ experience


indicates that people with


diabetes may benefit from peripheral


nerve blocks for surgical


procedures of the lower leg.”


transferred to his normal ward. At 1-year follow-up the patient was doing well, with no major documented events.


DISCUSSION The authors’ experience indicates that people with diabetes may benefit from peripheral nerve blocks for surgical procedures of the lower leg. The authors’ experience corresponds with previous investigations.[7,8] Avoiding general anaesthesia in this population may be a central concern, and improve short-term outcomes following lower-limb surgery. As long-standing diabetes impairs


various body systems, these patients have low reserves to preserve against additional straining factors during general anaesthesia.[9,10]


This includes:


• Preserving cardiopulmonary integrity, which is negatively influenced by positivepressure ventilation during general anaesthesia.[11]


• Negating the need for anaesthetic agents that reduce vascular tone and increase the need for vasopressive substances, which may impair capillary blood flow.


• Insufficient metabolic and excretory capacities may cause extended effects of muscle relaxants, inhalants and opioids, thereby impairing the early postoperative recovery period.[12]


The latter two


additionally reduce the integrity of the immune system.[13]


Combinations of these


factors are suspected to be responsible for increased pulmonary complications in people with diabetes.[14]


With the use of peripheral blocks, the


drawbacks of general anaesthesia are not only avoided, but additional benefits added: • By contrast to signal transduction under general anaesthesia, blocking a peripheral nerve means that afferent signals are stopped before they cause efferent endocrine stress responses.[15]


• Patients do not require postoperative fasting, so that continued oral medication and nutrition may help in preserving blood glucose homeostasis during this vulnerable period.[16]


CONCLUSION Healthcare professionals who are involved in surgical procedures of the lower limbs in vulnerable patients with diabetes may consider the use of peripheral nerve block


30


in stead of general anaesthesia, in those in whom it is appropriate. n


REFERENCES


1. American Diabetes Association (2003) Peripheral arterial disease in people with diabetes. Diabetes Care 26(12): 3333–41


2. Prompers L, Huijberts M, Apelqvist J et al (2007) High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 50(1): 18–25


3. Horlocker TT, Wedel DJ, Benzon H et al (2003) Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 28(3): 172–97


4. Kocum A, Turkoz A, Bozdogan N et al (2010) Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy. J Clin Anesth 22(5): 363–6


5. Heavner JE (2007) Local anesthetics. Curr Opin Anaesthesiol 20(4): 336–42


6. American Society of Anesthesiologists (2012) ASA Physical Status Classification System. Available from: http://bit.ly/I3B2V2 (accessed 09.08.2012)


7. Chia N, Low TC, Poon KH (2002) Peripheral nerve blocks for lower limb surgery--a choice anaesthetic technique for patients with a recent myocardial infarction? Singapore Med J 43(11): 583–6


8. Raith C, Kölblinger C, Walch H (2008) [Combined transgluteal ischial and femoral nerve block: retrospective data on 65 risk patients with leg amputation]. Anaesthesist 57(6): 555–61 [Article in German]


9. Chance WW, Rhee C, Yilmaz C et al (2008) Diminished alveolar microvascular reserves in type 2 diabetes reflect systemic microangiopathy. Diabetes Care 31(8): 1596–601


10. Faglia E, Clerici G, Clerissi J et al (2009) Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care 32(5): 822–7


11. Pinsky MR (1994) Heart-lung interactions during positive-pressure ventilation. New Horiz 2(4): 443–56


12. Bower WF, Jin L, Underwood MJ et al (2010) Overt diabetes mellitus adversely affects surgical outcomes of noncardiovascular patients. Surgery 147(5): 670–5


13. Brand JM, Kirchner H, Poppe C, Schmucker P (1997) The effects of general anesthesia on human peripheral immune cell distribution and cytokine production. Clin Immunol Immunopathol 83(2): 190–4


14. Morricone L, Ranucci M, Denti S et al (1999) Diabetes and complications after cardiac surgery: comparison with a non-diabetic population. Acta Diabetol 36(1–2): 77–84


15. Kehlet H (1998) Modification of responses to surgery by neural blockade: clinical implications, neural blockade. In: Cousins MJ (ed.) Clinical Anesthesia and Management of Pain (3rd Bridenbaugh, PO: 129–78


edn). Lippincott–Raven,


16. McCavert M, Mone F, Dooher M et al (2010) Perioperative blood glucose management in general surgery – a potential element for improved diabetic patient outcomes – an observational cohort study. Int J Surg 8(6): 494–8


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Technology update


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