Femoral Nerve Blocks

Julie Ronnebaum, DPT, GCS, CEEAA

ObjectivesObjectives 1. Become familiar with the evolution of peripheral nerve

blocks.

2. Describe the advantages and disadvantages of femoral nerve blocksnerve blocks

3. Identify up-to-date information on the use of femoral nerve block. .

4. Recognize future implications.

History of AnesthesiaHistory of Anesthesia The use of anesthetics began over 160 years ago.General AnesthesiaGeneral Anesthesia

In 1845, Horace Wells used nitrous oxide gas during a tooth extraction

1st- public introduction of general anesthesia October 16 18461 public introduction of general anesthesia October 16, 1846. Known as “Ether Day” ( William Morton) In front of audience at Massachusetts General Hospital

Fi d d h i 1847 d h h First reported death in 1847 due to the ether

Other complications Introduction to ether was prolongedt o uct o to et e was p o o ge Vomiting for hours to days after surgery

Schatsky 1995 Hardy 2001Schatsky, 1995, Hardy, 2001

History of AnesthesiaHistory of Anesthesia In 1874, morphine introduced as a pain killer.

In 1884 August Freund disco ers c clopropane for surger In 1884, August Freund discovers cyclopropane for 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 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. ( first recorded nerve block)g ( ) 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 anesthesia) g )

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 SocietyHistory of Anesthesia Society

History of Anesthesia 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 deliveryIn 1900 first spinal analgesia for vaginal delivery

In 1903, Ernest Fourneau introduced first synthetic local anesthetic ( Amylocain)

I 1946 P l A b i t d d ti bl k In 1946, Paul Ansbro introduced a continuous nerve block

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 AnesthesiaRegional 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 AnesthesiaTypes of Regional Anesthesia local anesthetic (Bier block)

spinal, epidural

Peripheral nerve blocks ( PNB) Truncal ( paravertebral, TAP blocks) Plexus (brachial plexus, lumbar plexus) Distal ( femoral sciatic) Distal ( femoral, sciatic)

Peripheral Nerve Blocks

AdvantagesAdvantages Can combine the regional anesthetic with light general

anesthetic.

Decrease in post operative nausea and vomiting, delirium and respiratory depressionrespiratory depression.

All with the goal of a decreased length of stay in the hospitallength of stay in the hospital. Decreased narcotic requirements after surgery Earlier return of bowel function Improved pain scores within first 24 hours

DisadvantagesDisadvantages Variable duration

Failed blocks

Intraoperative awareness and discomfort

Sustained Motor blockade

Rare serious complications

ContraindicationsContraindications Excessive sedation

On anticoagulants

Preexisting nerve injury

Infection

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

surgery. ( Capdevila,2005)

Earlier mobilization improves short and long term functional outcomes ( Atki 2008)outcomes ( Atkinson, 2008)

Complication of Peripheral Nerve Bl kBlocks Local anesthetic toxicity

Bleeding/hematoma

Infection (Neuburger , 2007)

Nerve injury ( transient paralysis 1-3%) ( Capdevila, 2005)

Permanent injury 1/10,000

Specific kinds of blocksSpecific kinds of blocks Brachial plexus Interscalene block Interscalene block Supraclavicular block Axillary block

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

Truncal Truncal Paravertebral block Transverse abdominus plane (TAP) block

Femoral Nerve Block for TKAFemoral 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

InjectionInjection

Motor and cutaneous distributionMotor and cutaneous distribution

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

Medications with Femoral Nerve Block

Bupivacaine (Allen, 1998)Medication On set Anesthesia (hrs) Analgesia (hrs)

3% 2- chloroprocaine 10-15 1 2

Ropivicaine (Morin, 2005)

Lidocaine (Macalou, 2004)

p(+HCO3)

3% 2- chloroprocaine (+HCO3+ epi)

10-15 1.5-2 2-3

1.5% Mepivacaine (+HCO2)

15-20 2-3 3-5

1.5% Mepivacaine 15-20 2-5 3-8p(+HCO2+ epi)

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 15-30 5-15 6-300.5 Bupivacaine 15 30 5 15 6 30

NYSORA

ApplicationApplication 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 Block #pt Outcomes ResultsReference Journal  Block #pt Outcomes Results

Allen et. al, 1998 Anesthesia and Analgesia

FNB, FNB + SNB 36 VAS, morphine consumption, sideeffects

The FSNB group had decreased pain scores only on POD 1

McNamee et al, 2001 ACTA  SSFNB+Sciatic, SSFNB  50 VAS, activity,  MorphineAnaesthesiologicaScandinavica

+Sciatic + PCA morphine consumption

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

Macalou et.al, 2004 Anesthesia and  SSFNB, PCA 57 VAS, morphine  Pain rating were the Anlgesia consumption, side 

effectssame for all groups, pain was experienced in back of knee

Pham Dang et.al, 2005

Regional Anesthesia d P i M di i

FNB, FNB + SNB 28 Amplitude of knee fl i id ff t

Pain scores at rest i ifi tl2005 and Pain Medicine flexion, side effects were significantly 

higher in the FNB group compared to the FSNB group.  This difference disappeared after 36disappeared after 36 hours after surgery.  The FSNB group consumed 81% less morphine compared to the FNB groupto the FNB group. 

Pain continuedReference 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 

Postoperative morphine consumption during 48 hours was significantly lower in 

distance 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 h l

FNB, FNB + SNB 88 VAS, morphine  The FSNB group had lArthroplasty consumption lower pain scores on the day of surgery both there was no difference on POD 1 and 2.  The FSNB 

dgroup used significantly less PCA morphine compared to the FNB and control group

Kadic et al 2009 ACTA CFNB PCA 53 VAS morphine h d lKadic, et al, 2009 ACTA AnaesthesiologicaScandinavica

CFNB, PCA 53 VAS, morphine consumption, side effects

CFNB had less pain and nausea.

Range of motionRange of motionReference Journal  Block #pt Outcomes Results

Singelyn et al 1998 Anesthesia and PCA CFNB+ SNB EPI 45 VAS Knee flexion Significantly betterSingelyn et al, 1998 Anesthesia and Analgesia

PCA, CFNB+ SNB, EPI 45 VAS, Knee flexion, side effects, length of stay

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 Th J l f PCA l FNB ( 15%) 60 VAS f tiNngai, et al, 2007 The Journal of Arthroplasty

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

60 VAS, range of motion, morphine use.

FNB had better range of motion initially

Kadic, et al, 2009 ACTA AnaesthesiologicaScandinavica

CFNB, PCA 53 VAS, morphine consumption, side effects

Better knee range of motion in first 6 days, after 3 months theScandinavica effects 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 Functional recovery At 6 months, gait distance was the same for all groups (Kadic, 2009)

Th TUG b f h PCA d The TUG times were better for the PCA group as compared 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 2007)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 recoverySensation and motor recovery Prolonged nerve blockade can last up to 30 hours ( Hadzic et al

l d l 2004, Selander et al 1988)

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

Summary of literatureSummary of literature Pain scores at rest At 24 hours majority of patients with CFNB exhibited less pain than At 24 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 those who received the sciatic block had better pain At 48 hours, those who received the sciatic block had better pain

scores.

Knee range of motiong There were no significant differences at discharge in knee range of

motion scores for all groups

What are the clinicians saying?What are the clinicians saying?

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

f h l f k Thi i d l f TKA d i d of the left knee. This patient underwent a left TKA and received a CFNB with Ropivacaine. The patient received physical therapy via the standard joint camp protocol, starting on postoperative day 1. g y

Ronnebaum, 2012,

Joint Camp ExercisesJoint Camp ExercisesTable #2 Total Knee Arthroscopy Exercises

Postoperative Day Exercises

Day 1

PM

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) short arch quad3. Maximum assistance needed to perform straight leg raise (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.

Day 2 1. Independent with gluteal sets, ankle pumps and heel slides.2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad

AM set.Patient performed 15 repetitions of each exercise in semi reclined position.

Day 2

PM

1. Independent with gluteal sets, ankle pumps and heel slides2. Moderate assistance needed for SLR, SAQ, and LAQ and moderate cuing for quad set.PMPatient performed 15 repetitions of each exercise in semi reclined position.

Day 3

AM

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 positionPatient performed 15 repetitions of each exercise in semi reclined position.

Ronnebaum, 2012

Functional OutcomesFunctional OutcomesTable 3: Functional Outcome Progression During the Inpatient Stay Table 3:

Functional OutcomeOutcome

Progression During the

Inpatient StayFunctional Postoperative Day Postoperative Day Postoperative Day Postoperative Day Functional Outcomes #1 afternoon #2 morning # 2 afternoon #3 morning Outcomes

Ambulation assist Minimal assistance

Contact guard assist

Contact guard assist

Contact guard assist

Ambulation assist

Ambulation device

Standard walker Wheeled walker Wheeled walker Wheeled walker Ambulation devicedevice device

Ambulation Distance

60 feet 150 feet 150 feet 150 feet Ambulation Distance

Ambulation Pattern

Step to gait Step to gait with verbal cues to step

f th i t th

Step to gait Step through gait Ambulation Pattern

further into the walker

Pain (Visual Analog Scale)

8 7 4 3 Pain (Visual Analog Scale)

Range of Flexion 94 NA Flexion 90 Flexion 90 Range of motion(degrees) Extension -10 Extension -6 Extension -6 motion(degrees)

Ronnebaum, 2012

ConclusionsConclusions 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 SAQand SAQ.

Patient did achieve 90 degrees of knee flexion by discharge but had -6 degrees of extension.g .

The patient went home with knee immobilizer secondary to quadriceps weakness.

Patient was referred to OPT PT secondary to quadriceps weakness.

Ronnebaum, 2012

Future studiesFuture 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 d bl kthe PCA and nerve blocks.

ReferencesReferences 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 Anesth Analg 1998;87:88 92 rehabilitation after unilateral total knee arthroplasty. Anesth Analg 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 2010 468: 135-140 Orthopedics and related research. 2010. 468: 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 U, editors. Amsterdam, Elsevier Science Publisher;1988: 77.J, j , , ;

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.

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 i i bi d f l d i ti bl k A t A th i l S d 2001 45 477 81bupivacaine in combined femoral and sciatic block. Acta Anaesthesiol Scand 2001; 45:477– 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. AnesthAnalg 2006;102:1240 – 6

K di L B t MC D W l M l fijt MC L k SJ J V E d J D i JJ C ti f l Kadic L, Boonstra MC, De Waal Malefijt MC, Lako SJ, J Van Egmond J, Driessen JJ: Continuous femoral 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 i f ti t i l b l ( t t) bl k ti f l Comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral 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 –7management and rehabilitation after total knee arthroplasty. Am J Orthop 2007; 36:554 7

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.

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

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.

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.