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Abstract
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Background and Aims 76 yo male with chronic non-ischemic cardiomyopathy (EF15%) and new onset atrial fibrillation scheduled for revision knee arthroplasty due to prosthetic infection. Upon admission (two days prior to surgery), he received apixaban and was subsequently bridged to a heparin infusion.
Methods We pursued surgical anesthesia utilizing the novel anterior lumbar plexus via inguinal entry approach (ALPINE); theorized to provide superior obturator nerve coverage than traditional femoral nerve blockade. Using anterior out-of-plane ultrasound technique, the femoral nerve was identified (Figure 1) and 15mL of bupivacaine 0.5%:lidocaine 2% (70:30) solution was deposited via an 18G 10cm Tuohy needle. A styletted catheter was then advanced 20cm proximally along the femoral sheath. An additional 10mL of solution was given via the catheter while ultrasound imaging focused at the distal femoral nerve; which was negative for additional fluid deposition at this site. Next, with the patient in lateral decubitus positioning, the ipsilateral subgluteal sciatic nerve was identified on ultrasound (Figure 2), and its identity confirmed using neurostimulation. Ten milliliters of solution was injected at this site using a 21G 10cm Pajunk needle.
Results Neurologic assessment confirmed blockade of the femoral, lateral femoral cutaneous, obturator, and sciatic distributions. Surgery proceeded lasting 2 hours; during which the patient maintained his native airway and remained hemodynamically normal. His postoperative course was notable for minimal pain requirements and a multifactorial AKI thought in part due to urinary obstruction.
Conclusions Surgical level anterior lumbar plexus via inguinal entry (ALPINE) combined with subgluteal sciatic is a feasible and safe alternative to general anesthesia.
Ultrasound view of femoral nerve, artery, out-of-plane needle tip and 70:30 0.5% bupivacaine, 2% Lidocaine (15mL) solution spread deep to fascia iliaca. Catheter then threaded cranially until resistance met (20cm). Bolused with additional 10mL of solution and removed
Ultrasound view of subgluteal sciatic nerve and 70:30 0.5% bupivacaine, 2% Lidocaine (10mL) solution spread