Femoral artery block: the relationship between visceral and ischemic pain

Boezaart, André P.; Smith, Cameron R.; Zasimovich, Yury; Reina, Miguel Ángel

doi:10.1136/rapm-2021-102622

Cited by 7 publications

(5 citation statements)

References 5 publications

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“…39,40 Recent microscopic analysis of the femoral artery revealed sympathetic nerve fibers in vascular adventitia. 41 A better scientific understanding of ACS ischemic pain transmission may enable targeted PNB without the risk of masking ACS.…”

Section: Pro: Modified Pnb Should Be Used Routinely In Extremity Trau...mentioning

confidence: 99%

“…In most brachial plexus, femoral or popliteal sciatic blocks, it is likely that local anesthetic infiltration in the area will also block the sympathetic pathways that transmit ischemic pain. 41 Fine nuances in pain transmission then become academic, as most clinical blocks maintain the risk of masking ischemic pain. According to this theory, femoral nerve block with periarterial spread may block ischemic transmission and mask a lower leg ACS despite sparing the sciatic innervation of the affected compartments.…”

Section: Con: Pnb Remains a Risky Intervention In Patients At Risk Fo...mentioning

confidence: 99%

“…Recent data suggest that ACS pain is ischemic in nature and is transmitted via nerve pathways that do not routinely travel with motor and sensory nerves are intriguing but not proven at this time. 8,39,41 Even if true, most sympathetic nerve fibers travel in vascular adventitia, which run adjacent to the large nerves or plexi that transmit sensation from the extremities. In most brachial plexus, femoral or popliteal sciatic blocks, it is likely that local anesthetic infiltration in the area will also block the sympathetic pathways that transmit ischemic pain.…”

Section: Anesthesia and Analgesiamentioning

confidence: 99%

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Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

Samet

Torrie

Chembrovich

et al. 2023

Anesthesia &Amp; Analgesia

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In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.

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Section: Pro: Modified Pnb Should Be Used Routinely In Extremity Trau...mentioning

confidence: 99%

Section: Con: Pnb Remains a Risky Intervention In Patients At Risk Fo...mentioning

confidence: 99%

Section: Anesthesia and Analgesiamentioning

confidence: 99%

See 1 more Smart Citation

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

Samet

Torrie

Chembrovich

et al. 2023

Anesthesia &Amp; Analgesia

View full text Add to dashboard Cite

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“…The risk, however, is that not all PNBs are purely somatic, which may confound the clinical examination. 4 In addition, their study was based on muscles in the gastrointestinal tract and the abdominal wall, 5 so it would be prudent to test this hypothesis in the appendicular skeleton. Furthermore, it is not only the masking of pain that confounds the clinical evaluation of compartment syndrome but also the masking of sensorimotor function.…”

mentioning

confidence: 99%

Reply to Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment

Kandemir

Cogan

2022

J Am Acad Orthop Surg

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T he Authors' Reply: We thank Smith et al and Pulos et al for their letter and continued discussion on our article: "Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment." 1 Their comments surrounding the use of peripheral nerve blocks (PNBs) in orthopaedic trauma highlight the paradox that some patients who stand to benefit from PNBs may be least often considered for it because of fear for missing or delaying the diagnosis of acute compartment syndrome (ACS). Our article highlights a gradation of recommendations for PNB use in different scenarios of clinical risk.The risk of compartment syndrome is 2% to 9% in tibia fractures 2 and 15% to 27% in high-energy tibia plateau fractures. 3 Smith et al refer to the retrospective study they are currently preparing for publication, with only two of 8,300 long bone fracture patients (0.02%) requiring fasciotomy for ACS in the setting of perioperative PNBs, which is not consistent with ACS incidence in the orthopaedic literature. It seems like either their practice comprises only very low-energy injuries, or there is a selection bias, which excludes high-risk patients.The timing of ACS is not necessarily predictable. Although most cases of ACS occur within 24 to 48 hours of injury, it can develop preoperatively, intraoperatively, or postoperatively. Significantly increased pain with passive stretch of specific compartment is commonly used to diagnose ACS; unfortunately, it is subjective. Moreover, the most objective sign to diagnose developing ACS is a neurologic deficit that usually starts with sensory and progresses to motor findings; therefore, a complete neurologic examination is critical. Smith et al bring up a very interesting point regarding the transmission of ischemic pain through the sympathetic nervous system, which should be unaffected by purely somatic PNBs. The risk, however, is that not all PNBs are purely somatic, which may confound the clinical examination. 4 In addition, their study was based on muscles in the gastrointestinal tract and the abdominal wall, 5 so it would be prudent to test this hypothesis in the appendicular skeleton. Furthermore, it is not only the masking of pain that confounds the clinical evaluation of compartment syndrome but also the masking of sensorimotor function. 6 Ischemia time of just 4 hours has been shown to lead to irreversible axonotmesis and 6 hours for irreversible necrosis. 7 Therefore, a timely physical examination that is monitored over time is crucial in the diagnosis of ACS, and inability to assess sensorimotor function due to PNBs that may last 8 to 18 hours eliminates these crucial data points. 8 A similar approach must be appreciated when evaluating injuries such as an acute distal radius fracture, where the development of acute carpal tunnel syndrome, which necessitates urgent carpal tunnel release, would be completely masked by PNBs. 9

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“…Furthermore, ACS causes ischemic pain, which has been demonstrated to be carried on afferent sympathetic fibers, which run separately from peripheral nerves 2 ; thus, PNBs cannot block ischemic pain. 3,4 Although there is literature linking regional anesthesia with delayed diagnosis of ACS, the cases involved used epidural anesthesia. 5-7 Using these examples as justification to avoid PNBs is inappropriate because PNBs, unlike epidurals, do not provide afferent sympathetic blockade.…”

mentioning

confidence: 99%

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment

Chembrovich

Wardhan

Smith

2022

J Am Acad Orthop Surg

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T o the Editor: Thank you for publishing this interesting work from Kandemir and Cogan. We have a few comments that we think merit additional discussion. In the section entitled Approach for Perioperative Peripheral Nerve Blocks (PNB), the authors suggested that a standardized approach to considering PNBs is important because "it also helps prevent complications associated with the inappropriate use of PNB for certain injuries," but they provided no references to support the assertion that there are injuries where the use of PNBs is inappropriate. 1 Throughout their article, there are unwritten assumptions that PNBs increase the risk of acute compartment syndrome (ACS) or missed ACS but nowhere are there any data or references to support these assumptions. Furthermore, ACS causes ischemic pain, which has been demonstrated to be carried on afferent sympathetic fibers, which run separately from peripheral nerves 2 ; thus, PNBs cannot block ischemic pain. 3,4 Although there is literature linking regional anesthesia with delayed diagnosis of ACS, the cases involved used epidural anesthesia. [5][6][7] Using these examples as justification to avoid PNBs is inappropriate because PNBs, unlike epidurals, do not provide afferent sympathetic blockade. Consequently, a large number of orthopaedic trauma patients are being denied effective analgesia and subjected instead to opioids and their associated risks based on unfounded fears. Furthermore, intravenous opioid patient-controlled analgesia is no less likely to interfere with the diagnosis of ACS. 8 In contradistinction to the framework presented by Kandemir and Cogan, our experience at the University of Florida suggests that broad application of continuous PNBs to orthopaedic trauma patients can be achieved with great safety when a culture of mutual trust and respect exists between the surgeons and the anesthesiologists. Ten years of electronic health record data from the University of Florida reveal over 8,300 patients with long bone fractures who were at high risk for ACS and fell into either the yellow or red groups described in the study by Kandemir and Cogan, all of whom were treated with PNBs. Of these, only two required fasciotomy and there were zero cases of missed ACS. These data are currently being analyzed for publication.We state with confidence that there is no convincing evidence to support the idea that PNBs mask or delay diagnosis of ACS. On the contrary, there is evidence that diagnosis of ACS is unaffected by the presence of PNBs. Breakthrough pain in the presence of PNBs is very concerning for ACS. 9-14 When ACS has been diagnosed in the presence of PNBs, it is preceded by severe, escalating pain. 15 Currently, there are no definitive guidelines on how to manage the analgesic needs of orthopaedic trauma patients. The article of Kandemir and Cogan laid out some of the advantages that PNBs have to offer, but they were also quick to

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Femoral artery block: the relationship between visceral and ischemic pain

Cited by 7 publications

References 5 publications

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

Reply to Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment

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