Increased electrical nerve stimulation threshold of the sciatic nerve in patients with diabetic foot gangrene

Keyl, Cornelius; Held, Tanja; Albiez, Georg; Schmack, Astrid; Wiesenack, Christoph

doi:10.1097/eja.0b013e328360bd85

Cited by 18 publications

(16 citation statements)

References 44 publications

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“… 4 In patients with diabetic gangrene, stimulation thresholds were increased seven-fold compared with non-diabetic controls, again with substantial interindividual variability among diabetic patients. 9 Our findings similarly indicate that the nerve stimulation threshold in diabetic neuropathy is increased, and we confirm the large interindividual variability. In our diabetic patients, we observed a direct correlation between the duration of diabetes mellitus and the stimulation threshold for the CPN, the nerve that is typically more affected by diabetic neuropathy than the TN.…”

Section: Discussionsupporting

confidence: 85%

“…Reports have shown increased stimulation thresholds for diabetic patients, including patients in which no motor response to PNS could be obtained with 2.4 mA, despite clear needle-nerve contact witnessed by ultrasound (US). 4 9 Animal data also suggest that low-threshold electrical stimulation does not protect against intraneural injection in the presence of diabetes mellitus. 10 Although nerve injury is usually followed by recovery, it remains a major concern 11 and harm can best be avoided by an approach whereby the needle does not enter the nerve.…”

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confidence: 99%

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Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block

Heschl

Hallmann

Zilke

et al. 2016

British Journal of Anaesthesia

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BackgroundPeripheral nerve stimulation is commonly used for nerve localization in regional anaesthesia, but recommended stimulation currents of 0.3–0.5 mA do not reliably produce motor activity in the absence of intraneural needle placement. As this may be particularly true in patients with diabetic neuropathy, we examined the stimulation threshold in patients with and without diabetes.MethodsPreoperative evaluation included a neurological exam and electroneurography. During ultrasound-guided popliteal sciatic nerve block, we measured the current required to produce motor activity for the tibial and common peroneal nerve in diabetic and non-diabetic patients. Proximity to the nerve was evaluated post-hoc using ultrasound imaging.ResultsAverage stimulation currents did not differ between diabetic (n=55) and non-diabetic patients (n=52). Although the planned number of patients was not reached, the power goal for the mean stimulation current was met. Subjects with diminished pressure perception showed increased thresholds for the common peroneal nerve (median 1.30 vs. 0.57 mA in subjects with normal perception, P=0.042), as did subjects with decreased pain sensation (1.60 vs. 0.50 mA in subjects with normal sensation, P=0.038). Slowed ulnar nerve conduction velocity predicted elevated mean stimulation current (r=−0.35, P=0.002). Finally, 15 diabetic patients required more than 0.5 mA to evoke a motor response, despite intraneural needle placement (n=4), or required currents ≥2 mA despite needle-nerve contact, vs three such patients (1 intraneural, 2 with ≥2 mA) among non-diabetic patients (P=0.003).ConclusionsThese findings suggest that stimulation thresholds of 0.3–0.5 mA may not reliably determine close needle-nerve contact during popliteal sciatic nerve block, particularly in patients with diabetic neuropathy.Clinical trial registrationNCT01488474

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Section: Discussionsupporting

confidence: 85%

mentioning

confidence: 99%

Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block

Heschl

Hallmann

Zilke

et al. 2016

British Journal of Anaesthesia

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“…This prospective cohort study suggests that type‐2 diabetic patients suffering from DPN experienced a longer median time to first opioid request of more than 150%, a 50% shorter onset time for sensory and motor blockades and decreased pain scores at 24 postoperative hours. Although other authors have demonstrated an increase in minimal stimulating current during peripheral nerve blockade in diabetic patients , we were unable to replicate these results, possibly due to potential type‐2 error. Indeed, a post‐hoc analysis suggested that at least 72 patients should have been included to detect a significant difference of the same amplitude in this outcome.…”

Section: Discussionmentioning

confidence: 58%

Comparison of peripheral nerve blockade characteristics between non‐diabetic patients and patients suffering from diabetic neuropathy: a prospective cohort study

et al. 2018

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Animal data have demonstrated increased block duration after local anaesthetic injections in diabetic rat models. Whether the same is true in humans is currently undefined. We, therefore, undertook this prospective cohort study to test the hypothesis that type-2 diabetic patients suffering from diabetic peripheral neuropathy would have increased block duration after ultrasound-guided popliteal sciatic nerve block when compared with patients without neuropathy. Thirty-three type-2 diabetic patients with neuropathy and 23 non-diabetic control patients, scheduled for fore-foot surgery, were included prospectively. All patients received an ultrasound-guided popliteal sciatic nerve block with a 30 ml 1:1 mixture of lidocaine 1% and bupivacaine 0.5%. The primary outcome was time to first opioid request after block procedure. Secondary outcomes included the time to onset of sensory blockade, and pain score at rest on postoperative day 1 (numeric rating scale 0-10). These outcomes were analysed using an accelerated failure time regression model. Patients in the diabetic peripheral neuropathy group had significantly prolonged median (IQR [range]) time to first opioid request (diabetic peripheral neuropathy group 1440 (IQR 1140-1440 [180-1440]) min vs. control group 710 (IQR 420-1200 [150-1440] min, p = 0.0004). Diabetic peripheral neuropathy patients had a time ratio of 1.57 (95%CI 1.10-2.23, p < 0.01), experienced a 59% shorter time to onset of sensory blockade (median time ratio 0.41 (95%CI 0.28-0.59), p < 0.0001) and had lower median (IQR [range]) pain scores at rest on postoperative day 1 (diabetic peripheral neuropathy group 0 (IQR 0-1 [0-5]) vs. control group 3 (IQR 0-5 [0-9]), p = 0.001). In conclusion, after an ultrasound-guided popliteal sciatic nerve block, patients with diabetic peripheral neuropathy demonstrated reduced time to onset of sensory blockade, with increased time to first opioid request when compared with patients without neuropathy.

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“…Keyl et al compared diabetic patients scheduled for surgical treatment of diabetic foot gangrene and nondiabetic patients undergoing orthopedic foot or ankle surgery. 19 They observed that the geometric mean of the motor stimulation threshold of diabetic patients during popliteal nerve block was 1.9 (95% confidence interval [CI], 1.6-2.2), compared to 0.26 (95% CI, 0.-24-0.28) of non-diabetic patients, indicating an increase by a factor of 7.2. Bigeleisen et al showed that the median stimulation threshold of diabetic patients undergoing supraclavicular brachial plexus blockade was 1.3 mA, while that of non-diabetic patients was 0.5 mA.…”

Section: Diabetes Mellitus and Electrical Stimulation Thresholdmentioning

confidence: 99%

<p>Diabetic Peripheral Neuropathy Increases Electrical Stimulation Threshold of Sciatic Nerve: A Prospective Parallel Cohort Study</p>

Zhang¹,

Chen²,

Dai³

et al. 2020

DMSO

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Increased electrical nerve stimulation threshold of the sciatic nerve in patients with diabetic foot gangrene

Abstract: The electrical stimulation threshold for a motor response of the sciatic nerve is increased by a factor of 7.2 in patients with diabetic foot gangrene, which might hamper nerve identification.

Cited by 18 publications

References 44 publications

Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block

Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block

Comparison of peripheral nerve blockade characteristics between non‐diabetic patients and patients suffering from diabetic neuropathy: a prospective cohort study

<p>Diabetic Peripheral Neuropathy Increases Electrical Stimulation Threshold of Sciatic Nerve: A Prospective Parallel Cohort Study</p>

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