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The anterior combined approach via a single skin injection site allows lower limb anesthesia in supine patients

[Une méthode antérieure combinée utilisant un seul site d’injection cutanée permet l’anesthésie des membres inférieurs chez des patients en décubitus dorsal]

From the Department of Anesthesiology and Resuscitation, Erasmus Hospital, Free University of Brussels, Brussels, Belgium.

Address correspondence to: Dr. Pierre C. Pandin, Department of Anesthesiology and Resuscitation, Erasmus Hospital, route de Lennik 808, B-1070 Brussels, Belgium. Fax: 32-2-555-43-63; E-mail: ppandin{at}ulb.ac.be Department and institution of attribution of the work: Department of Anesthesiology and Resuscitation, Erasmus Hospital, Brussels, Belgium.

Purpose: Lower limb anesthesia (LLA) requires the combination of, at least, three-in-one and sciatic nerve (SCN) blocks. Anterior approaches are easier to perform with minimal discomfort in supine patients, specially for traumatology. Feasibility of a single needle entry combined approach is reported.

Clinical features: The combined landmark was applied in 119 ASA I and II patients (32–68 yr) scheduled for surgery below the knee. Needle (nerve stimulation applied through a single 150-mm long b-bevelled insulated needle) was inserted at the midpoint between the two classical approaches. Thirty and 15 mL of 0.5% ropivacaine were injected close to the femoral and the SCN, respectively. During the following 45 min, the extent of sensory block and knee and ankle motor block were assessed.

Landmarks were determined within 1.7 min (0.7–2.2 min). The entire procedure was performed within 4.2 min (2.9–7.1 min) from the determination of the landmark to the SCN infiltration. The three-in-one technique was successful in 89.9% while SCN was successful in 94.9%. Femoral and tibial nerves were always blocked. Blockade of the posterior cutaneous femoral nerve was observed in 78% of patients. The extent and the quality of the sensory block always allowed surgery. Additional iv sedation was needed in 32.6% of patients. Motor block (adapted Bromage’s scale > 2) was observed in the femoral (98.3%), the obturator (84.8%), the tibial (97.4%) and the common peroneal (85.7%) nerve distributions. No important adverse effects were recorded.

Conclusion: The anterior combined approach via a single needle entry represents a technically easy and reliable technique to perform LLA in the supine patient.

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