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Canadian Journal of Anesthesia 54:952-953 (2007)
© Canadian Anesthesiologists' Society, 2007

Correspondence

Ultrasound-guided continuous sciatic nerve blocks in two children with venous malformations in the lower limb

Geert Jan van Geffen, MD, Jörgen Bruhn, MD PhD and Mathieu Gielen, MD PhD

Radboud University Nijmegen Medical Centre, Institute for Anaesthesiology, Nijmegen, The Netherlands E-mail: g.vangeffen{at}anes.umcn.nl

To the Editor:

We write to share our recent clinical experience with ultrasonographic-guided continuous sciatic nerve blocks in two children. The first was a three-year-old girl, weighing 30 kg, who had Proteus-like syndrome with serious congenital venous malformations extending from her left lower back via the buttock into the left foot. She was scheduled for a Lisfranc midfoot amputation. For postoperative analgesia an ultrasound-guided sciatic nerve block was planned. In the prone position, using a linear 7–13 MHz ultrasound probe (Sonosite Micromaxx, Bothell, WA, USA), the slightly blurred sciatic nerve surrounded by venous structures was visualized (FigureGo, panel A). Under ultrasonographic control in a long-axis view, a 4 cm insulated needle was inserted on the medial side at the distal 2/3 of the thigh. Avoiding vascular structures the needle was brought into close proximity of the nerve and 5 mL ropivacaine 0.375% was injected, which spread circumferentially around the nerve. A 20-G polyamide catheter was threaded through the needle, and the position verified by injecting 2 mL ropivacaine 0.375% under ultrasonographic control. Surgery proceeded uneventfully and no other analgesics were given. Postoperatively a perineural infusion of ropivacaine 0.2% at a rate of 1 mL·hr–1 was started for five days. During this period, no hematomas at the catheter insertion point were observed, nor did the child need additional pain relief. The parents and nurses judged the postoperative pain relief as excellent.


Figure 1
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  		FIGURE Subgluteal sciatic nerve (encircled by black line, panel A) and distal sciatic nerve in the popliteal fossa (panel B) both surrounded by multiple vascular malformations (white arrows). Lat = lateral.

 
A second child 12 yr of age, weighing 33 kg, with severe congenital venous malformations in lower back, pelvis and right leg, was scheduled for revision of an amputation stump of the lower leg. One month earlier, a lower limb amputation had been performed because of pain and asymmetrical growth. We under-took an ultrasound-guided sciatic nerve block for postoperative analgesia. The same block procedure was followed as described in the first case. On ultrasonographic visualization the vascular malformations were readily identified. The needle insertion and catheter advancement proceeded uneventfully without puncturing the vascular structures. A total dose of 8 mL ropivacaine 0.375% was injected around the nerve. Surgery was uneventful and no other analgesics were given. Postoperatively, a perineural infusion of ropivacaine 0.2% at a rate of 2-mL·hr–1 was started for five days. Again, no hematomas were observed at the catheter insertion point. Additional pain relief consisted of paracetamol orally. The verbal pain rating scores never exceeded 3, and the child, parents and nurses rated the pain relief as excellent. Unfortunately the patient subsequently developed a traumatic arteriovenous fistula in the amputation stump, which needed re-operation. The same procedure was followed as described earlier, and postoperative analgesia was again excellent.

These cases demonstrate how continuous peripheral nerve blocks may provide effective and prolonged postoperative analgesia postoperative pain relief in children.1,2 The distinguishing element of these two cases is that visible bluish venous malformations prevented the insertion of a needle at the classical insertion places for sciatic nerve block.3 Ultrasonographic guidance made it possible to visualize the sciatic nerve and avoid accidental puncturing of surrounding vascular structures. Direct observation of the spread of local anesthetic during injection through needle and catheter confirmed the correct position of both, prevented vascular injections and resulted in successful blocks. The direct visualization of the nerve and surrounding structures by ultrasonography has broadened the applications of peripheral nerve blocks for pediatric patients in whom traditional techniques would have been difficult or impossible.

Footnotes

Accepted for publication August 16, 2007.

References

1 Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005; 19: 309–21.[Medline]

2 Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005; 15: 87–90.[Medline]

3 Tobias JD. Regional anaesthesia of the lower extremety in infants and children. Paediatr Anaesth 2003; 13: 152–63.[Medline]





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