A 50-year-old man, 68 kg of weight and 165 cm of height, whose pathological history highlights long-standing diabetes mellitus not dependent on insulin and heavy smoker.
Among the surgical antecedents left femoropopliteal bypass stood out 6 months ago, which 1 month later suffered thrombosis of the anastomosis, which was treated with thrombectomy plus angioplasty and stent placement in the anastomosis.
One month later, she developed a new episode of subacute arterial ischemia that required thrombectomy under general anesthesia, with good postoperative outcome.
Later, she developed an episode of acute arterial ischemia, underwent a thrombectomy, with very poor post-operative evolution. A left supracondylar infusion of ropivacaine 0.15% continuous epidural infusion was indicated for continuous epidural catheter 0.15%.
In the first 12 postoperative patients presented mild pain at rest, but from this moment on there was a progressive increase of pain in mixed characteristics (rest, unbearable limb, phantom limb, phantom limb pain), which
At this time, pain was assessed with an intensity of 100 on a verbal numerical scale from 0 to 100.
Epidural analgesia ineffective was associated with intravenous analgesia with metamizole and chloride ̄, which did not improve patient pain.
Twenty-four hours later, accidental removal of the epidural catheter was observed, which led to the initiation of an intravenous chloride infusion into a PCA pump, which was also ineffective for pain control.
Acquisition of the situation and persistence of pain assessed as unbearable (verbal numerical scale [VNS] = 100), continuous sciatic nerve block was performed with stimulator catheter guided by ultrasound prior verbal informed consent.
With the patient in right lateral decubitus and the left hip slightly flexed, the sciatic nerve was proceeded to subglottic level with a 3-10 MHz linear ultrasound probe. Sono exploration® Titan scanner
Previously prepared the material and the area to be explored in sterile conditions, the probe was placed at the subglottis level and the sciatic nodule was explored proximal to distal, with a rounded diameter of approximately 1.5 cm distal to the fold.
Then, maintaining the catheter in this position, a subcutaneous instillation with 2% lidocaine 2 ml was performed at the midpoint of the probe's transverse axis.
A neurostimulation needle measuring 19.5G × 100 m was placed at this point and its advancement towards the sciatic nerve was visualized.
When the contact of the needle with the sciatic nerve was observed, its advancement was achieved and a HNS 11 neurostimulation device (Braun Medicals®) was connected, with a 0.3 m contraction in the posterior musculature.
An initial dose of 20 ml of 0.75% ropivacaine was then administered through the needle for 2 min, observing at all times the diffusion of local anesthetic around the nerve.
At the end of this dose, pain intensity decreased to 30.
Then, a 20G × 50 cm (Stimulong Plus 100mm, Pajunk®) stimulator catheter connected to the same motor stimulus was observed without direct ultrasound guidance.
The catheter was placed 5 cm distal to the tip of the needle and fixed in this position.
Subsequently, a second dose of 10 ml of 0.75% ropivacaine was administered through the catheter for 1 min, visualizing the diffusion of local anesthetic.
At the end of this dose, pain intensity decreased to 20.
At this time, a 0.2% ropivacaine PCA pump was connected to the catheter at a basal infusion rate of 5 ml/h, with the possibility of boluses of 10 ml every 30 min. Additionally, a multimodal rescue analgesic tramadol gum was administered.
Analgesia was assessed at rest as well as with movement of the amputated limb at 8, 16, 24, 36, 48 and 72 h after placement of the catheter in a VNS from 0 to 100 at rest.
During the first 72 h after catheter placement, the patient received stump dressings that were well managed and did not require additional analgesia.
During the time the catheter was maintained, the patient did not present any adverse effect attributable to the analgesic regimen, experienced a high degree of satisfaction with the analgesic treatment.
At 72 h the catheter was removed without incidents.
