Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.52 no.1 Campinas Jan./Feb. 2002
Prolonged regional analgesia with peripheral catheters. Case reports *
Analgesia regional prolongada con catéteres periféricos. Relato de casos
Karl Otto Geier, M.D.
Médico Colaborador da Clindor/PUCRS
BACKGROUND AND OBJECTIVES: Sympathetic
Maintenance Pain Syndrome, Obliterating Thromboangiitis, Progressive Systemic
Scleroderma (auto-immune disease) and postoperative analgesia are good responders
to prolonged local anesthetics. These reports aimed at spreading the use of
short catheters (venous catheters) or epidural catheter segments associated
to peripheral nerve stimulator in the above mentioned situations and when adequate
material (ContplexÒ and similar equipment) are
CASE REPORTS: Cases of Complex Regional Pain 1 and 2, leg ulcer by obliterating thromboangiitis in preparation to skin graft, and progressive systemic scleroderma with distal foot microcirculatory involvement are reported in which venous catheters were inserted close to the peripheral nerves of the respective territories aiming at continuously controlling pain through local anesthetic injections.
CONCLUSIONS: Based on regional anesthesia best practices and on the results obtained, all cases reported have shown that investigated catheters may replace those specially designed for the same purposes.
Key Words: ANESTHETIC TECHNIQUES, Regional:continuous; PAIN: cronic
JUSTIFICATIVA Y OBJETIVOS: Síndromes
de Dolor de Manutención Simpática, Tromboangiitis Obliterante, Esclerodermia
Sistémica Progresiva (enfermedad auto-inmune) y analgesia pós-operatoria
responden muy bien a los anestésicos locales cuando en uso prolongado El
objetivo de los casos relatados tiene por finalidad divulgar el uso de catéteres
cortos (catéteres venosos) el segmento de catéter peridural en las
situaciones arriba nombradas, en la falta de material apropiado (Contiplexâ
y similares) asociados al estimulador de nervio periférico.
RELATO DE LOS CASOS: Son relatados casos de Síndrome de Dolor Regional Complejo 1 y 2, úlcera de pierna por tromboangiitis obliterante para preparación de enjerto de piel, esclerodermia sistémica progresiva con comprometimiento microcirculatorio distal del pie, en que fueron colocados catéteres venosos contiguos a los nervios periféricos de los respectivos territorios, teniendo por finalidad el control continuo del dolor a través de inyecciones de anestésicos locales.
CONCLUSIONES: Apoyados en los principios que nortean la buena práctica de anestesia regional y en los resultados obtenidos, los casos presentados mostraron que los catéteres usados pueden substituir aquellos especialmente designados para las mismas finalidades.
Prolonged regional analgesia without systemically involving other physiological parameters resulting in hemodynamic, vascular or respiratory consequences has always been the anesthesiologist goal. Clinical situations such as: postoperative analgesia, painful dressing replacement, serial surgical reinterventions, painless physical therapy and acute and/or chronic pain sedation are common situations in hospital settings and in pain clinics. Unfortunately, due to the lack or even inexistence of compatible material and specific regional anesthesia techniques, performing most of these procedures in the above-mentioned situations was unfeasible. Alternative regional analgesia induced by repetitive punctures was uncomfortable and painful for the patient and labor-intensive for the anesthesiologist. Local long-lasting anesthetics in bolus had limited action and prolonged analgesia/anesthesia required the insertion of peripheral catheters. Basic requirements for the practice and good performance of regional anesthesia were then limited to anatomic knowledge, nervous fiber physiology, armamentarium, experience and individual skills of the anesthesiologist as to regional anesthetic techniques. However, even in the absence of optimal material, it is possible to induce blockade and continuous techniques. These reports aimed at showing that venous catheters or epidural catheter segments placed close to peripheral nerves or nervous plexus have prophylactic (phantom pain), diagnostic (somatic pain of sympathetic pain), therapeutic (postoperative analgesia) and prognostic (evolution of sympathetic maintenance pain syndromes) objectives.
Case 1 - Female patient, 28 years of age, operator of a shoe plant assembly line. In activating the machine, she suffered a total thumb luxation in the metacarpophalangeal region. Although reduced moments after, patient continued to refer continuous burning-type pain and physical inability during the following days. She was operated on aiming at articular reinforcement. The situation worsened in the postoperative period and she was referred to the Pain Department. By the time, her hand was cold, sweaty, cyanotic and with manifestations of allodynia and hyperalgesia. The diagnosis was Complex Regional Pain type 1. An 18G venous catheter was inserted in the elbow next to dermatomes and angiotomes corresponding to radial nerves and cutaneous muscle territory, aiming at sedating sympathetic activity with 8 ml of 0.25% bupivacaine, up to four times a day. Radial nerve peripheral blockade was initially obtained by puncture with a 25 x 7 needle, two centimeters above the articular cutaneous fold, laterally to the biceps tendon. With the needle in such position, an analgesic test dose was injected and analgesia was observed in few minutes. Next, the needle was replaced by a venous catheter carefully reproducing previous puncture until loss of resistance between muscle planes (approximately 2 cm from skin). Catheter was inserted and fixed, and a radiological study confirmed its correct position (Figure 1). After each anesthetic injection, vasodilation, redness and involved territory analgesia were observed. Treatment was completed with regional intravenous blockades with local anesthetics and guanethidine. Additionally, under the effect of regional block, painless physical therapy was started. After two weeks, the symptoms were considerably better.
Case 2 - Male patient, 45 years of age who suffered a traffic accident and had severe rupture of the rotator cuff of right shoulder. He was operated on and needed early physical therapy in the immediate postoperative period. Unable to perform active and passive movements of the scapulohumeral joint due to pain, he was referred to the Pain Department. After thorough evaluation, an 18G venous catheter was inserted in the scapula supraspinal fossa, next to the suprascapular nerve, aiming at shoulder active and passive painless physical therapy. 5 ml of 0.25% bupivacaine with epinephrine 1:200,000 20 minutes before physical therapy allowed for painless active movements for three days when the catheter was expelled. The treatment continued with NSAIDs and analgesics.
Case 3 - Female patient, 17 years of age, reached by a lost bullet which crossed the greater pectoral muscle and the left arm. Peripheral arterial beats were impaired. She was submitted to urgent revascularization of the subclavian artery with venous auto-graft. Less than 24 postoperative hours she referred hand and forearm continuous burning pain, hyperalgesia 8 and allodynia 8. She was initially treated with analgesics and NSAIDs, however without success. Forty-eight hours after, the Pain Department was called and diagnosed left upper limb Complex Regional Pain type 2. The patient was treated for three days with a series of intermittent blockades of the left cervicothoracic sympathetic nerve through an epidural catheter segment introduced through an 18G venous catheter previously inserted in C6-C7 at the level of the stellate ganglion. Although a short-duration pain relief, analgesia was effective, especially with regards to allodynia. When the catheter was displaced to outside at the end of the third day, procedures were replaced by intermittent brachial plexus blockades for six days through a venous catheter inserted in the interscalenic cleft. Injections of 8ml of 0.125% bupivacaine with epinephrine 1:400,000 and of 30 ml 0.25% bupivacaine with epinephrine 1:200,000 were used, respectively, for sympathetic activity sedation (stellate ganglion) and left upper limb somatic pain analgesia (brachial plexus) (Figure 3). Under brachial plexus analgesia, early physical therapy was started. Patient was discharged nine days later with marked improvement of symptoms.
Case 4 - Male patient, 54 years of age, with a huge painful leg ulcer of arteriosclerotic origin, located on the lower third of the leg, in territories enervated by internal saphenous and fibular D peripheral nerves, who had been submitted to a femoral-popliteal bypass. After surgery, an infection compromised revascularization with the need for a larger iliac-popliteal bypass, however still without good results. Two free skin grafts over the ulcer resulted in approximately 80% rejection. Right lower limb remained pale, cold, painful and swollen. Without perspective of resolution, the patient was a candidate to limb amputation. After evaluation by the Pain Department, patient was submitted to 18G venous catheters insertion next to the referred nerves. For the fibular nerve, the catheter was inserted at the level of the head of fibula and for the internal saphenous nerve, it was inserted 8 cm above the femorotibial joint by the transartorial technique. After 8 ml of 1.5% lidocaine injection in each catheter, symptoms evolved to an adequate analgesia. Continuous perfusion with low lidocaine concentrations and infusion pumps was maintained in each catheter. Six hours later the result was amazing. Left leg presented with analgesia, warm, colored and with a less ischemic ulcer. Treatment persisted for 24 hours when new grafting was performed. Catheters allowed for surgical anesthesia and postoperative analgesia. Patient was discharged the nex day and was advised to continue with the same analgesia via catheters with fractionated doses. He returned on the 7th postoperative day for evaluation. According to the surgeon, the skin graft over the ulcer presented with 70% integration.
Case 5 - Male patient, 7 years of age, accidentally reached by a gun shot on the right flank from upwards down in medial-lateral position with low abdominal penetration and exiting at the level of the lateral thigh, with total destruction of head of femur. Patient was submitted to laparotomy and then to transkeletal traction of the right lower limb with 5 kg. Pain at abdominal incision decreased after the third day, but he continued with severe pain in the coxofemoral joint which then presented with a purulent fistulous path through the bullets exit hole. Patient was under opioids. After ten days, patient was asymptomatic as to the laparotomy, however femoral pain was unbearable. The Pain Department diagnosed pain due to excessive nociception (purulent drainage). A diagnostic blockade was obtained with 5 ml of 1.5% lidocaine in the femoral nerve. After a 4-minute onset, pain decreased until total relief after 10 minutes. The 25 x 7 needle that remained in place was replaced by a 20G venous catheter reproducing the same puncture aiming at anesthetizing the whole somatic territory supplied by the femoral nerve. Intermittent blockades with 8 ml of 0.25% bupivacaine with epinephrine 1:200,000 every 6 hours during the first 24 hours and then under continuous infusion with pump resulted in surprising analgesia even during dressing replacements. Unfortunately, in the second day the catheter was expelled and had to be replaced by a new one. An epidural catheter was inserted in the same space through another venous catheter that worked as a guide, as in case 3. With the peripheral catheter it was possible to obtain surgical anesthesia for fistula debridement and postoperative analgesia. After 15 days and still under skeletal traction, the patient was better and the fistula was almost healed.
Case 6 - Female patient, 78 years of age, with associated Systemic Lupus Erithematosus and Sclerodermia, both auto-immune diseases, with the following history: 1) Raynauds syndrome symptoms on both hands, effectively treated with a series of anesthetic blocks on the cervicothoracic sympathetic chain (stellate ganglion); 2) several vascular surgeries on the right lower limb for the same reason. Recently, due to progressive circulatory problems typical of auto-immune diseases, she had her right lower limb amputated above the knee; 3) amputation of the second left foot toe due to an ulcer with hallux necrosis by distal circulatory failure. With ischemic pain on the third toe of the same foot also evolving to necrosis, patient was referred to the Pain Department. At evaluation, pain was unbearable. Treatment was started with a series of Bier blockades with local anesthetics, guanethidine and a microcirculation dilator. Then, a 20G venous catheter was inserted close to the posterior tibial nerve, in the internal malleolus aiming at analgesia and corresponding angiotome blockade. A test blockade with 6 ml of 0.25% bupivacaine resulted in total pain relief. Analgesia was maintained with infusion of the same solution every 6 hours and then under patients request. With the necrotic process limited to the third toe, there was no need to amputate the foot as previously scheduled, but only the toe. After three days, the catheter was expelled and replaced by a new venous catheter. The second catheter remained in situ for nine days and was helpful for preemptive analgesia, the surgery itself (amputation of the third toe), and postoperative and all residual ischemic pain analgesia.
Among Complex Regional Pain Syndromes classification 1,6, Complex Regional Pain 1, formerly called Reflex Sympathetic Dystrophy, corresponds to a neurological disorder caused by a nociceptive traumatic or surgical event, with clinical-pathological consequences manifested by pain and sensory abnormalities disproportional in intensity, distribution and duration 2,7. The etiologic noxious effect of case 1 was trauma. In addition, motor, autonomic, trophic and psychological dysfunctions were found which resulted in regional physical inability. Burning pain is severe and extremely uncomfortable. There are allodynia 3,8, hyperesthesia 3,8, edema, dystrophy due to rest of the affected area, lack of vasomotor and sudomotor control (hyperhidrosis or anhidrosis) of the affected area, caused by sympathetic autonomic hyperactivity, phenomena presented by the patient. Eventually, the symptoms evolved to articular rigidity or freezing with severe osteoporosis confirmed by radiological exam. It is more common on extremities, hands and fingers; also shoulders, coxofemoral joint and, sometimes, post-mastectomy pectoral region. Complex Regional Pain Syndromes are worsened after recurrent noxious events in active regions and under inadequate therapy or even no therapy whatosever. Diagnosis is confirmed by history and clinical evaluation being relevant a traumatic or noxious event. In case 1, allodynia would appear after a mere blow (aeolic allodynia) on the involved areas (dermatomes). Treatment consists of trunk and regional intravenous analgesia 4,5,9,10, respectively, with local anesthetics and local anesthetics/guanethidine, sympathetic hyperactivity sedation and early painless physical therapy (passive and active) under analgesia. This was our approach for the patient. Clinical history and physical evaluation associated to peripheral regional anesthetic blocks leads, very precisely, to the diagnosis 5,10. The repetition of the same blockades via catheter (Figure 1) influences therapy and prognosis. The rotator cuff receives major enervation from the suprascapular nerve (C4-C6). It is a joint tendon made up of supra and infraspinous rotating muscles, small, round and subscapular, constituting the caul of the scapulofemoral joint 6,11. Stretching injuries, traumas with complete or incomplete injury resulting in inflammation, fibrosis or cartilaginous degeneration of the glenohumeral joint are important etiologies affecting the rotator cuff. The trauma involving Case 2 patient is the major cause of hypovascularization due to constant compression involving the greater tuberosity and anterior and inferior portions of the acromium over the insertion of the supraspinous muscle and impairing its nutrition. Another major cause is the primary subacromial impact with rotator cuff degeneration, the conflict area of which is located at the insertion of the supraspinous muscle and the long biceps head. The constant attrition of those muscles against the acromial arch results in circulatory involvement and rotator cuff degeneration 7,12. When the rupture is confirmed, surgery is in general indicated, early followed by physical therapy. Physical therapy is important because with the early movement of scapulohumeral joint, the frozen shoulder is prevented. Rotator cuff analgesia may be attained by interscalenic brachial plexus block, anterior 8,13, posterior 9,14 or intra-articular 10,15 suprascapular nerve block. Depending on local anesthetics mass and concentration, the first option has the inconvenient of mildly or moderately blocking the whole superior limb, resulting in the inability for active movements or in insufficient analgesia during physical therapy. Suprascapular nerve block is the second effective alternative. In our hospital, the treatment of pain resulting from fractures isolated or not from the scapula, consists of continuous suprascapular nerve block with the patient in the sitting position, although the supine position being also described for the same disease 11,16. Satisfactory results of continuous suprascapular nerve block in other situations, such as postoperative analgesia 10,15 and shoulder oncologic pain 12,17, have broadened such blockade indications.
Patient was approached posteriorly, with a normal 25 x 7 needle until supraspinal fossa paresthesia was obtained. This technique has been used for other diseases 13,18, however with a modified position 14,19. With the needle in place, a therapeutic test was performed with 3 ml of 0.25% bupivacaine. After confirming analgesia, the needle was removed and puncture was reproduced with a 20G venous catheter introduced until the scapula was touched. First blockades were performed with patients in the sitting position and the access to the spinal fossa was vertical (Figure 2); currently, however, it is performed horizontally. With the catheter in place, the external segment is fixed with adhesive tape and protected with gauze. Analgesic 0.25% bupivacaine doses (5 ml every 6 hours) provided for patients recovery.
Duly oriented, patient and physical therapist performed, in the office and at home, painless physical therapy under bupivacaine for three days while the catheter remained in place. After seven days the patient was virtually asymptomatic.
As in Case 3, Complex Regional Pain Syndromes also involve Complex Regional Pain Syndrome 2, formerly called causalgia 1,6, which has a traumatic or surgical event as the underlying cause, however associated to neural injury. Most important algic manifestations are dysesthesias 3,8 (acute pain in twinges along the injured neural tissue) and allodynia. Similarly to Complex Regional Pain Syndrome 1, diagnosis is attained by clinical history and physical evaluation. Since our intention was to separate pain type and intensity (somatic pain from sympathetic autonomic pain) 15,20, we started with repetitive stellate ganglion blockades via catheter and not with successive punctures. Then, an epidural catheter segment was inserted via previously positioned venous catheter, which acted as a guide for the former catheter. Venous catheter removal was similar to the epidural space catheterization technique. A prolonged stellate ganglion sympathetic activity sedation had been obtained in previous situations 16,17,21,22. With low intermittent or continuous local anesthetic concentrations under PCA 17,22, sympathetic maintenance pain becomes more controlled. However, the short stay of the catheters in situ, probably due to unfavorable anatomic region, constant cervical movement and catheter fixation with adhesive tape made unfeasible a prolonged treatment. For this reason, we continued with the interscalenic treatment (Figure 3) with an 18G venous catheter inserted differently from the approach (needle direction) and the technique (loss of resistance) preconized by Winnie 18,23, which is a routine in our hospital. Patient was discharged after nine days and continued with outpatient therapeutic treatment.
Obliterating arteriosclerosis is the most common arterial disease of the inferior abdominal aorta, the iliac artery and its lower limb branches. Plates and thrombosis are particularly frequent in the femoral artery at the adductors channel level (Hunter channel) 19,24 and in the popliteal artery in the lower knee 20,25. As a consequence of circulatory involvement, patients present intermittent claudication and ischemic ulcers in the most distal parts of the limb, such as lower third of the leg, ankles and toes, with a seemingly spontaneous etiology, although trauma being relevant. Treatment consists in improving circulatory perfusion by surgical methods such as thromboendarterectomy, arterial bypass, arterial graft, by pharmacological methods by blocking the neuraxis or by peripheral blocks with local anesthetics 21,26 or neurolitic agents (phenol) on the lumbar sympathetic chain 22,23,27,28. In Case 4, we decided for simple vasodilating procedures, such as continuous anesthetic blocks of the angiotomes of involved nerves somatic territories 24,29. Venous catheter insertion at the fibular head level (superficial fibular nerve) and in the distal medial face of the thigh (internal saphenous nerve) 25,30 were performed by anatomical approaches and by the loss of resistance technique. After radiological confirmation (Figure 4 and Figure 5), catheters were connected to infusion pumps.
Case 5 presented with a traumatic event where the use of local anesthetics has a precise indication. The replacement of opioids by anesthetic solutions is relevant in pediatrics because it prevents secondary effects of opioids, especially intestinal and vesical smooth muscles palsy, very uncomfortable for patients forced to stay in bed for long periods. This was the situation in Case 5, under opioid therapy. Moreover, surgical stress markers, when general anesthesia is compared to regional pediatric anesthesia 26,31, were favorable to the latter, positively influencing healing and postoperative recovery. The radiological exam associated to physical evaluation has shown that pain was caused by excessive nociception with indication for local anesthetics. To evaluate whether the femoral nerve anesthetic block would relieve pain, a test block was induced, similarly to Cases 2 and 3. Continuous infusion with an anesthetic booster (Figure 6) allowed for the replacement of painful dressings and serial surgical reinterventions in the fistula.
The femoral nerve enervates the head of femur (sclerotome) and the anterior face of the thigh (dermatome). Paravascular femoral blocks 27,32 resulted in blockade 2:1 (femoral nerve and cutaneous femorolateral nerve) due to failure of obturator nerve anesthesia, which may be obtained when using: 1) long catheters and the same approach 28,29,33,34, 2) higher anesthetic volumes, or 3) Dalens approach 30,35. In spite of the immobilization provided by the transkeletal traction of the right lower limb, venous catheters (short) fixed with adhesives on the inguinal region tend to displace to outside. Since this was the case with the patient, we decided for an epidural catheter inserted approximately ten centimeters from the same site through another venous catheter acting as a guide. Then, it was fixed with adhesive as a sandwich 1, although Rajs star method is also recommended 15,20.
Lupus, dermatomyositis and scleroderma 31,36 are autoimmune diseases. Case 6 patient presented with Progressive Systemic Scleroderma with Raynauds vascular manifestations on the four limbs. Due to total circulatory involvement of the left lower limb, the foot became extremely painful. After identifying the adequate angiotome 23,28, prolonged anesthesia of the posterior tibial nerve with intermittent bupivacaine doses via catheter was induced (Figure 7). Some days later, ischemia with early necrosis was restricted to the third toe, which was amputated. The venous catheter has provided effective preemptive, surgical and postoperative analgesia.
The knowledge of the diseases, of both superficial and deep anatomy, of local anesthetics pharmacokinetics and pharmacodynamics and of peripheral anesthetic techniques; the awareness of the complications and the good results shown by short (venous) catheters and epidural catheter segments allow for a safe and good continuous regional anesthesia.
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to Submitted for publication February 16, 2001 *
Received from Serviço de Dor do Hospital São Lucas da Pontifícia
Universidade Católica do Rio Grande do Sul, RS
Dr. Karl Otto Geier
Rua Cel. Camisão, 172
90540-030 Porto Alegre, RS
Accepted for publication July 23, 2001
Submitted for publication February 16, 2001
* Received from Serviço de Dor do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, RS