Comments a recent paper
about the new 1 penetration/dual injection block for leg & foot
Borglum et al has described a new approach to block the saphenous and sciatic nerve with a single penetration and two injections in the proximal thigh.
They compared the SPEDI technique, as they call it, with sciatic nerve block at popliteal level and saphenous nerve block in the adductor canal in patients undergoing leg and foot surgery.
I read with really interest this paper as in the same way the authors explained, I found the popliteal sciatic approach required an elevation of the leg exposing the popliteal fossa or even placing the patient in a lateral or prone position, both being considered painful or inconvenient for a leg, ankle or foot fracture. Therefore, in those cases I am used to perform the sciatic anterior approach and a saphenous nerve block at the level of the midthigh, and I found this technique could be a good alternative to my clinical practice.
Some comments regarding the methods, analising the positioning time, they considered to remove the plaster and bandages as part of it, but most of the patients undergoing a leg and foot surgery it is covered just the leg, and you will be able to perform the popliteal block without removing them.
They described as a single penetration but sometimes I found I am not able to reach the sciatic nerve when I am visualising the saphenous nerve just redirecting the needle, as the femur bone does not allow me to aim it in a proper way and my needle appears too medial to sciatic nerve. I have noticed I need more volume of local anaesthetic to provide an effective block. Otherwise if I perform two penetrations I found it really easy and fast too, taking into account the patient is under general anasthesia I do not find a clear benefit of performing one penetration instead of two. Anyway I consider it is a very good option and faster that the sciatic anterior approach plus the adductor canal block, as I do not need to change the probe from convex to linear.
As they explained it, two anaesthetist perform all the blocks, because they were familiar with both block combinations, and their results may not be representative in all departments. Saphenous nerve visibility and its identification could be more difficult with the convex probe than with the linear one in the adductor canal, as the same way the sciatic nerve block in its anterior approach compared with the popliteal level. Nevertheless for a well experienced regional anaesthetist, that will not mean any challenge, but a very good option. In summary this approach should be considered as an alternative technique for leg and foot surgery.
Becoming an expert...
Consultant Anaesthetist. St George´s Hospital. London. UK
Wide experience in ultrasound guided regional blocks.
Coauthor of 2 books regarding US regional blocks, 7 chapters of books, 28 papers in British, American, Spanish and Portuguese journals.
Director of the online course www.cursoanestesia.es, 2012-2014, accredited with 65 CFC or 650 CPD equivalent.
Editor and co-author of the Advances and Controversies in Anesthesiology and Pain Medicine. Global Opinions
Member of the Core Commitee of LSORA (London Society of Regional Anaesthesia).
Chairman of the 57ª Annual Meeting of the Spanish Andaluza-Extremeña Society of Anaesthesia, in 2012.
Commitee member of the 58º Annual Meeting of the Spanish Andaluza-Extremeña Society of Anaesthesia in 2013.
Director of the I and II course of Ecoanatomy, 2011 and 2012.
Faculty member, demostrator and lecturing in 15 national and international courses, workshops and congresses.
Interview with the expert
1- In this moment you are known in several countries (and different continents!) like an expert in ultrasound-guided regional anesthesia, but you began your international career in this area without an ultrasound machine... How is that possible?
It was simple, I listened the first lecture about ultrasound (US) guided blocks and I knew I wanted to learn it, regarding if I had a scanner or not it was secondary, “I will manage it…” I thought. At this time I was really keen on regional anaesthesia blocks, but I was perfoming with neurostimulation, and I found the US technique as an accurate, precise, smart and elegant one. And fortunately Dr. Rafael Blanco let me to perform a clinical attachment with him, in London.
When I went back to Spain I explained to my clinical director I need an US machine, which answer was “go and talk with the chief executive”, and for my surprise he agreed to get one. Several months passed and there was no scanner, therefore I decided to buy one on myself. Two or three months later, the US machine arrived the anaesthetic department. I must say I am really satisfied with this purchase, and I continue using at home, not every day, but every week.
2- You talk about a "one puncture- double injection block". I know you worked a lot in the PECS block (and its brother, the Serratus block). Have the PECS 2 turned into a one puncture- double injection block?
I am glad you ask me this question because some people don´t understand about the two injections of Pecs II. Pecs I block consists in one injection, between pectoralis major and minor muscles. Pecs II block consists in two injections, one is between pecs major and minor and the other one is between pecs minor and serratus anterior muscles. And you could perform with just one penetration, or with two penetrations. We try to make things easier and simple, but it is up to you, your scanner view, your confidence, patient issues (awake or sleep, level of anxiety…).
3- Something to relax: You are a Faculty in a lot of Ultrasound-guided Regional Anesthesia courses in Europe, America... Share with the readers a great moment in those courses: funny, special,... up to you.
Special moment I could say, it happened last month, the president of the General Medical Council in Mexico was explaining how he was kidnapped by a band during eight hours, on his way home after being called from the hospital to attend a patient. He did not have any identification to prove he was a doctor, fortunately it was just several hours and he was not injured. But I realized how lucky we are the one who can live in a relative safe country. And when we are called in the middle of the night our thought never is “will I be kidnapped?”
Now I have to tell you something funny, it took place in Bristol five years ago, when I was a trainee. I was sitting having breakfast with Dr. Barry Nicholls, and others national and international recognition faculty members of the course he was running, even more it was the first time I met all of them. I stood up to take a croissant and I had the “good” idea to introduce it in the toaster, and of course… it was blocked! When the smoke flooded the place, the waiters appeared… and you could imagine the rest of the history… I must say I continue in touch and get on well with everyone!!
TERESA PARRAS MD
St George´s Hospital.