Research Article ISSN 2639-846X

Anesthesia & Pain Research

Benefit of Ultrasound Guided Peripheral Nerve Blocks for Patients

Undergoing Femoropopliteal Bypass Surgery Concerning Postoperative
Pain and Perfusion
Mohamed H. Khafaga1*, Nagwa M. El-Kobbia1, Hossam El-Din F. Reda1, Ehsan M.H Abdelrahman2,
Moustafa Abdelaziz1 and Ahmed Osmane Qorany3
Department of Anaesthesia and Surgical Intensive Care,
1

Alexandria University, Egypt. *

Correspondence:
Mohamed H Khafaga, Department of Anaesthesia and Surgical
2
Department of Medical Biochemistry, Alexandria University, Intensive Care, Faculty of Medicine, Alexandria University, Egypt.
Egypt.
Received: 11 January 2019; Accepted: 04 February 2019
Department of vascular surgery, Alexandria University, Egypt.
3

Citation: Mohamed H. Khafaga, Nagwa M. El-Kobbia, Hossam El-Din F. Reda, et al. Benefit of Ultrasound Guided Peripheral Nerve
Blocks for Patients Undergoing Femoropopliteal Bypass Surgery Concerning Postoperative Pain and Perfusion. Anesth Pain Res. 2019;
3(1): 1-6.

ABSTRACT
Background: Anaesthesia for peripheral revascularization surgery is really challenging and the choice of the
anaesthetic technique can contribute to the postoperative outcome.

Aims: To evaluate the effect of adding peripheral nerve blocks (Femoral and Sciatic) to general anaesthesia,
as an analgesic technique, on the control of postoperative pain, reduction of surgical stress response, providing
haemodynamic stability and reducing the vasospasm in the venous graft following femoropopliteal bypass surgeries

Methods: Patients were randomly categorized into two equal groups (20 each) by closed envelope method. In the
general anaesthesia group, patients were induced with fentanyl, propofol and cisatracurium. An LMA was inserted
and anaesthesia was maintained with isoflurane (1-2%) and fentanyl infusion with a controlled ventilation. In this
group, analgesia was achieved postoperatively with nalbuphine and Ketorolac. While in the regional anaesthesia
group, 20 patients received ultrasound guided femoral nerve block and sciatic nerve block 20 minutes prior to
induction of general anaesthesia. General anesthesia was induced and maintained with the same technique as in
group 1 without the fentanyl infusion. The parameters evaluated were the postoperative heart rate, mean arterial
blood pressure, visual analogue scale at rest and movement, plasma nitric oxide and interleukin levels, total opoid
consumption, patient’s satisfaction with the pain control and blood flow through the graft. Also complications such
as nausea and vomiting were evaluated.

Results: It was found that combining ultrasound guided peripheral sciatic and femoral nerves blocks to the general
anaesthesia provided a better postoperative pain control as demonstrated by a reduction in the heart rate, mean
arterial blood pressure, visual analogue scale, total opioid consumption and pain mediators levels. It also helped
the distal blood flow to the operated limb by reducing the vasospasm of the graft. Patient satisfaction did not show
a statistical significance between the two groups.

Conclusion: It is better to combine ultrasound guided sciatic and femoral nerve blocks to general anaesthesia for
peripheral revascularization surgeries.

Introduction
Keywords Peripheral vascular revascularization (PVR) surgery is classified
Ultrasound guided Femoral and Sciatic block, Peripheral as high risk by the recent American College of Cardiology
revascularization surgery, Distal blood flow, IL-6, Niric oxide. and American Heart Association (ACC/AHA) guidelines on
preoperative assessment, with a combined incidence of cardiac
Anesth Pain Res, 2019 Volume 3 | Issue 1 | 1 of 6
death and non-fatal myocardial infarction (MI) of >5% [1]. In the 20 patients randomized to the general anaesthesia group,
anesthesia was induced using fentanyl (1µg/kg), propofol (2-2.5
Complications after surgical bypass include wound infection, mg/kg), and cisatracurium (0.15 mg/kg). A laryngeal mask airway
necrosis, tissue loss, graft occlusion, and bleeding. Independent (LMA) was inserted. Anaesthesia was maintained using isoflurane
predictors of adverse outcomes include female sex, advanced age, (1-2 % in 100% oxygen) and continuous infusion of fentanyl
diabetes mellitus, and below-knee bypass. Other complications (0.5 µg/kg/h) [10]. Controlled ventilation was maintained at a
include graft failure, wound dehiscence, sepsis, patients who rate of (10 breath/min), and a tidal volume to maintain the end-
undergo infrainguinal bypass for limb salvage often experience tidal carbon dioxide at (35 mmHg). At the end of the operation,
delayed wound healing, episodes of recurrent ischemia, and need residual muscle relaxation was reversed with atropine (0.15 mg/
for repeat operations [2,3]. kg) and neostigmine (0.04 mg/kg). In this group, analgesia was
controlled postoperatively with nalbuphine in a dose of 10 mg/70
Acute stress in the perioperative period has four major sources: kg administered intravenously every 6 hours and ketorolac in a
anxiety; pain; surgical stress response; and potential neurotoxicity dose of 30 mg intravenousely every 6 hours. A rescue dose of
of anaesthetic agents. Hence the choice of the anaesthetic nalbuphine (10 mg) was given in case of a VAS (Visual Analogue
technique helps to modulate the surgical stress response and the Scale) ≥ 4.
postoperative outcome.
Group B: Bitrunckal femoral and sciatic nerve blocks preceding
The literature has not been very clear on the issue of which type of the general anaesthesia:
anaesthesia a patient receives for infrainguinal bypass is the safest In the 20 patients randomized to the bitrunckal block, realtime
in terms of postoperative complications, including early graft ultrasound guided femoral and sciatic nerve blocks were
failure. Therefore, the type of anaesthesia used is usually at the performed 20 minutes before the induction of general anaesthesia.
discretion of the anaesthesiologist and the surgeon, and it is usually Ultrasonographic identification of the femoral and sciatic nerves
based on their experience and comfort in the administration of one was done respectively and 15 mls of Bupivacaine 0.25% were
type of anaesthesia over another [4]. injected to completely surround each nerve separately. Then,
general anaesthesia was induced and maintained with the same
The rationale behind this study, was trying to identify an anaesthetic technique as in group A without fentanyl infusion.
plan that can achieve a good control of the postoperative pain
and a good control of the surgical stress response, while in the In this group, analgesia was controlled postoperatively with
same time gaining the benefits of regional anaesthesia in terms of ketorolac in a dose of 30 mg intravenously every 6 hours. A rescue
sympatholytic effect and peripheral vasodilation, without a dramatic dose of nalbuphine (10 mg) was given in case of a VAS ≥ 4.
haemodynamic change, hence improving the postoperative limb
perfusion as proved afterwards [5]. Measurements
Vital signs: Heart rate (beats/min) and Mean arterial blood pressure
Patients and Methods (mm/Hg) were recorded immediately postoperatively, every hour
This study was carried out on 40 adult (20-80 years old) vascular for the first 4 postoperative hours then every 4 hours for the rest of
patients of both sexes and scheduled to undergo femoropopliteal the 24 postoperative hours constituting the study period.
bypass with a venous graft surgery in Vascular surgery unit at
Alexandria main University Hospital. Laboratory: Peripheral blood sample was collected from all
patients in vacutainer tubes with EDTA on ice. The blood samples
After approval of the Ethics Committee, and a written consent were centrifuged to isolate plasma was stored at -20°C till the time
from each patient, all patients were randomly allocated to one of of the assay for the measurement of [9] Plasma nitrite/nitrate and
two groups, (20 patients each), via the sealed envelope technique: (NOx) Interleukin-6 (IL-6). Samples were collected preoperatively,
• Group A: General anesthesia and postoperative nalbuphine. 6 hours postoperatively and then at 24 postoperatively.
• Group B: Bitrunckal femoral and sciatic nerve block before
the conduction of general anaesthesia. Pain assessment: Visual analogue scale during rest (VASR)
and movement (VASM) at 6 hours postoperatively and then at
The sample size was determined according to the recommendations 24 postoperatively. Also, the total dose of postoperative rescue
of the Department of the Biostatistics. Evaluation of the patients analgesia with nalbuphine (mg) was measured by the end of the 24
was carried out on the day before surgery through proper history hours of the study period. When the patient was asleep, no attempt
taking, clinical examination, routine laboratory investigations, was made to wake him or her, and the patient was considered as
ECG for patients above 40 years, X- ray chest for patients above having pain relief.
60 years, or if otherwise indicated. All patients were informed of
the procedure and were trained to use the visual analogue scale Postoperative limb perfusion: Distal blood flow in the operated
(VAS) [6-8]. limb was measured using a duplex study (measuring the flow
velocity volume through the venous graft in cc/second) at 6 hours
Group A: General anaesthesia and postoperative nalbuphine: and 24 hours postoperatively.
Anesth Pain Res, 2019 Volume 3 | Issue 1 | 2 of 6
Statistical analysis Figure 2: Comparision between the studied groups according to mean
Data was fed to the computer and analyzed using IBM SPSS arterial blood pressure.
software package version 20.0 [10]. Qualitative data was described
using number and percent. Quantitative data was described using Plasma Nitric Oxide and interleukin 6 were statistically
range (minimum and maximum), mean, standard deviation significantly less in group B compared to group A 6 hours and 24
and median. Comparison between different groups regarding hours postoperatively (Table 1).
categorical variables was tested using Chi-square test. When more
than 20% of the cells have expected count less than 5, correction for NO IL6
chi-square was conducted using Fisher’s Exact test or Monte Carlo Pre 6thhr. 24thhr. Pre 6thhr. 24thhr.
correction. The distributions of quantitative variables were tested Min. 3.00 8.00 5.50 1.60 38.00 25.80
for normality using Kolmogorov-Smirnov test, Shapiro-Wilk test Max. 17.00 31.00 22.00 1062.40 1441.80 1277.80
and D'Agstino test. If it reveals normal data distribution, parametric Group
Mean 8.91 18.14 13.70 157.81 332.32 235.31
tests were applied. If the data were abnormally distributed, A
SD. ±3.77 ±6.05 ±4.82 ±231.52 ±374.12 ±294.43
non-parametric tests were used. For normally distributed data,
comparison between two independent population were done using Median 9.20 17.45 13.80 94.40 204.70 130.60
independent t-test, comparison between different periods using Min. 2.10 3.10 2.10 0.80 4.60 4.20
ANOVA with repeated measures and Post Hoc (LSD) test was Max. 13.50 15.20 9.80 78.60 209.00 145.60
Group
assessed. For abnormally distributed data, comparison between Mean 6.61 6.83 4.81 20.02 51.91 29.47
B
two independent population were done using Mann Whitney test. SD. ±2.92 ±2.77 ±2.30 ±24.40 ±60.07 ±36.64
To compare between the different periods Wilcoxon signed ranks Median 6.80 6.00 4.00 9.50 23.60 14.90
test was applied. Significance of the obtained results was judged t 6.599 7.606 7.448 3.949* 4.301 4.653
at the 5% level.
p 0.06 <0.001* <0.001* <0.007 <0.001* <0.001*
Results Table 1: Comparison between the studied groups according to Nitric
Regarding haemodynamics namely heart rate and mean arterial Oxide (NO) (nmol/l) and Interleukin 6 (pg/ml).
blood pressure, there was no significant difference between the two
t: Student t-test; Z: Z for Mann Whitney test;
groups in the immediate postoperative period while the measures
*: Statistically significant at p ≤ 0.05.
were statistically significantly less in group B relative to group A
in the subsequent postoperative study periods (Figures 1,2). Regarding pain assessment, comparing both groups, the mean
values of the Visual analogue scale during rest (VASR) were
significantly lower in group B compared to group A immediately
postoperatively and at 2 hours postoperatively (Figure 3) while
the mean values of the Visual analogue scale during movement
(VASM) were significantly lower in group B compared to group
A immediately postoperatively and at most of the postoperative
study periods (Figure 4).

Figure 1: Comparision between the studied groups according to post-

operative heart rate.

Figure 3: Comparision between the studied groups according to VAS at

rest.

As well, postoperative rescue analgesia in the form of intravenous

nalbuphine was statistically significantly lower in group B when
compared to group A (Table 2).

Anesth Pain Res, 2019 Volume 3 | Issue 1 | 3 of 6

 Comparing both groups, although there were more patients
scoring excellent and good satisfaction in group B than group
A, statistically speaking no significant difference could be found
between the two groups (Figure 5).

Figure 4: Comparision between the studied groups according to VAS at

movement.

Total Postoperative Nalbuphine (mg)

Group A Group B
Min. 0.00 0.00
Max. 40.00 20.00 Figure 5: Comparison between the two studied groups regarding patient
Mean 21.00 6.50 satisfaction.
SD. 9.68 8.75
When comparing the two groups, more patients were found to have
Median 20.00 0.00
PONV in group A than in group B but without a true statistically
Z(p) 3.941*(<0.001*)
significant evidence. Intravenous metoclopramide (10 mg) and
Table 2: Comparison between the studied groups according to total Ondansetron (4 mg) were given as the first and second lines of
Postoperative Nalbuphine (used as a rescue) consumption in mg. treatment of vomiting respectively (Figure 6).

Z: Z for Mann Whitney test; *: Statistically significant at p ≤ 0.05.

As regards to the distal blood flow when comparing the two

groups, the distal blood flow velocity was found to be significantly
less in group B than group A at 6 hours postoperatively (P˂0.001).
In the same way, it was found to be significantly less in group B
than group A 24 hours postoperatively (P=0.007) (Table 3).

Distal flow velocity (cc/second)

6thhr. 24thhr.
Min. 80.00 50.00
Max. 220.00 180.00
Group A Mean 122.50 82.50 Figure 6: Comparison between the two studied groups according to
postoperative nausea and vomiting (PONV).
SD. ±33.23 ±29.18
Median 110.00 75.00
Discussion
Min. 70.00 50.00
The current study aimed at evaluating the role of peripheral
Max. 100.00 90.00
nerve blocks as adjuncts to general anesthesia in peripheral
Group B Mean 83.40 63.85 revascularization surgeries. Observation of the haemodynamics
SD. ±8.46 ±9.85 throughout the study showed better haemodynamic control in
Median 83.50 63.50 the peripheral nerve blocks group when compared to the control
Z 4.831 2.713 group. These results were consistent with that of a previous study
p <0.001* 0.007* done by Baddoo [11], who found that the use of peripheral nerve
Table 3: Comparison between the studied groups according to distal blocks for lower limb amputation surgeries provided a better
arterial blood flow velocity (cc/second). postoperative pain control and more stable hemodynamics in the
postoperative period. Indices looked at were the effectiveness of the
Z: Z for Mann Whitney test; *: Statistically significant at p ≤ 0.05. nerve block, cardiovascular stability (Heart rate and mean arterial
Anesth Pain Res, 2019 Volume 3 | Issue 1 | 4 of 6
blood pressure) during surgery and the duration of postoperative a better postoperative pain control.
analgesia provided by the block. Postoperative pain relief provided
by the blocks ranged from 5 hours to 30 hours. Contrary to the There has been a number of studies [16-18] in the literature
current assumption that "pain triggers a sympathetic stress concerning the vasodilatory effect of the regional anaesthesia in
response". Ledowski et al. [12], conducted a study that stormed vascular surgery patients, assuming that the sympatholytic effect of
the current believes. They obtained 239 pain readings from 84 regional anaesthesia (whether it is neuroaxial or peripheral nerve
subjects undergoing orthopedic or plastic surgery. They disproved block) would cause a distal vasodilatation and a better blood flow
the existence of a correlation between NRS (numeric rating in the graft. In the present study, when comparing the two groups,
scale) and any of the studied haemodynamic parameters: heart the distal blood flow velocity was found to be significantly less
rate (HR), respiration rate (RR), mean arterial pressure (MAP) or in group B than group A at 6 hours and 24 hours postoperatively.
cardiac autonomic parameter: heart rate variability (HRV) or even The less the blood flow velocity in a vessel the more is its caliber
catecholamine plasma levels. which most probably signifies more vasodilatation and less
postoperative vasospasm. Modig et al. [16], succeeded to prove
Findings of the present study showed better postoperative pain in their study that the distal calf blood flow was better in patients
control in the blocks group compared to the opioids analgesia who received epidural block rather than patients who received
group as evidenced by the lower pain scores in addition to lower general anaesthesia with positive pressure ventilation for total hip
postoperative opioid requirements. These findings are in agreement replacement surgery. Contrary to these results, Pierce et al. [19],
with the results of the study done by Ayling et al. [13], who found concluded in their study enrolled on vascular patients that the
that peripheral nerve blocks provided a better postoperative type of anaesthesia whether regional or general did not influence
pain control and reduced opioid requirements after major limb the overall graft patency and the rate of success of vascular
amputation surgeries. reconstruction and hence the limb salvage.

In accordance with this study, Volka et al. [14], proved in their The present study shows that femoral and sciatic nerve blocks
study that patients receiving femoral nerve blocks required less during general anaessthesia for peripheral revascularization
postoperative analgesia and showed more overall satisfaction than surgery may achieve better haemodynamic stability, less surgical
patients receiving spinal anaesthesia for long saphenous stripping stress response and better postoperative pain control relative to
operations. the classic analgesia achieved with opioids and non-steroidal anti-
inflammatory drugs alone. As well, distal blood flow through the
The level of plasma Nitrite/Nitrate in both groups was measured graft may be an important advantage of peripheral nerve blocks in
preoperatively, at 6 hours and at 24 hours postoperatively. When such procedures.
comparing the two groups, there was a significant reduction
in the mean value of the plasma nitrite/nitrate levels at 6 hours The results obtained by the present study may be limited by the
postoperatively in group B (mean =6.83) compared to group 1 short course of follow up of the graft patency.
(mean=18.14). There was also a significant reduction in the mean
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© 2019 Mohamed H. Khafaga, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

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