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LETTERS TO EDITOR
Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 536-537  

Peripheral nerve block for nonoperative room challenges – New solution to an old problem


1 Department of Anaesthesiology, People Tree Hospital, 2, Tumkur Road, Goraguntepalya, Bengaluru, Karnataka, India
2 Deparment of Anaesthesiology, Yenepoya Medical College, Mangaluru, Karnataka, India

Date of Submission01-Apr-2020
Date of Decision21-Apr-2020
Date of Acceptance30-Apr-2020
Date of Web Publication01-Jun-2020

Correspondence Address:
Dr. Rammurthy Kulkarni
Department of Anaesthesiology, People Tree Hospital, 2, Tumkur Road, Goraguntepalya, Bengaluru - 560 022, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_836_19

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How to cite this article:
Kulkarni R, Bhat SG. Peripheral nerve block for nonoperative room challenges – New solution to an old problem. Indian J Anaesth 2020;64:536-7

How to cite this URL:
Kulkarni R, Bhat SG. Peripheral nerve block for nonoperative room challenges – New solution to an old problem. Indian J Anaesth [serial online] 2020 [cited 2020 Jul 7];64:536-7. Available from: http://www.ijaweb.org/text.asp?2020/64/6/536/285540



Sir,

Magnetic resonance imaging (MRI) scan requires the patient not to move during the procedure and usually does not require anaesthesia except for few cases. We present a case of an MRI scan for a painful hip, for which we administered combined lumbar plexus block (LPB) and sacral plexus block (SPB). 52-year-old male suffering from painful right hip metastasis was scheduled for an MRI scan of the hip. Initially, MRI scan without anaesthesia was unsuccessful due to severe pain. Hence, it was rescheduled under nerve stimulator-guided LPB and SPB.

After written informed consent, the patient was shifted to the MRI holding area. The peripheral line was established and standard American Society of Anaesthesiology monitors were attached.

With the patient in the left lateral decubitus position, his lower back was cleaned with 0.5% chlorhexidine in 70% alcohol and draped. A point 4 cm lateral to the intersection of a horizontal line at the level of the highest point of the iliac crest and a vertical line along the spine was taken as the needle insertion point for LPB. Then, the block needle was inserted and advanced until it encountered the transverse process. The needle was then walked off the bone caudally and advanced for 1 cm more till the quadriceps muscle twitch was observed at a current of 0.5 mA. After negative aspiration, 25 mL of 0.25% bupivacaine was injected.

For SPB, needle insertion point was taken at 6 cm caudal to posterior superior iliac spine. The needle was advanced till the plantar flexion response of the foot was elicited at a current of 0.5 mA. After negative aspiration, 15 mL of 0.25% bupivacaine was injected. The patient had complete pain relief within 15 min, following which the MRI procedure was started which lasted for 45 min. After successfully completing the procedure, the patient was monitored for 30 min.

Usually, sedation or general anaesthesia with either supraglottic device (SGD) or endotracheal tube is preferred for procedures outside the operating room.[1] Sedation has risks such as accidental movement, losing the airway and subsequent hypoxia.[2],[3] General anaesthesia with SGD or endotracheal tube needs muscle relaxation, has a risk of hypotension with the induction agents, dislodgment of SGD and circuit disconnection as the patient is taken inside the MRI magnet.[4]

In our case, the indication for anaesthesia was severe pain. The patient was unable to lie supine for a long period and thus we opted to provide regional anaesthesia. The hip joint has major sensory innervations from femoral, obturator nerve anteriorly and from sciatic as well as superior gluteal nerve posteriorly.[5] The LPB blocks femoral and obturator nerves whereas SPB blocks sciatic as well as the superior gluteal nerves. A pure femoral nerve block can provide reasonable (but not complete) analgesia for hip pain (as in case of hip fracture)[6] but we did not choose this as we wanted complete analgesia.

Advantages of regional anaesthesia in remote locations include no need for airway intervention and the patient can be shifted out of the MRI suite immediately after the scan, unlike general anaesthesia, no adverse effects like nausea, vomiting, residual paralysis and sore throat. However, LPB should be performed with caution under expert supervision. Complications of LPB include epidural spread causing neuralgia anaesthesia, iliopsoas or renal hematoma and local anaesthetic systemic toxicity. Prolonged motor block and risk of fall are also the problems following LPB and our patient was warned about that.

Subarachnoid block (SAB) would have been technically easier and only one case of SAB for MRI scanning has been reported in the literature.[7] We did not choose SAB for this patient because of undesirable effects like hypotension, bradycardia and urinary retention.

In conclusion, peripheral nerve blocks could be considered as a reliable option when feasible for the painful limb conditions in patients undergoing MRI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has/have given his consent for his and other clinical information to be reported in the journal. The patient understand that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Maddirala S, Theagrajan A. Non-operating room anaesthesia in children. Indian J Anaesth 2019;63:754-62.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
McBrien ME, Winder J, Smyth L. Anaesthesia for magnetic resonance imaging: A survey of current practice in the UK and Ireland. Anaesthesia 2000;55:737-43.  Back to cited text no. 2
    
3.
Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: Adverse events and outcomes. Br J Anaesth 2000;84:743-8.  Back to cited text no. 3
    
4.
Swarta R, Rae WID. Anaesthesia in the MRI suite. Southern African J Anesth Analg 2018;24:90-6.  Back to cited text no. 4
    
5.
Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--an anatomical study. Surg Radiol Anat 1997;19:371-5.  Back to cited text no. 5
    
6.
Amin NH, West JA, Farmer T, Basmajian HG. Nerve blocks in the geriatric patient with hip fracture: A review of the current literature and relevant neuroanatomy. Geriatr Orthop Surg Rehabil 2017;8:268-75.  Back to cited text no. 6
    
7.
Gozal D, Gozal Y. Spinal anesthesia for magnetic resonance imaging examination. Anesthesiology 2003;99:764.  Back to cited text no. 7
    




 

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