I just did a unilateral BKA the other day on a 80 kg middle-aged guy with chronic venous stasis wounds from prior DVT and associated chronic pain of the lower extremity.
For blocks I did a ss femoral with 20 mL Bupi 0.5% and then an infragluteal (about mid-thigh) sciatic catheter in which I dosed 25 mL Bupi 0.5% both placed pre-induction. Easy blocks with great anatomy and good spread of local everywhere.
Induction with 50 mg ketamine, 2 mg versed, 100 mcg fentanyl, propofol then LMA. Train track vitals through the procedure, RR 14 the entire time except occasional transient increases in RR while sewing the stump closed at the end for which I gave 1 mg dilaudid maybe 30 mins after tourniquet had come down. Total tourniquet time 20 mins.
In PACU the guy was screaming and swinging wildly, trying to climb out of bed, and terrified by his leg. He then continued to cry out in pain and got a couple mg hydromorphone and maybe 150 mcg fentanyl. He calmed down but continued to claim 8/10 of pain "where they cut off my leg." We started a bupi 0.25% infusion @ 6 mL/hr for the sciatic catheter.
He at baseline has been a difficult individual with chronic pain problems and continues to ask for all the narcs on the floor by POD1. but still I am kind of perplexed: How does he have any pain with these blocks? I mean, they were high, and the amputation was mid tib/fib.
Any insights? Would anyone do anything differently?
For blocks I did a ss femoral with 20 mL Bupi 0.5% and then an infragluteal (about mid-thigh) sciatic catheter in which I dosed 25 mL Bupi 0.5% both placed pre-induction. Easy blocks with great anatomy and good spread of local everywhere.
Induction with 50 mg ketamine, 2 mg versed, 100 mcg fentanyl, propofol then LMA. Train track vitals through the procedure, RR 14 the entire time except occasional transient increases in RR while sewing the stump closed at the end for which I gave 1 mg dilaudid maybe 30 mins after tourniquet had come down. Total tourniquet time 20 mins.
In PACU the guy was screaming and swinging wildly, trying to climb out of bed, and terrified by his leg. He then continued to cry out in pain and got a couple mg hydromorphone and maybe 150 mcg fentanyl. He calmed down but continued to claim 8/10 of pain "where they cut off my leg." We started a bupi 0.25% infusion @ 6 mL/hr for the sciatic catheter.
He at baseline has been a difficult individual with chronic pain problems and continues to ask for all the narcs on the floor by POD1. but still I am kind of perplexed: How does he have any pain with these blocks? I mean, they were high, and the amputation was mid tib/fib.
Any insights? Would anyone do anything differently?
