P012: CASE REPORT: NEUROPATHIC PAIN STATUS POST FASCIA ILIACA CATHETER PLACEMENT FOR TOTAL HIP ARTHROPLASTY.
Janaid Sheikh, DO; Larkin Community Hospital
Introduction: The FICB has become an alternative to femoral nerve and lumbar plexus block for post-operative pain management for hip and knee procedures. Large volume of local anesthetic within the fascia iliaca compartment provides analgesia to the distribution of the lateral femoral cutaneous nerve, femoral nerve, and the obturator nerve. The compartment block can provide analgesia with minimal motor loss as compared to the femoral nerve block. FICB is widely considered a safe block, however; there are no reports similar to this patient’s complication. This is a case of a patient who developed neuropathic pain within the distribution of the femoral nerve.
Description: The patient is a 53-year-old male who presented to the OR for right THA for end stage osteoarthritis of hip secondary to avascular necrosis. He has no known drug allergies and past medical history of hypertension and GERD, controlled with metoprolol, enalapril, and omeprazole. Surgical history of the patient includes right inguinal hernia repair and lumbar discectomy. Patient denies history of neuropathy post lumbar surgery. The anesthetic plan for this patient was a spinal and monitored anesthesia care with mild sedation. For postoperative pain management patient agreed to right fascia iliaca block catheter.
Identification of the spinal space confirmed via CSF from a 22 gauge cutting spinal needle. 1.2cc of 0.5% bupivacaine was administered in the spinal canal at the level of L3-L4. A propofol infusion of 20 mcg/kg/min and 2mg of midazolam was administered during the surgery. The surgery proceeded without any adverse events. After completion the patient was transported to the PACU with stable vital signs. Ultrasound guidance was used to identify the fascia iliata and fascia iliaca, just inferior to the femoral crease at the lateral one third region. Patient was comfortable and did not exhibit sensation to pin prick as spinal anesthesia was still in effect. Needle was inserted into the skin at a caudal to cephalad fashion, two pops were felt. After negative aspiration 30cc of 0.5% ropivacaine was administered and nerve block catheter was advanced without resistance. Once spinal anesthesia resolved with adequate bilateral lower extremity movement and sensation, the patient stated his pain was 0/10. Fascia iliaca compartment block (FICB) catheter was placed on a pump of 0.125% ropivacaine at 6cc per hour. POD1 the patient stated his pain WAS adequately managed, 2/10, and began physical therapy. On POD2 the patient complained of a 10/10 sharp, shooting pain on the anterior aspect of his thigh with movement. However, at rest is asymptomatic. 15 cc of 0.5% ropivacaine was bolused and he was reexamined later in the afternoon with no change in status. The catheter was subsequently removed and the patient exhibited immediate relief.
Discussion: It was speculated that the catheter was the source of pain, as it may have been in direct contact with the femoral nerve. This could have been due to improper advancement of catheter and/or anatomical deviation from previous surgery. An ultrasound at time of symptoms could have been beneficial in further understanding placement of catheter.