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Department of Anesthesiology, CTO Hospital, Rome, Italy Department of Anesthesiology, University of Parma,, Parma, Italy Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA Department of Anesthesiology, Vita-Salute University of Milano, Milan, Italy
To the Editor:
We read with great interest the review article by Liu and Salinas (1) on continuous peripheral nerve blocks. However, there are some practical issues that must be considered when choosing the best approach for catheter placement, such as patient comfort and simplicity of technique.
In particular, the authors chose the technique described by Sutherland (2) to place a gluteal sciatic catheter. After appropriate patient positioning, Sutherland inserted a first stimulating needle at the level of the midpoint between the greater trochanter and the ischial tuberosity, followed by a second insulated Tuohy needle, inserted through the gluteus muscle 5 cm proximal to the first one. Although several other approaches allow to block continuously the sciatic nerve without changing patient position (3,4), gluteal approaches may represent a useful alternative. Nonetheless, the technique described seems troublesome for both the anesthesiologist and the patient. Di Benedetto et al. (3,5) reported on a subgluteal approach, which allows to place the catheter using one single Tuohy needle inserted 4–5 cm below the greater trochanter-ischial tuberosity line (Figure 1). This technique has been demonstrated to be similarly effective, but easier and less painful to the patient as compared with a more proximal gluteal approach (probably due to the shallower depth at which the sciatic nerve is identified) (3,5–7). Although Drs. Liu and Salinas’ review has attempted to provide a very useful overview on continuous peripheral nerve blocks, anesthesiologists must be aware that the choice of the technique cannot be based only on theoretical considerations. The literature is still far from reflecting the research that is being conducted in this area of regional anesthesia.
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Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA
In Response:
We thank di Benedetto et al. for their interest in our review article (1), and specifically on the novel technique described by Sutherland for continuous sciatic perineural analgesia (2). Due to unforeseen circumstances, there was a substantial delay between delivery of the final version of the manuscript to the editorial office and publication. Otherwise, we would have certainly included their prospective, randomized trial comparing subgluteal to posterior popliteal approach for continuous sciatic analgesia in our overview (3).
We wish to also note several other studies that were published after finalization of our manuscript. Two prospective, randomized, blinded trials were published that demonstrated superior efficacy of continuous infraclavicular brachial plexus and sciatic nerve analgesia to systemic opioid-based analgesia in the ambulatory setting (4,5). An additional prospective, randomized, blinded trial demonstrated the suitability of either bupivacaine or ropivacaine for continuous axillary brachial plexus analgesia in the ambulatory setting (6). Finally, two open, randomized studies demonstrated the efficacy, pharmacokinetics, and safety of different ropivacaine infusions for continuous perineural analgesia (7,8).
Although these additional studies improve our state of knowledge, we agree with di Benedetto et al. that further well-designed clinical trials are needed to determine which surgical procedures gain benefit from continuous perineural analgesia, what are the optimal techniques/anatomic approaches for various continuous nerve blocks, and what are the optimal analgesic solutions and methods of delivery for each application.
References
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