The effects of varying local anesthetic concentration and volume on continuous popliteal sciatic nerve blocks: a dual-center, randomized, controlled study

Abstract

Background: It remains unknown whether local anesthetic concentration, or simply total drug dose, is the primary determinant of continuous peripheral nerve block effects. We therefore tested the null hypothesis that providing different concentrations and rates of ropivacaine, but at equal total doses, produces comparable effects when used in a continuous sciatic nerve block in the popliteal fossa.

Methods: Preoperatively, a perineural catheter was inserted adjacent to the sciatic nerve using a posterior popliteal approach in patients undergoing moderately painful orthopedic surgery at or distal to the ankle. Postoperatively, patients were randomly assigned to receive a perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Therefore, both groups received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. The primary end point was the incidence of an insensate limb, considered undesirable, during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction.

Results: Patients given 0.2% ropivacaine (n = 25) experienced an insensate limb with a mean (sd) of 1.8 (1.8) times, compared with 0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95% confidence interval, 0.3-2.0 episodes; P = 0.009). In contrast, analgesia and satisfaction were similar in each group.

Conclusions: For continuous popliteal-sciatic nerve blocks, local anesthetic concentration and volume influence block characteristics. Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine. During continuous sciatic nerve block in the popliteal fossa, a relatively concentrated solution in smaller volume thus appears preferable.

Figure 1

Effects of popliteal sciatic perineural ropivacaine concentration on postoperative pain after moderately painful surgery at or distal to the ankle. Pain severity indicated using a numeric rating scale of 0–10, with 0 equal to no pain and 10 being the worst imaginable pain. Data are expressed as median (horizontal bar) with 25th—75th (box) and 10th—90th (whiskers) percentiles for patients randomly assigned to Group 0.2% (0.2% ropivacaine, 8 mL/h basal, 4 mL bolus) or Group 0.4% (0.4% ropivacaine, 4 mL/h basal, 2 mL bolus). Because each comparison dilutes all other P values, we restricted our analysis to four comparisons among secondary end points. P values are provided where statistical comparisons were applied.