Prolonged regional analgesia in the complex treatment of extensive purulent-necrotic wounds on the background of decompensated arterial and venous insufficiency (case report

Objective: to demonstrate the successful complex treatment of a shin circular wound in a patient with intense pain due to critical limb ischemia and wound infection, which became possible against the background of prolonged peripheral blockade.

Materials and methods. A 72-year-old patient with critical ischemia of the right lower extremity was treated for a circular purulent-necrotic wound of the shin leg from November 2016 to April 2017 at the Wounds and Wound Infections Department of FSBI “A. V. Vishnevsky NRC of Surgery” Ministry of Health of Russia. An examination revealed the impossibility of right lower limb arterial insufficiency surgical correction. The patient refused amputation of the lower limb. For the relief of pain, a long-term blockage of the sciatic nerve was used (infusion of ropivacaine 6.0–8.0 mg / hr into the perineural catheter, additional 100 mg ropivacaine boluses were used before performing traumatic daily dressings). The intensity of pain was evaluated on a visual analogue scale (VAS), sought to achieve a pain intensity of not more than 3 points at rest and not more than 4 points on – when moving.

Results. Blockade of the sciatic nerve reduced the intensity of pain from 8–10 to 0–3 points, which made it possible to continue treatment. In total, the duration of sciatic nerve catheterization at the stages of treatment was 115 days (18 + 41 + 23 + 32), the maximum duration of one of the peripheral nerve catheterizations was 41 days. Complications associated with nerve catheterization were not observed in the patient. The pain syndrome is stopped, the area of the wound defect is reduced in size. Discharged for outpatient treatment.

Conclusion. Long-term peripheral analgesia made it possible to gain time necessary for cleansing the wound surface from necrotic tissues, therapy with drugs that improve arterial blood supply to the limbs, as well as for performing reconstructive and reconstructive operations after the wound process has passed to the reparative stage. Long-term peripheral blockade is a prerequisite for the successful treatment of extensive wounds of the lower extremities caused by insufficient arterial blood supply at the stage of critical limb ischemia, accompanied by intense pain. 

1. Покровский А. В. Клиническая ангиология. М.: Медицина, 2000. 368 c. [Pokrovsky A. V. Clinical angiology = Pokrovskiy A. V. Klinicheskaya angiologiya.- M.: Meditsina, 2000. 368 s. (In Russ.)]

2. Волчков В. А., Игнатов Ю. Д., Страшнов В. И. Болевые синдромы в анестезиологии и реаниматологии. М.: Медпресс-информ. 2006. [Volchkov V. A., Ignatov Yu. D., Strashnov V. I. Pain syndromes in anesthesiology and resuscitation = Volchkov V. A., Ignatov Yu. D., Strashnov V. I. Bolevyye sindromy v anesteziologii i reanimatologii. M.: Medpress-inform, 2006. (In Russ.)]

3. Овечкин А. М. Послеоперационная боль: состояние проблемы и современные тенденции послеоперационного обезболивания. Регионарная анестезия и лечение острой боли. 2015; IX (2): 32. [Ovechkin A. M. Postoperative pain: state of the problem and current trends in postoperative pain management = Ovechkin A. M. Posleoperatsionnaya bol': sostoyaniye problemy i sovremennyye tendentsii posleoperatsionnogo obezbolivaniya. Regionarnaya anesteziya i lecheniye ostroy boli. 2015; IX (2): 32. (In Russ.)]

4. Горобец Е. С., Гаряев Р. В. Рассуждения о послеоперационном обезболивании и внедрении эпидуральной анестезии в отечественную хирургическую клинику. Регионарная анестезия и лечение острой боли. 2007; 1 (1): 42–51. [Gorobets E. S., Garyaev R. V. Reasoning about postoperative analgesia and the introduction of epidural anesthesia in a domestic surgical clinic = Gorobets Ye. S., Garyayev R. V. Rassuzhdeniya o posleoperatsionnom obezbolivanii i vnedrenii epidural'noy anestezii v otechestvennuyu khirurgicheskuyu kliniku. Regionarnaya anesteziya i lecheniye ostroy boli. 2007; 1 (1): 42–51. (In Russ.)]

5. Каменев Ю. Ф. Природа хронической боли: критерии разграничения, классификация, механизмы возникновения, диагностика. М.: Триада-Х, 2003. 44 с. [Kamenev Yu. F. The nature of chronic pain: criteria for distinguishing, classification, mechanisms of occurrence, diagnosis = Kamenev Yu. F. Priroda khronicheskoy boli: kriterii razgranicheniya, klassifikatsiya, mekhanizmy vozniknoveniya, diagnostika. M.: Triada-X, 2003. 44 s. (In Russ.)]

6. D’Amours R.H., Ferrante F.M. Postoperative pain management. J Orthop Sports Phys Ther. 1996; 24 (4): 227–236.

7. Bonica J.J.. Postoperative pain. In The management of pain. J.J. Bonica, ed.. Philadelphia: Lea and Febiger, 1990. 461–480.

8. Pavlin D.J., Chen C., Penaloza D.A., et al. Pain as a factor complicating recovery and discharge after ambulatory surgery. Anesth Analg. 2002; 95 (3): 627–634.

9. Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anaesthetists, 3rd edition. Eds.: P. Macintyre, D. Scott, S. Schug. 2010.

10. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17 (2): 131–157.

11. Каратеев А. Е., Насонов Е. Л., Яхно Н. Н. и др. Рациональное применение нестероидных противовоспалительных препаратов (НПВП) в клинической практике: клинические рекомендации. Современная ревматология. 2015; 9 (1): 4–23. [Karateev A.E., Nasonov E.L., Yakhno N.N., et al. The rational use of non-steroidal anti-inflammatory drugs (NSAIDs) in clinical practice: Clinical recommendations = Karateyev A. Ye., Nasonov Ye. L., Yakhno N. N. i dr. Ratsional'noye primeneniye nesteroidnykh protivovospalitel'nykh preparatov (NPVP) v klinicheskoy praktike: klinicheskiye rekomendatsii. Sovremennaya revmatologiya. 2015; 9 (1): 4–23. (In Russ.)]