Experience in the use of prolonged analgesic peripheral nerve blocks as part of multimodal analgesia regimens in the treatment of patients with gunshot wounds of the limbs

Abstract

The use of regional analgesic techniques as part of multimodal analgesia regimens provides better control of acute pain. Effective anesthesia is one of the key tasks in the treatment of the wounded at all stages of medical care. Three clinical cases of the use of prolonged regional analgesic blockades as part of a multimodal analgesia regimen in the treatment of patients with gunshot wounds of the extremities are presented. Catheterizations of the perineural space of the peripheral nerves were performed using ultrasound imaging. Clinical case 1 - a patient with a gunshot shrapnel through wound of the left tibia with gunshot comminuted fractures of both bones of the lower third of the left tibia and the upper third of the fibula of the left tibia, was admitted two days after the injury. Performed catheterization of the perineural space of the left sciatic nerve in the popliteal fossa, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. A satisfactory analgesic effect was observed, narcotic analgesics were not prescribed. Clinical case 2 - a patient with a gunshot shrapnel through wound of the left shoulder with a gunshot comminuted fracture of the left humerus in the middle third and with damage to the neurovascular bundle, was admitted more than 6 weeks after the injury. Performed catheterization of the perineural space of the left brachial plexus interscalene access, continuous infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. However, in the absence of complaints of soreness at the fracture sites and postoperative wounds, the patient began to be disturbed by neuropathic pain.Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed. On the second day of observation, dislocation of the catheter was detected.Considering that the patient was more concerned about pain in the distal part of the limb, catheterization of the perineural space of the left brachial plexus was performed by supraclavicular access, and a constant infusion of 0.25 % bupivacaine solution was started at a rate of 5 ml per hour using a perfusor. Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed. Clinical case 3 - a patient with a gunshot shrapnel through wound of the left thigh with a gunshot comminuted fracture of the left femur in the lower third and with damage to the popliteal artery, was admitted three weeks after the injury. Performed paravertebral catheterization of the left lumbar plexus, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. In combination with oral analgesic adjuvants (effect on neuropathic pain), a satisfactory analgesic effect was observed without the prescription of narcotic analgesics.After repeated surgical treatment with the installation of the VAC-system on the posterior surface of the thigh, an unsatisfactory effect of non-opiate analgesia was observed, and narcotic analgesics were additionally prescribed.

Keywords

• gunshot wound
• regional anesthesia