Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block

S Heschl, B Hallmann, T Zilke, G Gemes, M Schoerghuber, M Auer-Grumbach, F Quehenberger, P Lirk, Q Hogan, M Rigaud, S Heschl, B Hallmann, T Zilke, G Gemes, M Schoerghuber, M Auer-Grumbach, F Quehenberger, P Lirk, Q Hogan, M Rigaud

Abstract

Background: Peripheral nerve stimulation is commonly used for nerve localization in regional anaesthesia, but recommended stimulation currents of 0.3-0.5 mA do not reliably produce motor activity in the absence of intraneural needle placement. As this may be particularly true in patients with diabetic neuropathy, we examined the stimulation threshold in patients with and without diabetes.

Methods: Preoperative evaluation included a neurological exam and electroneurography. During ultrasound-guided popliteal sciatic nerve block, we measured the current required to produce motor activity for the tibial and common peroneal nerve in diabetic and non-diabetic patients. Proximity to the nerve was evaluated post-hoc using ultrasound imaging.

Results: Average stimulation currents did not differ between diabetic (n=55) and non-diabetic patients (n=52). Although the planned number of patients was not reached, the power goal for the mean stimulation current was met. Subjects with diminished pressure perception showed increased thresholds for the common peroneal nerve (median 1.30 vs. 0.57 mA in subjects with normal perception, P=0.042), as did subjects with decreased pain sensation (1.60 vs. 0.50 mA in subjects with normal sensation, P=0.038). Slowed ulnar nerve conduction velocity predicted elevated mean stimulation current (r=-0.35, P=0.002). Finally, 15 diabetic patients required more than 0.5 mA to evoke a motor response, despite intraneural needle placement (n=4), or required currents ≥2 mA despite needle-nerve contact, vs three such patients (1 intraneural, 2 with ≥2 mA) among non-diabetic patients (P=0.003).

Conclusions: These findings suggest that stimulation thresholds of 0.3-0.5 mA may not reliably determine close needle-nerve contact during popliteal sciatic nerve block, particularly in patients with diabetic neuropathy.

Clinical trial registration: NCT01488474.

Keywords: diabetic neuropathies; nerve block; peroneal nerve; tibial nerve.

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Figures

Fig 1
Fig 1
Needle position for measurement of the stimulation threshold at the common peroneal nerve (a) and the tibial nerve (b). CPN, Common peroneal nerve; TN, Tibial nerve; PA, Popliteal artery; Arrowhead, needle tip.
Fig 2
Fig 2
Comparison of minimal stimulation current required to elicit a motor response with close needle-nerve contact between patients with and without diabetes mellitus for the common peroneal nerve (a) and tibial nerve (b).
Fig 3
Fig 3
Correlation of the conduction velocity of the ulnar nerve with minimal stimulation currents required to elicit a motor response with close needle-nerve contact for the common peroneal nerve (a) and the tibial nerve (b).

References

    1. Brull R, Wijayatilake DS, Perlas A et al. . Practice Patterns Related to Block Selection, Nerve Localization and Risk Disclosure: A Survey of the American Society of Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2008; 33: 395–403
    1. Sauter AR, Dodgson MS, Kalvøy H, Grimnes S, Stubhaug A, Klaastad O. Current threshold for nerve stimulation depends on electrical impedance of the tissue: a study of ultrasound-guided electrical nerve stimulation of the median nerve. Anesth Analg 2009; 108: 1338–43
    1. Dufour E, Quennesson P, Van Robais AL et al. . Combined ultrasound and neurostimulation guidance for popliteal sciatic nerve block: a prospective, randomized comparison with neurostimulation alone. Anesth Analg 2008; 106: 1553–8
    1. Bigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block. Anesthesiology 2009; 110: 1235–43
    1. Chan VWS, Brull R, McCartney CJL, Xu D, Abbas S, Shannon P. An ultrasonographic and histological study of intraneural injection and electrical stimulation in pigs. Anesth Analg 2007; 104: 1281–4
    1. Robards C, Hadzic A, Somasundaram L et al. . Intraneural injection with low-current stimulation during popliteal sciatic nerve block. Anesth Analg 2009; 109: 673–7
    1. Sala-Blanch X, López AM, Pomés J, Valls-Sole J, García AI, Hadzic A. No clinical or electrophysiologic evidence of nerve injury after intraneural injection during sciatic popliteal block. Anesthesiology 2011; 115: 589–95
    1. Seidel R, Natge U, Schulz J. Distal sciatic nerve blocks: randomized comparison of nerve stimulation and ultrasound guided intraepineural block. Anaesthesist 2013; 62: 183–92
    1. Keyl C, Held T, Albiez G, Schmack A, Wiesenack C. Increased electrical nerve stimulation threshold of the sciatic nerve in patients with diabetic foot gangrene: a prospective parallel cohort study. Eur J Anaesthesiol 2013; 30: 435–40
    1. Rigaud M, Filip P, Lirk P, Fuchs A, Gemes G, Hogan Q. Guidance of block needle insertion by electrical nerve stimulation: a pilot study of the resulting distribution of injected solution in dogs. Anesthesiology 2008; 109: 473–8
    1. Hogan QH. Pathophysiology of peripheral nerve injury during regional anesthesia. Reg Anesth Pain Med 2008; 33: 435–41
    1. Lirk P, Birmingham B, Hogan Q. Regional anesthesia in patients with preexisting neuropathy. Int Anesthesiol Clin 2011; 49: 144–65
    1. Boulton AJ, Gries FA, Jervell JA. Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabet Med 1998; 15: 508–14
    1. Viswanathan V, Snehalatha C, Seena R, Ramachandran A. Early recognition of diabetic neuropathy: evaluation of a simple outpatient procedure using thermal perception. Postgrad Med J 2002; 78: 541–2
    1. Wilbourn AJ. Nerve conduction studies: Types, components, abnormalities, and value in localization. Neurol. Clin 2002; 20: 305–38
    1. ASA Standards Guidelines and Statements: Standards for basic anesthetic monitoring. Methods 2011. Available at (accessed 7 March 2016)
    1. McCartney CJL, Brauner I, Chan VWS. Ultrasound guidance for a lateral approach to the sciatic nerve in the popliteal fossa. Anaesthesia 2004; 59: 1023–5
    1. Karmakar MK, Shariat AN, Pangthipampai P, Chen J. High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa. Reg Anesth Pain Med 2013; 38: 447–51
    1. Andersen HL, Andersen SL, Tranum-Jensen J. Injection inside the paraneural sheath of the sciatic nerve: direct comparison among ultrasound imaging, macroscopic anatomy, and histologic analysis. Reg Anesth Pain Med 2012; 37: 410–4
    1. Chan VWS, Nova H, Abbas S, McCartney CJL, Perlas A, Xu DQ. Ultrasound examination and localization of the sciatic nerve: a volunteer study. Anesthesiology 2006; 104: 309–14
    1. Sala Blanch X, López Am, Carazo J et al. . Intraneural injection during nerve stimulator-guided sciatic nerve block at the popliteal fossa. Br J Anaesth 2009; 102: 855–61
    1. Moayeri N, Groen GJ. Differences in quantitative architecture of sciatic nerve may explain differences in potential vulnerability to nerve injury, onset time, and minimum effective anesthetic volume. Anesthesiology 2009; 111: 1128–34
    1. Krishnan AV, Kiernan MC. Altered nerve excitability properties in established diabetic neuropathy. Brain 2005; 128: 1178–87
    1. Nodera H, Kaji R. Nerve excitability testing and its clinical application to neuromuscular diseases. Clin Neurophysiol 2006; 117: 1902–16
    1. Kroin JS, Buvanendran A, Tuman KJ, Kerns JM. Effect of acute versus continuous glycemic control on duration of local anesthetic sciatic nerve block in diabetic rats. Reg Anesth Pain Med 2012; 37: 595–600
    1. Sites B. Ultrasound-guided popliteal block demonstrates an atypical motor response to nerve stimulation in 2 patients with diabetes mellitus. Reg Anesth Pain Med 2003; 28: 479–82
    1. Halar EM, Graf RJ, Halter JB, Brozovich FV, Soine TL. Diabetic neuropathy: a clinical, laboratory and electrodiagnostic study. Arch Phys Med Rehabil 1982; 63: 298–303
    1. Sertoz N, Deniz MN, Ayanoglu HO. Relationship between glycosylated hemoglobin level and sciatic nerve block performance in diabetic patients. Foot Ankle Int 2013; 34: 85–90
    1. Cuvillon P, Reubrecht V, Zoric L et al. . Comparison of subgluteal sciatic nerve block duration in type 2 diabetic and non-diabetic patients. Br J Anaesth 2013; 110: 823–30
    1. Lirk P, Verhamme C, Boeckh R et al. . Effects of early and late diabetic neuropathy on sciatic nerve block duration and neurotoxicity in Zucker diabetic fatty rats. Br J Anaesth 2014; 114: 319–26
    1. Tsui BCH, Kropelin B. The electrophysiological effect of dextrose 5% in water on single-shot peripheral nerve stimulation. Anesth Analg 2005; 100: 1837–9
    1. Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007; 104: 965–74

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren