Peripheral Nerve Blocks for Short PFN Insertion

Block Selection and Risk Assessment

Peripheral nerve blocks can be divided into two risk categories based on hemorrhage risk and compressibility of the area: low-risk blocks, such as femoral block and sciatic block in popliteal fossa, and high-risk blocks, such as infraclavicular block and parasacral sciatic block, according to the American Society of Anesthesiologists 1
For short PFN insertion, a combination of blocks may be required, including femoral nerve block for anterior thigh coverage, sciatic nerve block for posterior thigh and lower leg coverage, and obturator nerve block for complete analgesia, as recommended by the American Academy of Orthopaedic Surgeons 2

Ultrasound guidance is strongly recommended to reduce the risk of local anesthetic systemic toxicity, improve accuracy of needle placement, and allow for reduced volumes of local anesthetic, according to the American Society of Regional Anesthesia and Pain Medicine 3
Use in-plane needling along the visual axis for improved speed and accuracy, and calculate safe dose of local anesthetic based on patient weight to prevent systemic toxicity, as suggested by the European Society of Regional Anaesthesia and Pain Therapy 2

For patients on anticoagulants, assess the risk-benefit ratio carefully, and low-risk peripheral blocks may be performed if the benefit/risk ratio is favorable, according to the American College of Cardiology 1
High-risk blocks are contraindicated unless dabigatran concentration is ≤30 ng/mL, and if general anesthesia is contraindicated and high-risk blocks are needed, consider administering idarucizumab to neutralize dabigatran, as recommended by the International Society on Thrombosis and Haemostasis 1

Peripheral nerve blocks have fewer physiological and hemodynamic side effects compared to neuraxial techniques, and most peripheral blocks do not cause sympathectomy leading to hypotension, according to the American Society of Anesthesiologists 3
Peripheral nerve blocks provide reduced risk of complications associated with neuraxial anesthesia, as suggested by the European Society of Anaesthesiology 3

Have resuscitation equipment immediately available, and monitor blood pressure and electrocardiogram, especially in patients with high cardiovascular risk, as recommended by the American Heart Association 4
Monitor blood pressure and electrocardiogram, especially in patients with high cardiovascular risk, according to the European Resuscitation Council 2

Thoroughly test for block success before proceeding with surgery, and position the patient appropriately with the leg slightly abducted for proximal approach techniques, as suggested by the American Academy of Orthopaedic Surgeons 2
Use standard aseptic technique similar to neuraxial procedures, and position the ultrasound machine in front of the operator rather than perpendicular for improved accuracy, according to the World Health Organization 2