Case report
Use of genitofemoral and ilioinguinal and iliohypogastric nerve block during orchiectomy in a post-lung transplant patient. A case report
Uso de bloqueo genitofemoral en combinación con bloqueo ilioinguinal e iliohipogástrico para orquiectomía en paciente postrasplantado pulmonar. A propósito de un caso
B.A. Rivas Rivero
, A. Mira Puerto, J. Cuenca
Corresponding author
Servicio de Anestesiología, Hospital Universitario Sant Joan de Reus, Reus, Spain
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A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "465" "paginaFinal" => "468" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B.A. Rivas Rivero, A. Mira Puerto, J. Cuenca" "autores" => array:3 [ 0 => array:4 [ "nombre" => "B.A." "apellidos" => "Rivas Rivero" "email" => array:1 [ 0 => "berthaixar@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Mira Puerto" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Cuenca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Sant Joan de Reus, Reus, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de bloqueo genitofemoral en combinación con bloqueo ilioinguinal e iliohipogástrico para orquiectomía en paciente postrasplantado pulmonar. A propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1155 "Ancho" => 1267 "Tamanyo" => 252936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound view of the left inguinal canal.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Organ transplantation has gone from being an exceptional intervention to the standard treatment for some serious diseases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The steady increase in the number of lung transplant patients in recent years, coupled with improved survival rates, increases the likelihood of encountering such patients in clinical practice, and it is essential to determine the status of the other organs and the patient's usual medication.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Transplant patients may live far from the hospital in charge of their follow-up, and may require a surgical procedure unrelated to the transplant. A number of different anaesthesia techniques have been used in such patients, but none has been found to be superior.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ultrasound-guided nerve block is emerging as a useful option. The technique has several advantages: it provides analgesia during the intra- and postoperative period, and in certain cases can be used instead of general or neuraxial anaesthesia in order to avoid the potential complications inherent to these procedures in patients with multiple pathologies.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We present the case of a post-lung transplant, ASA III patient sent for orchiectomy for testicular cancer, in whom a combination of iliohypogastric (ILH), ilioinguinal (ILI) and genitofemoral block (GF) was used for anaesthesia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was a 46-year-old man scheduled for left orchiectomy due to seminoma, weight 93<span class="elsevierStyleHsp" style=""></span>kg, height 169<span class="elsevierStyleHsp" style=""></span>cm, with single lung transplantation 1 year previously due to pulmonary sarcoidosis. He had a history of orchidopexy in adolescence, chronic kidney failure secondary to immunosuppressants and amphotericin B, steroid-induced diabetes, and arterial hypertension.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The preoperative work-up showed mild thrombocytopaenia (130,000<span class="elsevierStyleHsp" style=""></span>platelets) and chronic kidney disease (creatinine 1.36<span class="elsevierStyleHsp" style=""></span>g/dL). The remaining tests were unremarkable. Chest computed tomography showed postoperative changes due to left-sided single-lung transplantation, irregular, patchy, poorly defined consolidations in some segments of the lung graft. Right lung involvement was observed, in the form of ground glass opacities associated with a reticular pattern and traditional cylindrical bronchiectasis related to the underlying disease. Spirometry reported moderate bronchial obstruction, with FEV1 of 51%. An echocardiogram performed 6 months post transplantation showed preserved biventricular function and ejection fraction of 72%, slightly dilated right ventricle, with no notable valvular disease, pulmonary artery pressure not estimable, with no indirect indication of pulmonary hypertension. The pretransplant echocardiogram reported severe pulmonary hypertension.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was given antibiotic prophylaxis 30<span class="elsevierStyleHsp" style=""></span>min before the surgical incision. Standard monitoring with continuous electrocardiogram, blood pressure and pulse oximetry was performed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Nasal cannulas were placed, delivering 3<span class="elsevierStyleHsp" style=""></span>L min oxygen, and sedation began with midazolam (2<span class="elsevierStyleHsp" style=""></span>mg) and perfusion of 0.05<span class="elsevierStyleHsp" style=""></span>mcg/kg/min remifentanil. We performed ultrasound-guided left-sided ILI and ILH block at the level of the groin, using a high frequency linear transducer and 50<span class="elsevierStyleHsp" style=""></span>mm needle inserted in-plane lateral to medial, with the medial part of the transducer facing the navel. We administered 15<span class="elsevierStyleHsp" style=""></span>ml of 0.5% bupivacaine, and observed the spread of the local anaesthetic (LA) between the internal oblique and transversus abdominis muscles.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We then performed blockade of the genital branch of the left genitofemoral nerve, placing the transducer transversely, 2–3<span class="elsevierStyleHsp" style=""></span>cm lateral to the pubic symphysis, parallel to and above the inguinal ligament, where we identified the spermatic cord. The needle was inserted out-of-plane, administering 2<span class="elsevierStyleHsp" style=""></span>ml of 0.25% bupivacaine into the cord. The needle was then withdrawn to the edge of the cord, and the same dose of LA was administered (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Sedation continued with target-controlled infusion of 0.07<span class="elsevierStyleHsp" style=""></span>mcg/kg/min remifentanil combined with 0.7<span class="elsevierStyleHsp" style=""></span>mcg/ml propofol, which was maintained throughout the procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Surgery lasted about 45<span class="elsevierStyleHsp" style=""></span>min and was uneventful, with the patient under spontaneous ventilation and no sudden changes in vital signs, arterial pressure at a steady 70–80<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate at 70–85 beats per minute and SpO<span class="elsevierStyleInf">2</span> of 100% during the entire procedure. The patient remained pain-free from the time of the first surgical incision to the end of surgery. The urologists were not required to administer more LA under direct vision or additional opioids during the procedure. During the 2-h stay in the post-anaesthesia care unit, only 2<span class="elsevierStyleHsp" style=""></span>g metamizole were administered, and the patient was discharged home the following day.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Post-lung transplant patients often have post-induction hypotension caused by several mechanisms. Anaesthesia induction with propofol or thiopental has been shown to be safe in these cases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Propofol is suitable for intravenous maintenance of anaesthesia: its use at low doses, together with short-acting opioids, is well tolerated, prevents haemodynamic instability and allows rapid eduction.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Peripheral blockades are a good alternative, mainly because they provide anaesthesia and analgesia in the selected area without the haemodynamic instability associated with general and neuraxial anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The technique requires good knowledge of the local anatomy of the target area, in this case the inguinoscrotal region. We devised a practical, safe strategy that would provide adequate locoregional anaesthesia in our patient.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The inguinal area is innervated by the ILI, ILIH and GF nerves. The ILI and ILH nerves run in parallel through the psoas muscle; in men, the ILI nerve emerges from the lateral border of this muscle, continues between the transverse muscle of the abdomen and the internal oblique muscle until it crosses the inguinal canal. This nerve terminates behind the spermatic cord and innervates the skin of the anterior region of the scrotum, the anterior thigh, suprapubic region, pubic symphysis and base of the penis. The ILH nerve pierces the psoas muscle and descends between the transverse muscle of the abdomen and the internal oblique muscle, both of which it innervates, at the level of the anterior superior iliac spine. It gives off a lateral cutaneous branch, which innervates the skin of the posterolateral gluteal region, and an anterior branch, which pierces the aponeurosis of the external oblique muscle and supplies the hypogastric region.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The GF nerve emerges from the L1 and L2 nerve roots and divides into 2 branches. The femoral branch innervates the upper and inner area of the thigh and the femoral triangle. The genital branch travels along the spermatic cord through the inguinal canal to the scrotum. It lies immediately lateral to the cord, emerges from the superficial inguinal ring, and terminates in the anterior and superior portion of the scrotum; it also supplies motor branches to the cremasteric muscle.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">ILI and ILIH blocks are not suitable for visceral pain; blocking the genital branch of the GF nerve provides hemiescrotal anaesthesia and allows manipulation and intervention in the inguinoscrotal area without the need for deep sedation to improve the quality of anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> It is important for the LA to infiltrate both the spermatic cord and surrounding tissue in order to cover all anatomical variations of the nerve. The scrotum is also innervated by the posterior scrotal nerves, branches of the pudendal nerve and of the lower scrotal nerves, and branches of the posterior femoral cutaneous nerve, both of which emerge from the sacral plexus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Due to the approach used for this intervention, we believe that ILI, ILH and GF nerve block provides sufficient anaesthesia.</p><p id="par0090" class="elsevierStylePara elsevierViewall">It has been suggested for many years that regional anaesthesia is advantageous in high-risk patients, either as the sole anaesthetic technique or in combination with general anaesthesia. Ultrasound guidance has dramatically improved the safety and success rate of these techniques.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> It has also reduced the time needed to perform and establish the blockade, reduced the volume of LA required, and increased the safety of the technique by identifying and avoiding perineural structures. Furthermore, the effects of the locoregional anaesthesia continue after surgery and cause less motor blockade than neuraxial techniques; this facilitates early mobilisation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Some studies have shown the efficacy of ILI and ILH nerve blocks combined with GF nerve block. Sasaoka et al. used this technique in children undergoing inguinal hernia repair, and reported lower opioid requirements during surgery. It was also shown to be effective during manipulation of the hernial sac.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Wipfli et al. studied 20 adult patients undergoing scrotal surgery, all of whom received ILI, ILH and GF nerve block under sedation. They found that 95% did not require opioids during the intraoperative period, the remaining 5% received a short-acting opioid, and postoperative analgesia was improved.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Evidence suggests that the addition of the GF nerve block to the ILI and ILH blockade could give complete anaesthesia and avoid the adverse effects associated with general and neuraxial anaesthesia. This was the case in our patient, who required no additional opioids when performing the surgical incision in the inguinal area.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The increased life expectancy of the general population has in turn increased the number of high-risk patients encountered in routine clinical practice. We believe that ultrasound-guided anaesthetic techniques alone or in combination with other anaesthetic techniques are a good alternative in this type of patient. We used our knowledge of the sensory innervation of the testicular area to perform GF blockade to enhance the effect of ILI and ILH nerve block, and thus achieved complete anaesthesia for testicular surgery in a high-risk patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">None of the authors has any conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1092852" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035708" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092851" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1035707" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-03" "fechaAceptado" => "2018-02-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035708" "palabras" => array:5 [ 0 => "Lung transplant" 1 => "Genitofemoral block" 2 => "Ilioinguinal block" 3 => "Iliohypogastric block" 4 => "Testicular surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035707" "palabras" => array:5 [ 0 => "Trasplante pulmonar" 1 => "Bloqueo genitofemoral" 2 => "Bloqueo ilioinguinal" 3 => "Bloqueo iliohipogástrico" 4 => "Cirugía testicular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case is presented of a post-lung transplant patient, ASA III, proposed for orchiectomy due to testicular cancer. A combination of iliohypogastric (ILH), ilioinguinal (ILI) and genitofemoral (GF) nerve block together with sedation was used as anaesthetic technique.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The inguinal area received sensory innervation mainly from ILI, ILH and GF nerves. The genital branch of the GF nerve supplies innervation to skin of the anterosuperior portion of the scrotum.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">When performing the echo-guided block of GF nerve, it is necessary to identify the spermatic cord, and administer the local anaesthetic on the inside and periphery of the cord.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Peripheral nerve blocks are a valid option for complex patients. Its main advantage is the anaesthesia and analgesia level that it provides without the haemodynamic instability associated with general or neuraxial anaesthesia. GF nerve block provides hemi-scrotal anaesthesia, allowing manipulation and intervention in the inguinal-scrotal area, complementing the anaesthesia provided by ILI and ILH nerve blocks.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente postrasplantado pulmonar, ASA III, propuesto para orquiectomía por neoplasia testicular. La técnica anestésica era la combinación de bloqueo iliohipogástrico (ILH), ilioinguinal (ILI) y genitofemoral (GF) con sedación.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El área inguinal recibe inervación sensitiva principalmente de los nervios ILI, ILH y GF, la rama genital de este último inerva piel de la porción anterosuperior del escroto.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Al realizar el bloqueo ecoguiado del nervio GF, es necesario identificar el cordón espermático y administrar anestésico local por dentro y por fuera para cubrir variaciones anatómicas del nervio.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los bloqueos periféricos son una opción factible para pacientes complejos. Su principal ventaja es la anestesia y analgesia del área sin la inestabilidad hemodinámica asociada a la anestesia general y neuroaxial. El bloqueo del nervio GF aporta anestesia hemiescrotal, lo que permite la manipulación e intervención sobre esta área, complementando la anestesia aportada por el bloqueo de los nervios ILI e ILH.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rivas Rivero BA, Mira Puerto A, Cuenca J. Uso de bloqueo genitofemoral en combinación con bloqueo ilioinguinal e iliohipogástrico para orquiectomía en paciente postrasplantado pulmonar. A propósito de un caso. Rev Esp Anestesiol Reanim. 2018;65:465–468.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1155 "Ancho" => 1267 "Tamanyo" => 252936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound view of the left inguinal canal.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manejo perioperatorio de pacientes trasplantados sometidos a Cirugía General" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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