Ultrasound guided popliteal sciatic block combined with femoral nerve block for managing a high risk patient on apixaban for i&d of footabscess

Abstract

Current guidance is to avoid peripheral nerve blocks in the presence of anticoagulation. However in certain situations, where the risks of alternative techniques are high, then it may be appropriate to perform these blocks in the presence of anticoagulation. Here we present our management of a high risk anticoagulated patient who presented for incision and drainage of abscess using peripheral nerve blocks alone. Methods:We were asked to pre-assess a 89 year old patient posted for i&d of an absess of the foot. He had been admitted to hospital following falls and increased confusion and known to have COPD, hypertension, atrial fibrillation for which hewas on apixaban and congestive cardiac failure. His exercise tolerance was only 10 yards and saturations were 87% on air. Results: Ultrasound guided popliteal sciatic nerve and saphenous nerve block at the level of knee was performed. After 25 minutes there was almost complete motor block and surgery performedwithout any complications. Therewere no complications to report. Conclusions: Peripheral nerve blocks in the presence of anticoagulation can be associated with complications.Most of these have been associated with deep blocks or with peripheral nerve catheters. If the risks for alternative techniques are high, then on a relative risk basis, there may be role for peripheral nerve blocks in the presence of anticoagulation. The use of ultrasound guidance, helps avoid injury to vascular structures, which might cause nerve injury through haematoma formation.