Bilateral Continuous 3-in-1 Nerve
Blockade for Postoperative Pain
Relief after Bilateral Femoral Shaft
Xavier Capdevila, MD, PhD,*
Philippe Biboulet, MD,* Mohamed Bouregba, MD,†
Josh Rubenovitch, MD, BSc,† Samir Jaber, MD†
Department of Anesthesiology, Lapeyronie University Hospital, Montpellier, France
We tested the effectiveness of bilateral continuous paravascular
femoral nerve blocks in a patient following bilateral femoral shaft
surgery in whom other analgesic regimens were considered contra-
indicated or of limited effectiveness.
Bilateral continuous femoral paravascular nerve blocks were
performed using a previously described technique. General anes-
thesia was subsequently used to facilitate surgery, which was a
bilateral osteosynthesis using dynamic hip screws for osteolytic
metastases of the proximal extremities of both femurs. A continu-
ous infusion of lidocaine, morphine, and clonidine was estab-
lished in both femoral catheters preoperatively and used postoper-
atively as the principle source of analgesia. Radiographic contrast
was used to document the position of both catheters and to
document the spread of injectate. Visual analog scale (VAS) pain
scores were recorded in the recovery room and at 4, 16, 24, 48,
and 72 hours postoperatively. Plasma lidocaine levels were
determined by gas chromatography at 4, 16, and 48 hours
postoperatively. Sensory assessment in the distribution of the
femoral, lateral cutaneous, and obturator nerves was performed to
confirm the presence of sensory blockade.
We successfully provided analgesia with bilateral continuous
femoral paravascular nerve blocks. Pain scores at rest were
consistently rated good to excellent (VAS Ͻ 20 mm). Evidence of
sensory conduction block was present throughout the infusion.
Plasma concentrations of lidocaine were consistently below toxic
levels (1.35 to 1.65
g/ml). Radiographic contrast studies failed
to demonstrate movement of contrast to the level of the lumbar
Bilateral continuous femoral paravascular nerve blocks can be
used to provide effective and safe analgesia in patients requiring
aggressive analgesia in whom other techniques may be contrain-
dicated. © 1998 by Elsevier Science Inc.
Keywords: Anesthesia: local, regional; drugs: lidocaine,
morphine; nerve: femoral, lateral femoral cutaneous,
obturator; surgery, orthopedic.
The femoral paravascular nerve block was first described
by Winnie et al.
in 1973. Since that time, it has been used
to provide analgesia in a variety of clinical circumstanc-
Although controversial, the ability of a femoral
paravascular nerve block to enhance postoperative anal-
gesia in select groups of patients is supported by many
Specifically, analgesia following femoral shaft
fractures may be particularly amenable to treatment with a
femoral paravascular nerve block.
The patient described below required bilateral femoral
shaft surgery for osteolytic destruction of both femurs.
The patient refused neuraxial anesthesia and analgesia.
He had epidural analgesia in the past and had developed
*Assistant Professor of Anesthesiology
†Resident in Anesthesiology
Address correspondence and reprint requests to Dr. Capdevila at the
Department of Anesthesiology, Lapeyronie University Hospital, 295,
ave. du Doyen gaston Giraud, 34295 Montpellier, France.
Received for publication October 14, 1997; revised manuscript ac-
cepted for publication July 29, 1998.
Journal of Clinical Anesthesia 10:606 –609, 1998
© 1998 Elsevier Science Inc. All rights reserved. 0952-8180/98/$19.00
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