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Étude de cas : Anesthésie locorégionale sciatique et fémorale bilatérale chez un polytraumatisé

  • Issam TanoubiEmail author
  • Philippe Cuvillon
  • Emmanuel Nouvellon
  • Louis Philippe Fortier
  • Pierre Drolet
  • Jacques Ripart
Case Reports/Case Series

Résumé

Objectif: Nous présentons un cas d’anesthésie locorégionale bilatérale des deux membres inférieurs comme anesthésie principale, en mettant en relief les mesures d’atténuation de la toxicité liée aux doses importantes d’anesthésiques locaux nécessaires.

Éléments cliniques: Une femme de 32 ans, obèse (index de masse corporelle=30,4 kg·m−2), présentait des fractures bimalléolaires aux deux membres inférieurs nécessitant des ostéosynthèses urgentes. À cause de fractures au niveau de la face, de l’odontoïde et du bassin ainsi que de l’obésité et de l’estomac plein, nous avons priorisé l’indication de blocs bilatéraux des membres inférieurs. Des blocs fémoral et sciatique des deux membres inférieurs ont été réalisés avec un mélange de ropivacaïne et de mépivacaïne, en laissant un intervalle de 210 min entre chaque membre. Des dosages sanguins des anesthésiques locaux utilisés ont été faits 80 min après les blocs du premier membre et 45 min après les blocs du second. Les niveaux plasmatiques de ropivacaïne et de mépivacaïne étaient inférieurs aux seuils de toxicité habituels. La patiente n’a présenté aucun signe de toxicité et la chirurgie a été complétée sans complication.

Conclusion: La pratique d’une anesthésie locorégionale bilatérale exige parfois des doses élevées d’anesthésiques locaux s’approchant des seuils de toxicité. Ce cas montre qu’en tenant

Case report: Bilateral femoral and sciatic regional anesthesia in a polytraumatized. patient

Abstract

Purpose: To present a case requiring regional anesthesia for both lower limbs, and to highlight the considerations to avoid potential local anesthetic toxicity, as a result of high cumulative doses of local anesthetic in this setting.

Clinical Features: A 32-yr-old, obese (body mass index=30.4 kg·m−2) woman required urgent, open reduction of bilateral ankle fractures. She also had facial, odontoid and pelvic fractures, and, in view of full stomach considerations, the anesthetic plan was to use regional anesthesia. Bilateral femoral and sciatic nerve blocks were performed, using a combination of ropivacaine and mepivacaine, with a 210-min interval between limbs. Blood samples were drawn 80 and 45 min after the first and second blocks, respectively, to measure plasma con centrations of the local anesthetics. Ropivacaine and mepivacaine concentrations were below reported toxic levels, and the patient underwent surgery successfully, without any symptoms suggestive of local anesthetic toxicity.

Conclusions: Regional anesthetic techniques for the lower limb may require local anesthetic doses approaching toxic levels, especially when bilateral blocks are required. This case indicates that by considering the pharmacokinetic and pharmacodynamic characteristics of each agent, and by timing the blocks properly to minimize peak plasma concentrations, the potential for local anesthetic toxicity can be reduced.

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Copyright information

© Canadian Anesthesiologists 2008

Authors and Affiliations

  • Issam Tanoubi
    • 2
    Email author
  • Philippe Cuvillon
    • 1
  • Emmanuel Nouvellon
    • 1
  • Louis Philippe Fortier
    • 2
  • Pierre Drolet
    • 2
  • Jacques Ripart
    • 1
  1. 1.La Division Anesthésie Réanimation Douleur UrgencesGroupe Hospitalo-universitaire CarémeauNîmesFrance
  2. 2.Département d’AnesthésieHôpital Maisonneuve-RosemontMontréalCanada

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