Background and Aims:
Transfemoral/above knee amputations can be performed under general or neuraxial anesthesia. However, patients with multi-comorbidities may require peripheral nerve blocks. A combination of lumbar plexus block (LPB) and parasacral sciatic nerve block (PSNB) may be used as the main anesthetic method in high risk patients. Herein we report combined lomber erector spinae plane block (L-ESPB) and PSNB use in a multi-comorbid geriatric patient undergoing knee amputation.

Methods:
A 72 year old male patient required transfemoral lower-extremity amputation due to atherosclerotic and thromboembolic obstruction. Medical history was significant for renal failure requiring hemodialysis, diabetes mellitus, congestive heart failure, right hip amputation (10 years ago) and drainage under local anesthetic of a bile stone leading to hepatic coma 2 weeks previously. Preoperative evaluation revealed left ventricular ejection fraction to be 20%, creatinine 5.62 mg/dl and total bilirubin 8.30 mg/dl. Considered his high risk, regional anesthesia was chosen. Informed consent for procedures was obtained. LPB and PSNB in the lateral decubitus position was planned, but insufficient USG imaging was achieved for LPB. Due to lower volume and concentration requirements, L-ESPB (25ml) and PSNB (15ml) was performed with bupivacaine/lidocaine mixture..

Results
Pinprick test 30 minutes after block revealed sensorial block in all areas other than the obturator nerve. During the surgical time of 75 minutes, 170 mg of propofol (continuous infusion) was consumed. NRS<3 was achieved until postoperative 9th hour.

Conclusions:
L-ESPB is a safe alternative to other lumbar plexus or lumbar plexus component blocks and provides adequate anesthesia in transfemoral/above knee amputations when combined with PSNB.

COMBINATION OF LUMBAR ERECTOR SPINAE PLANE AND PARASACRAL SCIATIC NERVE BLOCK AS THE MAIN ANESTHETIC METHOD IN A HIGH RISK PATIENT UNDERGOING TRANSFEMORAL KNEE AMPUTATION