Dear Editor, Regional analgesia, encompassing techniques such as epidural and peripheral nerve blocks, has emerged as a pivotal component in managing pain and improving outcomes in critically ill patients within the intensive care unit (ICU).1 Amidst the complexity of critical care, effective pain management remains paramount for patient comfort, facilitating mechanical ventilation, preventing asynchrony, reducing ventilator-induced injury, and promoting early weaning and mobilization.2 Here, we report the use of regional analgesia as a successful pain controlling strategy in a young girl with septic arthritis which expedited her ICU discharge (informed consent was taken from the patient). A nursing student with history of lichen planus on oral steroids, methotrexate and dapsone, developed progressive bilateral knee joint pain and swelling. Subsequently, she developed progressive shortness of breath requiring hospital admission, intubation, and mechanical ventilation. Workup sent of ultrasound-guided knee aspirate showed raised white blood cells, 20 × 103/cu.mm (90% polymorphs), and growth of methicillin-resistant Staphylococcus aureus sensitive to teicoplanin. Blood culture also revealed methicillin-resistant coagulase negative Staphylococcus (CONS). Culture-based antibiotics were started. Magnetic resonance imaging of both knee joints revealed bilateral knee effusion with focal bone infarcts suggestive of septic arthritis. Bilateral knee joint arthroscopic drainage of the knee effusion with debridement was performed. Post arthroscopy, her fever resolved, but she had persistent bilateral knee pain with a Numerical Rating Scale (NRS) score of 9–10 requiring systemic opioid analgesics combined with non-steroidal anti-inflammatory drugs, intermittent sedation boluses restricting mobilization, physical rehabilitation, and weaning from ventilator despite her improved lung condition. The institute’s pain management team was consulted, and bilateral femoral nerve block was given Figure 1. Bilateral perineural catheters were placed under ultrasound guidance, and instillation of 0.2% 8 ml ropivacaine injection was done, followed by a continuous infusion of Ropivacaine (0.2% at 1 ml/hr). Post 1 hour, the NRS score reduced to 0–2. With the reduction in pain, systemic analgesia and sedatives were stopped in the next 24 hours. She could undergo a full range of motion exercises to restrict her knee joint disability, which improved gradually over the next 5 days. She was weaned off from the ventilator and discharged out of the ICU.Figure 1: Ultrasound image showing perineural catheter placed for femoral nerve block and local anaesthetic instillation seen as a “doughnut like appearance”Inadequate pain relief exacerbates delirium, impacting overall ICU outcomes and contributing to post-intensive care syndrome. Over-reliance on use of continuous systemic opioids has its own demerits such as delayed awakening, prolonging mechanical ventilation, and increasing delirium and ileus. Implementing regional analgesia techniques can complement a multimodal approach to pain management in critically ill patients. However, its use is still restricted because of challenges like procedural bleeding risks, infection, and potential nerve injury in heavily sedated patients. Additionally, the risk of systemic toxicity is also a significant consideration.3 It has been successfully used in trauma cases with flail chest, for burn dressings and/or debridements, for trauma to extremities, and in pancreatitis patients.4,5 Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sarkar et al. (Mon,) studied this question.