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Emergency Lower-Limb Surgeries under Peripheral Nerve Blocks in High-Risk Patients: A Case Series
*Corresponding author: Ganesh Bhong, Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India. ganeshbhong@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Diwan S, Bhong G, Gawai N, Diwan A, Sancheti P. Emergency Lower-Limb Surgeries under Peripheral Nerve Blocks in High-Risk Patients: A Case Series. J Trauma Anaesth Resusc Crit Care. 2025;1:61-7. doi: 10.25259/JTARCC_9_2025
Abstract
Neuraxial anesthesia is commonly employed for lower-limb (LL) procedures; however, lumbosacral or isolated peripheral nerve blocks (PNBs) remain underutilized for LL procedures compared with upper-limb blocks. Traditional landmark or neurostimulation-based techniques often require multiple needle passes and redirections, resulting in reduced patient comfort and satisfaction. The resurgence of LL blocks, enabled by ultrasound guidance in regional anesthesia, has led to a fundamental shift in clinical practice. When properly performed, LL-PNBs produce unilateral anesthesia, limited sympathetic blockade, and excellent post-operative analgesia; features that are particularly advantageous in patients with significant co-morbidities. Such high-risk patients are vulnerable to hemodynamic instability under neuraxial or general anesthesia, making anesthetic management challenging. We present a case series of 10 high-risk patients of American Society of Anesthesiologists physical status III and IV, who underwent damage control surgery or LL amputation using ultrasound-guided PNBs (sciatic and femoral) at a tertiary orthopedic hospital. Immediate post-operative outcomes were favorable, with stable hemodynamics and effective analgesia. This case series highlights that ultrasound-guided LL-PNBs may be a valuable alternative technique in selected high-risk patients when performed by expert regional anesthesiologists.
Keywords
Emergency
High-risk patients
Lower-limb surgeries
Peripheral nerve blocks
INTRODUCTION
Lower-limb (LL) surgeries are most commonly performed under neuraxial anesthesia. The lumbosacral or isolated peripheral nerve blocks (PNBs) remain underutilized for LL surgeries, compared with brachial plexus blocks for upper-limb procedures. Unlike the upper limb, the LL is innervated by two distinct plexuses- the lumbar and sacral, making regional anesthesia technically challenging and often requiring multiple injections. There is also a possibility of block failures, paresthesia, pain, and discomfort associated with evoked muscle contractions with neurostimulation and local anesthetic systemic toxicity (LAST).1 The advent of ultrasound has significantly transformed regional anesthesia by enabling accurate nerve localization, real-time needle guidance, and visualization of local anesthetic (LA) spread. When combined with peripheral nerve stimulation, ultrasound facilitates safer and more effective blockade of deeper neural targets. Importantly, ultrasound guidance reduces the minimum effective volume of LA, thereby substantially lowering the risk of LAST.2 LL blocks, when administered properly, provide effective post-operative analgesia, minimal sympathetic block, and unilateral anesthesia.
However, the role of LL PNBs in emergency LL surgery or damage-control surgery (DCS) in high-risk patients remains unclear. Legitimately, LLBs would be relevant to this patient subset. This particular cohort is often profoundly vasoconstricted and vulnerable to cardiovascular collapse, following sympathetic blockade induced by neuraxial or general anesthesia (GA). Highly selective LL blocks with minimal or no sedation may offer a safer alternative. We present a case series of 10 high-risk patients who underwent amputation or DCS at a tertiary orthopedic center, highlighting the feasibility and clinical relevance of this approach.
CASE SERIES
The Institutional Ethics Committee and Research Board approved publication of this case series involving emergency LL surgeries performed solely under PNBs in high-risk patients. After approval, medical records were retrospectively viewed for the period from January 2016 to December 2020. Medical files were manually scanned, and 10 multicomorbid patients who underwent emergency LL surgeries under PNBs were included in the study.
The cohort comprised 10 patients, including 7 males and 3 females, with a mean age of 62.2 years. Details regarding patient co-morbidities, abnormal laboratory findings, radiological findings, and coagulation profiles at the time of surgery are summarized in Table 1. Preoperative counseling was provided to all patients, and high-risk informed consent was obtained from their relatives in accordance with institutional protocol.
| S. No. | Age/Sex/ASA | Diagnosis | Surgery | Co-morbidities | Investigations | Preoperative optimization | |
|---|---|---|---|---|---|---|---|
| 1 | 28 years/M/ASA-III | Compound fracture tibia | Through knee amputation | Head injury with GCS 12/15 Acute Kidney Injury due to Rhabdomyolysis | Hb: 7.2 gm% K+: 5.4 mEq/L CPK MB: 30,000 ng/mL Serum creatinine: 3.98 mg% | Hemodialysis done 1 day prior surgery. Post dialysis,Hb: 6.8 gm%, Na+: 128 mEq/L, K+: 5.1 mEq/L | |
| 2 | 65 years/M/ASA IV | Left tibia compound segmental fracture | External fixation | Known case of Hypothyroidism and HT with severe alcohol withdrawal and pancreatitis. Left-sided hemopneumothorax. Head injury with frontal contusions – GCS 14/15 Patient drowsy. | Serum lipase: 16,869 U/L Amylase: 209 U/L Platelet: 1,06,000/cmm PaO2: 66 mm Hg, PaCO2: 23 mmHg, Procalcitonin: 3.92 ng/mL SGOT: 139 U/mL CT Thorax=Fracture left 7, 9, 11 ribs & Left-sided basal mild-to-moderate hemothorax with underlying basal atelectasis | Left-sided ICD was put to drain 1100 ml collection. inj. Octreotide was started for pancreatitis. Injection, piperacillintazobactam started. Conservative management for head injury | |
| 3 | 62 years/F/ASA III | Left tibia fracture | Debridement and External Fixation | Rheumatic heart disease (MS) and HT for 10 years | Patient on acitrom (stopped for 2 days) PT INR: 1.69, Serum urea: 63 mg%, serum creatinine: 1.57 mg%,serum bilirubin.: 1.2 mg%. History of chronic AF, sinus rhythm preoperatively. 2Decho - EF 40%, MVA 0.9 sq cm. LA, RA dilated, Mod. PH- 64, Mild MR |
Acitrom stopped, Enoxaparin started. PT INR - 1.3 Inj Vit K given. Preop: 2 units FFP given. Repeat INR=1.2 Intraoperative 2 units FFP given | |
| 4 | 78 years/M/ASA IV | Left LL gangrene (diabetic foot) | Below-knee amputation | DM+HT+K/C/O ischemic cardiomyopathy. History of PTCA and pacemaker insertion. Warfarin was stopped 15 days back. Clopidogrel was stopped 3 days back. | PT INR=1.3, Na+=129 mEq/L, ECG=RBBB 2Decho=EF 25%, Dilated LV, Global hypokinesia, mild MR, TR, PH | Patient started on Ivabradine, Torsemide, and Vit K BD | |
| 5 | 62 years/F/ASA IV | Non-healing ulcer | Debridement | DM, HT, obesity, and cerebrovascular accident. Hemiparesis 5 years back – partially recovered. Chronic Kidney disease – Dialysis done 2 days ago | Serum urea: 120 mg%, creatinine: 5.8 mg%, Na+: 135 mEq/L, K+: 3.2 mEq/L, Hb: 10.2 gm%, HBA1C: 6.9%, ECG=LBBB | Nephrologist opinion - can be posted under RA only | |
| 6 | 56 years/F/ASA IV | Infected knee | Above-knee amputation | HT, Hypothyroid. Patient in sepsis – On Noradrenaline infusion | K+: 2.9 mEq/L, Procalcitonin: 3.0 ng/mL, D dimer: 2.19 mg/dL, Trop T – weak positive, ECG – LBBB, 2D echo=LV Global Hypokinesia, EF-30% PaO2: 60 mmHg |
Potassium infusion started. K+: 3.4 mEq/L prior surgery Inj. Meropenem started | |
| S. No. | Age/Sex/ASA | Diagnosis | Surgery | Co-morbidities | Investigations | Preoperative optimization | |
| 7 | 83 years/M/ASA III | Gangrene right leg. | Below-knee amputation | DM+HT+Sepsis, SpO2 – 94% | Procalcitonin: 1.07, TLC: 33,400/cmm BNP: 879 ng/mL, PT INR: 1.3, Creatinine: 1.5 mg%, 2D Echo – EF=60%, sclerotic valves | 1 unit PRBC and 2 units FFP given | |
| 8 | 62 years/M/ASA III | Right Diabetic foot | Below-knee amputation | DM+IHD PTCA done 2 months back off antiplatelets×2 days | PT INR: 1.23,, random blood sugar: 260 mg%, HbA1c – 7.9 %, Na+- 128 mEq/L, ECG – Q waves in III, aVf 2D Echo-Inferior dyskinesia, EF-50% | 2 units FFP given intra op | |
| 9 | 68 years/M/ASA IV | Infected right knee | Above-knee amputation | DM+HT+COPD+Psychiatric illness+Bell’s palsy. On and off NIV for 4–5 days. Diastolic heart failure. Patient Drowsy, AE decreased bilateral Bases, SpO2 – 99% on O2 support by mask | BNP: 4130 pg/mL, K+: 5.2 mEq/mL, Hb: 8.2 gm%, Serum creatinine: 3.5 mg%, Urea: 109 mg%, D dimer=3.4 mg/L CT Thorax=Patchy consolidation right lower lobe. Bilateral ground-glass opacities in the lung parenchyma. 2D Echo– EF – 60% (diastolic failure) | Inj. Torsemide given. 2 units PRBCs given | |
| 10 | 58 years/M/ASA IV | Lt diabetic foot | Debridement | DM+HT+IHD+CVA+Diabetic nephropathy+Neuropathy+ Retinopathy. History of CABG and atrial flutter | Random blood sugar: 400 mg%, serum creatinine: 1.24 mg%, INR=1.23, BNP=4800 pg/mL ECG=VPCs present, CXR=Cardiomegaly 2D Echo=EF - 45%, Basal and inf. posterior wall thinned out and akinetic, dilated LV, mild PH | Insulin infusion started, blood sugar: 185 mg% 1 unit FFP given | |
ASA: American Society of Anesthesiologists, GCS: Glasgow coma scale, HT: Hypertension, Hb: Hemoglobin, PRBCs: Packed red blood cells, Na+: Sodium, K+: Potassium, PT INR: Prothrombin time international normalized ratio, Creatine phophokinase MB, ICD: Intercostal chest drain, PaO2: Partial pressure oxygen, PaCO2: Partial pressure carbon dioxide, SGOT: Serum glutamic oxaloacetic transaminase, CT: Computed tomography, pre op: Preoperative, MS: Mitral stenosis, AF: atrial fibrillation, 2D Echo: 2 dimensional echocardiography, EF: Ejection fraction, MVA: Mitral valve area, LA: Left atrium, RA: Right atrium, Mod.: Moderate, PH: Pulmonary hypertension, MR: Mitral regurgitation, FFP: Fresh frozen plasma, intra op: Intraoperative, LL: Lower limb, DM: Diabetes mellitus, PTCA: Percutaneous transluminal coronary angioplasty, TLC: Total leukocyte count, HbA1C: Glycosylated hemoglobin, RBBB: Right bundle branch block, LV: Left ventricle, TR: Tricuspid regurgitation, BD: twice daily, ECG: Electrocardiogram, LBBB: Left bundle branch block, RA: Regional anesthesia, ABG: Arterial blood gas, I/V/O: In view of, SpO2: Saturation of peripheral oxygen, BNP: B type natriuretic peptide test, IHD: Ischemic heart disease, COPD: Chronic obstructive pulmonary disease, NIV: Non-invasive ventilation, AE: Air entry, CVA: Cerebrovascular accident, CABG: Coronary artery bypass surgery, VPCs: Ventricular premature complexes, CXR: Chest X ray
Among the 10 multi-comorbid patients, six (patients 3, 4, 6, 8, 9, and 10) had significant cardiovascular disorders, including reduced ejection fraction and regional wall motion abnormalities. One (patient 6) required noradrenaline infusion preoperatively. Six patients (1, 3, 5, 7, 9, and 10) had deranged renal function, while four patients (3, 4, 7, and 8) had abnormal coagulation profiles [Table 1].
All patients transferred from the intensive care unit (ICU) were continuously monitored (electrocardiogram, noninvasive blood pressure, oxygen saturation, temperature) during transport from the ICU to the operating room (OR). One patient was transferred directly from the emergency room to the OR. In five patients (patients 3, 4, 6, 8, and 10), invasive arterial blood pressure monitoing was instituted due to associated cardiac comobidities and poor left ventricular function.
Of the 10 patients, 9 received ultrasound-guided femoral and sciatic nerve blocks, while 1 (patient 9) received an ultrasound-guided lumbar plexus and sciatic nerve block. Among the 10 sciatic blocks performed, 4 patients received posterior sciatic nerve blocks, 4 received anterior sciatic nerve blocks, and 2 received popliteal sciatic nerve blocks [Table 2]. A high-frequency linear ultrasound probe (Sonosite Edge II, HFL 38, 13-6 MHz) was used for femoral and popliteal nerve blocks, while a low-frequency curvilinear probe (Sonosite Edge II, C60, 5-2 MHz) was used for sciatic and lumbar plexus blocks. Femoral and anterior sciatic nerve blocks were performed with the patient in the supine position, while posterior sciatic and lumbar plexus blocks were administered in the lateral position.
| S. No. | Block type | Approach | Motor Response achieved with peripheral nerve stimulation (current in milliamperes) | US | Needle type | Drug volume and concentration |
|---|---|---|---|---|---|---|
| 1 | Anterior Sciatic | Anterior | 0.6 | Yes | 21 G, 100 mm stimuplex | 0.75% ropivacaine 20 mL |
| Femoral block | 0.48 | Yes | 2% lignocaine 15 mL | |||
| 2 | Anterior Scaitic | Anterior | 0.5 | Yes | 21 G, 100 mm stimuplex | 20 mL 0.5% bupivacaine |
| Femoral block | 0.5 | Yes | 10 mL 2% Lignocaine | |||
| 3 | Posterior Sciatic block | Subgluteal | 0.6 | Yes | 21 G, 100 mm stimuplex | 20 mL 0.5% Bupivacaine |
| Femoral block | 0.45 | Yes | 15 ml 2% lignocaine with adrenaline | |||
| 4 | Popliteal block | Posterior | 0.5 | Yes | 21 G, 100 mm stimuplex | 0.5% bupivacaine 10 mL+2% Lignocaine with adrenaline 10 mL |
| Femoral block | 0.5 | Yes | 0.5% bupivacaine 10 mL+2% lignocaine with adrenaline 10 mL | |||
| 5 | Posterior Sciatic block | Subgluteal | 0.6 | Yes | 21 G, 100 mm stimuplex | 15 mL 0.5% bupivacaine+2% lignocaine with adrenaline 10 mL |
| Femoral block | 0.48 | Yes | 5 mL 0.5% bupivacaine+10 mL 2% lignocaine with adrenaline | |||
| 6 | Anterior Sciatic | 0.6 | Yes | 21 G, 100 mm stimuplex | 15 mL of 0.5% Bupivacaine | |
| Femoral block | 0.5 | Yes | 15 mL of 2% Lignocaine | |||
| 7 | Posterior Sciatic block | Transgluteal | 0.5 | Yes | 21 G, 100 mm stimuplex | 20 mL 0.5% Bupivacaine |
| Femoral block | 0.5 | Yes | 10 mL of 2% Lignocaine with adrenaline | |||
| 8 | Anterior Sciatic block | 0.6 | Yes | 21 G, 100 mm stimuplex | 10 mL 2% lignocaine+10 mL of 0.5% bupivacaine. | |
| Femoral block | 0.5 | Yes | 10 mL 0.5% bupivacaine+5 mL 2% lignocaine | |||
| 9 | Lumbar plexus block | Shamrock | 0.48 | Yes | 21 G, 100 mm stimuplex | 10 mL 2% lignocaine+10 mL of 0.5% bupivacaine |
| Posterior Sciatic nerve block | Transgluteal | 0.6 | Yes | 10 mL 2% lignocaine+10 mL of 0.5% bupivacaine | ||
| 10 | Popliteal block | Posterior | 0.5 | Yes | 21 G, 100 mm stimuplex | 10 mL of 0.5% bupivacaine+10 mL of 2% lignocaine with adrenaline |
| Femoral block | 0.5 | Yes | 10 mL 0.5% bupivacaine+5 mL 2% lignocaine with adrenaline |
US: Ultrasound
As per the institutional protocol, all multi-comorbid patients were transferred to the ICU for post-operative monitoring.
Block techniques
Femoral nerve block
A high-frequency linear ultrasound probe was placed at the inguinal crease. The femoral artery was identified, and the femoral nerve was visualized lateral to the artery as a hyperechoic structure. Using a 100 mm 21 G Stimuplex needle, 10–20 mL of LA was injected around the nerve to achieve circumferential spread.
Anterior sciatic nerve block
A curvilinear probe was placed approximately 8 cm below the inguinal crease. The sciatic nerve was identified as a round hyperechoic structure medial to the femur and deep to the adductor magnus muscle. After confirming with peripheral nerve stimulation (motor response at <0.6 mA), 20–25 mL of LA was injected.
Posterior sciatic block
With the patient in the lateral position, a low-frequency curvilinear probe was placed between the ischial tuberosity and the greater trochanter of the femur. The sciatic nerve was identified beneath the gluteus maximus and superficial to the quadratus femoris muscle. A total of 20–25 mL of LA was deposited around the nerve.
Popliteal sciatic block
With the patient in the lateral position, a high-frequency linear probe was placed at the apex of the popliteal fossa. The popliteal artery was identified, and the sciatic nerve was localized superficially and laterally to the artery. 20–25 mL of LA was deposited at the bifurcation of the sciatic nerve into the tibial and peroneal nerves.
Lumbar plexus block
A lumbar plexus block was administered in one patient (patient 9) scheduled for above-knee amputation [Table1]. The patient was positioned in the lateral decubitus position with the operative side up. The transverse process and vertebral body of L4 were identified. With the psoas muscle anterior to the transverse process, erector spinae posteriorly, and the quadratus lumborum attached to the tip of the transverse process, the characteristic ‘shamrock’ appearance was visualized. Nerve roots were identified within the psoas muscle, and the block was performed using dual guidance with 20 mL of LA.
Block adequacy was assessed 20 minutes after LA injection for PNB using the pin-prick method. All surgeries were completed successfully without conversion to GA. Only one patient undergoing above-knee amputation (patient 6) was administered intravenous midazolam, fentanyl, and ketamine before commencement of the surgical procedure [Table 1]. As per the institute protocol, all multi-comorbid patients were transferred to the ICU for post-operative monitoring.
One patient required a prolonged ICU stay of 16 days due to the need for multiple transfusions and the development of atrial flutter. No mortality was reported in the immediate post-operative period.
DISCUSSION
In this case series, LL PNBs were successfully performed in all 10 high-risk patients (American Society of Anaesthesiologists physical status III–IV) undergoing DCS. All patients remained hemodynamically stable throughout the perioperative period, and only one patient required supplemental sedation and analgesia.
Giannoudis et al. proposed the fundamental stages of damage control orthopaedics (DCO).3-5 At our institute, a similar protocol is followed: patients with hemodynamic instability are admitted to the ICU for resuscitation, evaluation, and optimization. Following multidisciplinary discussion among the intensivist, surgeon, and anesthesiologist, patients are transferred to the OR.
Anesthetic management of patients with multiple comorbidities undergoing emergency LL surgery poses a significant challenge. These patients require optimization, aggressive monitoring, and post-operative ICU care, with an inherent risk of perioperative morbidity and mortality.
Neuraxial anesthesia, particularly spinal anesthesia, is traditionally considered the gold standard technique for LL surgeries.6-9 However, it can result in profound hypotension and cardiovascular collapse in patients with compromised cardiac status due to sympathetic blockade. Although alternatives such as super-selective spinal anesthesia and continuous segmental epidural techniques exist, they may still be detrimental.10 Epidural analgesia also requires high dependency post-operative care.11 In addition, it carries risk in the presence of a deranged coagulation profile. According to our institutional protocol, neuraxial anesthesia is considered safe only in patients with an INR <1.5, an activated partial thromboplastin time <35 s, platelet count >80,000/mcl, clopidogrel discontinuation of more than 5 days, and the last dose of low-molecular-weight heparin more than 12 h prior.12
GA may also be undesirable in this population due to the potential risk of exaggerated stress response, hemodynamic instability during induction and intubation, airway complications, inadequate post-operative analgesia, stress response during extubation, post-operative restlessness, delirium, and delayed recovery.13 In addition, GA involves the administration of multiple medications, each associated with potential adverse effects.
A retrospective study that compared anesthetic techniques for LL amputations demonstrated that regional anesthesia was associated with a lower incidence of post-operative pulmonary complications and cardiac arrhythmias.14 PNBs are particularly advantageous in critically ill patients, as they provide excellent analgesia with minimal or no sympathetic blockade, thereby maintaining hemodynamic stability.15
The introduction of ultrasound has significantly improved the success rate and safety of PNBs. Advances in needle design and imaging allow precise needle placement and accurate visualization of LA spread. Furthermore, catheter-based techniques can reduce opioid requirements and facilitate early mobilization and rehabilitation.16,17 For above-knee surgeries, the femoral, obturator, and lateral femoral cutaneous nerves must be blocked separately in addition to the sciatic nerve block. Alternatively, a lumbar plexus block combined with a sciatic nerve block may be employed. For surgeries performed below the knee, a femoral nerve block combined with a sciatic nerve block is generally sufficient.
A case series of 10 patients with above-knee amputation was reported by Baddoo,18 who used the landmark-based technique for a 3-in-1 femoral nerve block and Labat’s sciatic nerve block, with partial block failure in 3 cases. In contrast, a large prospective French study that included around 4000 patients demonstrated a success rate of up to 94% with a multiple-injection technique using nerve stimulation and <30 mL LA.1 In the 10 patients included in our case series, the dual-modality approach resulted in optimal blocks. Supplemental sedation and analgesia were required in only one patient (patient 6), who received femoral and sciatic nerve blocks for an above-knee amputation [Table 1]. This was likely due to sparing of the dermatomes of the lateral femoral cutaneous and obturator nerves.
Although previous studies have reported successful emergency LL surgeries under PNBs in anticoagulated patients, we optimized coagulation parameters in 6 of 10 patients before performing regional nerve blocks,19 [Table 1]. No adverse events, including LAST, were observed, despite the larger volume of LA used in significantly morbid patients. We were unable to assess the duration of analgesia and post-operative pain scores. In a retrospective single-cohort study, 57 high-risk patients who were administered PNB successfully underwent above-knee amputations.20 However, our case series included DCO surgeries, debridements, and amputations performed under PNB.
Since ultrasound has revolutionized nerve blocks with precise needle tip placement and visualization of LA spread, it would be prudent to use ultrasound for all nerve blocks.21,22
This study has several limitations. The sample size is small, block techniques were not standardized, and post-operative pain scores and duration of analgesia could not be assessed, as all patients received intravenous fentanyl infusions in the ICU. The effect of site-specific blocks on ICU length of stay was also not evaluated. Nevertheless, the strength of this case series lies in the successful completion of diverse emergency LL surgeries under tailored site-specific PNBs without intraoperative complications.
CONCLUSION
In this heterogeneous cohort of high-risk patients with multiple co-morbidities, site-specific LL PNBs enabled the successful completion of emergency surgeries without intraoperative adverse events. In experienced hands, LL PNBs represent a viable alternative to GA with the potential to improve patient outcomes and reduce perioperative morbidity and mortality.
Author’s contributions:
SD, GB: Data collection & analysis, Literature Review; SD, NG: Study Design; AD, PS: Manuscript Reading.
Ethical approval:
The research/study was approved by the Institutional Review Board at Sancheti Institute for Orthopedics and Rehabilitation, number IEC – SIOR/Agenda 061, dated September 02, 2020.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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