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PERİFERİK SİNİR SÜREKLİ KATETER TEKNİKLERİ

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... konulu sunumlar: "PERİFERİK SİNİR SÜREKLİ KATETER TEKNİKLERİ"— Sunum transkripti:

1 PERİFERİK SİNİR SÜREKLİ KATETER TEKNİKLERİ
Prof. Dr. Ercan KURT Gülhane Askeri Tıp Akademisi Anesteziyoloji ve Reanimasyon AD. Ankara

2 Tarihçe Paul Ansbro 1946 Supraklavikuler Kateter
Selander Axiller Kateter Tuominen İnterskalen Kateter Boezaart 1999 Stimüle Edici Kateter

3 Niçin Kateter Kardiyak stresi azaltır Mobilizasyonu arttırır
Bakım maliyetlerini azalır Hasta memnuniyetini arttırır Santral bloklara göre daha az hemodinamik bozukluk gözlenir Daha az opioid kullanımı (bulantı kusma, sedasyon, uyku bozukluğu) söz konusudur

4 Endikasyonlar Major ekstremite operasyonları Postoperatif analjezi
Kopan ekstremitenin yerine dikilmesi Ayak parmağının ele taşınması Analjezi İmmobilizasyon Sempatik blok ve kan akımında artış Yatağında pansuman olanağı Postoperatif analjezi Rehabilitasyon – İmmobilizasyon Kronik ağrı tedavisi Meme ca pleksusa metastaz Üst kolda ve omuzda tümöral kitle

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6

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8 Kateterler Nereye Konabilir
Üst ekstremite Aksiller İnfraklavikular Supraklavikuler İnterskalen Alt ekstremite Femoral Psoas kompartman Siyatik Popliteal Tibiyal sinir

9 PSB Devamlı Kateter Teknolojik yenilikler İğne sistemleri Kateterler
Görüntülemede ultrasonografi Sinir haritalaması İğne sistemleri İğne içinden kateter İğne üzerinden kateter Kateterler Stimüle edilmeyen kateterler Stimüle edilen kateterler Tek kullanımlık infüzyon pompaları Elektronik Elastometrik

10 Hastanede (Evde) Devamlı Periferik Sinir Kateterleri
Dikkatli hasta seçimi Hastanın onamı, istekli olması Hastanın yanında kalan birisi olmalı Perinöral kateterin iv yerleşimde olmamasının test edilmesi %0.05 Rop 1: epinefrin 5 ml. Hasta ve yakınını eğitimi Sözlü ve yazılı talimatlar verilmeli Breakthrough ağrı, ilave analjezikler Lokal anestezik toksisitesi Blokaja bağlı gelişen semptomlar İnfüzyon pompasının durdurulması veya çalıştırılması 7 gün 24 sa anestezistte ulaşılabilirlik Hastanın telefonla günlük takip ve kontrolü

11 Stimüle Edici Kateterler
Avantajları Blok güvenirliliğini artırıyor Blok oluşma zamanını kısaltır Kateter düşük akımla sinirin yakına yerleştirilebilir ( mA) Devamlı real-time stimulasyon Daha az LA harcanması Kateterin yerinin doğruluğunun postoperatifte kontrolü

12 Stimüle Edici Kateterler
Dezavantajları Kateterin düzgün yerleştirebilmesi için birden fazla deneme gereksinimi Kateterin sertliği ve ucundaki metalin özellikleri ideal mi? Deneyimli uygulayıcı Maliyet

13 RAJ Testi Kateterden lokal anestezik verip etkiliği gözlemek

14 Katetere Bağlı Sorunlar -I
Test doz İntratekal Epidural İV Yer değiştirme olasılığı (iv,interplevral) Myotoksisite

15 Katetere Bağlı Sorunlar - II
İV enjeksiyon Lokal anestezik toksisitesi Sinir hasarı Enfeksiyon Kateterin çalışmaması, tıkanması, kopması İnterskalen veya servikal paravertebral kateterlerde frenik sinir bloğu, ipsilateral diyafragmada paralizi

16 Stimüle Edici Kateterler
Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized, controlled, and observer-blinded trial (81 olguda) Morin AM Anesth Analg May;100(5): 1: Anesth Analg May;100(5): , table of contents. Links Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized, controlled, and observer-blinded trial. Morin AM, Eberhart LH, Behnke HK, Wagner S, Koch T, Wolf U, Nau W, Kill C, Geldner G, Wulf H. Department of Anesthesiology and Critical Care Medicine, Philipps-University Marburg, Baldingerstrasse, Marburg, Germany. Continuous peripheral nerve blocks offer the benefit of extended postoperative analgesia and accelerated functional recovery after major knee surgery. Conventional nerve localization is performed over a stimulating needle followed by blind insertion of the peripheral catheter. Correct catheter placement is confirmed by testing for satisfactory analgesia. Stimulating catheters offer the advantage of verifying correct placement close to the nerve during catheter placement. The aim of this randomized trial was to determine whether accurate catheter positioning under continuous stimulation accelerates the onset of sensory and motor block, improves the quality of postoperative analgesia, and enhances functional recovery. We compared femoral nerve catheters inserted under continuous stimulation with catheters that were placed using the conventional technique of blind advancement in 81 patients undergoing major knee surgery. Time of catheter placement was similar in both groups with 4 min (3/7.3; median, 25th/75th percentile) in the conventional group and 5 min (4/8.8) in the stimulating catheter group. In both groups, 42% of the catheters could be correctly placed (motor response of the patella with a current < or =0.5 mA) at first attempt. In 22 patients (58%) of the stimulating catheter group, the catheter had to be redirected 1-20 times, including 2 that could not be correctly placed within 20 min. The onset time of sensory and motor block was almost similar in both groups. There were no differences in the postoperative IV opioid consumption, and visual analog scale pain scores at rest and movement, or maximal bending and stretching of the knee joint during the 5 days after surgery. We conclude that with continuous femoral nerve blocks, blind catheter advancement is as effective as the stimulating catheter technique with respect to onset time of sensory and motor block as well as for postoperative pain reduction and functional outcome.

17 Konvansiyonel Kateter (n=43)
Stimulasyon Kateteri (n=38) Kateter yerleştirme zamanı(dk) 4 (3/7.3) 5 (4/8.8) İlk denemede Kateterin Doğru Yerleştirilmesi (≤5mA) 18 (41.9) 16 ( 42.1) Kateter yerleştirmede Hasta Memnuniyeti (VAS 0-10) 2 (0/4) Kateter Yerleştirme zorluğunun Anestezist Tarafından değerlendirilmesi Kolay 15 (34.9) 15 (39.5) Biraz kolay 14 (36.8) Biraz zor 11 (25.6) 8 (21.1) Zor 2(4.6) 1 (2.6) Kateter Süresi (gün) 4 (4/5)

18 Enfeksiyon The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Cuvillon P Anesth Analg Oct;93(4):104 We investigated the incidence of bacterial and vascular or neurological complications resulting from femoral nerve catheters used for postoperative analgesia. Patients requiring continuous femoral blockade were consecutively included. Using surgical aseptic procedure, 211 femoral nerve catheters were placed (short-beveled insulated needle, peripheral nerve stimulator). After 48 h, each catheter was removed and semiquantitative bacteriological cultures were performed on each distal catheter tip. Postoperative analgesia and antibiotics were standardized. All complications during the insertion of the catheters and postoperatively (after 48 h and 6 wk) were noted. Few initial complications with no immediate or delayed complications were noted (20 difficult insertions, 3 impossible injections, 3 ineffective catheters, and 12 vascular punctures). After 48 h, 208 catheters were analyzed; 57% had positive bacterial colonization (with a single organism in 53%). The most frequent organisms were Staphylococcus epidermidis (71%), Enterococcus (10%), and Klebsiella (4%). Neither cellulitis nor abscess occurred. Three transitory bacteremias likely related to the catheter occurred. After 6 wk, no septic complications were noted. One femoral paresthesia, partially recovered 1 yr later, was noted. We conclude that the risk of bacterial complications is small with femoral nerve catheters, although the rate of colonization is frequent. IMPLICATIONS: In this prospective study, continuous femoral nerve catheters were effective for postoperative analgesia but had a frequent rate of bacterial catheter colonization. We found no serious infections after short-term (2-day) infusion. Side effects were few, but one nerve injury occurred.

19 Enfeksiyon 208 femoral kateter 48 sa. sonra Kateter ucu
120 olgu da (57) pozitif kültür 3 olguda ısıda artış bakteriyemi kateter ve kan kültürü pozitif stafilokokus epidermitis antibiyotik vermeden takip ve iyileşme

20 İnfüzyon Hızı 4-8 ml Sa. %0.25 Bup + %1 lidokain
%0.125 Bup + 1 µg/ml fentanil Bolus 2-5 ml. Lockout dk Anatomik lokalizasyon Konsantrasyon arttıkça LA toksisitesi Adjuvanlar klonidin, fentanil, morfin, sufentanil, epinefrin

21 İnfüzyon Pompasının Seçimi
Programralanabilen tekrar kullanılabilir modeller Programralanabilen tek kullanılımlık modeller Programralanamayan tek kullanılımlık modeller bazal ve bolus olasılığı olan modeller Programralanamayan tek kullanılımlık modeller bazal veya bolus olasılığı olan modeller Doğruluk,güvenirlik Bolus doz imkanı Programlanabilme Tek kullanımlık olup olmaması Maliyet

22 Konvansiyonel Stimüle Edilmeyen Kateterler
Devamlı periferik sinir kateteri (İğne içinden kateter uygulaması)

23 Posterior İnterskalen Blok Uygulamasında Devamlı Kateter

24 Posterior İnterskalen Blok Uygulamasında Devamlı Kateter

25 Posterior İnterskalen Blok Uygulamasında Devamlı Kateter

26 Posterior İnterskalen Blok Uygulamasında Devamlı Kateter

27 Posterior İnterskalen Blok Uygulamasında Devamlı Kateter

28 Ayak Parmağının Ele Transferi (Toe – to – hand)

29 Ayak Parmağının Ele Transferi (Toe – to – hand)

30 Stimüle Edici Kateterler

31 Kateter ve Sinir ile Lokalizasyonu

32 Stimüle Edilebilen Kateterler

33 Stimüle Edilebilen Kateterler
Kateterin yerini doğrulama Nörolojik hasarı önleme Kateterin seviyesini tam ayarlama Anestezi altında uygulama olasılığı

34 Stimüle Edilebilen Kateterler
Does Interscalene Catheter Placement with Stimulating Catheters Improve Postoperative Pain or Functional Outcome After Shoulder Surgery? Regional Anest Vol 104(2) 2007 Stevens M.F. Kateterin yerinin kesin doğruluğu Motor sinir bloğunun başlama süresinin kısalması Does Interscalene Catheter Placement with Stimulating Catheters Improve Postoperative Pain or Functional Outcome After Shoulder Surgery? A Prospective, Randomized and Double-Blinded Trial [Regional Anesthesia] Volume 104(2), February 2007, pp Stevens, Markus F. MD, DEAA*; Werdehausen, Robert*; Golla, Elisabeth MD*; Braun, Sebastian MD*; Hermanns, Henning MD*; Ilg, Ansgar MD†; Willers, Reinhardt PhD‡; Lipfert, Peter MD, PhD* Section Editor(s): Horlocker, Terese T. From the Department of *Anesthesiology, †Orthopedics, and ‡Informatics, University of Düsseldorf, Düsseldorf, Germany Regional anesthesia not only reduces postoperative pain, but also facilitates functional recovery after orthopedic surgery (1–3). A major problem of peripheral nerve block catheters is that although a sufficient block can be achieved by initial bolus injection via the cannula, postoperative analgesia through the catheter is insufficient in up to 75% of patients (4,5). The secondary failure rate seems to be highest with interscalene catheters (4,5). Consequently, the interscalene block is theoretically the peripheral nerve block which might benefit most by use of a stimulating catheter. Stimulating catheters have been developed to precisely control catheter placement (6). No previous study has evaluated the effects of stimulating catheters during and after blocks of the upper extremity. Furthermore, there are no studies evaluating the long-term effect of stimulating catheters on the functional outcome after surgery. Hence, we investigated patients undergoing elective shoulder surgery. In these patients postoperative function and outcome are presumably dependent on the ability to perform physiotherapy (7). We hypothesized that a stimulating catheter, by producing superior analgesia, enhances functional recovery 6 wk after surgery. The use of the stimulating catheter improved onset of motor nerve block, but did not reduce postoperative pain, local anesthetic and analgesic requirements. Nevertheless, shoulder function scores improved significantly more in patients with a stimulating catheter. The relatively high complication rate of 10% of patients with long-term postoperative pain is similar to that in a recent study (25) after interscalene brachial plexus blockade with an incidence of postoperative neurologic symptoms of 9.3%–10.1%. Borgeat et al. (26) reported a complication rate after interscalene block of 14% after 10 days, 7.9% after 1 mo, and 3.9% after 3 mo. Likewise, it is always difficult to distinguish among symptoms related to positioning during surgery, surgery itself, or anesthetic technique . Several case reports described idiopathic brachial plexus neuritis after general anesthesia with and without interscalene block. Additional studies are needed to determine the relative risks and benefits of this technique.

35 Stimüle Edilebilen Kateterler

36 Stimüle Edilebilen Kateterler

37 Stimüle Edilebilen Kateterler

38 Stimüle Edici Kateterler

39 Stimüle Edici Kateter KATETERİN UCU GÜVENLİ Mİ? VOLÜM VERİLMELİ Mİ?
Paslanmaz çelik Altın kaplama Platin VOLÜM VERİLMELİ Mİ? %5 Dekstroz %0.9 S. Fizyolojik

40 Çocuklarda US ve Stimüle Edici Kateterler
Ultrasonographic guidance for sciatic and femoral nerve blocks in children Oberndorfer U Br J Anaesth Jun;98(6): Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children Willschke H Br J Anaesth Aug;95(2):226-30 1: Anesth Analg Jun;102(6): Links Ultrasonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume? Willschke H, Bösenberg A, Marhofer P, Johnston S, Kettner S, Eichenberger U, Wanzel O, Kapral S. Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria. Recently, our study group demonstrated the usefulness of ultrasonographic guidance in ilioinguinal/iliohypogastric nerve blocks in children. As a consequence, we designed a follow-up study to evaluate the optimal volume of local anesthetic for this regional anesthetic technique. Using a modified step-up-step-down approach, with 10 children in each study group, a starting dose of 0.2 mL/kg of 0.25% levobupivacaine was administered to perform an ilioinguinal/iliohypogastric nerve block under ultrasonographic guidance. After each group of 10 patients, the results were analyzed, and if all blocks were successful, the volume of local anesthetic was decreased by 50%, and a further 10 patients were enrolled into the study. Failure to achieve a 100% success rate within a group subjected patients to an automatic increase of half the previous volume reduction to be used in the subsequent group. Using 0.2 and 0.1 mL/kg of 0.25% levobupivacaine, the success rate was 100%. With a volume of 0.05 mL/kg of 0.25% levobupivacaine, 4 of 10 children received additional analgesia because of an inadequate block. Therefore, according to the protocol, the amount was increased to mL/kg of 0.25% levobupivacaine, where the success rate was again 100%. We conclude that ultrasonographic guidance for ilioinguinal/iliohypogastric nerve blocks in children allowed a reduction of the volume of local anesthetic to mL/kg.

41 Çocuklarda US ve Stimüle Edici Kateter Uygulaması
Ultrasonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume? Willschke H Anesth Analg Jun;102(6):1680-4 Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. Van Geffen GJ Anesth Analg Aug;103(2):328-33 1: Anesth Analg Aug;103(2):328-33, table of contents. Links Comment in: Anesth Analg Apr;104(4):1001-2; author reply 1002. Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. van Geffen GJ, Gielen M. Institute for Anesthesiology, Medical Centre, Radboud University, PO Box 9101, 6500 HB Nijmegen, The Netherlands. We describe our clinical experience of combining ultrasound guidance and nerve stimulation for the insertion of subgluteal sciatic catheters in children. Ten children scheduled for lower limb surgery with a combined general anesthetic and a subgluteal sciatic catheter placement for both operative anesthesia and postoperative pain relief were studied. Under ultrasonographic guidance the sciatic catheter was placed using an 17-gauge 50-mm Arrow continuous peripheral nerve block needle and a 19-gauge stimulating catheter (Stimucath). The minimal electrical current required for muscle contraction on the stimulating needle and catheter differed widely among patients. Based on the visualization of the spread of local anesthetic during injection through the catheter, a successful prediction for the sciatic block was made in all patients. All catheters were successfully placed and provided excellent postoperative pain relief without complications.

42 Çocuklarda US ve Stimüle edici kateter
Vertical infraclavicular brachial plexus block in children: a preliminary study Marhofer P Paediatr Anaesth Jun;15(6):530-1 Combined ultrasound and neurostimulation guidance for popliteal sciatic nerve block: a prospective, randomized comparison with neurostimulation alone Dufour E Anesth Analg May;106(5):1553-8

43 Elastometrik infüzyon pompası

44 Hareket kabiliyeti Kolay kullanım Evde tedavi olanağı
Anaest. Analg 97: ; 2003 Hareket kabiliyeti Kolay kullanım Evde tedavi olanağı

45 Tünel uygulaması

46 Tünel Uygulaması - I Subcutaneous tunnelling of interscalene catheters
Harrop-Griffiths W Can J Anaesth Jan;48(1):102-3

47 Tünel Uygulaması - II

48 Tünel Uygulaması - III

49 Sabitleme siStemleri

50 Supraklaviküler Kateter - I

51 Supraklaviküler kateter - II

52 Percutaneous Electrode Guidance
A noninvasive technique for prelocation of peripheral nerves to facilitate peripheral plexus or nerve block Urmey WF, Grossi P. Reg Anesth Pain Med 2002; 27:

53 Sinir Haritalaması ve PEG

54 Sinir Haritalaması ve PEG

55 Sinir Haritalaması ve PEG

56 Percutaneous Electrode Guidance
1) Brakiyal pleksus bloğu İnterskalen blok Supraklavikular blok Aksiller blok Midhumeral blok El bileği bloğu 2) Femoral sinir bloğu 3) Popliteal fossa bloğu 4) Tibial sinir bloğu

57 Sinir Haritalaması Haritalama bu yöntemde PEG yöntemine benzer olup cilt üzerinde yüzeyel periferik sinirleri yüksek akımla uyararak en uygun girişim yerini bulma easına dayanmaktadır Noninvaziv yöntemde uygun akımla genellikle mA ile uygun sinirler uyarılabilmekte böylece sinire en yakın yaklaşım noktası bulunabilmektedir Ancak bu yöntemde hasta bu cilt stimülusunda rahatsız olabilmektedir

58 Ultrasonografi Avantaj Dezavantaj Başarı oranını artırır
Cihazın taşınabilirliği Uygulama kolaylığı İncelemenin hiçbir riskinin olmayışı Doz düşük kullanımı Komplikasyon oranının az olması Dezavantaj Uygulayıcı kişinin bilgi ve becerisine bağlı olması Cihazın maliyeti

59 Sonuç PSB preoperatif dönemde hasta ile koopere iken konulmalıdır
Test doz mutlaka yapılmalıdır Lokal anestezik toksisitesi kateter tedavisi sürdüğü müddetçe akıldan çıkarılmamalıdır Uzun süreli kateter uygulamalarında enfeksiyon gelişebileceği bilinmelidir Ultrasonografi, stimüle edici kateterler ve disposibl pompalar gelecek için ümit verici çalışmalardır

60 İLGİNİZE TEŞEKKÜRLER... Prof. Dr. Ercan KURT


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