GÜNÜBİRLİK ANESTEZİDE SANTRAL BLOKLAR GÜVENLİ Mİ? Prof. Dr. Ercan KURT GATA Anesteziyoloji ve Reanimasyon AD

Günübirlik Cerrahide Santral Blokların Avantajları Genel anesteziden kaçınma (KOAH, Sleep apne, Obesite, DM, Kardiovaskuler sorunlar) Hastanın genel anestezi korkusu İşlem sırasında cerrahla hasta iletişimi İşlem sırasında tedavi/operasyon seçenekleri tartışılabilir Hızlı yara iyileşmesi Etkin postoperatif analjezi Postoperatif minimal bulantı ve kusma Hastanın hemen ikinci derece derlenme odasına nakli olasıdır Erken mobilizasyon

Günübirlik Cerrahide Santral Blokların Dezavantajı Bloğu gerçekleştirmek ve etkinliğini beklemek için ek zaman Uzamış motor blok İdrar retansiyonu PSBA Geçici sinir hasarı Yaşamı tehdit eden komplikasyonlar Spinal – epidural hematom Kord hasarı İV lokal anestezik enjeksiyonu ve toksisite

Hangi Santral Blok? Cerrahi işlemin tipi Tıbbi problemler Hasta bilgilendirme PSBA, epidural hematom, epidural apse taburculuk sonrası gelişebilir

Günübirlik Cerrahide Santral Bloklar Spinal anestezi Epidural anestezi Kaudal anestezi Kombine spinal epidural anestezi

Epidural Blok (Tek Doz veya Kateter) Avantaj Etkin analjezi PSBA beklenmez Dezavantaj Zaman alıcı Geç başlayabilir LA miktarı çok İV enjeksiyon Yamalı blok Spinal blok Uzamış blok İdrar retansiyonu Günübirlik anestezide kullanılabilir ancak Lokal anestezik toksisitesi, Zaman alması, Yamalı blok riski, göz önünde bulundurulmalıdır

Kaudal Anestezi Nadir kullanılır Uygun olgularda yapılabilir Epidural anestezinin avantaj ve dezavantajları söz konusudur

Spinal Anestezi Avantajları Dezavantajları Etkin blok PSBA Hızlı başlar Teknik kolay Blok süresi kısa LA miktarı az Etkin postoperatif analjezi Dezavantajları PSBA Geçici nörolojik semptomlar İdrar retansiyonu Uzamış motor blok KVS değişiklikleri GNS PSPA İdrar retansiyonu Uzamış motor blok

Kombine Spinal Epidural Anestezi Avantajları Spinal anestezinin hızlı etkisi Kateter postoperatif analjezi Dezavantajları PSBA Katetere bağlı sorunlar İV LA enjeksiyonu İdrar retansiyonu Maliyet Zaman alan bir uygulama Teknik güçlük Kateter Test dozu Gerekli mi? Gerekli

İlaç Seçimi Lidokain Klorprokain Artikain Mepivakain Ropivakain Prilokain Levobupivakain Bupivakain Serum fizyolojik Glikoz Epinefrin Fentanil Sufentanil Meperidin Morfin Neostigmin Klonidin

2-Klorprokain 2-Chloroprocaine superior to lidocaine for spinal anesthesia Spinal lidocaine was extensively used for outpatient Slaty gözden geçirilmeli Narinder Rawal Current Opinion in Anaesthesiology 2008, 21:736–742

Lidokain Nörotoksisiteden sorumlu LA Alternatif LA %2 Klorprokain Düşük doz bupivakain ile lipofilik opioid Düşük doz ropivakain ile lipofilik opioid Slaty gözden geçirilmeli

Spinal Anestezi - Selektif Spinal Anestezi Unilateral Saddle blok Duyusal blok motor bloktan daha güçlü olmalı Doz azaltılmalı; opioid ilavesi LA veriliş hızı, barisite Dezavantajı Zaman kaybı; 10-20 dk beklemek gerekiyor

Tek Taraflı Spinal Anestezi 15-30 dk beklemek uygun Dansitesi yüksek LA kullanılmalı Veriliş hızı 0.5 mL/dk Düşük doz – düşük volüm - düşük hız Beklemek - Başarısız blok Success rate of unilateral spinal anesthesia is dependent on injection flow Enk D Reg Anesth Pain Med 2001 Sep-Oct;26(5):420-7

Düşük Doz Spinal Anestezi 5 mg bupivakain + 10 µg fentanil Total 2 ml SF Yavaş enjeksiyon Etkin analjezi süresi 1-1,5 saat Tam motor çözülme 3-4 saat Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery Ben-David B Anesth Analg 1997 Sep;85(3):560-5

Selektif Spinal Anestezi Walk–in, walk–out spinal anestezi Grup I Lidokain 20 mg + 25 µg fentanil Grup II Lidokain 20 mg + 20 µg sufentanil Grup III Lidokain 10 mg + 10 µg sufentanil Total volüm 3 ml Selective spinal anesthesia for outpatient laparoscopy. I: characteristics of three hypobaric solutions. Bergeron L Anesthesiology 2001 Aug;95(2):314-23

Düşük Doz Hiperbarik Bupivakain 4 mg hiperbarik bupivakain + 10 µg fentanil 3 mg hiperbarik bupivakain + 10 µg fentanil Diz atroskopisi Lateral 10 dk Motor blok 80 dk geçmiş (50 olgunun %60’ında) Intrathecal hyperbaric bupivacaine 3 mg + fentanyl 10 µg for outpatient knee arthroscopy with tourniquet Korhonen AM Acta Anaesthesiol Scand. 2003 Mar;47(3):342-6

Düşük Doz Lokal Anestezik - Unilateral Spinal Blok 3 mg veya 4 mg % 0.5 hiperbarik bupivakain 3 mg 0.6 mL veya 4 mg 0.8 mL 25 G orta hat L3–4 aralığı 30 sn de enjeksiyon Lateral pozisyon da 10 dk bekletilip sonra supin Use of Small-Dose Bupivacaine (3 mg vs 4 mg) for Unilateral Spinal Anesthesia in the Outpatient Setting To the Editor: The use of lidocaine in outpatient anesthesia, especially in lithotomy and knee arthroscopy positions, increases the risk of transient neurological symptoms (1), whereas bupivacaine might delay the recovery of motor functions and cause urinary retention, leading to delayed discharge of the patient (2). This has increased the interest in small doses of bupivacaine and techniques to produce unilateral spinal anesthesia (3,4). Small-dose intrathecal local anestheticopioid combinations increase nausea and vomiting as well as pruritus (5,6). We designed a study to assess the efficacy of two different doses (3 mg and 4 mg) of 0.5% hyperbaric bupivacaine in patients undergoing outpatient knee arthroscopy under spinal anesthesia. After approval of hospital ethics committee, this study was conducted on 40 adult patients presenting for elective knee arthroscopy. Patients with contraindications to regional anesthesia, diabetes, or peripheral neuropathy were excluded. Informed consent was obtained from all the patients. Patients were randomized using a coded envelope technique to receive one of the two subarachnoid doses of 0.5% hyperbaric bupivacaine: 3 mg (0.6 mL) or 4 mg (0.8 mL). With the operative side dependent, a 25-gauge Yale® spinal BD needle with beveled tip was inserted in midline of L3–4 interspace. After ensuring free flow of CSF, the needle level was turned towards the dependent side and the dose was given over 30 s. Patients were kept in the lateral position for 10 min and then made supine. Highest dermatome level of sensory blockade, Shashi Kiran Anesth Analg 2004;99:301–13

Spinal Blok Özellikleri 3mg Grubu (s=19) 4mg Grubu Unilateral/bilateral Spinal Anestezi (Hasta Sayısı) 16/3 17/2 S2’ye Geri Dönüş Zamanı (dk) 124.0±32 137 ±19 Motor Blok Süresi (dk) 74 ± 27 77.3 ± 27.5 Miksiyon Zamanı (dk) 212.3 ± 95 200.2 ± 66.1 Taburcu Zamanı (dk) 232.0 ±90.0 224.2 ± 67.0 Shashi Kiran Anesth Analg 2004;99:301–13

Düşük Doz LA ile Spinal Anestezi 5 mg bupivakain 7,5 10 12,5 µg fentanil Intrathecal fentanyl added to intrathecal bupivacaine for day case surgery: a randomized study Goel S Eur J Anaesthesiol 2003 Apr;20(4):294-7

Düşük Doz LA ile Spinal Anestezi Hiperbarik ropivikain 7,5 mg Levobupivakain 5 mg Eve taburculuk 197 dk Spinal anesthesia with hyperbaric levobupivacaine and ropivacaine for outpatient knee arthroscopy: a prospective, randomized, double-blind study Cappelleri G Anesth Analg. 2005 Jul;101(1):77-82

Düşük Doz LA ile Spinal Anestezi Her bir mg bupivakain eve taburculuğu 21 dk geciktirir 7mg bupivakain < Dose-response characteristics of spinal bupivacaine in volunteers. Clinical implications for ambulatory anesthesia Liu SS, Ware PD, Allen HW, Neal JM, Pollock JE. Anesthesiology. 1996 Oct;85(4):729-36

Saddle Blok - Prostat Brakiterapi Hiperbarik bupivakain 5 mg İzobarik bupivakain 2,5 mg + 25µg fentanil Kombine yapılan grupta miksiyon, yürüme 40 dk daha hızlı An evaluation of general and spinal anesthesia techniques for prostate brachytherapy in a day surgery setting Flaishon R Anesth Analg 2005 Dec;101(6):1656-8

Spinal Anestezi ve İdrar Retansiyonu İdrar yapma güçlüğü olanlarda oran %5 Mesane distansiyonu Yüklenen sıvı miktarı Mesane ultrasonu 400 ml’den az ise eve taburcu edilebilir 600 ml’de kateterizasyon yapılabilir Postoperatif 8 saat takip Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia Mulroy MF Anesthesiology 2002 Aug;97(2):315-9

Düşük Doz LA ile Spinal Anestezi 8 mg bupivakain, 8 mg levobupivakain, 12 mg ropivakain İngunal herni tamiri Motor blok en hızlı levobupivakain ve ropivakainde kalkıyor Eve taburculuk aynı İdrar retansiyonu yok 5 saat içinde miksiyon A prospective, randomized, double-blind comparison of unilateral spinal anesthesia with hyperbaric bupivacaine, ropivacaine, or levobupivacaine for inguinal herniorrhaphy Casati A Anesth Analg 2004 Nov;99(5):1387-92

Hiperbarik Ropivakain-Unilateral Spinal Blok 2ml volüm grup I 1ml ropivakain (10mg/ml) 0.4 ml fentanil (20 µg/ml) 0.5 ml glikoz (300mg/ml) 0.1 ml sodyum klorid (9mg/ml) 2ml volüm grup II 1ml ropivakain (10mg/ml) 0.5 ml glikoz (300mg/ml) 27 G pencil point 20 sn üstünde, aspirasyon/barbotaj yapmadan Hızlı etki başlangıcı 1 saatte tam derlenme 2,5 saatte yürüme A Comparison of Intrathecal Plain Solutions Containing Ropivacaine 20 or 15 mg Versus Bupivacaine 10 mg Helena Kallio, MD, PhD*, Eljas-Veli T. Sna¨ll, MD*, Markku P. Kero, MD*, and Per H. Rosenberg, MD, PhD† *Department of Anesthesia, Forssa District Hospital, Forssa, Finland; and †Department of Anesthesiology Spinal Hyperbaric Ropivacaine-Fentanyl for Day-Surgery Helena Kallio Regional Anesthesia and Pain Medicine, Vol 30, No 1, 2005: pp 48–54

Spinal Anesteziden Derlenme Ropivakain 20 mg 15 mg Bupivakain 10 mg İlk oral alım zamanı (saat) 1.8 (1.6-2.1) 1.8 (1.6-2.2) 1.7 (1.5-2.1) Miksiyon zamanı 5.2 (4.6-5.7) 4.8 (4.0-5.8) 5.0 (4.4-5.6) Taburcu olmaya uyum (saat) 6.4 (5.5-8.0) 6.4 (5.4-6.9) 6.0(5.2-6.6) Taburcu 7.1 (6.0-8.6) 6.9 (5.8-20.0) 6.6 (5.9-9.0) Hastanede yatılı / günübirlik (sayı/sayı) 4/26 9/21 6/24 A Comparison of Intrathecal Plain Solutions Containing Ropivacaine 20 or 15 mg Versus Bupivacaine 10 mg Helena Kallio Anesth Analg 2004;99:713–7

Düşük Doz Lokal Anestezik Ropivakain 15 mg en uygun taburculuk kriteri sağlıyor Intrathecal, plain solutions containing ropivacaine 20 and 15 mg are suitable for ambulatory lowerextremity surgery of approximately one hour. The major advantage of ropivacaine 15 mg, in particular, is a faster motor recovery compared with bupivacaine 10 mg. A Comparison of Intrathecal Plain Solutions Containing Ropivacaine 20 or 15 mg Versus Bupivacaine 10 mg Helena Kallio Anesth Analg 2004;99:713–7

Günübirlik Cerrahide Spinal Anestezi Prilokain 60 mg Hiperbarik bupivakain 15 mg T-12 Motor blok S1 Miksiyon Prilokain(dk) 60 135 240 306 Bupivakain (dk) 120 210 360 405 Spinal anaesthesia in day-case surgery. Optimisation of procedures] (Spinalanästhesie in der Tageschirurgie. Optimierung der Abläufe.) Full Abstract BACKGROUND: Since prilocaine is being increasingly used for day case surgery as a short acting local anaesthetic for spinal anaesthesia and because of its low risk for transient neurological symptoms, we compared it to bupivacaine. PATIENTS AND METHODS: Patients (n=88) who were scheduled for lower limb surgery with spinal anaesthesia randomly received 15 mg hyperbaric bupivacaine 0.5% or 60 mg hyperbaric prilocaine 2% (administered in a sitting position). Onset time, intensity, duration of the sensomotoric block, vital parameters and time of spontaneous miction were recorded and patients were questioned on satisfaction with the anaesthesia procedure and the occurrence of adverse side-effects after 24 h. RESULTS: Bupivacaine caused a significantly higher sensory block than prilocaine (T6 vs. T8). Both groups were similar in reaching an analgesic level of at least T12, block intensity and onset times. Median analgesic levels at T12 were maintained for 60 min with prilocaine versus 120 min with bupivacaine, regression of the motor block was 135 min versus 210 min, sensory block S1 was 240 min versus 360 min, and time for spontaneous miction was 306 min versus 405 min, respectively (differences for all comparisons were statistically significant). CONCLUSION: Under the present study conditions, hyperbaric prilocaine 2% was superior to hyperbaric bupivacaine 0.5% due to a shorter effect profile but otherwise equivalent quality of block. However, puncture in a sitting position and positioning with elevated torso for restriction of the cranial expansion of block spread might cause an enhanced sacral block with delayed recovery of bladder function.

Düşük Doz LA ile Epidural Blok 20 ml 0,5mg lidokain + 0.5 µg/kg sufentanil Etki 6 – 10 dk Başarı %86 Kurtarıcı analjezi 5-10 ml lidokain aynı doz 20-30 mg iv Ketamin Low dose epidural lidocaine/sufentanil is effective for outpatient lithotripsy Kwa AM Middle East J Anesthesiol 13:71-78, 1995

Epidural Anestezide 2- Klorprokain %3 2 - Klorprokain 130 ± 17 dk (105 ile 160 dk) %1,5 Lidokain 191 ± 32 dk (144 ile 251 dk) %3 2 - Klorprokain 1 saat erken taburculuk Epidural 3% 2-chloroprocaine without epinephrine is an advantageous choice for ambulatory knee arthroscopy. It enables readiness for discharge an hour sooner than 1.5% lidocaine, requires fewer reinjection interventions, and may reduce delayed discharge secondary to prolonged time to void. This clinical study shows the superiority of epidural 3% 2-chloroprocaine over 1.5% lidocaine for expediting hospital discharge after ambulatory surgery. Reg Anesth Pain Med 2001;26:35-40. A computer-generated numbers list randomized patients to receive equipotent doses5 of either 3% 2-chloroprocaine (Nesacaine MPF [containing ethylenediaminetetraacetate (EDTA)]; Astra USA, Inc, Westborough, MA) or 1.5% lidocaine (preservative-free; Abbott Laboratories, North Chicago, IL), both without epinephrine. Hospital Discharge After Ambulatory Knee Arthroscopy: A Comparison of Epidural 2-Chloroprocaine Versus Lidocaine Joseph M. Neal Regional Anesthesia and Pain Medicine, Vol 26, No 1, 2001: pp 35–40

Epidural Serum Fizyolojik Enjeksiyonu Regional anaesthesia and pain medicine Vol. 23 No: 3, 1998 Epidural kateter 17G 15 ml % 2 lidokain 1 ml % 8.5 bikarbonat 20 ml SF Bolus uygulanınca Lokal anestezik dilüe Lokal anestezik yayılıyor ve emilim hızlanıyor

Epidural Serum Fizyolojik Enjeksiyonu Reversal of Prilocaine Epidural Anesthesia Using Epidural Saline or Ringer’s Lactate Washout Katırcıoglu K Regional Anesthesia and Pain Medicine Vol. 32 No. 5, 2007 Epidural kateter 17G 3 ml %2 prilokain 15 ml %2 prilokain bolus 45 ml SF Bolus veya infüzyon 45 ml RL Bolus veya infüzyon LA dilüe oluyor LA yayılıyor ve emilim hızlanıyor

Yüksek Volüm Epidural SF Uygulaması Epidural washout with high volumes of saline to accelerate recovery from epidural anaesthesia. Rodriguez J Acta Anaesthesiol Scand 2001;45:893-898 Reversal of lidocaine with epinephrine epidural anesthesia using epidural saline washout Sitzman BT Reg Anesth Pain Med 2001;26:246-251

Günübirlik Cerrahide Spinal ve Genel Anestezi Spinal anestezi: 5 mg Bupivakain + 25 µg fentanil Genel Anestezi: TİVA (propofol + remifentanil) Sonuç; TİVA 1 saat önce taburcu Postoperatif ağrı kalitesi spinal grupta daha iyi General anaesthesia or spinal anaesthesia for outpatient urological surgery Erhan E Eur J Anaesthesiol 2003; 20:647–652

Günübirlik Cerrahide Spinal ve Genel Anestezi TİVA Spinal 26 G pencil point oturur pozisyon L3-5 1ml %5 Hiperbarik bupivakain 2,5 mg Hiperbarik bupivakain +25 µg fentanil TİVA erken miksiyon ve erken taburculuk An Evaluation of General and Spinal Anesthesia Techniques for Prostate Brachytherapy in a Day Surgery Setting Ron Flaishon, MD*‡, Perla Ekstein, MD*, Haim Matzkin, MD†, and Avi A. Weinbroum, MD*§ Departments of *Anesthesiology and Critical Care Medicine, †Urology, ‡Day Surgery, and §Post-Anesthesia Care Units, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Israel We evaluated four anesthetic techniques for transperineal brachytherapy of the prostate in a day-surgery setting: general anesthesia with either fentanyl and propofol total IV anesthesia (TIVA) or with fentanyl, thiopental, and isoflurane (F-P-I), versus spinal block using 5mg of 0.5% large-dose spinal hyperbaric bupivacaine (LDS) or 2.5 mg of 0.5% hyperbaric bupivacaine plus fentanyl 25 g small-dose spinal (SDS). Operating room time was shorter in the general anesthesia groups. TIVA patients voided earlier (103 41 min) than F-P-I patients (131 65 min), SDS (126 55 min), and LDS patients (16965 min; P0.05 TIVA versus all groups and between spinal groups). TIVA patients were discharged earlier (11942 min) than F-P-I patients (160 69 min) and SDS or LDS patients (132 53 and 186 72 min, respectively; P 0.05 versus all groups and between the spinal groups). There were no intergroup differences regarding postanesthesia nausea or vomiting, pain score, return to normal function at home, or overall satisfaction. Whereas all four techniques are suitable for this procedure, TIVA provides the earliest voiding and consequently fastest discharge. Between spinal techniques, the SDS technique requires more intraoperative sedation but provides earlier voiding and consequently earlier discharge. TIVA, general anesthesia with isoflurane and fentanyl, and two spinal techniques (5 mg of bupivacaine 0.5% or 2.5 mg of bupivacaine 0.5% plus 25 g of fentanyl) are suitable techniques for transperineal brachytherapy in the daysurgery setting. TIVA allows for earliest voiding and therefore fastest discharge home. Spinal block with 2.5 mg of bupivacaine plus 25 g of fentanyl provides earlier voiding and consequently earlier discharge than 5mg of bupivacaine alone. An Evaluation of General and Spinal Anesthesia Techniques for Prostate Brachytherapy in a Day Surgery Setting Ron Flaishon, Anesth Analg 2005;101:1656–8

Günübirlik Anestezide Desfluran ve Spinal Anestezi Small-Dose Selective Spinal Anesthesia for Short-Duration Outpatient Laparoscopy: Recovery Characteristics Compared with Desflurane Anesthesia Pamela H. Lennox, Anesth Analg 2002;94:346–50 2mg/kg propofol 2µg fentanil 0.15 mg/kg mivaküryüm entübasyon %2-6 desfluran +%65 N2O 27 G Whitacre spinal iğne 10 mg 1% lidokain 10 µg sufentanil SF Toplam 3 mL Spinalde erken taburculuk Bulantı kusma az

Günübirlik Cerahide Genel Anestezi ile Nöroaksial Blok Etkilerinin Karşılaştırılması A Comparison of Regional Versus General Anesthesia for Ambulatory Anesthesia: A Meta-Analysis of Randomized Controlled Trials Spencer S. Liu Anesth Analg 2005;101:1634–42 SONUÇ Sayı Deneme Sayısı Santral Nöroaksial Blok(ortalama) Genel Anestezi (ortalama) Anestezi İnduksiyon Zamanı (Dk) 384 7 17.8 7.8 ASBÜ Zamanı (Dk) 476 10 56.1 51.9 ASBÜ deki VAS(mm) 563 12.7 24.4 Bulantı 637 12 % 5 %14.7 Faz 1 geçiş 218 4 % 30.8 %13.5 Postoperatif Analjezi İhtiyacı 716 11 % 31 %56 Ayaktan Cerrahi Ünitesinden Taburcu Olma Süresi (Dk) 839 14 190 153 Hasta Memnuniyeti Mükemmelliği 709 % 81 % 78

Santral bloklarda komplikasyonlar 0.45:10,000 spinal 0.52:10,000 epidural BACKGROUND: The Patient Injury Act has been in effect in Finland since 1 May 1987. This legislation is a no-fault compensation scheme and implies that if a patient during the course of medical treatment suffers any injury as a result of that treatment he or she may file a claim to the Patient Insurance Association (PIA). From 1 May 1987 to 31 December 1993, 23,500 claims for compensation were made. METHODS: All claims made to PIA involving spinal and epidural anaesthesias during the above period were collected and reviewed and a data base was prepared. The total number of anaesthetics given during this period was estimated by sending questionnaires to every hospital in the country. RESULTS: Eighty-six claims were associated with spinal and/or epidural anaesthesia. Respectively, the total the number of spinal and epidural anaesthesias administered was 550,000 and 170,000. There were 25 serious complications associated with spinal anaesthesia: cardiac arrests (2), paraplegia (5), permanent cauda equina syndrome (1), peroneal nerve paresis (6), neurological deficits (7), and bacterial infections (4). The 9 serious complications which were associated with epidural anaesthesia were: paraparesis (1), permanent cauda equina syndrome (1), peroneal nerve paresis (1), neurological deficit (1), bacterial infections (2), acute toxic reactions related to the anaesthetic solution (2), and overdose of epidural opioid (1). CONCLUSIONS: According to this material the incidence of serious complications was 0.45:10,000 following spinal and 0.52:10,000 following epidural anaesthesia. Atraumatic technique, careful patient selection and early diagnosis and treatment of complications are essential in avoiding permanent injury. Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient insurance claims. Aromaa U, Lahdensuu M, Cozanitis DA. Acta Anaesthesiol Scand. 1997 Apr;41(4):445-52.

Santral Bloklarda Komplikasyonlar Spinal Anestezi - 25 Nörolojik defisit (7) Peroneal sinir paralizisi (6) Parapleji (5) Bakteriyel enfeksiyon (4) Kardiak arrest (2) Kalıcı kauda equina sendromu (1)

Santral Bloklarda Komplikasyonlar Epidural Anestezi (9) Yüksek doz LA’e bağlı akut toksik reaksiyon (2) Bakteriyel enfeksiyon(2) Nörolojik defisit(1) Paraparezi (1) Kalıcı kauda equina sendromu(1) Peroneal sinir paralizisi(1) Yüksek doz epidural opioid (1)

PSBA İğne seçimi – pencil point 25-27 non travmatik spinal iğne Teknik zorlaşıyor Deneme sayısı artıyor Durayı geçme hissi alınamıyor Duranın birden çok delinmesi olasılığı

Geçici Nörolojik Semptomlar Lokal anestezik toksisitesi – Lidokain 50 mg üstü Litotomi ve atroskopi pozisyonu Nöral iskemi İğne travması Günübirlik cerrahi İnsidans %15-20 Bupivakain Ropivakain İnsidans % 0-3

Anestezi Sonrası Bakım Ünitesi Santral blokların avantajı Ağrı yok Bulantı kusma yok Sedasyon yok Erken taburculuk kriterleri Santral blokların dezavantajı Motor blok İdrar retansiyonu Patrik narchi

Günübirlik Cerrahide Taburculuk Kriterleri 4 A kriteri Alertness Uyanıklık Ambulation Yürüme Analgesia Analjezi Alimentation Beslenme Bulantı kusma Şiddetli ağrı Aşırı halsizlik Uzamış motor blok İdrar retansiyonu

Günübirlik Cerrahide Santral Bloklar Güvenilirdir Yazılı onam İyi yetişmiş anestezist Uygun endikasyon Uygun santral blok Uygun hasta seçimi Uygun malzeme ile uygulama 48-72 saat iletişim olanağı Therefore the question arises: Can we afford NOT to use regional anesthesia for outpatient surgery?

Günübirlik Anestezide Santral Bloklar GÜVENİLİR Kısa etkili LA Düşük doz LA + Düşük doz opioid İnce iğne ve atravmatik uç Selektif spinal anestezi Doz-volüm-hız Pozisyon Barisite Adjuvanlar

Günübirlik anestezide santral bloklar Sonuç Etkin postoperatif analjezi Minimal bulantı kusma Erken taburculuk kriterleri Günübirlik anestezide santral bloklar GÜVENİLİRDİR

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