YENİ PERİFERİK BLOK TEKNİKLERİNİN PRATİĞE KATKISI VAR MI?

... konulu sunumlar: "YENİ PERİFERİK BLOK TEKNİKLERİNİN PRATİĞE KATKISI VAR MI?"— Sunum transkripti:

1 YENİ PERİFERİK BLOK TEKNİKLERİNİN PRATİĞE KATKISI VAR MI?
Prof. Dr. Ercan KURT GATA Anesteziyoloji ve Reanimasyon AD

2 Tarihçe 1884 Halsted ve Hall: Kokaini brakial pleksus köklerine enjekte etti 1911 Hirshel: İlk perkütan aksiller brakial pleksus bloğu 1911 Kulenkampff: İlk perkütan supraklaviküler brakial pleksus bloğu 1917 Brazy: İlk infraklaviküler bloğu 1925 Etienne: İlk interskalen blok uygulaması 1962 Greenblatt: Sinir stimulatörü 1973 Raj: Kateter stabilitesi sağlanmış ilk infraklavikuler brakial pleksus bloğu 1979 Winnie: Pleksus anestezisi için tek enjeksiyonun yeterli olduğunu tanımladı 1981 Rosenblatt ve Cress: Sürekli interskalen blok için Seldinger tekniği 1999 Boezqaart: Sürekli interskalen blok için stimule edilebilir kateter kullanımı

3 Periferik Sinir Stimülatörü
Rejyonal anestezide ilk sinir stimülatörü kullanımı 1962 yılında Greenblatt ve Denson tarafından gerçekleştirilmiştir Needle nerve stimulator-locator: nerve blocks with a new instrument for location of nerves Greenblatt GM, Denson JS Anesth Analg 1962; 41:

4 Periferik Sinir Bloklarında Temel Hedef
Uygun periferik sinire ya da gangliyona uygun dozdaki lokal anesteziği vermektir

5 Periferik Sinir Bloklarında Kullanılan Teknikler
Parezi-parestezi Transarteriyal Sinir stimülasyonu Sinir stimülasyonu+ US Sinir haritalaması + Sinir stimülasyonu Percutaneous electrode guidance (PEG)

6 Periferik Sinir Bloklarında Yeni Tekniklere İhtiyaç Var Mıdır ?
Moore, ’’parestezi yoksa anestezi yoktur (no paresthesia no anaesthesia )’’ olarak verdiği cümleyi Gentili ve Wargnier ’’parestezi yoksa disestezi yoktur’’ olarak söylemişler ’’parestezi yoksa disestezi yoktur, fakat sıklıkla da anestezide başarısızlık vardır’’ Moore DC, Mulroy MF, Thompson GE. Peripheral nerve damage and regional anaesthesia. [Editorial]. Br J Anaesth 1994; 73: 435–6.

7 Alon P Winnie For ultrasound – guided local anaesthesia will become true ’Sooner or later someone will make a sufficiently close examination of anatomy involved, so that exact techniques will be developed’’ Eninde sonunda birisi ilgili anatominin yeteri kadar yakından muayenesini yapacak ve böylece doğru teknikler geliştirilecektir

8 Periferik Sinir Bloklarında Yeni Tekniklere İhtiyaç Var Mıdır ?
Eğitim Anatomik işaret noktalarının daha anlaşılır olması, alternatif teknikler gelişebilir Sinir haritalaması, PEG Kör teknik olması büyük dezavantaj US Birkaç sinirin blokajı için birden fazla enjeksiyon Komplikasyonların azaltılması

9 Periferik Sinir Bloklarında Yeni Tekniklere İhtiyaç Var Mıdır ?
’Anatomik işaret noktalarının hastadan hastaya değiştiği bilinmekte olup, tek başına iğnenin yerleştirilmesinde bu noktalar yeterli midir?’’ HAYIR

10 Periferik Sinir Bloklarında Yeni Tekniklere İhtiyaç Var Mıdır ?
Körlemesine yapılan bir işlemdir Periferik sinir blokları sinire zarar vermemeyi ümit ederek yapılan bir kapalı yaklaşımdır Modern görüntüleme teknikleri bu blokların daha başarılı yapılmasını sağlamaktadır

11 Rejyonel Anestezide Kullanılan Görüntüleme Yöntemlerini
X-ray Mobil Anjiografi Ultrasonografi (US) Renkli Doppler ultrasonografi Bilgisayarlı tomografi (BT) Magnetik rezonans görüntüleme (MRG) Percutaneous electrode guidance (PEG)

12 Periferik Sinir Bloklarında Komplikasyonlar
İNTRAVASKÜLER ENJEKSİYON PARESTEZİ İNTRANÖRAL ENJEKSİYON

13 ÜST EKSTREMİTE BLOKLARI

14 Brakiyal Pleksus Bloğu

15 Anterior İnterskalen Blok
Meiyer Tekniği

16 Posterior İnterskalen Blok

17 Posterior İnterskalen Blok
Pippa Tekniği

18 İnfraklavikular Vertikal Blok

19 Parestezi - Nerve Stimulator - Transarteriyel Teknik
Interscalene approach to the brachial plexus: Paresthesia versus nerve stimulator McClain DA, Finucane BT Reg Anesth 1987; 12:80-3 Does the transarterial technique of axillary block provide a higher success rate and lower complication rate than a paresthesia technique? Winnie AP Reg Anesth 1995; 20:482-5

20 İnterskalen Blok Dewees JL, Schultz CT, Wilkerson FK
Comparison of two approaches to brachial plexus anesthesia for proximal upper extremity surgery: interscalene and intersternocleidomastoid Dewees JL, Schultz CT, Wilkerson FK AANA J 2006, 74(3):201-6

21 İnterskalen Blok Nerve localization techniques for interscalene brachial plexus blockade: a prospective, randomized comparison of mechanical paresthesia versus electrical stimulation G. A. Liguori, V. M. Zayas, J. T. YaDeau, R. L. Kahn, L. Paroli, V. Buschiazzo, and A. Wu Anesth Analg 2006; 103(3):

22 Infraclavicular brachial plexus block a new approach
İnfraklavikular Blok Infraclavicular brachial plexus block a new approach Raj PP, Montgomery SJ, Nettles D, Jenkins MT Anesth Analg 1973,52(6):

23 İnfraklavikular Vertikal Blok
Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study Kilka HG, Geiger P, Mehrkens HH Anaesthesist 1995; 44(5):339-44

24 Aksiller Blok Comparison between conventional axillary block and a new approach at the midhumeral level Bouaziz H, Narchi P, Mercier FJ, Labaille T, Zerrouk N, Girod J, Benhamou D Anesth Analg 1997, 84(5):

25 ALT EKSTREMİTE BLOKLARI

26 Lomber Pleksus Bloğu Psoas kompartman bloğu
Winnie tekniği Capdevila tekniği Chayen tekniği Parkinson tekniği Femoral sinir bloğu (3-1 blok)

27 Psoas Kompartman Bloğu
CI Girişim noktası SİPS Vertebral kolon L5 L4 L3 Winnie Tekniği

28 Psoas Kompartman Bloğu
CI Girişim noktası SİPS Vertebral kolon L5 L3 L4 Capdevila Tekniği

29 Psoas Kompartman Bloğu
We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy In with the New, Out with the Old? Comparison of Two Approaches for Psoas Compartment Block Stephen Mannion Anesth Analg 2005;101: “ In every case in which an anesthetic is to be administered there are three factors which contribute to the result: the special action of the agent, the peculiarities of the patient, and the skill with which the agent is administered” G.MacLeod, Discussion on Anaesthetics,Medico- Churgical Society Proceedings, Glasgow, An accurate knowledge of anatomy must be added as a 4th, very important factor. In this workshop the most important anatomic features will be discussed. The anatomic knowledge is the best prevention against possible complications after peripheral or neuroaxial blocks. Regional block of the peripheral nerves is well described, but not universally used.Most investigations involving peripheral nerve blocks evaluate new techniques, efficacy, and complications. There are few outcome studies.This is unfortunate because PNB have many advantages and represent alternative regional techniques for both intraoperative anesthesia and postoperative analgesia. Peripheral nerve blocks may be used when neuroaxial blocks are contraindicated ( in the anticoagulated and in occasionally in the febrile patients). Advantages of PNB include: ▪ The incidence of severe complications, include cardiac arrest and neurologic injury, is lower in patients reciaving PNB compared with those who underwent neuraxial anesthesia. ▪ambulatory surgical patients are ideally suited for PNB ▪ reduced recovery room admissions, ▪ decreased nausea, vomiting, urinary retention, ▪ improved postoperative analgesia. This benefits may translate into shortened hospital stays, decreased probability of hospital admission and overall reduction in hospital costs and patients charges. Disadvantages ▪ PNB may be more technically demanding than neuraxial anesthesia, often requiring: -multiple injections and increased onset time. ▪ New risks : typically large volumes and dose of local anesthetics are administered over a short time ( test-dose, intermittent aspiration,incremental injection and consistent monitoring are the best prophylaxis ), ▪ Potential ineffectiveness of peripheral nerve blocks which require additional anesthesia Important rules in performing PNB : ▪Correct nerve block can be ensured only by a thorough understanding of the anatomy and by high degreee of technical skills of anesthesiologists. ▪We must determine which surgical procedures are optimally performed with PNB as a primary anesthetic and which are the best accomplished with a combined techniques.They are not suitable for all patients and all procedures. The commonly used PNB The anatomic relationships in following areas will be presented Head and Neck Region: Clinical features: ■Compact anatomy with constant and easy to locate landmarks. ■Close relationship of cranial and cervical nerves which supply many vital organs Therefore: ■Meticulous placement of the needle by thorough understanding of the anatomy ■Only small doses of the anesthetic agent are required.However small doses of the LA can provide: effective regional block but may also result in systemic toxicity! Deep and superficial cervical plexus: carotid endarterectomy, extirpation of cervical lymph nodes, plastic surgery Ganglionblocks Clavicle , shoulder, upper arm : Interscalene brachial plexus block ( single shot or continuous technique or in combination with basic general anesthesia ) Surgery in the arm below the elbow and in the hand : Axillary and infraclavicular brachial plexus block as the method of choice for all general, vascular,neurosurgical or orthopedic interventions and manipulations as single shot or continuous technique. Lower extremities ▪Inguinal femoral paravascular block ( “ three-in – one” block ) ▪Psoas compartment block “ Threee-in-one” nerve block and psoas compartment nerve block as a continuous or single technique are indicated for all surgical procedures in the region of the lower extremity in ischemia / tourniquet, but in combination with a block of the sciatic nerve. A need for larger volumes of local anesthetics must be expected (systemic toxicity). ▪Sciatic nerve block ( transgluteal, subgluteal ) ▪Distal scaiatic nerve block ( popliteal fossa nerve block) for procedures in the lower leg . ▪Ancle and foot block ( posterior tibial nerve,deep peroneal nerve, sural nerve / superficial peroneal nerve and saphenous nerve) for surgical procedures in the foot area. Femoral nerve block may replace epidural analgesia as the preferred method of postoperative pain relief in patients undergoing total knee arthroplasty.Femoral nerve blocks may be performed intermittently with a long-acting local anesthetic or administered through an indwelling catheter with no risk of spinal hematoma or urinary retention, and patients are able to ambulate. Large neural structures, such as the brachial plexus, sciatic and tibial nerves may be blocked continuously through surgical placement of a catheter within the nerve sheath. Nerve sheath catheters provide excellent analgesia after amputation. Additional studies are needed to evaluate their efficacy for prevention of the phantom limb pain. Upper extremity blocks are the most commonly performed.Lower extremity techniques other than ankle block are seldom used.The difference in use of upper and lower extremity techniques is statistically significant.A possible explanation for this finding may be the ease of performance and high success rate typically associated with brachial plexus block, neuraxial and intravenous regional anesthesia. In contrast, the lower extremity PNB`s may be considered more technically demanding, and multiple blocks may be required to anesthetize the entire extremity.In addition, neuraxial anesthesia is almost always a viable regional anesthesia option for lower extremity surgery, whereas an effective alternative for blocks of the upper extremity is not available. Paravertebral somatic nerve blocks Sympathetic nerve blocks Neuroaxial Blocks and related Anatomy The most important anatomic relationships in spinal anesthesia , epidural (and caudal) anesthesia will be discussed. Conclusion We must return to the antomy laboratory and anatomic texts to review the pertinent relationships and distances among skin, vessels, and nerves.The importance of instruction by anesthesiologists experienced in peripheral nerve blocks must be emphasized. In the foreword to Gaston Labat`s classic text, Regional Anesthesia.Its Technic and Application,William Mayo wrote : “ Regional anesthesia has come to stay.Its development and progress have been slow, principally because the anesthetist must have an accurate knowledge of anatomy and high degree of technical skill in order that the anesthesia be safe and satisfactory, and the operation not delayed” These words were visionary when written nearly a century ago and remain relevant as we approach the new millenium. References 1. Hadzic, A., Vloka,J.,Kuroda,M.,Koorn,R.,Birnbach,D.:The practice of peripheral nerve blocks in the United States: A national survey.Reg Anesth and Pain Med (23) (1998) 2. Horlocker,T.: Peripheral nerve blocks – regional anesthesia for the new millenium. Reg Anesth and Pain Med (23) (1998 ) 3. Jankovic, D.: Regional Nerve Blocks & Infiltrationstherapy, Textbook and Color Atlas (3rd ed).Blackwell Science, Oxford ( 2004 ) 4. Koch,T.,Heller, A.: Pathophysiologische und ökonomische Aspekte bei Regionalanästhesieverfahren.Anästhesie & Intensivmed. (41) ( 2000)

30 Psoas Kompartman Bloğu
CI Girişim noktası SİPS 5 cm Vertebral kolon 3 cm L3 L5 L4 Chayen Tekniği

31 Psoas Kompartman Bloğu
CI Girişim noktası SİPS 3-4 cm Vertebral kolon L5 L4 L3 Parkinson Tekniği

32 Siyatik Sinir Bloğu Anterior yaklaşım (Meier tekniği)
Posterior yaklaşım (Labat tekniği) Parasakral yaklaşım (Mansour tekniği) Litotomi yaklaşım (Raj tekniği)

33 Anterior Siyatik Sinir Bloğu Beck/Meier Tekniği
Beck Tekniği

34 Siyatik Sinir Bloğu Anterior Yaklaşım
Medial Lateral SİAS İnguinal ligament 2/3 1/3 . TM PT Meier Tekniği Girişim noktası

35 Siyatik Sinir Bloğu Posterior Yaklaşım
TM TM 1/2 1/2 1/2 SİPS SİPS SH Labat Tekniği Girişim noktası

36 Siyatik Sinir Bloğu Litotomi Yaklaşımı
Girişim noktası 1/2 TM TI TM Girişim noktası Raj Tekniği

37 Siyatik Sinir Bloğu Parasakral Yaklaşım
Girişim noktası SİPS TI Mansour Tekniği

38 Siyatik Sinir Bloğu The Effects of Three Different Approaches on the Onset Time of Sciatic Nerve Blocks with 0.75% Ropivacaine Taboada, Manuel MD Anesth Analg 98(1) 2004 pp 242-7

39 Siyatik Sinir Bloğu A new posterior approach to the sciatic block: a prospective, randomized comparison with the classic posterior approach Di Benedetto P, Bertini L, Casati A, et al Anesth Analg 2001; 93: 1040–4

40 Siyatik Sinir Bloğu Sciatic nerve block via posterior Labat approach is more efficient than lateral popliteal approach using a double-injection technique: a prospective, randomized comparison Taboada M, Rodríguez J, ALvarez J, Cortés J, Gude F, Atanassoff PG Anesthesiology 2004, 101(1):138-42

41 Siyatik Sinir Bloğu Lateral or Posterior Popliteal Approach for Sciatic Nerve Block: Difference is Related to the Anatomy March X, Pineda O, Carames D, Villalonga A, Trueta J Anesth Analg 2007; 105(1):

42 Siyatik Sinir Bloğu Parasacral sciatic nerve block: does the elicited motor response predict the success rate? Hagon BS, Itani O, Bidgoli JH, Van der Linden PJ Anesth Analg 2007; 105(1):263-6

43 Siyatik Sinir Bloğu Lateral popliteal sciatic nerve block: a single injection targeting the tibial branch of the sciatic nerve is as effective as a double-injection technique Arcioni R, Palmisani S, Della Rocca M, Romanò S, Mercieri M, De Blasi RA, Ronconi P, Pinto G Acta Anaesthesiol Scand 2007; 51(1):115-21

44 Siyatik Sinir Bloğu Infragluteal-parabiceps sciatic nerve block: an evaluation of a novel approach using a single- injection technique Sukhani R, Candido KD, Doty R, et al Anesth Analg 2003; 96: 868–73

45 Siyatik Sinir Bloğu The lateral approach to the sciatic nerve at the popliteal fossa: one or two injections? Paqueron X, Bouaziz H, Macalou D, Labaille T, Merle M, Laxenaire MC, Benhamou D. Anesth Analg 1999, 89(5):1221-5

46 flow detector in supraclavicular
Ultrasonografi ULTRASOUND GUIDED UPPER LIMB BLOCKS Zbigniew Koscielniak-Nielsen MD, PhD, FRCA Assistant Professor, Head of Orthopedic Anesthesia Rigshospital, University of Copenhagen, Denmark Introduction Medline and Embase (1966- January 2007) were searched using the following free terms: ultrasound and nerve and block, ultrasound and block, ultrasound and interscalene or supraclavicular or infraclavicular or axillary. Interscalene block One randomized-, two prospective studies and three case reports were identified. Soeding et al. [1] randomized 40 patients having interscalene and axillary blocks either to a high frequency ultrasound or a landmark-based method. Ultrasound significantly improved onset and quality of sensory and motor blocks. The incidence of paresthesia was also significantly reduced. Schwemmer et al. [2] prospectively compared 35 obese patients (BMI > 25) with 35 non-obese patiens (BMI < 25) using ultrasound guidance. Sufficient analgesia was obtained in 94% of patients with normal weight and 77% of patients with overweight (NS). He concluded that ultrasound efficiently depicts plexus structures and gives similar clinical results in either group. Yang et al. [3] placed perineural catheters using ultrasound in 20 cases (16 interscalene and 4 supraclavicular) obtaining successful block and postoperative analgesia in all patients. Chan VWS [4] described a successful interscalene block in a patient after two futile attempts to elicit twitches using the nerve stimulator. Blaivas et al. [5] used ultrasound for pain control and muscle relaxation in four cases of traumatic shoulder dislocation. All joints were effectively realigned. Van Geffen et al [6] reported a successful use of ultrasound in a child for removal of a painful exostosis on a rudimentary humerus. Supraclavicular block Three randomized- and two prospective studies were found in addition to 4 patients presented by Yang et al. [3]. Kapral et al. [7] randomized 40 patients to either supraclavicular or axillary block. He concluded that the ultrasound-guided supraclavicular approach gives a more extensive block and is equally safe as axillary approach. Williams et al. [8] compared ultrasound with a nerve stimulator in 80 patients. Block performance under ultrasound guidance was twice as fast as with a nerve stimulator (5 min vs. 10 min).The ultrasound group had also a faster and a more complete surgical analgesia, albeit not significantly. The ulnar nerve analgesia was poorer in the nerve stimulator group. Arcand et al. [9] compared ultrasound-guided supra- and infraclavicular blocks in 80 patients. Block performance times and surgical anesthesia were similar in either group. However, the infraclavicular group required more supplementary blocks of the radial nerve. No anesthesia-related complications were observed at the one week follow up. Chan et al. [10] prospectively assessed 40 patients using ultrasound and a nerve stimulation. They obtained a successful block in 38 cases. Shemesh et al. [11] used ultrasound in 31 uremic patients for arteriovenous fistula creation. The block was associated with a beneficial sympathectomy including vessel dilatation and a decreased pulsatility. In addition, an old report by La Grange et al. [12] described use of the Doppler blood flow detector to localize the subclavian artery and facilitate the block placement. Infraclavicular block Two randomized-, three prospective studies, two case reports, an anatomical study and a letter to editor were retrieved in full text. One Taiwanese study was only available as an abstract. Bigeleisen and Wilson [13] compared the medial and the lateral approach in 202 patients. The medial approach was faster and easier to perform (9 vs. 13 min). It also had a lower incidence of tourniquet pain and accidental vascular punctures. The lateral approach on the other hand was less likely to result in the pleural puncture. Both techniques provided excellent surgical anesthesia. Marhofer et al. [14] compared the ultrasound with a nerve stimulator in 40 children after isolated extremity trauma. Ultrasound guidance resulted in shorter block performance times, lower VAS during block performance, as well as faster, better and longer analgesia. In three separate studies, Ootaki et al. [15], Sandhu and Capan [16] and Sandhu et al. [17] prospectively assessed infraclavicular blocks in 200 patients. They obtained adequate surgical anesthesia in 90-95% of patients. Only one vascular puncture and three paresthesias occurred during block performance without sequele. All authors used a multiple injections around the artery and in the last study [17] as little as 14 ml of lidocaine were sufficient to produce a successful block. Sandhu et al. [18] also reported a successful bilateral block using 20 ml of lidocaine on each side. Porter et al. [19] suggested that, for a single injection technique, a needle tip or a catheter should be placed posterior to the axillary artery. Sandhu et al. [20] demonstrated decreased operating room time requirements for the ultrasound-guided blocks and a resultant cost reduction and Greher et al. [21] suggested a landmark modification for the vertical infraclavicular blocks to increase the success rate and reduce the risk of complications. In the Taiwanese report of 10 patients [22], nine had a successful block. Axillary block Two randomized-, four prospective and one retrospective studies one description of anatomy and one case report were retrieved in full text. Three Taiwanese studies (one randomized and two prospective) were only available as abstracts. In addition to previously described randomized studies [1,7], Sites et al. [23] compared an ultrasound guidance with a trans-arterial technique in 56 patients. They demonstrated a reduction in block performance times and fewer failures described as a conversion to general anesthesia or the inability to localize the artery in the ultrasound group. Kefalianakis and Spohner [24] as well as Schwemmer et al. [25], who studied 267 patients using a multi-injection technique, reported block success rates between 97 and 100% with the onset of analgesia between 2 and 7 minutes. Ting and Sivagnanaratnam [26] used ultrasound in 10 patients obtaining 100% success and no complications. Spence et al. [27] successfully used the ultrasound guidance to block the musculocutaneous nerve in 10 patients. Retzl et al. [28] described the variability in anatomical locations of the median, the radial and the ulnar nerves in volunteers and have shown that light pressure can displace the nerves from their original positions. Schwemmer et al. [29] estimated the cost-saving effects of ultrasound guidance compared with a nerve stimulator in 130 patients. They demonstrated the cost reduction of approximately 53€ per patient due to shorter block performance time, faster onset, lower needs for sedation or general anesthesia and resultant higher rates of PACU bypass. In a letter to editor, Güzeldemir and Űstűnsöz [30] reported a successful use of ultrasound for a perineural catheter placement in the axilla. In the studies available as abstracts, Liu et al. [31] compared ultrasound-guided single- or a double injection with a nerve stimulator guided double injections in 90 patients. Block success rates were higher in both double-injection groups compared with a single-injection. The same authors [32] reported 16 cases of ultrasound-guided block for arteriovenous fistula creation in end-stage renal failure. All blocks were successful and there were no complications. Su et al. [33] used ultrasound to guide an axillary catheter placement in 18 patients having finger re-implantations or toe-to-hand digit transfers after traumatic injuries. The infusions of ropivacaine increased temperature of the reconstructed digits for 24 hours after the surgery. Conclusions There is a class 1B-4 evidence that ultrasound speeds up onset of brachial plexus blocks, improves their effectiveness and reduces the costs of anaesthesia. Ultrasound may also reduce the incidence of complications but for the time being there is not enough scientific data to confirm this hypothesis. References Soeding PF, Sha S, Royse CF, Marks P, Hoy G, Royse AG. A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery. Anaesth Intensive Care 2005; 33: Schwemmer U, Papenfuss T, Greim C, Brederlau J, Roewer N. Ultrasound-guided interscalene brachial plexus anaesthesia: Differences in success between patients of normal and excessive weight. Ultraschall in Med 2006; 27; Yang WT, Chui PT, Metreweli C. Anatomy of the normal brachial plexus revealed by sonography and the role of sonographic guidance in anesthesia of the brachial plexus. AJR Am J Roentgenol 1998; 171: Chan VWS. Applying ultrasound imaging to interscalene brachial plexus block. Reg Anesth Pain Med 2003; 28: Blaivas M, Lyon M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. AJEM Am J Emergency Med 2006; 24: Van Geffen GJ, Tielens L, Gielen M. Ultrasound-guided interscalene brachial plexus block in a child with femur fibula ulna syndrome. Pediatric Anaesth 2006; 16: Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994; 78: Williams SR, Chouinard P, Arcand G, Harris P, Ruel M, Boudreault D, Girard F. Ultrasound-guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 2003; 97: Arcand G, Williams SR, Chouinard P, Boudreault D, Harris P, Ruel M, Girard F. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg 2005; 101: Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 97: Shemesh D, Olsha O, Orkin D, Raveh D, Goldin I, Reichenstein Y, Zigelman C. Sympathectomy-like effects of brachial plexus block in arteriovenous access surgery. Ultrasound in Med. & Biol. 2006; 32: La Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound blodflow detector in supraclavicular brachial plexus block. Br J Anaesth 1978; 50: Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth 2006; 96: Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children. Anaesthesia 2004; 59: Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: An alternative technique to anatomical landmark-guided approaches. Reg Anesth Pain Med 2000; 25; Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002; 89: Sandhu NS, Bahniwal CS, Capan LM. Feasibility of an infraclavicular block with a reduced volume of lignocaine with sonographic guidance. J Ulrasound Med 2006; 25: Sandhu NS, Marharlouei B, Patel B. Erkulwater E, Medabalmi P. Simultaneous bilateral infraclavicular brachial plexus blocks with low-dose lidocaine using ultrasound guidance. Anesthesiology 2006; 104: Porter JM, McCartney CJL, Chan VWS. Needle placement and injection posterior to the axillary artery may predict successful infraclavicular brachial plexus block: a report of three cases. Can J Anaesth 2005; 52: Sandhu NS, Capan LM. The cost comparison of infraclavicular brachial plexus block by nerve stimulator and ultrasound guidance. Anesth Analg 2004; 98: Greher M, Retzl G, Niel P, Kamolz L, Marhofer P, Kapral S. Ultrasonographic assessment of topographic anatomy suggests a modification of the infraclavicular vertical brachial plexus block. Br J Anaesth 2002; 88: Wu TJ, Lin SY, Liu CC, Chang HC, Lin CC. Ultrasound imaging aids infraclavicular brachial plexus block. Ma Zui Xue Za Zhi 1993; 31: Sites BD, Beach ML, Spence BC, Wiley CW, Shiffrin J, Hartmann GS, Gallagher JD. Ultrasound guidance improves the success rate of a perivascular axillary block. Acta Anaesthesiol Scand 2006; 50: Kefalianakis F, Spohner F. Ultraschallgestützte Blockade des axillären Plexus brachialis in der Handchirurgie. Handchir Mikrochir Plast Chir 2005; 37: Schwemmer U, Markus CK, Greim C, Brederlau J, Roewer N. Ultrasound-guided anaesthesia of the axillary brachial plexus: Efficacy multiple injection approach. Ultraschall in Med 2005; 26: Ting PL, Sivagnanaratnam V. Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth 1989; 63: Spence BC, Sites BD, Beach ML. Ultrasound-guided musculocutaneous nerve block: A description of a novel technique. Reg Anesth Pain Med 2005; 30: Retz G, Kapral S, Greher M, Mauritz W. Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg 2001; 92: Schwemmer U, Schleppers A, Markus C, Kredel M, Kirschner S, Roewer N. Prozessmanagement bei axillären Plexusblockade. Vergleich von Ultraschal und Nervenstimulation. Anaesthesist 2006; 55: Güzeldemir ME, Űstűnsöz B. Ultrasound guidance in placing a catheter for continuous axillary brachial plexus block. Anesth Analg 1995; 81: Liu FC, Liou JT, Tsai YF, Li AH, Day YY, Hui YL, Lui PW. Efficacy of ultrasound-guided axillary brachial plexus block: a comparative study with a nerve stimulator-guided method. Chang Gung Med J 2005; 28: Liu FC, Lee LI, Liou JT, Hui YL, Lui PW. Ultrasound-guided axillary brachial plexus block in patients with chronic renal failure: a report of sixteen cases. Chang Gung Med J 2005; 28: Su HH, Lui PW, Yu CL, Liew CS, Lin CH, Lin YT, Chang CH, Yang MW. The effects of continuous axillary brachial plexus block with ropivacaine infusion on skin temperature and survival of crushed fingers after microsurgical replantation. Chang Gung Med J 2005; 28: La Grange P, Foster P, Pretorius L. Application of the Doppler ultrasound blood flow detector in supraclavicular brachial plexus block Br J Anaesth 1978; 50: 965–7

47 Ultrasonografi Avantaj Dezavantaj Düşük maliyet
Cihazın taşınabirlirliği Uygulama kolaylığı İncelemenin hiçbir riskinin olmayışı Doz düşürülebilir Dağılım gözlenebilir Eş zamanlı izleme Dezavantaj Uygulayıcı kişinin bilgi ve becerisine bağlı olması Ultrasonographic guidance for online observation of spread of local anaesthetic around nerves is an excellent method to reduce the volume of local anaesthetic for most of regional anaesthetic techniques. In all techniques where the target nerves are directly visible an individual volume of local anaesthetic solution could be administered. On the other hand in techniques, where the target nerve structures are not directly visible (e.g. intercostal nerve blocks, paraumbilical blockade, some cases of psoas compartment blocks in adults) a predefined volume of local anaesthetic is necessary for a sufficient blockade

48 Ultrasonografi

49 Ultrasonografi

50 Ultrasonografi

51 Percutaneous electrode guidance:
PEG 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:

52 Percutaneous Electrode Guidance
Principles of PEG The PEG concept acts to optimize the above variables in such a way as to make transcutaneous stimulation and therefore pre-location of the target-nerve or nerves possible at relatively low amperage (< 5 mAmp). The use of a smooth-tipped electrode allows indentation of the skin without significant discomfort. Indentation of the skin acts to minimize distance to the nerve and to decrease electrical impedance by compressing the underlying tissues, which increases electrical conductance. By contrast to traditional needle tip location, where a very short pulse duration is desirable for precise location with the needle-tip, cutaneous stimulation benefits from longer pulse durations ( msec). Higher pulse duration allows for motor response at lower amperage. Indentation of the skin (in some cases several centimeters is necessary) brings the cutaneous electrode into fairly close proximity of the nerve or neural plexus. Since much of the locating is done by the probe, which indents the skin toward the nerve, the needle tip typically travels only a short distance to the nerve. Initial Clinical Experience with the PEG Technique Urmey and Grossi4 reported the first clinical cases of peripheral or plexus blocks utilizing the PEG technique. The authors used a cylindrical cutaneous electrode with a 1 mm diameter metallic conductive tip. After positioning the probe and indenting the skin over the target nerve, specific motor responses were sought. At the point of maximal motor response at minimal cutaneous probe amperage (2 Hz, 0.2 msec) the cutaneous stimulator was turned off and a standard commercial nerve stimulator needle was passed through the probe to the nerve. This method was used in 7 patients. Since the nerves were pre-located with the cutaneous electrode, the needle was introduced in each case with beginning amperage of 0.5 mAmp (normally acceptable as an endpoint). In only one case was it necessary to increase the needle amperage above 0.5 mAmp. Targeted nerves were found easily within seconds of the start of indentation and exploration of the skin with the cutaneous electrode. Minimal transcutaneous stimulation current in mAmp correlated directly with the measured needle depth (beyond the probe tip). Maximal needle protrusion depth in these initial patients was 2 cm. Thus the technique is more useful for blocking superficial nerves or plexuses. These include 1) brachial plexus block, 2) midhumeral block, 3) wrist block, 4) femoral nerve block, 5) popliteal fossa block and, 6) posterior tibial nerve block. PEG is in its infancy and has tremendous potential to make peripheral nerve blocks less intimidating to the beginning practitioner. PEG may decrease time for block performance and increase safety of peripheral nerve blockade by decreasing the number of invasive needle passes. The probe has been successfully used to teach in workshop settings. Further clinical studies are certainly indicated. Sequential Electrical Nerve Stimuli (SENS) to Locate Nerves On presently manufactured nerve stimulators, current amplitude (amperage) is able to be continuously varied in an analog manner, for example by potentiometer, at constant frequency and constant pulse duration (time-based width of the square wave). Although nerve stimulators have been produced and used that have the capability of changing pulse duration, to date, only one fixed pulse duration has been used at any given time. Most commercial nerve stimulators have been manufactured to stimulate with a single fixed pulse duration (e.g. 0.1 or 0.2 ms). Some newer nerve stimulators allow pulse duration to be set at different fixed pulse widths (e.g. 0.05, 0.1, 0.3, 0.5, or 1.0 ms) by the push of a button, while current amplitude is varied in an analog manner. Although successful stimulation of the nerve with small pulse durations favors optimal final positioning of the needle electrode near the nerve, in practice motor responses often disappear with only minor changes in needle position during the search for the nerve. Thus, with conventional nerve location, sensitivity has been sacrificed in the interest of enhancing specificity. Urmey and Grossi12 recently evaluated a novel technique for nerve location utilizing an electrical nerve stimulator programmed to deliver sequenced electrical nerve stimuli (SENS). The nerve stimulator generated alternating sequential electrical pulses of differing pulse durations at an overall set frequency of 3 Hz. Repeating pulse duration sequences of 0.1, 0.3, and 1.0 ms were generated with 1/3 second period intervals separating each pulse. The theory was that specificity of nerve location would be maintained as indicated by 3 motor responses per second at current flow  0.5 mA at final nerve location, since all 3 pulses would be expected to stimulate the nerve at close proximity. At greater distance from the nerve, only the higher duration pulses would be expected to stimulate the nerve, resulting in only 1 or 2 motor responses per second. This would serve to increase the range or sensitivity of successful nerve stimulation at distance, without sacrificing specificity for final endpoint. Eight patients were studied during combined sciatic/psoas blocks for a total of sixteen separate blocks. Blocks were performed and analyzed using SENS for nerve or plexus location. Nerve location was performed in a conventional manner, using an 80 mm stimulating needle coupled to a nerve stimulator set an initial amperage of 1.0 mA. The ground lead was positioned in view, on the calf of the lower extremity to be blocked. The nerve stimulator had been programmed to deliver repeating sequenced electrical nerve stimuli (SENS) of 0.1, , 0.1, 0.3, 1.0 ms…at 1/3 second intervals between pulses for a maximum stimulating frequency of 3 Hz. The stimulator had also been programmed to immediately revert to customary single (0.1 ms) pulses at 3 Hz at the discretion of the anesthesiologist at the push of a single button. To avoid motor responses that were too strong, automatic attenuation of the amperage of the 0.3 ms and 1.0 ms pulses was programmed. The current (amperage) for the 0.3 ms and 1.0 ms pulses were attenuated to values equal to 60% and 32% of the value of the 0.1 ms pulse. This selective attenuation of current resulted in the 3 pulses having less disparate (more equivalent) charges.

53 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

54 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

55 Sinir Haritalaması

56 Sinir Haritalaması

57 Sinir Haritalaması Surface stimulation to determine needle direction and angle when performing an infraclavicular brachial plexus block Albert DB, Dudarevitch D, Bloom K, Rosenberg AD Pain Pract 2006, (2):104-6

58 Sinir Haritalaması ve PEG

59 Sinir Haritalaması ve PEG

60 Rejyonel Anestezide Periferik Sinir Blokları Uygularken
Eğitimde başarı için Kolay gerçekleşebilir Güvenilir Başarısız bloklarda alternatif tekniklere sahip olmak için Hasta konforunu artırmak için Pozisyon Parestezi aramamak Bir çok blok yerine tek bir blok Komplikasyonları azaltmak için Yeni periferik blok tekniklerine ihtiyaç vardır

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