Yeni Monitörizasyon Sistemleri

Yeni Monitörizasyon
Sistemleri
Doç.Dr.Alparslan KUŞ
Einthoven, 1903
Korotkoff, 1905
Yeni monitorizasyon sistemleri sayesinde
THE LANCET. Volume 362. Issue 9398, 29
November 2003, Pages 1839–1846
Anestezi ile ilişkili morbidite ve mortalite
Periferik Sinir Bloklarında Monitörizasyon
Başarı
Periferik Sinir Bloğu Komplikasyonları
•  Nörolojik komplikasyonlar
•  Vasküler hasarlanma
•  LA sistemik toksisitesi
•  Solunumsal komplikasyonlar
Komplikasyonlar
–  Pnömotoraks
–  Hemidiafragmatik parazi
Sinir
Stimülatörü
1990 yılından bu yana 5230 dava
%20’si rejyonal anestezi ile
%26’sı ölüm ile
%22’si sinir hasarı ile
%9’u kalıcı beyin hasarı ile
Sinir stimülatörü
Basınç
monitorizas
yonu
USG
Sinir Stimülatörü
Avantajları
1780
Galvani
•  Parestezi tekniğine göre daha objektif iğne
sinir lokalizasyonu
•  Hasta koperasyonu gerekmez, hastaya sedatif
ve analjezikler kullanılabilir
•  Kolay kullanılabilirlik
•  Maliyet
Sinir Stimülatörü
Dezavantajları
•  İğne ucunun sinirden uzaklığı ile motor cevabın
korelasyonu zayıf
•  İğne sinir içinde olabilir ve kas cevabı yada
enjeksiyon sırasında ağrı olmayabilir
•  Kırık bir ekstremitede uygulanan stimuluslar
ağrıya neden olabilir
Sinir Stimülatörü
•  <0.2 mA den küçük stimuluslarda bile
motor cevabın olması büyük olasılıkla
intranöral enjeksiyon ve histolojik
yaralanma ile ilişkili
0.2-0.5mA arası stimülasyona yanıt olmaması
intranöral enjeksiyonu ekarte ettirmeyebilir
Ultrasonografi (USG)
USG avantajları
•  Sinirin ve anatomik yapıların direkt
görüntülenebilmesi
•  Anatomik varyasyonların tespiti
•  İğne hareketinin eş zamanlı izlenebilmesi
•  Lokal anestezik dağılımının görülmesi;
LA miktarının azaltılabilmesi veya arttırılması
•  1978 ilk kez periferik sinir bloğu uygulaması
•  Kas kasılmasından kaçınabilme, artan hasta
konforu
Casati et al
•  US LA dozunu azaltıyor
USG; sinirin direkt görüntülenmesi
USG; lokal anestezik dozunun azaltılması
Pnömotoraks
SONOANATOMi…
Letters to the Editors
REFERENCES
USG; sinir stimülatörünün kullanılamayacağı durumlarda
1. Koscielniak-Nielsen ZJ. An unusual toxic
reaction to axillary block by mepivacaine
with adrenaline. Acta Anaesthesiol Scand
1998;42:868Y871.
2. Zetlaoui PJ, Labbe JP, Benhamou D.
Ultrasound guidance for axillary plexus block
does not prevent intravascular injection.
Anesthesiology 2008;108:761.
Blok başarısı
Peripheral Nerve Block Complications
’
61
Table 4. Nerve Injuries Associated With Peripheral Nerve Blocks in ASA Closed Claims
Database (n = 97)
Nerve Injured
Brachial plexus
Median
Ulnar
Spinal cordw
Phrenic
Femoral
Radial
Sciatic
Lumbosacral nerve root
Other nervesz
n (% of 97 Claims)*
37
20
16
8
8
4
3
2
1
13
Permanent/Disabling (n)
(38)
(21)
(16)
(8)
(8)
(4)
(3)
(2)
(1)
(13)
12
6
3
8
1
0
2
2
1
5
*Percentages sum to greater than 100% due to multiple nerve injuries in some claims and to
rounding.
wSix of the 8 spinal cord injury claims were related to interscalene blocks with cervical spinal
cord damage, and 4 of these 6 blocks were performed under general anesthesia. All of these 6
interscalene blocks with cervical spinal cord damage were performed in 2001 or earlier.
zOther nerves include accessory, axillary, facial, lingual, obturator, peroneal, popliteal,
posterior tibial/peroneal, right CN III, Horner’s Syndrome, Reflex Sympathetic Dystrophy.
ASA indicates American Society of Anesthesiologists.
Complications
Associated
anesthesia.
Test doses were used in 4 claims, divided
dosing in 1 claim,
and
unknown dosing
in 2 claims. Onset of symptomsNerve
and signs occurred Blocks:
With
Peripheral
within 5 minutes of injection in 3 claims with seizure activity alone
(nLessons
= 1) or followed by ventricular
tachycardia progressing
ventricular Closed
From
the toASA
fibrillation (n = 2). Onset of cardiac arrhythmias in another 3 claims
Claims Project
Lorri A. Lee, MD*w
Lee
Karen L. Posner, PhD*
Christopher D. Kent, MD*
Karen B. Domino, MD, MPH*w
LA, et al. 2011
University of Washington Medical Center Seattle, Washington
’
Introduction
Figure 1. Type of peripheral nerve blocks associated with nerve injuries.
Ciddi Komplikasyon: 0.1-0.6/1000
New techniques and regional blocks
haveR, brought
a 2007
renewed
www.anesthesiaclinics.com
Brull
Anesth Analg
enthusiasm for the use of regional anesthesia for surgery. The use of
ultrasound-guided anesthesia has become widespread.1 Meetings on
regional anesthesia are focusing on new or increased use of regional
blocks such as the transverse abdominus plane (TAP), ilioinguinal or
iliohypogastric, lumbar plexus, psoas, and paravertebral blocks, and also
continuous peripheral nerve catheters in the ambulatory setting. Some
of the benefits of these changes in regional anesthesia that have been
reported include greater success of blocks, improved efficiency, and
improved analgesia and patient satisfaction.2,3 Typically, new procedural
techniques provide both new benefits and new risks. We previously
reported on complications associated with peripheral nerve blocks from
Kapanmış dava dosyaları incelendiğinde blok iğnesine bağlı
travma ve lokal anestezik toksisitesinin ultrason kullanımı
ile azaldığı bildirilmiştir.
FROM THE DEPARTMENT OF ANESTHESIOLOGY AND PAIN MEDICINE AND THE wDEPARTMENTOF NEUROLOGICAL SURGERY
(ADJUNCT), UNIVERSITY OF WASHINGTON, SEATTLE, WA.
REPRINTS: LORRI A. LEE, MD, DEPARTMENT OF ANESTHESIOLOGY AND PAIN MEDICINE, UNIVERSITY OF WASHINGTON
MEDICAL CENTER, BOX 356540, HEALTH SCIENCES—BB 1469, 1959 PACIFIC STREET, SEATTLE, WA 98195-6540,
E-MAIL: [email protected]
INTERNATIONAL ANESTHESIOLOGY CLINICS
Volume 49, Number 3, 56–67
r 2011, Lippincott Williams & Wilkins
56 | www.anesthesiaclinics.com
gional anesthesia (RA) with subsequent
seizure have been recently reported,1 although to our knowledge, there is no case
of cardiac arrest under ultrasound-guided
RA. We report a case of reversible cardiac
arrest during an ultrasound-guided sciatic
nerve block with ropivacaine.
CASE REPORT
An 82-year-old woman, height
163 cm, weight 45 kg, ASA III, was scheduled for an excision of toe osteophytosis.
Regional anesthesia was accepted by the
patient. Her medical history included arterial hypertension and chronic atrial
4. Foxall G, McCahon R, Lamb J, et al.
fibrillation, but no ischemic heart disease
Levobupivacaine-induced seizures and
or neurologic alterations. In the operating
cardiovascular collapse treated with
room, standard monitoring was applied.
Intralipid. Anaesthesia 2007;62:516.
She received oxygen 3 L/min via a face
5. Brull SJ. Lipid emulsion for the treatment of
mask. Two milligrams midazolam was inlocal anesthetic toxicity: patient safety
jected. A parasacral approach to the sciimplications. Anesth Analg 2008;106:
atic nerve was performed under ultrasound
1337Y1339.
guidance (10-MHz probe; Siemens Ultra6. Storgaard H, Jensen CB, Vaag AA, et al.
sound Systems, Acuson CV70; Siemens
Insulin secretion after short and long term low
AG, Erlangen, Germany); using the ingrade free fatty acid infusion in men with
plane approach with a 22-gauge, 100-mm
increased risk of developing type 2 diabetes.
insulated needle associated with neurosti• Blok uygulama süresi
Metabolism 2003;52:885Y894.
mulation. A tibial nerve response was ob• İğne
yönlendirme
sayısı
7. Leibowitz AB, O_Sullivan
P, Iberti
TJ.
served. After repeated negative aspiration
• 
B
lok
oturma
süresi
Intravenous fat emulsions and the pancreas.
tests, a mixture of 20 mL 0.5% ropivacaine
Mt Sinai J Med 1992;59:38Y42.
• Lokal anestezikand
dozu!!
50 Kg clonidine was slowly injected
(around 90 secs). Immediately after the
8. Strichartz GR, Sanchez V, Arthur GR, et al.
Fundamental properties of local anesthetics.
injection, the patient had difficulties in
II. Measured octanol:buffer partition
speaking, lost consciousness, and had a
coefficients and pKa values of clinically used
generalized tonic-clonic seizure. Mask vendrugs. Anesth Analg 1990;71:158Y170.
tilation with 100% oxygen and tracheal
intubation were performed after adminis9. Warren JA, Thoma RB, Georgescu A, Shah
tration of 325 mg thiopental and 100 mg
SJ. Intravenous lipid infusion in the
successful resuscitation of local
suxamethonium. The seizure stopped,
anesthetic-induced cardiovascular collapse
but approximately 1 min later, ventricular
after supraclavicular brachial plexus block.
fibrillation was observed. There was no
Anesth Analg 2008;106:1578Y1580.
palpable pulse. Chest compressions were
started. Two defibrillations (200 and 300 J)
10. Picard J, Weinberg G, Meek T, et al. on behalf
were necessary to return to the initial
of the AAGBI Working Party on the
Vascular management
puncture
LA
systemic
toxicity
of severe local anaesthetic
rhythm of atrial fibrillation. Blood prestoxicity. Treatment of severe local anaesthetic
sure was 110/70 mm Hg; heart rate, 125
toxicity. A reply. Anaesthesia 2008;63:203.
beats/min; and the SpO2, 99%. Infusion
of amiodarone 300 mg and 70 mL of intra11. The Association of Anaesthetists of Great
lipid 20% (Baxter Deutschland GmbH,
Britain and Ireland (AAGBI). Guidelines for
the management of severe local anaesthetic
Unterschleissheim, Germany) was admintoxicity. http://www.aagbi.org/publications/
istered during the transfer to the intenguidelines.htm. Accessed July 27, 2008.
sive care unit under propofol (100 mg/hr).
Blood level of ropivacaine 15 min after
the injection was 2.48 mg/mL. RecovCardiac Arrest During an
ery was uneventful, and the patient was
discharged on the day after her arrival in
Ultrasound-Guided Sciatic
intensive care unit without neurologic
Nerve Block Combined With sequelae.
In this case, we observed clear
Nerve Stimulation
sonogram images of the main structures
Gnaho
A, et al. 2009
RAPM2008 and with the in-plane approach2 could
Accepted
for Publication:
9 August
follow the path of the needle throughout
To the Editor:
the procedure. This information is not
ascular puncture and local anesthetic available with neurostimulation alone.
injection during ultrasound-guided re- The probe could have compressed vascular
3. Rosenblatt MA, Abel M, Fischer GW, et al.
Successful use of a 20% lipid emulsion to
resuscitate a patient after a presumed
bupivacaine-related cardiac arrest.
Anesthesiology 2006;105:217Y218.
Step Sign
Regional Anesthesia and Pain Medicine
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&
V
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ing u
ment
from
have
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278
Copyright @ 2009 American Society of Regional Anesthesia and Pain Medicine. Unauthorized
RAPM 2007
Ultrasonografi? Sinir Stimülatörü?
520 blok- 398 hata.
En sık yapılan 2 hata:
1. İğneyi görmeden ilerletmek
2. İstemsiz prob hareketi.
USG rehberliği
ü başarını oranını arttırmakta
ü Blok oturma süresini kısaltmakta
ü Uygulama süresini azaltmakta
ü Vasküler hasarlanmayı azaltmakta
USG başarılı ancak, postoperatif nörolojik hasar konusunda SS ile arasında fark yok
İkili monitorizasyon “dual
control”
Ultrasonografi&Sinir Stimülatörü
•  Başarı
§  Lokalizasyon
§  LA dağılımı
Nörostimülasyon
Ultrasonografi
§  Nöral yapının doğrulanması
§  Emniyet
§  Intranöral enjeksiyon ?
§  Eğitim
blockYrelated adverse occurrences. We hypothesized that adverse complications of nerve blockade are less common when ultrasonography is
used in conjunction with peripheral nerve stimulation to guide needle
placement, when compared with the sole use of physical landmarks and
nerve stimulation.
Methods: We queried our departmental Quality Improvement
electronic database for adverse outcomes associated with peripheral
nerve blocks. Billing records were used to provide the denominator of
the total number of blocks using both techniques of neurolocation. The
types of blocks considered in this analysis were interscalene, axillary,
femoral, sciatic, and popliteal sciatic blocks. The total numbers of
complications of nerve blockade with each type of guidance were then
compared, as were specific subsets of adverse effects.
Results: There were 5436 consecutive peripheral noncatheter block
cases (interscalene, axillary, femoral, sciatic, popliteal) during the 28month period surveyed, with 3290 guided by landmarkYnerve stimulation, and 2146 by ultrasoundYnerve stimulation. Eight adverse outcomes
occurred among patients having blocks guided by landmarkYnerve
stimulation technique, including 5 seizures and 3 nerve injuries. There
were no such occurrences in the ultrasoundYnerve stimulation group.
When comparing the 4 brachial plexus blockYrelated seizures that
occurred with landmark guidance versus none with ultrasound guidance,
the associated risk of seizures reached statistical significance (P = 0.044
by Fisher exact test). There was no difference between the 2 groups in the
number of seizures occurring with lower extremity blocks, or in the
frequency of neurologic injury.
Conclusions: High-definition ultrasonography offers potential advantages in the administration of peripheral nerve blockade. The significant
difference in major central nervous system local anesthetic toxicity
observed in this study supports the use of ultrasound guidance in
conjunction with peripheral nerve stimulation to provide brachial plexus
peripheral nerve blockade in an academic, ambulatory anesthesia
practice.
versity.2 The increasing use of ultrasonographic imaging for
needle placement and local anesthetic deposition may have the
potential to impact the safety of peripheral nerve blockade, if it
permits the operator to avoid some untoward events, such as
needle trauma to nerves, intraneural or intravascular injection of
local anesthetic solutions, and needle puncture of unintended
targets.3,4 However, there is a paucity of large-scale outcomes
data available related to the provision of ultrasound-guided
peripheral blocks. In this retrospective study, we queried our
Quality Improvement (QI) database of anesthetic-related
complications to evaluate the frequency of noncatheter peripheral nerve block (NCPNB)Yrelated adverse occurrences in our
academic anesthesiology practice, which uses a Bclinical pathway[ concept to minimize dosing variability, and encourage
uniform practice patterns.5Y8 We hypothesized that complications of NCPNB are less common when ultrasonography (US) is
used in conjunction with peripheral nerve stimulation (PNS) to
guide needle placement (US-PNS), when compared with the
sole use of physical landmarks (LM) and PNS (LM-PNS), for
the 5 types of blocks considered.
METHODS
This data query was approved by the University of
Pittsburgh institutional review board. We queried our deidentified departmental QI electronic database for adverse outcomes
associated with peripheral nerve blocks (PNBs). The following
events were specifically queried: seizure, cardiovascular toxicity,
local anatomic injury from needle trauma, unintended neuraxial
blockade during PNB, pneumothorax, and peripheral nerve injury. Further details of this QI database are given below.
The period from which data were queried was the 28-month
period from January 1, 2006, to April 30, 2008. This interval
was chosen because US-PNS was introduced at the beginning of
(Reg Anesth Pain Med 2009;34: 251Y255)
this time frame as a clinical pathway option for our anesthesia
LTRASOUND RTICLE
group and was gradually phased in over the ensuing 2 years, to
the point that 50% to 60% of our blocks are now performed
with ultrasound guidance. In addition, January 2006 marked
the origin of our group’s formal documentation of US-PNS on
the anesthetic record, rendering the use of this neurolocation
technique as reliably quantifiable. Because of our facility’s case
From the *University of Pittsburgh Medical CenterYSouth Side, and
†University of Pittsburgh Medical CenterYMagee Hospital, Pittsburgh, PA.
volumes, and the initial availability of only 1 imaging unit, as
Accepted for publication August 21, 2008.
well as the gradual adoption of ultrasound technique, there were
Address correspondence to: Steven L. Orebaugh, MD, University of
more LM-PNS blocks than US-PNS blocks.
Pittsburgh Medical CenterYSouth Side, 2000 Mary St, Pittsburgh, PA
Exclusion criteria included block procedures that were in15203 (e-mail: [email protected]).
No specific funding was obtained for this research.
tended, but not actually carried out, and block procedures that
Copyright * 2009 by American Society of Regional Anesthesia and Pain
were solely carried out at our site by either LM-PNS (eg,
Medicine
L. Orebaugh,
MD,* Brian A. Williams, MD, MBA,* Manuel
Vallejo,
MD,Þ
posterior
lumbar
plexus block) or US guidance (eg, midcalf
ISSN: 1098-7339
and Michael L. Kentor, MD*
saphenous nerve block).
DOI: 10.1097/AAP.0b013e3181a3438e
U
A
Adverse Outcomes Associated With Stimulator-Based
Peripheral Nerve Blocks With Versus Without
Ultrasound Visualization
Steven
Regional Anesthesia and Pain Medicine
performed. During the procedure, neurostimulation and
Michael J. Barrington, F.A.N.Z.C.A.,
Su-Ling K. Lai, Chris A. Briggs, Ph.D.,
CONCLUSION:
Jason J. Ivanusic, Ph.D., and Samuel R. Gledhill, M.Med.Stat.
Sinir stimülatörü
ve ultrasonografi
birlikte
İkisinin
Background and Objectives:
Ultrasound-guided sciatic nerve block
is a relativelykullanılabilir.
new regional anesthesia
technique with few descriptions in the literature. The objective of this study was to assess the ease with which
the sciatic nerve could be imaged in the midthigh region using ultrasound and to describe the anatomy
surrounding
the sciatic nerve at
this location.
birlikte
kullanımı
infraklaviküler
blok uygulamasının güvenliğini
arttırmaktadır.
rastlandı; 5 hastada nöbet ve 3 hastada sinir hasarı
Ultrasound-evidenced
spread of local anaesthetics increased the
Results: The sciatic nerve was identified with ultrasound and its image validated using nerve stimulation in
Ultrason & sinir stimülasyonu grubunda herhangi bir komplikasyona
38 of 40 patients (95%). In 15 patients (37.5%) nerve stimulation was required to confirm identification of the
sciatic nerve. Surrounding muscles (biceps femoris, vastus lateralis, and adductor magnus) and fascial planes
(lateral intermuscular septum) were identified as sonographic landmarks and were confirmed in the anatomical
study.
success rate of ICB.
rastlanmadı
Conclusions: Ultrasonic identification of the sciatic nerve at the midthigh level can be achieved; however, in
this study, 37.5% of patients required nerve stimulation to confirm its sonographic appearance. Target nerve
localization and the subsequent performance of the sciatic nerve block may be enhanced by recognition of
surrounding muscular and fascial structures which were also identified using ultrasound. Reg Anesth Pain Med
2008;33:369-376.
popliteal sciatic approach in 10 patients,5 and 1
randomized trial using the lateral femoral approach.6 The objective of this study was to assess
the ease with which the sciatic nerve could be imaged in the midthigh region using ultrasound, and
to describe the anatomy surrounding the sciatic
nerve at this location.
LM-PNB (3/475) versus US-PNB (0/401; P = 0.255).
251 injury in the QI
were no episodes of local tissue
database related to PNB. In addition, no unintentional neuraxial
no casesreproduction
of cardiovascular
local
anesthetic toxicity
There Copyright
were 5436
consecutive
NCPNB
casesAnesthesia
(Table and
1) Pain blocks
@ 2009
American Society
of Regional
Medicineand
. Unauthorized
of this article
is prohibited.
were
reported.
performed by either LM-PNS or US-PNS in the 28-month
period of January 1, 2006, to April 30, 2008. Overall, there were
DISCUSSION
3290 blocks guided by LM-PNS and 2146 by US-PNS (Table 1).
Eight adverse events relevant to this report were reported in the
In our retrospective review of our institution’s QI database,
database (Table 2).
seizures associated with the conduct of brachial plexus PNB
Regional Anesthesia and Pain Medicine
RESULTS
Methods
Clinical Study
From the Department of Anaesthesia (M.J.B., S.-L.K.L.,
S.R.G.), St. Vincent’s Hospital, Melbourne; and the Department
of Anatomy and Cell Biology (C.A.B., J.J.I.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne,
Melbourne, Australia.
Accepted for publication December 3, 2007.
Reprint requests: Michael J. Barrington, F.A.N.Z.C.A., Department of Anaesthesia, St. Vincent’s Hospital, Melbourne,
PO Box 2900 Fitzroy, Victoria 3065 Australia. E-mail: Michael.
[email protected]
Crown Copyright © 2008 Published by Elsevier Inc. on behalf
of the American Society of Regional Anesthesia and Pain Medicine. All rights reserved.
1098-7339/08/3304-0001$34.00/0
doi:10.1016/j.rapm.2007.12.004
In this prospective, observational study we recruited 40 patients scheduled for lower limb surgery
(major knee or foot surgery) where sciatic nerve
block was indicated. The study was approved by the
Human Research Ethics Committee of St. Vincent’s
Hospital, Melbourne, and written informed consent
was obtained from all patients. The sciatic nerve
was identified with an ultrasound machine (Vivid-i®,
GE Healthcare) with color flow Doppler and image
capture capabilities, using a linear probe in the 6 to
10 MHz range (8L-RS) and, when required, a lower
Ultrasound-Guided Midthigh Sciatic Nerve
Block—A Clinical and Anatomical Study
40
Volume 34, Number 3, May-June 2009
There
TABLE 2. Characteristics of Adverse Events
Derin bloklarda ve özellikle obez hastalarda stimülatör ile doğrulama
Event No.
Regional Anesthesia and Pain Medicine Vol. 33 No. 4 July–August 2008
Regional Anesthesia and Pain Medicine, Vol 33, No 4 (July–August), 2008: pp 369 –376
&
Bazen sinirler çok derinde ya da çok küçük olabiliyorlar…
Michael J. Barrington, F.A.N.Z.C.A., Su-Ling K. Lai, Chris A. Briggs, Ph.D.,
Jason J. Ivanusic, Ph.D., and Samuel R. Gledhill, M.Med.Stat.
372
between
the 2US-PNS
groups.
was
chosen because
was introduced at the beginning of
this timeDuring
frame asthe
a clinical
pathway
option
for ourthere
anesthesia
period
of this
study,
were 3 nerve injuries
group and was gradually phased in over the ensuing 2 years, to
documented by EMG and nerve conduction studies that were
the point that 50% to 60% of our blocks are now performed
attributable
to PNB.
All 3 January
of these
blocks were
with
ultrasound guidance.
In addition,
2006peripheral
marked
the
origin
of
our
group’s
formal
documentation
of
US-PNS
on
posterior popliteal-sciatic blocks, conducted
by LM-PNS
the anesthetic record, rendering the use of this neurolocation
technique.
Each
nerve injury
in case
sensory loss, neurotechnique
as reliably
quantifiable.
Because resulted
of our facility’s
pathic and
pain,
and aavailability
variableofdegree
of motor
deficiency. Two of
volumes,
the initial
only 1 imaging
unit, as
well
as
the
gradual
adoption
of
ultrasound
technique,
there
were
these patients have progressively improved since initial diagnomore LM-PNS blocks than US-PNS blocks.
sis,Exclusion
whereas
1 included
patient’s
symptoms
have
taken on the
criteria
block
procedures that
were since
intended,
but not actually
out, andregional
block procedures
characteristics
ofcarried
complex
pain that
syndrome. For all
were
solelyevaluated,
carried out atand
our site
by either LM-PNS
(eg,
blocks
specifically
for popliteal
blocks, the
posterior lumbar plexus block) or US guidance (eg, midcalf
incidence
of
nerve
injury
was
not
significantly
different
after
saphenous nerve block).
assays, if improvement was evident within the first 6 months.
(Reg Anesth Pain Med 2009;34: 251Y255)
Those with improvement
or resolution during this time frame
were not included in the database as nerve injuries.
The sum of all the described adverse outcomes comprised
the numerator, per neurolocation technique (LM-PNS vs USPNS), with theFromdenominator
consisting of the billing
the *University of Pittsburgh Medical CenterYSouth Side, and
†University
of Pittsburgh
Medical CenterYMagee
Hospital,Statistical
Pittsburgh, PA.
dataYderived caseload
per
neurolocation
technique.
Accepted for publication August 21, 2008.
analysis of the data
was
carriedto:out
using
the MD,
2-tailed
Address
correspondence
Steven
L. Orebaugh,
UniversityFisher
of
Pittsburgh Medical CenterYSouth Side, 2000 Mary St, Pittsburgh, PA
exact test; P G 0.05
considered
statistically significant.
15203was
(e-mail:
[email protected]).
No specific
funding
was obtained for
this
research. because this
Sample size was
not
determined
a
priori,
Copyright * 2009 by American Society of Regional Anesthesia and Pain
Medicine
methodology was specifically
a consecutive-case review of the
ISSN: 1098-7339
aforementioned QI
database.
Data
were
analyzed
using
SPSS
DOI: 10.1097/AAP.0b013e3181a3438e
Statistical Software (version 14.0; SPSS Inc, Chicago, Ill).
Ultrasound, Peripheral nerve block, Sciatic nerve.
ltrasound-guided sciatic nerve block has recently been described.1 The use of ultrasound
technology for regional anesthesia is relatively new
and compared with sciatic nerve block performed
using surface landmarks and nerve stimulation,2-4
there are few descriptions of sciatic nerve block
using ultrasound. The literature includes 1 volunteer study1 that focused on the gluteal, infragluteal,
and proximal thigh regions, 1 case report of the
Nerve Blocks With/Without Ultrasound
Anatomik noktalar & sinir stimülatörü grubunda; 8 hastada komplikasyona
Methods: In this prospective observational study, 40 patients scheduled for surgery where sciatic nerve block
was indicated were scanned between the gluteal and the popliteal regions using an ultrasound machine
(Vivid-i®, GE Healthcare, Chalfont St. Giles, Bucks, UK). Patients then received real time ultrasound-guided
sciatic nerve block. Validation of the ultrasound image of the sciatic nerve was achieved using nerve stimulation.
Description and confirmation of the anatomy surrounding the sciatic nerve was based on a review of anatomical
texts and an anatomical study on 5 unembalmed cadavers.
U
Volume 34, Number 3, May-June 2009
A
Ultrasound-Guided Midthigh Sciatic Nerve
ultrasound
wereStudy
combined.
Block—A Clinical
andguidance
Anatomical
Key Words:
&
Regional Anesthesia and Pain Medicine & Volume
34, Number
3, May-June
2009
251
dverse
events from
peripheral
nerve blockade, such as local
Background and Objectives: In this retrospective study, we
anesthetic toxicity, peripheral nerve injury, and local tissue
queried our Quality Improvement database of anesthetic-related cominjury, may lead to discomfort, impaired rehabilitation after
plications to evaluate
the frequency
of noncatheter
1
@ 2009
Americanperipheral
Society nerve
of Regional
Anesthesia
and Pain
Medicine. Unauthorized
reproduction
of this article is prohibited.
Copyright
surgery,
life-threatening
complications,
and medicolegal
adblockYrelated
occurrences.ofWePeripheral
hypothesized that
adverseBlocks
comTABLE 1. Frequency
and adverse
Techniques
Nerve
versity.2 The increasing use of ultrasonographic imaging for
plications of nerve blockade are less common when ultrasonography is
needle placement and local anesthetic deposition may have the
used in conjunction with peripheral nerve stimulation to guide needle
potential to impact the safety
ISBcompared with the sole use
AxB
SCIof peripheral nerve blockade,
PFB if it
Total
placement, when
of physical landmarks and FEM
permits the operator to avoid some untoward events, such as
nerve stimulation.
needle trauma to nerves, intraneural
or intravascular injection
LM-PNS
892
96
1177
650
475 of
3290
Methods: We queried our departmental Quality Improvement
local anesthetic solutions, and needle puncture of unintended
electronic 1093
database for adverse outcomes220
associated with peripheral
US-PNS
277
2146
targets.3,4 However, there 155
is a paucity of large-scale 401
outcomes
nerve blocks. Billing records were used to provide the denominator of
data available related to 805
the provision of ultrasound-guided
Total
1985
316
1454
876
5436
the total number of blocks using both techniques of neurolocation. The
peripheral blocks. In this retrospective study, we queried our
types of blocks considered in this analysis were interscalene, axillary,
Quality
Improvement
of anesthetic-related
LM indicates landmark guided; US, ultrasound guided; PNS, peripheral nerve
stimulator
guided;(QI)
ISB,database
interscalene
block; AxB, axillary block; FEM,
femoral, sciatic, and popliteal sciatic blocks. The total numbers of
complications
to
evaluate
the
frequency
of
noncatheter
periphfemoral nerve block;complications
SCI, sciatic
nerve
block
not
using
popliteal
approach; PFB, popliteal fossa block of the sciatic nerve.
of nerve
blockade
with
each
type ofthe
guidance
were then
eral nerve block (NCPNB)Yrelated adverse occurrences in our
compared, as were specific subsets of adverse effects.
academic anesthesiology practice, which uses a Bclinical pathResults: There were 5436 consecutive peripheral noncatheter block
way[ concept to minimize dosing variability, and encourage
cases (interscalene, axillary, femoral, sciatic, popliteal) during the 28uniform practice patterns.5Y8 We hypothesized that complicamonth period surveyed, with 3290 guided by landmarkYnerve stimulations of NCPNB are less common when ultrasonography (US) is
tion, and
stimulation.
Eight adverse
outcomes
seizures
relatednerve
to stimulation
PNB conducted
by LM-PNB
standard for entry
in 2146
theby ultrasoundYnerve
QI database,
included
signs
or
used in Five
conjunction
with peripheral
(PNS) to
occurred among patients having blocks guided by landmarkYnerve
guide
needle placement
(US-PNS),
when compared
the occurred during
occurred
during this
28-month
period:withtwo
symptoms of epidural
or spinal blockade after PNB. Peripheral
stimulation technique, including 5 seizures and 3 nerve injuries. There
sole use of physical landmarks (LM) and PNS (LM-PNS), for
interscalene block, one during femoral block, and one each
nerve injury waswere
specified
as sensory
or motor dysfunction
no such occurrences
in the ultrasoundYnerve
stimulation group.
the 5 types of blocks considered.
When examination
comparing the 4 brachial
plexus blockYrelated
seizures to
that
immediately on cessation of injection after axillary block and
detected on follow-up
and judged
to be attributed
occurred with landmark guidance versus none with ultrasound guidance,
interscalene blockMETHODS
(Table 3). None were delayed. No seizures
the nerve block the
after
referral
to thereached
department
of physical
associated
risk of seizures
statistical significance
(P = 0.044
Thisreported
data query related
was approved
by the University
Fisher exact
test). There
was no difference between
the 2 groups
in the
were
to US-PNB.
When ofcomparing the 4
medicine. Thoseby with
motor
involvement
or pain
in the
Pittsburgh institutional review board. We queried our deidentiof seizuresunderwent
occurring with consultation
lower extremity blocks,
the
brachial
plexus
block seizures
outadverse
of a outcomes
total of 988 (0.4%; 95%
peripheral nerve number
distribution
withor inour
fied
departmental
QI electronic
database for
frequency of neurologic injury.
confidence
interval,nerve
0.0%Y0.7%)
plexus blocks with
physical medicineConclusions:
and rehabilitation
for diagnosis,
associated
with peripheral
blocks (PNBs).brachial
The following
High-definition physicians
ultrasonography offers
potential advanevents
were
specifically
queried:
seizure,
cardiovascular
toxicity,
tages
in
the
administration
of
peripheral
nerve
blockade.
The
significant
LM-PNB, versus none of 1313 with US-PNB,
this associated
follow-up, and rehabilitation, as well as EMG and nerve
local anatomic injury from needle trauma, unintended neuraxial
difference in major central nervous system local anesthetic toxicity
risk ofduring
seizures
after LM-PNB
reachednerve
statistical
significance
conduction testing.
Purely sensory abnormalities, including
blockade
PNB, pneumothorax,
and peripheral
inobserved in this study supports the use of ultrasound guidance in
jury.
Further
details
of
this
QI
database
are
given
below.
(P = 0.044 by Fisher exact test). There was no difference in
loss of sensationconjunction
or altered
perception
of tosensation,
with peripheral
nerve stimulation
provide brachialwere
plexus
The
period
from
which
data
were
queried
was
the
28-month
peripheral
nerve
blockade
in
an
academic,
ambulatory
anesthesia
the frequency of seizure related to lower extremity blockade
followed for progression, but not studied with nerve conduction
period from January 1, 2006, to April 30, 2008. This interval
practice.
A single stimulation lateral approach technique of ICB was
369
Type of Event
Type of Block
Practitioner
1
Seizure
FEM
Resident
3
4
5
6
7
8
Nerve injury (sensorimotor)
Seizure
Nerve injury (sensorimotor)
Nerve injury (sensorimotor)
Seizure
Seizure
PFB
AxB
PFB
PFB
ISB
ISB
Resident
Attending
Resident
Resident
Resident
Attending
Solution Injected
30 mL 0.5% Ropiv
2
Seizure
ISB görüntülenebilirliği
Attending
36 mL 0.75% Ropiv
gerekebilmekte
aynı zamanda iğne
azalmaktadır
Background and Objectives: Ultrasound-guided sciatic nerve block is a relatively new regional anesthesia
technique with few descriptions in the literature. The objective of this study was to assess the ease with which
the sciatic nerve could be imaged in the midthigh region using ultrasound and to describe the anatomy
hastada
USG
ile siyatik
surrounding
the sciatic
nerve at this location.
USG rehberliği&SS birlikteliği
In this prospective
sinir Methods:
tanımlanmaya
çalışıldı.observational study, 40 patients scheduled for surgery where sciatic nerve block
was indicated were scanned between the gluteal and the popliteal regions using an ultrasound machine
(Vivid-i , GE Healthcare, Chalfont St. Giles, Bucks, UK). Patients then received real time ultrasound-guided
15 hastada
(%37.5) siyatik
40 mL
30 mL
40 mL
40 mL
0.5% Ropiv plus 0.75% mepiv
0.5% Ropiv plus 0.75% mepiv
0.5% Ropiv plus 0.75% mepiv
0.5% Ropiv plus 0.75% mepiv
30 mL 0.75% Ropiv
30 mL 0.75% Ropiv
All events were associated with landmark-based peripheral nerve stimulator use without ultrasound.
FEM indicates femoral nerve block; ISB, interscalene block; PFB, popliteal fossa block; AxB, axillary block; Ropiv, ropivacaine; mepiv,
mepivacaine.
®
sciatic nerve block. Validation of the ultrasound image of the sciatic nerve was achieved using nerve stimulation.
Description and confirmation of the anatomy surrounding the sciatic nerve was based on a review of anatomical
sinirin
USG ile iyi
texts and an anatomical study on 5 unembalmed cadavers.
Results: The sciatic nerve
was identified with ultrasound and its image validated using nerve stimulation in
tanımlanamamasından
dolayı
253
* 2009 American Society of Regional Anesthesia and Pain Medicine
38 of 40 patients (95%). In 15 patients (37.5%) nerve stimulation was required to confirm identification of the
sciatic nerve. Surrounding
SS doğrulaması
gerekti. muscles (biceps femoris, vastus lateralis, and adductor magnus) and fascial planes
Copyright @ 2009 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
(lateral intermuscular septum) were identified as sonographic landmarks and were confirmed in the anatomical
study.
Conclusions: Ultrasonic identification of the sciatic nerve at the midthigh level can be achieved; however, in
this study, 37.5% of patients required nerve stimulation to confirm its sonographic appearance. Target nerve
localization and the subsequent performance of the sciatic nerve block may be enhanced by recognition of
surrounding muscular and fascial structures which were also identified using ultrasound. Reg Anesth Pain Med
2008;33:369-376.
Key Words:
Ultrasound, Peripheral nerve block, Sciatic nerve.
U
popliteal sciatic approach in 10 patients,5 and 1
ltrasound-guided sciatic nerve block has recently been described.1 The use of ultrasound
randomized trial using the lateral femoral apFig 2. Visualization of the sciatic nerve was graded
as (A) excellent; nerve recognized with confidence on ultrasound
proach.6 The objective of this study was to assess
technology for regional
anesthesia is relatively new
because of the typical sonographic appearance of a nerve, including being hyperechoic and fascicular, and continuously
the(B)ease
with
which
the sciatic
nerve could
be im- because of typical
and compared with identifiable
sciatic nerve
block
performed
between
anatomical
boundaries;
good;
nerve
recognized
with confidence
on ultrasound
2-4 as described
sonographic
appearance
of nerve
but only region
intermittently
aged inabove,
the midthigh
using identifiable
ultrasound,between
and the anatomical
using surface landmarks
and nerve
stimulation,
boundaries;
average;
nerve
identified to
intermittently
but required
nerve
stimulation for
and (D) poor;
describe the
anatomy
surrounding
theconfirmation;
sciatic
there are few descriptions
of (C)
sciatic
nerve
block
nerve could not be identified using ultrasound. The static images do not reflect the dynamic nature of scanning.
nerve at this location.
using ultrasound. The literature includes 1 volunINTRANEURAL INJECTIONS AND REGIONAL ANESTHESIA
teer study1 that focused on the gluteal, infragluteal,
and proximal thigh greater
regions,trochanter
1 case report
the
line toof
the
popliteal
crease. The
site of the transverse sonogram of the sciatic nerve
Methods
Enjeksiyon basınç monitörü
Regional Anesthesia and Pain Medicine, Vol 33, No 4 (July–August), 2008: pp 369 –376
•  İntrafasiküler mi ekstrafasiküler mi?
JENG
İntrafasiküler Enjeksiyon:Sinir Hasarı
remainder of the results from the clinical study
that resulted in the typical appearance we had noted
Clinical
Study in vivo was at 57 ! 6% of the distance from the ischial
are presented in Table 1. No symptoms
indicating
From the Departmentpossible
of Anaesthesia
(M.J.B., S.-L.K.L.,
neurological
complications were detuberosity/greater trochanter line to the popliteal The practice of regional anesthesia has unIn this prospective,
observational study we reS.R.G.), St. Vincent’s Hospital,
Melbourne;
and the Department
tected
at the 6-week
phone follow-up.
crease. Following injection of, on average, 8 mL of
of Anatomy and Cell Biology
(C.A.B.,
J.J.I.), Faculty
of Medicruited
40and
patientsdye,
scheduled
for lower
limb surgery
For
the anatomical
study,
3 frozen and
thawed
there was
approximately
a 7-cm spread bothdergone monumental changes over the last two
cine, Dentistry and Health Sciences, University of Melbourne,
(major
surgery)
sciatic
2 refrigerated cadavers (average age at death:
85 knee
! 8.0 or foot
proximal
and where
distal from
thenerve
site of injection withindecades. The progression from paresthesia techMelbourne, Australia.
years)
were
dissected. Relevant structures
on the
theThe
nerve
sheath.
block was
indicated.
study
was approved by the
Accepted for publication
December
3, 2007.
niques to NS and then to US has greatly imsonogram
were identified
following
the
dissections.
Reprint requests: Michael
J. Barrington,
F.A.N.Z.C.A.,
DeHuman
Research Ethics Committee of St. Vincent’s
proved the success, onset and quality of nerve
nerve
was Melbourne,
correctly identified
on ultrapartment of Anaesthesia,The
St. sciatic
Vincent’s
Hospital,
Hospital,
Melbourne,
and written informed consent
Discussion
PO Box 2900 Fitzroy, Victoria
3065
Australia.
E-mail:
Michael.
sound
in all
5 cadavers
and
seen to be located close to
blocks. The use of US offers the ability to visualwas obtained
from
all
patients.
The
sciatic
nerve
[email protected] the biceps femoris, vastus lateralis, and adductor
In this clinical and anatomical study we were ableize what has historically been performed blindly,
magCrown Copyright © 2008
Published
by
Elsevier
Inc.
on
behalf
was
identified
with
an
ultrasound
machine
(Vivid-i®,
to identify the sciatic nerve in the midthigh region
nus muscles (Fig 4). The well defined fascia on the
of the American Society of Regional Anesthesia and Pain MedGE Healthcare)
color
flow Doppler
image the ultrasoundallowing practitioners to determine the location
using
ultrasound,
and and
to validate
posteromedial surface of the vastus lateralis
muscle is with
icine. All rights reserved.
appearance
of the
sciatic
shown in Figure 5 and contributes to the
sonographic
capture
capabilities,
using a linear
probe
innerve
the 6 and
to its surroundingof the needle tip and observe the spread of lo1098-7339/08/3304-0001$34.00/0
structures
using required,
nerve stimulation
appearance of the lateral intermuscular 10
septum
doi:10.1016/j.rapm.2007.12.004
MHzwhich
range (8L-RS)
and, when
a lower and anatomicalcal anesthetic. Interestingly, the incidence of
dissection. Despite 15 patients (37.5%) having their
separates it from biceps femoris. In all cadavers the
sciatic nerve image graded as average or poor andneurologic injuries associated with peripheral
image quality was graded as excellent; a typical sonogram with fascicular pattern is shown in Figure 6. The
therefore requiring nerve stimulation to confirmnerve blocks has not decreased. Fredrickson et
369
al. looked at 1,010 consecutive US guided peripheral nerve blocks, including single shot and
continuous interscalene, supraclavicular, infraclavicular, femoral, and sciatic nerve blocks, and
found that the rate of postoperative neurological
complications was similar to the low rates previously reported when following traditional techniques. They postulated that this was a reflection
of the fact that most post-block neurological
complications are the result of non-block-related
causes.3 In a recent study of over 7,000 peripheral nerve and plexus blocks performed with US
(13%), NS (30%), US with NS (50%), and others (7%), 30 patients (0.5%) had clinical features
that required a referral for neurologic assessment. Neurologic assessments included eliciting
a complete history and physical examination and
then, when indicated, patients underwent testing that may have included elctrophysiologic
testing (nerve conduction, electromyography),
imaging studies (computed tomography or magnetic resonance imaging) and blood tests. With
this information, the neurologist determined
whether the neurologic deficit was related to the
surgical procedure. In only 3 of these 30 patients
was the nerve injury determined to be related
to the peripheral nerve block, yielding an incidence of 0.4 complications per 1,000 blocks
(0.04%).4 Although these results do not prove
that US guidance improves nerve block safety,
Perineurium
Epineurium
Perineurium
space
Facicles containing
nerve fibres
Figure 1.
Perinöral: Sinirin dışı
rium. Bonnel and Rabischong showed that from
proximal to distal, there is an increase in fascicle
number and a decrease in their diameter.5, 6 This
İntranöral: Epineuriumun altı
was corroborated by the work of Moayeri et al.
demonstrating that in the proximal the brachial
plexus,
i.e., interscalene
and supraclavicular
İntrafasiküler:
Perineuriumun
içi regions, the nerves tend to be more solid and oligofascicular, while more distally, the fascicles are
more dispersed, polyfascicular and with large
amounts of stromal tissue.7 The perineurium is a
tough and resistant tissue;8 therefore, it is unlikely to be easily penetrated by a blunt short-bevel
needle. This may explain why simple penetration
of the epineurium does not always result in neural damage.
In a study in rats, in which injection of the
sciatic nerve was performed under direct visualization, intraneural injections of 0.2 mL of either 0.2% or 0.75% ropivacaine did not have
any deleterious effect on sciatic nerve motor
function.9 In a recent study, Chan 10 supported
the potential safety of intraneural injections in
a pig model. Under direct US guidance, 5 mL
of 5% dextrose and Sennelier black India ink
was injected into 28 brachial plexus nerves, and
nerve expansion was visualized in 24 of them.
Upon histologic examination of the 24 nerves,
the ink had penetrated the epineurium in 22
INTRANEURAL INJECTIONS AND REGIONAL ANESTHESIA
El ile hissetmek subjektif
ü  enjeksiyon hızı
ü  iğne çapı
ü  Doku direnci
The practice of regional anesthesia has undergone monumental changes over the last two
decades. The progression from paresthesia techniques to NS and then to US has greatly improved the success, onset and quality of nerve
blocks. The use of US offers the ability to visualize what has historically been performed blindly,
allowing practitioners to determine the location
of the needle tip and observe the spread of local anesthetic. Interestingly, the incidence of
neurologic injuries associated with peripheral
nerve blocks has not decreased. Fredrickson et
al. looked at 1,010 consecutive US guided peripheral nerve blocks, including single shot and
continuous interscalene, supraclavicular, infraclavicular, femoral, and sciatic nerve blocks, and
found that the rate of postoperative neurological
complications was similar to the low rates previously reported when following traditional techniques. They postulated that this was a reflection
of the fact that most post-block neurological
complications are the result of non-block-related
causes.3 In a recent study of over 7,000 peripheral nerve and plexus blocks performed with US
(13%), NS (30%), US with NS (50%), and others (7%), 30 patients (0.5%) had clinical features
that required a referral for neurologic assessment. Neurologic assessments included eliciting
a complete history and physical examination and
then, when indicated, patients underwent testing that may have included elctrophysiologic
testing (nerve conduction, electromyography),
imaging studies (computed tomography or magnetic resonance imaging) and blood tests. With
this information, the neurologist determined
whether the neurologic deficit was related to the
surgical procedure. In only 3 of these 30 patients
was the nerve injury determined to be related
to the peripheral nerve block, yielding an incidence of 0.4 complications per 1,000 blocks
(0.04%).4 Although these results do not prove
that US guidance improves nerve block safety,
they clearly confirm the fact that post-peripheral
nerve block neurologic deficits are rare events.
To understand nerve injury, one must review
neural anatomy (Figure 1). Within the epineurium, the neural tissue is formed by individual
nerve fibers enveloped by endoneurium, which
are organized in fascicles surrounded by perineu-
JENG
Perineurium
Epineurium
Perineurium
space
Facicles containing
nerve fibres
Figure 1.
rium. Bonnel and Rabischong showed that from
proximal to distal, there is an increase in fascicle
number and a decrease in their diameter.5, 6 This
was corroborated by the work of Moayeri et al.
demonstrating that in the proximal the brachial
plexus, i.e., interscalene and supraclavicular regions, the nerves tend to be more solid and oligofascicular, while more distally, the fascicles are
more dispersed, polyfascicular and with large
amounts of stromal tissue.7 The perineurium is a
tough and resistant tissue;8 therefore, it is unlikely to be easily penetrated by a blunt short-bevel
needle. This may explain why simple penetration
of the epineurium does not always result in neural damage.
In a study in rats, in which injection of the
sciatic nerve was performed under direct visualization, intraneural injections of 0.2 mL of either 0.2% or 0.75% ropivacaine did not have
any deleterious effect on sciatic nerve motor
function.9 In a recent study, Chan 10 supported
the potential safety of intraneural injections in
a pig model. Under direct US guidance, 5 mL
of 5% dextrose and Sennelier black India ink
was injected into 28 brachial plexus nerves, and
nerve expansion was visualized in 24 of them.
Upon histologic examination of the 24 nerves,
the ink had penetrated the epineurium in 22
and had minimally penetrated the perineurium
(intrafascicular) in 2, but there was no evidence
of dysplasia of any of the fascicles. These results
were confirmed by Lupu et al. in a porcine study
demonstrating that nerve expansion observed by
ultrasound during intraneural injections of clinically relevant volumes of local anesthetic (up to
Düşük basınçlı enjeksiyon nörolojik hasar riskinden koruyabilir
Gaddens et al
Vol. 77 - No. 1
MINERVA ANESTESIOLOGICA
55
Sinir
Stimülatörü
•  SS ile lomber plx bloğu,
35 ml LA
•  Grup 1: <15psi enjeksiyon
•  Grup 2:>20psi enjeksiyon
Ultrason
Basınç
Monitörizasyonu
Yüksek basınçlı enjeksiyon nöroaksiyel
yayılımla ilişkili
NYSORA
NIH Public Access
Author Manuscript
Reg Anesth Pain Med. Author manuscript; available in PMC 2010 May 13.
NIH-PA Author Manuscript
Published in final edited form as:
Reg Anesth Pain Med. 2008 ; 33(5): 404–415. doi:10.1016/j.rapm.2008.07.527.
ASRA Practice Advisory on Neurologic Complications in Regional
Perfüzyon İndeksi (PI)
Anesthesia and Pain Medicine
NIH-PA Author Manuscript
Joseph M. Neal, M.D., Christopher M. Bernards, M.D., Admir Hadzic, M.D., James R. Hebl,
M.D., Quinn H. Hogan, M.D., Terese T. Horlocker, M.D., Lorri A. Lee, M.D., James P. Rathmell,
M.D., Eric J. Sorenson, M.D., Santhanam Suresh, M.D., and Denise J. Wedel, M.D.
Department of Anesthesiology (J.M.N., C.M.B.), Virginia Mason Medical Center, and the
Department of Anesthesiology (J.M.N., C.M.B., L.A.L.), University of Washington, Seattle, WA; the
Department of Anesthesiology (A.H.), St. Luke's–Roosevelt Hospital Center, New York, NY;
Department of Anesthesiology (J.R.H., T.T.H., D.J.W.), and the Department of Neurology (E.J.S),
Mayo Clinic. Rochester, MN; Department of Anesthesiology (Q.H.H.), Medical College of Wisconsin,
Milwaukee, WI; Department of Anesthesiology (J.P.R.), Massachusetts General Hospital, Harvard
University, Boston, MA; and the Department of Anesthesiology (S.S.), Childrens’ Memorial Hospital,
Northwestern University, Chicago, IL.
•  Pulsatil kan akımı/Nonpulsatil kan akımı
Ne yazık ki!!
Hiçbir monitörizasyon yöntemi tam anlamıyla
Abstract komplikasyonları ortadan kaldıramamaktadır
Neurologic complications associated with regional anesthesia and pain medicine practice are
extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia
and Pain Medicine addresses the etiology, differential diagnosis, prevention, and treatment of these
complications. This Advisory does not focus on hemorrhagic and infectious complications, because
they have been addressed by other recent ASRA Practice Advisories. The current Practice Advisory
offers recommendations to aid in the understanding and potential limitation of neurologic
complications that may arise during the practice of regional anesthesia and pain medicine.
periferik sinir stimülatörü,
ultrasonografi rehberliği,
basınç monitörizasyonu
Keywords
Complications of anesthesia; Nerve injury; Spinal anesthesia; Epidural anesthesia; Peripheral nerve
block; Regional anesthesia; Pain medicine; Transforaminal block
NIH-PA Author Manuscript
The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened a group
of experts to develop a Practice Advisory on Neurologic Complications in Regional Anesthesia
and Pain Medicine. The goal of this Practice Advisory is to provide information for
practitioners of regional anesthesia and pain medicine regarding the etiology, differential
diagnosis, prevention, and treatment of neurologic complications. This Practice Advisory
focuses on neurologic injuries apart from those caused by hemorrhagic1 or infectious2-6
complications, both of which have been the subject of other recent ASRA-sponsored Practice
Advisories. The current report is a summation of the Practice Advisory's findings and
recommendations. Anesthesiologists are strongly encouraged to read the manuscripts that
accompany the present summary document, because they contain the details upon which
recommendations are based. The accompanying manuscripts represent most of the subtopics
discussed at the conference.
© 2008 Published by Elsevier Inc. on behalf of the American Society of Regional Anesthesia and Pain Medicine.
No reprints will be available.
• Ekstremite cerrahisi
geçirecek 66 hasta
• SS ile Siyatik veya
aksiller blok
• Pinprik ve soğuk test
Perfüzyon İndeksi
Avantaj
•  Başarılı/Başarısız bloğun erken tespiti
•  Eğitim gerekmiyor
•  Objektif değerlendirme
•  Pinprick veya soğuk uygulama yok
Dezavantaj
•  Diabetik, nöropatisi olan hastalarda, pah larında ?
•  Uygulanabilir blok sayısı sınırlı?
•  Bireysel farklılık söz konusu PI değerinde 0.1-10
Analjezi Nosisepsiyon Indeks: ANI
Parasempatik tonusun sürekli ölçümüdür
0-100 arası bir ölçekte değerlendirilir
ANI
ANI
Özellikle
eğer >70 ise opioid dozu
azaltılabilir
50-70 arası ideal bölge
<50 ise muhtemelen
hemodinamik reaktivite söz
konusudur
Opioid aşırı dozuna duyarlı yaşlı hastalarda
Çocuklarda
Obez hastalarda
Bağımlı hastalar
>3 saat süren operasyonlar
Hasta Güvenliği
Ultrason
Anatomik bigi
Perfüzyon
İndeks
Standart
monitorizasyon
Basınç
monitorizasyonu
(ECG, SPO2,
NIBP, vb)
Sinir Stimülasyonu
Fonksiyonel Bilgi
Sabrınız için teşekkürler
ANI