Yeni Monitörizasyon Sistemleri
Transkript
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: LORLEE@UW.EDU 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 V & V struc ing u ment from have of n secon have cular bloo sever rapid on ca ultra ways also flow disto tance the L lipid Depa 1. Z U b i 7 2. G a A 3. W a r R Visu Inje Acce To th W 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: orebaughsl@anes.upmc.edu). 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. Barrington@svhm.org.au 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: orebaughsl@anes.upmc.edu). 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 Barrington@svhm.org.au 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