kurs 5: ceea 5: neuromišićna blokada, regionalna
TRANSCRIPT
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Kurs 5: CEEA 5: Neuromišićna blokada, regionalna anestezija i
terapija bola
Naziv teme: Periferni nervni blokovi za gonje i donje ekstremitete-upotreba ultrazvuka i nervnog stimulatoraDatum: 02.03.2018.
Jezik: Srpski
Grad: Kopaonik
Zemlja: Srbija
Predavač: Dr Svetlana Srećković
www.esahq.org/education/courses-in-anaesthesiology/ceea-courses
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Periferni nervni blokovi
• Anestezije
• Dijagnostički
• Prognostički
• Preemptivni
• Multimodalne analgezije
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Periferni nervni blokovi
• kardiorespiratornu stabilnost
• minimalnu pripremu pacijenta
• postoperativna kontola bola
• ↓ upotrebu opioida
• ↓ postoperativne mučnine i povraćanja
• ↓ broja bolničkih dana
• prevenciji ponovnog prijema pacijenata
• brži otpust pacijenata
• rana rehabilitacija
• ↓ ukupnih troškova
• ↑ zadovoljstvo pacijenata
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Nervni stimulator
• 0,2-0,3mA (0-5mA)
• 0,1ms (0,1-1ms)
• 2Hz
• kod bolesnika sa perifernim
neuropatijama, uključujući i
dijabetičare: 0.3 – 1.0 ms da bi se
dobio motorni odgovor
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5-18MHz
2.5 – 5MHz
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• Ehogenost
hiperehogene (bele)
hipoehogene (sivo)
anehogene (crno)
Distalni nervi hiperehogeni kao tetive i ligamenti (anizotropija- hipo u
hiperehogene)
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• Intraneuralno (intraneuralno
ekstrafascikularno?)
• Paraneuralno (ili intra-plexus)
perineuralno
perivaskularno
• Izvan fascije ili peri-plexus
INTRANEURALNO=EPINEURIUM
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Interskalenski blok
Indikacije
• hirurgija lateralne 2/3 klavikule (unutrašnju trećinu cervikalni
plexus)
• hirurgija ramena
• hirurgija proksimalnog humerusa (zadnji artroskopski port
može zahtevati lokalnu infiltraciju)
• Ne preporučuje se za hirurgiju lakta, podlaktice i šake-
neadekvatna blokada donjeg trunkusa (C8-Th1)
plexus brahialis trunks – gornji (C5-C6)
srednji (C7)
donji (C8-Th1)
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Interskalenski blok
Stimulacija brahialnog pleksusa
strujom jačine 0.2-0.5 mA (0.1 ms)
Motorni odgovor:
• m. pectoralis
• m. deltoideus
• m. triceps brachii
• m. biceps brachii
• pokret podlaktice ili šake
25-35 ml lokalnog anestetika
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Interskalenski blok
15-25 ml lokalnog anestetika
peripleksus
m.scalenus anterior (ASM) , m.scalenus medium (MSM). bela strelica-superficial cervical plexus a.vertebralis (VA), a.carotis (CA)
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Interskalenski blok- komlikacije
• Ipsilateralni blok n. phrenicus-a (C6 pareza dijafragme 100%
pacijenata, ↓ 25 % res volumena)
• Pneumothorax
• Trajno neurološko oštećenje
• Blok: n. vagus, n.laryngeus recurrens
• Horner’s syndrome ( blok cervical sympathetic nerava-
ptoza, mioza, enoftalmus, anhidroza)
• Epiduralna ili subarachnoidalna injekcija
• Hipotenzija i bradikardija (Bezold-Jarisch reflex)
• Punkcija arterije vertebralis
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Kontraindikacije
• Infekcija kože
• Odbijanje pacijenta
• Poremećaji koagulacije
• Kontralateralna paraliza n. phrenicus-a, n.laryngeus recurrens
• Poznata neuropatija ruke koja se operiše
• Bronhopulmonalno oboljenje
• Poznata alergija na lokalni anestetik
• Prethodno neurološko oštećenje brahijalnog pleksusa
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Supraklavikularni blok
• operacije gornjeg
ekstremiteta distalno od
ramena
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Supraklavikularni blok
• Pacijent u polusedećem
položaju sa glavom
rotiranom u suprotnu
stranu
• Cilj identifikacija
a.subclavia, prvo rebro i
pleura
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Supraklavikularni blok
20-25 ml lokalnog anestetika
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Supraklavikularni blok- komlikacije
• Pneumothorax (0,5-6%) do 24h !!!
• Blok n. phrenicus-a (40-60%)
• Horner’s syndrome
• Trajno neurološko oštećenje
• Hematom
• Punkcija krvnog suda
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Infraklavikularni blok
• Indikacija: operacije distalne nadlaktice, lakta, podlaktice i
šake
• Mala verovatnoća za nastanak pneumotoraksa
• Preporuka da se radi pod kontrolom ultrazvuka (±nervni
stimulator)
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Infraklavikularni blok
• Dubina 3-6 cm
• Linearna sonda 8-12 MHz
• Cilj: vizuelizacija a.axilaris
ispod m. pectoralis minor
• Lokalni anestetik u obliku
slova U oko a. axilaris
(laterni, posteriorni i
medijalni snop)
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Infraklavikularni nervni blok
20-30 ml lokalnog anestetika
LC-lateralni snop, PC- zadnji snop, MC- srednji snop, AA-a.axilaris, PMiM-m.pectoralis minor, PMaM-m.pectoralis maior
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Aksilarni blok
Hirurgija lakta, podlaktice i šake
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Aksilarni blok
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Aksilarni blok
Nervni stimulator
0,2-0,5 mA
2 Hz
0.1-0.3 ms
igla 5 cm, 22G, pod uglom
od 45°
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Aksilarni blok
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Aksilarni blok
15-20 ml lokalnog anestetikaintrapleksus
MN-n. medianus, UN-n.ulnaris, RN-n.radialis, MCN-n.musculocutaneus
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Blok perifernih nerava na nivou lakta
N. radialis
3-4cm iznad lakta
Dve grane: superficijalna (senzitivna)duboka (motorna)
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Blok perifernih nerava na nivou lakta
N. ulnaris
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Blok perifernih nerava na nivou lakta
N. medianus
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Blok perifernih nerava na nivou ručjaN. medianus
N. radialis
N. ulnaris
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BLOKOVI DONJIH EKSTREMITETA
- tehnički se teže izvode, zahtevaju mnogo više prakse
- današnja njihova primena je uglavnom u okviru
postoperativne analgezije
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Lumbalni paravertebralni blok ili psoas
kompartment blok
• Hirurgija kuka, femura,
kolena
• Igla 21G, 10 cm dužine
• Prati se motorni odgovor
kvadricepsa
• 20-30 ml lokalnog
anestetika
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Konveksna sonda, dubina >8cm i 20-30 ml lokalnog anestetika
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Lumbalni paravertebralni blok ili psoas
kompartment blok- komlikacije
• Subarahnoidalno ili epiduralno ubrizgavanje 1,8-16%
• Povreda bubrega
• Krvarenje
• Epiduralni ili paravertebralni hematom
• Sistemski toksični efekat lokalnog anestetika
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Perivaskular 3 u 1 (femoralni) nervni blok
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Dubina 3-5 cm30-40 ml lokalnog anestetika
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- 0.3-0.5 mA (2 Hz, 0.1-0.3
msec)
- noga u 30º abdukciju
- Tuberkulum pubis 1,5cm
lateralno i kaudalno
- Igla 22G, 10cm
- 10-15 ml lokalnog
anesteika
Motorni odgovor je mera
efikasnosti bloka
Blok n. obturatorius
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Blok n. obturatorius-a
m. adductor longus (ALM), m. adductor brevis (ABM), m.adductor magnus (AMM)
5-10 ml lokalnog anestetika
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Femoralni blok
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Femoralni nervni blok
• VAN
• Nervni stimulator, odgovor
kvadricepsa na 0,2-0,4 mA
• 15-20 ml lokalnog
anestetika
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Femoralni nervni blok
Linearna sonda , 8-14Hz, dubina 2-4 cm
10-20 ml lokalnog anestetika
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Aduktor kanal blok
Linearna sonda , 8-14Hz, dubina 2-4 cm Nervni stimulator 0,5mA- parastezije
5-10 ml lokalnog anestetika
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Blok n. saphenus-a
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Parasakralni blok
n.ischiadicus i n.cutaneus femoralisposterior
20-30 ml lokalnog anestetika
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Blok n. ishiadicus-a
• prednji pristup
• zadnji pristup
transglutealno
infraglutealno
• poplitealni blok
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Blok n. ishiadicus-a – prednji pristup
• Noga u abdukciji do 30°
• Konveksna sonda (2-8MHz),
medijalni deo natkolenice
• Igla 10cm, G22
• Dubina 6-8cm
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Blok n. ishiadicus-a – prednji pristup
15-20 ml lokalnog anestetika
AMM-m.adductor magnus, FA-a.femoralis
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Blok n. ishiadicus-a – zadnji pristup
transglutealno
Motorni odgovor na dubini od 5-8cm0,2-0,5mA
15-20 ml lokalnog anestetika
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Blok n. ishiadicus-a – zadnji pristup
transglutealno
• Konveksna sonda 2-8MHz
• Tuber ischiadicum-Trochanter
major
• 10cm, 21-22 G
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Blok n. ishiadicus-a – zadnji pristup
transglutealno
IT-tuber ischiadicum, GMM-m.gluteus maximus, ScN-n.ischiadicus
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Blok n. ishiadicus-a – zadnji pristup
subglutealno
Dubina 3-5cmLinearna ili konveksna sonda 4-12MHz
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-Hirurgija skočnog zgloba i stopala
-Analgezija kod hirurgije kolena
Poplitealni blok
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Poplitealni blok
• Dubina:3-5 cm
• Linearna sonda 8-12 MHz
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Poplitealni blok
15-20ml lokalnog anestetika-epineurijumili 20-30 ml
ScN-n.ischiadicus, BFM-m.biceps femoris, SmM-m.semimemranosus, StM-m.semitendinosus, PA-a.poplitea
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Blok stopala
• N. tibialis posterior
• N. peroneus profundus
• N.superficialis peronei
• N.suralis
• N.saphenus
• Hirurgija stopala i prstiju
• UZ- linearna sonda
• Lokalni anestetik: 3-5 mL
po nervu
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Blok n.tibialis-a posterior-a
PTN-n.tibialis posterior, PTA-a.tibialis posterior, PTV-v.tibialis posterior
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Blok n. peroneus profundus-a
DPN-n.peroneus profundus,ATA-a.tibialis anterior
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N. Peroneus superficialis
N. suralis
PBM-peroneus brevis muscle
sural nerve (SuN),small saphenous vein (SSV) SoM-soleus muscle
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Blok n.saphenus-a
small saphenous vein (SaV), n.saphenus-SaN
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Periferni nervni blokovi gornjih i donjih
ekstremiteta
• Najviši stepen uspešnosti i sigurnosti za pacijenta
• U cilju obezbeđivanja što duže postoperativne analgezije –
sistemsko davanje ili perineuralno
plasiranje katetera (neadekvatna pozicija,
knikovanje, curenje)
NEOHPODNA EDUKACIJA I OSOBLJA I PACIJENATA
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HVALA NA PAŽNJI!