術後止痛新潮流 - 區域神經止痛術.

Transcription

1 The clinical implication of peripheral nerve block ( including the techniques of single shot & continuous catheter) The current status of peripheral nerve block technique in USA, Singapore and Taiwan 台大醫院麻醉部陳李魁醫師助理教授 clk0619@ntu.edu.tw 術後止痛新潮流 - 區域神經止痛術

2 Indications of Different Analgesia Methods for Postoperative Pain Control Complications Disadvantage Benefit Advantage Intravenous Patient Controlled Analgesia (IVPCA) Regional Analgesia: Epidural Analgesia (PCEA) Peripheral Nerve Block

3 The clinical implication of peripheral nerve block (NYSORA) ilioinguinal/hypogastric (e.g., herniorrhaphy) paracervical (e.g., dilation/curettage, cone biopsy) penile (e.g., circumcision) peroneal /femoral/saphenous/tibial/sural (e.g., podiatric) femoral/obturator/lateral femoral cutaneous/sciatic (e.g., leg) brachial plexus/axillary/ulnar/median/radial (e.g., arm/hand) peribulbar/retrobulbar (ophthalmologic procedures) mandibular/maxillary (e.g., oral surgery) IV regional (Bier block) (e.g., arms, legs)

4 The clinical implication of peripheral nerve block technique with single shot

5 The clinical implication of peripheral nerve block technique with continuous catheter 1) Ultrasound-Guided Continuous Interscalene Block (upper extremities) 2) Ultrasound-guided Continuous Femoral Nerve Block (lower extremities)

6 Continuous Catheter Of Peripheral Nerve Block Technique for Postoperative Pain Management Catheterization equipment 1) Catheter through needle 2) Cannula over needle & Catheter through cannula The catheter through an insulated Tuohytipped needle (catheter through needle technique)

7 New Advances in Peripheral Nerve Blocks

8 Portable infusion pumps, including traditional pumps and disposable pumps, as well as newer disposable electromechanical or elastomeric balloon pumps

9 Success of continuous PNB depends on. Knowledge of anatomy Familiarity with the equipment Block/infusate/rescue selection for specific operations Aware of limitations/ complications Follow up p ts to constantly adjust technique and management

10 Pearls for catheters Review patient daily Remove catheter when indicated 3 rd day post TKR 10 th to 14 th day post tenolysis of hand Signs of inflammation Need for ambulation Follow-up patient until block recedes

11 A Comparison of Epidural Analgesia With Combined Continuous Femoral-Sciatic Nerve Blocks After Total Knee Replacement (Anesth Analg 2006;102:1240 6) 60 patients were prospectively randomized to receive either epidural infusion or combined continuous femoral and sciatic nerve blocks. The primary outcome measure was the total incidence of side effects (urinary retention and moderate to severe degrees of dizziness, pruritus, sedation, and nausea/vomiting on the first postoperative day). Intensity of motor blockade, pain at rest and on mobilization, and rehabilitation indices were also registered for 72 h. One or more side effects were present in 87% of patients in the epidural group whereas only 35% of patients in the femoral and sciatic block groups were affected on the first postoperative day.

12 Complications of Peripheral Nerve Block Uncommon: % Needle related Nerve injury Damage to surrounding structures Vascular puncture (Bleeding) Drug related LA toxicity Catheter related Inflammation to infection Catheter migration Catheter shearing Catheter knotting

13 LA Toxicity ( %) Intravascular injection Neurological and Cardiorespiratory sequelae (Neurotoxicity Cardiovascular or respiratory toxicity) Bupivacaine > L bupivacaine > Ropivacaine > Xylocaine

14 Current status of applying peripheral nerve block technique in USA & Singapore Technique training & mature (V) Widely clinical implication (V) Cost Benefit analysis (V) Patient safety consideration (V) Induction room setting (V) Legal issues protection (V) Insurance system coverage (V)

15 Induction room setting (V)

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17 Peripheral nerve block technique with single shot experience in NTUH Brachial plexus block N=50 Effect: complete work Effect: Incomplete work with partial effect Effect: (Failure) Incomplete work without any effect Brachial plexus block in the interscalene area (N=22) Brachial plexus block in the supraclavicular area (N=11) Brachial plexus block in the axillary area (N=17) 17/22 4/22 1/22 9/11 2/11 0/11 13/17 4/17 0/17

18 Current status of applying peripheral nerve block technique in Taiwan Technique training & mature (V) Widely clinical implication (X) Cost Benefit analysis (X) Patient safety consideration (X) Induction room setting (X) Legal issues protection (X) Insurance system coverage (X)