Dr. Georgi Valchev Fellow in regional anaesthesia UZ Leuven

Transcription

1 Dr. Georgi Valchev Fellow in regional anaesthesia UZ Leuven

2 55 years old woman Latarjetprocedure ASA-1, 49 kg. NKDA Informed consent for RA ISB with catheter uneventful throughout, rate 4/4/60 according to her weight Open Latarjet operation - unremarkable

3 up to 10 % neurological complications (musculucutaneous, axillary, radial and truncal)

4 POD 1 VAS - 0-4/10, The patient had unwitnessed syncope at very early morning. Wrist drop-noted with sensory loss at all fingers. The pump stopped at midday due to extended area of sensory deficit and new onset of loss of muscle power of the fingers,the wrist and the forearm up to the elbow.

5 POD 2 VAS-2-5/10, pain only on movement of the shoulder Total sensorylossat the fingers, the wristand the elbow with very difficult elbow flexion and impossible elbow extension Neurology consult midday: We merken een volledige plegieen en areflexievan de rechterarm. Er is ook een hypo-esthesie esthesiemet proximo- distale gradiënt en bewaarde scherp stompdifferentiatie en positiezin. - Emergency ultrasound performed after the consultation

6 DD: 1. Haematoma 2. Perioperative plexus trauma (compression / elongation) 3. Related to RA and the catheter nerve injury 4. Psychogenic

7 The ultrasound showed - -haematoma at the axillary fossa -- large collection of the anterior side of the right shoulder to the left axillary artery extending from the inferior surgical scar and below the m. Pectoralis major. The estimated size - CC 9 x LL 5x AP 2,5 cm. Emergency surgery at the early afternoon-wound exploration and evacuation of the haematoma

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10 POD- 2 postoperatevely Recoveredsensationat the hand and the wristwith goodmotor function of the 1,2,and 3 fingersand diminishedmusclepower of the 4 and 5 fingers Still persistent sensory loss of the forearm with recoverd flexion but impossible extension

11 POD 8- EMG : -the signsof nerve(s) injuryare present-but notclear which part of the brachial plexus is affected: - axillarynerve? - upper brachial plexus? -toberepeatedin 4 weeks time

12 POD-35 Anaesthetic consult : - long conversation with the patient and the spouse regarding the nerve injury -totalmotor deficit in the area of the right ulnarnerve distribution. - Unabletodo eitherelbowflexionor extension and shoulder abduction - Active follow up and treatment option

13 POD-62 MRI of the brachial plexus-appeared oedematosus. EMG - brachial plexus injury. Neurology consult: -paralysis of the proximal arm (shoulder abduction, elbow flexion and extension) and paresis of 3 to 4/5 of the hand and the wrist. -sensory loss in the upperarmwith areflexia. -partial recovery of the hand.

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15 Treatment option(s): ONLY ACTIVE PHYSIOTHERAPY Prognosis: POOR

16 Meta analysis 32 studies including > 1 million of encounters(1) Neuropathy Spinal: 0.04% (4/10,000) Epidural: 0.02% Interscalene: 3% Axillary: 1.5% Femoral: 0.34% (3/1,000)

17 Permanent nerve injury Spinal: 0% to 0.04% (4/10,000) Epidural: 0% to 0.07% Peripheral block: 1 case among 16 studies

18 Investigator Approach Number Incidence Follow-up Auroy (2) Mixed 21, % Anaesthetic report Schroeder (3) Mixed % Retrospective Chart Review Horlocker (4) Axillary 1, % Retrospective Chart Review Stan (5) Axillary % Surgeon Referral Fanelli (6) Mixed 1, % Surgeon Referral Urban (7) Mixed % Direct Follow-up Borgeat (8) ISB % Direct Follow-up Hartung (9) Axillary % Direct Follow-up

19 2118blocks 5 cases reported with suspected nerve injury Only 1 proved to be related to RA Lack of follow up protocol

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23 Direct trauma caused by the needle Local anaesthetic neurotoxicity Ischemic injury secondary to pressure and volume of local anaesthetic or added vasoconstrictors. Hematoma or vascular injury Intra-operative factors including surgical trauma and positioning Tourniquet injury Postoperative factors including swelling and positioning

24 Short versus long bevel needle The frequency of injury is greater with long bevel needles, The duration and severity of the injury is greater with short bevel needles.(10) Less severe when the bevel orientation is kept parallel to nerve fibers.(10)

25 Direct neurotoxicity of local anaestheticsis related to exposure to excessive concentrations or doses. Among the available local anaesthetics.(11) Ropivacaine opivacaineseems to have the least potential for neurotoxicity.(12) The concept of drug volume should be favored over the concept of drug concentration.

26 Intra-neural injection of local anesthetics may cause increased pressure within nervesand may compromise neural blood flow. (13) Nerve stimulation versus paraesthesia

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28 Detailed patient history Physical exam Detailed case history Anaesthesia procedure Perioperative events Referral Investigations Follow-up

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30 1.Brull, McCarthy, Chan, El Beheiry. Neurological complications after regional anesthesia: Contemporary estimates of risk. Anes Analg. 2007;104(4): AuroyY, NarchiP, Messiah A, et al. Serious complications related to regional anesthesia. Results of a prospective survey in France. Anesthesiology.1997;87: Schroeder LE, Horlocker TT, Schroeder DR. The efficacy of axillary block for surgical procedures about the elbow. Anesth Anal. 1996;83: HorlockerTT, KufnerRP, Bishop AT, et al. The risk of persistent paresthesia is not increased with repeated axillary block. Anesth Analg. 1999; 88: Stan TC, KrantzMA, Solomon DL, et al. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach. Reg Anesth. 1995;20: FanelliG, Casati A, TorriG. Nerve stimulator and multiple injection technique for upper and lower limb blockade: Failure rate, patient acceptance, and neurologic complications. Study group on regional anesthesia. Anesth Analg. 1999;88: Urban MK, Urquart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth. 1994;19: Borgeat A, EkatodramisG, KalbererF. et. al. Acute and nonacutecomplications associated with interscalene block and shoulder surgery. A prospective study. Anesthesiology. 2001;95: Hartung HJ, Rupprecht A. The axillary brachial plexus block: A study of 178 patients. Reg Anaesthesie. 1989;12: Selander D, Dhuner KG, Lundborg G. Peripheral nerve injury due to injection needles used for regional anesthesia. An experimental study of the acute effects of needle point trauma. Acta Anaesthesiol Scand 1977; 21: Selander D. Neurotoxicity of local anesthetics: animal data. Reg Anesth 1993; 18: MalinovskyJM, Charles F, Baudrimont M, et al. Intrathecal ropivacainein rabbits: pharmacodynamicand neurotoxicologic study. Anesthesiology 2002; 97:

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