Ultraheli kasutamine anestesioloogias

Transcription

1 Ultraheli kasutamine anestesioloogias Andres Sell SA TÜK Anestesioloogia ja intensiivravi kliiniku üldanestesioloogia osakond - Tsentraalsete veenide kanüleerimine - Perifeersete närvipõimikute / närvide blokaadide teostamine 1

2 Tsentraalveeni kanüleerimised üldanestesioloogia osakonnas aastatel n = kanüleerimisi kokku v.subcl. v.jug.int. v.femoralis Keskm 4134 tsentraalveeni kanüleerimiste tüsistused üldanestesioloogia osakonnas aastatel n = 242 (5,8 %) Aastas keskm. Kokku Sagedus % arteri punktsioon 13, ,8 õhkrind* 2,8 33 0,8 verirind 0,3 4 0,1 sondi väljanihkumine 1,8 22 0,5 infusioon naha alla 0,3 4 0,1 sondi pöördumine kaelale 0,3 4 0,1 defektne kateeter 0,3 4 0,1 rütmihäired kateetrist 0,2 2 0,03 sondi murdumine 0,4 5 0,16 sondi vigastus 0,1 1 0,03 infusioon pleuraõõnde 0,1 1 0,03 infektsioon 0,1 1 0,03 * 24-l õhkrinnaga haigel kasutati pleuraõõne dreenimist 2

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4 Fig. 1. Schematic representation of the concept of reflection and explanation of anisotropy. The echoes reflected following contact with an interface are returned to the transducer (A) and are identified as corresponding to a hyperechogenic structure; however, if contact is not transversal, the reflected echoes are not returned to the transducer, and a hypoechogenic image results (B). This artifact is known as anisotropy. De Andres and Sala-Blanch,

5 Fig 3 Sonographic visualization of the cannula. The linear probe produces an image of rectangular cross-section depending on the dimensions of the probe, owing to the frequency-dependent penetration depth (the higher the ultrasound frequency, the smaller the penetration depth). The cannula can be adducted to any point of this crosssection and is identified as a hypoechoic structure with a dorsal acoustic shadow. Marhofer et al Hind et al

6 Gray AT, 2006 Kapral and Marhofer,

7 Cousins et al Cousins et al

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10 Gray AT, 2006 V A Fig 4 Transverse view of the brachial plexus at the lateral border of the sternocleidomastoid muscle, at the level of the posterior interscalene space between the anterior and the median scalene muscles, using an Aplio system with an 8 14-MHz linear probe. The arrows indicate the roots of the brachial plexus, which are reflected as hypoechoic oval structures. ASM=anterior scalene muscle; MSM=median scalene muscle; SCM=sternocleidomastoid muscle. Marhofer et al

11 A Fig 5 View of the interscalene space after administration of 15 ml local anaesthetic, using an Aplio system with an 8 14-MHz linear probe. The arrows indicate the nerve roots of the brachial plexus surrounded by local anaesthetic. LA=local anaesthetic; SCM=sternocleidomastoid muscle. Marhofer et al Kapral and Marhofer,

12 Sheppard et al Sheppard et al

13 Sheppard et al Gray AT,

14 Right-hand side Fig 9 Transverse view of the axillary part of the brachial plexus, using an Aplio system with an 8 14-MHz linear probe. AA=axillary artery; BV=basilic vein. Marhofer et al Right-hand side Fig 10 Transverse view of the musculocutaneous nerve between the biceps muscle and the coracobrachial muscle, using an Aplio system with an 8 14-MHz linear probe. AA=axillary artery; BM=biceps muscle; CBM=coracobrachial muscle. Marhofer et al

15 Retzl et al Fig 11 Transverse view of the median nerve (arrows) at the cubital level next to the brachial artery visualized by colour Doppler, using an Aplio system with an 8 14-MHz linear probe. BA=brachial artery. Marhofer et al

16 Potential advantages Direct visualization of nerves 13, 17, 21, 26, 27, 37, 39, 40, 52, 54, 62, 66 Direct visualization of anatomical structures 23, 26, 27, 31, 32, 33, 37, 38, (blood vessels, muscles, bones, tendons) 39, 40, 52, 54, 57, 62, 66 facilitating identification of nerves Direct and indirect visualization of the spread of 26, 27, 37, 38, 39, 40, 54 local anaesthetic during injection with the possibility of repositioning the needle in cases of maldistribution of local anaesthetic Avoidance of side-effects (e.g. intraneuronal injection of local anaesthetic, inadvertent intravascular injection) References Avoidance of painful muscle contractions during 40 nerve stimulation (e.g. in cases of fractures) Reduction of the dose of local anaesthetic 38, 39 Faster sensory onset time 37, 39, 40, 54 Longer duration of blocks 40 Improved quality of block 37, 39, 40, 54 20, 21, 26, 27, 37, 38, 39, 40, 54 Marhofer et al Gray AT. Ultrasound-guided Regional Anesthesia: Current State of the Art. Anesthesiology 2006; 104:

17 Conclusions Clinical studies suggest that ultrasound guidance has advantages over more traditional nerve stimulation-based techniques for regional block. If desired, ultrasound guidance can be combined with nerve stimulation to confirm proximity to neural structures. However,it is not necessary to use electrical stimulation or obtain paresthesias to achieve reliable conduction block of peripheral nerves. Given clinical experience, practitioners will become confident in assigning nerve identity based on ultrasound appearance alone. Because ultrasound imaging is especially useful in patients with difficult external anatomy, many clinicians have now integrated its use into their routine clinical practice to gain expertise with this important technology. Gray AT,