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Ultraheli kasutamine regionaalanesteesias- pro

Andres Sell, MD, PhDSA TÜK Anestesioloogia ja

intensiivravi kliiniku üldanestesioloogia osakond

- Närvi- ja närvipõimikute blokaadide teostamine - Epiduraalruumi punktsioon ja kateteriseerimine

Ultraheli (UH) regionaal-anesteesias (RA) • Anesteesia eesmärgiks on

valutustamine ja organismi füsioloogilise tasakaalu säilitamine operatsiooni ajal

• Oluline moment meie tegevuses on lähtumine printsiibist-Primum non nocere (Hippocrates) (mitte kahjustada (haiget))

• Avatud meetod – lokaalanesteetikumi otsene aplikatsioon avatud närvile (Halsted, 1884; Crile, 1897)

• Närvistimulatsiooni meetod (70.a.-te lõpp)• Transarteriaalne meetod (70.a.-te lõpp)• UH meetod (esmakordselt – Friedl et al.

1992; Tartus- aprill 2006)

Närvi- ja närvipõimikute blokaadide teostamine

Auroy et al. 2002

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Auroy et al. 2002Selander and Sjöstrand, 1978

Selander 1999( Finucane et al. 1999) Winnie, 1993

Benumof, 2000

Out-of-plane needle approach(i.e., transversal, tangential)

In-plane needle approach

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Blokaad interskaleenselt

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., 2005

V

A

Marhofer et al., 2005

V

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.

Blokaad supraklavikulaarselt

Marhofer et al., 2005

Fig 6 Transverse view of the supraclavicular brachial plexus craniolateral to the subclavian artery. The arrows indicate the brachial plexus. The skin-to-pleura distance is 2.2 cm. SA=subclavian artery.

Blokaad infraklavikulaarselt

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Marhofer et al., 2005

Fig 8 Transverse view of the infraclavicular part of the brachial plexus near the coracoid process, using an Aplio system with an 8–14-MHz linear probe. Lateral and medial to the subclavian artery, the lateral and median cords are visualized. The posterior cord is not visualized in this view. The arrows in the bottom left corner indicate the pleura. CP=coracoid process; CV=cephalic vein; PMM=pectoris major muscle; SA=subclavian artery.

Blokaad aksillaarselt

Marhofer et al., 2005

Fig 9 Transverse view of the axillary part of the brachial plexus, using an Apliosystem with an 8–14-MHz linear probe. AA=axillary artery; BV=basilic vein.

Right-hand side

Musculocutaneusnerve

Marhofer et al., 2005

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.

Cousins et al., 1998

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Fig 12 Transverse view of the femoral nerve lateral to the femoral artery and femoral vein, using an Aplio system with an 8–14-MHz linear probe. FA=femoral artery; FV=femoral vein.

Marhofer et al., 2005

Fig 13 Transverse view of the sciatic nerve (see arrows) of a 5-yr-old child along the posterior part of the upper third of the thigh between the biceps femoris, the semitendinous and the great adductor muscles, obtained with a Sonosite 180 Plus (Sonosite, Seattle, WA, USA) and a 10-MHz linear probe. BFM=biceps femoris muscle; F=femur; GAM=great adductor muscle; STM=semitendinous muscle. Marhofer et al., 2005

Retzl et al., 2001

Anatomic variations of the main nervesof the brachial plexus in the axilla

Figure 1. Schematic drawing of a transverse section ultrasound-scan through the axilla at level A with sectional template overlay for plexus nerve position analysis. The template is shown with broken lines for better visibility. A = brachial artery; V = brachial vein; M = median nerve; U = ulnar nerve; R = radial nerve. Sites et al., 2006

Chan et al., 2007 Sites et al., 2004

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• Paresteesiad tekivad närvide identifitseerimisel 38,2%-l juhtudest

• Närvistimulatsiooni tundlikkus on 74,5 %

Perlas et al., 2006

Willschke et al., 2006

Fig 1 Epidural insertion was performed using a midline approach and a paramedian longitudinal position of the ultrasound probe

Willschke et al., 2006

Fig 2 Measuring points for skin–epidural distance and diameter of epidural space in a longitudinal transversal paramedianultrasonographic view. The lower grey arrow indicates the dura

Cheney et al., 2006

Fig. 2. Respiratory and cardiovascular (CV) damaging events and claims where pulse oximetry (SpO2) and end-tidal carbon dioxide (ETCO2) monitoring were in use as a percent of total claims for death or permanent brain damage by year of injury. SpO2 became an American Society of Anesthesiologists standard for intraoperative monitoring in 1990 (↑1.) and ETCO2 in 1991 (↑2.).

• Otsene närvide visualiseerimine• Otsene teiste anatoomiliste struktuuride (sh.

veresooned) visualiseerimine • LA leviku jälgimine• Intraneuraalse ja –arteriaalse süste

ärahoidmine

UH kasutamise eelised

• Närvistimulatsioonist tingitud valulike lihaskontraktsioonide ärahidmine

• LA doosi vähendamine• Kiirem sensoorse blokaadi algus• Pikem blokaadi kestvus• Blokaad kvaliteetsem• Epiduraalpunktsioonil (lastel) anatoo-

miliste struktuuride identifitseerimine

UH kasutamise eelised

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Tänan tähelepanu eest!