Anıl MARŞAN, Pakize KIRDEMİR, AYKUT URFALIOĞLU, Nermin GÖĞÜŞ

Alt ekstremite girişimlerinde, iki rejyonel anestezi tekniğinin analjezi ve hemodinamik etkilerinin karşılaştırılması

Alt ekstremite girişimleri genellikle rejyonel anestezi altında yapılmaktadır. Kombine siyatik femoral sinir bloğu ve unilateral spinal blok sıklıkla uygulanan rejyonel anestezi teknikleridir. Bu çalışma iki farklı rejyonel anestezi tekniğini, analjezi ve hemodinamik etkileri açısından karşılaştırmak amacıyla planlandı. Elektif diz artroskopisi planlanan, ASA I-II 30 hastanın hemodinamik baz değerler kaydedildikten sonra hastalar unilateral spinal blok (Grup S) ve kombine siyatik-femoral sinir bloğu (Grup SF) uygulanmak üzere randomize olarak iki gruba ayrıldı. Spinal blok uygulanacak hastalar öpere olacak taraf altta kalacak şekilde yan yatırıldı ve orta hat yaklaşımla L4-5 intervertebral aralıktan subaraknoid aralığa 25 gauge Quincke iğne ile girildi. Serbest BOS akımı gözlendikten sonra iğne ucu aşağa bakacak şekilde ayarlandı ve 10 mg 0.5% hiperbarik bupivakain 40 saniyede verildi. Hastalar bu pozisyonda 15 dakika bekledi. Kombine siyatik-femoral sinir bloğu 2 Hertz ve 0.5-1 mA akımla periferik sinir stimülatörü kullanılarak kısa uçlu teflon kaplı iğne ile femoral sinirin üç dalın ayrı ayrı kontraksiyonları görülerek 20 ml % 1 prilokain verilerek yapıldı. Siyatik sinir bloğu, modifiye subgluteal posterior yaklaşımla tibial ve peroneal sinirlerin stimulasyonu ile 10 ml % 1 prilokain verilerek yapıldı. Noninvaziv ortalama kan basıncı (OKB) ve kalp atım hızı (KAH) spinal blok öncesi ve bloktan sonraki 5., 15.,30 ve 45. dakikalarda ölçüldü. Ayrıca motor blok gerileme zamanı (MBGZ) ve ilk analjezik ihtiyaç zamanı (İAZ) ve 24 saat sonunda hasta memnuniyeti kaydedildi. Veriler Mann-Whitney U ve Wilcoxon testleri kullanılarak değerlendirildi ve p

Anahtar Kelimeler:

Artroskopi, Anestezi, blok, Analjezi

A comparison of the analgesic and hemodynamic effects of two different regional anesthesia techniques for low extremity procedures

Lower limb procedures are widely performed under regional anesthesia. Among regional anesthesia techniques, unilateral spial block and combined sciatic-femoral nerve block are usually used. This study was performed to compare the analgesic and hemodynamic effects of different regional anesthesia techniques for lower extremity procedures. After baseline measurements of cardiovascular parameters were recorded, 30 ASA I-II patients scheduled for elective outpatient knee arthroscopy were randomized to receive either unilateral spinal block (Group S) or combined sciatic-femoral block (Group SF). Patients in GroupS were lying in a lateral position on the side to be operated on. Spinal puncture was performed at the L 4-5 intervertebrasl space with a 25 gauge Quincke needle. After free flow of cerebrospinal fluid had been observed, with the point of the needle facing downwards, lOmg 0.5% hyperbaric bupivacaine was injected in 40 seconds. Patients remained in the lateral position for 15 minutes. In the Group SF, the block was performed with the nerve stimulator using a short-bevelled, Teflon-coated stimulating needle. For the femoral nerve block, after each of the three following muscle twitches: 20 ml 1% prilocaine was used for femoral nerve block. Sciatic nerve block was performed according to the modified subgluteal posterior approach. When the stimulation of both of the tibialis and the common peroneal nerves was achieved, 10 ml 1% prilocaine was given. Noninvasive blood pressure and the heat rate were recorded before the blocks and 5,15, 30 and 45 minutes after the blocks. Motor block regression time and first analgesic demand time were recorded. Statistical analysis was performed using Mann-Whitney U and Wilcoxon tests where p<0.05 was considered significant. There were no significant differences between the groups in terms of demographic data and surgical times. In Group SF, no hemodynamic differences were recorded. The period between motor block regression time and first analgesic demand time were significantly longer in Group S. In Group SF, the period was rather close. In conclusion, unilateral spinal block and combined sciatic-femoral block were performed with similar anesthetic effect and surgical anesthesia was provided with both of the techniques in patients undergoing ambulatory knee arthroscpy .

Keywords:

Arthroscopy, Anesthesia, Conduction, Analgesia,

PDF

___

1. Benedetto P, Bertini L, Casati A, Borghi B, Albertin A,Fanelli G. A New Posterior Approach to the Sciatic Nerve Block: A Prospective, randomized Comparison with the Classic Posterior Approach. Anesth Analg 2001; 93: 1040-4.
2. Liu SS, Ware PD, Allen HW, Neal JM, Pollock JE. Dose-response characteristic of spinal Bupivacaine in Volunteers. Clinical Implications for Ambulatory Anesthesia. Anesthesiology 1996; 85: 729-36.
3. Pittoni G, Toffoletto F, Calcarella G, Zanette G, Giron GP Spinal Anesthesia in Outpatient Knee Surgery: 22-gauge versus 25-gauge Sprotte Needle. Anesth Analg 1995; 81: 73-9.
4. Ben-David B, Levin H, Solomon E et al. Low Dose Diluted Spinal Bupivakain for Ambulatory Surgery. Anesth Analg 1996; 83: 716-20.
5. Auroy Y, Narchi P, Messiah A et al. serious complications Related to Regional Anesthesia. Anesthesiology 1997; 87: 479-86.
6. Fanelli G, Casati A, Aldegheri G et al. Cardiovascular Effects of Two Different Regional Anaesthetic Techniques for Unilateral Leg surgery. Acta Anaesthesiol Scand 1998; 42: 80-4.
7. Wedel DJ, Brown DL. Nerve Blocks. In miller RD, ed. Anesthesia. 3rd edn. New York: Churchill-Livingstone, 1990: 1407-37.
8. White PF. Outpatient Anesthesia. In Miller RD, ed. Anesthesia. 3rd edn. New York: Churchill-Livingstone, 1990: 2025-59.
9. Dahl V, Gierloff C, Omland E, Raeder JC. Spinal, Epidural and Propofol Anaesthesia for Outpatient Knee Arthroscopy? Acta Anaesthesiol Scand 1997; 41: 1341-5.
10. Cappelleri G, casati A, Fanelli G, Borghi B, Anelati D, Berti M, Albertin A.Unilateral Spinal Anestesia or Combined Sciatic-femoral Nerve Block for Day-case Knee Arthroscopy. A prospective, randomized comparison. Minerva Anestesiol 2000; 66(3): 131-6.
11. Casati A, Cappelleri G, Aldegheri G, Marchetti C, Messina M, De Ponti A. Total Intravenous Anesthesia, Spinal Anesthesia or Combined Sciatic-femoral block for Outpatient Knee Arthrocopy. Minerva Anestesiol 2004; 70(6):493-502.
12. Liu SS, Chiu AA, Carpenter RL et al.Fetanyl prolongs lidocaine spinal anesthesia without prolonging recovery. Anesth Analg 1995; 80: 730-4.
13. Fanelli G, Sansore V, Nobili F, Aldegheri G. Locoregiona anesthesia for surgical arthroscopy of the knee. Minerva Anesthesiol 192; 58: 121-5.
14. Iavoie J, martin R, Tetrault JP, Lote DJ, Colas MJ. Axilary plexus block using a peripheral nerve stimulator: Single or multiple injections. Can J Anaesth 1992; 39: 583-6.
15. Fanelli G. Peripheral nerve block with electric neurostimulation. Minerva Anesthesiol 1992; 58: 1035-6.
16. Agostoni M, Fanelli G, Nobili F, Aldegheri G, Sansore V, Magni F. Plasma level of mepivacaine in the double block of the sciatic and femoral nerve. Minerva Anesthesil 1992; 58: 281-4.
17. Casati A, Fanelli G, Beccaria P, Cappelleri G, Berti M, Aldegheri G, Torri G. The Effects of the Single or Multiple Injection Technique on the Onset Time of Femoral Nerve Blocks with 0.75% Ropivacaine. Anesth Analg 2000; 91:181-4.
18. Fanelli G, Casati A, Garancini P, Torri G. Nerve Stimulator and Multiple Injection Technique for Upper and Lower Limb Blockade: Failure rate, Patient Acceptance and Neurologic Complications.AnesthAnalgl999;88: 847-52.
19. Taboada M, Alvarez J, Cortes J, Rodriguez J, Atanassoff PG. Is a Double-injection Technique Superior to a Single Injection in Posterior Subgluteal Sciatic Nerve Block? Acta Anaesthesiol Scand 2004; 48: 883-7.
20. Me Coy EP, Wilson CM. A Comparison of Lignocaine with prilocaine in Axillary Brachial Plexus Anaesthesia. Anaesthesia 1991; 46: 309-11.
21. Kırdemir P, Marşan A, Mutlu M, Pala Y, Göğüs N. Unilateral ve Bilateral Spinal Anestezinin Hemodinami, Postoperatif Analjezi ve Derlenme Özelliklerinin Karşılaştırılması. Gülhane Tıp dergisi 2001; 43(3): 271-4.
22. Pollock JE, Neal JM, Stephenson CA, Wiley CE. Prospective study of the incidence of transient radicular in patients undergoing spina anesthesia.Anesthesiology 1996; 84: 1361-7.
23. Liu SS, Ware PD, alien HW, Neal JM, Pollock JE. Dose-response characteristics of spinal bupivacaine in volunteers. Clinical implication for ambulatory anesthesia. Anesthesiology 1996; 85: 729-36.
24. Casati A, Borghi B, Fanelli G, Torri G. Ropivacaine or 2% Mepivacaine for Lower Limb Peripheral Nerve Blocks. Anesthesiology 1999; 90:1047-53.