NEZİH SERTÖZ, Fikret Oğuz ERİŞ, Hilmi Ömer AYANOĞLU

İntertorakanterik femur fraktürlü yüksek riskli bir hastada lumbar pleksus ve siyatik sinir bloğu uygulaması: Olgu sunumu

Periferik sinir blokları, özellikle yaşlı ve yüksek kardiyak riskli hastalarda, hemodinamik stabiliteyi koruyarak yeterli anestezi sağlaması açısından ideal uygulamalardır. 65 yaşında, düşme sonucunda sol intertorakanterik femur fraktürü gelişen kadın hastaya intramedüller çivileme operasyonu planlandı. Özgeçmişinde hipertansiyon, diabetes mellitus, geçirilmiş miyokard enfarktüsü, geçirilmiş serebrovasküler olaya bağlı sağ hemipleji mevcuttu. Fizik muayenede; akciğer oskültasyonunda alt zonlarda krepitan raller, ortopne ve pretibial ödem mevcuttu. Hastanın EKG’sinde yüksek ventrikül yanıtlı AF, V1-V3 derivasyonlarında QS (+) ve ekokardiyogramında sol ventrikül ejeksiyon fraksiyonu % 15-20 ile miyokard global hipokinezi saptanmıştı. Hasta (ASA IV E) olarak değerlendirildi ve hastaya lumbar pleksus ve siyatik sinir bloğu planlandı. Hastaya sağ lateral dekubit pozisyonunda Winnie tekniği ile, 150 mm stimuplex iğne ve sinir stimulatörü 1 mA akımda, 2Hz frekans ve 0.1 ms hızda ayarlanarak elektrostimulasyon yöntemi kullanıldı. 15 mL % 0.5 levobupivakain ve 10 mL % 2 prilokain karışımı, stimulatörde 0.5 mA akım altında patella ve kuadrisepsin kontraksiyonu görülerek lumbar pleksusa uygulandı. Aynı pozisyonda 10 mL % 0.5 levobupivakain ve 10 mL % 2 prilokain kullanarak, siyatik sinir bloğu uygulandı. Sonuç olarak bu yüksek riskli kalça kırığı olgusunda lumbar pleksus ve siyatik sinir bloğunun, nöroaksiyel blok ve genel anestezi yöntemlerine göre iyi ve güvenli bir alternatif uygulama olduğu düşünülebilir.

Lumbar plekus and sciatic nerve blockade in a high risk patient with intertrochanteric femur fracture: Case report

Peripheral nerve blockade is an optimal application for elderly and high cardiac risk patients, because it provides effective anesthesia and protects hemodynamic stability. Intramedullary naillig (PFN) operation was planned for a 65 year old female patient who had intertrochanteric femur fracture. Her previous history revealed that she had hipertension, diabetes mellitus and right hemiplegia after stroke as well as a previous myocardial infarction. Physical examination revealed bilateral rales at the base of the lungs. She had orthopnea and pretibial edema. At laboratory tests: Electrocardiography showed atrial fibrilation with high ventricular rate, there was QS forms in V1-V3. Echocardiography measured left ventricle ejection fraction 15-20 % and global myocardial hypokynesia. The patient was classified as ASA IV E and lumbar plexus and sciatic nerve blockade was applied. The procedure was performed at the right lateral decubital position with 150 mm stimuplex needle by using the electrostimulation method as 15 mL 0,5 % levobupivacaine and 10 mL 2 % prilocaine under 0,5 mA current while observing the contraction of patella and quadriceps muscles. At the same position, sciatical nerve blockade was applied as 10 mL 0,5 %. Levobupivacain and 10 mL % 2 prilocain. In conclusion; lumbar plexus and sciatic nerve blockade applied together is a more safe and efficient anaesthesic procedure than neuroaxial blockade or general anaesthesia for the high risk patients with femoral fracture.

PDF

___

1. Mollhoff T, Theilmeir G, Van Aken H. Regional anaesthesia in patients at coronary risk for noncardiac and cardiac surgery. Current Opinion in Anesthesiology 2001; 14: 17- 25.
2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, Van Zundert A, et all. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overwiev of randomized trials. BMJ 2000; 321: 1493-1497.
3. Winnie AP, Ramamurthy S, Durrani Z, Radonijc R. Plexus blocks for lower extremity surgery. Anesthesia Rev 1974; 1: 11.
4. Labat G. Regional Anesthesia: Its Technic and clinical application. Philadelphia, WB Saunders 1922.
5. Lee Thomas H, Marcantonio Edward R, Mangione Carol M, Thomas Eric J, Polanczyk Carisi A, Cook F, et all. Derivation and Prospective Validation of a simple Index for Prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043-1049.
6. Naja Z, Hassan MJ, Khatib H, Ziade MF, Lönnqvist PA. Combined sciatic- paravertebral nerve block and general anaesthesia for fractured hip of the elderly. Middle East J Anaesthesiol 2000; 15: 559- 68.
7. Fanelli G, Casati A, Aldegheri G, Beccaria P, Berti M, Leoni A, et all. Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery.Acta Anaesthiol scand 1998; 42: 80-84.
8. Critcley LA, Conway F. Hypotension, subarachnoid block and the elderly patient. Anaesthesia 1996; 51: 1139-43.
9. Casati A, Cappelleri G, Fanelli G, Borghi B, Anelati D, Berti M, et all. Regional Anaesthesia for outpatients knee arthroscopy: a randomised clinical comparison of two different anaesthetic techniques. Acta Anaesthesiol Scand 2000; 44: 543-547.
10. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip surgery: a metaanalysis of randomized trials. Br J Anaesth 2000; 84: 450-55.
11. Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R. Incidence and risk factors for side effects of spinal anaesthesia. Anaesthesiology 1992; 76: 906-916.
12. Becchi C, Al Malyan M, Coppini R, Campolo M, Magherini M, Boncinelli S. Opioid free analgesia by continous psoas compartment block after total hip arthroplasty. A randomized study. Eur J.Anaesthiol 2007; 21: 1-6.
13. Gentili M, Aveline C, Bonnet F. Total spinal anesthesia after posterior lumbar plexus block. Ann Fr Anesth Reanim 1998; 17: 740- 742.
14. Aida S, Takahashi H, Shimoji K. Renal subcapsular hematoma after lumbar plexus block. Anesthesiology 1996; 84: 452-455.
15. Klein SM, D’Ercole F, Greengrass RA, Warner DS. Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology 1997; 87: 1576-1579.