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.

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