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- 1. Xavier Paqueron MD, PhD Clinical Centre, Angoulême, France Ultrasound-guided regional anesthesia. : What do ultrasound bring to regional anesthesia ? xavier.paqueron@orange.fr
- 2. Close to Bordeaux and Cognac Where is , France ?
- 3. Close to Cognac Close to Bordeaux Where is , France ?
- 4. Private 300 beds Hospital My Institution : The Clinical Centre Ambulatory Care Unit Surgery • Orthopedic • Hand • Urologic • Vascular • Abdominal • Gynecologic • Breast • OPH • ENT Obstetrics Pain Clinic Medicine • Oncology • Internal medicine • Cardiology • Pneumology www.centre-clinical.fr/ Regional anesthesia room PACU
- 5. Current place of regional anesthesia ① Postoperative pain control ② Improved postoperative recovery ③ Alternative to GA ④ Ambulatory surgery ⑤ PONV 1
- 6. RA superior to morphine during the 2 first postoperative days 0 2 4 6 8 10 24 Hrs 48 Hrs catheter opiates 0 1 2 3 4 24 Hrs 48 Hrs 72 Hrs catheter opiates Mean VASMax VAS Continuous blocks = the reference
- 8. Alternative to GA In ambulatory surgery
- 9. Post Operative Nausea & Vomiting
- 11. Evidence-based & ultrasound guidance ① Success rate ② Comfort ③ Other benefits 2
- 12. Evidence-based Improved Success Rate 0 25 50 75 100 Complete sensory block at 30 min Successful surgical anesthesia Percentatge (%) NS US US&NS 0 5 10 15 Procedure Bme (min) Time (minutes) NS US US&NS * * * P= 0.07 * P< 0.05
- 13. Success Rate Conversion to GA or spinal A Meta-analysis (Abrahams 2009)
- 14. Onset time of block A Meta-analysis (Abrahams 2009)
- 15. Casati 2007, Orebaugh 2007 Reduction of number of needle trajectories with USGRA Perceived pain is less frequent 20 % with USGRA vs 48 % nerve stimulation
- 16. How USGRA does improve safety ? ① Control of needle tip ② Diagnose early • intravascular ③ Reduce toxicity • Reduce volumes ④ Diagnose early • Intraneural 3
- 17. Always believe that what you think is the needle tip may not be it Control of needle tip - Whatever the approach Always consider you may not see the needle tip
- 18. Move the probe to see the needle Tissue movements / needle AssociaIon with nerve sImulaIon HydrolocaIon THE Obsession - Know where the needle tip is
- 19. Diagnose Early Intravascular injection Look here !
- 21. Systemic toxicity Number of blocks = 5436 • US = 2146! • PNS = 3290! Adverse events = 8 • Seizures = 5 (PNS)! • Nerve injury = 3 (PNS)! 2009 Adverve event with US = 0
- 25. UltraSound-Guided Regional Anesthesia doesn’t avoid nerve damage Two recent case reports of persistent nerve damage with • No pain • No paresthesia • at least one followed an intraneural injection
- 27. Ultrasound Contribution The anesthetist is no longer blind • Accuracy ~ 1 mm with high frequency probes Visualisation of one third of all fascicles Silvestri et al. Radiology 1995 • Fascicles size ~ 0.25 - 0.5 mm
- 28. Ultrasound Contribution Contact between nerve and needle • motor response ≤ 0.5 mA: 74.5% • paresthesia: 38.2% Perlas RAPM 2006 Stimulating needle can touch a nerve with no motor response !
- 29. Bigeleisen 2006 Frequent intraneural / subepineural injection of local anesthetics … under US guidance Nerve swelling = 70% Ultrasound Contribution
- 30. Bigeleisen 2009 Ultrasound-guided supraclavicular block and nerve stimulation 1. Needle-nerve contact Ä minimal stimulating current 2. Needle advanced intraneurally Ä minimal stimulating current Ultrasound Contribution
- 31. Ultrasound Contribution DM: Diabetis Mellitus Stimulating thresholds ≤ 0.2 mA never observed outside the trunk > 0.5 mA within the trunk : 10% of patients
- 32. Better understanding of the limits of nerve stimulation • Intraneural injection is (very) frequent • MIS ≥ 0.5 mA : No guarantee of being extraneural • Contact needle-nerve without motor response = frequent • Subepineural needle placement without motor response = frequent • Intraneural injection without pain or paresthesia … and without nerve damage Ultrasound Contribution
- 33. Sala-Blanch 2009 Needles through human sciatic nerve Intraneural injection & nerve damage More likely: transverse the nerve between the fascicles rather than through them
- 34. A- EXTRA NEURAL Extraneural connective tissue B- EPINEURAL Connective tissue between fascicles C- INTRA-FASCICULAR Into (between) nerve fibres I choose where I inject… Ultrasound contribution
- 35. • probability of subepinerium location of needle tip • If motor response at an intensity < 0.2 mA • Use a test dose (1 ml) = hydrolocation • If you see • Swelling = STOP all further injection (subepineural) • Nothing when you inject = iv injection or needle tip not in US beam • If you stop the injection • In case of swelling … unknown risk! • When nothing appears = risk well known (intravascular) Nerve swelling after 1 ml Motor response < 0.2 mA Ultrasound contribution needle tip is Subepineural
- 36. Learnig US-guidance ① Learning curve ② Rapid improvment ③ But mistakes persist … 4
- 38. Learnig US-guidance Mistakes persist Video analyses 6 anesthesia residents Novices in USGRA Two most common errors • Failure to visualize needle before advancement • UnintenBonal probe movement
- 40. Conclusion
- 41. Improve efficiency with Ultrasound Cheaper Compared with Nerve stimulation Improved success rate • Less time to perform blocks • Reduction of volumes • Improve patient comfort Easy learning • Rapid learning curve ü See needle tip ü Unintentional probe movements
- 42. Improve safety with Ultrasound Decrease LAST • Monitor needle tip • Reduce volumes • Detect intravascular injection early Decrease Nerve damage • Don’t inject intraneurally = No nerve swelling • Association with nerve stimulation • Monitor injection pressures • Use blunt tip needle • Monitor needle tip
- 43. Thank You