İnfraklaviküler brakial pleksus bloğunda blok iğnelerinin elektron mikroskobik incelenmesi

Öz

Amaç: Periferik blok uygulamaları anestezi pratiğinde sıklıkla kullanılmaktadır. Bu işlemin en önemli komplikasyonlarından biri de kullanılan iğnelere bağlı gelişebilecek periferik sinir hasarıdır. Çalışmamızda brakial pleksus blok işlemlerinde kullanılan iğnelerin işlem sonrası elektron mikroskobisi ile incelenerek iğne üzerinde kalan doku parçalarının varlığı ile iğnenin işlem sırasında çevre dokulara verdiği hasar hakkında bilgi sahibi olmak amaçlanmıştır.

Yöntemler: Prospektif kohort olarak planlanan çalışmamızda ortopedi kliniğinde ön kol veya el cerrahisi yapılacak hastalara farklı iki teknik ile infraklaviküler brakial pleksus bloğu ile anestezi yapıldı. İnfraklaviküler blok; Grup 1’de subklavian arterin saat 6 ve 9 hizasına lokal anestezik verilerek, Grup 2’de subklavian arterin saat 2, 6 ve 9 hizasına verilerek uygulandı. Blok sırasında kullanılan iğneler glutaraldehit solüsyonunda korunarak sonrasında elektron mikroskobik olarak incelendi. İğne üzerinde doku varlığı kaydedildi, istatistiksel olarak değerlendirildi.

Bulgular: İnfraklaviküler brakial pleksus bloğunda iki farklı teknikte kullanılan iğnelerin SEM değerlendirilmesinin yapıldığı çalışmamızda. Grup 1'de iğne üzerinde kalan doku kalıntısı miktarı grup 2’den daha az saptanmıştır (P<0,001).

Sonuç: Ultrasonun iki boyutlu görüntü vermesi göz önüne alındığında brakial pleksus blok uygulamalarında işlem sırasında iğne yönlendirme sayısı ne kadar az olursa çevre dokulara daha az zarar verilecektir dahası muhtemel mekanik sinir hasarı olasılığı da azalacaktır.

Anahtar Kelimeler

• İnfraklaviküler blok,Elektron mikroskopi,Nöronal hasar

Electron microscopic examination of needles used in infraclavicular brachial plexus block

Öz

Aim: The application of peripheral block is frequently used in anesthesia practice. One of the most significant complications of this procedure is peripheral nerve damage that can develop due to the needles used. The aim of this study was to determine the presence of tissue residue on the needle and to obtain information about damage to surrounding tissues during this procedure by examining the needles used in brachial plexus block with electron microscopy. 

Methods: This prospective-cohort study included patients who were to undergo forearm or hand surgery in the Orthopedics Clinic under anesthesia with infraclavicular brachial plexus block performed with 2 different techniques: The local anesthetic agent was administered to the subclavian artery at 6 and 9 o’clock levels in Group 1 and 2, 6 and 9 o’clock levels in Group 2. The needles used during the block were preserved in glutaraldehyde solution then examined with electron microscopy. The presence of tissue on the needles was recorded and statistical evaluations were made. 

Results: The needles used in two different techniques of infraclavicular brachial plexus block were examined under scanning electron microscope. The amount of tissue residue remaining on the needle in Group 1 was significantly less than that in Group 2 (P<0.001). 

Conclusion: When it is considered that ultrasound provides a 2-dimensional image, the fewer the number of needle manipulations made during the procedure of brachial plexus block application, the less damage will be made to the surrounding tissues, thus reducing the possibility of mechanical nerve damage.

Anahtar Kelimeler

• Infraclavicular block,Electron microscopy,Neuronal Damage

Kaynakça

1. 1. Casati A, Danelli G, Baciarello M, et al. A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block. Anesthesiology. 2007;106:992–6.
2. 2. Perlas A, Brull R, Chan VW, McCartney CJ, Nuica A, Abbas S. Ultrasound guidance improves the success of sciatic nerve block at the popliteal fossa. Regional Anesthesia and Pain Medicine. 2008;33:259–65.
3. 3. Oberndorfer U, Marhofer P, Bosenberg A, et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. British Journal of Anaesthesia. 2007;98:797–801.
4. 4. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children. Anaesthesia. 2004;59:642–6.
5. 5. Hadzic A, Sala-Blanch X, Xu D. Ultrasound guidance may reduce but not eliminate complications of peripheral nevre blocks. Anesthesiology. 2008;108:557–8.
6. 6. Neal JM, Bernards CM, Hadzic A, et al. Asra practice advisory on neurologic complications in regional anesthesia and pain medicine. Regional Anesthesia and Pain Medicine. 2008;33:404–15.
7. 7. Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Regional Anesthesia and Pain Medicine. 2008;33:449–60.
8. 8. Reina, Miguel Angel, et al. Electron microscopy and the expansion of regional anesthesia knowledge. Techniques in Regional Anesthesia and Pain Management. 2002;6(4):165-71.

9. 9. Taboada M, Rodriquez J, Amor M. Is ultrasound guidance superior to conventional nerve stimulation for coracoid infraclavicular brachial plexus block? Reg Anesth Pain Med. 2009;34:357–60.
10. 10. Liu SS, YaDeau JT, Shaw PM, Wilfred S, Shetty T, Gordon M. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia. 2011;66:168–74.
11. 11. Robards C, Hadzic A, Somasundaram L, et al. Intraneural injection with low-current stimulation during popliteal sciatic nerve block. Anesthesia and Analgesia. 2009;109: 673-7.
12. 12. Hara K, Sakura S, Yokokawa N, Tadenuma S. Incidence and effects of unintentional intraneural injection during ultrasound – guided subgluteal sciatic nerve block. Reg Anesth Pain Med. 2012;37:289-93.
13. 13. Desgagnes MC, Levesque S, Dion N, et al. A comparison of a single or triple injection technique for ultrasound-guided infraclavicular block: a prospective randomized controlled study. Anesth Analg. 2009;109:668-72.
14. 14. Tran de QH, Bertini P, Zaouter C, Munoz L, Finlayson RJ. A prospective, randomized comparison between single and double injection ultrasound-guided infraclavicular brachial plexus block. Reg Anesth Pain Med. 2010;35:16-21.
15. 15. Fredrickson MJ, Wolstencroft P, Kejriwal R, Yoon A, Boland MR, Chinchanwala S. Single versus triple injection ultrasound-guided infraclavicular block: confirmation of the effectiveness of the single injection technique. Anesth Analg. 2010 Nov;111(5):1325-7.
16. 16. Bowens C Jr, Gupta RK. et al. Selective local anesthetic placement using ultrasound guidance and neurostimulation for infraclavicular brachial plexus block. Anesth Analg 2010;110:1480–5
17. 17. Sermeus LA, Sala-Blanch X, McDonnell JG, Lobo CA, Nicholls BJ, van Geffen GJ, et al. Ultrasound-guided approach to nerves (direct vs. tangential) and the incidence of intraneural injection: a cadaveric study. Anaesthesia. 2017 Apr;72(4):461-9.