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Do W e Need Ultrasound Guidance for Regional Anesthesia ?? - PowerPoint PPT Presentation


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Director: Peripheral nerve Analgesia Director: regional anesthesia Fellowship Section Head: Orthopedic Anesthesia Cleveland Clinic . Loran Mounir Soliman M.D. Do W e Need Ultrasound Guidance for Regional Anesthesia ??. Goals and Objectives. 1. 3. 2.

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do w e need ultrasound guidance for regional anesthesia
Director: Peripheral nerve Analgesia

Director: regional anesthesia Fellowship

Section Head: Orthopedic Anesthesia

Cleveland Clinic

Loran Mounir Soliman M.D

Do We Need Ultrasound Guidancefor Regional Anesthesia??
slide3

Goals and Objectives

1

3

2

Why to use Ultrasound versus Not??

Another View

Is there any evidence?

Do we need Ultrasound for regional Anesthesia??

advantage of ugra

1

Advantage of UGRA……..

We talked about them before

advantages of ugra
Advantages of UGRA

Safe Technology

Non-invasive.

Real- time pictures

Reproducible results

Seeing is believing.

Higher Resolution

Portable machines

Better picture enhansmentsoftwares

Needle Guiding softwares

Better sonographic needles

Easy to use interface

slide6

Why to change??

Needextratraining

Long history of experience and safety of conventionaltechniques

Need to reducecost & expenses

is t here e nough evidence

2

Is There Enough Evidence?

What type of outcomes are we looking at??

better outcomes
Better Outcomes?

Did UGRA resulted in…….

types of outcomes
Types of outcomes

Quicker blocks

Faster Onset

Lesser attempts

Better Success rate

Longer duration

Patient Satisfaction

Vascular puncture

Pneumothorax

Diaphragmatic paresis

Post Operative Neurologic Symptoms (PONSs)

Local Anesthetic Systemic Toxicity (LAST)

slide10
Has it been that long?

1. Kirvela O, Svedstrom E, Lundbom N. Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique. Reg Anesth. 1992;17:43Y46. 2. Ootaki C, Hayashi H, Amano M. Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to landmark-guided approaches. Reg Anesth Pain Med. 2000;25:600Y604. 3. Kapral S, Krafft P, Eibenberger K, et al. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg. 1994;78:507Y513. 4. Ting PL, Sivagnanaratnam V. Ultrasonographic study of the spread of local anaesthetic during axillary brachial plexus block. Br J Anaesth. 1989;63:326Y329.

slide11

complications

Less volume

New approach

slide12

Is one study is enough?

Meta Analysis

1999

succesfull block equals surgical anesthesia no ga spinal nor suplementation blocks
Succesfull Block equals Surgical anesthesia (No GA, Spinal nor suplementationblocks)

Succesfull Block equals Surgical anesthesia

(No GA, Spinal nor suplementation blocks)

slide14

US provided more successful blocks with risk ratio for block failure 0.41

No significant difference in success rate of US guided blocks

Other benefits of Ultrasound included: faster onset, longer duration and higher patient satisfaction.

No single report suggesting that Ultrasound is inferior to other techniques or carry a higher risk.

19 studies

US faster in 15 studies

19 Studies

US slower in One study

Performance time of the block

Same in 2 studies

slide17
US for upper extremity Blocks is found also to have :Faster Sensory onsetHigher Success RateLess Complication Rate
slide18

Only 7 Studies found

US faster onset and higher success rate

neuraxial
Neuraxial

Ultrasound is superior than landmarks in determination of the midline, identification of the level and the depth from the skin

Ultrasound is better than Anatomical method but inferior to radiology imaging

slide21

Not Enough Data from the small studies in pediatrics.

Trend toward faster blocks and lower volumes

complications
Complications
  • Less with Ultrasound
  • Pneumothorax
  • Hemidiaphragmatic paresis
  • Vascular Puncture
  • No Difference
  • LAST (local Anesthetic Systemic toxicity)
  • Peripheral Nerve injuries
  • 17,000 cases reviewed
slide26

There are no RCT data that unequivocally supportsuperior safety outcomes consequent to the use of UGRACase reports emphasize that absolute elimination of these seriouscomplications has not occurred.

local anesthetic toxicity
Local Anesthetic toxicity

Seizure 0.8%(one case)

Cardiac toxicity 0 cases

nerve injury
The Risk is not still eliminatedNerve injury

1.8% neurological symptoms lasting more than 5 days

0.9% lasting longer than 6 months

nerve injury is multi factorial
Nerve Injury is Multi Factorial
  • Preexisting lesions
  • Surgical techniques
  • Position details
  • Volume of local anesthetics
  • Needle trauma
  • Regional Anesthesia & Pain Medicine.Sept 2012 p490
  • Reported the incidence of perioperative nerve injury after total shoulder is 2.2% with no additional increase of risk with ISB