Der Anaesthesist

, Volume 56, Issue 11, pp 1155–1162 | Cite as

Elektrische Nervenstimulation für Plexus- und Nervenblockaden

Regionalanästhesie

Zusammenfassung

Trotz der zunehmenden Anwendung des Ultraschalls repräsentiert die elektrische Nervenstimulation derzeit wahrscheinlich noch den quantitativ überwiegenden Standard bei der Durchführung von Plexusanästhesien und peripheren Nervenblockaden. In den letzten Jahren haben zahlreiche Untersuchungen zu einem besseren Verständnis physiologischer und klinischer Zusammenhänge beigetragen. Die verwendeten Stromstärken und Impulsbreiten in Abhängigkeit vom Abstand zwischen Nadelspitze und Nerv sind mittlerweile auch an Patienten besser definiert worden. Handelsübliche Geräte erlauben eine transkutane Nervenstimulation und eröffnen damit neue Möglichkeiten beim Auffinden von Punktionsstellen sowie bei der Ausbildung. Eine elektrisch optimale Nadelposition wird in der Regel über motorische Stimulationsantworten definiert, die ohne profunde funktionell-anatomische Kenntnisse nicht interpretierbar sind. So können interskalenäre Blockaden auch über motorische Reaktionen im M. deltoideus oder in der Pektoralismuskulatur erfolgreich sein. Infraklavikuläre Blockaden sollten eine Stimulation des posterioren Faszikels anstreben (Extensionsbewegungen). Axilläre Single-shot-Verfahren führen häufiger zu inkompletten Blockaden verglichen mit dem Aufsuchen der Einzelnerven weiter distal. Für Blockaden des N. femoralis ist es möglich, ganz auf Stimulationen zu verzichten, wenn ein Fascia-iliaca-Block durchgeführt wird. Unabhängig von den zahllosen Zugangsvarianten für den N. ischiadicus sind eine Supinations-/Inversionsbewegung oder die Plantarflexion die beste Option für Single-shot-Blockaden. Ob Stimulationskatheter einen entscheidenden Vorteil bei kontinuierlichen Blockaden bieten, bleibt Gegenstand weiterer klinischer Untersuchungen.

Schlüsselwörter

Elektrische Nervenstimulation Regionalanästhesie Erfolgsrate Reizantwort Stimulationskatheter 

Electrical nerve stimulation for plexus and nerve blocks

Abstract

Despite the increasing use of ultrasound, electrical nerve stimulation is commonly used as the standard for both plexus and peripheral nerve blocks. Several recent randomized trials have contributed to a better understanding of physiological and clinical correlations. Traditionally used currents and impulse widths are better defined in relation to the distance between needle tip and nerves. Commercially available devices enable transcutaneous nerve stimulation and provide new opportunities for the detection of puncture sites and for training. The electrically ideal position of the needle usually is defined by motor responses which can not be interpreted without profound anatomical knowledge. For instance, interscalene blocks can be successful even after motor responses of deltoid or pectoral muscles. Infraclavicular blocks should be aimed at stimulation of the posterior fascicle (extension). In contrast to multiple single nerve blocks, axillary single-shot blocks more commonly result in incomplete anaesthesia. Blockade of the femoral nerve can be performed without any nerve stimulation if the fascia iliaca block is used. Independently of the various approaches to the sciatic nerve, inversion and plantar flexion are the best options for single-shot blocks. Further clinical trials are needed to define the advantages of stimulating catheters in continuous nerve blocks.

Keywords

Electrical nerve stimulation Regional anesthesia Success rate Stimulating catheter Twitch response 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Auroy Y, Benhamou D, Bargues L et al. (2002) Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 97: 1274–1280PubMedCrossRefGoogle Scholar
  2. 2.
    Benzon HT, Kim C, Benzon HP et al. (1997) Correlation between evoked motor response of the sciatic nerve and sensory blockade. Anesthesiology 87: 547–552PubMedCrossRefGoogle Scholar
  3. 3.
    Birnbaum J, Volk T (2006) Use of a stimulating catheter for femoral nerve block. Br J Anaesth 96: 139–140PubMedCrossRefGoogle Scholar
  4. 4.
    Bollini CA, Urmey WF, Vascello L, Cacheiro F (2003) Relationship between evoked motor response and sensory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med 28: 384–388PubMedCrossRefGoogle Scholar
  5. 5.
    Borene SC, Edwards JN, Boezaart AP (2004) At the cords, the pinkie towards: Interpreting infraclavicular motor responses to neurostimulation. Reg Anesth Pain Med 29: 125–129PubMedCrossRefGoogle Scholar
  6. 6.
    Borgeat A, Blumenthal S, Karovic D et al. (2004) Clinical evaluation of a modified posterior anatomical approach to performing the popliteal block. Reg Anesth Pain Med.29: 290–296Google Scholar
  7. 7.
    Brull R, McCartney CJ, Chan VW, El-Beheiry H (2007) Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 104: 965–974PubMedCrossRefGoogle Scholar
  8. 8.
    Capdevila X, Biboulet P, Bouregba M et al. (1998) Comparison of the three-in-one and fascia iliaca compartment blocks in adults: clinical and radiographic analysis. Anesth Analg 86: 1039–1044PubMedCrossRefGoogle Scholar
  9. 9.
    Casati A, Fanelli G, Koscielniak-Nielsen Z et al. (2005) Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters. Anesth Analg 101: 1192–1197PubMedCrossRefGoogle Scholar
  10. 10.
    Dalens B, Vanneuville G, Tanguy A (1989) Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 69: 705–713PubMedGoogle Scholar
  11. 11.
    Fournier R, Weber A, Gamulin Z (2005) Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia. Acta Anaesthesiol Scand 49: 683–686PubMedCrossRefGoogle Scholar
  12. 12.
    Gaertner E, Kern O, Mahoudeau G et al. (1999) Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve-blocking sequence. Acta Anaesthesiol Scand 43: 609–613PubMedCrossRefGoogle Scholar
  13. 13.
    Hadzic A, Vloka JD, Claudio RE et al. (2004) Electrical nerve localization: effects of cutaneous electrode placement and duration of the stimulus on motor response. Anesthesiology 100: 1526–1530PubMedCrossRefGoogle Scholar
  14. 14.
    Handoll HH, Koscielniak-Nielsen ZJ (2006) Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. Cochrane Database Syst Rev: CD003842Google Scholar
  15. 15.
    Johnson CR, Barr RC, Klein SM (2007) A computer model of electrical stimulation of peripheral nerves in regional anesthesia. Anesthesiology 106: 323–330PubMedCrossRefGoogle Scholar
  16. 16.
    Karaca P, Hadzic A, Yufa M et al. (2003) Painful paresthesiae are infrequent during brachial plexus localization using low-current peripheral nerve stimulation. Reg Anesth Pain Med 28: 380–383PubMedCrossRefGoogle Scholar
  17. 17.
    Koscielniak-Nielsen Z (2002) Axillary block by double-, triple-, or quadruple-nerve stimulation. Reg Anesth Pain Med 27: 442–443PubMedCrossRefGoogle Scholar
  18. 18.
    Lecamwasam H, Mayfield J, Rosow L et al. (2006) Stimulation of the posterior cord predicts successful infraclavicular block. Anesth Analg 102: 1564–1568PubMedCrossRefGoogle Scholar
  19. 19.
    Liisanantti O, Luukkonen J, Rosenberg PH (2004) High-dose bupivacaine, levobupivacaine and ropivacaine in axillary brachial plexus block. Acta Anaesthesiol Scand 48: 601–606PubMedCrossRefGoogle Scholar
  20. 20.
    Minville V, Fourcade O, Bourdet B et al. (2007) The optimal motor response for infraclavicular brachial plexus block. Anesth Analg 104: 448–451PubMedCrossRefGoogle Scholar
  21. 21.
    Neuburger M, Rotzinger M, Kaiser H (2001) Elektrische Nervenstimulation in Abhängigkeit von der benutzten Impulsbreite. Eine quantitative Untersuchung zur Annäherung der Nadelspitze an den Nerven. Anaesthesist 50: 181–186PubMedCrossRefGoogle Scholar
  22. 22.
    Neuburger M, Gultlinger O, Ass B et all. (2005) Einfluss der Blockade mit Lokalanästhetika auf die Stimulierbarkeit eines Nerven mit der peripheren Nervenstimulation. Ergebnisse einer randomisierten Studie. Anaesthesist 54: 575–577PubMedCrossRefGoogle Scholar
  23. 23.
    Parkinson SK, Mueller JB, Little WL, Bailey SL (1989) Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 68: 243–248PubMedGoogle Scholar
  24. 24.
    Rodriguez J, Taboada M, Carceller J et al. (2006) Stimulating popliteal catheters for postoperative analgesia after hallux valgus repair. Anesth Analg 102: 258–262PubMedCrossRefGoogle Scholar
  25. 25.
    Salinas FV, Neal JM, Sueda LA et al. (2004) Prospective comparison of continuous femoral nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural placement in volunteers. Reg Anesth Pain Med 29: 212–220PubMedCrossRefGoogle Scholar
  26. 26.
    Silverstein WB, Saiyed MU, Brown AR (2000) Interscalene block with a nerve stimulator: a deltoid motor response is a satisfactory endpoint for successful block. Reg Anesth Pain Med 25: 356–359PubMedCrossRefGoogle Scholar
  27. 27.
    Sukhani R, Nader A, Candido KD et al. (2004) Nerve stimulator-assisted evoked motor response predicts the latency and success of a single-injection sciatic block. Anesth Analg 99: 584–588PubMedCrossRefGoogle Scholar
  28. 28.
    Taboada M, Atanassoff PG, Rodriguez J et al. (2005) Plantar flexion seems more reliable than dorsiflexion with Labat’s sciatic nerve block: a prospective, randomized comparison. Anesth Analg 100: 250–254PubMedCrossRefGoogle Scholar
  29. 29.
    Tonidandel WL, Mayfield JB (2002) Successful interscalene block with a nerve stimulator may also result after a pectoralis major motor response. Reg Anesth Pain Med 27: 491–493PubMedCrossRefGoogle Scholar
  30. 30.
    Tsui BC, Kropelin B (2005) The electrophysiological effect of dextrose 5% in water on single-shot peripheral nerve stimulation. Anesth Analg 100: 1837–1839PubMedCrossRefGoogle Scholar
  31. 31.
    Winnie AP (1970) Interscalene brachial plexus block. Anesth Analg 49: 455–466PubMedCrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag 2007

Authors and Affiliations

  1. 1.Universitätsklinik für Anästhesiologie und operative IntensivmedizinCampus Charité Mitte und Campus Virchow-Klinikum,Charité - Universitätsmedizin BerlinBerlinDeutschland
  2. 2.Centrum für AnatomieCharité - Universitätsmedizin BerlinBerlinDeutschland

Personalised recommendations