Anästhesie (Subject) / Regionalanästhesie (Lesson)

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• 3 in 1 Block Blockade Plexus lumbalis: N. femorslis, N. cutaneus fem. lat., N. obturatorius 1. N femoralis: Hüftbeuger (M. psoas, iliacus), -strecker (M. quadrizeps), Hüft- und Kniebeuger (m. sartorius), Hüftbeuger + Adduktion (M. pectineus). Sensibel: Innenseite Bein (Saphenus-Ast) 2. obturatorius: Adduktion. Sensibel: Hüftgelenk, Hautfeld OS Innenseite Verlauf an lat. Blasenwand! Cave bei Elektrocauter. 3. N cutaneus femoris lateralis: sensibel: lateraler Oberschenkel
• Ganglion Stellatae Sympathisches Ganglion vor WK C7 Efferenzen zu Kopf, Hals, obere Extremität, Herz Blockade Indikation: sympathische Reflexdystrophie u.a. Schmerzsyndrome im Bereich Kopf, Hals, Arm, arterielle Insuffizienz (Sklerodermie, Raynaud u.a.) > Pupillenkonstriktion und Verlust Lakrimation ipsilateral > Vasodilatation, Erwärmung, Schmerzlinderung obere Extremität ipsilateral KI: Bradykardie, Glaukom, kürzlicher Herzinfarkt, Koagulopathie    
• Plexus brachialis   Rami ventralis C5 to T1 (C4 and T2) Nervus musculocutaneous: M. biceps, M. brachialis und M. coracobrachialis N. thoracodorsalis: M. latissimus dorsi N. thoracicus longus: M. serratus anterior The intercostobrachial nerve has a T2 sensory distribution (branch or the second intercostal nerve) and needs to be blocked separately if anaesthesia is required for the skin of the medial upper arm, extending posteriorly and axilla. Whichever approach for brachial plexus block is used this nerve is often 'missed'. This nerve is very superficial and can be blocked by infiltration analgesia from the superior margin of the biceps at the anterior axillary fold to the border of the triceps along the floor of the axilla. This block will not be effective against ischaemic pain induced by tourniquets.  
• Lokalanästhetika, Eigenschaften The binding of local anaesthetics by plasma proteins influences the duration of action. The amide local anaesthetics are mainly bound to α1-glycoproteins. This can affect the pharmacokinetics and dynamics of a drug. Typical plasma protein binding values of the local anaesthetics are as follows: Bupivacaine 95% Ropivacaine 94% Levobupivacaine 97% Lidocaine 75% Lipid solubility appears to be the most significant property of local anaesthetic molecules in determining anaesthetic potency. The lipid nature of the nerve cell membrane probably explains this relationship between lipid solubility and potency. Local anaesthetic molecules that are highly lipophilic easily penetrate nerve cell membranes. Tissue pKa and relationship to pH will determine the degree of ionisation. The pKa of a local anaesthetic will determine the speed of onset. Un-ionised molecules readily penetrate nerve cell membranes and at a pH of 7.4 the onset of lidocaine is quicker than bupivacaine. Lidocaine (pKa 7.7) approximately 33% exists in the un-ionised form Bupivacaine (pKa 8.1) approximately 17% exists in the un-ionised form. Amide local anaesthetics are metabolised in the liver and are not subject to local metabolism.
• block for inguinal hernia repair A field block for an inguinal hernia repair is ideal for high risk patients unsuited for general or spinal anaesthesia. The innervation of the inguinal region is through the ventral rami of T11 and T12 and the two upper branches of the lumbar plexus, the iliohypogastric and ilioinguinal nerves. The anterior cutaneous branch of the iliohypogastric nerve supplies the skin above the pubis and medial end of the inguinal ligament. The ilioinguinal nerve supplies the skin over the root of the penis and scrotum. The ventral ramus of the 12th thoracic or subcostal nerve sends a branch to join the first lumbar root and supplies the skin over the lower anterior abdominal wall. The genital branch of the genitofemoral nerve may supply skin in the medial part of the groin. Prilocaine 0.5% with adrenaline is a suitable choice of agent, which allows a large volume of solution to be used safely.
• Sakralblock   The sacral canal results from the fusion of the laminae of the five sacral vertebrae in the midline. Failure of fusion of the S4 and S5 results in the formation of the sacral hiatus. The sacral hiatus is easily identifiable as a small depression between the sacral cornua, hence making the performance of the sacral block possible with the use of landmarks. The posterior superior iliac spines and sacral hiatus form an equilateral triangle pointing downwards and can be felt in the lateral and prone positions. The dural sac ends at the level of S2 in adults and S3 in children.  
• Ganglion stellatae The stellate ganglion is formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. It occurs in 80% of subjects. Chassaignac's tubercle is the transverse process of the sixth cervical vertebra at the level of the cricoid cartilage, and is the bony landmark used when performing a stellate ganglion block. The vertebral artery lies in front of the ganglion. A stellate ganglion block may be performed for painful arm conditions which are sympathetically mediated (for example, complex regional pain syndrome type 1, herpes zoster and phantom limb pain) and to improve circulation (for example, in Raynaud's syndrome).
• Fussblock Anästhesie von 5 Nerven: 1. N. saphenus (terminaler Zweig des N. femoralis) Äste des Ischiadicus: tibial Sural Superficial peroneal  Deep peroneal nerves
• interscalenäre Plexusblockade Successful interscalene block (ISB) will produce an ipsilateral phrenic nerve block. The phrenic nerve is the sole motor supply to the diaphragm, and ipsilateral hemidiaphragmatic paresis occurs in up to 100% of patients receiving ISBs. Usually, phrenic nerve palsy is well tolerated, and is often unnoticed by healthy patients. However, forced vital capacity decreases by approximately 25%, which can produce ventilatory compromise in patients with limited pulmonary reserve, requiring assisted ventilation. If the recurrent laryngeal nerve is inadvertently blocked, vocal cord palsy occurs with symptoms of hoarseness and possibly acute respiratory insufficiency. This complication is ordinarily of little consequence unless bilateral laryngeal nerve palsy results, which may produce severe laryngeal obstruction. Cranial nerve X and XII palsy (Tapia's syndrome), may also occur following ISB. Symptoms include one-sided cord paralysis, aphonia, and the patient's tongue deviating toward the side of the block. Horner's syndrome may occur when the local anaesthetic spreads to the stellate ganglion with its cervical sympathetic nerves. Symptoms include ptosis of the eyelid, miosis, and anhidrosis of the face. However, the existence of Horner's syndrome may not indicate that the brachial plexus is adequately blocked.
• Caudalblock bei Kindern     Failure of fusion of the laminae of the fifth sacral segment results in the formation of the sacral hiatus. The sacral cornua form the lateral border and the spinous process of the fourth sacral segment forms the superior border. The sacrococcygeal membrane forms the roof of the sacral hiatus (posterior sacrococcygeal ligament). The spinal cord terminates at L1/2. The cauda equina (lumbar and sacral nerve roots), which is covered by the dura, terminates at S2.   complications (seldom)   intraosseous injection of local anaesthetic, causing profound hypotension or cardiac arrest   Urinary retention Lower limb blockade Dural puncture Hypotension.   volume of local anaesthetic  Sacral procedure 0.5 ml/kg Inguinal procedure 0.75 ml/kg Lower thoracic 1 ml/kg Mid-thoracic 1.5 ml/kg   avoid exceeding the upper safe dose limit best: long duration and minimal effect on the nerve serving motor function (L-Bupivacaine: 0.25% provides analgesia with minimal motor block for four to six hours)    
• peribulbar block The four recti muscles (superior, medial, lateral and inferior) originate from a tendinous ring (the annulus of Zinn) and extend anteriorly to insert beyond the equator of the globe. Bands of connective tissue are present between the rectus muscles forming a conical structure. These bands hinder the passage of local anaesthetic. The superior oblique muscle is situated outside this conical structure and is the most difficult muscle to anaesthetise completely, particularly with a single inferotemporal peribulbar injection. Performing a medial injection as well may help to prevent this. The extraocular muscles are supplied by the Third (inferior oblique, inferior recti, medial and superior) Fourth (superior oblique) and Sixth cranial nerves (lateral rectus). The sensory supply to the globe is via the long and short ciliary nerves, which are branches of the nasociliary nerve, (which is itself a branch of the ophthalmic division of the trigeminal nerve). These nerves enter the fibrotendinous ring and need to be fully blocked to anaesthetise the eye for surgery.
• Bier's Block The drug of choice for intravenous regional anaesthesia is prilocaine (40 ml 0,25%). It has the largest therapeutic index of all the amide local anaesthetics. Prilocaine has become the agent of choice for Bier's block, since 1983 when the product licence of bupivacaine was withdrawn for this purpose owing to fatal or serious complications.  Keine Methämoglobinbildung bis Dosen von 40 ml Prilocain 0,5%.
• Nervenfaserblockade: Reihenfolge  smaller (less than 1 micrometre in diameter) unmyelinated C fibres  B fibres (1-3 micrometres)   finally the larger A fibres (1-20 micrometres). C fibres: Temperature and pain sensation A-alpha fibres: proprioception, Motor function
• spread of local anaesthetic solution is determined by ...many factors including: Injection speed as the faster the solution is injected the wider the spread Baricity of solutions as hyperbaric solutions spread more quickly than isobaric ones. Barbotage causes turbulent flow and increases the spread of solutions in an unpredictable manner and is thus not adviced
• Antikoagulantien und rückenmarksnahe Anästhesie Pause vorher: Marcoumar, Sintrom: INR <= 1,4 ADP-Rezeptor -Antagonisten:   Clopidogrel (Plavix) 7d,  Prasugrel (Effient) 10d,  Ticagrelor (Brilique) 7d Prostaglandine:  Ilprost (Ilomedin): 2h Prostazyklin (Flolal): o,5 h COX-Hemmer: keine Pause Xa-Inhibitoren:  Rivaroxaban (Xarelto): 18h; > 15 mg je nach Nierenfunktion (1-3d) Apixaban (Eliquis): Gfr> 50: 24 h, 30-50: 2d Thrombininhibitoren:  Dabigatran (Pradaxa): je nach Nierenfkt 36 h- 3d Glykoprotein IIb/IIIa Inhibitoren:  Abciximab (Reopro): 48 h Tirofiban (Aggrastat): 8h Eptifibatid (Integrilin): 8h LmWH: Enoxaparin (Clexane), Dalteparin (Fragmin) prophylaktisch: 12h therapeutisch 36 h + xa Aktivität < = 0,1 E/ml unfraktioniertes Heparin prophylaktisch 4 h therapeutisch: 4h + PTT/ACT im Zielbereich  
• Sympathikolyse Herz sympathetic control to the myocardium (T2 - 5) results in bradycardia and an inability to increase contractility.

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