Publikationsserver der Universitätsbibliothek Marburg

Titel:Der Einfluss der unisolierten Stromemissionsfläche an der Stimulationskanülenspitze während der Nervenlokalisation zur peripheren Regionalanästhesie
Autor:Wichmann, Julia
Weitere Beteiligte: Steinfeldt, Thorsten (Prof. Dr.)
Veröffentlicht:2016
URI:https://archiv.ub.uni-marburg.de/diss/z2016/0430
DOI: https://doi.org/10.17192/z2016.0430
URN: urn:nbn:de:hebis:04-z2016-04301
DDC:610 Medizin
Publikationsdatum:2016-06-30
Lizenz:https://creativecommons.org/licenses/by-nc-sa/4.0

Dokument

Schlagwörter:
Nadel-Nerv-Kontakt, Nervenstimulation, regional anesthesia, nerve localization, needle-nerve-contact, Regionalanästhesie, Nervenlokalisation

Zusammenfassung:
Einleitung: Die elektrische Nervenstimulation ist ein etabliertes Standardverfahren zur Nervenlokalisation bei der Durchführung peripherer Nervenblockaden. Neurologische Defizite nach peripheren Regionalanästhesien lassen sich jedoch trotz Berücksichtigung vermeintlich nervenschonender Techniken bisher nicht vollends vermeiden und stellen ein klinisch relevantes Problem dar. Als häufige Ursache wird die Nervenverletzung während der Kanülenplatzierung diskutiert. Nadel-Nerv-Kontakte gelten als gesicherter Risikofaktor für Nervenschäden. Die verfügbaren Designs isolierter Stimulationskanülen unterscheiden sich zum Teil beträchtlich in der Größe ihrer Stromemissionsfläche. Bisher liegen keine vergleichenden Daten zur Inzidenz von Nadel-Nerv-Kontakten in Abhängigkeit von der Emissionsfläche vor. Material und Methoden: An sechs anästhesierten Schweinen wurde am offenen Plexus brachialis eine Nadel-Nerv-Distanzmessung bei minimaler Reizantwort unter Anwendung eines Schwellenstroms von 0,3 bis 0,8 mA durchgeführt. Es wurden drei Kanülentypen untersucht: Stimuplex® A (Standardkanüle mit mittlerer Emissionsfläche, n = 2025), Stimuplex® D (kleine Emissionsfläche, n = 1800) und eine Tuohy-Kanüle (StimucathTM, große Emissionsfläche, n = 2025). Die relativen Häufigkeiten für Nadel-Nerv-Kontakte wurden mittels Fishers Exact Test verglichen. Unterschiede zwischen den Nadel-Nerv-Abständen wurden mittels Friedman-Test und anschließendem Paarvergleich ermittelt. Ergebnisse: Insgesamt wurden 5850 Stimulationsversuche durchgeführt. Im Intervall 0,3 - 0,5 mA fand sich eine hohe Anzahl an unerwünschten Nadel-Nerv-Kontakten. Im Niedrigstrombereich traten zudem Nadel-Nerv-Kontakte ohne begleitende Stimulationsantwort auf. Die höchste Stimulationsversagerrate wies die Tuohy-Kanüle auf, gefolgt von der Stimuplex® D und der Stimuplex® A. Der Unterschied zwischen den untersuchten Nadeltypen war signifikant (p < 0,0001 für 0,3 mA). Im Intervall 0,6 - 0,8 mA wies die Stimuplex® A die geringste Inzidenz von Nadel-Nerv-Kontakten auf und unterschied sich signifikant von den beiden anderen Kanülen (Stimuplex® A vs. Stimuplex® D p < 0,005 für 0,6 mA, p < 0,0001 für 0,7 mA, p < 0,005 für 0,8 mA, Stimuplex® A vs. Tuohy p < 0,0001 für 0,6 mA bis 0,8 mA). Für die Tuohy-Nadel zeigte sich im Vergleich zur Stimuplex® D eine höhere Inzidenz von Nadel-Nerv-Kontakten. Schlussfolgerung: Beim Einsatz von Stimulationskanülen mit kleinen Emissionsflächen treten Nadel-Nerv-Kontakte nicht seltener auf als bei der Verwendung von Kanülen mit großen Emissionsflächen. Dennoch implizieren die signifikanten Unterschiede in der Inzidenz von Nadel-Nerv-Kontakten mit und ohne Stimulationserfolg differente Stimulationseigenschaften der unterschiedlichen Kanülenmodelle. Das Tuohy-Design scheint besonders anfällig für Nadel-Nerv-Kontakte und das Ausbleiben einer Reizantwort bei unmittelbarer Berührung des Zielnerven. Bei Stimulation mit Strömen oberhalb von 0,5 mA ist im Vergleich zu niedrigeren Schwellenwerten unabhängig vom Kanülendesign von einer größeren Sicherheit durch seltenere Nadel-Nerv-Kontakte bei vergleichbarer Nähe der Stimulationsnadel zum Nerv auszugehen. Darüber hinaus variiert der optimale Stimulationsstrom in Abhängigkeit vom verwendeten Kanülentyp.

Summary:
Introduction: So far, there are no techniques available to completely prevent neurologic impairment after peripheral nerve blockade. Although these complications do happen unfrequently with nerve stimulator guided regional anesthesia, they come along with a high clinical relevance. Needle-nerve-contact while needle positioning is discussed as a common risk factor for nerve injury. The conductive electrode area of the applied isolated stimulation needles may differ. Aim of this study was to determine whether the use of needles with small emitting surfaces for electrical nerve stimulation is associated with a lower incidence of needle-nerve-contacts compared to needle-tips with larger emitting surfaces. Methods: In six anaesthetized pigs the brachial plexus was surgically exposed bilaterally and underwent a measurement of needle-nerve-distance eliciting a minimal motoric response with 0,3 to 0,8 mA using either a Stimuplex® A (standard needle with a medium conductive surface, n = 2025) or a Stimuplex® D (small conductive surface, n = 1800) cannula or a Tuohy-tip needle (StimucathTM, large conductive surface, n = 2025). The incidence of needle-nerve-contacts for the different needles was compared using Fishers Exact Test. Differences between the needle-nerve-distances were assessed by Friedman´s Test and confirmatory post hoc pairwise testing. Results: A total of 5850 stimulation attempts were examined. For a current intensity of 0,3 to 0,5 mA there was a high incidence of needle-nerve-contacts for all of the examined needle types. Besides, for low amperages there were needle-nerve-contacts without stimulation success for all tested needle designs. For the Tuohy-needle the frequency of unseccussful stimulations was highest, followed by the Stimuplex® D and the Stimuplex® A. The occurance of failed stimulation attempts was significantly different between the needles (p < 0,0001 for 0,3 mA). For 0,6 to 0,8 mA the incidence of needle-nerve-contacts was lowest for the Stimuplex® A and there was a significant difference between the needles (Stimuplex® A vs. Stimuplex® D p < 0,005 for 0,6 mA, p < 0,0001 for 0,7 mA, p < 0,005 for 0,8 mA, Stimuplex® A vs. Tuohy p < 0,0001 for 0,6 mA to 0,8 mA). The incidence of needle-nerve-contacts for the Tuohy-needle was higher compared to the Stimuplex® D. Conclusions: The use of stimulation needles with small conductive areas is not associated with a lower incidence of needle-nerve-contacts. However, the significant difference in the rate of needle-nerve-contacts with and without stimulation success between the tip configurations imply different stimulation properties of the individual designs. The Tuohy-design seems to be particularly prone to needle-nerve-contacts and stimulation failure in spite of immediately touching the target nerve. Regardless of the cannula design, stimulation above 0,5 mA is associated with more safety and leads to equivalent needle-nerve-proximity in comparison to lower thresholds. With higher current amplitudes the ideal threshold moreover varies dependent on the used needle type.

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