Periferik Sinir Bloğu Başarısını Göstermede Modern Yöntemler
Özet
Geleneksel periferik sinir bloğu değerlendirmeleri, hasta kooperasyonu gerektiren subjektif yöntemlere dayanmaktadır. Ancak günümüzde, sempatik blokaj sonucu oluşan vazodilatasyon ve sıcaklık artışı gibi objektif kriterleri temel alan non-invaziv teknikler öne çıkmaktadır. Bu yöntemlerin başında Near İnfrared Spektroskopisi (NIRS) ile ölçülen Doku Oksijen Satürasyonu (StO2) gelmektedir. StO2, doku perfüzyonundaki artışı hızlı bir şekilde yansıtır ve blok sonrası ilk 5 dakikada anlamlı artışlar göstererek başarının güçlü bir göstergesi olur. Bir diğer parametre olan Doku Hemoglobin İndeksi (THI), damarsal tıkanıklıkların ve vazodilatasyonun belirlenmesinde kantitatif veriler sunar. Perfüzyon İndeksi (PI), nabız pulsasyon gücü üzerinden gerçek zamanlı kan akışı değişikliklerini izleyerek blok başarısını %100 hassasiyetle öngörebilmektedir. Non-invaziv Toplam Hemoglobin (SpHb) ölçümü, laboratuvar değerlerinin yerini tutmasa da sürekli izleme avantajıyla blok sürecini destekler. Son olarak, kızılötesi termometrelerle yapılan Vücut Sıcaklığı ölçümleri, bölgesel sıcaklık artışını tespit ederek başarılı blokları öngörmede ucuz ve güvenilir bir seçenek sunar. Sonuç olarak StO2, PI ve cilt sıcaklığı, klinik pratikte blok etkinliğini değerlendirmek için en etkili ve objektif parametreler olarak kabul edilmektedir.
Traditional peripheral nerve block assessments rely on subjective methods requiring patient cooperation. Today, however, non-invasive techniques based on objective criteria such as vasodilation and temperature increase resulting from sympathetic blockade have come to the fore. Leading these methods is Tissue Oxygen Saturation (StO2), measured via Near-Infrared Spectroscopy (NIRS). StO2 rapidly reflects increases in tissue perfusion and serves as a strong indicator of success, showing significant increases within the first 5 minutes post-block. Another parameter, the Tissue Hemoglobin Index (THI), provides quantitative data for identifying vascular obstructions and vasodilation. The Perfusion Index (PI) monitors real-time blood flow changes through pulse pulsation strength and can predict block success with 100% sensitivity. While non-invasive Total Hemoglobin (SpHb) measurement does not replace laboratory values, it supports the block process with the advantage of continuous monitoring. Finally, Body Temperature measurements using infrared thermometers offer a cheap and reliable option for predicting successful blocks by detecting regional temperature increases. In conclusion, StO2, PI, and skin temperature are recognized as the most effective and objective parameters for evaluating block efficacy in clinical practice.
Referanslar
Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002; 97(5): 1274-80.
Hadzic A. (2013). Hadzic Periferik Sinir Blokları ve Ultrasonografi Eşliğinde Rejyonal Anestezi İşlemleri İçin Anatomi (2. Baskı). Ankara: Güneş Tıp Kitapevi
Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L, et al. Infraclavicular block causes less discomfort than axillary block in ambulatory patients. Acta Anaesthesiol Scand. 2005; 49: 1030-4.
Özyalçın SN, Erdine S. (2005). Üst ekstremite somatik blokları. Rejyonel Anestezi. (1. Baskı). İstanbul: Nobel Tıp Kitabevi
Kus A, Gurkan Y, Gormus SK, et al. Usefulness of perfusion index to detect the effect of brachial plexus block. Journal of Clinical Monitoring and Computing, 2013; 27:325-8.
Bergek C, Zdolsek JH, Hahn RG. Non-invasive blood haemoglobin and plethysmographic variability index during brachial plexus block. British Journal of Anaesthesia 2015; 114 (5): 812–7.
Minville V, Gendre A, Hirsch J, et al. The Efficacy of Skin Temperature for Block Assessment After Infraclavicular Brachial Plexus Block, Anesth Analg. 2009 Mar;108(3):1034-6.
Tsai PB, Tokhner V, Li J, at all. A new application for near-infrared spectroscopy in regional anesthesia? J Anesth. 2011 Feb;25(1):140-1.
Karahan MA, Binici O, Büyükfırat E. Tissue Oxygen Saturation Change on Upper Extremities After Ultrasound-Guided Infraclavicular Brachial Plexus Blockade; Prospective Observational Study. Medicina 2019; 55: 274-5.
Myers D, McGraw M, George M, et al. Tissue hemoglobin index: a non-invasive optical measure of total tissue hemoglobin. Critical Care 2009, 13(Suppl 5):S2 (doi:10.1186/cc8000)
Ginosar Y, Weiniger CF, Meroz Y, et al. Pulse oximeter perfusion index as an early indicator of sympathectomy after epidural anesthesia. Acta Anaesthesiol Scand. 2009; 53: 1018-26.
Sebastiani A, Philippi L, Boehme S, et al. Perfusion index and plethysmographic variability index in patients with interscalene nerve catheters. Can J Anaesth. 2012; 59: 1095-101.
Lange KHW, Jansen T, Asghar S, et al. Skin temperature measured by infrared thermography after specific ultrasound-guided blocking of the musculocutaneous, radial, ulnar, and median nerves in the upper extremity. British Journal of Anaesthesia 2011;106 (6): 887–95.
Ferrari M, Mottola L, Quaresima V. Principles, techniques, and limitations of near infrared spectroscopy. Can J Appl Physiol. 2004;29: 463-87.
De Blasi RA1, Ferrari M, Natali A et al. Noninvasive measurement of forearm blood flow and oxygen consumption by near infrared spectroscopy. J Appl Physiol. 1994;76: 1388-93.
Yalçın Ş, Karahan MA, Sürücü M, Aksiller blok yapılan üst ekstremite cerrahisinde Near İnfrared Spektroskopisi (NIRS) kullanılarak doku oksijenizasyonunun değerlendirilmesi. Harran Üniv. Anest. ve Rean. AD Uzmanlık Tezi, 2016.
Binici O, Karahan MA, Buyukfirat E. Evaluation of tissue oxygenation and block quality using Near Infrared Spectroscopy (NIRS) in patients undergoing ultrasound-guided infraclavicular block at different arm angles A prospective observational study. Ann Ital Chir. 2019;90:357-363.
Van de Velde S, Kalmar AF, Raes M, et al. Lower Extremity Near-infrared Spectroscopy After Popliteal Block For Orthopaedic Foot Surgery. Open Orthop J. 2016 Jul 20;10:258-63.
Phil B Tsai, Vadim Tokhner, Jichang Li, et al. A new application for near-infrared spectroscopy in regional anesthesia?. Journal of Anesth. 2011; 25:140–14
Xu Z, Zhang J, Shen H, et al. Assessment of pulse oximeter perfusion index in pediatric caudal block under basal ketamine anesthesia. Scientific World Journal. 2013; 19;183493.
Lima A, Bakker J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med 2005; 1316-26.
Hales JR, Stehens FR, Fawcett AA, et al. Observations on a new non-invasive monitor of skin blood flow. Clin Exp Pharmacol Physiology, 1989; 16: 403–15.
Lima A, Jansen TC, van Bommel J, et al. The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Critical Care Medicine, 2009; 37: 934–8.
Van Genderen ME1, Bartels SA, Lima A, et al. Peripheral perfusion index as an early predictor for central hypovolemiain awake healthy volunteers. Anesthesia Analgesia, Feb; 2013; 116(2):351-6.
Fei Y, Xu MM, Huang B, et al. Assessment of the radial and ulnar arteries hemodynamic changes by ultrasound in patients with primary palmar hyperhidrosis after thoracic sympathetic block. Zhonghua Yi Xue Za Zhi. 2017;97: 1729-33.
Acar S., Gürkan Y, Solak M, et al. Coracoid versus lateral sagittal infraclavicular block. Acta Orthop Traumatol Turc, 2013; 47(1):32-7.
Chin KJ, Perlas A, Chan VWS, et al. Needle visualization in ultrasoundguided regional anesthesia: challenges and solutions. Reg. Anesth. Pain Med. 2008; 33: 532–44.
Yamazaki H, Nishiyama J, Suzuki T. Use of perfusion index from pulse oximetry to determine efficacy of stellate ganglion block. Local Reg Anesth. 2012;5:9-14.
Abdelnasser A, Abdelhamid B, Elsonbaty Aet al. Predicting successful supraclavicular brachial plexus block using pulse oximeter perfusion index. Br J Anaesth. 2017; 119: 276-80.
Nieuwveld D, Mojica V, Herrera AE et al. Medial approach of ultrasoundguided costoclavicular plexus block and its effects on regional perfussion. Rev Esp Anestesiol Reanim. 2017; 64: 198-205.
Galvin EM, Niehof S, Medina HJ, et al. Thermographic temperature measurement compared with pinprick and cold sensation in predicting the effectiveness of regional blocks. Anesth Analg 2006; 102: 598–604.
Davis BH, Jungerius B. International Council for the Standardization of Haematology (ICSH) International Council for Standardization in Haematology technical report 1—2009: new reference material for haemiglobincyanide for use in standardization of blood haemoglobin measurements. Int J Lab Hematol 2010;32:139–41.
Zwart A, Van Assendelft OW, Bull BS, et al. Recommendations for reference method for haemoglobinometry in human blood (ICSH standard 1995) and specifications for international haemiglobinocyanide standard (4th edition). J Clin Pathol. 1996; 49: 271–4.
Barker SJ, Shande A, Ramsay MA, Continuous Noninvasive Hemoglobin Monitoring: A Measured Response To A Critical Review, Anesth Analg. 2016 Feb; 122(2): 565-72
Asghar S, Lange KHW, Lundstrom LH. Blinded observer evaluation of distal skin temperature for predicting lateral ınfraclavicular block success. Anesthesia & Analgesia January 2015, Volume 120, Number 1, DOI: 10.1213/ANE.0000000000000475
Kavakli AS, Enginar F, Arslan U, et al. Thermochromic nail polish as a novel indicator to predict infraclavicular brachial plexus block success. Eur J Anaesthesiol 2019; 36:911–917
