05-การระงับ-สมศักดิ์

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1 541 π æπ åμâπ ß «Á ª«â â ßÀ Õ Õ (Bier's block) â««single tourniquet π ºà μ «Õ âõ Õ» Ï «ß«ß»å æ..* πå Õ ÈÕ æ πå æ.. æ ÿ ÿ æ.. Õ»«âÕß μ æ.. «ß ßÀ æ..** *»Ÿπ å æ å æ ßÕÕ å ªî å ßæ π æ å ** ÿà ß π««ßæ π æ å Abstract Elective Surgery of Upper Limb Using Single Tourniquet Intravenous Regional Anesthesia (Bier s block) Leechavengvongs S*, Uerpairojkit C*, Thuvasethakul P*, Asavakongkiat C*, Sanghirun D** *Upper Extremity and Reconstructive Microsurgery Unit, Center of Excellence in Orthopaedics, Lerdsin General Hospital, **Department of Anesthesiology, Lerdsin General Hospital Bull Dept Med Serv 2009; 34: A number of methods to achieve adequate anesthesia for upper extremity surgery have been described. Intravenous regional anesthesia is an interesting alternative method. The purpose of this paper is to study the results and the consequents of intravenous regional anesthesia (Bier s block) with single tourniquet technique in minor hand and wrist surgery. From September 1994 to August 1995, Intravenous regional anesthesia (Bier s block) with single - tourniquet technique had been performed in minor hand and wrist surgery in 102 patients. The patients were divided into 3 groups according to the pre-operative analgesic drugs: acetaminophen, floctafenine and placebo. The success rate of Bier s block were 93%. Average onset of anesthesia was 3.11 min., peak time of anesthesia was 6.19 min., and time for recovery of anesthesia was min. There were no different of these parameters among the groups of patients. About two-thirds of the patients did not suffer from tourniquet pain at all and only one-forth of patients and minor systemic complications caused by effect of local anesthesia agent. The modified single tourniquet Bier s block was effective and safe with low rate of local and systemic complications. Furthermore, it could be performed easily by any medical personel with no need of sophisticated equipment or intensive monitoring. Key words: Bier s block, regional anesthesia, wrist and hand surgery, results ËÕß àõ Àâ ß «Ÿâ æ Ë À«à ß ºà μ Á «Õ, âõ Õ, π À «Àâ Õ â Bier's block ª ÿ μå â single tourniquet technique ªìπÕ «Àπ Ëß Ëπà π π ËÕß âõ À ª Õ à ß Áμ ª æ «ª Õ «âõπ ß ß ªìπªí Ëπà» ºŸâ ß π â Ë» μ Èß μà Õπ π π

2 542 «æ å ªï Ë 34 Ë 7 Æ 2552 æ.» π ß Õπ ßÀ æ.» ºŸâªÉ«ÈßÀ 102 Ë â ºà μ Á «Õ âõ Õ Àâ ß «Ÿâ æ Ë Bier's block «π single tourniquet technique ºŸâªÉ«ÈßÀ Ÿ àßõõ ªìπ 3 ÿà Ëß â pre-operative analgesic drugs Ëμà ß π Õ acetaminophen, floctapenine ÿà «ÿ º» æ «à ª º Õß Bier's block à âõ 93 onset of anesthesia à 3.11 π, time for recovery of anesthesia à π à ÈßÀ ß à «à «μ μà ßÕ à ß π ß μ π μà ÿà Èßπ Èæ «à 2 π 3 ÕߺŸâªÉ«ÈßÀ à Õ ª«tourniquet pain ºŸâªÉ«1 π 4 Õß ÈßÀ º â ß ß æ ß Á πâõ À ß tourniquet deflation Ëß Õ ß à «À ª Õß àμâõß Àâ μàõ à ß Õ μ æ à Ë «π À μ π«πâ ß Ëμ Õ ºà μ «âπ à«ßà ß tourniquet deflation ª â«10 π Ëßæ «à à ß à «ßÕ à ß π ß μ ÿª çsingle tourniquet" Bier's block ª º «ª Õ π Ÿß Õÿ μ å local systemic complications μë à ÿπ ß âßà «à ªìπμâÕß âõÿª åæ» À Õ monitor Õ à ß â : º Àâ æ Ë ßÀ Õ Õ ºà μ «Õ âõ Õ π ªí ÿ π À μ À Õ ºà μ «âõ Õ àπ carpal tunnel release, ganlioncyst excision, closed reduction of fracture distal radius π ªìπÀ μ Ë ºŸâªÉ«â π Õß Èß Õ π ªìπ π«π π μà ªï π«πâ Ë æ Ë π«π Èπ ËÕ Ê À μ ß à «âßà â «àõπ â ß Èπ π Àâ ß «Ÿâ À«à ß À μ À à π È Àâ Õ À «Èß general regional anesthesia intravenous regional anesthesia (Ivra, Bier's block ) ªìπÕ π Àπ Ëß Ë «À À ª Ë ß π Èß Karl Alfred Bier πªï.» â ª ª ÿß Holme πªï.» π ªìπ π Ëπ â Õ à ß æ àà πªí ÿ π À Õ à À μ (exanguination) «πà Õ Ë ºà μ â«ß inflate tourniquet æ ËÕ Àâ «vascular isolation À ß π Èπ ß â π À Õ Õ «πà Õ π Èπ π Bier's block â π À μ À Õ ºà μ Á ßÕÕ å ªî å πà ªìπ ß Õ Ë «À μàõ π å ÿ π ªí ÿ π Ëß Àâ ß à æ ßæÕ Ë Õß «μâõß Õߪ π ß ºŸâ ß π ß â» Ivra (Bier's block) ª ÿ μå â ªìπ single tourniquet μ Õ Àâ π À«à ߺà μ Ëß ªìπÕÿª å Ë âª μ π bloodless surgery» π È «μ ÿª ß å æ ËÕ» ß âõ Ÿ Ë«ª Ë Ë «âõß single tourniquet Bier's block â à onset of anesthesia, time for peak of anesthesia, time for recovery from anesthesia μ Õ π success rate Õß π ß à ««âõπ Ë Èπ Bier's block Èß local systemic π ßà Õß Õÿ μ å incidence severity Ë «μ ÿ «ºŸâªÉ«ÈßÀ Ë â ºà μ Á «Õ âõ Õ ªìπ elective day case surgery π ßæ π μ Èß μà à«ß Õπ π π æ.» π ß Õπ ßÀ æ.» π«π Èß Èπ 102 ºŸâªÉ«ÿ â π π ß«Ivra (Bier's block) Àâ «π Õ π â à Èßπ È ±å ÕÕ â à ºŸâªÉ«Ë ª μ «Ÿ ÀâÕ Ÿà π ÿà ºŸâ ªÉ«μ American society of anesthesiotogist (ASA) μ Èß μà class III Èπ ª 2,3,5

3 543 ºŸâªÉ«Ë active infection π «Ë ºà μ ºŸâªÉ«Ë» æ åºÿâ ºà μ ªÆ â Bier's block π ºà μ ºŸâªÉ«ÈßÀ â àß ÿà μ Ë ºà μ àõπà ß (sequential sampling) àß ªìπ 3 ÿà à Ê π Ëß â pre operative analgesic drugs μà ß π Õ ÿà A â acetaminophen (paracetamol) 500 mg 2 tabs ÿà B â floctafenine (idarac) 200 mg 2 tabs ÿà C â placebo (multivitamin) 2 tabs À⺟âªÉ«ª π àõπ ºà μ ª 20 π «Àâ ß «Ÿâ single tourniquet Bier's block ºŸâªÉ«â æ π tourniquet «μâπ π â ß Ë ºà μ ß Á ÀâπÈ Õ π Õ å â «À Õ Õ À ß Õ Èß 2 â ß π Èπ à Õ «π â ß Ë ºà μ â«esmarch â«ß inflate tourniquet âõ 0.5 xylocaine π Ë 3 μàõ 1,3,4,5 ( Ÿª Ë 2 3) À Õ ªìπª ßπ È πºÿâªé«πè Àπ πºÿâªé«πè Àπ 61 Èπ ª Ë «π à μà ßÊ ß πμ ß ßπ È Õ 1. time for onset of anesthesia Õ «μ Èß μà Ë ª πºÿâªé«ë Õ «Õ À Õ âõ Õ 2. time for achieve peak of anesthesia Õ «μ Èß μà Ë ª πºÿâªé«ÿâ «Õ À Õ âõ Õ μá Ë Ë ºà μ â» æ å â surgical forceps test 3. æ (vital signs) Õ «π À μ Õ μ æ «ÿ 5-10 π 4. «âõπ ªìπ 4.1 local Õ tourniquet pain À«à ß ºà μ àß àõ μ severity ªìπ Grade 0 ºŸâªÉ«à Ÿâ ª««tourniquet Grade 1 ºŸâªÉ«Õ ª«μ ßÊ «tourniquet Á πâõ Grade 2 ºŸâªÉ«Ÿâ ª««tourniquet ª π ß æõ π â Grade 3 ºŸâªÉ«Ÿâ ª««tourniquet πμâõß ß ª«À Õ μâõß Àâ Õ tourniquet ÕÕ 4.2 systemic «æ Õ Õ Õ Ë ªìπ subjective symptoms ºŸâªÉ«àπ numbness, tinnitus, palpttation, fainting ªìπμâπ À ºŸâªÉ«Õ ß cardiovascular â«μ «â«ëõß EKG μàõ ª 5. time for recovery from anesthesia Õ «μ Èß μà Ë off tourniquet ª πºÿâªé«ë Õ ª««º ºà μ deflate tourniquet àõ Ê ß 50 mmhg ÿ Ê 1-3 π â ß «âª 30 «π μàõ pressure 1 Èß π Ëß off tourniquet â ºŸâªÉ«ÿ Ÿ ß μõ μàõ πàâõßæ øóôπ ªìπ «π πª 30 π æ ËÕ ΩÑ ß μ late systemic complications ËÕ ÈπÀ ß deflate tourniquet «Àå âõ Ÿ» ß «μ μà ß Õß à Ë «π À μ æ π μà à«ß «Õß Àâ ß «Ÿâ μ Èß μà àõπ Àâ πà ß off tourniquet π º Ë â ª «μ μà ß π ß μ º ºŸâªÉ«ÈßÀ 102 àß ªìπ æ» 13 ( âõ 12.7) æ»à ß 89 ( âõ 87.3) Õ ÿ Ë 41 ªï (18-72 ªï) πè Àπ Ë 61 (38-

4 544 «æ å ªï Ë 34 Ë 7 Æ ) Pre operative status ASA grade 1 79 ( âõ 77.5) ASA grade 2 23 ( âõ 22.5) Pre operative diagnosis àß ªìπ carpal tunnel syndrome 94 ( âõ 92.2) de quervain's disease, ganglion cyst 8 ( âõ 7.8) π ºà μ àß ªìπ 1. open carpal tunnel release (OCTR) 60 ( âõ 58.8) 2. endoscopic carpal tunnel release (ECTR) 34 ( âõ 33.3) 3. Õ ËπÊ àπ excision 8 ( âõ 7.8) π ÿà ºŸâªÉ«μ preoperative analgesic drug àß ªìπ ÿà 1 (acetaminophen) = 35 ( âõ 34.3) ÿà 2 (floctafenine) = 32 ( âõ 31.4) ÿà 3 (control) = 35 ( âõ 34.3) à Ë Õ ËπÊ Ë π ºŸâªÉ«- ª Õß 0.5% xylocaine Ë â (CC) = 39.9 μ - operative time (min) = 30 π - time for onset of anesthesia (min) = 3.11 π - time for achieve peak of anesthesia (min) = 6.19 π - time for recovery from anesthesia (MIN) = π - total tourniquet time (MIN) = 38.4 π π«πºÿâªé«èßà 102 ºŸâªÉ«7 à adequate anesthesia æõ Ë ºà μ â μâõß æ Ë local infiltration π «Ë ºà μ ªìπ success fate = âõ 93 ºŸâªÉ«1 ªí À tourniquet Ë«À«à ߺà μ ( âõ 0.9) ºŸâªÉ«π È â ß μõ Õ à ß â àæ «âõπ Ê πõ subjective tinntus Õ ß à «À ª Õß π 5 π àμâõß Àâ Ê ª à Ë π À«à ß ÿà ºŸâªÉ«Ë â pre-operative analgesic drug μà ß πæ «à à time for onset of anesthesia à «μ μà ß πõ à ß π ß μ (unpaired T test, P,0.05) π μà ÿà à time for achieve peak of anesthesia à «μ μà ß πõ à ß π ß μ (unpaired T test, P 0.05) π μà ÿà à time for recovery from anesthesia à «μ μà ß πõ à ß π ß μ (unpaired T test, P 0.05) π μà ÿà º Õ Èß à mean arterial pressure pulse rate Ë à«ß «μà ßÊ π À«à ß Bier's block à «μ μà ßÕ à ß π ß μ ËÕ à control Õ à«ß pre injection «âπ à«ß «μ ß Ë 1 Vital signs π à«ß «μà ßÊ À«à ß Bier's block Timing Pre Injection Post injection Post Tourniquet deflation Vital Sign (control) Immediate At 10 min Immediate At 10 min Mean Arterial (NS) 96.5 (NS) 96.4 (NS) 93.4 (SIG, P<0.05) Pressure (MMHg) Pulse rate (Beats/MIN) (NS) 82 (NS) 79.4 (NS) 78.8 (SIG, P<0.05)

5 545 μ ß Ë 2 Õÿ μ å tourniquet pain «ÿπ ß Õß complication ß à «Pre Medication Paracetamol Floctafenine Placebo Total Severity of pain n = 35 ( âõ ) n = 32 ( âõ ) n = 35 ( âõ ) n = 102 ( âõ ) Grade 0 19 (54.35) 25 (78.1) 23 (65.7) 67 (65.7) Grade 1 5 (22.9) 1 (3.1) 6 (17.1) 15 (14.7) Grade 2 6 (17.1) 6 (18.8) 6 (17.1) 18 (17.6) Grade 3 2 (5.7) (1.9) μ ß Ë 3 Õÿ μ å Õß systemic complication Ëß ªìπ central nervous system Pre Medication Paracetamol Floctafenine Placebo Total Severity of pain n = 35 ( âõ ) n = 32 ( âõ ) n = 35 ( âõ ) n = 102 ( âõ ) Tinnitus 7(20) 6(18.8) 7(20) 20(19.6) Dizziness 2 (5.7) 0 2 (5.7) 4 (3.9) Circumoral 0 2 (5.7) 2 (5.7) 4 (3.9) Numbness 10 π À ß tourniquet deflation Ëßæ «à Èß à mean arterial pressure pulse rate ß ËÕ à control Õ à ß π ß μ (unpaired t-test, p 0.05) ºŸâªÉ«ÿ Ë systemic complication â ΩÑ Ÿ À ß Õ Õ à ß â æ «à Õ ß à «À ª â Õß π 10 π à μâõß Ê àæ ºŸâªÉ«Ë «âõπ ÿπ ßÕ ËπÊ πõ Àπ Õ ª «âõπ â ßμâπ «å Àâ ß «Ÿâ æ Ë (regional anesthesia) π ºà μ «Õ âõ Õ ª π â«πà «μ Èß μà local anesthesia infiltration À Õ regional block àπ brachial plexus block, specific nerve block «ß intravenous regional anesthesia (Bier's block) ßπ Èπ Õ â technique Ë À ºŸâªÉ«μà Õ ªìπ Ëß ªìπ Ë Èß«æ å» æ å Ë ºà μ ªìπμâÕßæ Àâ Õ Õ ª Õ «åªí ÿ π Ë ºŸâªÉ«Ë â æ π π Õß Èß Õ π æ Ë Èπ ÿ «π À ºŸâªÉ«Ë â ºà μ ªìπ day case surgery ª À Èß «à â à μ Õ π Àâ âõ à ß ª πå Ÿß ÿ Õ â ß «Ÿâ π ºà μ ºŸâªÉ«Ë ª æ Ÿß «ª Õ Ÿß «âõπμë μ Õ π à â à μë ««Á«ßà μàõ à ªìπμâÕß â ÿ Ë ªìπæ» π à«àâ À π À μ À Õ ºà μ ªìπ ª âõ à ß ª º Ÿß ÿ» π È æ «à single tourniquet Bier's block πºÿâªé«èß 102 ª º (success rate) à âõ 93 Ëß â ß» Õ ËπÊ Ëß À⺠«Á Õ Ÿà Ë âõ ,6-8,10 onset of anesthesia «Á«à Ë = 3.11 π

6 546 «æ å ªï Ë 34 Ë 7 Æ 2552 â peak of anesthesia π 6.19 π Ëß ß à «à μ μà ß Àâ ß «Ÿâ «Õ Ëπ μà Õ à ß π μà ÿà Ë â pre operative analgesic drug Ë μ μà ß π Èß 3 ÿà æ «à à parameters Èß onset, peak of anesthesia success rate à «μ μà ß πõ à ß π ß μ» ß ËÕß local complication æ «à ª 2/3 ÕߺŸâªÉ«à Õ ª«tourniquet ºŸâªÉ«æ ß âõ 5 Ë Õ ª«ß à «πμâõß ß Õ ª«Õ ËπÊ æ ËÕ à«õ ª«Õ ªìπ à«π àõπ â ßπâÕ æ «à Bier's block Ë ß π π«μà ß ª»ª âõ 70 â technique double tourniquet with sequential inflation æ ËÕ ªí À tourniquet pain ß à «μà Á à ªí À ß à «ß âõ à ß Èπ ß 7,15 ËÕæ ß à Õÿª å ËÕß Õæ» ËμâÕß âμ Õ π «ÿàß â «Ë «à π Bier's block double tourniquet technique â«æ «à single tourniquet technique «««Á«ª À «à Ë «ªí À systemic complications æ «à Õÿ μ å μë à«π À à ªìπ æ ß mild central nervous system complications Ëß indirect indicator Ëß ß«à local anesthetic agent Ë ß À ÕÕ Ÿà Ÿ Ÿ â Ÿà systemic vascular circulation ßÕ Ÿà π Ë àõπ â ßμË Õ Ÿà π ±å ˪ Õ ß â«à ºŸ âªé«π» π È 1 ( âõ 0.9) Ëæ ªí À ËÕß accidental intraoperative tourniquet leakage Á à «âõπ ÿπ ß ªí À ß à «π (Sloan) 7 â ««ß π Bierûs block ÈßÀ π ª»Õ ß ƒ π«π 45,000 Èß æ «à ºŸâªÉ«2 Ë ªí À tourniquet failure àæ «âõπ Ë ÿπ ß Èπ π ß π ß à «àπ π Ëß π πÿ𠫪 Õ π â Bierûs block â ªìπÕ à ß ª «æ ««π À μ ÕߺŸâªÉ«À«à ß Bier's block æ «à à Ë Õß æ «π À μ π à«ß «μà ß π à «μ μà ß πõ à ß π ß μ «âπ Ë à«ß «10 π À ß off tourniquet æ «à Èß à Ë æ «π À μ ßμË «à à control Õ à ß π ß ºŸâ ß πμ Èß μ π Õߪ Æ å ß à ««à Õ º ß systemic effect Õß local anesthetic agent Ë º μ ßμàÕ cardiac contractility, conductive system º μàõ peripheral vascular smooth muscle 4,5 Àâ º ß à «À ß deflate tourniquet Õ à ß Áμ º ß à «ªìπ æ ß objective monitoring parameters à ºŸâªÉ«Ë Õ ß systemic symptoms àπ palpitation fainting μàõ à ß» ß Ë «â Bier's block π À μ μà ßÊ «Õ âõ Õ π 6-10 æ «à πμà ߪ» â Bier's block Õ à ß æ àà μ Èß μà πàâõߺà μ ª π ß πàâõß ÿ π Ëß ªìπºŸâªÉ«trauma à ªìπμâÕß â«æ å À Õ «æ Ë «π æ» àμâõß â sophisticated equipment Èß π Àâ monitor ºŸâªÉ«μàÕ à ß 7,8,15,16 π Bier's block â π orthopaedic trauma patients àπ closed reduction Õß fracture distal radius 9,17,18 À Õ fracture below the elbow Õ ËπÊ «Ë π Õ â Ÿß ß âõ 33 ÕߺŸâªÉ«ÈßÀ 9 πõ π È ß π â π elective day case surgery 6 Õ ËπÊ â«àπ carpal tunnel release À Õ ganglion excision ªìπμâπ ËÕæ ª Àâ ß «Ÿâ æ Ë«Õ Ëπ àπ local anesthetic infiltration ß â â ««Á«μà Á ßæ ªí À inadequate anesthetic level â9,17 Èß ß â π æ å ß ÿà ß â local anesthesia infiltration π closed reduction «à ªìπ 17 Àâ closed fracture ªìπ open type â

7 547 πõ π Ȫí À tissue planes edema Ë â ª π «operative field Àâ º interfere μàõ identify tissue À«à ߺà μ â specific nerve block àπ median À Õ ulnar nerve block â «ª Õ Ÿß μà ªìπμâÕß â«æ å À Õ» æ å Ë π block ß à «àπ «brachial plexus block πõ π È ßÕ potential serious complications â àπ neurovascular injuries, hemopneumothorax À Õ inadvertent intravascular local anesthetic injection Õß 2,4,5 ª πå Ë Õ ª π â Bier's block π ºà μ nerve À Õ tendon surgery Õ» æ åºÿâ ºà μ μ «ß π Õß motor nerve À Õ tendon Ë accidental injury π À«à ß ºà μ â μ «Õ à ß àπ μ «function Õß thenar muscles Ë È ß recurrent branch Õß median nerve π À«à ß carpal tunnel release Èß endoscopic À Õ open technique ÿª â intravenous regional anesthesia (Bier's block) «single tourniquet technique π À μ À Õ ºà μ Á «hand, wrist and forearm Ë â «à π 1 Ë«ß ªìπ«Ë ª æ Ÿß âßà «âõÿª å Ë Õ Ÿà â«μ ÀâÕߺà μ ÀâÕß ÿ π Õß ßæ Ë«ª à ªìπμâÕß â ÿ Ë «π ªìπæ» Èß ß «ª Õ μàõ «âõπμà ßÊ Ÿß À À π â πà μ ß à «π «å ß ÿ πªí ÿ π Õ Õâ ßÕ ß 1. Valley MA, Colo-Polanco J. Intravenous regional anesthesia. Problem in Anesthesia 200--;8: James CF. Local and regional anesthesia. In: Manual of complication during anesthesia. Philadelphia: JB Lippincort; p Pattison CW. A review of the Bier's block technique. Practitioner 1984;228: Bernstein RL, Rosenberg AD. Intravenous regional anesthesia in upper extremities. In manual of orthopaedic anesthesia and related pain syndrome. New York: Churchill Livingstone; 1993: Ellis JS. Local anesthesia. In : Kirby RR. Clinical anesthesia practice. Philadelphia: WB Saunders company; 1994: Dunlop DJ, Graham CM, Waldram MA, Mulligan PJ, Watt JM. The use of Bier's block for day case surgery. J Hand Surg Br 1995;20: Bartholomew K, Sloan JP. Prilocaine for Bier's block: how safe is safe? Arch Emerg Med 1990;7: Lowen R, Taylor J. Bier's block the experience of Australian emergency departments. Med J Aust 1994;160: Cobb AG, Houghton GR. Local anaesthetic infiltration versus Bier's block for Colles' fractures. Br Med J 1985; 291: Eastwood D, Griffiths S, Jack J, Porter K, Watt J. Bier's block--an improved technique. Injury 1986;17: Blyth MJ, Kinninmonth AW, Asante DK. Bier's block: a change of injection site. J Trauma 1995;39: Jones NC, Pugh SC. The addition of tenoxicam to prilocaine for intravenous regional anaesthesia. Anaesthesia 1996; 51: El-Hassan KM, Hutton P, Black AM. Venous pressure and arm volume changes during simulated Bier's block. Anaesthesia 1984;39: Lawes EG, Johnson T, Pritchard P, Robbins P. Venous pressures during simulated Bier's block. Anaesthesia 1984; 39: James NK, Khoo CT, Fell RH. The çmini-bier's blocké: a new technique for prevention of tourniquet pain during axillary brachial plexus anaesthesia. J Hand Surg Br 1994; 19: O'Sullivan I, Brooks S, Maryosh J. Is fasting necessary before prilocaine Bier's block? J Accid Emerg Med 1996; 13: Kendall JM, Allen PE, McCabe SE. A tide of change in the management of an old fracture?. J Accid Emerg Med 1995 Sep;12: Charies A, Rockwood JR, David P. Green anesthesia in fracture treatment. massive hand trauma and multiple fractures. In: Rockwood and green fractures in adults. Philadelphia: JB Lippincort; p