Ultraschallgesteuerte Nervenblockade des Nervus femoralis und ischiadicus im Vergleich zur Epiduralanästhesie bei orthopädischen Eingriffen am Hund

Zusammenfassung

Ziel: Vergleich von Epiduralanästhesie und ultraschallgesteuerter Nervenblockade bezüglich analgetischer Effektivität, klinischer Anwendbarkeit sowie Nebenwirkungen bei orthopädischen Eingriffen an der Hintergliedmaße des Hundes. Material und Methoden: In die prospektive, geblindete, randomisierte klinische Studie gingen 22 Hunde der ASA(American Society of Anesthesiologists)-Stufen I und II ein, bei denen ein orthopädischer Eingriff ab dem distalen Drittel des Femurs erfolgte. Den Hunden wurden randomisiert 0,5 mg/kg Bupivacainhydrochlorid (0,5%) und 0,1 mg/kg Morphinsulfat (1%) epidural (EPI) oder unter Ultraschallkontrolle perineural (LA) verabreicht. Intraoperativ wurden Herzfrequenz, Atemfrequenz, mittlerer arterieller Blutdruck (MAP), endexspiratorische Isoflurankonzentration und die Anzahl der zusätzlich benötigten Fentanyl-Boli (5 µg/kg i. v.) als Rescue-Analgesie protokolliert. Präoperativ sowie postoperativ zu Stunde 2, 4, 6, 12 und 24 nach Extubation wurde der Schmerzgrad mittels der Kurzform des Glasgow Composite Measure Pain Scale (GCMPS) bestimmt. Bei einem GCMPS > 6 erhielten die Hunde Methadon (0,2 mg/kg i. v.) als Rescue-Analgesie. Zur statistischen Auswertung dienten Chi-Quadrat-Test, Fisher-Test, Wilcoxon-Test sowie ein- und zweifaktorielle ANOVA mit Signifikanz bei p < 0,05. Ergebnisse: Während der Anästhesie betrug der mittlere MAP in Gruppe EPI 86,6 ± 8,7 mmHg und in Gruppe LA 111,2 ± 11,2 mmHg. Postoperativ lag der MAP in Gruppe EPI bei 95,2 ±13,1 mmHg und in Gruppe LA bei 119,3 ± 18,2 mmHg. Der MAP der Gruppe EPI war durchgehend signifikant niedriger als der der Gruppe LA (p = 0,0421). Weitere signifikante Unterschiede ergaben sich nicht. Urinretention oder motorische Beeinträchtigungen wurden nicht beobachtet. Schlussfolgerung: Die ultraschallgesteuerte Nervenblockade des N. femoralis und des N. ischiadicus garantieren eine zur Epiduralanästhesie vergleichbare perioperative Analgesie. Die Unterschiede des MAP zeigten klinisch keine Relevanz. Unter stationären Bedingungen ergab sich kein Nachteil bezüglich der Gliedmaßen- und Blasenfunktion.

Summary

Objective: Comparison of ultrasound-guided femoral and sciatic nerve block versus epidural anaesthesia with bupivacaine and morphine for orthopaedic surgery of the pelvic limb in dogs with respect to analgesic effectiveness, clinical utility and side effects. Material and methods: The study included 22 dogs (American Society of Anesthesiologists, ASA grades I and II) undergoing orthopaedic surgery distal to the mid-femoral bone. The study was designed as a randomized, prospective, blinded clinical trial. All dogs were randomly assigned to receive 0.5 mg/kg bupivacaine (0.5%) and 0.1 mg/kg morphine sulphate (1%) either as epidural anaesthesia (group EPI) or by ultrasound-guided femoral and sciatic nerve block (group LA). During surgery, the heart rate, respiratory rate, mean arterial pressure (MAP), end-tidal isoflurane concentrations and dose of rescue analgesia (fentanyl boluses of 5 µg/kg i. v.) were measured. Pain severity was scored (short form of the Glasgow Composite Measure Pain Scale, GCMPS) before surgery and postoperatively at 2, 4, 6, 12 and 24 hours after extubation. Post-operative rescue analgesia consisted of methadone (0.2 mg/kg i. v.), and was applied when the GCMPS > 6. For statistical analysis, the Chi-square, Fisher, and Wilcoxon tests and one- and two-way ANOVA were applied. Differences were considered statistically significant at p < 0.05. Results: Only the MAP was significantly different between the two treatment groups. Intra- and postoperative MAP of group LA (111.2 ± 11.2 mmHg and 119.3 ± 18.2 mmHg, respectively) was higher than in group EPI (86.6 ± 8.7 mmHg and 95.2 ± 13.1 mmHg, respectively). None of the dogs developed urinary retention or ambulatory deficits when completely recovered from anaesthesia. No other side effects were noted. Clinical relevance: In conclusion, femoral and sciatic nerve blocks and epidural anaesthesia ensure comparable analgesic effects in canine patients undergoing orthopaedic surgery of the pelvic limb. The lower mean arterial blood pressure of group EPI was not of clinical relevance.

Schlüsselwörter

Ultrasonographie - Lokalanästhesie - Schmerzmanagement - Beckengliedmaße

Keywords

Ultrasound - local anaesthetics - pain management - pelvic limb

• Literatur

• 1 Bonath K, Gerlach K. et al. Einfluss der extraduralen Langzeitanästhesie mit Bupivacain und Langzeitanalgesie mit Morphin auf Kreislauf und Atmung des Hundes. Fortschr Vetmed 1983; 37: 237-239.
• 2 Bonath K, Herberg L. et al. The effect of epidural anaesthesia on plasma catecholamines, corticosteroids, respiration and circulation in non-sedated dogs. (Is epidural anaesthesia with bupivacaine tolerable for the non-sedated dog?). Z Versuchstierkd 1987; 29 (3–4): 111-120.
• 3 Bosmans T, Schauvliege S, Gasthuys F. et al. Cardiovascular effects of epidural administration of methadone, ropivacaine 0.75% and their combination in isoflurane anaesthetized dogs. Vet Anaesth Analg 2011; 38: 146-157.
• 4 Campoy L, Martin-Flores M, Looney AL. et al. Distribution of a lidocaine methylene blue solution staining in brachial plexus, lumbar plexus and sciatic nerve blocks in the dog. Vet Anaesth Analg 2008; 35: 348-354.
• 5 Campoy L. Fundamentals of Regional Anaesthesia Using Nerve Stimulation in the Dog. In: Recent Advances in Veterinary Anesthesia and Analgesia: Companion Animals [e-book]. Gleed RD, Ludder JW. eds. Ithaca (NY, USA): International Veterinary Information Service; Letzte Aktualisierung 16. April 2008. [zitiert am 15.12.2015]. Zugang: http://www.ivis.org/advances/Anesthesia_Gleed/campoy/chapter.asp
• 6 Campoy L, Bezuidenhout AJ, Gleed RD. et al. Ultrasound-guided approach for axillary brachial plexus, femoral nerve, and sciatic nerve blocks in dogs. Vet Anaesth Analg 2010; 37: 144-153.
• 7 Campoy L, Martin-Flores M, Ludders JW. et al. Comparison of bupivacaine femoral and sciatic nerve block versus bupivacaine and morphine epidural for stifle surgery in dogs. Vet Anaesth Analg 2012; 39: 91-98.
• 8 Caniglia AM, Driessen B, Puerto DA. et al. Intraoperative antinociception and postoperative analgesia following epidural anesthesia versus femoral and sciatic nerve blockade in dogs undergoing stifle joint surgery. J Am Vet Med Assoc 2012; 241: 1605-1612.
• 9 Gorgi AA, Hofmeister EH, Higginbotham MJ. et al. Effects of body position on cranial migration of epidurally injected methylene blue in recumbent dogs. Am J Vet Res 2006; 67: 219-221.
• 10 Davies AF, Segar EP, Murdoch J. et al. Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth 2004; 93: 368-374.
• 11 Durant PA, Yaksh TL. Drug effects on urinary bladder tone during spinal morphine-induced inhibition of the micturition reflex in unanesthetized rats. Anesthesiology. 1988; 68 (03) 325-334.
• 12 Echeverry DF, Gil F, Laredo F. et al. Ultrasound-guided block of the sciatic and femoral nerves in dogs: A descriptive study. Vet J 2010; 186: 210-215.
• 13 Echeverry DF, Laredo FG, Gil F. et al. Ventral ultrasound-guided suprainguinal approach to block the femoral nerve in the dog. Vet J 2012; 192: 333-337.
• 14 Fowler SJ, Symons J, Sabato S. et al. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth 2008; 100: 154-164.
• 15 Gaynor JS, Dunlop CI, Wagner AE. et al. Complications and mortality associated with anesthesia in dogs and cats. J Am Anim Hosp Assoc 1999; 35: 13-17.
• 16 Goodchild CS, Serrao JM. Cardiovascular effects of propofol in the anaesthetized dog. Br J Anaesth 1989; 63: 87-92.
• 17 Grant CRK, Checketts MR. Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia. Continuing Education in Anaesthesia. Crit Care Pain 2008; 8: 56-61.
• 18 Haberman CE, Kang CW, Morgan JD. et al. Evaluation of oscillometric and Doppler ultrasonic methods of indirect blood pressure estimation in conscious dogs. Can J Vet Res 2006; 70: 211-217.
• 19 Iff I, Moens Y. Two cases of bradyarrhythmia and hypotension after extradural injections in dogs. Vet Anaesth Analg 2008; 35: 265-269.
• 20 Klein SM, Evans H, Nielsen KC. et al. Peripheral nerve block techniques for ambulatory surgery. Anesth Analg 2005; 101: 1663-1676.
• 21 Laur JJ, Weinberg GL. Comparing safety in surface landmarks versus ultrasound-guided peripheral nerve blocks: an observational study of a practice in transition. Reg Anesth Pain Med 2012; 37: 569-570.
• 22 Lee I, Yamagishi N, Oboshi K. et al. Distribution of new methylene blue injected into the lumbosacral epidural space in cats. Vet Anaest Analg 2004; 31: 190-194.
• 23 Lemke KA, Dawson SD. Local and Regional Anesthesia. Vet Clin North Am Small Anim Pract 2000; 30: 839-857.
• 24 Luyet C, Constantinescu M, Waltenspül M. et al. Transition from nerve stimulator to sonographically guided axillary brachial plexus anesthesia in hand surgery: block quality and patient satisfaction during the transition period. J Ultrasound Med 2013; 32: 779-786.
• 25 Mahler SP, Adogwa AO. Anatomical and experimental studies of brachial plexus, sciatic, and femoral nerve-location using peripheral nerve stimulation in the dog. Vet Anaesth Analg 2008; 35: 80-89.
• 26 Mahler SP. Ultrasound guidance to approach the femoral nerve in the iliopsoas muscle: a preliminary study in the dog. Vet Anaesth Analg 2012; 39: 550-554.
• 27 Naganobu K, Hagio M. The effect of body position on the hanging drop method for identifying the extradural space in anaesthetized dogs. Vet Anaesth Analg 2007; 34: 59-62.
• 28 Portela DA, Otero PE, Tarragona L. et al. Combined paravertebral plexus block and parasacral sciatic block in healthy dogs. Vet Anaesth and Analg 2010; 37: 531-541.
• 29 Portela DA, Otero PE, Briganti A. et al. Femoral nerve block: a novel psoas compartment lateral pre-iliac approach in dogs. Vet Anaesth Analg 2013; 40: 194-204.
• 30 Puggioni A, Arnett R, Clegg T. et al. Influence of patient positioning on the L5–L6 mid-laminar distance. Vet Radiol Ultrasound 2006; 47: 449-452.
• 31 Rawal N, Möllefors K, Axelsson K. et al. An experimental study of urodynamic effects of epidural morphine and of naloxone reversal. Anesth Analg 1983; 62: 641-647.
• 32 Reid J, Nolan AM, Hughes JML. et al. Development of the short-form Glasgow Composite Measure Pain Scale (CMPS-SF) and derivation of an analgesic intervention score. Animal 2007; 16: 97-104.
• 33 Sarotti D, Rabozzi R, Corletto F. Efficacy and side effects of intraoperative analgesia with intrathecal bupivacaine and levobupivacaine: a retrospective study in 82 dogs. Vet Anaesth Analg 2011; 38: 240-251.
• 34 Sawyer DC, Guikema AH, Siegel EM. Evaluation of a new oscillometric blood pressure monitor in isoflurane-anesthetized dogs. Vet Anaesth Analg 2004; 31: 27-39.
• 35 Seidel R, Natge U, Schulz J. [Distal sciatic nerve blocks: Randomized comparison of nerve stimulation and ultrasound guided intraepineural block]. Anaesthesist 2013; 62: 183-192.
• 36 Shilo Y, Pascoe PJ, Cissell D. et al. Ultrasound-guided nerve blocks of the pelvic limb in dogs. Vet Anaesth Analg 2010; 37: 460-470.
• 37 Steffey EP, Howland D. Isoflurane potency in the dog and cat. Am J Vet Res 1977; 38: 1833-1836.
• 38 Torske KE, Dyson DH. Epidural analgesia and anesthesia. Vet Clin North Am Small Anim Pract 2000; 30: 859-874.
• 39 Troncy E, Junot S, Keroack S. et al. Results of preemptive epidural administration of morphine with or without bupivacaine in dogs and cats undergoing surgery: 265 cases (1997–1999). J Am Vet Med Assoc 2002; 221: 666-672.
• 40 Vettorato E, Bradbrook C, Gurney M. et al. Peripheral nerve blocks of the pelvic limb in dogs: A retrospective clinical study. Vet Comp Orthop Traumatol (VCOT) 2012; 25: 314-320.
• 41 Ward RJ, Bonica JJ, Freund FG. et al. Epidural and subarachnoid anesthesia. Cardiovascular and respiratory effects. JAMA 1965; 191: 275-278.