„Dual Guidance“? – kombinierte Anwendung von Ultraschall und Nervenstimulator – Contra

Zusammenfassung

Die Sonografie ist eine hochgradig vom Anwender abhängige Technik. Sie setzt ein erhebliches Maß an sonoanatomischen und sonografischen Kenntnissen voraus und verlangt gute Fertigkeiten des Untersuchers. Sie ermöglicht die Identifikation des Punktionsziels, die Beobachtung des Kanülenvorschubs und Beurteilung des Ausbreitungsmusters des Lokalanästhetikums in Echtzeit. Diese Vorteile kann die PNS nicht im selben Maße bieten, sie kann aber die Nervenlokalisation unter schwierigen sonografischen Verhältnissen ermöglichen. Die Kombinationen beider Lokalisierungstechniken ist in der praktischen Umsetzung komplex. Teilweise wird die eine Technik durch die Kombination mit der zweiten sogar erschwert. Die Stimulation parallel zur Sonografie dient in 1. Linie als Warntechnik bei nicht sichtbarer Kanülenspitze. Sie sollte nicht als Kompensationstechnik für mangelnde sonografische Fertigkeiten und Kenntnisse verstanden werden. Sie kann jedoch hilfreich im Sinne eines Bridging sein, sofern sich der Anwender der Limitationen der Technik bewusst ist.

Abstract

Sonography is a highly user-dependent technology. It presupposes a considerable degree of sonoanatomic and sonographic knowledge and requires good practical skills of the examiner. Sonography allows the identification of the puncture target, observes the needle feed and assesses the spread pattern of the local anesthetic in real time. Peripheral electrical nerve stimulation (PNS) cannot offer these advantages to the same degree, but may allow nerve localization under difficult sonographic conditions. The combination of the two locating techniques is complex in its practical implementation. Partially, the use of one location technique is made even more difficult by the combination with the second. PNS in parallel to sonography serves primarily as a warning technology in the case of an invisible cannula tip. It should not be construed as a compensation technique for the lack of sonographic skills or knowledge. However, PNS may be helpful in the sense of a bridging technology as long as the user is aware of its limitations.

Kernaussagen

• Mittels Sonografie können Zielstruktur, Kanülenbewegungen und das Ausbreitungsmuster des Lokalanästhetikums zeitgleich dargestellt werden.

• Die periphere elektrische Nervenstimulation (PNS) ist ein etabliertes und verbreitetes Verfahren. In erfahrenen Händen werden gute Ergebnisse erzielt.

• Die PNS ist im Gegensatz zur Sonografie keine Guidance-, sondern eine Lokalisationstechnik.

• Der Surrogatparameter Kanülen-Nerv-Abstand hat bei der PNS eine große Spannbreite. Fehlende motorische Antworten schließen eine intraneurale Lage nicht aus.

• Das Verteilungsmuster des Lokalanästhetikums kann mittels PNS nicht beurteilt werden.

• Fehlpunktionen benachbarter Organe und Gefäße sind durch die PNS nicht vermeidbar.

• Kombiniert man PNS und Sonografie, wird das Verfahren komplexer, teilweise behindern sich beide Techniken.

• Das Prinzip der PNS, möglichst nahe an den Nerven zu gelangen, widerspricht dem sonografischen Gedanken, eine ausreichende Distanz zum Nerv zu wahren.

• Die Sonografie kann die Limitationen der PNS umgehen.

• Anwenderfehler sonografisch geführter Blockaden können durch die PNS nicht behoben werden. Kann nicht sonografiert werden, sollte stimuliert werden.

• Die PNS könnte als Warntechnik parallel zur Sonografie bei nicht darzustellender Kanüle verwendet werden. Die Zuverlässigkeit ist aber fraglich.

Schlüsselwörter:

periphere elektrische Nervenstimulation (PNS) - Sonografie - sonografisch-gestützte Regionalanästhesie - ultraschallgestützte Regionalanästhesie - kombinierte Anwendung

Key words:

peripheral electrical nerve stimuation (PNS) - sonography - ultrasound guided regional anesthesia - combined use

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