Periphere Regionalanästhesieverfahren – Standards im Wandel?!

In der peripheren Regionalanästhesie gibt es einige aktuelle Entwicklungen – basierend auf Diskussionen bei Fachveranstaltungen und Anfragen an den Arbeitskreis Regionalanästhesie der DGAI stellt dieser Beitrag sie dar. Relevante Themen sind u. a. die Handhabung antithrombotischer Medikation bei peripheren Blockaden, der Entlasszeitpunkt nach Plexusanästhesien sowie periphere Nervenblockaden unter Allgemeinanästhesie und in der Notfallmedizin.

Abstract

This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA.

Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances.

Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques.

Kernaussagen

• Für oberflächliche periphere Nervenblockaden gibt es keine Einschränkungen unter antithrombotischer Medikation.

• Rebound Pain ist eine mittlerweile besser verstandene Schmerzmodalität nach abklingender Nervenblockade. Dexamethason scheint eine protektive Wirkung zu haben.

• Das Mischen von kurz- und langwirksamen Lokalanästhetika für periphere Blockaden verbessert nicht die Anschlagzeit und bewirkt eine intermediäre Wirkdauer.

• Präklinische Nervenblockaden sind bisher noch schlecht untersucht, eine Durchführung außerhalb von Studien wird nicht empfohlen.

• Nervenblockaden zur Schmerzreduktion oder vor Gelenkreposition in der Notaufnahme sind effektiv und risikoarm.

Schlüsselwörter

periphere Regionalanästhesie - Standards - Analgosedierung - präklinische Analgesie - Lokalanästhetika

Keywords

peripheral regional anesthesia - standards - analgosedation - prehospital analgesia - local anesthetics

Publication History

Article published online:
21 March 2024

• Literatur

• 1 Steinfeldt T, Marx A, Dauster M. Alte und neue Regionalanästhesieverfahren unter Review – Kopf bis Bauch. Anästhesiol Intensivmed Notfallmed Schmerzther 2024; 59: 138-158
• 2 Kessler P. Alte und neue Regionalanästhesieverfahren unter Review – Bauch bis Fußzeh. Anästhesiol Intensivmed Notfallmed Schmerzther 2024; 59: 159-179
• 3 Kietaibl S, Ferrandis R, Godier A. et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesth 2022; 39: 100-132 DOI: 10.1097/eja.0000000000001600. (PMID: 34980845)
• 4 Waurick K, Zarbock A, Gogarten W. et al. S1-Leitlinie Rückenmarksnahe Regionalanästhesien und Thrombembolieprophylaxe/antithrombotische Medikation. 3. überarbeitete Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). 2021. AWMF-Register-Nr.: 001–005. Accessed January 30, 2024 at: https://register.awmf.org/de/leitlinien/detail/001–005
• 5 Working Party: Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists’ Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation: the Association of Anaesthetists of Great Britain & Ireland The Obstetric Anaesthetists’ Association Regional Anaesthesia UK. Anaesthesia 2013; 68: 966-972 DOI: 10.1111/anae.12359. (PMID: 23905877)
• 6 Steinfeldt T, Kessler P, Vicent O. et al. Periphere Rumpfwandblockaden – Übersicht und Bewertung. Anaesthesist 2020; 69: 860-877 DOI: 10.1007/s00101-020-00809-3.
• 7 Wiesmann T, Schubert A-K, Dinges H-C. et al. S1-Leitlinie: Regionalanästhesie bei ambulanten Patienten – Empfehlungen zur Durchführung. Anästh Intensivmed 2021; 62: 267-276 DOI: 10.19224/ai2021.267.
• 8 Kwon H-J, Kim YJ, Lee D. et al. Factors Associated with rebound pain after patient-controlled epidural analgesia in patients undergoing major abdominal surgery. Clin J Pain 2022; 38: 632-639 DOI: 10.1097/ajp.0000000000001067. (PMID: 36037091)
• 9 Barry GS, Bailey JG, Sardinha J. et al. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery. Br J Anaesth 2021; 126: 862-871 DOI: 10.1016/j.bja.2020.10.035. (PMID: 33390261)
• 10 Williams BA, Bottegal MT, Kentor ML. et al. Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Reg Anesth Pain Med 2007; 32: 186-192 DOI: 10.1016/j.rapm.2006.10.011. (PMID: 17543812)
• 11 Sort R, Brorson S, Gögenur I. et al. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study. Acta Anaesthesiol Scand 2018; 63: 396-402 DOI: 10.1111/aas.13290. (PMID: 30411313)
• 12 Streb T, Schneider A, Wiesmann T. et al. [Rebound pain – from definition to treatment]. Anaesthesiologie 2022; 71: 638-645 DOI: 10.1007/s00101-022-01120-z. (PMID: 35513729)
• 13 Schubert A, Wiesmann T, Volberg C. et al. Rebound pain and postoperative pain profile following brachial plexus block compared to general anaesthesia – An observational study. Acta Anaesthesiol Scand 2023; 67: 1414-1422 DOI: 10.1111/aas.14318. (PMID: 37642227)
• 14 Walker BJ, Long JB, Sathyamoorthy M. et al. Complications in pediatric regional anesthesia. Anesthesiology 2018; 129: 721-732 DOI: 10.1097/aln.0000000000002372. (PMID: 30074928)
• 15 Steinfeldt T, Schwemmer U, Volk T. et al. Nerve localization for peripheral regional anesthesia. Recommendations of the German Society of Anaesthesiology and Intensive Care Medicine. Anaesthesist 2014; 63: 597-602 DOI: 10.1007/s00101-014-2343-6. (PMID: 25052719)
• 16 Barrington MJ, Watts SA, Gledhill SR. et al. Preliminary Results of the Australasian Regional Anaesthesia Collaboration. Reg Anesth Pain Med 2009; 34: 534-541 DOI: 10.1097/aap.0b013e3181ae72e8. (PMID: 19916206)
• 17 Kubulus C, Schmitt K, Albert N. et al. Awake, sedated or anaesthetised for regional anaesthesia block placements?. Eur J Anaesthesiol 2016; 33: 715-724 DOI: 10.1097/eja.0000000000000495. (PMID: 27355866)
• 18 Schnorr C, Menges T, Hempelmann G. Lokalanästhetika-Mischungen bei verschiedenen Verfahren der Regionalanästhesie. Anästhesiol Intensivmed Notfallmed Schmerzther 1990; 25: 193-197 DOI: 10.1055/s-2007-1001047.
• 19 Moore DC, Bridenbaugh LD, Bridenbaugh PO. et al. Does compounding of local anesthetic agents increase their toxicity in humans?. Anesth Analg 1972; 51: 579-585 (PMID: 5064792)
• 20 Booke H, Booke M. Lokalanästhetika: Zwei sind eines zu viel. Anaesthesist 2020; 69: 596-596 DOI: 10.1007/s00101-020-00816-4. (PMID: 32761521)
• 21 Zink W, Steinfeldt T, Wiesmann T. Lokalanästhetika – mischen oder nicht?. Anaesthesist 2020; 69: 597-598 DOI: 10.1007/s00101-020-00818-2. (PMID: 32761522)
• 22 Wiesmann T, Schubert A-K, Volk T. et al. S1-Leitlinie: Prävention & Therapie der systemischen Lokalanästhetika-Intoxikation (LAST). Aktualisierte Handlungsempfehlungen der DGAI. Anästh Intensivmed 2020; 61: 225-238 DOI: 10.19224/ai2020.225.
• 23 Munson ES, Paul WL, Embro WJ. Central-nervous-system toxicity of local anesthetic mixtures in monkeys. Anesthesiology 1977; 46: 179-183 DOI: 10.1097/00000542-197703000-00004. (PMID: 402868)
• 24 Gadsden J, Hadzic A, Gandhi K. et al. The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene block. Anesth Analg 2011; 112: 471-476 DOI: 10.1213/ane.0b013e3182042f7f. (PMID: 21156983)
• 25 Laur JJ, Bayman EO, Foldes PJ. et al. Triple-blind randomized clinical trial of time until sensory change using 1.5% mepivacaine with epinephrine, 0.5% bupivacaine, or an equal mixture of both for infraclavicular block. Reg Anesth Pain Med 2012; 37: 28-33 DOI: 10.1097/aap.0b013e318236bc30. (PMID: 22157740)
• 26 Sripriya R, Sivashanmugam T, Rajadurai D. et al. Equal mixture of 2% lidocaine with adrenaline and 0.5% bupivacaine 20 mL provided faster onset of complete conduction blockade during ultrasound-guided supraclavicular brachial plexus block than 20 mL of 0.5% bupivacaine alone: a randomized double-blinded clinical trial. Reg Anesth Pain Med 2023; DOI: 10.1136/rapm-2023-104542. (PMID: 37295795)
• 27 Gunjiyal MS, Mohammed S, Bhatia P. et al. Effect of combined versus sequential injection of 2% lidocaine and 0.5% bupivacaine on the onset and duration of supraclavicular brachial plexus block: A double blinded randomised controlled trial. J Clin Anesth 2021; 72: 110313 DOI: 10.1016/j.jclinane.2021.110313. (PMID: 33905902)
• 28 Schubert A-K, Wiesmann T, Dinges H-C. Measures to prolong duration of sensory block after regional anaesthesia. Curr Opin Anaesthesiol 2023; 36: 103-108 DOI: 10.1097/aco.0000000000001204. (PMID: 36326074)
• 29 Gros T, Hatterer E, Plasse C. et al. [Iliofascial block in prehospital care]. Ann Fr Anesth Reanim 1999; 18: 282-283 (PMID: 10207607)
• 30 Lopez S, Gros T, Bernard N. et al. Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003; 28: 203-207 DOI: 10.1097/00115550-200305000-00006. (PMID: 12772137)
• 31 Fichtner A, Schrofner-Brunner B, Magath T. et al. Regional anesthesia for acute pain management in pre-hospital and in-hospital emergency medicine. Dtsch Arztebl Int 2023; 120: 815-822 DOI: 10.3238/arztebl.m2023.0221. (PMID: 37850298)
• 32 Wolmarans M, Albrecht E. Regional anesthesia in the emergency department outside the operating theatre. Curr Opin Anaesthesiol 2023; 36: 447-451 DOI: 10.1097/aco.0000000000001281. (PMID: 37314169)
• 33 Büttner B, Mansur A, Kalmbach M. et al. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial. PLoS One 2018; 13: e0199776 DOI: 10.1371/journal.pone.0199776. (PMID: 29965991)
• 34 Raatiniemi L, Magnusson V, Hyldmo PK. et al. Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64: 1038-1047 DOI: 10.1111/aas.13600. (PMID: 32270488)
• 35 Christiansen TG, Nielsen R. Reduction of shoulder dislocations under interscalene brachial blockade. Arch Orthop Trauma Surg 1988; 107: 176-177 DOI: 10.1007/bf00451598. (PMID: 3382337)
• 36 Gawel RJ, Grill R, Bradley N. et al. Ultrasound-guided peripheral nerve blocks for shoulder dislocation in the emergency department: a systemic review. J Emerg Med 2023; 65: e403-e413 DOI: 10.1016/j.jemermed.2023.05.021. (PMID: 37741738)
• 37 Exsteen OW, Svendsen CN, Rothe C. et al. Ultrasound-guided peripheral nerve blocks for preoperative pain management in hip fractures: a systematic review. BMC Anesthesiol 2022; 22: 192 DOI: 10.1186/s12871-022-01720-7. (PMID: 35729489)
• 38 Guay J, Kopp S. Peripheral nerve blocks for hip fractures in adults. Cochrane Database Syst Rev 2020; (11) CD001159 DOI: 10.1002/14651858.cd001159.pub3. (PMID: 33238043)