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Interscalene block [Elektronische Ressource] : a comparison between electrostimulation and ultrasound-guided techniques / by Mohamed Hamed Salem

87 pages
Universitäts- und Rehabilitationskliniken Ulm (RKU) Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie Ärztlicher Direktor: Dr. med. Peter Geiger INTERSCALENE BLOCK A Comparison between Electrostimulation and Ultrasound-Guided Techniques Dissertation Submitted for the obtainment of the Doctoral degree in Medicine from Faculty of Medicine Ulm University By Mohamed Hamed Salem Born in Tripoli, Libya 2009 Amtierender Dekan: Prof. Dr. med. Klaus-Michael Debatin 1.Berichterstatter: Prof. Dr. med. Hans-Hinrich Mehrkens 2.Berichterstatter: Prof. Dr. med. Alexander Brinkmann Tag der Promotion: 17.07.2009 This Work is Dedicated To My Parents, Brothers & Sisters My Wife & Children Index List of Abbreviations 1. Introduction 1 2. Materials and Methods: 6 2.1. Criteria of Inclusion 6 2.2. Criteria of Exclusion 6 2.3. Patient Groups 7 2.4. Anatomical Considerations 7 2.5. Local Anaesthetics 14 2.6. Anaesthetic Procedure 17 2.7. Block Techniques 19 2.8. Endpoints 29 2.9. Statistical Analysis 31 3. Results 32 4. Discussion 47 5. Summary 61 6. References 63 7. Acknowledgement 75 8. Curriculum Vitae 76 List of Abbreviations aft: After. ASA: American Society of Anaesthesiologists.
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Universitäts- und Rehabilitationskliniken Ulm
(RKU)
Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie
Ärztlicher Direktor: Dr. med. Peter Geiger



INTERSCALENE BLOCK

A Comparison between
Electrostimulation and Ultrasound-Guided
Techniques


Dissertation
Submitted for the obtainment of the Doctoral degree in
Medicine

from
Faculty of Medicine
Ulm University



By
Mohamed Hamed Salem

Born in
Tripoli, Libya






2009



































Amtierender Dekan: Prof. Dr. med. Klaus-Michael Debatin
1.Berichterstatter: Prof. Dr. med. Hans-Hinrich Mehrkens
2.Berichterstatter: Prof. Dr. med. Alexander Brinkmann
Tag der Promotion: 17.07.2009












This Work is Dedicated
To My Parents, Brothers & Sisters
My Wife & Children Index
List of Abbreviations
1. Introduction 1
2. Materials and Methods: 6
2.1. Criteria of Inclusion 6
2.2. Criteria of Exclusion 6
2.3. Patient Groups 7
2.4. Anatomical Considerations 7
2.5. Local Anaesthetics 14
2.6. Anaesthetic Procedure 17
2.7. Block Techniques 19
2.8. Endpoints 29
2.9. Statistical Analysis 31
3. Results 32
4. Discussion 47
5. Summary 61
6. References 63
7. Acknowledgement 75
8. Curriculum Vitae 76 List of Abbreviations

aft: After.
ASA: American Society of Anaesthesiologists.
ASAD: Arthroscopic Subacromial Decomprssion.
ASM: Anterior Scalene Muscle.
BMI: Body Mass Index.
C: Cervical.
C/O: Complications.
CA: Carotid Artery.
Cath: Catheter.
Clon: Clonidine.
cm: centimeter.
CN: Cervical Nerve.
CNS: Central Nervous System
CO : Carbon Dioxide. 2
CT: Computer Tomography.
DM: Diabetes Mellitus.
dur: During.
ES: Electrical Stimulation.
Fent: Fentanyl.
G: Gauge.
GA: General Anaesthesia.
h: Hour. Hz: Hertz.
IDDM: Insulin Dependent Diabetes Mellitus.
IJ: Internal Jugular.
ins: Insertion.
ISBPB: Interscalene Brachial Plexus Block.
IV: Intravenous.
Ket: Ketamine.
kg: kilogram.
kHz: kilohertz.
LA: Local Anaesthesia.
LCR: Lateral Clavicular Resection.
mA: milliamper.
mg: milligram.
µg: microgram.
MG: Muscle Grade.
MHz: Megahertz.
min: minutes.
Mid: Midazolam.
ml: milliliter.
mm: millimeter.
MR: Muscle Response.
MRI: Magnetic Resonance Imaging.
m/s: meter per second
ms: millisecond
µsec: microsecond. MSM: Middle Scalene Muscle.
n: Number.
NIDDM: Non Insulin Dependent Diabetes Mellitus.
NS: Nerve Stimulator.
Op: Operation.
ORIF: Open Reduction and Internal Fixation.
PCA: Patient Controlled Analgesia.
pH: Power of Hydrogen Ions.
pKa: Partition coefficient.
PNB: Peripheral Nerve Block.
PNS: Peripheral Nerve Stimulation.
Premed: Premedication.
Prop: Propofol.
RCT: Randomized Controlled Trial.
RFT: Renal Function Tests.
RKU: Rehabilitationskrankenhaus Ulm.
SAM: Scalenus Anterior Muscle
SAS: Statistical Analysis Software.
SCM: Sternocleidomastoid.
SMM: Scalenus Medius Muscle.
St: Satisfaction.
T: Thoracic.
t: Time.
US: Ultrasound.
VAS: Visual Analogue Scale. Introduction

1. Introduction
An ever increasing demand for regional anaesthesia from patients and surgeons
matches the growing realization that regional anaesthesia can provide superior pain
management and perhaps improve patient outcomes to meet evolving expectations for
ambulatory, cost-effective surgery. Our aging population presents with an increasing
range of co-morbidities, demanding a wider choice of surgical anaesthesia options
including the use of a variety of regional techniques in conjugation with general
anaesthesia to optimize clinical care, while at the same time reducing the risks of
complications. Thus, the practice of regional anaesthesia remains an art for many
practitioners and consistent success with these techniques often appears to be limited to
anaesthesiologists who are regional anaesthesia enthusiasts (Tsui, 2007).
With modern anaesthetic techniques, recovery after surgery can be rapid, smooth
and complete. However, in many day-case patients regional anaesthetic techniques might
be preferable. Regional anaesthesia can reduce or avoid the hazards and discomfort of
general anaesthesia including sore throat, airway trauma, and muscle pain, but it also
offers a number of advantages to outpatients undergoing surgery. These techniques
provide analgesia without sedation, prolonged postoperative analgesia and allow earlier
patient’s discharge. Regional anaesthesia reduces the requirements of opioids, reducing
the incidence of postoperative nausea and vomiting. It can be used alone, in combination
with sedation or as a part of balanced analgesia with general anaesthesia (Rawal, 2001).
The ideal in the practice of regional anaesthesia would be the ability to precisely
deliver to the target nerve exactly the right dose of local anaesthetic without incurring any
risk of damage to the nerve or its related structures taking in consideration that nerves are
not blocked by the needle but by the local anaesthetic around. The introduction around
30 years ago of electric stimulation (ES) as an objective means for identifying needle-
nerve proximity was an integral step towards transforming regional anesthesia into a
‘science’ (Peterson et al., 2002).
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