Efficiency and safety of peripheral regional anesthesia application in urgent traumatology

Abstract

In Ukraine, more than 4.5 million people sustain injuries of varying severity annually, and damage to extremities constitutes 60–65 % in the structure of traumatism. Patients with traumatic limb injuries require effective anesthesia / analgesia at an early stage. An urgent anesthesia should provide a sufficient relaxation of the extremity, adequate operative and postoperative pain management and should be safe for patients of different age groups. Peripheral regional anesthesia meets the requirements indicated, but there are a number of outstanding issues: difficulties in identifying plexuses and nerves, high rate of complications. Neither a larger injection volume of local anesthetic nor plexuses and nerves identification using a neurostimulator solves the problem completely. At the same time, ultrasound-guided nerve block does not have the weaknesses mentioned and its use is increasingly covered in literature.

The purpose of this work is to analyze the effectiveness and safety of the ultrasound-guided nerve block of the extremities in urgent traumatology.

Material and methods. Cases of isolated mechanical traumatic injuries of the limbs in patients who were at the clinical base of the Department of Disaster Medicine, Military Medicine, Anesthesiology and Intensive Care of Zaporizhzhia State Medical University from 2016 to 2018 were analyzed. The average age of the trauma patients was 62.5 (47.0; 82.5) years with a body weight of 78.7 (64.3; 94.6) kg. All the patients underwent ultrasound-guided nerve block using an ultrasound device Logiq E with a standard 12 MHz linear array transducer or the “classical” method (anatomical landmark and paraesthesia technique of plexus location). Anesthesia was performed with 0.5 % bupivacaine at a dose of 1–2 mg/kg. Analgesia was performed with a solution of propofol at 1.5–2.0 mg/kg /h with the addition of ketamine at 1–2 mg/kg/h in case of need. The level of analgesia was evaluated on the Ramsay sedation scale. The study analyzed the duration of plexus and nerves location, block onset time, the duration of motor and sensory block; hemodynamics monitoring with the help of UM-300 monitor at the study stages; complications were recorded. Statistical analysis of the data included descriptive statistics methods. When the values did not follow a normal distribution, these data were expressed as a median (lower quartile; higher quartile). Mann-Whitney U test was used to compare variables; the categorical data were analyzed by Chi-square test with Yates correction and Fischer's exact test. In all statistical calculations, P < 0.05 was the level of significance. Data processing was performed using Statistica 10.0 software.

Results. The ultrasound-guided method of plexus and nerves location was faster than the “classical” method by paresthesia (3.8 (2.8; 4.3) min and 7.2 (4.2; 9.4) min, respectively; P = 0.001). But the method of plexus and nerves location did not influence the block onset time and the motor and sensory block duration. However, the level of analgesia in patients with ultrasound-guided nerve block (according to the Ramsay sedation scale) at the III and IV study stages was lower than in those with the “classical” method by paresthesia (3.2 (2.4; 3.7 ) and 5.4 (3.8; 5.7) points, respectively; P = 0.027), indicating a greater efficiency of ultrasound-guided plexus and nerve sensory block. The absence of statistically significant changes in hemodynamic parameters at the study stages indicated an effective intraoperative analgesia in patients with ultrasound-guided nerve block which was complicated in 6 cases (6.0 %). But the “classical” method of plexus and nerve block by paresthesia was complicated in 16 cases (32.0 %). Therefore, the ultrasound-guided method of plexus and nerve block was safer.

Thus, it can be concluded that ultrasound-guided location of plexuses and nerves was faster than paresthesia method (3.8 (2.8; 4.3) min and 7.2 (4.2; 9.4) min, respectively; P = 0.001) in urgent traumatology. The sensory block in patients according to the analgesia level on the Ramsay sedation scale at the III and IV study stages was lower as compared to the “classical” method by paresthesia (3.2 (2.4; 3.7) and 5,4 (3.8; 5,7) points, respectively, indicating a more effective ultrasound-guided block of plexuses and nerves. Ultrasound-guided block was effective for intraoperative analgesia based on hemodynamic parameters in urgent traumatology. The method of ultrasound-guided block of plexuses and nerves was safer (6.0 % of complications versus 32.0 % when using the “classical” method by paresthesia).