Intraartikulær Lokal bedøvelse Med eller uden binyrebarkhormon

Præsentationer af emnet: "Intraartikulær Lokal bedøvelse Med eller uden binyrebarkhormon"— Præsentationens transcript:

1 Intraartikulær Lokal bedøvelse Med eller uden binyrebarkhormon

2 34500 artroskopier/år + X antal blokader….
Specialevejledning for ortopædisk kirurgi Arthroskopisk kirurgi i knæled fx meniskkirurgi (25.000) Rekonstruktion af forreste korsbånd og andre ligamenter (3.500) Arthroskopisk kirurgi i andre led end knæ- og hofteled (1.500) Artroskopisk operation for afklemningssyndrom i skulderleddet (4.000) Revisionskirurgi på forreste korsbånd (300): Artroskopisk kirurgi i hofteleddet (200):

3 Hvad bruger vi i Region Midt? mini survey

4 Viborg Lidokain med adrenalin 20 ml før og prøver aktuelt  med marcain med adrenalin efter vægt efter, max. 40 ml. Til korsbånd smertekateter i høstningskanal i 2 døgn.

5 Århus 10 ml Marcain 5 mg/ml + 10 ml morfin 0.4 mg/ml til skopier. (adrenalin?) Blokader: Kenalog 40 mg i 10 ml lidokain 1 %.

6 Herning Efter a-skopier 20 ml 0.5 % Marcain + adrenalin
Blokader: 1 ml Depomedrol + 9 ml 0.5 % Marcain

7 Randers Intraarticulært ved a-skopi og ACL: 20 ml Marcain adrenalin 5 mg/ ml + 5 mikrog/ml Blokade i knæ: 10 ml Lidocain1% + Depomedrol 1 ml 40mg/ml

8 Bent Wulff Jakobsen Skopi: Marcain 5 mg/ml 20 ml med noradrenalin 5 ml i subcutis resten i leddet. Ingen Morfin ACL: femoral blokade suppleret med Bupivacain 5 mg/ml 20 ml i subcutis, og donor sted.

9 Horsens Skopi: 20 ml Marcain 2,5 mg/ml med adrenalin 10 ml i leddet og 10 ml i subcutis præoperativt ACL: Fem blok + ovenstående + 20 ml i donerstedet. Blokader: Kenalog 1 ml 40mg + 7 ml Lidocain 1% uden adrenalin Triamcinolonacetonid

10 ”AAOS Now” juni 2010 Raising a ”red flag” on intra-articular injections By Mary Ann Porucznik An interview with Constance R. Chu, MD Pain management, particularly after orthopaedic surgery, continues to be an issue for both surgeons and patients. Recent events—including the proliferation of lawsuits following the use of continuous infusion pain pumps after shoulder surgery—have called into question certain pain management practices.

11 2007 Am J Sports Med Results: 19 shoulders, of 30 with capsular procedures, had intra-articular pain pump catheters filled with bupivacaine and epinephrine. Of these, 12 have been identified with chondrolysis. Conclusion: Use of intra-articular pain pump catheters eluting bupivacaine with epinephrine appear highly associated with postarthroscopic glenohumeral chondrolysis.

12 2009 The Journal of Arthroscopic and Related Surgery Conclusions: Chondrolysis developed in 3 of 16 patients (19%) with glenohumeral joint infusion of 0.5% bupivacaine without epinephrine at 4.16 mL/h for 65 hours. No patient using a 2.08-mL/h reservoir for 48 hours into the glenohumeral joint and no patient with a subacromial infusion device had chondrolysis.

13 2006 The Journal of Arthroscopic and Related Surgery
Cellekultur: Saltvand og 0,5 % Bupivacain Exponering 15 min Måling 60 min The Journal of Arthroscopic and Related Surgery, Vol 22, No 7 (July), 2006: pp Results of flow cytometry of alginate bead cultures treated with 0.5% bupivacaine. Combined results 1 hour after treatment for 15, 30, and 60 minutes.
P
.001 compared with saline-treated controls.

14 2006 The Journal of Arthroscopic and Related Surgery
Cellekultur: 0.5% bupivacaine 15, 30, and 60 min.

15 2006 The Journal of Arthroscopic and Related Surgery
Brusk plugs Saltvand 0,5 % Bupivacain Exponering 30 min % levende bruskceller

16

17 Piper JBJS 2008 Eksponering 30 minutter, prøve efter 24 timer
Celle kultur Monolayer

18 Piper JBJS 2008 Eksponering 30 minutter, prøve efter 24 timer
4 mm brusk plug

19

20 Grishko JBJS 2010 Cellecultur Exponering 1 time C:. saltvand L1:
Grishko JBJS 2010 Cellecultur Exponering 1 time C: saltvand L1: Lidocain 1% L 0,5: Lidocain 0,5% % levende celler B 0,5: Bupivacain 0,5% B 0,25: Bupivacain 0,25% R 0,5: Robivacain 0,5% R 0,2. Robivacian 0,2% Viability of human chondrocytes as determined by flow cytometry analysis at twenty-four hours, seventy-two hours, and 120 hours after exposure to saline solution (C), 1% and 0.5% lidocaine (L) (top panel); 0.5% and 0.25% bupivacaine (B), and 0.5 and 0.2% ropivacaine (R) (bottom panel). The results were obtained from a minimum of seven independent experiments. The shaded bars represent the mean percentage of viable cells, and the I-bars represent the standard error of the mean. An asterisk indicates a significant difference (p < 0.05) between local anesthetic-treated and nontreated chondrocytes.

21 Grishko JBJS 2010 Apoptosis (døende celler) 120 timer (5 dage) efter eksponering i 60 minutter
C: kontrol

22

23 Cellecultur Eksponering 15 min, måling efter 24 timer

24 2010

25

26 C: Diprospan (betametasone) D: Prednisolon E: Diprospan+ Lidocain
Celle cultur Exponering A: Saltvand B: Lidocain C: Diprospan (betametasone) D: Prednisolon E: Diprospan+ Lidocain F: Prednisolon+ Lidocain The results of flow cytometry analysis of chondrocyte cell cultures treated with control phosphate-buffered saline, lidocaine, betamethasone, prednisolone, betamethasone-lidocaine combination, and prednisolonelidocaine combination are shown. The time course changes of apoptotic and necrotic cells upto 24 hours of exposure with respect to the three detection points of 2, 6, and 24 hours are indicated in the X axis. The ratio of the apoptotic or necrotic cells is shown in the Y axis in percent. The bars represent the mean of three independent experiments with standard error as error bars. Results from the various experimental groups were compared with those of the PBS control group. Exact probability values also are shown as p values.

27 A: Lidocain +/- Diprospan B: Marcain +/- Diprospan
Celle cultur Nekrotiske celler A: Lidocain +/- Diprospan B: Marcain +/- Diprospan C: Robivacain +/- Diprospan Fig. 4A–C The ratios of necrotic chondrocytes treated with different local anesthetics alone or in combination with betamethasone are shown. Substantial differences are detectable between administration of (A) lidocaine or lidocaine + betamethasone, (B) bupivacaine or bupivacaine + betamethasone, and (C) ropivacaine or ropivacaine + betamethasone combinations. The X axis represents the exposure time in hours. The Y axis shows the ratio of necrotic chondrocytes in percent. The bars represent the mean of the three independent experiments with standard error as error bars. Results from the various experimental groups were compared with those of the PBS control group. Exact probability values are shown as p values.

28 April 2009

29 Celle cultur Undersøgt efter 24 timer

30 Hvorfor ser vi ikke større skader eller problemer end vi gør?
Der forskel på in vitro og in vivo

31

32 48 rotter Saltvand og 0,5 % Marcain Undersøgt efter 1 , 4, 12 uger og 6 måneder Ingen forskel på celle liv og overfladen, men Efter 6 måneder var Chondrocyt densiteten nedsat med 50 % sammenlignet med saltvand Tyder på toxitet

33 ESSKA 2012

34

35

36

37 Betydning? Skal vi ændre adfærd?
Har vi set skader eller smerter der kan relateres til eftervirkninger til lokalbedøvelse med eller uden adrenalin? Reumatologerne bruger store mængder blokader og hævder at de ikke ser bivirkninger (men deres pt ender ofte med at skulle have en alloplastik). Ved gentagne artroskopier kan ses bruskskader/degeneration, som kan være svære at forklare

38