Adjuvants for Peripheral Nerve Blockade A Review of the ：用于外周神经阻滞的综述佐剂.ppt

Adjuvants for Peripheral Nerve Blockade: A Review of the Literature Jonathan Weed, M.D. Disclosures None Reasons to use adjuvants for nerve blocks Increase duration of action Increase speed of onset Increase density or quality of the block Improve overall analgesic effect What’s been tried? Epinephrine Sodium bicarbonate α-agonists (clonidine, dexmedetomidine) Opioids (fentanyl, sufentanil, morphine, buprenorphine, nalbuphine, tramadol) Steroids (dexamethasone, methylprednisolone) Midazolam Neostigmine Verapamil Magnesium Ketamine NSAIDS (ketorolac) Lysine acetylsalicylate And probably many more... Do they work? Epinephrine Mechanism: vasoconstriction via α1-activation reduces blood flow to the nerve, decreasing clearance of the LA and prolonging exposure of the nerve to the LA. Epi has been shown to prolong the duration of PNB anesthesia in many studies, however, much more pronounced with shorter-acting agents: 70% longer duration with Lidocaine 20% longer duration with Bupivacaine or Ropivacaine Other benefits: Decrease systemic absorption: LA plasma levels 30-50% lower with Epi. Most texts list higher acceptable LA doses with addition of epinephrine Can be used as an “intravascular marker” during PNB Epinephrine Dose: 1:200,000 (5 mcg/ml) commonly used for neuraxial, but lower doses recommended for PNB (1:400,000 or 2.5 mcg/ml) Concerns: Systemic “reaction” (ie, tachycardia, anxiety, etc) Decreased PNF may be detrimental. ? increased risk for LA-induced nerve injury? Evidence for this is limited, but reduction in PN blood supply can be significant, and some patients (DM, HTN, smoking) may be more susceptible to injury. Sodium Bicarbonate Increases the nonionized form of LA, speeding onset; but has no effect on block duration. Useful for Lidocaine and mepivacaine, but can cause precipitation when mixed with bupivacaine or ropivacaine Data exists supporting its use for neuraxial blockade, but studies of its use with PNB shows little efficacy.