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comment je prolonge mon bloc : gros bolus, kt, adjuvants

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o! Ambulatoire : douleur modérée à sévère à 24h : 30 %
McGrath B, Elgendy H, Chung F. Can J Anaesth. 2004
o! Gestion du rebon douloureux
McCartney C, Brull R, Chan W. Anesthesiology 2004
COMMENTJEPROLONGEMONBLOC
GROSBOLUS–KT–ADJUVANT
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ANFAR 2008
Indications :
Femoral
Interscalenique
Sciatique
PLUSSIMPLESOUSECHOGUIDAGE
Echoguidage
Efficace
Rapiditémiseenplace
Confort
Réduc'ondesrisquesdeponc'onsvasculaire
SwensonJ,BayN,LooseE.AnesthAnalg2006
MarianoER,LolandVJ,SandhuNS.JUltrasoundMed.2010
MarianoER,ChengGS,ChoyLP.RAPM2009
MarianoER,LolandVJ,SandhuNS.JUltrasoundMed.2009
MarianoER,LolandVJ,BellarsRH.JUltrasoundMed.2009
Matérieldédié
Réduc'ondesfuites
Réduc'ondéplacement
TsuiBC,IpVH.BrJAnaesth.2014
LuyetC,RomanSeilerR.RAPM2011
ADJUVANTS:LEQUELCHOISIR
CLONIDINE
DEXMEDETOMIDINE
DEXAMETHASONE
BUPRENORPHINE
EXPAREL®
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DEXAMETHASONE
Author
Dexa
LA
Block
Total/P-IV
Result
DesmetM
BJA2013
10mg
Ropi0,5%
30ml
Interscalen
144/49/49
IV=PN
Fredrickson
RAPM2013
8mg
Bupiv0,5%
30ml
Scia'c
Ankle
126/61/65
IV=PN
RahangdaleR
AA-2014
8mg
Bupiv0,5%
30ml
Scia'c
80/27/26
IV=PN
KawanishiR
LRA-2104
4mg
Ropi0,75%
20ml
Interscalen
34/12/10
PN>IV
AbdallahFW
RAPM2015
8mg
Bupiv0,5%
30ml
Supraclavicular
75/25/25
IV=PN
DawsonRL
Anaesthesia2016
8mg
Ropi0,75%
30ml
Ankle
90/30/30
IV=PN
LeurcharusmeeP
RAPM2016
5mg
lido1%-bupiv0.25%
35ml
Infraclavicular
150/75/75
PN>IV
RosenfeldDM
Anaesthesia2016
8mg
Ropi0.5%
30ml
Interscalene
120/42/37
IV=PN
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DEXAMETHASONE
RAPM2013
Insummary,comparedwithsystemicadministra'on,perineuraldexamethasonehadonlya
minoreffectonthedura'onandanalgesiceffec'venessofbupivacainescia'candankleblocks
DEXAMETHASONE
RAPM2013
Insummary,comparedwithsystemicadministra'on,perineuraldexamethasonehadonlya
minoreffectonthedura'onandanalgesiceffec'venessofbupivacainescia'candankleblocks
DEXAMETHASONE
IntraVeineux
ü 
IV=Perinerveux
DesmetM,BraemsH,ReynvoetM.BJA2013
AbdallahFW,JohnsonJ,ChanV.RAPM2015
1,5mg<<2,5mg<10mg
DesmetM,VannesteB,ReynvoetM.Anesthesia2015
Perinerveux:Pasd’effetdose
ü 
4vs8mg
TandocMN,FanL,KolesnikovS.JAnesth.2011
LiuJ,RichmanKA,GrodofskySR.JClinAnesth.2015
1vs2vs4
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EXPAREL
ü Sécurité
6étudesprospec'vesrandomisés–335pa'entsrecevantExparel
Liposomebupivacaine:similarsafetyprofiletobupivacaineHClandnormalsaline
Liposomebupivacaineisnotcurrentlyindicatedforuseinperipheralnerveblocks
andmustbeconsideredexperimentalatthis'me.
IlfeldB,ViscusiE,HadzicA.RAPM2015
Efficacité
ü 
Blocfémoralbilatéral–Bupivacaineliposomale(0-80mg)
Efficacedosesélevée
Grandevariabilité
IlfeldBM,MalhotraN,FurnishT.AnesthAnalg.2013
COMMENTJEPROLONGEMONBLOC
GROSBOLUS
Inadaptéàl’analgésiedelonguedurée
CATETHERS
Efficace
Simplifié:echo–matérieladapté
Analgésiemodulable:temps–intensité
ADJUVANTS
Dexamethasone
Simple
Efficacejusqu’à24–30heures
POURQUOIJEPROLONGE
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BLOCS COMBINES
BJA2011
62pa'ents:elec'vewristandhandsurgery
42mlinfraclavicularlidocaine+ropivacaine
30mlinfraclavicularlidocaine+ropivacaine
+12mlmedian,radial,andulnar
MotorandSensoryscore:
Op'mumapproachtoanaesthesia/analgesiaforwristandhandsurgery:
Short-acPngbrachialplexusblock+Long-acPngdistalblocks
Acceleratedblockonset'me==>logis'cimportance
Facilitatesthegoalsoftourniquetanalgesia
Surgicalanaesthesia
Prolongedpostopera'veanalgesia
Accelera'ngtheearlyreturnofupperarmmotorfunc'on
3:Maximum
0:absent
New
Outcomes
BLOCS DISTAUX
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BLOCS DISTAUX
125 patients
20 mois
Chirurgie main et poignet
Bloc axillaire + Tronculaires
BLOCS DISTAUX
Association d’un bloc chirurgical de courte durée
d’action et d’un bloc analgésique de longue durée
d’action pour la chirurgie du pied
O Rontes – SFAR 2012
Sédation per-opératoire (%)
0%
Durée bloc moteur (min)
480 min (300-1380)
Durée bloc sensitif (min)
2005 min (1005-3000)
EVS post-opératoire maximale sur 36 h
1 (0-5)
Reprise déambulation à la levée bloc moteur (%)
100 %
Lésion neurologique à J+15
O
LESECOURS
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CONCLUSION
1-AdjuvantsetCathétersnes’opposentpas
2-Envisagerlatechniqueidéale
Chirurgie
Pa'ent Douleurchronique
Traitementantalgique
Traitementan'dépresseur
Programmeréhabilita'on
3-Blocsdistaux
4-EvaluersespraPques
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