Perioperative Peripheral Nerve Injuries A Retrospective Study of 380,680 Cases during a 10-year Period at a Single Institution Anesthesiology, V 111, No 3, Sep 2009 主講人 : 黃水元 醫師

Introduction 造成 peri-operative peripheral nerve injury 的原因 : -- patient comorbidities, positioning, surgical conditions, direct trauma 造成 nerve injury 的 病理機制 : -- stretch, compression, ischemia, metabolic/environmental abnormalities

Goals of the present study To determine whether injury is associated with preexisting patient characteristics To determine whether injury is associated with the type of anesthetic technique or surgical specialty To determine the 10-yr frequency of peri-operative peripheral neuropathies

Materials and Methods Definition of peri-operative peripheral nerve injury : new (within 48 h) sensory and/or motor deficit in any patient who had been sedated or anesthetized Injuries as a result of the surgical procedure itself were excluded Tertiary care university hospital from May 1997 to May 2007.

Results Total of 380,680 surgeries ; over a 10-yr period 480 cases of potential perioperative peripheral nerve injuries Actually total of 112 perioperative peripheral nerve injuries mean age : 46 yr (13 ~ 86 yr) Men : women = 54% : 46%

upper extremity > lower extremity

Sensory > motor

Discussion

Disease Associated with Nerve Injuries DM, HTN, and tobacco use were associated with perioperative nerve injury Diabetes : -- a known cause of chronic neuropathy and vascular disease. Hypertension : -- a chronic disease process that affects blood flow, and may leave the nerve more susceptible to injury.

Ulnar Neuropathy It was found to be a risk factor in the development of ulnar neuropathy and lower extremity neuropathy in the lithotomy position. Especially patients with heavy sedation. Conscious patients should retain more of their protective reflexes and be able to reposition themselves.

Possible Mechanism of Nerve Injuries Mechanism of nerve injury to an anesthetized patient -- Ischemia , infarct Patients with already compromised vasculature (ex. PAOD.) will be more susceptible to perioperative injury. The use of pneumatic tourniquets has been associated with perioperative neuropathy in two previous studies.

Which Surgical Services Distribution of the location of injuries : -- upper extremity > lower extremity CVS surgery has a high incidence of nerve injury : -- median sternotomy leading to brachial plexus injuries -- hypothermia and hemodynamic changes during bypass -- internal jugular vein cannulation, internal mammary artery dissection GS, Ortho, and NS were also found to be associated with injury

This is the largest number of consecutive patients ever reviewed for all types of perioperative peripheral nerve injuries. The 10-yr frequency of perioperative peripheral nerve injuries : -- 0.03% ( 112/380,680 ) perioperative peripheral nerve injuries also noted in children : -- 6 nerve injuries occurred in children

Conclusion Higher risk of perioperative peripheral nerve injuries : -- metabolic syndrome : Hypertension, DM -- tobacco use -- vascular disease Surgical services (CVS, GS, Ortho, NS), general anesthesia and epidural anesthesia were also uniquely noted to have associations.

Conclusion Management : -- perioperative anesthetic care, -- proper positioning, -- adequate padding -- intermittent massage

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