Introduction
L’anesthésie locorégionale s’est pratiquée d’abord sur la base de repères anatomiques de surface et sur la recherche de paresthésies qui témoignaient du contact entre l’aiguille et le nerf [1, 2] : « No paresthesia, no anesthesia » disaient nos aînés [3].
Certains progrès ont accompagné l’avènement de la neurostimulation : des impulsions électriques appliquées à l’extrémité d’une aiguille positionnée près d’un nerf déclenchent le passage d’un influx nerveux et une réponse musculaire spécifique du nerf concerné [4, 5]. À l’aide d’une stimulation électrique d’intensité donnée, le praticien se fie à la réponse motrice pour évaluer la distance entre l’aiguille et le nerf. L’utilisation de l’échographie a démontré que les relations entre intensité électrique, position de l’aiguille et réponse musculaire n’étaient pas aussi simples qu’on le croyait : la disparition d’une réponse musculaire lorsque le praticien diminue l’intensité de la stimulation (0,3 à 0,5 mA) ne signifie pas nécessairement que l’aiguille se situe à l’extérieur du nerf ; a contrario, l’aiguille peut être positionnée dans le nerf sans qu’il y ait de réponse motrice, et ceci, même sous forte stimulation du nerf (> 1,5 mA) [6, 7].
Ces deux techniques « à l’aveugle » présentaient donc des désavantages majeurs : impossibilité de confirmer le placement correct de l’aiguille et, par conséquent, risque de ponction et de lésion nerveuse, multiples tentatives inconfortables, voire douloureuses pour les patients, procédures longues et retards des programmes opératoires [6, 8].
• distinguer entre une injection extra- et intraneurale [9–11] ;
• distinguer entre une injection extra- et intravasculaire [12] ;
• améliorer le taux de succès des blocs locorégionaux [13–16] ;
• accélérer la vitesse d’installation et la durée du bloc [17, 18] ;
• diminuer le temps de la procédure [19, 20] ;
• diminuer les besoins en anesthésiques locaux [21–24] ;
• diminuer le taux de complications locales et systémiques [22, 25, 26] ;
Références
[1] De Jong, R. H. Axillary block of the brachial plexus. Anesthesiology. 1961; 22:215–225.
[2] Winnie, A. P. Interscalene brachial plexus block. Anesth Analg. 1970; 49:455–466.
[3] Moore, D. C. Regional Block : A Handbook for Use in the Clinical Practice of Medicine and Surgery. Springfield, Il: Thomas, 1979; 83.
[4] Montgomery, S. J., Raj, P. P., Nettles, D., Jenkins, M. T. The use of the nerve stimulator with standard unsheathed needles in nerve blockade. Anesth Analg. 1973; 52:827–831.
[5] Smith, B. L. Efficacy of a nerve stimulator in regional analgesia ; experience in a resident training programme. Anaesthesia. 1976; 31:778–782.
[6] Tsai, T. P., Vuckovic, I., Dilberovic, F., et al. Intensity of the stimulating current may not be a reliable indicator of intraneural needle placement. Reg Anesth Pain Med. 2008; 33:207–210.
[7] Robards, C., Hadzic, A., Somasundaram, L., et al. Intraneural injection with low-current stimulation during popliteal sciatic nerve block. Anesth Analg. 2009; 109:673–677.
[8] Selander, D., Edshage, S., Wolff, T. Paresthesiae or no paresthesiae ? Nerve lesions after axillary blocks. Acta Anaesthesiol Scand. 1979; 23:27–33.
[9] Bigeleisen, P. E. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury. Anesthesiology. 2006; 105:779–783.
[10] Chan, V. W., Brull, R., McCartney, C. J., Xu, D., Abbas, S., Shannon, P., et al. An ultrasonographic and histological study of intraneural injection and electrical stimulation in pigs. Anesth Analg. 2007; 104:1281–1284. [tables of contents].
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[17] Marhofer, P., Schrogendorfer, K., Koinig, H., Kapral, S., Weinstabl, C., Mayer, N. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg. 1997; 85:854–857.
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[21] Casati, A., Baciarello, M., Di Cianni, S., et al. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth. 2007; 98:823–827.
[22] Riazi, S., Carmichael, N., Awad, I., Holtby, R. M., McCartney, C. J. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008; 101:549–556.
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