Therapeutic blockade in neurology - Causes, symptoms and treatment. MF.

Since the most common reason for patients to seek medical attention is pain, the doctor's task is not only to establish the cause, but also to eliminate the pain, and if possible, to do it as quickly as possible. There are many ways to treat pain: medication, physiotherapy, massage, manual therapy, acupuncture, etc.

One of the methods of treatment of pain syndrome in the practice of a neurologist is a curative blockade.

The method of therapeutic blockades is the youngest, in comparison with others - medical, surgical, psychotherapeutic and numerous physical methods of treatment, such as massage, acupuncture, manual therapy, traction, etc.

Anesthetic blockades, breaking the vicious circle: pain - muscle spasm -pain, have a pronounced pathogenetic effect on the pain syndrome.

Therapeutic blockade is a modern method of therapy of pain syndrome and other clinical manifestations of diseases, based on the introduction of medicinal substances directly into the pathological focus responsible for the formation of the pain syndrome. Compared with other methods( medication, physiotherapy, massage, manual therapy, acupuncture, etc.), therapeutic blockades are used relatively recently - about 100 years and fundamentally differ from other methods of therapy of pain syndromes.

The main goal of the blockade is to eliminate the cause of the pain, if possible. But an important point is also the fight against pain itself. This fight should be carried out quickly enough, with the least amount of side effects, material and time costs. In other words, quickly and efficiently. It is to these conditions that the blockade method is responsible.

There are several options for blockades.

These are local blockades and are segmented.

Local blockade of is done directly in the affected area, in the zone of altered tissue reaction, under or around the lesion, where there is inflammation, scar, etc. They can be periarticular( into periarticular tissues) and perineural( in the channels where the nerves pass).

Paravertebral blockades are classified as segmental , i.e.in the projection of certain segments of the spine. The variant of such segmental therapy has an explanation. Each segment of the spine and spinal cord corresponds to a specific area of ​​the skin, connective tissue( called dermatitis), muscle( myotome) and a certain "segment" of the bone system( sclerotome).In the segment there is a switching of nerve fibers, so it is possible and cross-influencing. Influencing by intradermal administration of the drug substance in a certain dermatome can affect both the corresponding segment of the spine and the state of the internal organs innervated by this segment of the spinal cord, achieving therapeutic effect. And, conversely, with diseases of internal organs in a certain segment, the corresponding dermatome or myotome can be affected. In accordance with this mechanism, by influencing the myotome or sclerotome, it is possible to achieve a therapeutic effect on the internal organs.

What drugs are used for blockades? Mostly it is local anesthetics( novocaine, lidocaine, etc.) and steroid preparations( diprospan, kenalog, etc.), it is possible to use vascular drugs. Drugs differ from each other in the duration of the effect, in terms of toxicity, in effectiveness, in the mechanism of action. Only a doctor can determine whether the blockade is shown in this case, which drug and which blockade option is preferable.

What is the advantage of the therapeutic blockade method?

• The rapid analgesic effect of

The rapid analgesic effect of blockade is due to the fact that the anesthetic directly reduces the increased impulse mainly on slow conductors of the nervous system, through which chronic pain also spreads. In other methods( electroneurostimulation, acupuncture, and other physical factors), stimulation of mostly fast nervous conductors occurs, which reflexively and indirectly inhibits painful impulses, so the analgesic effect develops more slowly.

• Minimal side effects of

When medication( taking pills or intramuscular injections), medications first enter the total bloodstream( where they are not needed) and only then, in a smaller amount, into a painful focus. When blockade, the medicinal substances are delivered directly to the pathological focus( where they are most needed), and then only in a smaller amount enter the general bloodstream.

• The possibility of repeated use of

Of course, with blockade, the anesthetic only temporarily interrupts painful, pathological impulses, while retaining other types of normal nerve impulses. However, a temporary, but multiple blockade of painful impulse from the pathological focus allows for a pronounced and prolonged therapeutic effect. Therefore, therapeutic blockades can be applied repeatedly, with each exacerbation.

• Complex therapeutic effects of

In addition to the main advantages( rapid anesthesia, minimal toxic effect), therapeutic blockades have a variety of therapeutic effects. They remove for a long time local pathological muscle tension and vascular spasm, inflammatory reaction, edema. They restore the broken trophic of local tissues. Therapeutic blockades, interrupting painful impulses from the pathological focus, lead to the normalization of reflex relationships at all levels of the central nervous system.

Thus, therapeutic blockades are a pathogenetic method of treating clinical manifestations of a number of diseases and pain syndromes. Experience in the use of therapeutic blockades suggests that therapeutic blockades are one of the most effective methods of treating pain syndrome.

However, it must be remembered that therapeutic blockades, like any other method of therapy, especially injecting, is associated with a risk of some complications, has its own indications, contraindications and side effects.

Many years of experience of doctors and a wide experience of other medical institutions shows that complications from blockades of toxic, allergic, traumatic, inflammatory and other character are observed no more often than from usual intramuscular and intravenous injections. High qualification of doctors of the clinic reduces the probability of occurrence of complications from medical blockades to a minimum.

But in any case, the need for this type of treatment is determined only by the doctor.

Indications for the use of therapeutic blockades

The main indication for the use of the method of therapeutic blockade is the pain syndrome caused by osteochondrosis of the cervical, thoracic and lumbar spine, arthralgia, neuralgia, facial and head pains, vertebro-visceralgia, postoperative and phantom pains, plexopathies,pain syndrome, etc. Therapeutic blockades are also used in the Miniera syndrome, myotonic syndrome, trophic limb disorders, tunnel syndromes, etc.

AnesthesiaThe blockade is the same as the diagnostic method ex juvantibus - assessing the effectiveness of the blockade, as a rule, provides substantial assistance to the doctor in setting the right diagnosis, allows us to more fully imagine the ways of forming the pain syndrome, and to determine the sources of its production.

When planning therapeutic interventions with the use of therapeutic blockades, study possible sources of pain syndrome. It is based on disorders in various anatomical structures of the vertebral motor segment:
• intervertebral disc
• posterior longitudinal ligament
• epidural vessels
• spinal nerves
• spinal cord shells
• arcuate joints
• muscles, bones
• ligaments

Innervation of the listedstructures is carried out due to the recurrent( nerve Lyushka) and the posterior branch of the spinal nerve. Both the back and the back branches carry information that later spreads over a sensitive portion of the nerve root in the centripetal direction.

Accordingly, the innervation of the vertebral segment can determine the level of interruption of pathological impulses due to blockade of the nervous branches. From this point of view, the blockades are divided into several groups:

1. Block in the innervation zone of the posterior branch of the spinal nerve
• paravertebral blockades of muscles, ligaments, intraarticular
• paraarticular blockade of the
arched joints • paravertebral blockades of the posterior branches of the spinal nerves during
2. Blockages in the zone of the return branch of the spinal nerve
• intra-disk injections
• epidural blockade of
• selective blockage of spinal nerve
3. A separate group consists of blocks of myotonically stressed muscles of coursetei.

The therapeutic effect of blockades is due to several mechanisms:
• pharmacological properties of anesthetic and concomitant medications
• reflex action at all levels of the nervous system
• effect of maximum drug concentration in the pathological focus, etc.

! !!The main mechanism of the therapeutic effect of blockades is the specific property of the anesthetic to temporarily suppress the excitability of the receptors and conduct impulses along the nerves.

An anesthetic penetrates biological media to nerve fibers, adsorbs on their surfaces, due to interaction with polar groups of phospholipids and phosphoproteins, is fixed on the membrane of the receptor and / or conductor. Anesthetic molecules included in the structure of membrane proteins and lipids enter into competitive interactions with calcium ions and disrupt the exchange of sodium and potassium, which inhibits the transport of sodium through the membrane and blocks the occurrence of excitation in the receptor and carrying it along the nerve fiber.
The degree of action of an anesthetic on nerve fiber depends on one side of the physico-chemical properties of the anesthetic, on the other - on the type of nerve conductor. The anesthetic exerts a predominant influence on those conductors where it binds a large area of ​​the membrane, that is, it blocks first the demyelin, slow fibers - painful and vegetative conductors, then myelin, carrying epicritic pain and, lastly, motor fibers.

To block the excitation of myelinated fibers, an anesthetic should be applied to at least 3 Ranvier interceptions, since neural stimulation can be transmitted through 2 such interceptions.
Selective action of anesthetic on slow conductors creates conditions for normalization of the ratio of painful afferentation over slow and fast fibers.

! !!According to the modern theory of "gate pain control", the main regulation of nociceptive afferentation occurs at the segmental level, the main mechanism of which is that the stimulation of fast fibers inhibits afferentation in slow - "closes the gates."

In pathological conditions, the stimulation of slow fibers predominates, which facilitates afferentation - "opens the gates" and forms a pain syndrome.

There are two ways to influence this process:

1. to stimulate predominantly fast fibers - using percutaneous electroneurostimulation
2. to drive predominantly slow ones - using a local anesthetic.

In conditions of pathology, the second method is preferable, preferential suppression of afferentation over slow fibers, which allows not only to reduce pain afferentation, but also to normalize the relationship between afferent flows along slow and fast conductors at a more optimal physiological level.

! !!The predominant effect on slow-conducting fibers can be achieved by injecting a slightly reduced concentration in the tissue of the anesthetic.

Acting mainly on demyelin-free slow conductors, the anesthetic blocks not only painful afferents, but also demyelinated efferents - primarily vegetative fibers. Therefore, for the duration of the action of the anesthetic and for a long time after complete removal from the body, pathological autonomic responses are reduced in the form of vasospasm, trophic disorders, edema and inflammation. Normalization of afferent flows at the segmental level leads to the restoration of normal reflex activity and at all higher levels of the central nervous system.

The following factors play an important role in achieving the therapeutic effect of blockade:
1. the correct selection of the concentration of an anesthetic sufficient to block the demyelin and blocking myelinated fibers
2. from the accuracy of the anesthetic solution to the receptor or nerve conduitan anesthetic will be delivered to the conductor, the less it will be diluted with interstitial fluid, the lower initial concentration of anesthetic will be sufficient to perform a high-quality blockcadets, the less the risk of toxic complications)

! !!From this point of view, the blockade must in fact be a "sniping prick, that is, the therapeutic blockade must meet the principle -" where it hurts - there. "

When performing the treatment blockade, a characteristic, three-phase change in the pain syndrome is noted:
1) the first phase -exacerbation of the "recognizable pain" that occurs as a result of mechanical irritation of the painful zone receptors upon administration of the first portions of the solution( the duration of the phase corresponds to the latent period of the anesthetic)
2) the second phase is anesthesia,(the duration of this phase corresponds to the duration of the action of the anesthetic in the painful zone)
3) the third phase - the therapeutic effect, when after the end of the anesthetic and removing it from the body, the pain resumes, but on average up to 50% of the initial level of the pain syndrome( the duration of this phase can be from several hours to several days).

Let us turn to the question mentioned above about the application of the blockrows as a diagnostic sredstva. Tselyu diagnostics is the determination of disease areas, which leads provocation palpation pain. As a rule, with several pain syndromes there are several such zones and often the usual methods of diagnosis can be difficult to determine the main focus of pathological irrigation.

In this case, one should focus on the effectiveness of therapeutic blockades. In such a situation, the doctor has an alternative task:
• or to infiltrate several painful points?
• or block one of the most painful?

In the first case - with the blockade of several painful points, the therapeutic dose of medicines will be divided into several points and in the most actual zone their concentration will be insufficient, in addition, the simultaneous absorption of drugs from several points increases their toxic effect. In this case, the diagnostic value of such manipulation is reduced, since blocking of several painful points does not allow to determine the most relevant, taking a primary part in the formation of a specific pain syndrome and does not allow further to purposefully influence this most actual zone.

In the second case, the blockade of one of the most painful zones allows the maximum concentration of drugs in her tissues to be achieved and to minimize the possibility of a toxic reaction. Naturally, this option is more preferable. With the same soreness of several points, they are alternately blocked. On the first day, blockade of one point is made, as a rule, more proximal, and the pain syndrome changes during the day. If the drug solution is injected into the actual painful area, then the patient usually has a phenomenon of "recognizable pain", and later, the pain syndrome regresses not only at the point where the blockade is performed, but also at other painful points. If after the first blockade the phenomenon of "recognizable pain" and the therapeutic effect were not sufficiently expressed, then the next blockade should be performed in another painful zone.

Local anesthetics

Local anesthetics include those drugs that temporarily inhibit receptor excitability and block the impulse conduction through nerve fibers. Most local anesthetics are synthesized on the basis of cocaine and are nitrogenous compounds of two groups - ester( cocaine, dicaine, etc.) and amide( xichain, trimecaine, bupivacaine, ropivacaine, etc.).

Each anesthetic is characterized by several parameters:
• strength and duration of action of
• toxicity of
• latent period and penetration rate in nerve tissue
• strength of fixation to neural tissue
• time and method of inactivation of
• ways of elimination of
• stability in the environmentand to sterilization of

! !!As the concentration increases, the strength of the anesthetic increases approximately in arithmetic, and the toxicity increases exponentially.

The duration of action of a local anesthetic is less dependent on its concentration.

The concentration of anesthetic in the blood essentially depends on the mode of administration of the anesthetic, that is, from what tissues it is injected into. The concentration of anesthetic in the blood plasma is achieved faster when administered intravenously or intraosseously, more slowly - with subcutaneous injection. Therefore, each time when carrying out this or that therapeutic blockade, it is necessary to carefully select the concentration and dose of anesthetic and not to allow its intravascular entry.

For local anesthetics, in addition to the analgesic effect, it is characterized by:
• persistent local over 24 hours vasodilation, it improves microcirculation and metabolism,
• stimulation of reparative regeneration of
• resorption of fibrous and scar tissue, which leads to regress of the local degenerative dystrophic process
• relaxationsmooth and striated muscles, especially when administered intramuscularly( this removes the pathological reflex muscle tension, is eliminated pathologicallye postures and contractures, the normal volume of movements is restored)

Each anesthetic has its own characteristics.

• Procaine( Novocain) is an ethereal anesthetic. It is characterized by minimal toxicity and sufficient strength of action. It is the benchmark in assessing the quality of all other anesthetics. Many authors now prefer novocaine in carrying out, for example, myofascial blockades. They justify their point of view by the fact that novocaine is destroyed mainly in local tissues by pseudocholinesterase, thereby positively affecting the metabolism of these tissues. The main disadvantages of novocaine are frequent vascular and allergic reactions, insufficient strength and duration of action.

• Xylocalaine( lidocaine) is an amide type anesthetic, metabolized mainly in the liver, to a lesser extent excreted in the urine. Xylocain advantageously differs from other anesthetics by a rare combination of positive properties: increased stability in solutions and re-sterilization, low toxicity, high strength of action, good permeability, short latent period of onset of action, pronounced depth of anesthesia, virtually no vascular and allergic reactions. Due to this xylocaine is currently the most commonly used anesthetic.

• Trimecaine( mesocaine) is very similar in chemical structure and action to xylocaine, it is used quite often. It yields xylocaine in all respects to 10-15%, having the same low toxicity and practical absence of vascular and allergic reactions.

• Prilocaine( citrate) is one of the few anesthetics that has less toxicity and about the same duration of anesthesia as xylocaine, but is inferior to the latter in terms of the degree of penetration into the nerve tissue. It has a successful combination of two properties: a pronounced affinity for the nerve tissue, which causes prolonged and deep local anesthesia, and rapid disintegration in the liver under the action of amides, which makes possible toxic complications insignificant and rapid passing. Such qualities of the citinest allow to apply it to pregnant women and children.

• Mepivacaine( carbocaine) - the strength of the action is not inferior to xylocaine, but more toxic than it. Carbocaine does not dilate blood vessels, unlike other anesthetics, which slows its resorption and provides a longer duration of action than xylocaine. Carbocaine is slowly inactivated in the body, so when it is overdosed there may be severe toxic reactions, which should be taken into account when choosing the dose and concentration of the drug and apply it with caution.

• Bupivacaine( marcaine) is the most toxic, but also the longest acting anesthetic. The duration of anesthesia can be up to 16 hours.

To prolong the action of anesthetic in local tissues, prolongators are used:

• vasoconstrictors - to the anesthetic solution immediately before use, adrenaline is added, in the dilution 1/200 000 - 1/400000, that is a small drop of 0.1% adrenaline by 10-20a gram syringe of an anesthetic solution( epinephrine causes vasospasm along the periphery of the infiltrate and, slowing its resorption, prolongs the local action of the anesthetic, reduces its toxic and vascular responses)

• large-molecule compounds - dextrans( prolong the action of anesthetics about 1.5-2 times), blood substitutes( 4-8 times), gelatin( 8% solution - up to 2-3 days), protein blood products, autograft( at 4-8 times) - large molecules, adsorbing the molecules of anesthetic and other drugs, stay in the vascular bed of local tissues for a long time, thereby prolonging the local and reducing the general toxic effect of the anesthetic

! !!The ideal prolongator from this group can be considered as hemolyzed autograft, which prolongs the effect of anesthetic up to a day; besides, unlike other large-molecule preparations, it does not cause allergies, is carcinogenic, free and available, has an immunostimulating and resolving effect and reduces the irritant effect of injections.preparations for local tissues. Other prolongators are used less often.

Various medications are used to enhance and / or to obtain a special therapeutic effect of the therapeutic blockade.

Glucocorticoids

Provides powerful anti-inflammatory, desensitizing, anti-allergic, immunosuppressive, anti-shock and antitoxic action. From the standpoint of preventing various complications from therapeutic blockades, glucocorticoids are an ideal drug.

In degenerative-degenerative processes in the locomotor apparatus, autoimmune nonspecific inflammatory processes play an important role, proceeding against the background of relative glucocorticoid insufficiency in local ischemic tissues. The introduction directly into such a focus of the glucocorticoid allows the most effective suppression of these pathological processes. To achieve a positive effect, a small amount of glucocorticoid is needed, which is almost completely realized in the tissues of the degenerative focus, and its resorptive effect is minimal, but sufficient to eliminate the relative adrenal glucocorticoid insufficiency thatoften observed with chronic pain syndromes. The use of steroid hormones in minimal doses,especially locally, is not dangerous. However, in patients with hypertension, gastric ulcer and duodenal ulcer, diabetes mellitus, purulent and septic processes, as well as in elderly patients, glucocorticoids should be used with extreme caution.

• Hydrocortisone acetate or its microcrystalline suspension of 5-125 mg per blockade - it must be shaken carefully before use and administered only in solution with a local anesthetic to avoid the development of necrosis with periarticular or intraarticular administration of the microcrystalline hydrocortisone suspension
• dexamethasone is more active than hydrocortisone25-30 times, relatively little effect on the exchange of electrolytes, unknown cases of necrosis of soft tissues when it is applied, one blockade is used 1-4 mg dexamethatezone
• Kenalog( triamcinolone acetonide), due to slow absorption, lasts for a long time in local tissues( therapeutic blockages with kenalog are carried out mainly with chronic arthrosis-arthritis to create a long-acting depot of glucocorticoid in local tissues;for its introduction, it is necessary to have an accurate idea of ​​the localization of the pathological process, when carrying out the first blockades that carry a large diagnostic load, the use of the kenologist is notOring)

B vitamins

• Apply to enhance the therapeutic efficacy of therapeutic blockade.
• Have a moderate ganglioblokiruyuschim action.
• Potentiate the action of local anesthetics.
• Participate in the synthesis of amino acids.
• Have a beneficial effect on the metabolism of carbohydrates and lipids.
• Improve biochemical metabolism of the nervous system.
• Improve tissue trophism.
• Have a moderate analgesic effect.

Vitamin B1 is used in the form of thiamine chloride - 1 ml 2.5% or 5% solution or thiamine bromide - 1 ml 3% or 6% solution.
Vitamin B6, pyridoxine - 5% 1 ml.
Vitamin B12, cyanocobalamin - 1 ml of 0.02% or 0.05% solution.

! !!B group vitamins should be used with caution in patients with angina pectoris, a tendency to thrombosis, adverse allergic anamnesis. It is not recommended joint administration of vitamins B1, B6 and B12 in one syringe. Vitamin B12 contributes to the destruction of other vitamins, can enhance the allergic reactions caused by vitamin B1.Vitamin B6 makes it difficult to convert vitamin B1 into a biologically active( phosphorylated) form.

Antihistamines

Reduces some of the central and peripheral effects of pain syndrome, are a preventive tool for the development of toxic and allergic reactions, enhance the therapeutic effect of therapeutic blockades. Antihistamines are added to the anesthetic in the usual single dose:

• Dimedrol 1% - 1 ml
• or diprazine 2.5% - 2 ml
• or suprastin 2% - 1 ml

Vasodilators

Also used to enhance the therapeutic effect of the therapeutic blockade.

• papaverine, as a myotropic antispasmodic, lowers tone and reduces the contractility of smooth muscles, which is the reason for its spasmolytic and vasodilating effect.
• no-spike has a longer and more pronounced vasodilator effect.

Usually add 2 ml of 2% papaverine hydrochloride or no-shpa to the anesthetic solution.

For therapeutic blockades it is possible to use the following composition:
• lidocaine 1% - 5-10 ml
• dexamethasone 1-2 mg - 0,25-0,5 ml
• at the doctor's discretion, vitamin B12-0, 05% - 1 ml, but-spoon 2% - 2 ml, autoglobin - 4-5 ml

In a 20-gram syringe consecutively these medications are taken, then the venipuncture is performed and the autologous syringe is typed. The contents of the syringe are mixed for 30 seconds until complete hemolysis of the erythrocytes, and then the prepared mixture is injected into the painful area.

Contraindications to the use of

treatment blockages •
feverish conditions •
hemorrhagic syndrome • infectious tissue damage in the
zone chosen for the treatment blockade • severe cardiovascular failure
• hepatic and / or renal insufficiency
• immunity of drugs used in the treatment blockade
• the possibility of exacerbation of another disease from drugs used in medical blockade( diabetes mellitus, open stomach ulcer,porphyria, etc.)
• Severe CNS diseases

Complications resulting from therapeutic blockades

Statistical studies have shown that as a result of the use of therapeutic blockades and local anesthesia, various complications occur in less than 0.5% of cases and depend on the type of blockade, the quality of its implementationand the general condition of the patient.

Classification of complications of

1. Toxicity associated with:
• Use of a large dose or high concentration of anesthetic agent
• Accidental injection of anesthetic into vessel
2. Allergic:
• delayed type
• immediate type
3. Vegetative-vascular:
• bysympathetic type
• parasympathetic type
• with accidental blockade of the upper cervical sympathetic node
4. Puncture of cavities:
• pleural
• abdominal
• spinal space
5. TrAutoimmune complications:
• Vessel damage
• Nerve damage
6. Inflammatory reactions.
7. Local reactions.

Complications are also distinguished according to the degree of their severity:
• light
• medium
• severe

Toxic complications develop when the dose and concentration of local anesthetic are incorrectly selected, random injection of anesthetic into the vascular bed, violation of blockade techniques and preventive measures. The degree of intoxication depends on the concentration of local anesthetic in the blood plasma.

• With mild intoxication with an anesthetic, the following symptoms are observed: numbness of the tongue, dizziness, darkening in the eyes, tachycardia.
• With severe intoxication - muscle twitching, agitation, convulsions, nausea, vomiting.
• With severe intoxication - sopor, coma, oppression of respiratory and cardiovascular activity.

The duration of toxic reactions depends on the dose of the injected drug, the rate of its absorption and excretion, as well as on the timeliness and correctness of the methods of treatment. When a large dose of local anesthetic is injected intramuscularly, signs of intoxication develop within 10-15 minutes, gradually increasing, starting with symptoms of excitation and continuing convulsively, up to coma. When the usual dose of a local anesthetic hits the vessel, the symptoms of intoxication develop within a few seconds, sometimes starting immediately with convulsive manifestations, as it can be with the occasional introduction into the carotid artery of even small doses of anesthetic.

! !!When carrying out blockades in outpatient settings, it is necessary to have the whole set of resuscitation measures ready and be able to use them. Even the most severe toxic complications are stopped by timely treatment and resuscitation measures and should not result in death.

Allergic reactions

Allergic reactions to the ingredients of the treatment blockade are often manifested as:
• delayed-type allergies - skin rashes and itching, swelling that develops a few hours after the blockade.
• Anaphylactic shock - develops immediately after the administration of the drug and is manifested by a rapid and significant drop in blood pressure, swelling, respiratory failure and even cardiac arrest.

Sometimes, the introduction of even minimal doses of the drug mixture is manifested by an allergic reaction in the form of short-term bronchospasm, accompanied by a sense of fear, excitation, a drop in blood pressure, symptoms of respiratory failure. Allergic reactions, as a rule, develop into etheric anesthetics( novocaine) and extremely rarely - to amide( lidocaine, trimecaine).

Vegetative-vascular reactions.

During the treatment blockade, some patients experience vegetative-vascular reactions. They are characterized by a fairly rapid onset and short duration of symptoms of violation of blood pressure without threatening signs of irritation or depression of the central nervous system, respiratory and cardiac activity.
• Vegetative-vascular reactions of the sympathetic type develop in sympathotons and more often when adrenaline is added to local anesthetics. They are characterized by tachycardia, hypertension, headache, anxiety, hyperemia of the face. They are stopped by the introduction of sedative, hypotensive and vasodilating drugs.
• Parasympathetic type vegetative-vascular reactions occur in the vagotons primarily during the treatment blockade in an upright position or during a fast rise after blockade. They are characterized by bradycardia, hypotension, pallor of the skin. They are stopped by the introduction of cardiotics, by adopting a horizontal position.

Cavity punctures

• Puncture of the pleural cavity is rare and dangerous with the development of conventional and valve pneumothorax. Within 1-2 hours after the blockade, there are chest pains, shallow breathing, tachycardia, a drop in blood pressure, choking, dyspnoea, subcutaneous emphysema, percussion - box sound, auscultatory - weakened breathing, roentgenologically - a decrease in lung tissue size.
• Puncture of the abdominal cavity is fraught with development in the long-term period after blockade of suppurative complications that may require surgical intervention.
• Puncture of the spinal space and introduction of local anesthetic into it during the epidural or paravertebral blockade at the upper intercostal level can occur when the diverticulum of the cerebrospinal membranes is punctured. In this case, bradycardia, hypotension, loss of consciousness, depression of respiratory and cardiac activity, signs of total spinal paralysis quickly occur.

Traumatic complications of

• Damage to the vessel is dangerous due to the development of the hematoma.
• If a blockade occurs in the face area, which is richly vascularized, bruising may occur.
• Nerve damage accompanied by pain syndrome, sensitive and, more rarely, motor impairment in the innervation zone of the damaged nerve.

Inflammatory complications of

The most dangerous infectious complications are:
• meningitis
• periostitis or osteomyelitis after intraosseous blockade

Local reactions

Irritation of local tissues develop both from improper execution of the blockade technique and from poor or incorrect composition of the drug mixture.

Thus, excessive injury to soft tissues with a needle or a large volume of solution can cause:
•
bruise • edema of
• nonspecific inflammation of
• intensification of pain syndrome

Introduction to local tissues of an overdue or "mistaken" drug, a cocktail of incompatible drugs - can cause:
• with intramuscular calcium chloride local tissue reaction up to necrosis
• administration of norepinephrine or large hydrocortisone particles can also cause tissue necrosis

Treatment of complications of

blockades When the first symptoms of intoxication appear, it is necessary to start the patient with oxygen inhalation. When signs of irritation( tremor, convulsions) are introduced, diazepam, hexenal or sodium thiopental, seduxen or relanium intravenously. With the inhibition of the central nervous system, cardiovascular and respiratory function, the use of barbiturates is contraindicated. Apply vasoconstrictors, stimulants of the respiratory center, conduct intubation of the trachea, detoxification infusion therapy: glucose solutions, hemodez, rheopolyglucin;forced diuresis. With the development of collapse, stopping breathing and cardiac activity, conventional resuscitative measures are carried out: artificial lung ventilation, indirect heart massage, etc.

With the development of anaphylactic shock, it is necessary to cut off the blockade with adrenaline solution, intravenously inject dexamethasone, suprastin, cardiotonics and stimulants of the respiratory center;urgently call resuscitation specialists and, if necessary, start the whole complex of resuscitation measures, including indirect heart massage and artificial respiration. When allergies of delayed type are used, antihistaminic, desensitizing and steroid preparations - suprastin and pipolfen, prednisolone or hydrocortisone, calcium chloride 10% -10.0 w / w, diuretics - lasix w / m or iv. With allergic dermatitis, steroid ointments are used. When bronhospazme use atropine, adrenaline.

When puncture the spinal space and the appearance of terrible symptoms during the blockade, it is necessary, without removing the needle, to try to evacuate spinal fluid with anesthetic dissolved in it - up to 20 ml. The rapid development of these symptoms is an indication for urgent resuscitation.

If it is found after the blockade of the developing hematoma, it is necessary to pinch the blockade with a finger for a few minutes, apply a pressure bandage and cold, and also rest for 1-2 hours. If the hematoma is formed, then it must be punctuated and emptied, appoint resorptive, anti-inflammatory therapy, thermal procedures.

In the formation of bruising in the face( although this cosmetic complication does not pose a health hazard, however, it causes a lot of inconvenience to the patient, and therefore requires treatment), immediately appoint resorptive therapy, physiotherapy, heparin ointment, lead lotions, thermal procedures.

Treatment of nerve injury is performed as in traumatic neuropathy: resolving therapy - iontophoresis with lidase or chymotrypsin;anti-inflammatory and analgesic - indomethacin, rheopyrin, etc.; drugs that improve the excitation( proserin, ipidakrin) and biochemical exchange of the nerve cell( nootropics);percutaneous electroneuromyostimulation, acupuncture, massage, physiotherapy exercises. It is known that nerve fibers are restored slowly, about 1 mm per day, so long-term treatment is needed, requiring patient and doctor perseverance and patience. Delay and passivity in treatment worsen results and prognosis.

Inflammatory complications in the form of infiltrates and abscesses require appropriate anti-inflammatory, physiotherapeutic, antibacterial and, if necessary, and surgical treatment.
Meningitis, which can occur with epidural or paravertebral block, requiring active treatment with liquor sanation and endolyumbal administration of antibacterial drugs.

With the development of periostitis and osteomyelitis, both local( antibiotic cure) and general antibiotic therapy are performed.
With the development of local reactions to therapeutic blockade, symptomatic therapy is needed in all cases: anti-inflammatory, resorptive, physical.

Prevention of complications of

1. It is necessary to have clear ideas about this pathology, the topography of the zone chosen for blockade, the rules and techniques for the implementation of a specific blockade, the pharmacology of curative blockades, knowledge of possible complications and their treatment.

2. When examining a patient, it is necessary to assess his general state of the view of possible complications: age, weight, condition of the cardiovascular and vegetative system, type of nervous activity, level and lability of arterial pressure, functional state of the liver and kidneys, gastrointestinal tract, levelsugar in the blood, a general blood test, allergic anamnesis.

3. When examining the local status, it is necessary to assess the skin condition( the presence of nausea and inflammatory phenomena) and subcutaneous fat( the presence of adipocytes, lipomas, vascular formations, varicose veins), identify foci of myofibrosis, trigger points, the location of large vessels and nerves. On the basis of such a careful palpation study, it is as accurate as possible to determine the location for the blockade.

4. The patient should be explained in an accessible form, what is the therapeutic blockade, what are the main mechanisms of its action, and what can we expect results to give examples of successful application of such blockades.

5. It is necessary to have a properly equipped treatment room in compliance with all rules of antiseptics;drugs and instruments for blockades to keep in a separate place, constantly monitor the shelf life of drugs. It is necessary to keep the reanimation kit separately and at the ready. Direct preparation and implementation of the blockade should be carried out in the treatment room or clean dressing.

! !!As necessary( acute, severe pain syndrome), a simple blockade can be made on the patient's bed. But in any case, when carrying out the therapeutic blockade, the rules of asepsis should be strictly observed, as in a small operation: the doctor should disinfect hands, put on sterile gloves, treat the site of blockade with 70% alcohol or other antiseptic. In the process of preparing and conducting a blockade, to prevent inflammatory complications, one should not talk and breathe on the syringe, you can not touch the needle with your fingers, even if they are in sterile gloves.

6. Strict control by the doctor himself should what preparations he types in the syringe, their concentration, expiration dates, transparency, the integrity of the syringe, needle, ampoule and vial packing with preparations.

7. To perform a particular blockade, you must have a suitable syringe or needle. The need to select different syringes and needles when carrying out various blockages is dictated by the volume of the solution administered, the thickness and density of the tissues where the solution is injected, the principle of minimal traumatization of soft tissues when the treatment blockade is performed. In the technique of performing blockade, the state of the tip of the needle is important. If the tip of the needle is dulled like a "fishing hook", then this needle can not be used, since such a needle leads to traumatization of soft tissues, which is fraught with the development of local reactions, hematoma and suppuration.

! !!In the manufacture of blockade, you can not immerse the needle in soft tissues to its base, since the weakest point of the needle is the place where the base is connected to the cannula, where the fracture most often occurs. If this fracture occurs at the time of the complete immersion of the needle to the cannula, it will remain in the soft tissues. In this case, extracting it, even surgically, is quite difficult.

8. At the time of the blockade, several rules for the prevention of various complications must be observed:

• The needle needs to be promoted gently but surely.
• The syringe must be kept in constant opposition to the translational motion of the needle in order to be able to quickly stop the movement of the needle at any time and do not pierce any formation found in the soft tissues.
• As the needle moves deeper into the soft tissues, it is necessary to infiltrate them with a solution of local anesthetic, that is, constantly presuppose a drug solution to the translational movement of the needle, which is essentially a hydraulic dissection of the tissues.
• The amount of the solution presumed at the time the needle moves to the deep painful area does not usually exceed 10-20% of the syringe volume and is essentially a biological breakdown of the tolerability of the drugs administered, after which it is necessary to wait 1-2 minutes, observing the patient's condition,whether it has signs of an allergic, vascular or other systemic reaction.

• Before entering the main volume of the solution, it is necessary to make an aspirate sample once more and if it is negative, then insert the main contents of the syringe into soft tissues.

• The aspirate sample needs to be run several times as the needle moves into the tissues and after each puncture of tight formation.

• During the blockade, it is necessary to constantly communicate with the patient, talk, maintain verbal contact with him, thereby controlling his general condition.

! !!Ideally, a procedural nurse must constantly monitor the patient's general condition at the time of the treatment blockade.

After the end of the blockade, the patient is recommended to keep bed rest for 1-2 hours. This is the prevention of complications in the treatment blockade, both vegetative and vascular, and the underlying disease, since in the first hours after the blockade, when the anesthetic operates, its symptomatic effect prevails over the therapeutic, that is, pain and muscle-tonic syndromes are significantly reduced, whereassigns of dystrophy and nonspecific inflammation in active motor structures( muscles, ligaments, articular bags, cartilage, etc.) still persist. The action of the anesthetic removes the muscle tension, which leads to an increase in the volume of movements in the affected part of the locomotor apparatus. But under the influence of anesthetic, not only the pathological, but also the protective muscle tension is removed. In this case, under the influence of anesthesia, when performing active movements in full volume in the affected section of the locomotor apparatus, an exacerbation of the neuroorthopedic disease may occur, the main manifestation of which will be revealed after the anesthetic has ended in the form of an intensification of the neurological symptomatology, including the pain syndrome.

! !!Therefore, immediately after the blockade should be refrained from performing the full volume of active movements in the affected joint or spine, it is necessary to comply with bed rest or use of orthosis( corset, head, etc.) for the affected section of the locomotor apparatus for the duration of the anesthetic - 2-3 hours.

When carrying out complex blockades, to determine the location of the tip of the needle and a more accurate administration of the drug solution, and to obtain documentary evidence of the correct blockade, X-ray control is necessary.

Premedication

Premedication is one of the ways to prevent complications from blockages. Somatically healthy patients, it is usually not required. However, if the patient has signs of vegetative-vascular lability, excessive emotionality, fear of blockade, or it is necessary to perform a complex and prolonged blockade, then in these cases premedication is necessary.

Premedication aims to:
• reduce the emotional tension of the patient
• improve the tolerability of the
procedure • prevent systemic reactions of
• reduce the toxic effects of

drugs Most often for premedication, 1-2 hours before blockade,

benzodiazepine derivatives:
• elenium-5-10 mg,
• or Seduxenum -5-10 mg,
• or phenazepam - 0.5-1 mg or other

antihistamines( and also for the prevention of allergic reactions):
• Suprastin 20-25 mg
• or pipolfen25 mg
• tavegil

Sometimes two-stage premedication is used.
1) In the first stage( at night), prescribe any sleeping pills in the usual dose.
2) In the second stage, 30-60 minutes before the blockade, Seduxenum and Dimedrolum are prescribed, 0.5-1 ml of 0.1% atropine can be administered subcutaneously.

In rare cases, before carrying out complex blockades resort to narcotic analgesics( promedol, morphine, fentanyl, moradol).

Let's consider further the technique of some medical blockades.

Paravertebral blockade of

Technique of execution. After processing the skin with antiseptics( solution of iodine alcohol, ethyl alcohol, etc.), according to the standard technique, an anesthetic of the skin at four points is made by a thin needle, to the right and left of the ovitic processes, retreating 1.5-2 cm from the midline. Then a thicker needle( not less than 10cm long) with a syringe is pierced by the skin in one of the anesthetized points and, slowly moving the needle perpendicular to the frontal plane of the body and presuming an anesthetic jet, reach the arch of the vertebra. Anesthetic( 0.5-0.75% solution of lidocaine) with the possible addition of a glucocorticoid drug is injected fan-shaped in the cranial, lateral and caudal directions. The total amount of anesthetic should not exceed its one-time maximum dose. Paravertebral blockades are used mainly with a therapeutic purpose in combination with other methods of treatment of dystrophic-destructive diseases of the lumbar spine( manual therapy, underwater and bed stretching, drug therapy, etc.).As a rule, when the paravertebral blockade is performed in the lumbar spine, the anesthetic solution is injected into the area between the and interstitial ligaments, which significantly increases the efficiency of the treatment procedure. Most often, the indication for the use of paravertebral blockades is the myotonic reactions of paravertebral muscles in various clinical variants of osteochondrosis.

Articular blockades of arcuate joints

Technique of implementation. The technique of puncture of the articular joints of the lumbar spine is selected depending on the orientation of the facet joints. With orientation in the frontal plane up to 45 °, the joint is punctured as follows. The needle is pinned 1.5 times the diameter of the finger from the line of spinous processes, is carried to the end of the needle tip into the bone tissue, after which the patient is asked to turn at an angle corresponding to the orientation of the joint space. At the moment of its coincidence with the direction of the needle, the latter is pushed into the joint cavity 1-2 mm. It should be noted a number of features of the technique of introducing a needle into the joint. Usually, after a puncture of the skin and fascia, reflex muscle tension is noted, which leads to a change in the direction of needle movement. To exclude this, it is necessary to perform thorough infiltration anesthesia of the skin and muscles along the needle, up to the capsule of the joint. When the frontal orientation of the articular facets is more than 45 °, the joint is punctured in the lower turn. Puncture is carried out in the position of the patient on his side or on the abdomen with an indispensable flexor installation in the lumbar spine. The needle is inserted, orienting along the lower edge of the spinous process corresponding to the level of the punctured joint, receding laterally by 2-3 cm and additionally caudally at a distance previously altered in the spondylograms. The tip of the needle is held in the lower twig of the joint until it stops in the cartilaginous surface of the upper articular process. After insertion of the needle intra-articularly, an aspiration test is performed to evacuate the synovial fluid. Then, an anesthetic solution and a corticosteroid preparation with a total volume of up to 2-3 ml are injected. For blockade use a needle of at least 12 cm in length. The capacity of the joint varies from 0.3 to 2.0 and even up to 2.5 ml, which is due to the nature of the pathological changes in it. With the saved capsule of the joint after the injection of 0.5 ml of the solution, a spring resistance with an amplitude of 0.1-0.4 ml is felt. With instability, looseness of the joint, the capacity of its cavity increases. Decrease in capacity, as a rule, is observed with gross destructive-dystrophic changes in the joints. Indications for the use of intraarticular blockages of articular joints is lumbar spondyloarthrosis, the clinical manifestations of which are leading or occupy a significant place in their formation. To conduct a course of treatment, as a rule, 3-4 injections with an interval of 5-7 days are used.

Blockades of the posterior branches of the spinal nerves

Technique of execution. After treatment of the skin with antiseptics, it is anesthetized, for which the needle is injected, retreating three finger diameters lateral from the lower edge of the spinous process and one by a caudal one. After puncturing the skin, the needle is inclined caudally at an angle of 15-20 ° in the sagittal plane, placing the cannula laterally, carried in the tissues until the end of the needle ends at the base of the transverse process. Introduce 3-4 ml of anesthetic solution in a mixture with 1 ml diprospan, and then, moving the needle fan-shaped, another 5-6 ml of the mixture is injected into the area of ​​the intertransverse ligament. Thus, in turn, the medial, medial and lateral branches of the posterior branch of the spinal nerve innervating the joints, muscles and ligaments of the dorsal surface of the trunk are blocked. Blockades of the posterior branches of the spinal nerve are used to diagnose pain syndromes caused by the pathology of the joint-muscular-ligament complex, and for muscle relaxation in combination with other conservative treatment methods. When this kind of blockade is performed, if the injection points are incorrectly chosen, the tip of the needle can pass into the zone of the intervertebral foramen, which leads to the occurrence of paresthesias in the zones of innervation of the corresponding spinal nerve.

Epidural blockade of

Blockade of small pectoral muscle

Blockade of small pectoral muscle is performed in the position of the patient on the back. The doctor palpates the places of attachment of the small pectoral muscle( the beak-like process of the scapula and the IV rib in the place of their transition of the cartilaginous part to the bone) and iodine on the patient draws its projection. The places of attachment of the small pectoral muscle are connected by straight lines. From the corner, located above the beak-like process of the scapula, the bisectrix descends, which is divided into three parts. Between the outer and middle parts of the bisector, the needle is punctured by skin, subcutaneous fat, anterior fascial leaf, muscle tissue and posterior fascial sheet of the large pectoral muscle. Then the needle is pushed by the doctor 5 mm forward, reaching the small pectoral muscle. The volume of the injected substance is 3.0-5.0 ml.

Blockade of large pectoral muscle

Blockade of large pectoral muscle is carried out in the position of the patient sitting or lying down. When palpating the most painful points are determined and an injection is made in each of them. The volume of the injected substance for each zone is 0.5-1.0 ml.

Blockade of the clavicle-acromial joint

Blockage of the clavicle-acromial joint is performed in the patient's sitting position facing the doctor. The doctor palpatorically determines the line of the joint and marks it with iodine. The needle is inserted perpendicularly, in front in the center of the joint. The volume of the injected substance is 0.3-0.5 ml. Blockade of the shoulder joint is carried out in the patient's sitting position. At lateral access the acromion serves as a reference point. The doctor finds its most convex part and, since immediately below it is the head of the humerus, the needle points under the acromion, passing it between it and the head of the humerus.
At the beginning of the injection, the patient's hand is pressed against his body. After the needle penetrates deep into the deltoid muscle, the arm is lifted slightly upward and returned a little to the bottom. Continuing to press the needle, the doctor feels as it passes through an obstacle consisting of a dense articular capsule, and penetrates into the joint cavity. When the blockade is performed by the front access, the doctor rotates the patient's shoulder to the inside, placing the forearm of his arm on the abdomen. The doctor palpates the beak-shaped process and tries to determine the line of the joint by moderately rotating the shoulder.

Blockade of the subclavian muscle

Blockade of the subclavian muscle is performed in the patient's sitting or lying position. The clavicle is divided into three parts. Between the outer and middle parts of the lower edge of the collarbone, the needle is perpendicular to the frontal plane of the puncture with a depth of 0.5 to 1.0 cm( depending on the thickness of the layer of subcutaneous fat) until the tip of the needle touches the edge of the clavicle. Then the tip of the needle is turned upwards at an angle of 45 ° and is advanced further by 0.5 cm.
The volume of the injected substance is up to 3.0 ml.

Blockade of the chest-arm joint

Blockade of the chest-arm joint is performed in the position of the patient lying or sitting. The doctor palpates the line of the joint and marks it with iodine, the needle is inserted perpendicularly. The volume of the introduced substance is 0.2-0.3 ml.

Blockade of the sternoclavicular joint

Blockage of the sternoclavicular joint is carried out in the position of the patient sitting or lying down. The needle is directed perpendicular to the surface of the chest to a depth of not more than 1 cm. The volume of the injected substance is 0.3 ml.

Blockade of the front staircase

The sitting patient is asked to tilt the head slightly to the sore side to relax the sternocleidomastoid muscle, the external edge of which( above the clavicle) the physician pushes to the inside with the index or middle finger of the left hand - depending on the side of the blockade. Then the patient should take a deep breath, hold his breath and turn his head to a healthy side. At this point, the surgeon continues to move the sternocleidomastoid muscle to the inside, deepening the index and middle fingers downward and, as it were, covering the lower pole of the front staircase, which is well contoured, as it is tense and painful. With your right hand, insert a thin short needle, put on the syringe, between the fingers of the left hand into the body of the staircase to a depth of 0.5-1.0 cm and inject 2 - 3 ml of 0.5-1% solution of novocaine.

Blockade of the lower oblique muscle of the head

The lower oblique muscle of the head is on the second layer of the neck muscles. It starts from the spinous process of the second cervical vertebra, goes up and out and is attached to the transverse process of the first cervical vertebra. Ahead of the muscle is the nervous reserve loop of the vertebral artery. The fascia, which surrounds the muscle, has close contact with a number of neural formations. At the middle of the length of the muscle, the second intervertebral ganglion is located at the anterior surface of the fascial leaf, from which the posterior branch of the great occipital nerve leaves, like a loop embracing the muscle. In this case, the occipital nerve is between the muscle and the arc of the second cervical vertebra, and the reserve loop of the vertebral artery is between the muscle and the capsule of the atlanto-axial articulation. The technique of blockade: Iodine draws a line connecting the spinous process C2 with the mastoid process. At a distance of 2.5cm from the spinous process along this line towards the mastoid process, the skin is punctured with needle No. 0625. The needle is guided at an angle of 45 ° to the sagittal plane and 20 ° to the horizontal to the stop in the base of the spinous process. The tip of the needle is pulled back by 1-2 cm, and the drug substance is injected. The volume of the drug administered is 2.0 ml.

Perivascular curative block of the vertebral artery

The vertebral artery usually enters the opening of the transverse process of the sixth cervical vertebra and rises in the same channel, formed by holes in the transverse processes of the cervical vertebrae. In front are interdigitic muscles, between the long neck muscle and the front staircase passes the carotid artery, the esophagus and the trachea are several inside. The blockade technique: The patient is in the position on the back. A small pillow is put under the shoulder blades. The neck is unbent. The head is turned in the opposite direction from the blockade. An index finger between the trachea, esophagus, carotid artery and anterior staircase is palpable with the dorsal tubercle of the transverse process of the sixth cervical vertebra. At the tip of the finger, the needle No. 0840 pierces the skin and fascia of the neck until it stops in the transverse process. Then the needle gently advances to the upper edge of the transverse process. Before the introduction of the solution, it is checked whether the tip of the needle is in the vessel. The volume of the introduced solution is 3.0 ml. With the correct performance of LMB after 15-20 minutes, occipital pain, tinnitus, and vision become clearer.

Blockade of intercostal nerves

It is used for intercostal neuralgia, thoracic radiculopathy and pain along the course of intercostal nerves with ganglionovritis( shingles).In the patient's position on the side, skin anesthesia and needle insertion are made before contact with the outer surface of the lower edge of the rib at the attachment site to the vertebrae. Then the needle is slightly pulled out and its end is directed downwards. Slipping from the edge of the rib, with a slight advance into the depth, the needle enters the zone of the neurovascular bundle, where it enters 3.0 ml.0.25-0.5% solution of novocaine. Applying this method, it should be remembered that the true neuralgia of the intercostal nerves is very rare.

Therapeutic blockade of the muscle that lifts the

scapula The muscle that lifts the scapula lies in the second layer, starts from the posterior tubercles of the transverse processes of the sixth-seventh cervical vertebrae, and is attached to the upper inner corner of the scapula. Dorsally it is closed by a trapezius muscle. Trigger zones are found most often at the point of attachment of the muscle to the upper corner of the scapula or in the thickness of it. Technique of blockade: The patient lies on the stomach. Having groped for the upper inner angle of the scapula, needle No. 0840 the doctor makes a puncture of the skin, subcutaneous adipose tissue, trapezius muscle until it stops in the angle of the scapula. If the trigger zone is found in the muscle thickness, the medicinal substances are introduced into it. The volume of the solution is 5.0 ml.

Therapeutic block of the suprathinus nerve

The suprathiopathic nerve runs along the posterior edge of the lower abdomen of the scapular-hyoid muscle, then enters the scapular notch and innervates at first the supraspinous, then subacute muscle. Above the notch is the upper transverse ligament of the scapula, behind the nerve is the supraspinatus and trapezius muscle. Technique of blockade: The blade is divided into three parts. Between the upper and middle third needle No. 0860 is a puncture of the skin, subcutaneous fat, trapezius and supraspinatus muscles at an angle of 45 ° to the frontal plane. The needle moves up to the stop in the cutting edge, then is moved back by 0.5 cm. The volume of the injected substance is 1.0-2.0 ml.