Perioperative nerve injury prevention

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Perioperative nerve injury prevention - #52

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Identify causes of anesthesia related nerve injury.

Assessment

TABLE 1:  Common Positions Associated with Peripheral Nerve Injury in the Operating Room

/sites/default/files/editor/fastfacts/AnesthesiologyPositionTable.pdf

Context

Nerve Injuries Associated with Anesthesia

Action

Prevention of nerve injuries in the perioperative period

Incidence / Prevalence

Anesthesia related nerve injuries accounted for 16% (670) of the 4183 claims documented in the anesthesiology closed claims analysis.  The ulnar nerve was the most commonly injured nerve and made up 28% of the claims.  Older age appears to be a risk factor for anesthesia-related nerve injury since the median age of patients with perioperative ulnar nerve injury was 50 years old, while the median age for non-nerve damage claims was 39 years old.

Underlying Sciences

See Figures a and b

The structure of a nerve is organized by the layers of connective tissue on the outside, around each fascicle, and surrounding the individual nerve fibers (tissue source: simian). LM × 40. (Micrograph provided by the Regents of University of Michigan Medical School c 2012).

See Additional Figure by following link below:

OpenStax College. Anatomy & Physiology [OpenStax-CNX Web site]. September 4, 2014. Available at: http://legacy.cnx.org/content/col11496/1.7/.

 

Peripheral nerves consist of parallel bundles of axons enveloped by connective tissue

  1. Epineurium
  2. Perineurium: surrounds fascicle
  3. Endoneurium: surrounds axon

Influence of Aging on the Peripheral Nerve:

  1. Peripheral nerve conduction velocity decreases with age secondary to decrease in size and amount of myelin.
  2. Maintenance of cell metabolism at long distances from cell body is decreased with age secondary to alterations in anterograde and retrograde axonal transport.
  3. Rate and degree of nerve recovery and regeneration after peripheral nerve injury decreases with age.

Mechanisms of Nerve Injury associated with Anesthesia

  • Stretch (most common)
  • Stretch results in a decrease in cross-sectional area of fascicule leading to increased intrafascicular pressure compromising microcirculation.
  • Rupture of a fascicle may occur with elongation of the nerve of only 4% beyond original length, once all of the slack has been removed from the fascicle.

Compression

  • Short term (<8hrs) compression-related nerve injuries are thought to be secondary to ischemia.
  • More severe compression injuries in which function is lost for weeks or permanently is thought to be secondary to mechanical deformation of the nerve.

Ischemic

Laceration

  • Laceration of fascicule with cutting needles during regional anesthesia.

Cytotoxic

  • Secondary to local anesthetics during regional anesthesia.

 

FIGURES BELOW

Science Principles

Connective Tissue Changes

Objectives

  1. Identify the potential causes resulting in anesthesia associated nerve injury.
  2. Describe the common scenarios associated with nerve injury in the operating room.
  3. Describe preventative measures correlating to each of the common scenarios.

Keywords/Tags

References

  1. Sharma G, Goodwin J. Effect of aging on respiratory system physiology and immunology. Clinical Interventions in Aging. 2006;1 (3): 253-260.
  2. Janssens JP. Aging of the respiratory system: Impact on pulmonary function tests and adaptation to exertion. Clinics in Chest Medicine. 2005; 26(3): 469-484, vi-vii.
  3. Choe KH, Kim YT, Shim TS, Lim CM, Lee SD, Koh Y, Kim WS, Kim DS, Ryu JS, Kim WD. Closing volume influences the postural effect on oxygenation in unilateral lung disease. Am J Resp Crit Care Med. 2000; 161: 1957-1962.
  4. Schubert, A. (2008). Positioning Injuries in Anesthesia: An Update. Advances in Anesthesia. 26:31-66.
  5. Warner M. (January 7, 2011). Perioperative positioning problems you hope to never encounter. Lecture conducted from Medical College of Wisconsin, Milwaukee, WI.
  6. Knight DJ, Mahajan RP. Patient positioning in anaesthesia. Continuing Education in Anesthesia, Critical Care and Pain. 2004; 4(5):160-163. Retrieved December 15, 2013 from http://ceaccp.oxfordjournals.org/content/4/5/160
  7. Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy 2011;27(4): 532-541.  doi: 10.1016/j.arthro.2010.09.008 Epub 2010 Dec. 2 .
  8. Gerken S. Lateral and Prone Positioning Risks in Orthopaedic Surgery. In AAOS Now. Retrieved December 15, 2013 from http://www.aaos.org/news/aaosnow/feb13/managing9.asp
  9. Carofino BC, Brogan DM, Kircher MF, Elhassan BT, Spinner RJ, Bishop AT, Shin AY. Iatrogenic nerve injuries during shoulder surgery. J Bone Joint Surg Am 2013 95(10):1667-74.
  10. Gerken S. Preventing Positioning Injuries: An Anesthesiologist’s Perspectives. In AAOS Now. Retrieved December 15, 2013, from  http://www.aaos.org/news/aaosnow/jan13/managing7.asp
  11. Coppieters MW, Van de Velde M, Stappaerts KH.  Positioning in anesthesiology: toward a better understanding of stretch-induced perioperative neuropathies. Anesthesiology. 2002 97(1):75-81.
  12. Closhen D, Berres M, Werner C, Englehard K, Schramm P. Influence of beach chair position on cerebral oxygen saturation: A Comparison of INVOS and FORE-SIGHT cerebral oximeter. J Neurosurg Anesthesiol. 2013 25(4):414-9. doi: 10.1097/ANA.0b013e3182973349.
  13. Neligan P. Beachchair and blood pressure.  In AnaesthesiaWest. Retrieval December 15, 2013, from http://anaesthesiawest.com/2013/01/24/beachchair-and-blood-pressure/
This GFF ___ my competence in geriatrics.

Authors

Robert Biechler MD, Kevin Jenner MD, Olivia Mac, Steve Denson, MD

Author Affiliation

Medical College of Wisconsin, Milwaukee WI

Copyright

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