颈肩部手术神经阻滞PPT课件.ppt

颈肩部神经阻滞,1,.-,2019/11/12,2,.-,2019/12/15,3,.-,2019/12/15,PhrenicNervePalsyandRegionalAnesthesiaforShoulderSurgeryAnatomical,Physiologic,andClinicalConsiderationsAnesthesiology,2017,127(1):173,区域麻醉在为肩部手术提供围手术期镇痛方面发挥着重要作用。但是，膈神经麻痹是一种严重的并发症，特别是在高危患者中。该作者描述了与膈神经麻痹有关的解剖学，生理学和临床原理。全面回顾了确保充分肩部手术镇痛,如何减少膈神经麻痹的策略及其临床影响。,4,.-,2019/12/15,局部解剖,5,.-,2019/12/15,肩部神经支配,皮肤的支配神经:包括C5-6的腋神经，肩胛上神经，和颈丛C3-4的锁骨上神经。骨和肩关节囊的支配神经：包括肩胛上神经，腋神经，胸外侧神经（C5-7）,肌皮神经（C5-7），胸长神经（C5-7）。肩胛上神经提供肩关节70%的神经支配，其余的大部分是腋神经支配。,El-BoghdadlyK,ChinKJ,ChanV.PhrenicNervePalsyandRegionalAnesthesiaforShoulderSurgery:Anatomical,Physiologic,andClinicalConsiderationsJ.Anesthesiology,2017,127(1):173.,6,.-,2019/12/15,肩部神经支配,肩部肌肉的感觉组成：第三和第四颈神经的腹侧支支配斜方肌。胸前神经（C5-C7）支配胸大肌。肩胛背神经（C5）支配肩胛提肌和菱形肌。腋神经（C5-C6）支配三角肌。肩胛上，肩胛下（C5-C6）和腋神经支配肩袖肌肉。,7,.-,2019/12/15,锁骨上神经,腋神经,肩胛上神经,肩胛上神经,桡神经,肩胛下神经,胸长神经和肩胛上神经,8,.-,2019/12/15,胸背神经,9,.-,2019/12/15,10,.-,2019/12/15,11,.-,2019/12/15,12,.-,2019/12/15,解剖学基础,1、舌骨hyoidbone适对第3、4颈椎间盘平面；舌骨体两侧可扪到舌骨大角，是寻找舌动脉的标志。2、甲状软骨thyroidcartilage上缘平第4颈椎上缘，即颈总动脉分叉处：前正中线上的突起为喉结。3、环状软骨cricoidcartilage环状软骨弓两侧平对第6颈椎横突，是喉与气管、咽与食管的分界标志，又可作计数气管环的标志。,13,.-,2019/12/15,14,.-,2019/12/15,阻滞方法,15,.-,2019/12/15,16,.-,2019/12/15,超声引导下颈浅丛阻滞,17,.-,2019/12/15,18,.-,2019/12/15,19,.-,2019/12/15,20,.-,2019/12/15,超声引导下肌间沟神经阻滞,21,.-,2019/12/15,在确认了肌间沟臂丛神经的位置后。我们确认最表层的神经结构(可能是C5，或上干)。探头向头侧和中间滑动，直到它和肌间沟中其他神经结构分离。前中斜角肌常常不好分辨。继续向头侧滑动，可以见到神经根以比较大的角度进入脊椎。,KatherineH.Dobie,YapingShietal.NewtechniquetargetingtheC5nerverootproximaltothetraditionalinterscalenesonoanatomicalapproachisanalgesicforoutpatientarthroscopicshouldersurgery。journalofClinicalAnesthesia(2016)34,7984,22,.-,2019/12/15,A1mLtestdoseoflocalanestheticwasgiventoexcludeintraneuralinjectionandtoassessthespreadoftheinjectionaroundthestructure.15mLoflocalanestheticwasinjectedinincrementaldosesadjacenttothenervestructure,and,whennecessary,minoradjustmentsweremadetoensurespreadoflocalanestheticaroundthestructure.,23,.-,2019/12/15,CadaverdissectionafternewtechniqueperformedunderultrasoundguidanceinFig.2with.2ccmethyleneblueinjectedatC5nerveroot;remainderofbrachialplexusinview.ArrowshowsmethyleneblueatC5nerveroot.ForcepsshownatdistalbrachialplexusinrelationtoinjectionatC5.,24,.-,2019/12/15,25,.-,2019/12/15,26,.-,2019/12/15,27,.-,2019/12/15,膈神经麻痹,28,.-,2019/12/15,膈神经麻痹,在表面上，暂时的膈神经麻痹似乎没有什么临床意义在客观（呼吸支持）和主观方面（呼吸困难）功能。随机控制试验通常排除肺部疾病，肥胖，或阻塞性睡眠呼吸暂停。持续性膈神经麻痹。发生率范围从1/2000到1/100。有些文献报道了持续性膈神经麻痹出现的潜在原因，如在体表标志法的肌间沟神经阻滞后的膈神经麻痹阻滞与直接针头损伤或神经鞘内注射引起的神经损伤注射相关。,29,.-,2019/12/15,30,.-,2019/12/15,膈神经麻痹,膈神经主要来源于第四颈神经腹侧支，但也有部分来至第三和第五颈神经腹侧支，以及颈交感神经节或胸交感神经丛。这些小神经在斜角肌前部的上部外侧缘形成，在前斜角肌表面向着沿着斜下方朝向其内侧边缘下行。膈神经在甲状软骨水平距离C5水平的平均距离为18至20mm，随着膈神经沿着前斜角肌表面下降，每下降1cm远离3mm。,31,.-,2019/12/15,32,.-,2019/12/15,副膈神经大多发自第5、或第5、6、第4颈神经。多为单侧。副膈神经与臂丛的关系要比与颈丛的关系更为密切。副膈神经与膈神经迟早必将合并为一。根据膈神经与副膈神经的支数多少,可归纳成五个类型:第一型一支,即膈神经本身。第二型二支,即膈神经与副膈神经各一支。第三型三支,即膈神经一支,副膈神经二支。五型中以第一型(占43.1%)与第二型(占43.3%)最多,均可列为国人之标准型,33,.-,2019/12/15,肥胖患者,Using30mLof0.5%ropivacainewithepinephrine1:400,000.AllparticipantsdemonstratedhemidiaphragmaticparesisafterISB.ISBisassociatedwithgreaterFVCandFEV1reductionsinobeseparticipantscomparedtonormal-weightparticipants.Despitethesechanges,obesitywasnotassociatedwithincreasedclinicalrespiratorysymptomsorevents.,MeltonMS,MonroeHE,QiW,etal.EffectofInterscaleneBrachialPlexusBlockonthePulmonaryFunctionofObesePatients:AProspective,ObservationalCohortStudy.J.AnesthesiaASM：anteriorscalenemuscle;Blackarrows：needle;CA,carotidartery;MSM：middlescalenemuscle;VA：vertebralartery;X：后结节.Theanteriortubercleisabsent.,41,.-,2019/12/15,Extrafascialinjectionforinterscalenebrachialplexusblockreducesrespiratorycomplicationscomparedwithaconventionalintrafascialinjection,Thefinalneedletippositionwas4mmlateraltothebrachialplexussheath,atalevelequidistantbetweenC5andC6roots.Thedistanceof4mmwaschosenaccordingtothecalculatedsuccessrateover90%reportedrecentlyandourdailyexperienceinauniversityteachinghospital.Theon-screencalipermeasurementtoolwasusedtodefinethisdistanceof4mm,PalhaisN,BrullR,KernC,etal.Extrafascialinjectionforinterscalenebrachialplexusblockreducesrespiratorycomplicationscomparedwithaconventionalintrafascialinjection:arandomized,controlled,double-blindtrialJ.BritishJournalofAnaesthesia,2016,116(4):531.,42,.-,2019/12/15,43,.-,2019/12/15,Extrafascialinjectionforinterscalenebrachialplexusblockreducesrespiratorycomplicationscomparedwithaconventionalintrafascialinjection,Theincidencesofhemidiaphragmaticparesiswere90%and21%intheconventionalandextrafascialinjectiongroups,respectively(P0.0001).围神经丛注射相比神经丛内注射，FEV1，用力肺活量和呼气峰值流速的分别下降16和28，17次vs28，8和24。Themeantimetofirstopioidrequestwassimilarbetweengroups.,PalhaisN,BrullR,KernC,etal.Extrafascialinjectionforinterscalenebrachialplexusblockreducesrespiratorycomplicationscomparedwithaconventionalintrafascialinjection:arandomized,controlled,double-blindtrialJ.BritishJournalofAnaesthesia,2016,116(4):531.,44,.-,2019/12/15,肩胛上神经和腋神经阻滞,在关节镜手术中，相对于安慰剂或肩峰下局部麻醉药浸润注射，肩胛上神经阻断单独或与腋神经阻滞结合已被证明提供优越的镇痛。与肌间沟神经阻滞相比，效果较差。这个外周神经阻滞技术主要针对的是这个肩关节囊的神经支配，在开放或广泛的肩部手术效果欠佳。,45,.-,2019/12/15,SuprascapularandInterscaleneNerveBlockforShoulderSurgeryASystematicReviewandMeta-analysis,Thisreviewsuggeststhattherearenoclinicallymeaningfulanalgesicdifferencesbetweensuprascapularblockandinterscaleneblockexceptforinterscaleneblockprovidingbetterpaincontrolduringrecoveryroomstay.Suprascapularblockhasfewersideeffects.Thesefindingssuggestthatsuprascapularblockmaybeconsideredaneffectiveandsafeinterscaleneblockalternativeforshouldersurgery.,HussainN,GhazalehG,RaginaN,etal.SuprascapularandInterscaleneNerveBlockforShoulderSurgery:ASystematicReviewandMeta-analysisJ.Anesthesiology,2017:1.,46,.-,2019/12/15,AComparisonofCombinedSuprascapularandAxillaryNerveBlockstoInterscaleneNerveBlockforAnalgesiainArthroscopicShoulderSurgeryAnEquivalenceStudy,和ISB相比，联合肩胛上和腋神经阻滞可以为肩关节关节镜提供非等效的镇痛效果。在24小时时SSAX对静息痛可以提供更好质量的疼痛缓解，且不良影响更少，ISB的术后即刻镇痛效果更佳。对于肩关节镜手术，SSAX可以是一种临床上可接受的止痛剂选择与不同镇痛剂特征相比较与ISB。,MartyP,RontesO,DelbosA.AComparisonofCombinedSuprascapularandAxillaryNerveBlockstoInterscaleneBlock:InterpretWithCaution.J.RegionalAnesthesia&PainMedicine,2017,42(2):273.,47,.-,2019/12/15,48,.-,2019/12/15,肩胛上神经阻滞,49,.-,2019/12/15,冈上肌,斜方肌,50,.-,2019/12/15,腋神经阻滞,51,.-,2019/12/15,三角肌,小圆肌,旋肱后动静脉,52,.-,2019