椎旁阻滞临床应用

椎旁阻滞的临床应用,梅伟华中科技大学同济医学院附属同济医院麻醉科,椎旁神经阻滞历史,1905年由Sellheim首先在Leipzig报道，替代腰麻用于剖宫产术麻醉也有报道认为是在1908年Tuebingen开始的,Hugo Sellheim ( 28. Dezember 1871 in Biblis bei Worms; 22. April 1936 in Leipzig) war ein deutscher Gynkologe und Geburtshelfer.,Arthur Lwen 验证PVB(1911年),Arthur Georg Lwen ( 6. Februar 1876 in Waldheim, Sachsen; 30. Januar 1958 in Lneburg) war ein deutscher Chirurg und Wegbereiter der heutigen Ansthesiologie,Richardson, J. et al., Br J Anaesth. 1998;81(2):230-8.,Arthur Lwen的其他贡献,1912年：首次联合使用硬膜外联合全麻1912年：在局麻药中加入碳酸氢钠首次采用骶管阻滞1912年：首次在手术中使用箭毒呼吸衰竭患者的辅助通气,Max Kappis（ 1919年）,Kappis M. Sensibilitaet und locale anaesthesia gebeit der Bauchoele mit besonderer beruchsichtigung der Splanchnicus anaesthesia. Beitr Klin Chir 1919; 115: 16175Fujita Y. Max Kappis, an inventor of splanchnic nerve block. Masui. 1993 Sep;42(9):1378-80. Article in Japanese,Max Kappis (6. Oktober 1881 in Tbingen; 5. August 1938) war ein deutscher Chirurg,PVB的早期应用,1920s应用极为流行：心绞痛、癌痛、股骨颈骨折、肢体缺血痛，室上性心动过速，哮喘，辅助排石，带状疱疹痛（Mandel F. Paravertebral block. New York: Grune and Stratton, 1946）1950s-1960s 文献报道几乎消失1970s，阻力消失法引入后，再度流行(Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia. 1979;34(7):638-42.),Richardson, J. et al., Anesth Analg. 1998;87(2):373-6.,Figure 2. In the presence of complete numbness on sensory examination, depression of the S1 dermatomal SSEP ranged from 0% (A), to greater than 50% (B), to 100% (C) Data are representative examples.,Benzon HT et al., Anesth Analg. 1993;76(2):328-32.,PVB vs 硬膜外: 4-8h 和48h VAS评分,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:吗啡量和尿潴留,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:PONV和低血压,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:失败率和肺部并发症,Ding, X. et al., PLoS One. 2014;9(5):e96233,区域阻滞与术后慢性疼痛,Andreae MH and Andreae DA. Br J Anaesth. 2013; 111(5):711-20,椎旁神经解剖,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,椎旁神经解剖,Schematic thoracic spinal nerve. AD=anterior division, PD=posterior division, C=spinal cord, SG=spinal ganglion, RM=recurrent meningeal, SC=sympathetic chain, RC=ramicommunicantes, PC=posterior cutaneous, LC=lateral cutaneous, AC=anterior cutaneous, P=pleura.,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,穿刺方法,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,穿刺技巧,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,Eason和Wyatt阻力消失法成功率,Lonnqvist, P. A. et al., Anaesthesia. 1995;50(9):813-5,Eason和Wyatt法神经刺激器定位,Naja, Z. and Lonnqvist, P. A. Anaesthesia. 2001;56(12):1184-8.,容量和感觉平面范围（针刺痛）,志愿者，阻力消失法，1% 利多卡因，头侧10ml（2秒推完），转向尾侧5ml（ 1.5秒推完）。置管15分钟后再推1%利多卡因7ml。,Saito, T. et al., Acta Anaesthesiol Scand. 2001;45(1):30-3,容量和温度平面范围,TM：鼓膜，C7：前臂内侧，T4：锁骨中线第四肋间，T10：锁骨中线脐平面，L2：大腿前中部，S2：小腿中后部,Saito, T. et al., Acta Anaesthesiol Scand. 2001;45(1):30-3,2ml 利多卡因=1个节段,剂量与容量和阻滞范围无关,Cheema, S. et al, Anaesthesia. 2003;58(7):684-7,73例慢性疼痛成人，横突上单点注射造影剂X光确认后，推注0.5% 布比卡因10-15ml（60秒），9例无平面。,超声定位平面外穿刺PVB,Hara, K. et al., Anaesthesia. 2009;64(2):223-5.,3-11MHz 线性探头（Philips SONOS 5500）平面外技术穿刺，主要是判断深度,靶向肋间内膜平面外穿刺,Marhofer, P. et al., Br J Anaesth. 2010;105(4):526-32.,肋间入路靶向横突间内膜PVB,Ben-Ari, A. et al., Anesth Analg. 2009;109(5):1691-4.,肋间入路PVB,Ben-Ari, A. et al., Anesth Analg. 2009;109(5):1691-4.,靶向横突下PVB,Shibata, Y. and Nishiwaki, K. Anesth Analg. 2009;109(3):996-7,根据Kappis技术改良（中线旁开3 指，45度角向中线穿刺，触及椎旁间隙的后外侧壁骨质后注药，后被弃用），无需触及骨质，利用IICM和肋横突韧带的连续性,肋间入路平面内穿刺PVB,注药前,探头和针位置,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,肋间入路平面内穿刺PVB,注药后,针尖位置错误,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,肋间入路平面内穿刺PVB,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,肋间入路平面内穿刺PVB,0.75%罗哌卡因5ml+0.75% 罗哌卡因10ml，置管后再给0.75%罗哌卡因5ml （总量20ml）阻滞成功率100% （三个节段）阻滞平面6（中位数）,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,斜轴位靶向肋横突上韧带PVB,Luyet, C., et al., Br J Anaesth. 2009;102(4):534-9,椎管内扩散,Luyet, C., et al., Br J Anaesth. 2009;102(4):534-9,靶向肋横突上韧带的PVB,O. Riain SC et al., Anesth Analg. 2010;110(1):248-51,椎旁阻滞入路,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,SCTL和iimb的异同,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙头侧和尾侧的边界,Krediet AC., et al., Anesthesiology 2015; 123:459-74,肋骨平面-横切面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,横突平面-横切面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,iimb = internal intercostal membrane (green);,横突平面-横切面扫描穿刺法,Krediet AC., et al., Anesthesiology 2015; 123:459-74,imim = innermost intercostal muscle,1: 20 ml lidocaine (15 mg/ml) a median of 5 dermatomes (interquartile range, 4 to 6).2: 20 ml ropivacaine 0.75% a median of 4 or 6 dermatomes (range, 3 to 7), a cadaver study 20 ml injected dye over 3 to 4 TPV spaces (range, 1 to 10) with 40% incidence ofepidural spread.3: 20 ml mepivacaine 1% a dist a median of 3.5 to 4 dermatomes (range, 2 to 6) epidural spread of 25%, while the same volunteers had a sensory blockade over a median of 10 dermatomes,下关节突平面-横切面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,IAP = inferior articulate process; iimb = internal intercostal membrane (green),暂无临床报道,下关节突平面-横切面扫描穿刺法,Krediet AC., et al., Anesthesiology 2015; 123:459-74,4：暂无临床报道5：cadaver study, 34 of 36 needle tips were correctly positioned in the TPV, epidural spread of dye was noted in six instances,肋间平面-矢状面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,iimb = internal intercostal membrane (green),肋间平面-矢状面扫描穿刺法,Krediet AC., et al., Anesthesiology 2015; 123:459-74,6：13 of 14 injections of 1 ml methylene blue 1% resulted in spread of dye to the TPV space. The same study also evaluated a transversal in-plane intercostal approach (fig. 9, arrow no. 1) and found that more attempts were required to successfully place the needle with the sagittal technique compared with the transversal technique: two (range, 1 to 4) and four (range, 1 to 7), respectively).15,Off Side靶向肋横突上韧带,Abdallah, F. W. and Brull, R. Reg Anesth Pain Med. 2014;39(3):240-2,肋横突关节平面-矢状面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,SCTL = superior costotransverse ligament (pink),肋横突关节-矢状面扫描穿刺法,Krediet AC., et al., Anesthesiology 2015; 123:459-74,7：insertion of catheters through the needle was found to be difficult or impossible in 6 of 20 catheters placed, and a high variability in spreadof injectate occurred, including 30% epidural spread.,横突平面-矢状面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,SCTL = superior costotransverse ligament (pink),横突平面-矢状面扫描穿刺法,8：目前尚无临床数据9：目前尚无临床数据,Krediet AC., et al., Anesthesiology 2015; 123:459-74,体会,横突平面-横切面扫描穿刺法,肋间平面-矢状面扫描穿刺法,目标结构：穿破肋间内膜，到达横突下缺点：朝向中线穿刺，有盲区，肩胛间区不易操作，不易置管优点：平面内穿刺角度小，穿刺针清楚用于：低位胸段椎旁,目标结构：穿破肋间内膜或肋横突韧带，到达肋间内膜和肋间最内肌之间缺点：穿刺角度大，针道消失困难优点：肩胛间区可操作，易于鉴别节段用于：低位和高位椎旁,横突平面-横切面扫描,肋间平面-矢状面扫描,节段的鉴别：12Rib,0.5% Ropivacaine 20ml单次平面,连续 vs 单次(Eason和Wyatt法),Catala, E. et al., J Cardiothorac Vasc Anesth. 1996;10(5):586-8.,单次能达到什么效果,Hill, S. E. et al., Anesthesiology. 2006;104(5):1047-53,单次能达到什么效果,0.5% Ropivacaine 30 mL,浓度和连续阻滞范围,0.5%罗哌卡因20ml切皮前+20ml手术结束白色：0.2% 罗哌卡因组黑色：0.5% 罗哌卡因组6ml/h连续阻滞,Yoshida, T. et al., Anaesthesia. 2014;69(3):231-9,肝右叶切除术后镇痛的问题,静脉内阿片为主镇痛的问题：镇痛效果不佳，药物代谢影响，呼吸抑制硬膜外镇痛的风险：肝叶切除术后凝血功能不良（70% 术后第一天PT延长），交感阻滞肝血流增加，输血风险增加，输液量增加，（Tzimas P, et al., Anaesthesia. 2013;68:628635）PVB的可行性：病例报告研究PVB用于两例肝右叶切除术（Ho, A. M. et al., Br J Anaesth. 2004;93(3):458-61）,PVB 在肝胆手术应用,胆囊切除术后镇痛Giesecke K, Hamberger B, Jarnberg PO, Klingstedt C. Paravertebral block during cholecystectomy: effects on circulatory and hormonal responses. Br J Anaesth 1988;61: 652-656Kumar CM. Paravertebral block for post-cholecystectomy pain relief. Br J Anaesth 1989;63: 129.Naja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. Eur J Anaesthesiol 2004;21: 489-495肝癌射频消融Culp WC, Payne MN, Montgomery ML. Thoracic paravertebral block for analgesia following liver mass radiofrequency ablation. Br J Radiol 2008;81: e23-25.经皮胆道穿刺引流Culp WC, McCowan TC, DeValdenebro M, et al. Paravertebral block: an improved method of pain control in percutaneous transhepatic biliary drainage. Cardiovasc Intervent Radiol 2006;29: 1015-1021肝区创伤痛Hall H, Leach A. Paravertebral block in the management of liver capsule pain after blunt trauma. Br J Anaesth 1999;83: 819-821.胆道内扩张引起的疼痛Culp WC, Jr., Culp WC. Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol 2005;16: 1397-1400.,PVB用于肝右叶切除的解剖基础,右肋下皮肤感觉神经纤维：发自T5 到T11 （）肝脏交感神经纤维：来自双侧T7到T11交感神经，支配肝脏包膜和肝内血管（Berthoud HR. Anat Rec A Discov Mol Cell Evol Biol 2004;280: 827-835）（ ）副交感纤维：自迷走神经（）,一般资料,舒芬太尼用量和PCA按压次数,静息和咳嗽时疼痛评分,全凭椎旁阻滞经皮肾镜,躯体痛：经10肋间、11肋间、肋缘下建立碎石通道内脏痛：,PVB用于PCNL的解剖基础,Millers Anesthesia. Philadelphia: Churchill Livingstone; 2009,PVB等躯干外周神经阻滞,1920s年：心绞痛、