新版超声引导技术应用于区域麻醉和镇痛final

上海交通大学附属第六人民医院麻醉科 W. Jiang,超声在麻醉与疼痛医学中的应用Application of ultrasound in anesthesia and pain medicine,麻醉与超声 Anaesthesia and ultrasound,传统麻醉 现代麻醉 traditional anaesthesia modern anaesthesia 药物 : 单一，不良反应多 选择，安全性，可控性 技术 : 盲探操作 可视操作理论 : 麻醉基础和临床理论日益丰富超声技术与麻醉 ultrasound technique and anaesthesia以其独特优点成为近年热点, 方兴未艾喻为现代麻醉医生的“第三只眼睛”麻醉各领域广泛应用,“The third eye ” for anaesthetist,内 容 Contents,局部麻醉的发展 development of local anesthesia超声设备和原理 ultrasound equipments and principles超声技术在现代麻醉中的应用 application of ultrasound technique in anesthesia 临床麻醉 clinical anesthesia 疼痛治疗 pain management 危重病医学 Critical Care Medicine,从古柯树叶中提取的生物碱 Alkaloid derived from the leaves of Erythroxylon coca 1860年Niemann制成纯白结晶物，取名可卡因 Niemann in 1860 produced pure white crystals which named cocaine,局麻药物-可卡因 local anesthetic-cocaine,古柯叶 folium cocoe coca leaf gukeye,罂粟花 poppy flower,1884年, Carl Koller将Cocaine成功用于眼局部手术 Carl Koller in the summer of 1884 applied cocaine to the conjunction with success可卡因 Cocaine毒性 toxicity时效短 short duration 成瘾性 addiction,Carl Koller (1857-1944),可卡因 cocaine,普鲁卡因 procaine (1904) 低毒性、无成瘾 low toxicity , lack of addictive properties 时效短、过敏反应 short duration ,allergic reactions,探索新的更加安全的局麻药 (1890s1940s) the introduction of safer local anesthetics,地卡因 amethocaine (1937) 强效、时效长 potent, long duration 毒性、过敏反应 toxic, allergic reactions,局麻药物 local anesthetic,1943: Nils Lofgren 合成利多卡因 Nils Lofgren synthesized lidocaine in 1943利多卡因衍生物的合成 the synthesis of lidocaines derivatives甲哌卡因 mepivacaine (1956)布比卡因 bupivacaine (1963)丙胺卡因 prilocaine (1960)罗哌卡因 ropivacaine (1980)左旋布比卡因 levobupivacaine(1993),局麻药物 local anesthetic,首次神经阻滞 the first nerve blockWilliam Burke (the end of Nov. 1884)William Halsted and Richard Hall (the end of 1885)至1900年, 大部分现今局部麻醉技术已用于临床 most currently used techniques of RA were devised by 1900臂丛阻滞（腋、锁骨上） brachial plexus block腹腔神经丛阻滞 celiac plexus block头、颈部神经阻滞 nerve block about the head and neck静脉内局部麻醉 bier block脊麻 spinal block硬膜外阻滞 epidural block,神经阻滞 nerve block,传统神经定位方法 conventional methodology for nerve location 解剖定位 anatomical landmarks操作难度高 difficult to perform成功率低 low success rates异感定位 paresthesia techniques神经损伤 nerve damage成功率 90 success rates神经定位方法的发展 development for nerve location神经刺激器 nerve stimulator 超声引导定位 ultrasound guidance,神经定位方法 methodology for nerve location,Title in here,局 限 性周围神经病变 装有心脏起搏器者 费用 肌群收缩致患者不适和疼痛,周围神经电刺激 peripheral nerve stimulation (PNS),Disadvantages,超声引导局部麻醉 Ultrasound-guided regional anesthesia (UGRA),1978年La Grange最早报道 超声下锁骨上臂丛阻滞 UGRA was first described by La Grande et al. in 1978 Br J Anesth, 1978, 50:965-967近十年来UGRA得到长足发展 UGRA developed become a more significant area of interest to anesthesiologists便携式 portable更精确 more refined价格合理 affordable,原理 principles of ultrasound technology不同的人体解剖结构均有各自的反射特性 different human anatomical structures have varying reflective properties反射（回声）能够被超声探头收集 the reflection (echo) is collected by the probe反射的信号经放大处理后显示在数字监测仪上 the amplitude of reflected signal is displayed on a digital monitor,超声技术原理 principles of ultrasound technology,组织回声 different type of ultrasound“高回声”结构“亮”图像（如：骨、腱） “hyperechoic” structures “bright” on screen (e.g. bone, tendons)“低回声”结构“暗”图像（如：脂肪、血管） “ hypoechoic” tissues “dark” on screen (e.g. fat, vessels) 外周神经一般为高回声 peripheral nerves usually have a hyperechoic appearance,超声技术原理 principles of ultrasound technology,高频超声 higher-frequency ultrasound高清晰度(分辨率), 低穿透力 higher resolution, low penetration低频超声 lower-frequency ultrasound低清晰度、高穿透力 lower image resolution, deeper penetration位置较浅神经 superficial nerve 肌间沟、锁骨上、腋路臂丛: 1013 MHzinterscalene, supraclavicular, axillary brachial plexus位置较深神经 deep nerve 锁骨下、腘、腰丛: 57 MHzInfraclavicular or popliteal region, lumbar plexus,超声技术原理-频率 principles of ultrasound-frequency,超声引导的外周神经阻滞优点Advantages of Ultrasound Guided Peripheral Nerve Blocks,Adopted from Marhofer et al 2004,Ultrasound-guided Regional Anesthesia. Anesthesiology 2006; 104:36873.,NA=not applicable. NS=not statistically significant (P0.05). Ref.=reference,Ultrasound-guided Regional Anesthesia. Anesthesiology 2006; 104:36873.,NA=not applicable. NS=not statistically significant (P0.05). Ref.=reference,平面内和平面外 in plane and out of plane,超声下肌间沟臂丛阻滞ultrasound guided interscalene brachial plexus blockade,颈动脉三角,肌间沟,锁骨,臂丛上干,臂丛中干,臂丛下干,胸锁乳突肌,前斜角肌,短轴平面内技术,典型的臂丛三干超声图,液性暗区,臂丛,臂丛完全被液性暗区包围,超声下肌间沟臂丛阻滞ultrasound guided interscalene brachial plexus blockade,The femoral nerve was surrounded by a fluid space. FN: femoral nerve 股神经, FA: femoral artery 股动脉, LA: local anesthetic 局麻药 , IF: iliac fascia髂筋膜,超声下股神经阻滞ultrasound guided femoral nerve blockade,注射局麻药有利于靶神经结构显像 the targeted nerve structures often can be more easily identified following the injection of local anesthetic,甜圈征 doughnut,Ultrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206,Ultrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206,Fig 3. High resolution images from median longitudinal (A), paramedian longitudinal (B) scans. All relevant structures are named.,硬膜外腔,硬膜外腔,硬膜外腔,Ultrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206,Fig 3. High resolution images from median longitudinal (A), paramedian longitudinal (B)scans. All relevant structures are named.,Caudal injection can be reliably imaged using portable ultrasound a preliminary study. Pediatric Anesthesia, 2005, 15: 948952,Real-time three-dimensional ultrasound for continuous interscalene brachial plexus blockade. J Anesth (2009) 23:466468,Case 1,一般情况患者：男，25岁，65公斤，腰2骨折复位内固定术后两月诊断：右足跟软组织缺损，拟行手术：右足跟清创+腓肠神经加强皮瓣转移术麻醉方法：坐骨神经+股神经阻滞,腰2骨折术后,超声下坐骨神经阻滞,超声下股神经阻滞,Case 1,术中情况体位：左侧卧位静脉药物：咪唑安定，1mg；芬太尼，0.1mg生命体征平稳，术者满意术后镇痛良好，患者满意度高,左侧卧位，吸氧,手术部位,一般情况患者：男，86岁病史冠心病，前间壁心梗史5年高血压病史18年脑梗史10年血肌酐升高史5年,肾性贫血；骨质疏松史5年 诊断双下肢动脉粥样硬化性闭塞症右第二足趾截趾术后，右第三足趾坏死并感染右足跟软组织缺损拟行手术：右大腿截肢术 高龄，高危！,Case 2,麻醉过程术前：神经阻滞股神经+坐骨神经+股外侧皮 神经+闭孔神经术中镇痛良好生命体征平稳,全麻？腰麻 or 硬膜外？神经阻滞？,一般情况患者：男，68岁，病史重度鼾症，BMI 40 kg/m2 慢性心衰拟行手术：右膝关节置换术麻醉方法术前：神经阻滞 (股神经+坐骨神经 +股外侧皮神经+闭孔神经术中喉罩浅麻醉维持术后患者清醒迅速，无痛避免了鼾症病人术后拔管延迟，呼吸抑制等并发症,Case 3,无痛关节置换 no pains for Joint Replacement,术 前神经阻滞,无痛的关节置换 no pains for Joint Replacement,Image Info www.wizdata.co.kr - Note to customers : This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,术 中强阿片药物,术 后切口周围注射局麻药镇痛泵,目标,多模式镇痛,超声与疼痛 ultrasound and pain management,疼痛治疗-神经阻滞 pain management-nerve block,治疗药物 drugs for pain management局麻药糖皮质激素 作用原理 principles暂时阻断痛觉传导阻断交感神经，扩张血管，改善局部血供消除软组织水肿，减轻神经受压消除细胞因子、炎性介质对神经的刺激消除神经炎症、水肿帮助神经修复,超声与疼痛 ultrasound and pain management,腰交感神经节阻滞 lumbar sympathetic and celiac plexus block Kirvela等首先以超声多普勒引导实行超声可精确定位腰交感神经干，阻滞有效率100%优点：定位精确、价廉、无射线、机体影响小、良好的应用前景Kirvel O, et al. Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique. Reg Anesth, 1992, 17(1):43-6.星状神经节阻滞 stellate ganglion block (SGB) Kapral超声监控下实施观察到针尖和药物的扩散安全性提高：SGB并发症 副作用Kapral S, et al. Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth, 1995, 20(4):323-8.,超声与疼痛 ultrasound and pain management,腰交感神经节阻滞 lumbar sympathetic and celiac plexus block Kirvela等首先以超声多普勒引导实行超声可精确定位腰交感神经干，阻滞有效率100%优点：定位精确、价廉、无射线、良好的应用前景Kirvel O, et al. Ultrasonic guidance of lumbar sympathetic and celiac plexus block: a new technique. Reg Anesth, 1992, 17(1):43-6.星状神经节阻滞 stellate ganglion block (SGB) Kapral超声监控下实施观察到针尖和药物的扩散安全性提高：SGB并发症 Kapral S, et al. Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth, 1995, 20(4):323-8.,超声与疼痛 ultrasound and pain management,肩部注射疗法治疗肩峰下滑囊炎 shoulder injections in the treatment of subacromial bursitis两组 two groups盲目穿刺 blind group超声引导穿刺 ultrasound-guided group标准 standard注药1周后肩部活动度大小作为疗效评价结果与结论 result and conclusion超声引导组疗效 对照组超声引导准确定位针的位置,注射时安全有效,明显增加肩部的活动度，是很好的辅助措施,Chen MJL, et al. Ultrasound-Guided Shoulder Injections in the treatment of Subacromial Bursitis. Am. J. Phys. Med. Rehabil. 2006, 85(1): 32-5,超声与疼痛 ultrasound and pain management,肩部注射疗法治疗肩峰下滑囊炎 shoulder injections in the treatment of subacromial bursitis,Figure 1 Patients sit in an upright position and with the back well supports, the arms are positioned behind their backs and with the elbows bent.,超声与疼痛 ultrasound and pain management,岗上肌,肱骨头,肩峰下滑囊,岗上肌,肱骨头,肩峰,肩峰,三角肌,三角肌,岗上肌,肩峰下滑囊,肩峰,肩峰下滑囊,肩峰下滑囊,小关节源性疼痛 pain of facet Joint in the Lumbar Spine,小关节源性小关节功能紊乱小关节退行性变小关节的神经支配脊神经背支内侧支,Ultrasound Guidance for Facet Joint Injections in the Lumbar Spine: A computed tomography-Controlled feasibility Study. Anesth Analg 2005;101:57983.,穿刺针,If,mf,If,mf,If : lateral facet 外侧关节面mf: medial facet 中关节面 ：needle 穿刺针,食道超声心动图 Transesophageal echocardiography (TEE),基本设备 basic equipmentTee 探头 (换能器)主机图像记录系统主要临床应用main clinical application血流动力学检测心肌缺血监测手术效果即刻评价其他术中监测：肺栓塞等,食道超声心动图 Transesophageal echocardiography (TEE),TEE in right atrial long axis two-dimensional,Plinks et al. Cardiovascular Ultrasound 2006 4:6 doi:10.1186/1476-7120-4-6,Real-Time 3-Dimensional Echocardiography in the Operating Room. Semin Cardiothorac Vasc Anesth. 2008, 12(4):248-64.,AML: anterior mitral leaflet 二尖瓣前叶 PML: posterior mitral leaflet 二尖瓣后叶,食道超声心动图 Transesophageal echocardiography (TEE),TEE在ICU的应用 application in the intensive care unit 对于ICU危重病人诊断和监测，有很强的指导作用急需确诊的心脏瓣膜病感染性心内膜炎低血压和血容量的具体评价病情危重状态下左、右室功能评价心源性栓塞的功能诊断低氧血症者有无卵圆孔未闭的右向左分流胸痛的鉴别诊断，特别是主动脉夹层和心肌梗死后并发症的鉴别心包积液、心包占位性病变、纵隔出血的诊断胸部外伤后心脏并发症的诊断,肺栓塞 pulmoamy embolism, PETEE对于确诊肺栓塞 for confirmation of PE灵敏度: 70% 特异性: 81% 70% sensitivity and 81% specificity Impact of TEE in noncardiac surgery. International Anesthesiology Clinics, 2008, 46: 121-136.可能在肺动脉的主要分支和右肺动脉看到栓子 may be seen in the main pulmonary artery or the right pulmonary arteryUsefulness of Transesophageal echocardiography to diagnose perioperative pulmonary embolism. Journal of Clinical Anesthesia, 2005, 17: 146-154,TEE与肺栓塞 TEE and pulmoamy embolism,TEE与肺栓塞 TEE and pulmoamy embolism,Singh A, Fleming N. Right heart embolism and acute right atrial dilation during total knee arthroplasty. Anesth Analg, 2007, 105(5):1224-7.,Figure 1. Mid-esophageal bicaval view showing a large horseshoe shaped embolus in the right atrium,Figure 2. Mid-esophageal bicaval view showing the inter-atrial septum and its significant bulging after tourniquet release.,空气栓塞 air embolismTEE 是监测心内气体栓子的最敏感方法。一般从经胃短轴和四腔长轴两个切面观察，直径小于2 mm 的栓子能清楚显示全髋置换术 (THR)右心中气体栓子的检出率很高静脉空气栓塞可能是THR心肺功能障碍的重要原因股骨假体植入是心腔内栓子发生最明显时段，几乎每个患者都发生术中用TEE 监测有助于早期诊断,TEE与空气栓塞 TEE and air embolism,1 王爱忠, 江伟. 全髋置换术与静脉空气栓塞.中国骨与关节损伤杂志, 2008, 23(4): 348-350. 2 王爱忠,张卫兴, 江伟. 全髋置换术中经食管超声心动图监测栓子和室壁运 动异常的临床研究.临床麻醉学杂志, 2008, 24(5): 373-375.,脂肪栓塞和空气栓塞 fat embolism and air embolism,脂肪栓塞 fat e