区域麻醉在产科的运用Fingerman

Regional Anesthesia in Obstetric Anesthesia Practice:,Mitchell Fingerman, M.D.Division Chief & Fellowship DirectorRegional & Ambulatory AnesthesiologyWashington University School of Medicine, St. Louis, MONo Pain Labor & Delivery Global Health Initiative NPLD-GHIWuhan, China June 2015,Headquarters-Barnes Jewish Hospital,Disclosures:,On-Q/Halyard Health,AGENDA:TRANSVERSUS ABDOMINIS PLANE BLOCK-Classical Approach-Subcostal Approach,Transversus Abdominis Plane (TAP) Block:,Transversus Abdominis Plane (TAP) Block:,TAP Block Outline:,History of the TAP Block Indications Efficacy/Applicability in Obstetric Anesthesia Anatomy Techniques:Classical ApproachSubcostal Approach Risks,History of the TAP Block:,Originally described by A.N. Rafi, IrelandPerformed on 200 pts. without any “untoward sequelae”Landmark technique with fascial “pop” described,History of the TAP Block:,Lumbar Triangle of PetitThe only area of the abdominalwall where the internal obliquemuscle can be localized directly,Limitations with Initial Technique:,Blind techniqueDependence on “pops”Obese patientsElderly patientsPediatric patients,Why TAP Blocks?,Significant reduction of opioid useLess nausea/vomitingLess urinary retentionLess constipationImproved pain controlAvoidance of epidural issuesHypotensionAnticoagulants/antithromboticsImproved patient and nurse satisfaction,Which Patients?,Cesarean Section*General Surgery: Inguinal hernia repairUmbilical hernia repairBread and butter (CCK, Exp-lap)Colorectal patientsGyn/Onc patientsGU patientsOrthopedics:ICBGAnterior spinal fusionsRescue for an inadequate epidural*,TAP Applications:,Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery.Charlton S, Cyna AM, Middleton P, Griffiths JD.SourceDepartment of Womens Anaesthesia, Womens and Childrens Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006.AbstractBACKGROUND:The transversus abdominis plane (TAP) block is a peripheral nerve block which anaesthetises the abdominal wall. The increasing use of TAP block, as a form of pain relief after abdominal surgery warrants evaluation of its effectiveness as an adjunctive technique to routine care and, when compared with other analgesic techniques.OBJECTIVES:To assess effects of TAP blocks (and variants) on postoperative analgesia requirements after abdominal surgery.SEARCH STRATEGY:We searched specialised registers of Cochrane Anaesthesia and Cochrane Pain, Palliative and Supportive Care Review Groups, CENTRAL, MEDLINE, EMBASE and CINAHL to June 2010.SELECTION CRITERIA:We included randomised controlled trials (RCTs) comparing TAP block or rectus sheath block with: no TAP or rectus sheath block; placebo; systemic, epidural or any other analgesia.DATA COLLECTION AND ANALYSIS:At least two review authors assessed study eligibility and risk of bias, and extracted data.MAIN RESULTS:We included eight studies (358 participants), five assessing TAP blocks, three assessing rectus sheath blocks; with moderate risk of bias overall. All studies had a background of general anaesthesia in both arms in most cases.Compared with no TAP block or saline placebo, TAP block resulted in significantly less postoperative requirement for morphine at 24 hours (mean difference (MD) -21.95 mg, 95% confidence interval (CI) -37.91 to 5.96; five studies, 236 participants) and 48 hours (MD -28.50, 95% CI -38.92 to -18.08; one study of 50 participants) but not at two hours (all random-effects analyses). Pain at rest was significantly reduced in two studies, but not a third.Only one of three included studies of rectus sheath blocks found a reduction in postoperative analgesic requirements in participants receiving blocks. One study, assessing number of participants who were pain-free after their surgery, found more participants who received a rectus sheath block to be pain-free for up to 10 hours postoperatively. As with TAP blocks, rectus sheath blocks made no apparent impact on nausea and vomiting or sedation scores.AUTHORS CONCLUSIONS:No studies have compared TAP block with other analgesics such as epidural analgesia or local anaesthetic infiltration into the abdominal wound. There is only limited evidence to suggest use of perioperative TAP block reduces opioid consumption and pain scores after abdominal surgery when compared with no intervention or placebo. There is no apparent reduction in postoperative nausea and vomiting or sedation from the small numbers of studies to date. Many relevant studies are currently underway or awaiting publication.,COCHRANE REVIEW SHOWING A REDUCTION IN NARCOTIC USE WHEN TAP BLOCKS UTILIZED,Can J Anesth (2012) 59:766-778.,Purpose: To assess the efficacy of TAP block in improving analgesia following Cesarean delivery Nine studies with 524 patients included (261 received TAP block and 263 as controls)Seven studies under spinal and two studies performed under general anesthesiaAnatomical landmark technique in 3 studies and US-guided technique in 6 studies,Can J Anesth (2012) 59:766-778.,TAP block significantly reduced opioid consumption after Cesarean delivery at: 6 hours, 12 hours and at 24 hoursTAP block also reduced pain scores for up to 12 hours and nausea in patients who did not receive intrathecal morphineWhen compared with intrathecal morphine, pain scores on movement and opioid consumption at 24 hours were lowerTime to first rescue analgesic was longer with intrathecal morphine (8 hours vs. 4 hours) although opioid related side effects were more common,British Journal of Anaesthesia 2012: 109(5): 679-87.,Five trials including 312 patientsTAP block reduced the mean 24 hour IV morphine consumption by 24 mg when spinal morphine was not usedTAP block also reduced visual analogue scale pain scores and decreased the incidence of opioid-related side effectsDifferences in primary and secondary outcomes were not significant when spinal morphine was used,TAP Block-Limitations:,Not a panacea for all abdominal painGreat somatic pain coverage due to innervation of abdominal skin, muscles and parietal peritoneumDull visceral pain will still be experienced,TAP Anatomy-Triangle of Petit:,Borders of the lumbar triangle:-Latissimus dorsi-External oblique-Iliac crestFirst pop: entry into plane between external oblique and internal obliqueSecond pop: Entry into TAP plane between internal oblique and transversus abdominis,TAP Anatomy:,Innervation of the ant/lat. abdominal wall arises from the anterior rami of spinal nerves T7 to L1Intercostal nerves (T7-T11)Subcostal nerve (T12)Iliohypogastric and ilioinguinal nerves (L1)The anterior divisions of T7-T11 continue from the intercostal space to enter the abdominal wall between the internal oblique and transversus abdominis,NYSORA.COM,TAP ANATOMY,External Oblique,Internal Oblique,Transversus Abdominis,Intercostal Nerve,RAPM, Vol 32, No 5, 2007: pp. 399-404.,RAPM, Vol 32, No 5, 2007: pp. 399-404.,RAPM, Vol 32, No 5, 2007: pp. 399-404.,TAP Anatomy-Schematic:,TAP Technique- Classical Approach:,Patient supineAbdomen exposed between costal margin and iliac crest80-120 mm 22g short beveled needle (18/19g Tuohy for catheters)Linear high frequency transducer in an axial (transverse) planeNerves cannot be visualized-potential space blockLarge volume block (20-30 ml of dilute local anesthetic per side),TAP Block Anatomy,Lateral Scan,Medial Scan,Sub-q,Ext. Oblique,Ext. Oblique,Int. Oblique,Int. Oblique,Sub-q,Trans. Abdominis,Trans. Abdominis,Bowel loop,Peritoneal Cavity,TAP Block Injection,Ext. Oblique,Local,Trans. Abdominis,Peritoneal Cavity,Int. Oblique,Needle,TAP Anatomy-Discoveries:,Nerves of T6-T9 enter the TAP medial to the anterior axillary lineT6 enters the TAP just lateral to the linea albaT7-T9 enter at progressively increasing distances from the linea albaNerves running in the TAP lateral to the anterior axillary line are T9-L1 segmental nerveThis may explain why the classic TAP is only suitable for lower abdominal surgeryIn addition, extensive branching and communication was discovered (The “TAP plexus” of T9 to L1)-explains the power of a single injection,Rozen WM, Tran TM, Ashton MW, et al. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 2008; 21(4):325.,Rozen WM, Tran TM, Ashton MW, et al. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 2008; 21(4):325.,“TAP PLEXUS”,Headscratching ensued,Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008;106(2): 674.,TAP Schematic- Subcostal Approach:,Hebbard PD et al. Ultrasound-Guided Continuous Oblique Subcostal Transversus Abdominis Plane Blockade: Description of Anatomy and Clinical Technique. Regional Anesthesia and Pain Medicine. Volume 35(5): 436-41.,Varying U/S Views- Subcostal Approach:,Hebbard PD et al. Ultrasound-Guided Continuous Oblique Subcostal Transversus Abdominis Plane Blockade: Description of Anatomy and Clinical Technique. Regional