股神经、髂筋膜、隐神经-蒋嘉

,朝阳医院超声麻醉疼痛周,髂筋膜、股神经和隐神经/收肌管阻滞,朝阳医院麻醉科蒋嘉,.,膝关节置换镇痛,TerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37,.,膝关节置换镇痛,Primaryoutcomes:(1)acutepostoperativepain(duringrestandmovement)(2)postoperativeopioidconsumption(3)qualityofearlypostoperativerehabilitation(functionalassessments)Secondaryoutcomes:postoperativecomplications(e.g.,nausea,vomiting,falls),durationofhospitalization,bloodloss,procedurefailure,andpatientwithdrawalTerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37,.,与PCA比较,(A)Overallpainscoresinthefirst72hduringrest(B)overallpainscoresinthefirst72hduringmovement,(C)overallopioidconsumptioninthefirst72h(D)overallrangeonmotioninthefirst72h.,TerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37,.,RankingF/S(6)F/O(6)LP/S(3)FIC(3)PA(2)Rankingonhigh-qualitystudiesF/SFICLPPAACB,TerkawiAS,MavridisD,SesslerDI,etal.PainManagementModalitiesafterTotalKneeArthroplasty.ANetworkMeta-analysisof170RandomizedControlledTrials.Anesthesiology2017;126:923-37,.,闭孔神经股神经,股外侧皮神经,隐神经,.,髂筋膜阻滞,阻滞的是什么？,.,髂筋膜,外界：髂嵴内侧缘内界：小骨盆的界线向下一直延续到股骨小转子水平覆盖腰大肌和髂肌,.,髂筋膜,闭孔神经与髂肌和髂筋膜并没有密切的联系,闭孔神经,.,髂筋膜阻滞的扩散范围（MRI）,SwensonJD,DavisJJ,etal.Localanestheticinjectiondeeptothefasciailiacaattheleveloftheinguinalligament:thepatternofdistributionandeffectsontheobturatornerve.JournalofClinicalAnesthesia(2015)27,652657,腹股沟韧带水平,骶骨水平,冠状位,腹股沟韧带水平髂筋膜阻滞,.,超声引导髂筋膜阻滞的方法,腹股沟韧带下法寻找缝匠肌和髂肌药液扩散：缝匠肌和髂肌之间阻滞：股神经、股外侧皮神经？,.,超声引导髂筋膜阻滞,腹股沟韧带上法,BullockWM,YalamuriSM,GregorySH,etal.Ultrasound-GuidedSuprainguinalFasciaIliacaTechniqueProvidesBenefitasanAnalgesicAdjunctforPatientsUndergoingTotalHipArthropla.JUltrasoundMed2017;36:433438,.,超声引导腹股沟韧带上髂筋膜阻滞,寻找髂前上棘、髂肌、腹横肌药液扩散：腹横肌和髂肌之间阻滞：股神经、股外侧皮神经、髂腹股沟神经,BullockWM,YalamuriSM,GregorySH,etal.Ultrasound-GuidedSuprainguinalFasciaIliacaTechniqueProvidesBenefitasanAnalgesicAdjunctforPatientsUndergoingTotalHipArthropla.JUltrasoundMed2017;36:433438,.,股神经阻滞,如何提高成功率？,.,股神经解剖,股神经,.,股神经超声影像,腹股沟水平股动脉外侧，髂筋膜深部，髂肌表面高回声，宽而扁，椭圆形深度：13cm,.,超声探头的最佳位置,旋股内、外侧动脉,.,超声探头的最佳位置,旋髂深浅动脉必要时用多普勒调整位置腹股沟韧带和腹横纹中间位,置或许最佳,OGAMIK,MURATAH,SAKAIA,etal.DeepandSuperficialCircumflexIliacArteriesandTheirRelationshiptotheUltrasound-GuidedFemoralNerveBlockProcedure:ACadaverStudy.ClinicalAnatomy30:413420(2017),.,进针点？药液？置管位置？,短轴，平面内法,短轴，平面外法,.,进针点？药液？置管位置？,BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:2329,.,进针点？药液？置管位置？,TopographicviewoftheterminalbranchesofthefemoralnerveACN：anteriorcutaneousnerveMCN：medialcutaneousnervePMN：pectineusmusclenerve;RFMN：rectusfemorismusclenerveSMN：SartoriusmusclenerveSN：saphenousnerveVIMN：vastusintermediusmusclenerveVLMN：vastuslateralismusclenerveVMMN：vastusmedialismusclenerve隐神经部分与神经其他部分可能存在隔断平面内由外向内进针，一直到神经内侧，药液包绕，神经前方置管,BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:2329,.,辨认不清髂筋膜怎么办？,BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:2329,GIPM：髂腰肌凹槽（agrooveformedbytheiliacandlateralpsoasmuscles）,.,股神经阻滞寻找GIPM旁结构,BenoitFanara,Jean-LucChristophe,AnnieBoillot,etal.Ultrasoundguidanceofneedletippositionforfemoralnerveblockade.Anobservationalstudy.EurJAnaesthesiol2014;31:2329,髂筋膜,GIPM:85%髂筋膜：68%,.,阔筋膜张肌股外侧皮神经缝匠肌,股外侧皮神经阻滞,支配：大腿前外侧适应证：髋部手术为主过去：髂前上棘内下12cm，皮下0.51cm变异大：以解剖标志为基础的传统阻滞技术不可靠,.,超声引导股外侧皮神经阻滞,高频探头扫描方式：阔筋膜张肌和缝匠肌超声影像：低回声椭圆形（此处可能已经分支）进针路径：平面内或平面外局麻药：5ml目标：局麻药在神经周围或阔筋膜张肌和缝匠肌之间阔筋膜下方扩散,.,隐神经阻滞,与收肌管阻滞？,.,隐神经阻滞,股神经的最大感觉支支配：内侧膝关节、髌骨下方、小腿内侧和足内侧缘的皮肤适应证：膝关节手术、大隐静脉手术、坐骨神经阻滞的补充不影响股四头肌力量局麻药：低浓度，510ml,.,隐神经走行,股动脉伴行，内下行通过收肌管，接近膝盖穿出大腿中段：缝降肌深面，与股动脉伴行膝上：缝匠肌和股内肌之间的收肌管内，与股动静脉伴行膝下：胫骨粗隆表面，与大隐静脉伴行,.,隐神经阻滞入路Subsartorialplexusblock（大腿中段）AdductorCanalblock（大腿远端/收肌管）Subcoutaneousinfiltrationblock（小腿近端）,.,.,收肌管,收肌肌腱键膜管状间隙,构成：股内侧肌、缝匠肌、长收肌和大收肌近端：股三角顶点远端：收肌管裂孔表面：股内收膜内容：股神经的股内侧肌支、隐神经、股中间皮神经、股动脉、股静脉,.,收肌管相关肌肉,.,收肌管超声,起点：股三角（倒）顶点，缝匠肌与长收肌内侧缘相交处终点：股动脉偏离缝匠肌，进入股内侧肌和大收肌之间（收肌腱裂孔）S：缝匠肌VM：股内侧肌AL：长收肌AM：大收肌WongWY,etal.DefiningtheLocationoftheAdductorCanalUsingUltrasound.RegAnesthPainMed2017;42:241245,.,股内收膜,vastoadductormembrane,WongWY