椎旁阻滞临床应用PPT参考幻灯片

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,1,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,HugoSellheim(28.Dezember1871inBiblisbeiWorms;22.April1936inLeipzig)wareindeutscherGynkologeundGeburtshelfer.,2,ArthurLwen验证PVB(1911年),ArthurGeorgLwen(6.Februar1876inWaldheim,Sachsen;30.Januar1958inLneburg)wareindeutscherChirurgundWegbereiterderheutigenAnsthesiologie,3,Richardson,J.etal.,BrJAnaesth.1998;81(2):230-8.,4,ArthurLwen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,5,MaxKappis（1919年）,KappisM.SensibilitaetundlocaleanaesthesiagebeitderBauchoelemitbesondererberuchsichtigungderSplanchnicusanaesthesia.BeitrKlinChir1919;115:16175FujitaY.MaxKappis,aninventorofsplanchnicnerveblock.Masui.1993Sep;42(9):1378-80.ArticleinJapanese,MaxKappis(6.Oktober1881inTbingen;5.August1938)wareindeutscherChirurg,6,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（MandelF.Paravertebralblock.NewYork:GruneandStratton,1946）1950s-1960s文献报道几乎消失1970s，阻力消失法引入后，再度流行(EasonMJ,WyattR.Paravertebralthoracicblock-areappraisal.Anaesthesia.1979;34(7):638-42.),7,Richardson,J.etal.,AnesthAnalg.1998;87(2):373-6.,8,Figure2.Inthepresenceofcompletenumbnessonsensoryexamination,depressionoftheS1dermatomalSSEPrangedfrom0%(A),togreaterthan50%(B),to100%(C)Dataarerepresentativeexamples.,BenzonHTetal.,AnesthAnalg.1993;76(2):328-32.,9,10,PVBvs硬膜外:4-8h和48hVAS评分,Ding,X.etal.,PLoSOne.2014;9(5):e96233,11,PVBvs硬膜外:吗啡量和尿潴留,Ding,X.etal.,PLoSOne.2014;9(5):e96233,12,PVBvs硬膜外:PONV和低血压,Ding,X.etal.,PLoSOne.2014;9(5):e96233,13,PVBvs硬膜外:失败率和肺部并发症,Ding,X.etal.,PLoSOne.2014;9(5):e96233,14,区域阻滞与术后慢性疼痛,AndreaeMHandAndreaeDA.BrJAnaesth.2013;111(5):711-20,15,椎旁神经解剖,Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42,16,椎旁神经解剖,Schematicthoracicspinalnerve.AD=anteriordivision,PD=posteriordivision,C=spinalcord,SG=spinalganglion,RM=recurrentmeningeal,SC=sympatheticchain,RC=ramicommunicantes,PC=posteriorcutaneous,LC=lateralcutaneous,AC=anteriorcutaneous,P=pleura.,Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42,17,穿刺方法,Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42,18,穿刺技巧,Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42,19,Eason和Wyatt阻力消失法成功率,Lonnqvist,P.A.etal.,Anaesthesia.1995;50(9):813-5,20,Eason和Wyatt法神经刺激器定位,Naja,Z.andLonnqvist,P.A.Anaesthesia.2001;56(12):1184-8.,21,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.etal.,ActaAnaesthesiolScand.2001;45(1):30-3,22,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.etal.,ActaAnaesthesiolScand.2001;45(1):30-3,2ml利多卡因=1个节段,23,剂量与容量和阻滞范围无关,Cheema,S.etal,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。,24,超声定位平面外穿刺PVB,Hara,K.etal.,Anaesthesia.2009;64(2):223-5.,3-11MHz线性探头（PhilipsSONOS5500）平面外技术穿刺，主要是判断深度,25,靶向肋间内膜平面外穿刺,Marhofer,P.etal.,BrJAnaesth.2010;105(4):526-32.,26,肋间入路靶向横突间内膜PVB,Ben-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.,27,肋间入路PVB,Ben-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.,28,靶向横突下PVB,Shibata,Y.andNishiwaki,K.AnesthAnalg.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,29,肋间入路平面内穿刺PVB,注药前,探头和针位置,Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6,30,肋间入路平面内穿刺PVB,注药后,针尖位置错误,Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6,31,肋间入路平面内穿刺PVB,Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6,32,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.,etal.RegAnesthPainMed.2010;35(2):212-6,33,斜轴位靶向肋横突上韧带PVB,Luyet,C.,etal.,BrJAnaesth.2009;102(4):534-9,34,椎管内扩散,Luyet,C.,etal.,BrJAnaesth.2009;102(4):534-9,35,靶向肋横突上韧带的PVB,O.RiainSCetal.,AnesthAnalg.2010;110(1):248-51,36,椎旁阻滞入路,KredietAC.,etal.,Anesthesiology2015;123:459-74,37,椎旁间隙的解剖,KredietAC.,etal.,Anesthesiology2015;123:459-74,38,椎旁间隙的解剖,KredietAC.,etal.,Anesthesiology2015;123:459-74,39,椎旁间隙的解剖,KredietAC.,etal.,Anesthesiology2015;123:459-74,40,SCTL和iimb的异同,KredietAC.,etal.,Anesthesiology2015;123:459-74,41,椎旁间隙的解剖,KredietAC.,etal.,Anesthesiology2015;123:459-74,42,椎旁间隙头侧和尾侧的边界,KredietAC.,etal.,Anesthesiology2015;123:459-74,43,肋骨平面-横切面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,44,横突平面-横切面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,iimb=internalintercostalmembrane(green);,45,横突平面-横切面扫描穿刺法,KredietAC.,etal.,Anesthesiology2015;123:459-74,imim=innermostintercostalmuscle,1:20mllidocaine(15mg/ml)amedianof5dermatomes(interquartilerange,4to6).2:20mlropivacaine0.75%amedianof4or6dermatomes(range,3to7),acadaverstudy20mlinjecteddyeover3to4TPVspaces(range,1to10)with40%incidenceofepiduralspread.3:20mlmepivacaine1%adistamedianof3.5to4dermatomes(range,2to6)epiduralspreadof25%,whilethesamevolunteershadasensoryblockadeoveramedianof10dermatomes,46,下关节突平面-横切面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,IAP=inferiorarticulateprocess;iimb=internalintercostalmembrane(green),暂无临床报道,47,下关节突平面-横切面扫描穿刺法,KredietAC.,etal.,Anesthesiology2015;123:459-74,4：暂无临床报道5：cadaverstudy,34of36needletipswerecorrectlypositionedintheTPV,epiduralspreadofdyewasnotedinsixinstances,48,肋间平面-矢状面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,iimb=internalintercostalmembrane(green),49,肋间平面-矢状面扫描穿刺法,KredietAC.,etal.,Anesthesiology2015;123:459-74,6：13of14injectionsof1mlmethyleneblue1%resultedinspreadofdyetotheTPVspace.Thesamestudyalsoevaluatedatransversalin-planeintercostalapproach(fig.9,arrowno.1)andfoundthatmoreattemptswererequiredtosuccessfullyplacetheneedlewiththesagittaltechniquecomparedwiththetransversaltechnique:two(range,1to4)andfour(range,1to7),respectively).15,50,OffSide靶向肋横突上韧带,Abdallah,F.W.andBrull,R.RegAnesthPainMed.2014;39(3):240-2,51,肋横突关节平面-矢状面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,SCTL=superiorcostotransverseligament(pink),52,肋横突关节-矢状面扫描穿刺法,KredietAC.,etal.,Anesthesiology2015;123:459-74,7：insertionofcathetersthroughtheneedlewasfoundtobedifficultorimpossiblein6of20cathetersplaced,andahighvariabilityinspreadofinjectateoccurred,including30%epiduralspread.,53,横突平面-矢状面扫描,KredietAC.,etal.,Anesthesiology2015;123:459-74,SCTL=superiorcostotransverseligament(pink),54,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,KredietAC.,etal.,Anesthesiology2015;123:459-74,55,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,56,横突平面-横切面扫描,57,肋间平面-矢状面扫描,58,节段的鉴别：12Rib,59,0.5%Ropivacaine20ml单次平面,60,连续vs单次(Eason和Wyatt法),Catala,E.etal.,JCardiothoracVascAnesth.1996;10(5):586-8.,61,单次能达到什么效果,Hill,S.E.etal.,Anesthesiology.2006;104(5):1047-53,62,单次能达到什么效果,0.5%Ropivacaine30mL,63,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.etal.,Anaesthesia.2014;69(3):231-9,64,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，（TzimasP,etal.,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.etal.,BrJAnaesth.2004;93(3):458-61）,65,PVB在肝胆手术应用,胆囊切除术后镇痛GieseckeK,HambergerB,JarnbergPO,KlingstedtC.Paravertebralblockduringcholecystectomy:effectsoncirculatoryandhormonalresponses.BrJAnaesth1988;61:652-656KumarCM.Paravertebralblockforpost-cholecystectomypainrelief.BrJAnaesth1989;63:129.NajaMZ,ZiadeMF,LonnqvistPA.Generalanaesthesiacombinedwithbilateralparavertebralblockade(T5-6)vs.generalanaesthesiaforlaparoscopiccholecystectomy:aprospective,randomizedclinicaltrial.EurJAnaesthesiol2004;21:489-495肝癌射频消融CulpWC,PayneMN,MontgomeryML.Thoracicparavertebralblockforanalgesiafollowinglivermassradiofrequencyablation.BrJRadiol2008;81:e23-25.经皮胆道穿刺引流CulpWC,McCowanTC,DeValdenebroM,etal.Paravertebralblock:animprovedmethodofpaincontrolinpercutaneoustranshepaticbiliarydrainage.CardiovascInterventRadiol2006;29:1015-1021肝区创伤痛HallH,LeachA.Paravertebralblockinthemanagementoflivercapsulepainafterblunttrauma.BrJAnaesth1999;83:819-821.胆道内扩张引起的疼痛CulpWC,Jr.,CulpWC.Thoracicparavertebralblockforpercutaneoustranshepaticbiliarydrainage.JVascIntervRadiol2005;16:1397-1400.,66,67,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（BerthoudHR.AnatRecADiscovMolCellEvolBiol2004;280:827-835）（）副交感纤维：自迷走神经（）,68,69,一般资料,70,舒芬太尼用量和PCA按压次数,71,静息和咳嗽时疼痛评分,72,全凭椎旁阻滞经皮肾镜,73,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,MillersAnesthesia.Philadelphia:Churchi