超声引导下臂丛神经阻滞知更.ppt

超声引导下臂丛神经阻滞技术,浙医二院麻醉科周金锋,一、臂丛相关解剖基础,由第5-8颈神经前支和第1胸神经前支大部分构成，经椎动脉后方、斜角肌间隙向外侧穿出，组成三条干：C5、C6前支组成上干C7前支单独成为中干C8前支和T1前支大部分合成下干在锁骨后第1肋骨中外缘分为前后两股腋窝水平分成三束：上干和中干的前股合成外侧束-肌皮和正中神经下干的前股成为内侧束-尺神经三条干的后股组成后束-桡神经,一、臂丛相关解剖基础,一、臂丛相关解剖基础,一、臂丛相关解剖基础,一、臂丛相关解剖基础,二、超声下图像,C5C6C7VA,二、超声下图像,C5C6C7C8VA,二、超声下图像,MAUR,三、实战攻略,临床关注点起效时间阻滞程度药物剂量成功率操作难度并发症,超声技术可以解决以上问题的关键神经的定位及辨识度设备因素神经变异（50%）操作技术,三、实战攻略定位,三、实战攻略定位,三、实战攻略定位,三、实战攻略定位,三、实战攻略,三、实战攻略,单点阻滞用于术后镇痛Anultrasound(US)-guidedblockattheC7root；Initialvolumeofropivacaine0.75%was6mL；Blocksuccessorfailuredetermineda1-mLdecreaseorincreaseforthesubsequentpatient；Theminimumeffectivevolumeoflocalanestheticin50%and95%ofthepatientswas2.9mL(95%confidenceinterval,2.4-3.5mL)and3.6mL(95%confidenceinterval,3.3-6.2mL)；Minimumeffectivevolumeoflocalanestheticforshoulderanalgesiabyultrasound-guidedblockatrootC7withassessmentofpulmonaryfunction.RegAnesthPainMed.2010Nov-Dec;35(6):529-34.,三、实战攻略,分干阻滞最低剂量Successfulsurgicalanesthesiaforarthroscopicshouldersurgerycanbeachievedwith5mLof0.75%ropivacaine,orapproximately1.7mLpereachofthe3trunksofthebrachialplexus(superior,middle,andinferior).Forthegroupasawhole,themedian(range)sensoryblockonsettimewas5(5-20)minutes,themedian(range)motorblockforthebicepswas7.5(5-15)minutes.Themedian(range)blockdurationwas9.9(5-19)hours,andthemean(SD)blockperformancetimewas8.03.2minutes.Meandurationofanalgesiawas9.93.7hours.DurationofanalgesiawasnotassociatedwithvolumeofLA(r=0.05,P=0.83)Theminimumeffectiveanestheticvolumeof0.75%ropivacaineinultrasound-guidedinterscalenebrachialplexusblock.AnesthAnalg.2011Oct;113(4):951-5.,三、实战攻略,单点阻滞最低剂量研究Theproportionofpatientswithsuccessfulblockadeincreasedsharplyfromapproximately57%at6mlto100%by7ml,indicatingthatasmallincreaseinvolumeofropivacaine0.75%markedlyaffectsthesuccessrate.Themedian(min-max)sensoryblockonsettimewas5(5-20)min,themedian(min-max)motorblocksforthebicepsandthedeltoidmuscleswere7.5(5-15)minand10(5-15)min,respectively.Themedian(min-max)blockdurationwas8.9(3-15)h.Effectivevolumeofropivacaine0.75%throughacatheterrequiredforinterscalenebrachialplexusblockade.Anesthesiology.2013Apr;118(4):863-7.,三、实战攻略,最低剂量及作用时间研究Lidocaine1.5%withepinephrine1:200000Themean(95%CI)volumetosurroundeachnervewas:radial3.42(2.84-3.99)ml,median2.75(2.31-3.19)ml,ulnar2.58(2.14-3.03)ml,andmusculocutaneous2.30(1.96-2.64)ml.Themean(95%CI)onsettimeforcompletesensoryblockwas:radial22.5(13.5-31.5)min,median26.8(18.5-35.0)min,ulnar26.6(17.8-35.4)min,andmusculocutaneous15.8(7.45-24.2)min.Themean(95%CI)lastrecordedtimewithcompleteblockwas:radial137.1(105.6-168.7)min,median144.7(123.4-166.0)min,ulnar183.2(158.1-208.2)min,andmusculocutaneous158.3(131.8-184.9)min.Minimumvolumeoflocalanaestheticrequiredtosurroundeachoftheconstituentnervesoftheaxillarybrachialplexus,usingultrasoundguidance:apilotstudy.BrJAnaesth.2010May;104(5):633-6.,三、实战攻略,锁骨下阻滞High-resolutionultrasonographyhasrevealedanatomicalvariationsofC5,C6andC7nerverootsinalmosthalfofthepatientsexamined,withoutnegativeblockeffectiveness.Infraclavicularcathetersprovidesuperioranalgesiawhencomparedwithsupraclavicularcatheters.Multiple-siteinjectionsoflocaloffernoadvantageoverasingle-siteinjectionduringaninfraclavicularblock.Ultrasound-guidedperipheralnerveblockadeoftheupperextremity.CurrOpinAnaesthesiol.2012Apr;25(2):253-9.,三、实战攻略,锁骨下阻滞Thesupraclavicularapproachofthebrachialplexushasahighsuccessrateincludingblockadeoftheulnarandmusculocutaneousnerve,whichcanbemissedrespectivelywiththeinterscaleneandaxillaryapproach.Supraclavicularbrachialplexusblocks:reviewandcurrentpractice.ActaAnaesthesiolBelg.2012;63(1):15-21.,三、实战攻略,地塞米松Theadditionofdexamethasonemayprolonganalgesiaaftersingle-shotinterscaleneandsupraclavicularblocks.Ultrasound-guidedperipheralnerveblockadeoftheupperextremity.CurrOpinAnaesthesiol.2012Apr;25(2):253-9.,三、实战攻略,地塞米松Themediantimeofasensoryblockwasequivalentforperineuralandi.v.dexamethasone:1405min(IQR1015-1710)and1275min(IQR1095-2035)forRDandRDiv.I.V.dexamethasoneisequivalenttoperineuraldexamethasoneinprolongingtheanalgesicdurationofasingle-shotISBwithropivacaine.Therewasasignificantdifferencebetweentheropivacainegroup:757min(IQR635-910)andthedexamethasonegroups(P0.0001).Asdexamethasoneisnotlicensedforperineuraluse,cliniciansshouldconsideri.v.administrationofdexamethasonetoachieveanincreaseddurationofInterscalenebrachialplexusblock（ISB）.I.V.andperineuraldexamethasoneareequivalentinincreasingtheanalgesicdurationofasingle-shotinterscaleneblockwithropivacaineforshouldersurgery:aprospective,randomized,placebo-controlledstudy.BrJAnaesth.2013Sep;111(3):445-52.,三、实战攻略,右旋美托嘧啶Ultrasound-guidedulnarnerveblock(UNB)wasperformedin36volunteerswitheither3mlropivacaine0.75%(R),3mlropivacaine0.75%plus20gdexmedetomidine(RpD),or3mlropivacaine0.75%plussystemic20gdexmedetomidine(RsD).Thedurationofsensoryblockwas350(54)mininGroupR,555(118)mininGroupRpD,and395(40)mininGroupRsD(P0.01GroupRpDvsothergroups,P0.05GroupRsDvsGroupR).MotorblockdurationwassimilartothedurationofsensoryblockDexmedetomidineasanadjuvanttoropivacaineprolongsperipheralnerveblock:avolunteerstudy.BrJAnaesth.2013Mar;110(3):438-42.,三、实战攻略,剂量与年龄Theminimumeffectivelocalanestheticvolumesignificantlydifferedbetweenmiddle-agedandelderly23.0ml,95%confidenceinterval(CI)13.7-32.3vs.11.9ml,95%CI9.3-14.6;95%CIofthedifference1.6-20.6,P=0.027.Effectsofageonminimumeffectivevolumeoflocalanestheticforultrasound-guidedsupraclavicularbrachi