股神经髂筋膜隐神经蒋嘉

1、1会计学股神经髂筋膜隐神经蒋嘉股神经髂筋膜隐神经蒋嘉Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文库文档分享Primary outcomes:(1) acute postoperative pain (during rest and movement)

2、(2) postoperative opioid consumption(3) quality of early postoperative rehabilitation (functional assessments)Secondary outcomes:postoperative complications (e.g., nausea, vomiting, falls), duration of hospitalization, blood loss, procedure failure, and patient withdrawalTerkawi AS, Mavridis D, Sess

3、ler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文库文档分享与与PCA比较比较(A ) Overall pain scores in the first 72 h duringrest(B) overall pain scores in the first 72 h during movement,(C) ov

4、erall opioid consumption in the first 72 h(D) overall range on motion in the first 72 h.Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials.Anesthesiology 2017; 126:923-37牛牛文库文档分享Ranking F/S

5、(6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPP AACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文库文档分享闭孔神经闭孔神经股神经股神经股外侧皮神经股

6、外侧皮神经隐神经隐神经牛牛文库文档分享阻滞的是什么？牛牛文库文档分享髂髂筋膜筋膜 外界：髂嵴内外界：髂嵴内侧缘侧缘 内界：小骨盆内界：小骨盆的的界线界线 向下一直延续向下一直延续 到股骨小转子到股骨小转子 水平水平 覆盖腰大肌和覆盖腰大肌和 髂肌髂肌牛牛文库文档分享髂髂筋膜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与髂肌和髂筋膜并没有密切的联系闭闭 孔孔 神神 经经牛牛文库文档分享Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the in

7、guinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (2015) 27, 652657腹股沟韧带水平腹股沟韧带水平骶骨水平骶骨水平冠状位冠状位腹股沟韧带水平髂筋膜阻滞腹股沟韧带水平髂筋膜阻滞牛牛文库文档分享超超声引声引导导髂筋髂筋膜膜阻滞阻滞的的方方法法牛牛文库文档分享腹股沟韧带上法腹股沟韧带上法Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSupr

8、ainguinal Fascia Iliaca Technique ProvidesBenefit as an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438牛牛文库文档分享超超声引声引导导腹股腹股沟沟韧带韧带上上髂筋髂筋膜膜阻阻滞滞Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Ben

9、efit as an Analgesic Adjunct for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438牛牛文库文档分享如何提高成功率？牛牛文库文档分享股神经解剖股神经解剖股神经股神经牛牛文库文档分享股股神神经经超超声影像声影像牛牛文库文档分享超超声声探头探头的的最佳最佳位置位置旋股内、外侧动脉旋股内、外侧动脉牛牛文库文档分享 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OGAMI K, MURATA H, SAKAI A, et al. Deep and

10、Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017)牛牛文库文档分享短轴，平面内法短轴，平面内法短轴，平面外法短轴，平面外法牛牛文库文档分享Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle t

11、ip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329牛牛文库文档分享n，Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329牛牛文库文档分享辨

12、辨认不认不清清髂筋髂筋膜膜怎么怎么办办？Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329GIPM：髂腰肌凹槽髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）牛牛文库文档分享Benoit Fanara, Je

13、an-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329髂筋膜髂筋膜GIPM:85% 髂筋膜：68%牛牛文库文档分享阔筋膜张肌阔筋膜张肌 股外侧皮神经股外侧皮神经缝匠肌缝匠肌股股外侧外侧皮皮神经神经阻阻滞滞 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

14、础的传统阻 滞技术不可靠牛牛文库文档分享超超声声引导引导股股外侧外侧皮皮神经神经阻滞阻滞 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 筋膜下方扩散牛牛文库文档分享与收肌管阻滞？牛牛文库文档分享隐隐神经神经阻阻滞滞 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牛牛文库文档分享隐隐神经神经走走行行 股动脉伴行，内下行 通过收肌管，接

15、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，与大隐静脉伴行牛牛文库文档分享隐隐神经神经阻阻滞入滞入路路Subsartorial plexus block（大腿中段） Adductor Canal block（大腿远端/收肌管） Subcoutaneous infiltration block（小腿近端）牛牛文库文档分享牛牛文库文档分享收收肌肌管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 脉牛

16、牛文库文档分享牛牛文库文档分享起点：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：缝匠肌肌VM：股内侧：股内侧肌肌AL：长收：长收肌肌AM：大收肌：大收肌Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245牛牛文库文档分享vastoadductor membraneWong WY, et al. Defining the Location of the

17、 Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245牛牛文库文档分享小结小结髂筋膜阻滞： 阻滞：股神经+股外侧皮神经 腹股沟上髂筋膜阻滞（更佳）：髂前上棘、髂肌和腹横肌 腹股沟下髂筋膜阻滞：缝匠肌和髂肌 股神经 一般：股动脉和髂筋膜 特殊：GIPM旁结构 外侧进针平面内法、药液包绕、神经前方置管 隐神经 收肌管水平最佳：缝匠肌和股外侧肌膝关节置换：股神经联合坐骨神经阻滞最佳牛牛文库文档分享牛牛文库文档分享Ranking F/S (6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPP AACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文库文档分享髂髂筋膜筋膜 外界：髂嵴内外界：髂嵴内侧缘侧缘 内界：小骨盆内界：小骨盆的的界线界线 向下一直延续向下一直延续 到