超声引导下臂丛神经阻滞技术.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,超声引导下臂丛神经阻滞技术,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,神经分支,主要运动功能,正中神经,屈指屈腕拇外展,尺神经,屈指屈腕拇内收,肌皮神经,屈肘,桡神经,伸指、伸腕、伸肘,腋神经,肩关节外展,一、臂丛相关解剖基础,二、超声下图像,C5,C6,C7,VA,二、超声下图像,C5,C6,C7,C8,VA,二、超声下图像,M,A,U,R,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,An ultrasound(US)-guided block at the,C7 root,；,Initial volume of,ropivacaine 0.75%,was 6 mL；,Block success or failure determined a 1-mL decrease or increase for the subsequent patient；,The minimum effective volume of local anesthetic in 50%and 95%of the patients was,2.9 mL,(95%confidence interval,2.4-3.5 mL)and,3.6 mL,(95%confidence interval,3.3-6.2 mL)；,Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function.Reg Anesth Pain Med.2010 Nov-Dec;35(6):529-34.,三、实战攻略,分干阻滞最低剂量,Successful surgical anesthesia for arthroscopic shoulder surgery can be achieved with,5 mL of 0.75%ropivacaine,or approximately 1.7 mL per each of the 3 trunks of the brachial plexus(superior,middle,and inferior).,For the group as a whole,the median(range),sensory block,onset time was 5(5-20)minutes,the median(range),motor block,for the biceps was 7.5(5-15)minutes.,The median(range),block duration,was 9.9(5-19)hours,and the mean(SD)block performance time was 8.0 3.2 minutes.,Mean,duration of analgesia,was 9.9 3.7 hours.Duration of analgesia was not associated with volume of LA(r=0.05,P=0.83),The minimum effective anesthetic volume of 0.75%ropivacaine in ultrasound-guided interscalene brachial plexus block.Anesth Analg.2011 Oct;113(4):951-5.,三、实战攻略,单点阻滞最低剂量研究,The proportion of patients with successful blockade increased sharply from approximately 57%at 6 ml to 100%by 7 ml,indicating that a small increase in volume of ropivacaine 0.75%markedly affects the success rate.,The median(min-max)sensory block onset time was 5(5-20)min,the median(min-max)motor blocks for the biceps and the deltoid muscles were 7.5(5-15)min and 10(5-15)min,respectively.The median(min-max)block duration was 8.9(3-15)h.,Effective volume of ropivacaine 0.75%through a catheter required for interscalene brachial plexus blockade.Anesthesiology.2013 Apr;118(4):863-7.,三、实战攻略,最低剂量及作用时间研究,Lidocaine 1.5%,with epinephrine 1:200 000,The mean(95%CI)volume to surround each nerve was:,radial 3.42,(2.84-3.99)ml,median 2.75,(2.31-3.19)ml,ulnar 2.58,(2.14-3.03)ml,and,musculocutaneous 2.30,(1.96-2.64)ml.,The mean(95%CI)onset time for complete sensory block was:,radial 22.5,(13.5-31.5)min,median 26.8,(18.5-35.0)min,ulnar 26.6,(17.8-35.4)min,and,musculocutaneous 15.8,(7.45-24.2)min.,The mean(95%CI)last recorded time with complete block was:radial 137.1(105.6-168.7)min,median 144.7(123.4-166.0)min,ulnar 183.2(158.1-208.2)min,and musculocutaneous 158.3(131.8-184.9)min.,Minimum volume of local anaesthetic required to surround each of the constituent nerves of the axillary brachial plexus,using ultrasound guidance:a pilot study.Br J Anaesth.2010 May;104(5):633-6.,三、实战攻略,锁骨下阻滞,High-resolution ultrasonography has revealed,anatomical variations,of C5,C6 and C7 nerve roots in almost half of the patients examined,without negative block effectiveness.,Infraclavicular catheters,provide superior analgesia when compared with supraclavicular catheters.,Multiple-site injections,of local offer no advantage over a single-site injection during an infraclavicular block.,Ultrasound-guided peripheral nerve blockade of the upper extremity.Curr Opin Anaesthesiol.2012 Apr;25(2):253-9.,三、实战攻略,锁骨下阻滞,The supraclavicular approach of the brachial plexus has a high success rate including blockade of the,ulnar and musculocutaneous nerve,which can be missed respectively with the interscalene and axillary approach.,Supraclavicular brachial plexus blocks:review and current practice.Acta Anaesthesiol Belg.2012;63(1):15-21.,三、实战攻略,地塞米松,The addition of,dexamethasone,may prolong analgesia after single-shot interscalene and supraclavicular blocks.,Ultrasound-guided peripheral nerve blockade of the upper extremity.Curr Opin Anaesthesiol.2012 Apr;25(2):253-9.,三、实战攻略,地塞米松,The median time of a sensory block was equivalent for perineural and i.v.dexamethasone:1405 min(IQR 1015-1710)and 1275 min(IQR 1095-2035)for RD and RDiv.I.V.dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine.,There was a significant difference between the ropivacaine group:757 min(IQR 635-910)and the dexamethasone groups(P0.0001).,As dexamethasone is not licensed for perineural use,clinicians should consider i.v.administration of dexamethasone to achieve an increased duration of Interscalene brachial plexus block（ISB）.,I.V.and perineural dexamet。