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1、上海交通大学附属第六人民医院麻醉科 W. Jiang超声在麻醉与疼痛医学中的应用Application of ultrasound in anesthesia and pain medicine麻醉与超声 Anaesthesia and ultrasoundu传统麻醉 现代麻醉 traditional anaesthesia modern anaesthesia 药物 : 单一，不良反应多 选择，安全性，可控性 技术 : 盲探操作 可视操作 理论 : 麻醉基础和临床理论日益丰富u超声技术与麻醉 ultrasound technique and anaesthesia以其独特优点成为近年热点,
2、方兴未艾喻为现代麻醉医生的“第三只眼睛”麻醉各领域广泛应用“The third eye ” for anaesthetist 内 容 Contents u超声设备和原理ultrasound equipments and principlesu超声技术在现代麻醉中的应用application of ultrasound technique in anesthesia 临床麻醉 clinical anesthesia 疼痛治疗 pain management 危重医学 Critical Care Medicineu原理 principles of ultrasound technology 不同的
3、人体解剖结构均有各自的反射特性different human anatomical structures have varying reflective properties 反射（回声）能够被超声探头收集the reflection (echo) is collected by the probe 反射的信号经放大处理后显示在数字监测仪上the amplitude of reflected signal is displayed on a digital monitor超声技术原理 principles of ultrasound technologyu组织回声 different type
4、 of ultrasound “高回声”结构“亮”图像（如：骨、腱）“hyperechoic” structures “bright” on screen (e.g. bone, tendons) “低回声”结构“暗”图像（如：脂肪、血管）“ hypoechoic” tissues “dark” on screen (e.g. fat, vessels) 外周神经一般为高回声peripheral nerves usually have a hyperechoic appearance超声技术原理 principles of ultrasound technologyu高频超声 higher-f
5、requency ultrasound 高清晰度(分辨率), 低穿透力 higher resolution, low penetrationu低频超声 lower-frequency ultrasound 低清晰度、高穿透力 lower image resolution, deeper penetrationu位置较浅神经 superficial nerve 肌间沟、锁骨上、腋路臂丛: 1013 MHz interscalene, supraclavicular, axillary brachial plexusu位置较深神经 deep nerve 锁骨下、腘、腰丛: 57 MHz Infra
6、clavicular or popliteal region, lumbar plexus超声技术原理-频率 principles of ultrasound-frequency超声引导局部麻醉Ultrasound-guided regional anesthesia (UGRA)u1978年La Grange最早报道 超声下锁骨上臂丛阻滞UGRA was first described by La Grande et al. in 1978 Br J Anesth, 1978, 50:965-967u近十年来UGRA得到长足发展UGRA developed become a more sig
7、nificant area of interest to anesthesiologists 便携式 portable 更精确 more refined 价格合理 affordable超声引导的外周神经阻滞优点 Advantages of Ultrasound Guided Peripheral Nerve Blocks项项 目 优优 点定 位 神经及周围组织 直接可视 直接可见穿刺针行走方向直接可见局麻药注射时的扩散减少局麻药剂量安全性避免血管内或神经内注射 避免创伤病人疼痛性肌收缩阻滞效果神经阻滞起效更快，作用更持久提高阻滞效果Adopted from Marhofer et al 200
8、4 Ultrasound-guided Regional Anesthesia. Anesthesiology 2006; 104:36873.NA=not applicable. NS=not statistically significant (P0.05). Ref.=referenceUltrasound-guided Regional Anesthesia. Anesthesiology 2006; 104:36873.NA=not applicable. NS=not statistically significant (P0.05). Ref.=reference平面内和平面外
9、in plane and out of plane超声下肌间沟臂丛阻滞 ultrasound guided interscalene brachial plexus block颈动脉三角肌间沟锁骨臂丛上干臂丛中干臂丛下干胸锁乳突肌 前斜角肌短轴平面内技术 典型的臂丛三干超声图液性暗区臂丛针尖臂丛局麻药穿刺针在阻滞过程中的显像臂丛完全被液性暗区包围超声下肌间沟臂丛阻滞 ultrasound guided interscalene brachial plexus blocku注射局麻药有利于靶神经结构显像the targeted nerve structures often can be more
10、 easily identified following the injection of local anesthetic 超声引导的外周神经阻滞 Ultrasound Guided Peripheral Nerve Blocks甜圈征 doughnut超声引导的外周神经阻滞Ultrasound Guided Peripheral Nerve BlocksUltrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206Ultrasoun
11、d Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206Fig 3. High resolution images from median longitudinal (A), paramedian longitudinal (B) scans. All relevant structures are named.硬膜外腔硬膜外腔硬膜外腔Ultrasound Imaging of the Thoracic Epidural Space. Region
12、al Anesthesia and Pain Medicine,2002, 27(2): pp 200206硬膜外腔Fig 3. High resolution images from median longitudinal (A), paramedian longitudinal (B)scans. All relevant structures are named.Caudal injection can be reliably imaged using portable ultrasound a preliminary study. Pediatric Anesthesia, 2005,
13、 15: 948952Real-time three-dimensional ultrasound for continuous interscalene brachial plexus blockade. J Anesth (2009) 23:466468Case 1u一般情况 患者：男，25岁，65公斤，腰2骨折复位内固定术后两月 诊断：右足跟软组织缺损， 拟行手术：右足跟清创+腓肠神经加强皮瓣转移术u麻醉方法：坐骨神经+股神经阻滞腰2骨折术后超声下坐骨神经阻滞超声下股神经阻滞Case 1u术中情况 体位：左侧卧位 静脉药物：咪唑安定，1mg；芬太尼，0.1mg 生命体征平稳，术者满意u术
14、后 镇痛良好，患者满意度高左侧卧位，吸氧手术部位u一般情况 患者：男，86岁, 39kg 病史 冠心病，前间壁心梗史5年 高血压病史18年 脑梗史10年血肌酐升高史5年, 肾性贫血； 骨质疏松史5年 诊断 双下肢动脉粥样硬化性闭塞症 右第二足趾截趾术后，右第三 足趾坏死并感染右足跟软组织 缺损 拟行手术：右大腿截肢术高龄，高危！Case 2u麻醉过程术前：神经阻滞 股神经+坐骨神经+股外侧皮神经+闭孔神经术中 镇痛良好 生命体征平稳全麻？ 腰麻 or 硬膜外？ 神经阻滞？u一般情况 患者：男，68岁， 病史 重度鼾症，BMI 40 kg/m2 慢性心衰 拟行手术：右膝关节置换术u麻醉方法 术前
15、：神经阻滞 (股神经+坐骨神经+股外侧皮神经+闭孔神经 术中 喉罩浅麻醉维持 术后 患者清醒迅速，无痛 避免了鼾症病人术后拔管延迟，呼 吸抑制等并发症Case 3无痛关节置换 no pains for Joint Replacement 术 前神经阻滞无痛的关节置换no pains for Joint ReplacementImage Info www.wizdata.co.kr - Note to customers : This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use. 术 中 强阿片药物术 后 切口周围注 射局麻药 镇痛泵目标多模式镇痛超声与疼痛 ultrasound and pain management疼痛治疗-神经阻滞 pain management-nerve block u治疗药物 drugs for pain management局麻药糖皮质激素 u作用原理 principles暂时阻断痛觉传导阻断交感神经，扩张血管，改善局部血供消除软组织水肿，减轻神经受压消除细胞因子、炎性介质对神经的刺
