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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 ultrasound,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 超声技术与麻醉 ultrasound technique and anaesthesia 以其独特优点成为近年
2、热点, 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,超声设备和原理 ultrasound equipments and principles 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 Medicine,原理 principles of ultrasound techno
3、logy 不同的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 technology,组织回声 di
4、fferent type 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 technolo
5、gy,高频超声 higher-frequency ultrasound 高清晰度(分辨率), 低穿透力 higher resolution, low penetration 低频超声 lower-frequency ultrasound 低清晰度、高穿透力 lower image resolution, deeper penetration 位置较浅神经 superficial nerve 肌间沟、锁骨上、腋路臂丛: 1013 MHz interscalene, supraclavicular, axillary brachial plexus 位置较深神经 deep nerve 锁骨下、腘、
6、腰丛: 57 MHz Infraclavicular 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),1978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, 50:965-967 近十年来UGRA得到长足发展 UGRA develo
7、ped become a more significant 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,Adopted from Marhofer et al 2004,Ultrasound-guided Regional Anesthesia. Anesthesiology 2006; 104:36873.,NA=not appli
8、cable. NS=not statistically significant (P0.05). Ref.=reference,Ultrasound-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 in plane and out of plane,超声下肌间沟臂丛阻滞 ultrasound guided interscalene brachial plex
9、us 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,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 block,注射局麻药有利于靶神经结构显像 the targeted nerve structures often can be more easily identified following the injection of local anesthetic,超声引导的外周神经阻滞 Ultrasound
10、Guided Peripheral Nerve Blocks,甜圈征 doughnut,超声引导的外周神经阻滞 Ultrasound Guided Peripheral Nerve Blocks,Ultrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206,Ultrasound Imaging of the Thoracic Epidural Space. Regional Anesthesia and Pain Medicine,2
11、002, 27(2): pp 200206,Fig 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. Regional Anesthesia and Pain Medicine,2002, 27(2): pp 200206,Fig 3. High resolutio
12、n 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, 15: 948952,Real-time three-dimensional ultrasound for continuous interscalene
13、 brachial plexus blockade. J Anesth (2009) 23:466468,Case 1,一般情况 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 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 1,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 术后 镇痛良好，患者满意度高,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
14、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 2,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？,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 麻醉方法 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 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
15、 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 Replacement,Image 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
16、式镇痛,超声与疼痛 ultrasound and pain management,疼痛治疗-神经阻滞 pain management-nerve block,治疗药物 drugs for pain management 局麻药 糖皮质激素 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激 消除神经炎症、水肿 帮助神经修复,超声与疼痛 ultrasound and pain management,腰交感神经节阻滞 lumbar sympathetic and celiac plexus block Kirvela等首先以超声多普勒引导实行 超声可精确定位腰交感神经干，阻滞有效率100% 优点：定位精确、价廉、无射线、良好的应用前景 Kirvel O, et al. Ultrasonic guidance of lumbar
