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1、椎旁阻滞的临床应用,梅伟 华中科技大学同济医学院 附属同济医院麻醉科,椎旁神经阻滞历史,1905年由Sellheim首先在Leipzig报道,替代腰麻用于剖宫产术麻醉 也有报道认为是在1908年Tuebingen开始的,Hugo Sellheim ( 28. Dezember 1871 in Biblis bei Worms; 22. April 1936 in Leipzig) war ein deutscher Gynkologe und Geburtshelfer.,Arthur Lwen 验证PVB(1911年),Arthur Georg Lwen ( 6. Februar 1876
2、in Waldheim, Sachsen; 30. Januar 1958 in Lneburg) war ein deutscher Chirurg und Wegbereiter der heutigen Ansthesiologie,Richardson, J. et al., Br J Anaesth. 1998;81(2):230-8.,Arthur Lwen的其他贡献,1912年:首次联合使用硬膜外联合全麻 1912年:在局麻药中加入碳酸氢钠 首次采用骶管阻滞 1912年:首次在手术中使用箭毒 呼吸衰竭患者的辅助通气,Max Kappis( 1919年),Kappis M. Sen
3、sibilitaet und locale anaesthesia gebeit der Bauchoele mit besonderer beruchsichtigung der Splanchnicus anaesthesia. Beitr Klin Chir 1919; 115: 16175 Fujita Y. Max Kappis, an inventor of splanchnic nerve block. Masui. 1993 Sep;42(9):1378-80. Article in Japanese,Max Kappis (6. Oktober 1881 in Tbingen
4、; 5. August 1938) war ein deutscher Chirurg,PVB的早期应用,1920s应用极为流行:心绞痛、癌痛、股骨颈骨折、肢体缺血痛,室上性心动过速,哮喘,辅助排石,带状疱疹痛(Mandel F. Paravertebral block. New York: Grune and Stratton, 1946) 1950s-1960s 文献报道几乎消失 1970s,阻力消失法引入后,再度流行(Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia. 1979;34(7)
5、:638-42.),Richardson, J. et al., Anesth Analg. 1998;87(2):373-6.,Figure 2. In the presence of complete numbness on sensory examination, depression of the S1 dermatomal SSEP ranged from 0% (A), to greater than 50% (B), to 100% (C) Data are representative examples.,Benzon HT et al., Anesth Analg. 1993
6、;76(2):328-32.,PVB vs 硬膜外: 4-8h 和48h VAS评分,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:吗啡量和尿潴留,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:PONV和低血压,Ding, X. et al., PLoS One. 2014;9(5):e96233,PVB vs 硬膜外:失败率和肺部并发症,Ding, X. et al., PLoS One. 2014;9(5):e96233,区域阻滞与术后慢性疼痛,Andreae M
7、H and Andreae DA. Br J Anaesth. 2013; 111(5):711-20,椎旁神经解剖,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,椎旁神经解剖,Schematic thoracic spinal nerve. AD=anterior division, PD=posterior division, C=spinal cord, SG=spinal ganglion, RM=recurrent meningeal, SC=sympathetic chain, RC=ramicommunican
8、tes, PC=posterior cutaneous, LC=lateral cutaneous, AC=anterior cutaneous, P=pleura.,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,穿刺方法,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,穿刺技巧,Eason, M. J. and Wyatt, R. Anaesthesia. 1979;34(7):638-42,Eason和Wyatt阻力消失法成功率,Lonnqvist, P
9、. A. et al., Anaesthesia. 1995;50(9):813-5,Eason和Wyatt法神经刺激器定位,Naja, Z. and Lonnqvist, P. A. Anaesthesia. 2001;56(12):1184-8.,容量和感觉平面范围(针刺痛),志愿者,阻力消失法,1% 利多卡因,头侧10ml(2秒推完),转向尾侧5ml( 1.5秒推完)。置管15分钟后再推1%利多卡因7ml。,Saito, T. et al., Acta Anaesthesiol Scand. 2001;45(1):30-3,容量和温度平面范围,TM:鼓膜,C7:前臂内侧,T4:锁骨中线第
10、四肋间, T10:锁骨中线脐平面,L2:大腿前中部,S2:小腿中后部,Saito, T. et al., Acta Anaesthesiol Scand. 2001;45(1):30-3,2ml 利多卡因=1个节段,剂量与容量和阻滞范围无关,Cheema, S. et al, Anaesthesia. 2003;58(7):684-7,73例慢性疼痛成人,横突上单点注射造影剂X光确认后,推注0.5% 布比卡因10-15ml(60秒),9例无平面。,超声定位平面外穿刺PVB,Hara, K. et al., Anaesthesia. 2009;64(2):223-5.,3-11MHz 线性探头(
11、Philips SONOS 5500) 平面外技术穿刺,主要是判断深度,靶向肋间内膜平面外穿刺,Marhofer, P. et al., Br J Anaesth. 2010;105(4):526-32.,肋间入路靶向横突间内膜PVB,Ben-Ari, A. et al., Anesth Analg. 2009;109(5):1691-4.,肋间入路PVB,Ben-Ari, A. et al., Anesth Analg. 2009;109(5):1691-4.,靶向横突下PVB,Shibata, Y. and Nishiwaki, K. Anesth Analg. 2009;109(3):9
12、96-7,根据Kappis技术改良(中线旁开3 指,45度角向中线穿刺,触及椎旁间隙的后外侧壁骨质后注药,后被弃用),无需触及骨质,利用IICM和肋横突韧带的连续性,肋间入路平面内穿刺PVB,注药前,探头和针位置,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,肋间入路平面内穿刺PVB,注药后,针尖位置错误,Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,肋间入路平面内穿刺PVB,Renes, S. H., et al. Reg Anesth Pain M
13、ed. 2010;35(2):212-6,肋间入路平面内穿刺PVB,0.75%罗哌卡因5ml+0.75% 罗哌卡因10ml,置管后再给0.75%罗哌卡因5ml (总量20ml) 阻滞成功率100% (三个节段) 阻滞平面6(中位数),Renes, S. H., et al. Reg Anesth Pain Med. 2010;35(2):212-6,斜轴位靶向肋横突上韧带PVB,Luyet, C., et al., Br J Anaesth. 2009;102(4):534-9,椎管内扩散,Luyet, C., et al., Br J Anaesth. 2009;102(4):534-9,靶
14、向肋横突上韧带的PVB,O. Riain SC et al., Anesth Analg. 2010;110(1):248-51,椎旁阻滞入路,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123
15、:459-74,SCTL和iimb的异同,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙的解剖,Krediet AC., et al., Anesthesiology 2015; 123:459-74,椎旁间隙头侧和尾侧的边界,Krediet AC., et al., Anesthesiology 2015; 123:459-74,肋骨平面-横切面扫描,Krediet AC., et al., Anesthesiology 2015; 123:459-74,横突平面-横切面扫描,Krediet AC., et al., Ane
16、sthesiology 2015; 123:459-74,iimb = internal intercostal membrane (green);,横突平面-横切面扫描穿刺法,Krediet AC., et al., Anesthesiology 2015; 123:459-74,imim = innermost intercostal muscle,1: 20 ml lidocaine (15 mg/ml) a median of 5 dermatomes (interquartile range, 4 to 6). 2: 20 ml ropivacaine 0.75% a median of 4 or 6 dermatomes (range, 3 to 7), a cadaver study 20 ml injected dye over 3 to 4 TPV spaces (range, 1 to 10) with 40% incidence of epidural spread. 3: 20 ml mepivacaine 1% a dist a m