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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HugoSellheim(28.Dezember1871inBiblisbeiWorms;22.April1936inLeipzig)wareindeutscherGynäkologeundGeburtshelfer.ArthurLäwen验证PVB(1911年)ArthurGeorgLäwen(6.Februar1876inWaldheim,Sachsen;30.Januar1958inLüneburg)wareindeutscherChirurgundWegbereiterderheutigenAnästhesiologieRichardson,J.etal.,BrJAnaesth.1998;81(2):230-8.ArthurLäwen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MaxKappis(1919年)KappisM.SensibilitaetundlocaleanaesthesiagebeitderBauchoelemitbesondererberuchsichtigungderSplanchnicusanaesthesia.BeitrKlinChir1919;115:161–75FujitaY.[MaxKappis,aninventorofsplanchnicnerveblock].Masui.1993Sep;42(9):1378-80.[ArticleinJapanese]MaxKappis(6.Oktober1881inTübingen;5.August1938)wareindeutscherChirurgPVB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(MandelF.Paravertebralblock.NewYork:GruneandStratton,1946)1950s-1960s文献报道几乎消失1970s,阻力消失法引入后,再度流行(EasonMJ,WyattR.Paravertebralthoracicblock-areappraisal.Anaesthesia.1979;34(7):638-42.)Richardson,J.etal.,AnesthAnalg.1998;87(2):373-6.Figure2.Inthepresenceofcompletenumbnessonsensoryexamination,depressionoftheS1dermatomalSSEPrangedfrom0%(A),togreaterthan50%(B),to100%(C)Dataarerepresentativeexamples.BenzonHTetal.,AnesthAnalg.1993;76(2):328-32.PVBvs硬膜外:4-8h和48hVAS评分Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:吗啡量和尿潴留Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:PONV和低血压Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:失败率和肺部并发症Ding,X.etal.,PLoSOne.2014;9(5):e96233区域阻滞与术后慢性疼痛AndreaeMHandAndreaeDA.BrJAnaesth.2013;111(5):711-20椎旁神经解剖Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42椎旁神经解剖Schematicthoracicspinalnerve.AD=anteriordivision,PD=posteriordivision,C=spinalcord,SG=spinalganglion,RM=recurrentmeningeal,SC=sympatheticchain,RC=ramicommunicantes,PC=posteriorcutaneous,LC=lateralcutaneous,AC=anteriorcutaneous,P=pleura.Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42穿刺方法Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42穿刺技巧Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42Eason和Wyatt阻力消失法成功率Lonnqvist,P.A.etal.,Anaesthesia.1995;50(9):813-5Eason和Wyatt法神经刺激器定位Naja,Z.andLonnqvist,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.etal.,ActaAnaesthesiolScand.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.etal.,ActaAnaesthesiolScand.2001;45(1):30-32ml利多卡因=1个节段剂量与容量和阻滞范围无关Cheema,S.etal,Anaesthesia.2003;58(7):684-773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PVBHara,K.etal.,Anaesthesia.2009;64(2):223-5.3-11MHz线性探头(PhilipsSONOS5500)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.etal.,BrJAnaesth.2010;105(4):526-32.肋间入路靶向横突间内膜PVBBen-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.肋间入路PVBBen-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.靶向横突下PVBShibata,Y.andNishiwaki,K.AnesthAnalg.2009;109(3):996-7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.,etal.RegAnesthPainMed.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.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVBRenes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVB0.75%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.,etal.RegAnesthPainMed.2010;35(2):212-6斜轴位靶向肋横突上韧带PVBLuyet,C.,etal.,BrJAnaesth.2009;102(4):534-9椎管内扩散Luyet,C.,etal.,BrJAnaesth.2009;102(4):534-9靶向肋横突上韧带的PVBO.RiainSCetal.,AnesthAnalg.2010;110(1):248-51椎旁阻滞入路KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74SCTL和iimb的异同KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙头侧和尾侧的边界KredietAC.,etal.,Anesthesiology2015;123:459-74肋骨平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74横突平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74iimb=internalintercostalmembrane(green);横突平面-横切面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-74imim=innermostintercostalmuscle1:20mllidocaine(15mg/ml)amedianof5dermatomes(interquartilerange,4to6).2:20mlropivacaine0.75%amedianof4or6dermatomes(range,3to7),acadaverstudy20mlinjecteddyeover3to4TPVspaces(range,1to10)with40%incidenceofepiduralspread.3:20mlmepivacaine1%adistamedianof3.5to4dermatomes(range,2to6)epiduralspreadof25%,whilethesamevolunteershadasensoryblockadeoveramedianof10dermatomes下关节突平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74IAP=inferiorarticulateprocess;iimb=internalintercostalmembrane(green)暂无临床报道下关节突平面-横切面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-744:暂无临床报道5:cadaverstudy,34of36needletipswerecorrectlypositionedintheTPV,epiduralspreadofdyewasnotedinsixinstances肋间平面-矢状面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74iimb=internalintercostalmembrane(green)肋间平面-矢状面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-746:13of14injectionsof1mlmethyleneblue1%resulte
本文标题:椎旁阻滞临床应用
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