神经阻滞定位方法进展

神经阻滞定位方法进展AdvanceinLocatlizaionofNerveBlock杭燕南YannanHangM.D.DepartmentofAnesthesiologyRenJiHospitalShanghaiSecondMedicalUniversityShanghai200001外周神经阻滞的优点Advantageofperipheralnerveblock阻滞成功率高Highsuccessfulratio安全性高Moresafety应激反应轻Lessstressresponse降低深静脉血栓形成AvoidDVT恢复快Fastrecovery生理机能稳定stablephysicalstatus病人欢迎Welcomedbypatients费用低Lowcost内容提要Contents1.神经阻滞定位方法Localizationmethodsofnerveblock2.神经刺激器与神经刺激针Nervestimulatorandneedles3.下肢神经阻滞在老年重危病人中的应用Applicationoflowerextremitynerveblockinelderlyseverepatients一、神经阻滞的定位方法I.Locationmethodsofnerveblock解剖定位Anatomylocation异感定位Sensorylocation超声和放射学定位Ultrasoundandradiological（一）解剖定位Anatomylocation神经解剖变异，神经分布不规则，神经不是集中某个单一的点，解剖标记不明确或不易辨认，因此，临床操作难度较大。Variationanddecentralizationofnerves,irregulardistribution,ambiguityofanatomylandmarks,it’sdifficulttooperateinclinic（二）异感定位Sensorylocationn是否需要寻找异感尚有争议Debateoffindingspecialsensory找到“异感”，麻醉效果并非一定完善Unsatisfiedanestheticeffectswithsensorylocation神经分布与病人状态，可能无法引出异感Sensationmaybenotfoundinsomepatients寻找异感可能损伤神经Maybedamagenerves（三）超声和放射学定位Ultrasoundandradiologicallocation优点Advantages提高神经阻滞的成功率Increasethesuccessfulrateofnerveblock观察局麻药注射后的扩散规律Observethedistributionoflocalanesthetics避免血管内注射的发生Avoidintravascularinjection减少麻醉药用量Reducethedosageofanesthetics缺点Disadvantages需要特殊设备和人员技术培训Needequipmentsandtraining增加了操作步骤Moreoperationsteps仪器体积较大，价格昂贵Largesizeandexpensiveequipment超声的基本原理BasicprinciplesofUltrasound临床应用的超声频率为2.5~20MHzClinicalultrasoundwith2.5~20MHz频率越高空间分辨率越好，但穿透性越差；反之亦然Higherfrequencywithbetterspacedifferentiationratiobutlesspenetrability;viceversa浅表神经可用＞10MHz，而深部神经需用＜7.5MHz，超声定位深部神经应与局部解剖学相结合＞10MHzfrequencyusedinsuperficialnervesand＜7.5MHzindeepones,ultrasoundshouldbeusedwithtopographyespeciallyindeepnerveblock超声引导下神经阻滞Nerveblockguidedbyultrasound1、肌间沟中轴斜面2、锁骨上冠状斜面3、锁骨下矢状面4、腋部横断面5、肱骨中部横断面超声探头的位置LocationofultrasoundprobePerlasA,etal.Anesthesiology,2003;99:429.1、Mid-axisobliquesurfaceofinterscalenegroove2、Supra-claviclecoronalobliquesurface3、Sub-claviclesagittalsurface4、transectofaxilla5、transectofmid-humerus肌间沟经路定位InterscalenelocationHadzicA,etal.Anesthesiology,2003;98:969.超声定位穿刺操作时，一手持探头，一手握绝缘针Onehandwithprobe,anotherwithinsulatedneedleCH为胸锁乳突肌锁骨头，SH为胸骨头CH=clavicleheadofsternocleidomastoid,SH=sternalhead锁骨上经路定位Supraclaviclelocation腋路定位AxillarylocationInterscaleneBlockTransversesonogramintheinterscaleneregionshowingbrachialplexusashypoechoicnodules(arrows)interposedbetweenscalenusanterior(SAM)andmedius(SMM)muscles,beneaththeposteriormarginofthesternocleidomastoidmuscle(SCM).CA,carotidartery;IJ,internaljugularvein.Transversesonogramoftheneedle(arrows)incontactwiththenervetrunksintheinterscalenegroove.InterscaleneBlockTransversesonogramshowinglocalanestheticspreadanddistention(arrows)intheinterscalenegroove.InterscaleneBlockInfraclavicularBlockTransversesonogramintheinfraclavicularregionshowingbrachialplexusashypoechoicnodules(Nwitharrow).AAaxillaryartery;AVaxillaryvein;PMaMpectoralismajormuscle;PMiMpectoralisminormuscle.HadzicA,etal.Anesthesiology,2003;98:969.腋部径路超声图中针头位置（箭头所示）Needlepositionofaxillarynerveblockinsonogram(arrows)AA:腋动脉axillaryarteryAxillaryBlockTransversesonograminthemidhumeralregionshowingtwoterminalbranchesofthebrachialplexusashypoechoicnodules(Nwitharrows).BAbrachialartery;BMbicepsmuscle;Hhumerus;TMtricepsmuscle.MusculocutaneuousNerveBlockA12-MHzultrasoundimagedemonstratingthemusculocutaneousnerveandsurroundingstructures.B,bone(humerus);Bi,bicepsmuscle;CB,coracobrachialismuscle;A,axillaryartery;v,axillaryvein.Themusculocutaneousnerveisfoundinthejuncturebetweenthebicepsandcoracobrachialismuscles.Thenerve,asdoesthemediannerve,appearsasaconstellationofhypodense(dark)grapelikestructureswithhyperechoic(bright)rings.Ultrasound-GuidedMusculocutaneousNerveBlock•Spence,Sites,andBeach199(四)神经刺激器定位Locationwithnervestimulator1.周围神经刺激器Peripheralnervestimulator神经刺激器的优点Advantages刺激后肌肉反应的指标客观明确Objectiveandcorrectsignsafterstimulation用于无法准确说明异感或定位困难病人(小儿、老年、不合作用及神智不清的病人)Usedinpediatrics,elderly,disoperativeandunconsciouspatients最大程度减少神经损伤Reducenervedamages神经阻滞成功率较高Highsuccessfulrate病人感觉触电、痛苦Electricshocksensoryanddiscomfortfeeling血管内意外注药危险Dangerinintra-vesselinfusion麻醉效果难以保证Pooranalgesiasometime定位无客观指标Noobjectivesigns成功率相对低Comparativelowersuccessratio病人感觉舒适Feelcomfort血管内意外注药少Avoidintra-vesselinfusion麻醉镇痛效果满意Betteranalgesia定位指标明确Precise&objectivelocation成功率高，并发症少Highersuccessratio&rarecomplication传统异感定位法Sensorylocation神经刺激器定位Stimulatorlocation神经刺激器与传统异感定位的对比Comparisonofnervestimulatorandtraditionalsensorylocation世界上第一个神经刺激器Firstnervestimulatorintheworld1912StimuplexHNS神经刺激器StimuplexHNSstimulatorStimuplexHNS采用全数字显示技术和人性化设计Digitaldisplayandpersonaldesign具有两种不同的显示方法(预设电流和实时显示)Twodifferentdisplay(initialcurrentanddisplayinrealtime)电流范围在0-1mA或0-5mA，调节精度高Currentranges0-1or0-5mA,preciseregulation脉冲时间有0.1、0.3或1.0ms三档可调Impulsetimewith0.1,0.3,1.0ms脉冲频率可设在1,2HzImpulsefrequency1or2Hz具有不同报警功能(防止电路故障和低电池量)Differentalarmfunction(preventelectrocircuitdisorderandlowbattery)StimuplexDigRC单人操作OperationwithsingledoctorStimuplexDigRC仅有一个调节按钮Onlyhaso