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1、超声引导下对门诊病人的区域麻醉(双语)introductionSpecifically,orthopedic patients are the group of ambulatory patients with the highest incidence(16.1%)of pain in the PACU.具体来说,在PACU中骨科病人是门诊病人中疼痛发生率最高的 Peripheral nerve blocks(PNBs)offer predictable intraoperative anesthesia,as well as provide analgesia into the posto
2、perative period,the opportunity to bypass Phase I recovery,and the avoidance of airway manipulations.外周神经阻滞(PNBs)提供可预测的术中麻醉,还提供术后镇痛,绕过复苏第一阶段,避免了气道处理。introductionUltrasound(US)imaging permits direct visualization of peripheral nerves,needle location and distribution of local anesthetic.超声成像能直接看到周围神经、
3、针的位置及局麻药的分布。The use of US-guidance to perform nerve blocks is associated with decreased time to onset and quality of block which is equal to or better than PNBs performed with nerve stimulator(NS)techniques,使用超声引导进行神经阻滞与减少起效时间相关,阻滞的效果等于或优于使用神经刺激器(NS)技术。introductionand the use of US facilitates the p
4、lacement of blocks in patients who are obese,may be on anticoagulants and those with challenging external anatomy.超声的使用方便了肥胖病人、可能使用抗凝剂的病人、有挑战的解剖异常的病人的阻滞。introductionPerforming US-guided nerve blocks requires an entirely new skill set for practitioners.超声引导下神经阻滞要求医生掌握一项全新技能。Firstly,one must learn to
5、operate ultrasound equipment and then use this to identify anatomy as it appears on a two-dimensional screen.首先,你必须学会操作超声设备,然后使用它识别出现在二维屏幕上的解剖。Secondly,one must be able to simultaneously use both hands(one holding the ultrasound transducer and the other holding the block needle),watch the display sc
6、reen,and manipulate the needle into the nerve sheath.其次,一个人必须能同时使用双手(一边拿着超声波换能器，一边握着阻滞针),观察显示屏,操作针使其进入神经鞘。Lastly,it is necessary to learn to identify patterns of local anesthetic spread that are associated with optimal plexus blockade.最后,必须学会识别局部麻醉药扩散的模式，这与最佳神经阻滞相关。introductionEnlisting the surgeon
7、to introduce the concept of PNBs when they offer patients their preoperative instructions will improve patient acceptance.让外科医生给病人术前指导时介绍外周神经阻滞的概念,会提高病人的接受度。Local anesthetics should be chosen to minimize onset times and limit the use of GA in order to prevent operating room delays.Meticulous follow-
8、up until resolution of all blocks along with communication with the surgeons can add to overall satisfaction.应选择可以缩短起效时间和限制使用全身麻醉的使用的局部麻醉药来防止手术延迟。仔细的观察直到所有的阻滞有效，并与外科医生沟通，可以增加整体满意度。Local Anesthetics and Adjuvants局部麻醉剂和佐剂Local anesthetic(LA)agents should be chosen according to the desired duration of
9、action and the required degree of motor blockade.局部麻醉剂选用应根据所需阻滞的持续时间和所需的运动神经阻滞深度，An insensate extremity in a patient whose procedure may not produce much post-operative discomfort may be at risk for injury secondary to the loss of protective reflex to pain,or place the patient at risksecondary to a
10、loss of proprioception本体感觉blocks of the longest possible duration are not always the wisest choice.对一个手术后可能不会有什么不适的病人让其肢体没有感觉，可能有继发损伤的风险，由于疼痛保护性反射消失或失去本体感觉，最长阻滞时间并不总是最明智的选择。Galindo concluded that mixing LAs leads to unpredictable blockade characteristics.Galindo得出使用混合的局部麻醉将导致不可预知的阻滞得出使用混合的局部麻醉将导致不可预
11、知的阻滞效果效果。Gratenstein looked at US-guided interscalene blocks with 30 mL in 3 different solutionsmepivacaine 1.5%,bupivacaine0.5%and a 50:50 mixture of the two,and found that mixing the short and long-acting agents does not result in a significant difference in onset time compared with either solutio
12、n alone.Gratenstein观察观察在超声引导下使用在超声引导下使用1.5%甲哌卡甲哌卡因因,0.5%布比卡因和这两个药物对等混合的各布比卡因和这两个药物对等混合的各30 ml分别进行行肌间沟阻滞分别进行行肌间沟阻滞,发现短效和长效混发现短效和长效混合的这一组与在起合的这一组与在起效效时间方面与单独使用一种时间方面与单独使用一种药物相比并没有显著性差异药物相比并没有显著性差异nWhereas some practitioners combine LAs to decrease onset time while providing long duration,combining chl
13、oroprocaine 2%and bupivacaine 0.5%causes pH changes that create a block that resembles one produced by bupivacaine alone.n而一些医生结合使用局部麻醉以减少起效时间,同时提供长时间麻醉,将2%氯普鲁卡因和0.5%布比卡因混合引起pH值的变化导致阻滞效果类似于单独使用布比卡因。Local anesthetics diffuses into nerves and the rate of diffusion is determined by the concentration,th
14、erefore higher concentrations of LAs result in more rapid onset of blockade.局部麻醉药扩散到神经，其扩散的速率是由浓度决定的,因此越高浓度的局部麻醉药导致扩散速率越快Ropivacaine 0.75%has been shown to have similar or shorter onset times for femoral,sciatic and interscalene blocks,while providing significantly longer postoperative analgesia tha
15、n mepivacaine and bupivacaine.0.75%罗哌卡因已被证明作用在股神经,坐骨神经和肌间沟神经阻滞有类似甚至更短的起效时间,同时提供术后镇痛时间明显比甲哌卡因和布比卡因长。The effect of alkalinization of agents on the speed of onset of the block is unclear.碱化剂对阻滞的起效速度的影响还不清楚。It has been shown to offer no advantage in perivascular blocks with 0.5%bupivacaine but improveme
16、nt in onset and quality of analgesia in axillary blocks with 1.25%mepivacaine,and in femoral and sciatic blocks with 2%mepivacaine has been demonstrated.已证明使用0.5%布比卡因在血管周围阻滞并没有优势,但使用1.25%甲哌卡因行腋神经阻滞、2%甲哌卡因行股神经和坐骨神经阻滞被证实改善了起效时间及镇痛的效果。Adding sodium bicarbonate to lidocaine has been shown to have no eff
17、ect on the onset of axillary block,and in rats it has been shown to decrease the intensity and duration of the block.在利多卡因液中加入碳酸氢钠已被证明对腋神经阻滞的起效时间上没有效果，在老鼠身上它已被证明可降低阻滞的强度和持续时间In one study fentanyl improved the sensory blockade achieved with an axillary block using 1.5%lidocaine,but the pH changes it
18、conferred delayed the onset of analgesia.Other studies have not shown efficacy of either fentanyl or morphine in the improvement of onset or quality of axillary blocks.在一项研究中显示在用1.5%利多卡因进行腋神经阻滞时，芬太尼可改善感觉阻滞，但它的pH值的变化导致镇痛起效时间延迟。其他研究没有表明芬太尼或吗啡在改善腋神经阻滞起效时间和效果有效，Clonidine,an 2-agonist,is known to prolong
19、 the duration of sensory and motor blockade,particularly when added to local anesthetics of intermediate duration.可乐定，一种a2受体激动剂,众所周知，它可延长感觉和运动阻滞持续时间,特别是添加到中等时效局麻药时持续时间更长。One study of 56 patients undergoing carpal tunnel release under axillary block with 1%lidocaine and varying amounts of clonidine,s
20、howed a reduction in block onset time.一项研究56例准备行腕管减压的病人以1%利多卡因混合不同剂量的可乐定予腋神经阻滞，证实阻滞起效时间缩短。However,even with doses as small as 30g,patients experienced sedation.然而,即使有剂量小至30 微克,对患者都有镇静作用。More than 50%of patients were reported to fall asleep intermittently at 140 minutes after performance of the block
21、.超过50%的患者报告显示在阻滞效果产生后的140分钟内都睡着了Recently the utility of adding dexamethasone to upper extremity blocks.The addition of dexamethasone 8 mg to 30 mL mepivaciane has been shown to significantly prolong the duration of a supraclavicular block.最近使用加入地塞米松来对上肢进行阻滞。加入地塞米松8毫克至30毫升甲哌卡因中被证明能显著延长锁骨上神经阻滞的持续时间。Ei
22、ght mg of dexamethasone was shown to prolong the duration of action of ropivacaine(11.8 vs 22.2 hrs)and bupivacaine(14.8vs 22.4 hrs)when added to 30 mL of local anesthetic for interscalene anesthesia.当8毫克的地塞米松添加到30毫升的局部麻醉剂中，对肌间沟的麻醉效果被证明可延长罗哌卡因的作用时间(11.8 vs 22.2小时)和布比卡因的作用时间(14.8vs 22.4小时)。Tando and
23、colleagues found no difference in the duration of analgesia between adding 4 mg and 8 mg doses of dexamethasone to interscalene blocks using 40mL bupivacaine.There exact mechanism of this prolongation of action is yet to be elucidated.Tando和同事们发现在40毫升布比卡因加入4或8毫克剂量的地塞米松，行肌间沟阻滞，在镇痛的持续时间上没有不同。延长作用时间的确切
24、机制仍有待阐明。The 5 US-Guided PNBs Every Ambulatory Practitioner Needs and When to Use Them 5种每个种每个医师需要知道医师需要知道及何时使用超声引导下神经阻滞及何时使用超声引导下神经阻滞Mastery of the interscalene(ISB),supraclavicular,femoral股骨,popliteal腘肌 and transverses腹横肌 abdominis plane(TAP)blocks will be adequate for almost all of the needs of th
25、e anesthesiologist who has an ambulatory-based practice.掌握肌间沟、锁骨上,股骨、腘肌和腹横肌平面的阻滞可满足门诊麻醉实践的麻醉医师几乎所有的需要。Upper Extremity US-Guided Peripheral Nerve Blocks超声引导下上肢周围神经阻滞learning a simple scanning technique.The region to be blocked is sterilely prepped:阻滞区域消毒 1)Identify the carotid artery and internal jug
26、ular vein,with the probe in the horizontal position,just above the clavicle.确认颈动脉和颈内静脉,将探头放在水平位置,略高于锁骨。2)Moving the probe laterally along the clavicle and aiming the beam caudad,towards the first rib,the subclavian artery is identified as the next pulsatile structure that is visualized.沿着锁骨向外侧横向移动探头
27、，探头尾端方向，对着第一肋骨,即可确定跳动的结构为锁骨下动脉,这是可见的。The patient is placed in the supine position with his or her head flat on the bed(without pillows)and turned towards the contralateral shoulder.病人仰卧位，去枕平卧，头转向对侧的肩膀。The brachial plexus at the level of the divisions appears as a“bag of grapes”located lateral to the
28、 artery.臂丛的一级分支像“葡萄”样出现位于动脉的一侧。To perform a supraclavicular block at that level,a 22 gauge block needle is inserted in-plane(parallel to the probe),until it reaches the location that is bordered by the subclavian artery medially,the first rib inferiorly,and the divisions of the brachial plexus super
29、ior laterally-the“eight ball in the corner pocket”position.This block is ideal for all procedures of the elbow and distally.在这样的平面上操作锁骨上神经阻滞,一个22号规格针插入平面(平行于探针),直到它到达锁骨下动脉内侧的位置，在第一肋下缘,上级部门臂丛神经外侧“八球在角落里的口袋”位置。这阻滞对肘部及远端手术是理想的。30-40 ml of local anesthetic will be more than adequate to provide a block.3
30、0-40毫升局部麻醉剂足够用来提供阻滞。3)It is then possible to choose the largest of the nerves,appearing as a radiolucent circle and trace it cephalad,as the probe is kept in the horizontal position.然后你就可以选择最大的然后你就可以选择最大的神经神经,出现一个射线可透过的圆，然后向头侧跟踪它出现一个射线可透过的圆，然后向头侧跟踪它,探探头头保持在水平位置。保持在水平位置。When the C-6 level is reached,
31、this nerve and the others of the brachial plexus are seen in a vertical orientation,between the anterior and middle scalene muscles.当当到到达达颈6水平时水平时,这根神经和其他的臂丛神经根在这根神经和其他的臂丛神经根在垂直方向可看见垂直方向可看见,在前部和中部肌肉之间的三角形。在前部和中部肌肉之间的三角形。The 22-gauge block needle is inserted either in-plane or out-of-plane and direct
32、ed towards the previously identified nerve,within the sheath.22 号阻滞针平面号阻滞针平面内内或平面外插入并指向之前确定的的神经鞘或平面外插入并指向之前确定的的神经鞘内神经。内神经。The out-of-plane approach may be preferable to an in-plane one for practitioners who have experience with using a vessel finder for central venous line placement平面外平面外接近接近的方法可能更的
33、方法可能更适合适合于一个于一个实践实践者者已已具备平面具备平面内借内借助寻找血管法置入助寻找血管法置入中中心心静脉经验静脉经验者者。Again,30-40 ml of local anesthetic will provide adequate anesthesia.同样的同样的,30-40毫升的局部麻醉剂会提供足够的麻醉。毫升的局部麻醉剂会提供足够的麻醉。In a study looking at 170 patients undergoing shoulder surgery,Spence sought to describe the ideal location to inject LA
34、either peri-plexus(between the middle scalene muscle and brachial plexus),or intra-plexus(injection within the brachial plexus sheath).在一项观察在一项观察170例患者接受肩膀手术例患者接受肩膀手术,Spence寻求寻求理想的位置注入局部麻醉剂理想的位置注入局部麻醉剂-要么从周围神经丛要么从周围神经丛(在斜角肌在斜角肌和臂丛之间的和臂丛之间的之之中中),或内部神经丛或内部神经丛(注射在臂丛神经鞘注射在臂丛神经鞘内内)。After injecting 30 mL
35、bupivacaine 0.5%,they looked for loss of shoulder abduction.在注射在注射30毫升毫升0.5%布比卡因后布比卡因后,他他们检查们检查肩关肩关节节外展外展的活的活动动是否存在。是否存在。Onset times and block quality were equal,but the intra-plexus blocks resulted in statistically significantly longer block duration(2.6 hrs,p=0.03).起效起效时间时间和阻滞效果都是一和阻滞效果都是一样样的的,但内部
36、神但内部神经丛经丛阻滞阻滞导导致了阻滞持致了阻滞持续时间显续时间显著的延著的延长长(2.6小小时时,p=0.03)Data show that when 5mL vs.20 ml of ropivacaine are used for in ISB combined with GA for the surgical procedure,patients have fewer respiratory and other complications with no change in postoperative analgesia.资料显示5毫升与20毫升罗哌卡因相比较用于肌间沟阻滞复合全身麻醉的
37、手术,病人更少呼吸及其它并发症，而术后镇痛没有不同。More recently this group showed that with the use of US,the minimum effective analgesic volume of ropivacaine 0.5%in an ISB required to provide analgesia in the immediate post op period is 0.9mL最近这个研究小组发现在超声的使用下,0.5%罗哌卡因肌间沟阻滞提供术后即刻镇痛的最低有效的止痛剂量是0.9毫升。After the needle tip was
38、 determined to be in the interscalene groove the nerve stimulator was turned on and the lowest current eliciting a response was noted.当当针针尖被尖被认为认为是在肌是在肌间间沟沟时时，打开神，打开神经经刺激器，刺激器，并并记录最低最低电流引起的反流引起的反应。The sensory analgesia achieved between the groups with responses at 0.5 mA was similar,thus confirming
39、that US-guided blocks produce successful analgesia regardless of the motor stimulation evoked.感感觉觉神神经镇痛的痛的获得在得在 0.5 mA组组是是相似的相似的,因因此此证实了无了无论运运动刺激刺激诱发与否与否，超声引，超声引导导阻滞都可以阻滞都可以产产生生满意的意的镇痛效果。痛效果。Perlas etal described their experience with 510 consecutive US-guided supraclavicular blocks,and reported a 9
40、4.6%success at achieving surgical anesthesia with a single attempt.Perlas等描述他们在510个病人连续超声引导下锁骨上神经的阻滞的经验，仅一次尝试就实现外科麻醉的成功率为94.6%。Complications included symptomatic hemidiaphragmatic paresis(1%),Horner syndrome(1%),vascular puncture(0.4%)and transient sensory deficit(0.4%).并发症包括膈肌麻痹症状(1%),霍纳综合征(1%)、误穿血
41、管(0.4%)和短暂感觉障碍(0.4%)。A prospective registry of 1,169 US-guided ISB and supraclavicular blocks for shoulder surgeries shows a 0%incidence of vascular puncture,0.4%incidence of short-term postoperative neurologic symptoms and a 0%incidence of permanent nerve injury.1169个超声引个超声引导导下的肌下的肌间间沟阻滞和沟阻滞和锁锁骨上神骨
42、上神经经阻滞的肩阻滞的肩膀手膀手术术的前瞻性研究的前瞻性研究显显示血管穿刺的示血管穿刺的发发生生率率0%，术术后后短期神短期神经经症状症状发发生生率率0.4%,永久神永久神经损伤发经损伤发生生率率0%。Since Sauter used MRI to define the anatomic location of the cords of the infraclavicular brachial plexus,we know that needle placement at the“VIII oclock”position adjacent to the axillary artery in
43、the cranioposterior quadrant and observing satisfactory spread of local anesthetic between the“III oclock and IX oclock”positions will predict a successful infraclavicular block.由于sauter使用核磁共振成像技术来明确的锁骨下臂丛的解剖位置,我们知道针位于毗邻腋动脉的“八点”位置颅后象限，观察局部麻醉在“三点和九点”位置满意的扩散将预测一次成功的锁骨下阻滞。Mccairre described using US-gu
44、ided median and ulnar nerve blocks at the wrist to provide anesthesia for endoscopic carpal tunnel release.Mccairre描述了对内镜下腕管减压手术提供麻醉使用超声引导在腕部阻滞正中神经和尺神经。Through a single injection site located 5 to 10 cm proximal to the wrist crease in the anterior forearm,both nerves are blocked under direct vision,
45、each with 4 ml of 1.5%mepivacaine.通过前臂位于腕横纹近端5到10厘米的位置单次注射，在直视下两神经都可被阻滞，各需4毫升的1.5%甲哌卡因。This is supplemented with 1-2 ml of local anesthetic at the level of incision in the wrist crease in order to block the palmaris ramus of the median nerve.在腕横纹切口处可补充1-2毫升的局部麻醉剂以便阻滞正中神经的掌支。Lower Extremity US guided
46、Peripheral Nerve Blocks超声引导下肢周围神经阻滞超声引导下肢周围神经阻滞 The femoral nerve is located by placing the linear probe in the inguinal crease.将线阵探头置于腹股沟折痕处可定位股神经。It is the dense white structure,lateral to the hypoecoic pulsatile femoral artery and deep to both the fascia lata and fascia iliaca.它是致密白色结构,在低回声跳动性的股动
47、脉外侧，在阔筋膜和髂筋膜的深部。This can be blocked with a 22g needle in an in-or out-of plane approach and a successful block is anticipated when local anesthesia spread is seen surrounding the nerve.这可以被22号针使用平面内或外接近方法阻滞，当局部麻醉剂围绕神经扩散，成功的阻滞是可预期的。This block is particularly useful for patients undergoing repairs of
48、the anterior cruciate ligament or surgical procedures involving the patella.Performing a fascia iliaca block is an alternative to the femoral nerve block,and may be more successful for blocking the lateral femoral cutaneous nerve and occasionally the obturator nerve.这阻滞在患者接受前交叉韧带修补或涉及膝盖骨的手术特别有用。行髂筋膜
49、阻滞是股神经阻滞替代方法,可能更有效阻滞股外侧皮神经，有时还能阻滞到闭孔神经。A line drawn between the anterior superior iliac spine and pubic tubercle is divided in thirds.At the junction between the middle and lateral thirds an ultrasound probe is placed in a transverse position and the fascia lata and iliaca are identified.在髂前上棘棘和耻骨结节
50、之间划一条线分为三等分。在中外三分之一处，超声波探头放置在横向位置，阔筋膜和髂筋膜可被识别。The needle is placed under the fascia iliaca,and 30 ml of local anesthetic is injected.Spread of local anesthetic in medial and lateral directions under the fascia iliaca is evidence of correct needle placement.针位于髂筋膜下,注入30毫升局部麻醉药。局部麻醉药在髂筋膜下向内侧和外侧方向扩散是针位