【正文】 神經(jīng)阻滯定位方法進(jìn)展 Advance in Locatlizaion of Nerve Block Department of Anesthesiology Ren Ji Hospital Shanghai Second Medical University Shanghai 202201 外周神經(jīng)阻滯的優(yōu)點(diǎn) Advantage of peripheral nerve block 阻滯成功率高 High successful ratio ? 安全性高 More safety ? 應(yīng)激反應(yīng)輕 Less stress response ? 降低深靜脈血栓形成 Avoid DVT ? 恢復(fù)快 Fast recovery ? 生理機(jī)能穩(wěn)定 stable physical status ? 病人歡迎 Weled by patients ? 費(fèi)用低 Low cost ? 內(nèi)容提要 Contents Localization methods of nerve block 2. 神經(jīng)刺激器與神經(jīng)刺激針 Nerve stimulator and needles 3. 下肢神經(jīng)阻滯在老年重危病人中的應(yīng)用 Application of lower extremity nerve block in elderly severe patients 一、神經(jīng)阻滯的定位方法 I. Location methods of nerve block ? 解剖定位 Anatomy location ? 異感定位 Sensory location ? 超聲和放射學(xué)定位 Ultrasound and radiological ? 神經(jīng)刺激器定位 Nerve stimulator location （一 ） 解剖定位 Anatomy location 神經(jīng)解剖變異，神經(jīng)分布不規(guī)則，神經(jīng)不是集中某個(gè)單一的點(diǎn)，解剖標(biāo)記不明確或不易辨認(rèn)，因此，臨床操作難度較大。 Variation and decentralization of nerves, irregular distribution, ambiguity of anatomy landmarks, it’s difficult to operate in clinic （ 二 ） 異感定位 Sensory location ? 是否需要尋找異感尚有爭(zhēng)議 ? Debate of finding special sensory ? 找到“異感”，麻醉效果并非一定完善 ? Unsatisfied anesthetic effects with sensory location ? 神經(jīng)分布與病人狀態(tài)，可能無(wú)法引出異感 ? Sensation may be not found in some patients ? 尋找異感可能損傷神經(jīng) ? Maybe damage nerves （三）超聲和放射學(xué)定位 Ultrasound and radiological location ? 優(yōu)點(diǎn) Advantages ? 提高神經(jīng)阻滯的成功率 ? Increase the successful rate of nerve block ? 觀察局麻藥注射后的擴(kuò)散規(guī)律 ? Observe the distribution of local anesthetics ? 避免血管內(nèi)注射的發(fā)生 ? Avoid intravascular injection ? 減少麻醉藥用量 ? Reduce the dosage of anesthetics ? 缺點(diǎn) Disadvantages ? 需要特殊設(shè)備和人員技術(shù)培訓(xùn) ? Need equipments and training ? 增加了操作步驟 ? More operation steps ? 儀器體積較大，價(jià)格昂貴 ? Large size and expensive equipment 超聲的基本原理 Basic principles of Ultrasound ? 臨床應(yīng)用的超聲頻率為 ~20MHz ? Clinical ultrasound with ~20MHz ? 頻率越高空間分辨率越好，但穿透性越差；反之亦然 ? Higher frequency with better space differentiation ratio but less perability。 vice versa ? 淺表神經(jīng)可用＞ 10MHz，而深部神經(jīng)需用＜ ，超聲定位深部神經(jīng)應(yīng)與局部解剖學(xué)相結(jié)合 ? ＞ 10MHz frequency used in superficial nerves and ＜ in deep ones, ultrasound should be used with topography especially in deep nerve block 超聲引導(dǎo)下神經(jīng)阻滯 Nerve block guided by ultrasound 肌間溝中軸斜面 鎖骨上冠狀斜面 鎖骨下矢狀面 腋部橫斷面 肱骨中部橫斷面 超聲探頭的位置 Location of ultrasound probe Perlas A, et al. Anesthesiology,2022。99:429. Midaxis oblique surface of interscalene groove Supraclavicle coronal oblique surface Subclavicle sagittal surface transect of axilla transect of midhumerus 肌間溝經(jīng)路定位 Interscalene location Hadzic A, et al. Anesthesiology,2022。98:969. 超聲定位穿刺操作時(shí)，一手持探頭，一手握絕緣針 One hand with probe, another with insulated needle CH為胸鎖乳突肌鎖骨頭， SH為胸骨頭 CH=clavicle head of sternocleidomastoid, SH=sternal head 鎖骨上經(jīng)路定位 Supraclavicle location 腋路定位 Axillary location Interscalene Block Transverse sonogram in the interscalene region showing brachial plexus as hypoechoic nodules (arrows) interposed between scalenus anterior (SAM) and medius (SMM) muscles, beneath the posterior margin of the sternocleidomastoid muscle (SCM). CA, carotid artery。 IJ,internal jugular vein. Transverse sonogram of the needle (arrows) in contact with the nerve trunks in the interscalene groove. Interscalene Block Transverse sonogram showing local anesthetic spread and distention (arrows) in the interscalene groove. Interscalene Block Infraclavicular Block Transverse sonogram in the infraclavicular region showing brachial plexus as hypoechoic nodules (N with arrow). AA axillary artery。 AV axillary vein。 PMaM pectoralis major muscle。 PMiM pectoralis minor muscle. Hadzic A, et al. Anesthesiology,2022。98