超声引导下臂丛神经阻滞知更

超声引导下臂丛神经阻滞技术浙医二院麻醉科周金锋内容提要解剖基础超声图像实战攻略一、臂丛相关解剖基础由第5-8颈神经前支和第1胸神经前支大部分构成，经椎动脉后方、斜角肌间隙向外侧穿出，组成三条干：①C5、C6前支组成上干②C7前支单独成为中干③C8前支和T1前支大部分合成下干在锁骨后第1肋骨中外缘分为前后两股腋窝水平分成三束：①上干和中干的前股合成外侧束-肌皮和正中神经②下干的前股成为内侧束-尺神经③三条干的后股组成后束-桡神经一、臂丛相关解剖基础一、臂丛相关解剖基础一、臂丛相关解剖基础一、臂丛相关解剖基础二、超声下图像C5C6C7VA二、超声下图像C5C6C7C8VA二、超声下图像MAUR三、实战攻略临床关注点起效时间阻滞程度药物剂量成功率操作难度并发症超声技术可以解决以上问题的关键——神经的定位及辨识度设备因素神经变异（50%）操作技术三、实战攻略——定位三、实战攻略——定位三、实战攻略——定位三、实战攻略——定位三、实战攻略三、实战攻略单点阻滞用于术后镇痛Anultrasound(US)-guidedblockattheC7root；Initialvolumeofropivacaine0.75%was6mL；Blocksuccessorfailuredetermineda1-mLdecreaseorincreaseforthesubsequentpatient；Theminimumeffectivevolumeoflocalanestheticin50%and95%ofthepatientswas2.9mL(95%confidenceinterval,2.4-3.5mL)and3.6mL(95%confidenceinterval,3.3-6.2mL)；Minimumeffectivevolumeoflocalanestheticforshoulderanalgesiabyultrasound-guidedblockatrootC7withassessmentofpulmonaryfunction.RegAnesthPainMed.2010Nov-Dec;35(6):529-34.三、实战攻略分干阻滞最低剂量Successfulsurgicalanesthesiaforarthroscopicshouldersurgerycanbeachievedwith5mLof0.75%ropivacaine,orapproximately1.7mLpereachofthe3trunksofthebrachialplexus(superior,middle,andinferior).Forthegroupasawhole,themedian(range)sensoryblockonsettimewas5(5-20)minutes,themedian(range)motorblockforthebicepswas7.5(5-15)minutes.Themedian(range)blockdurationwas9.9(5-19)hours,andthemean(SD)blockperformancetimewas8.0±3.2minutes.Meandurationofanalgesiawas9.9±3.7hours.DurationofanalgesiawasnotassociatedwithvolumeofLA(r=0.05,P=0.83)Theminimumeffectiveanestheticvolumeof0.75%ropivacaineinultrasound-guidedinterscalenebrachialplexusblock.AnesthAnalg.2011Oct;113(4):951-5.三、实战攻略单点阻滞最低剂量研究Theproportionofpatientswithsuccessfulblockadeincreasedsharplyfromapproximately57%at6mlto100%by7ml,indicatingthatasmallincreaseinvolumeofropivacaine0.75%markedlyaffectsthesuccessrate.Themedian(min-max)sensoryblockonsettimewas5(5-20)min,themedian(min-max)motorblocksforthebicepsandthedeltoidmuscleswere7.5(5-15)minand10(5-15)min,respectively.Themedian(min-max)blockdurationwas8.9(3-15)h.Effectivevolumeofropivacaine0.75%throughacatheterrequiredforinterscalenebrachialplexusblockade.Anesthesiology.2013Apr;118(4):863-7.三、实战攻略最低剂量及作用时间研究Lidocaine1.5%withepinephrine1:200000Themean(95%CI)volumetosurroundeachnervewas:radial3.42(2.84-3.99)ml,median2.75(2.31-3.19)ml,ulnar2.58(2.14-3.03)ml,andmusculocutaneous2.30(1.96-2.64)ml.Themean(95%CI)onsettimeforcompletesensoryblockwas:radial22.5(13.5-31.5)min,median26.8(18.5-35.0)min,ulnar26.6(17.8-35.4)min,andmusculocutaneous15.8(7.45-24.2)min.Themean(95%CI)lastrecordedtimewithcompleteblockwas:radial137.1(105.6-168.7)min,median144.7(123.4-166.0)min,ulnar183.2(158.1-208.2)min,andmusculocutaneous158.3(131.8-184.9)min.Minimumvolumeoflocalanaestheticrequiredtosurroundeachoftheconstituentnervesoftheaxillarybrachialplexus,usingultrasoundguidance:apilotstudy.BrJAnaesth.2010May;104(5):633-6.三、实战攻略锁骨下阻滞High-resolutionultrasonographyhasrevealedanatomicalvariationsofC5,C6andC7nerverootsinalmosthalfofthepatientsexamined,withoutnegativeblockeffectiveness.Infraclavicularcathetersprovidesuperioranalgesiawhencomparedwithsupraclavicularcatheters.Multiple-siteinjectionsoflocaloffernoadvantageoverasingle-siteinjectionduringaninfraclavicularblock.Ultrasound-guidedperipheralnerveblockadeoftheupperextremity.CurrOpinAnaesthesiol.2012Apr;25(2):253-9.三、实战攻略锁骨下阻滞Thesupraclavicularapproachofthebrachialplexushasahighsuccessrateincludingblockadeoftheulnarandmusculocutaneousnerve,whichcanbemissedrespectivelywiththeinterscaleneandaxillaryapproach.Supraclavicularbrachialplexusblocks:reviewandcurrentpractice.ActaAnaesthesiolBelg.2012;63(1):15-21.三、实战攻略地塞米松Theadditionofdexamethasonemayprolonganalgesiaaftersingle-shotinterscaleneandsupraclavicularblocks.Ultrasound-guidedperipheralnerveblockadeoftheupperextremity.CurrOpinAnaesthesiol.2012Apr;25(2):253-9.三、实战攻略地塞米松Themediantimeofasensoryblockwasequivalentforperineuralandi.v.dexamethasone:1405min(IQR1015-1710)and1275min(IQR1095-2035)forRDandRDiv.I.V.dexamethasoneisequivalenttoperineuraldexamethasoneinprolongingtheanalgesicdurationofasingle-shotISBwithropivacaine.Therewasasignificantdifferencebetweentheropivacainegroup:757min(IQR635-910)andthedexamethasonegroups(P<0.0001).Asdexamethasoneisnotlicensedforperineuraluse,cliniciansshouldconsideri.v.administrationofdexamethasonetoachieveanincreaseddurationofInterscalenebrachialplexusblock（ISB）.I.V.andperineuraldexamethasoneareequivalentinincreasingtheanalgesicdurationofasingle-shotinterscaleneblockwithropivacaineforshouldersurgery:aprospective,randomized,placebo-controlledstudy.BrJAnaesth.2013Sep;111(3):445-52.三、实战攻略右旋美托嘧啶Ultrasound-guidedulnarnerveblock(UNB)wasperformedin36volunteerswitheither3mlropivacaine0.75%(R),3mlropivacaine0.75%plus20µgdexmedetomidine(RpD),or3mlropivacaine0.75%plussystemic20µgdexmedetomidine(RsD).Thedurationofsensoryblockwas350(54)mininGroupR,555(118)mininGroupRpD,and395(40)mininGroupRsD(P<0.01GroupRpDvsothergroups,P<0.05GroupRsDvsGroupR).MotorblockdurationwassimilartothedurationofsensoryblockDexmedetomidineasanadjuvanttoropivacaineprolongsperipheralnerveblock:avolunteerstudy.BrJAnaesth.2013Mar;110(3):438-42.三、实战攻略剂量与年龄Theminimumeffectivelocalanestheticvolumesignificantlydifferedbetweenmiddle-agedandelderly[23.0ml,95%confidenceinterval(CI)13.7-32.3vs.11.9ml,95%CI9.3-14.6;95%CIofthedifference1.6-20.6,P=0.027].Effectsofageonminimumeffectivevolumeoflocalanestheticforultrasound-guidedsupraclavicularbrachialplexusblock.ActaAnaesthesiolScand.2013Jul;57(6):761-6.攻略 总结 初级经济法重点总结下载党员个人总结TXt高中句型全总结.doc高中句型全总结.doc理论力学知识点总结pdf 超声追踪定位是区分神经分支的有效方法；肌间沟单点（C70.75%罗哌卡因5-10ml）神经阻滞可产生良好的镇痛效果；肌间沟分干阻滞单干最低剂量（0.75%罗哌卡因）约为1.7-3ml，总量最低可控制在5-7ml，最快起效时间约为5-10min；锁骨下阻滞可以提供完善的尺神经和肌皮神经效果，但气胸及局麻药误入血管风险较大；静脉辅助地塞米松10mg或局部使用右旋美托咪定20ug可以显著延长罗哌卡因的作用时间。