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1、椎旁阻滞的临床应用,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,Hugo Sellheim(28.Dezember 1871 in Biblis bei Worms;22.April 1936 in Leipzig)war ein deutscher Gynkologe und Geburtshelfer.,Arthur Lwen 验证PVB(1911年),Arthur Georg Lwen(6.Februar 1876 in Waldheim,Sachsen;30.Januar 1958
2、in Lneburg)war ein deutscher Chirurg und Wegbereiter der heutigen Ansthesiologie,Richardson,J.et al.,Br J Anaesth.1998;81(2):230-8.,Arthur Lwen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,Max Kappis（1919年）,Kappis M.Sensibilitaet und locale anaesthesia gebeit der Bauc
3、hoele mit besonderer beruchsichtigung der Splanchnicus anaesthesia.Beitr Klin Chir 1919;115:16175Fujita Y.Max Kappis,an inventor of splanchnic nerve block.Masui.1993 Sep;42(9):1378-80.Article in Japanese,Max Kappis(6.Oktober 1881 in Tbingen;5.August 1938)war ein deutscher Chirurg,PVB的早期应用,1920s应用极为流
4、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（Mandel F.Paravertebral block.New York:Grune and Stratton,1946）1950s-1960s 文献报道几乎消失1970s，阻力消失法引入后，再度流行(Eason MJ,Wyatt R.Paravertebral thoracic block-a reappraisal.Anaesthesia.1979;34(7):638-42.),Richardson,J.et al.,Anesth Analg.1998;87(2):373-6.,Figure 2.In
5、the presence of complete numbness on sensory examination,depression of the S1 dermatomal SSEP ranged from 0%(A),to greater than 50%(B),to 100%(C)Data are representative examples.,Benzon HT et al.,Anesth Analg.1993;76(2):328-32.,PVB vs 硬膜外:4-8h 和48h VAS评分,Ding,X.et al.,PLoS One.2014;9(5):e96233,PVB v
6、s 硬膜外:吗啡量和尿潴留,Ding,X.et al.,PLoS One.2014;9(5):e96233,PVB vs 硬膜外:PONV和低血压,Ding,X.et al.,PLoS One.2014;9(5):e96233,PVB vs 硬膜外:失败率和肺部并发症,Ding,X.et al.,PLoS One.2014;9(5):e96233,区域阻滞与术后慢性疼痛,Andreae MH and Andreae DA.Br J Anaesth.2013;111(5):711-20,椎旁神经解剖,Eason,M.J.and Wyatt,R.Anaesthesia.1979;34(7):638
7、-42,椎旁神经解剖,Schematic thoracic spinal nerve.AD=anterior division,PD=posterior division,C=spinal cord,SG=spinal ganglion,RM=recurrent meningeal,SC=sympathetic chain,RC=ramicommunicantes,PC=posterior cutaneous,LC=lateral cutaneous,AC=anterior cutaneous,P=pleura.,Eason,M.J.and Wyatt,R.Anaesthesia.1979;3
8、4(7):638-42,穿刺方法,Eason,M.J.and Wyatt,R.Anaesthesia.1979;34(7):638-42,穿刺技巧,Eason,M.J.and Wyatt,R.Anaesthesia.1979;34(7):638-42,Eason和Wyatt阻力消失法成功率,Lonnqvist,P.A.et al.,Anaesthesia.1995;50(9):813-5,Eason和Wyatt法神经刺激器定位,Naja,Z.and Lonnqvist,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%
9、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.et al.,Acta Anaesthesiol Scand.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.et al.,Acta Anaesthesiol Scand.2001;45(1):30-3,2ml 利多卡因=1个节段,剂量与容量和阻滞范围无关,Cheema,S.et al,Anaesthesia.2003;58(7):684-7
10、,73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PVB,Hara,K.et al.,Anaesthesia.2009;64(2):223-5.,3-11MHz 线性探头（Philips SONOS 5500）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.et al.,Br J Anaesth.2010;105(4):526-32.,肋间入路靶向横突间内膜PVB,Ben-Ari,A.et al.,Anesth Analg.2009;109(5):1691-4.,肋间入路PVB,Be
11、n-Ari,A.et al.,Anesth Analg.2009;109(5):1691-4.,靶向横突下PVB,Shibata,Y.and Nishiwaki,K.Anesth Analg.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.,et al.Reg Anesth Pain Med.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,
12、S.H.,et al.Reg Anesth Pain Med.2010;35(2):212-6,肋间入路平面内穿刺PVB,Renes,S.H.,et al.Reg Anesth Pain Med.2010;35(2):212-6,肋间入路平面内穿刺PVB,0.75%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.,et al.Reg Anesth Pain Med.2010;35(2):212-6,斜轴位靶向肋横突上韧带PVB,Luyet,C.,et al.,Br J Anae
13、sth.2009;102(4):534-9,椎管内扩散,Luyet,C.,et al.,Br J Anaesth.2009;102(4):534-9,靶向肋横突上韧带的PVB,O.Riain SC et al.,Anesth Analg.2010;110(1):248-51,椎旁阻滞入路,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,椎旁间隙的解剖,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,椎旁间隙的解剖,Krediet AC.,et al.,Anesthesiology 2015;
14、123:459-74,椎旁间隙的解剖,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,SCTL和iimb的异同,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,椎旁间隙的解剖,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,椎旁间隙头侧和尾侧的边界,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,肋骨平面-横切面扫描,Krediet AC.,et al.,Anesthesiology 20
15、15;123:459-74,横突平面-横切面扫描,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,iimb=internal intercostal membrane(green);,横突平面-横切面扫描穿刺法,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,imim=innermost intercostal muscle,1:20 ml lidocaine(15 mg/ml)a median of 5 dermatomes(interquartile range,4 to 6).2:20
16、 ml ropivacaine 0.75%a median of 4 or 6 dermatomes(range,3 to 7),a cadaver study 20 ml injected dye over 3 to 4 TPV spaces(range,1 to 10)with 40%incidence ofepidural spread.3:20 ml mepivacaine 1%a dist a median of 3.5 to 4 dermatomes(range,2 to 6)epidural spread of 25%,while the same volunteers had
17、a sensory blockade over a median of 10 dermatomes,下关节突平面-横切面扫描,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,IAP=inferior articulate process;iimb=internal intercostal membrane(green),暂无临床报道,下关节突平面-横切面扫描穿刺法,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,4：暂无临床报道5：cadaver study,34 of 36 needle
18、tips were correctly positioned in the TPV,epidural spread of dye was noted in six instances,肋间平面-矢状面扫描,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,iimb=internal intercostal membrane(green),肋间平面-矢状面扫描穿刺法,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,6：13 of 14 injections of 1 ml methylene b
19、lue 1%resulted in spread of dye to the TPV space.The same study also evaluated a transversal in-plane intercostal approach(fig.9,arrow no.1)and found that more attempts were required to successfully place the needle with the sagittal technique compared with the transversal technique:two(range,1 to 4
20、)and four(range,1 to 7),respectively).15,Off Side靶向肋横突上韧带,Abdallah,F.W.and Brull,R.Reg Anesth Pain Med.2014;39(3):240-2,肋横突关节平面-矢状面扫描,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,SCTL=superior costotransverse ligament(pink),肋横突关节-矢状面扫描穿刺法,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,7：inse
21、rtion of catheters through the needle was found to be difficult or impossible in 6 of 20 catheters placed,and a high variability in spreadof injectate occurred,including 30%epidural spread.,横突平面-矢状面扫描,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,SCTL=superior costotransverse ligament(pink),横突平面
22、-矢状面扫描穿刺法,8：目前尚无临床数据9：目前尚无临床数据,Krediet AC.,et al.,Anesthesiology 2015;123:459-74,体会,横突平面-横切面扫描穿刺法,肋间平面-矢状面扫描穿刺法,目标结构：穿破肋间内膜，到达横突下缺点：朝向中线穿刺，有盲区，肩胛间区不易操作，不易置管优点：平面内穿刺角度小，穿刺针清楚用于：低位胸段椎旁,目标结构：穿破肋间内膜或肋横突韧带，到达肋间内膜和肋间最内肌之间缺点：穿刺角度大，针道消失困难优点：肩胛间区可操作，易于鉴别节段用于：低位和高位椎旁,横突平面-横切面扫描,肋间平面-矢状面扫描,节段的鉴别：12Rib,0.5%Ropi
23、vacaine 20ml单次平面,连续 vs 单次(Eason和Wyatt法),Catala,E.et al.,J Cardiothorac Vasc Anesth.1996;10(5):586-8.,单次能达到什么效果,Hill,S.E.et al.,Anesthesiology.2006;104(5):1047-53,单次能达到什么效果,0.5%Ropivacaine 30 mL,浓度和连续阻滞范围,0.5%罗哌卡因20ml切皮前+20ml手术结束白色：0.2%罗哌卡因组黑色：0.5%罗哌卡因组6ml/h连续阻滞,Yoshida,T.et al.,Anaesthesia.2014;69(3
24、):231-9,肝右叶切除术后镇痛的问题,静脉内阿片为主镇痛的问题：镇痛效果不佳，药物代谢影响，呼吸抑制硬膜外镇痛的风险：肝叶切除术后凝血功能不良（70%术后第一天PT延长），交感阻滞肝血流增加，输血风险增加，输液量增加，（Tzimas P,et al.,Anaesthesia.2013;68:628635）PVB的可行性：病例报告研究PVB用于两例肝右叶切除术（Ho,A.M.et al.,Br J Anaesth.2004;93(3):458-61）,PVB 在肝胆手术应用,胆囊切除术后镇痛Giesecke K,Hamberger B,Jarnberg PO,Klingstedt C.Par
25、avertebral block during cholecystectomy:effects on circulatory and hormonal responses.Br J Anaesth 1988;61:652-656Kumar CM.Paravertebral block for post-cholecystectomy pain relief.Br J Anaesth 1989;63:129.Naja MZ,Ziade MF,Lonnqvist PA.General anaesthesia combined with bilateral paravertebral blockad
26、e(T5-6)vs.general anaesthesia for laparoscopic cholecystectomy:a prospective,randomized clinical trial.Eur J Anaesthesiol 2004;21:489-495肝癌射频消融Culp WC,Payne MN,Montgomery ML.Thoracic paravertebral block for analgesia following liver mass radiofrequency ablation.Br J Radiol 2008;81:e23-25.经皮胆道穿刺引流Cul
27、p WC,McCowan TC,DeValdenebro M,et al.Paravertebral block:an improved method of pain control in percutaneous transhepatic biliary drainage.Cardiovasc Intervent Radiol 2006;29:1015-1021肝区创伤痛Hall H,Leach A.Paravertebral block in the management of liver capsule pain after blunt trauma.Br J Anaesth 1999;
28、83:819-821.胆道内扩张引起的疼痛Culp WC,Jr.,Culp WC.Thoracic paravertebral block for percutaneous transhepatic biliary drainage.J Vasc Interv Radiol 2005;16:1397-1400.,PVB用于肝右叶切除的解剖基础,右肋下皮肤感觉神经纤维：发自T5 到T11（）肝脏交感神经纤维：来自双侧T7到T11交感神经，支配肝脏包膜和肝内血管（Berthoud HR.Anat Rec A Discov Mol Cell Evol Biol 2004;280:827-835）（）
29、副交感纤维：自迷走神经（）,一般资料,舒芬太尼用量和PCA按压次数,静息和咳嗽时疼痛评分,全凭椎旁阻滞经皮肾镜,躯体痛：经10肋间、11肋间、肋缘下建立碎石通道内脏痛：,PVB用于PCNL的解剖基础,Millers Anesthesia.Philadelphia:Churchill Livingstone;2009,PVB等躯干外周神经阻滞,1920s年：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2016年：？,第一或通讯作者临床研究SCI论文,Chen H,Liao Z,Fang Y,Niu B,Chen A,Cao F,Mei W,Tian Y.Reg
30、 Anesth Pain Med.2014;39(6):506-12Li M,Wan L,Mei W,Tian Y.Drug Des Devel Ther.2014;8:1269-1276Niu B,Fang Y,Miao JM,Yu Y,Cao F,Chen HX,Zhang ZG,Mei W,Tian YK.Br J Anaesth.2014;112(1):72-8Mei W,Li M,Yu Y,Cheung CW,Cao F,Nie B,Zhang Z,Wang P,Tian Y.Eur J Pain.2014;18(2):238-48Li M,Mei W,Wang P,Yu Y,Qia
31、n W,Zhang ZG,Tian YK.Acta Anaesthesiol Scand.2012 Mar;56(3):368-75Mei W,Jin C,Feng L,Zhang Y,Luo A,Zhang C,Tian Y.Anesth Analg.2011;113(1):134-7Zou H.,Mei W.,Qiu J.,Li Y.,Zhang Z.,Tian Y.,Zhang C.Asia-Pacific Psychiatry 2011(3):67-72Mei W,Seeling M,Franck M,Radtke F,Brantner B,Wernecke KD,Spies C.Eur J Pain.2010;14(2):149.e1-7,非常感谢您的关注！,
