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1、连续外周神经阻滞麻醉与镇痛,山东中医药大学附属医院麻醉科 王连主,为何要行连续神经阻滞,手术长时间手术如：血管神经吻合、断指再植，即能满足长时间需要又能扩张血管对术中及术后病情都有利。,术后镇痛（PCNA）对血流动力学影响小，无需严密监测，减少恶心、呕吐、皮肤瘙痒、尿潴留，以及对凝血机制异常病人的担忧。外周神经阻滞可有效阻止疼痛刺激的传入，防止中枢敏化。对运动疼痛效果好，早期下床锻炼。可行走，可带回家。,疼痛治疗骨折的术前疼痛、神经病理性疼痛、癌性疼痛等,连续神经阻滞用药,手术麻醉：成人：0.5罗哌卡因 初始剂量：0.5ml/kg 最大量30ml 小儿：0.375罗哌卡因 初始剂量：0.5ml
2、/kg 最大量20ml,连续神经阻滞用药,术后镇痛与疼痛治疗：成人：0.2罗哌卡因 小儿：0.125罗哌卡因 PCNA：负荷剂量：5ml 输注速率：2ml/h 单次剂量：0.5ml 锁定时间：15min,主要内容,连续肌间沟臂丛神经阻滞连续股神经阻滞连续髂筋膜间隙阻滞,一、连续肌间沟臂丛神经阻滞,臂丛神经解剖分布,C5腋神经三角肌肩外展 C6肌皮神经肱二头肌肘屈曲 C7桡神经伸肌群肩肘腕伸 C8 正中神经屈肌群腕指屈 T1 尺神经手内肌拇对掌小指屈,腋N,上臂内侧皮N和肋间臂,前臂内侧皮N,桡N,尺N,前臂外侧皮N(肌皮N),正中N,连续肌间沟臂丛神经阻滞应用,上肢桡侧部、肩部和锁骨（C4）的
3、手术或镇痛。年轻较瘦患者的尺侧（T1）手术也可进行，但需要的容积要足够大，起效相对较慢。,连续肌间沟臂丛穿刺技术,穿刺点定位第一条线：从胸锁乳突肌的起点到胸锁乳突肌的胸骨头第二条：从胸锁乳突肌的起点到胸锁乳突肌的锁骨头第三条：沿肌间沟向上第四条：环状软骨的水平线第三第四的交点向上1cm即进针点,患者仰卧位，头偏向健侧，患肢垂直贴身体一侧。使用连续臂丛神经阻滞套件，借助神经刺激仪寻找臂丛神经，刺激仪起始强度为1.2mA，引发肱三、二头肌或三角肌抽动时，将刺激强度减至0.3mA，仍有肌肉抽动时，回抽无血注药置管。,连续肌间沟臂丛神经阻滞操作技巧,头侧向45度为宜沿肌间沟平行划线局麻充分且需切皮后进
4、针进针角度不宜过大（15度），与床面平行引出肌肉收缩后将扶持针的手松开，利于观察针的位置和角度置管忌粗暴，防止导管打折导管置入神经干间45cm。,二、连续股神经阻滞,股神经解剖,起自L24，在腹股沟韧带下方进入股三角，并分出前支和后支。后支的感觉纤维终支是隐神经。,股神经分布,混合神经 感觉神经：大腿前面、膝关节、内踝以上小腿内侧面皮肤。运动神经：股四头肌、缝匠肌。,股外侧皮神经,股神经前皮支,隐神经,坐骨神经,连续股神经阻滞的应用,膝部、大腿中段的手术大腿前面软组织探查和裂伤缝合术及膝关节镜检查。股骨、髌骨、膝关节、踝关节术前术后疼痛治疗,全膝置换（TKA）Effect of continu
5、ous femoral nerve block in analgesia and the early rehabilitation after total knee replacement.Zhongguo Gu Shang.Yu HP,Liu ZH al.2010 Nov;23(11):825-7.Chinese.Conclusion:The continuous femoral nerve block is an effective pain relieve method and is benefical to rehabilitation from total knee arthropl
6、asty early.,Comparison of the influences of continuous femoral nerve block and patient controlled intravenous analgesia on total knee arthroplasty.Tang S al.Department of Anesthesiology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China.Conclusion After TKA,CFNB technique provides more stable intraope
7、rative hemodynamics than PCIA,with better pain relief,faster postoperative knee rehabilitation,less side effects,and higher patient satisfaction.,股骨干骨折 Low cost continuous femoral nerve block for relief of acute severe cancer related pain due to pathological fracture femur.Koshy RC al.Indian J Palli
8、at Care.2010 Sep;16(3):180-2.Conclusion:continuous femoral nerve block was used as an efficient,cheap and safe method of pain relief for two of our patients with pathological fracture femur.This method was proved to be quite efficient in decreasing the fracture-related pain and improving the level o
9、f well being.,连续股神经阻滞技术,采用长50mm的绝缘型穿刺针，腹股沟韧带下方2.5cm、股动脉搏动点外侧12cm为穿刺点，以与皮肤成40度角向头端刺入穿刺针。通过神经刺激器在0.3mA仍能诱发出髌骨上移运动时，回抽无血，注药置管。,连续股神经阻滞操作技巧,清晰画出腹股沟韧带、股动脉和缝匠肌内侧缘构成的三角进针方向与股动脉平行，进针点不能离腹股沟韧带太远，缝匠肌或最近皱褶与腹股沟韧带之间进针角度约3040度引出肌肉收缩应以膝盖运动为主置管约4cm左右,三、连续髂筋膜间隙阻滞,髂筋膜间隙解剖,前界为腹股沟韧带，后界为髂骨，内侧为髂耻弓。内有髂腰肌、股外侧皮神经及股神经通过。,连续髂
10、筋膜间隙阻滞应用,髋关节、股骨颈、股骨干、膝关节术前急性疼痛控制和术后镇痛,髋部骨折 Fascia iliaca compartment blockade for acute pain control in hip fracture patients:a randomized,placebo-controlled trial.Foss NB al.Conclusion:Pain relief was superior at all times and at all measurements in the FICB group.The study supports the use of FICB
11、 in acute management of hip fracture pain because it is an effective,easily learned procedure that also may reduce opioid side effects in this fragile,elderly group of patients.,A Continuous Infusion Fascia Iliaca Compartment Block in Hip Fracture Patients:A Pilot Study 42位髋部骨折患者（5399岁间）初始剂量60ml 0.5
12、%罗哌卡因，0.2%持续输注，10ml/h。与2010年平均VAS比，其术后第0天4.1vs1.7,第一天，平均住院天数5.9vs4.8.J Clin Med Res.2012 February;4(1):4548.Elizabeth Dulaney-Cripe,a,f Scott Hadaway,b Ryan Bauman,c Cathy Trame et al.,Effect of fascia iliaca compartment block with ropivacaine on early analgesia in children with development dislocat
13、ion of the hip received salter arthroplasty treatment 0.2%罗哌卡因1ml/kg,最大量30ml，观察术后1、4、24h VAS 安全、有效、持久、简便 Wang G,Wang XL,Li SZ.Zhonghua Yi Xue Za Zhi.2011 Oct 11;91(37):2638-40.,交叉韧带、股骨干手术 Comparison of continuous 3-in-1 and fascia Iliaca compartment blocks for postoperative analgesia:feasibility,cat
14、heter migration,distribution of sensory block,and analgesic efficacy.The authors conclude that a catheter for continuous lumbar plexus block can be placed more quickly and at lesser cost using the fascia iliaca technique than the perivascular technique with equivalent postoperative analgesic efficac
15、y.Morau D al.,膝关节置换 Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty:a case report and description of a catheter technique.SR al.Anesth.1997 Jul-Aug;22(4):372-7.Conclusion:Lumbar plexus blockade with continuous local anesthetic infusion via the
16、 fascia iliaca compartment is an effective means of providing postoperative analgesia after total knee arthroplasty when epidural analgesia is contraindicated.,连续髂筋膜间隙阻滞技术,沿股动脉、腹股沟韧带、缝匠肌画三条线，围成一个三角形，在其外上角内腹股沟韧带下1.52cm距髂前上棘5cm处为穿刺点，局麻后将穿刺针以与皮肤成40度并指向该角的方向刺入，穿过阔筋膜出现第一次落空感，继续深入通过其下方的髂筋膜时可有第二次落空感，然后注药置管
17、。,髂筋膜腔隙解剖,连续髂筋膜间隙阻滞操作技巧,以突破感为穿刺到位的标志容积大，初始剂量一般为30ml置管约10cm,连续神经阻滞时应注意的问题,防止神经损伤，缓慢进针，当刺激强度0.2mA仍可触发肌肉收缩时，应将穿刺针回退。注药时遇到较大的阻力或患者感到剧烈疼痛或强烈的躲避反应时应停止注药。防止局麻药入血，可先注入1ml后将电流调至1mA看有无肌颤搐。注药时应反复回抽，避免快速大量注入。,穿刺前患者可适度镇痛，无需过度镇静 当使用低电流刺激和缓慢进针时，很少给患者带来不适感。患者的合作有助于避免出现神经损伤。咪达唑仑可以降低肌肉紧张度，这将不利于穿刺点的解剖定位。,当扶持针的手离开时仍能引起肌肉抽动为最佳,确定置入导管的位置 注入局麻药 超声 可刺激导管,穿刺过程中一定要保证置管时穿刺针位置的稳定性。调整针尾的方向或预充药物（或生理盐水）会协助导管的置入。穿刺针粗钝，刺入皮肤困难，有时会使套管变得弯曲，最好先打局麻后用破皮针破皮。避免反复穿刺，尤其是正在进行抗凝治疗的患者；如果不小心刺破动脉，需要按压5分钟以上。临床上少见。定位神经困难的，可辅助超声。,谢谢！,
