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1、超声引导下臂丛神经阻滞技术,浙医二院麻醉科 周金锋,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：C5、C6前支组成上干C7前支单独成为中干C8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：上干和中干的前股合成外侧束-肌皮和正中神经下干的前股成为内侧束-尺神经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
2、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An ultrasound(US)-guided block at the C7 root；Initial volume of ropivacaine 0.75%was 6 mL；Block success or failure determined a 1-mL decrease or increase for the subsequent
3、 patient；The minimum effective volume of local anesthetic in 50%and 95%of the patients was 2.9 mL(95%confidence interval,2.4-3.5 mL)and 3.6 mL(95%confidence interval,3.3-6.2 mL)；Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment
4、of pulmonary function.Reg Anesth Pain Med.2010 Nov-Dec;35(6):529-34.,三、实战攻略,分干阻滞最低剂量Successful surgical anesthesia for arthroscopic shoulder surgery can be achieved with 5 mL of 0.75%ropivacaine,or approximately 1.7 mL per each of the 3 trunks of the brachial plexus(superior,middle,and inferior).For
5、 the group as a whole,the median(range)sensory block onset time was 5(5-20)minutes,the median(range)motor block for the biceps was 7.5(5-15)minutes.The median(range)block duration was 9.9(5-19)hours,and the mean(SD)block performance time was 8.0 3.2 minutes.Mean duration of analgesia was 9.9 3.7 hou
6、rs.Duration of analgesia was not associated with volume of LA(r=0.05,P=0.83)The minimum effective anesthetic volume of 0.75%ropivacaine in ultrasound-guided interscalene brachial plexus block.Anesth Analg.2011 Oct;113(4):951-5.,三、实战攻略,单点阻滞最低剂量研究The proportion of patients with successful blockade inc
7、reased sharply from approximately 57%at 6 ml to 100%by 7 ml,indicating that a small increase in volume of ropivacaine 0.75%markedly affects the success rate.The median(min-max)sensory block onset time was 5(5-20)min,the median(min-max)motor blocks for the biceps and the deltoid muscles were 7.5(5-15
8、)min and 10(5-15)min,respectively.The median(min-max)block duration was 8.9(3-15)h.Effective volume of ropivacaine 0.75%through a catheter required for interscalene brachial plexus blockade.Anesthesiology.2013 Apr;118(4):863-7.,三、实战攻略,最低剂量及作用时间研究Lidocaine 1.5%with epinephrine 1:200 000The mean(95%CI
9、)volume to surround each nerve was:radial 3.42(2.84-3.99)ml,median 2.75(2.31-3.19)ml,ulnar 2.58(2.14-3.03)ml,and musculocutaneous 2.30(1.96-2.64)ml.The mean(95%CI)onset time for complete sensory block was:radial 22.5(13.5-31.5)min,median 26.8(18.5-35.0)min,ulnar 26.6(17.8-35.4)min,and musculocutaneo
10、us 15.8(7.45-24.2)min.The mean(95%CI)last recorded time with complete block was:radial 137.1(105.6-168.7)min,median 144.7(123.4-166.0)min,ulnar 183.2(158.1-208.2)min,and musculocutaneous 158.3(131.8-184.9)min.Minimum volume of local anaesthetic required to surround each of the constituent nerves of
11、the axillary brachial plexus,using ultrasound guidance:a pilot study.Br J Anaesth.2010 May;104(5):633-6.,三、实战攻略,锁骨下阻滞High-resolution ultrasonography has revealed anatomical variations of C5,C6 and C7 nerve roots in almost half of the patients examined,without negative block effectiveness.Infraclavic
12、ular catheters provide superior analgesia when compared with supraclavicular catheters.Multiple-site injections of local offer no advantage over a single-site injection during an infraclavicular block.Ultrasound-guided peripheral nerve blockade of the upper extremity.Curr Opin Anaesthesiol.2012 Apr;
13、25(2):253-9.,三、实战攻略,锁骨下阻滞The supraclavicular approach of the brachial plexus has a high success rate including blockade of the ulnar and musculocutaneous nerve,which can be missed respectively with the interscalene and axillary approach.Supraclavicular brachial plexus blocks:review and current pract
14、ice.Acta Anaesthesiol Belg.2012;63(1):15-21.,三、实战攻略,地塞米松The addition of dexamethasone may prolong analgesia after single-shot interscalene and supraclavicular blocks.Ultrasound-guided peripheral nerve blockade of the upper extremity.Curr Opin Anaesthesiol.2012 Apr;25(2):253-9.,三、实战攻略,地塞米松The median
15、time of a sensory block was equivalent for perineural and i.v.dexamethasone:1405 min(IQR 1015-1710)and 1275 min(IQR 1095-2035)for RD and RDiv.I.V.dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine.There was a significant
16、 difference between the ropivacaine group:757 min(IQR 635-910)and the dexamethasone groups(P0.0001).As dexamethasone is not licensed for perineural use,clinicians should consider i.v.administration of dexamethasone to achieve an increased duration of Interscalene brachial plexus block（ISB）.I.V.and p
17、erineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery:a prospective,randomized,placebo-controlled study.Br J Anaesth.2013 Sep;111(3):445-52.,三、实战攻略,右旋美托嘧啶Ultrasound-guided ulnar nerve block(UNB)was perfor
18、med in 36 volunteers with either 3 ml ropivacaine 0.75%(R),3 ml ropivacaine 0.75%plus 20 g dexmedetomidine(RpD),or 3 ml ropivacaine 0.75%plus systemic 20 g dexmedetomidine(RsD).The duration of sensory block was 350(54)min in Group R,555(118)min in Group RpD,and 395(40)min in Group RsD(P0.01 Group Rp
19、D vs other groups,P0.05 Group RsD vs Group R).Motor block duration was similar to the duration of sensory blockDexmedetomidine as an adjuvant to ropivacaine prolongs peripheral nerve block:a volunteer study.Br J Anaesth.2013 Mar;110(3):438-42.,三、实战攻略,剂量与年龄The minimum effective local anesthetic volum
20、e significantly differed between middle-aged and elderly 23.0 ml,95%confidence interval(CI)13.7-32.3 vs.11.9 ml,95%CI 9.3-14.6;95%CI of the difference 1.6-20.6,P=0.027.Effects of age on minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block.Acta Anaesthesiol Scand.2013 Jul;57(6):761-6.,攻 略 总 结,超声追踪定位是区分神经分支的有效方法；肌间沟单点（C7 0.75%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。,感谢您的聆听，欢迎批评指正。,
