貝朗局麻學(xué)校外周神經(jīng)阻滯培訓(xùn)資料

1、Page 1Page PNB 概述Part I：上肢外周神經(jīng)阻滯技術(shù)肌間溝入路鎖骨上入路鎖骨下入路腋路Part II：下肢外周神經(jīng)阻滯技術(shù)腰叢神經(jīng)阻滯坐骨神經(jīng)阻滯股神經(jīng)及“三合一”阻滯Part III：連續(xù)外周神經(jīng)阻滯技術(shù)總結(jié)2Page The first demonstration of electrical nerve stimulation was performed as early as 1780 by Luigi Galvani on a frog.3Page 外周神經(jīng)由無數(shù)根神經(jīng)纖維組成。神經(jīng)纖維分為感覺性、運(yùn)動(dòng)性或混合性神經(jīng)纖維。 電流刺激運(yùn)動(dòng)纖維會(huì)引起效應(yīng)器肌肉的收縮刺激感覺

2、纖維，則在神經(jīng)分布區(qū)域產(chǎn)生異感這一神經(jīng)電刺激的基本原理可用于外周神經(jīng)的區(qū)域麻醉。 Moore DC (1965): NO paraesthesia, NO anaesthesia4Page In 1912, Perthes developed the first electrical nerve stimulator for selective stimulation of nerves and the corresponding muscles.5Page 6Page The reliability of peripheral nerve stimulation was greatly im

3、proved by the introduction of constant current sources for the electronic stimulators making it the procedure of choice for safe and reliable nerve location in plexus anesthesia.7Page 神經(jīng)刺激器定位技術(shù)超聲定位技術(shù)8Page Completely insulated needles with a pin-point electrode provide optimal conditions for accurate

4、 nerve location 9Page 基強(qiáng)度（rheobase intensity）使刺激產(chǎn)生動(dòng)作電位所需的最小強(qiáng)度。時(shí)值（chronaxie）用兩倍于基強(qiáng)度的刺激所引起的動(dòng)作電位所需的最短時(shí)間。時(shí)值被用來反應(yīng)不同神經(jīng)的興奮性大小，如A運(yùn)動(dòng)纖維，所需的刺激時(shí)值為50100s，而傳導(dǎo)痛覺的更細(xì)的A和C纖維的時(shí)值較長(zhǎng)，約150400s。10Page 2倍基強(qiáng)度基強(qiáng)度時(shí)值11Page Coulombs定律 E=K(Q/r2) 電量（nC） 刺激電流刺激時(shí)程（ms）當(dāng)ms一定時(shí)，刺激神經(jīng)所需的最小電流同針尖到目標(biāo)神經(jīng)的距離呈正比。12Page 應(yīng)用神經(jīng)電刺激的優(yōu)點(diǎn)阻滯成功的指標(biāo)客觀、明確；可用于

5、既往無法定位的深部神經(jīng)阻滯；神經(jīng)定位精確，分別阻滯各支神經(jīng)成為可能適用于無法準(zhǔn)確說明異感或定位困難病人；減少病人的不適感,可適度鎮(zhèn)靜；提高阻滯成功率；最大程度減少神經(jīng)損傷 切記：神經(jīng)解剖學(xué)定位是一切神經(jīng)定位技術(shù)的基礎(chǔ)。神經(jīng)解剖學(xué)定位是一切神經(jīng)定位技術(shù)的基礎(chǔ)。13Page 14Page 神經(jīng)刺激器定位定位指標(biāo)明確病人感覺舒適,鎮(zhèn)靜血流動(dòng)力學(xué)平穩(wěn)麻醉鎮(zhèn)痛效果滿意盡早恢復(fù)出院并發(fā)癥少傳統(tǒng)異感定位法定位無客觀指標(biāo)。病人感覺觸電、痛苦血管內(nèi)意外注藥危險(xiǎn)麻醉效果難以保證，成功率相對(duì)低。神經(jīng)損傷15Page 16Page 對(duì)病人生理功能干擾小血流動(dòng)力學(xué)穩(wěn)定有效阻斷各種不良的神經(jīng)反射、預(yù)防手術(shù)創(chuàng)傷應(yīng)激反應(yīng)便于

6、手術(shù)后早期活動(dòng)和康復(fù)術(shù)后鎮(zhèn)痛17Page 18Page 19Page 上、中、下干前股外側(cè)束內(nèi)側(cè)束臂叢神經(jīng)與上肢肌肉的關(guān)系20Page 上、中、下干后股后束21Page 22Page 尺神經(jīng)前臂內(nèi)側(cè)皮神經(jīng)肋間臂神經(jīng)、臂內(nèi)側(cè)皮神經(jīng)肌間溝入路的阻滯盲區(qū)肌間溝入路的阻滯盲區(qū)C7、C8、T1支配區(qū)域23Page 開放性的肩部手術(shù)肩關(guān)節(jié)成形術(shù)肩關(guān)節(jié)復(fù)位術(shù)鎖骨骨折手術(shù)（外側(cè)）上臂外側(cè)手術(shù)肱骨切開復(fù)位內(nèi)固定或內(nèi)固定取出術(shù)上臂橈神經(jīng)探察術(shù)可能需聯(lián)合全身麻醉24Page 前路后路25Page 前路后路26Page 神經(jīng)刺激器引發(fā)肱二頭肌、肱三頭肌或三角肌收縮若引發(fā)膈肌收縮，說明進(jìn)針位置偏內(nèi)/前若引發(fā)肩胛肌收縮，

7、說明進(jìn)針位置偏外/后一般應(yīng)用單次給藥法引發(fā)肌肉收縮后，則給予局麻藥1530ml27Page 28Page 氣胸高位硬膜外阻滯或全脊麻風(fēng)險(xiǎn)膈神經(jīng)麻痹聲嘶Horners綜合癥全身中毒反應(yīng)29Page 血管損傷 (頸內(nèi)/外靜脈， 頸內(nèi)動(dòng)脈, 椎動(dòng)脈) 偶有Horners 綜合癥 12 - 75%膈神經(jīng)麻痹 7 100%喉返神經(jīng)麻痹 6 8%流涎 2 4%咳嗽 少見Meier G: J Anasth Intensivbeh (1999) 2: 66-67Urmey FW: Tech Reg AnesthPain Management (1997) 4: 185-193.Vester-Andersen

8、T: Acta Anaesthesiol Scand (1981) 25: 81-84.30Page 31Page 對(duì)側(cè)膈神經(jīng)麻痹對(duì)側(cè)氣胸COPD凝血功能障礙32Page 33Page 氣胸發(fā)生率高超聲實(shí)時(shí)定位34Page 35Page 36Page 安全、有效特定體位常需多點(diǎn)法止血帶反應(yīng)血管損傷多37Page 38Page 阻滯成功率高，范圍廣泛操作簡(jiǎn)單省時(shí)單次注藥，病人易于接受病人體位舒適體表標(biāo)志明確并發(fā)癥少止血帶耐受良好留置導(dǎo)管舒適且不易移位39Page 40Page 41Page 42Page VIP入路：鎖骨中點(diǎn)，緊貼鎖骨下緣，垂直進(jìn)針 喙突入路：喙突尖內(nèi)下2cm，垂直進(jìn)針43Pag

9、e 連接神經(jīng)刺激器，初始電流1.0mA喙突內(nèi)下2cm，垂直進(jìn)針引發(fā)肌肉運(yùn)動(dòng)：伸腕伸指若遇到屈肘，則向后向下調(diào)整調(diào)整進(jìn)針方向時(shí)需注意應(yīng)在矢狀面內(nèi)調(diào)整逐漸調(diào)小刺激電流0.5mA局麻藥3040ml44Page 喙突胸大肌止點(diǎn)旁矢狀面45Page 定位后束預(yù)示阻滯成功起效時(shí)間也隨定位的不同神經(jīng)束而異46Page Anesth Analg, 2006,102:1564-156847Page 中華醫(yī)學(xué)雜志中華醫(yī)學(xué)雜志 2007，87（21）：1470-1473 48Page 49Page 臂叢神經(jīng)在鎖骨下的旁矢狀面磁共振分析與局部解剖分析50Page 51Page 單點(diǎn)阻滯不能完成整個(gè)下肢麻醉下肢神經(jīng)阻滯

10、深度明顯大于上肢椎管內(nèi)麻醉在下肢手術(shù)中的廣泛應(yīng)用用藥容量大，局麻藥毒性反應(yīng)阻滯失敗率高(5%以上)52Page 定位技術(shù)的進(jìn)步神經(jīng)刺激器，超聲定位技術(shù)的臨床應(yīng)用。新型局麻藥、穿刺針及導(dǎo)管的研制和應(yīng)用羅哌卡因，左旋布比卡因 區(qū)域阻滯麻醉價(jià)值的再認(rèn)識(shí)循證醫(yī)學(xué)；能有效阻斷損傷刺激的上傳通路順應(yīng)外科新發(fā)展：微創(chuàng)和可視化方向，術(shù)后有效鎮(zhèn)痛，術(shù)后恢復(fù)快，并發(fā)癥少。53Page 不宜全麻或椎管內(nèi)麻醉的高危病人；術(shù)中情況穩(wěn)定（如心血管狀態(tài)）；減少術(shù)中出血（20-50%）；有效的術(shù)前控制疼痛和術(shù)后鎮(zhèn)痛；減少惡心嘔吐；減少深靜脈血栓形成，并降低對(duì)免疫功能的影響；避免或減少阿片類鎮(zhèn)痛藥，減少譫妄發(fā)生率不影響腸道運(yùn)動(dòng)

11、和尿道功能；有利于術(shù)后早期活動(dòng)。54Page 缺點(diǎn)（1）時(shí)間花費(fèi)：起效時(shí)間大多在15-30min,（2）局部麻醉藥中毒和神經(jīng)損傷（3）存在失敗率（約1-5%）禁忌證（1）患者不合作； （2）出血體質(zhì)；（3）感染； （4）周圍神經(jīng)病變；（5）骨筋膜間室綜合征高?；颊?。55Page 局麻藥和其佐劑的神經(jīng)毒性作用：與高濃度和接觸時(shí)間長(zhǎng)正相關(guān)，尤其在直接注入神經(jīng)束內(nèi)時(shí)。其機(jī)制主要與增加細(xì)胞內(nèi)鈣濃度相關(guān)。神經(jīng)機(jī)械損傷：直接穿刺損傷通常很輕微，若伴隨神經(jīng)束內(nèi)注射可加重。神經(jīng)局部缺血-再灌注損傷：止血帶損傷56Page 神經(jīng)不是同質(zhì)的單一結(jié)構(gòu)，而是在神經(jīng)鞘內(nèi)大量神經(jīng)軸突反復(fù)融合、分化聚集成束，形成復(fù)雜的神經(jīng)

12、網(wǎng)絡(luò)。57Page 神經(jīng)髂腹下神經(jīng)腹外斜肌、腹內(nèi)斜肌、腹橫肌髂腹股溝神經(jīng)髂腹下神經(jīng)大腿上內(nèi)側(cè)皮膚和部分外生殖器生殖股神經(jīng)大腿前內(nèi)生殖器大腿前、股神經(jīng)大腿前面肌肉(縫匠肌,股四頭肌);大腿內(nèi)收肌(恥骨肌和髂腰肌)，大腿前內(nèi)側(cè)面隱神經(jīng)58Page 59Page Psoas compartment block. The needle entry site is marked 1 cm cephalad to the intercristal line, two thirds of the distance from the midline to the posterior superior ilia

13、c spine line. The lumbar plexus is identified between the transverse processes of L4 and L5. Dural sleeves extend 3 to 5 cm laterally. The circle is the site of needle insertion.60Page 61Page Paravertebral nerve block. A, Patient position and surface landmarks.B, The needle is advanced perpendicular

14、ly until it contacts the transverse process. It is redirected to walk off the caudad edge of the transverse process and advanced 1 to 2 cm.62Page A, Anatomic landmarks for the lateral femoral cutaneous, femoral, and obturator nerve blocks. B, For an obturator nerve block, the needle is walked off th

15、e inferior pubic ramus in a medial and cephalad direction until it passes into the obturator canal. 63Page 恥骨肌腰(大)肌髂肌縫匠肌闊筋膜髂筋膜生殖股神經(jīng)64Page Proximal lower extremity blocks. A, Fascia iliaca compartment block. B, Classic femoral nerve block. C, Relationship of the femoral nerve in the groin. D, Inserti

16、on routes of the most common proximal blocks of the lower extremity (cross section of the thigh). 65Page 神經(jīng)臀小肌、臀中肌、闊筋膜張肌伸?。ㄍ未蠹。┌腚旒　肽ぜ。淮笫占。ㄅc閉孔神經(jīng)）；會(huì)陰肌肉，包括泌尿生殖隔膜和尿道和肛門外括約肌; 外生殖器皮膚及相關(guān)骨骼?。ㄇ蚝＞d體肌）66Page Parasacral block. This is the most proximal approach to the sciatic nerve and also results in block of

17、the posterior femoral cutaneous nerve. The most prominent aspects of the posterior superior iliac spine and the ischial tuberosity are identified, and a line is drawn joining these two points. The needle insertion site is along the line, 6 cm inferior to the posterior superior iliac spine.67Page Ana

18、tomic landmarks for the posterior approach to a sciatic nerve block. 68Page Sciatic nerve block (subgluteal approach). The sciatic nerve is relatively superficial at this level. Needle insertion is near the gluteal crease, between the hamstring muscles 69Page Anatomic landmarks for the anterior appr

19、oach to a sciatic nerve block 70Page A, Anatomic landmarks for the posterior approach to the sciatic nerve in the popliteal fossa. B, Anatomic landmarks for the lateral approach to the sciatic nerve in the popliteal fossa. 71Page Anatomic landmarks for a block of the posterior tibial and sural nerve

20、s at the ankle. B, Posterior tibial nerve and method of needle placement for a block at the ankle. C, Sural nerve and method of needle placement for a block at the ankl 72Page Anatomic landmarks for blockade of the deep peroneal, superficial peroneal, and saphenous nerves at the ankle. B, Method of

21、needle placement for a block of the deep peroneal, superficial peroneal, and saphenous nerves through a single needle entry site. 73Page (Lumbar Plexus Block)1.髂嵴 2.第四腰椎棘突 3.髂后上棘 4.穿刺點(diǎn)74Page 75Page Computed tomographic scan determination of the distance between spinous processes of L4 and L5 and lin

22、es through the lumbar plexus (LP) (top) and through the posterior superior iliac spine (bottom; landmarks of Winnie et al.). The median value of the ratio between these two distances (A and B) was 0.67. Consequently, it was warranted to situate the cutaneous puncture point for the continuous psoas c

23、ompartment block at the junction of the medial two thirds and lateral third of the line between the spinous process of L4 and the line through the posterior superior iliac spine parallel to the spinal column.76Page Depth of the lumbar plexus (LP) and the distance between the lumbar plexus and the tr

24、ansverse process (TP) in men and women.Capdevila X, et al. Anesth Analg 2002;94:16061377Page 定位：深度：男6.1-10.1cm,女5.7-9.3cm與體重指數(shù)正相關(guān)；橫突下2cm(平均1.8cm)，與體重指數(shù)無關(guān)（避免穿刺過深的標(biāo)志）。最常見的副作用是硬膜外擴(kuò)散(進(jìn)針點(diǎn)偏內(nèi))穿刺過深并發(fā)癥：腎血腫（進(jìn)針點(diǎn)偏高L3）、全脊椎麻醉，導(dǎo)管誤入腹腔或椎間盤。78Page Femoral Nerve Block79Page Anesth Analg 1999;89:146770Anatomical landma

25、rks for femoral nerve block; needle insertion sites. IL= inguinal ligament (line between the anterosuperior iliac spine and the pubic tubercle), IC= inguinal crease (a natural skin fold 46 cm below the inguinal ligament), FA 5 femoral artery, numbers 1 through 4 needle insertion sites.80Page 坐骨神經(jīng)阻滯體

26、 位81Page 坐骨神經(jīng)阻滯82Page 坐骨神經(jīng)阻滯骶骨旁法83Page C = capsule; P = piriformis muscle; SP = sacral plexus; SB = small bowel. O = ovary; R = rectum;SV = seminal vesicles; BV = blood vessel. Line 1 represents perpendicular to the skin. Line 2 represents the simulated needle trajectory.An Anatomical Study of the P

27、arasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers. 200984Page 坐骨神經(jīng)阻滯前路法前路法In the union of the mid third with the internal third of the line from the anterior superior iliac spine to the angle of the pubic tubercle, a point is marked and a perpendicular line is drawn cutting a li

28、ne that crosses parallel from the great trochanter.85Page 坐骨神經(jīng)阻滯The needle is inserted posteriorly and laterally with a 1015 angle relative to the vertical plane, 2.5 cm medial to the femoral artery and 2.5 cm distal to the inguinal crease. 前路法前路法86Page 坐骨神經(jīng)阻滯側(cè)入法87Page 坐骨神經(jīng)阻滯坐骨神經(jīng)阻滯坐骨神經(jīng)阻滯前路法和側(cè)入法斷面圖88

29、Page 坐骨神經(jīng)阻滯下法89Page 男性，98歲。右股骨頭骨折伴肺部感染少量胸腔積液。擬行全髖置換術(shù)。麻醉方法：腰叢（后路）+坐骨神經(jīng)阻滯（骶旁入路），0.4%羅哌卡因各30ml，鎮(zhèn)靜咪唑安定0.5mg iv、鎮(zhèn)痛舒芬太尼2.5g iv。術(shù)中病人血壓、心率和呼吸功能無明顯變化，手術(shù)順利，術(shù)后恢復(fù)良好。男性， 38歲。左股骨頭無菌性壞死，伴強(qiáng)直性脊柱炎，頸、胸、腰部強(qiáng)直，不能平臥。擬行全髖置換術(shù)。麻醉方法：腰叢（后路）+坐骨神經(jīng)阻滯（骶旁入路），0.5%羅哌卡因各30ml ；鎮(zhèn)靜咪唑安定2.0mg iv、異丙酚25g/kgmin泵注，鎮(zhèn)痛舒芬太尼15g iv。術(shù)中病人安靜，手術(shù)順利，術(shù)后恢復(fù)

30、良好。90Page 股神經(jīng)3合1阻滯很少獲得完全的腰叢神經(jīng)阻滯.腰叢或股神經(jīng)阻滯，應(yīng)引出股直肌收縮“膝蓋跳動(dòng)”坐骨神經(jīng)阻滯，引出脛神經(jīng)運(yùn)動(dòng)反應(yīng)（足跖屈，屈趾）總比腓神經(jīng)運(yùn)動(dòng)反應(yīng)更有效腰叢和坐骨神經(jīng)阻滯效果容量是一個(gè)重要因素。91Page 下肢外周神經(jīng)阻滯為下肢手術(shù)提供了新的麻醉選擇。尤其ASA分級(jí)越低，其優(yōu)點(diǎn)越明顯。髖關(guān)節(jié)手術(shù)，由于解剖關(guān)系，存在部分皮膚和皮下組織阻滯不全，術(shù)中應(yīng)充分鎮(zhèn)靜和鎮(zhèn)痛。其術(shù)后鎮(zhèn)痛可選擇腰叢置管。膝關(guān)節(jié)手術(shù)通常阻滯完善，適當(dāng)鎮(zhèn)靜和鎮(zhèn)痛。其術(shù)后鎮(zhèn)痛可選擇股神經(jīng)置管周神經(jīng)阻滯的神經(jīng)系統(tǒng)并發(fā)癥顯著少于椎管內(nèi)麻醉92Page 93Page 1. 連續(xù)神經(jīng)阻滯需考慮的常規(guī)要點(diǎn)2.

31、 局部麻醉連續(xù)灌注3. 連續(xù)臂叢神經(jīng)阻滯4. 連續(xù)腋窩阻滯5. 連續(xù)腰叢阻滯6. 連續(xù)坐骨神經(jīng)阻滯7. 連續(xù)胸椎椎旁阻滯 94General Considerations for Continuous Nerve Blocks1. 連續(xù)神經(jīng)阻滯需考慮的常規(guī)要點(diǎn)2. 局部麻醉連續(xù)灌注3. 連續(xù)臂叢神經(jīng)阻滯4. 連續(xù)腋窩阻滯5. 連續(xù)腰叢阻滯6. 連續(xù)坐骨神經(jīng)阻滯7. 連續(xù)胸椎椎旁阻滯 Page 骨科急性術(shù)后疼痛鎮(zhèn)痛優(yōu)勢(shì)鎮(zhèn)痛減少住院天數(shù)促進(jìn)恢復(fù)減少創(chuàng)傷廣泛適應(yīng)癥96Page 大骨科手術(shù)包括肩部手術(shù)、上下肢創(chuàng)傷、上下肢移植、關(guān)節(jié)置換、長(zhǎng)期物理治療、理療 使用方法與適應(yīng)癥直接相關(guān)肩部手術(shù)：連續(xù)斜角肌

32、（較少使用鎖骨上阻滯）肩部以下手術(shù)使用鎖骨下，腋窩等阻滯下肢手術(shù)使根據(jù)具體平面，選擇多樣化 97Page 局部麻醉藥物1%普魯卡因1% 利多卡因0.1%, 0.2%, 0.25%, 0.5%鹽酸布比0.2% 羅派卡因0.15%左旋布比卡因雞尾酒包括阿片類藥物的使用嗎啡(0.03 mg/mL)芬太尼(2 mg/mL)二醋嗎啡(0.02 mg/mL)舒芬太尼(0.1 mg/mL)可樂定(1 mg/mL)98Page 無菌操作：神經(jīng)周導(dǎo)管置入無菌環(huán)境，手套、口罩、皮膚消毒手術(shù)室操作 雖然單次、連續(xù)阻滯的鎮(zhèn)靜程度相似，但在換算劑量和濃度時(shí)需考慮阻滯使用的針孔較粗大因此流量、濃度流速更 穿刺針軸線應(yīng)與神

33、經(jīng)軸平行，并在最小角度與神經(jīng)進(jìn)行接觸導(dǎo)管置入后，先給予初始單次快速注射擴(kuò)張和形成神經(jīng)周間隙 柔和操作在遠(yuǎn)離穿刺點(diǎn)3-4cm距離送置導(dǎo)管并同時(shí)送、推交替以無菌鹽水進(jìn)行導(dǎo)管封關(guān)、消毒和覆膜粘貼、固定 測(cè)試導(dǎo)管：注射5ml麻醉藥物991. 連續(xù)神經(jīng)阻滯需考慮的常規(guī)要點(diǎn)2. 局部麻醉腰連續(xù)輸注3. 連續(xù)臂叢神經(jīng)阻滯4. 連續(xù)腋窩阻滯5. 連續(xù)腰叢阻滯6. 連續(xù)坐骨神經(jīng)阻滯7. 連續(xù)胸椎椎旁阻滯 Page 表1：局麻藥物濃度、建議劑量以及阻滯特點(diǎn)濃度(%)起始持續(xù)時(shí)間 (小時(shí))最大劑量 (mg)pH利多卡因1.5-2快1-2300-500 +腎上腺素6.5甲哌卡因1.5-2快2-3500-600 +腎上

34、腺素4.5布比卡因0.5慢4-12150-225 +腎上腺素4.5-6羅哌卡因0.5-0.75慢2-6225-3004-6左布比卡因0.5慢4-121504-6101Page 濃度(%)輸注率(ml/h)利多卡因15-10布比卡因0.125-0.255-10羅哌卡因0.25-10左布比卡因0.125-0.255-10102Continuous Plexus Nerve Block1. 連續(xù)神經(jīng)阻滯需考慮的常規(guī)要點(diǎn)2. 局部麻醉連續(xù)灌注3. 連續(xù)臂叢神經(jīng)阻滯4. 連續(xù)腋窩阻滯5. 連續(xù)腰叢阻滯6. 連續(xù)坐骨神經(jīng)阻滯7. 連續(xù)胸椎椎旁阻滯 Page 連續(xù)肌間溝阻滯經(jīng)典入路胸鎖乳突肌間入路斜角肌旁入

35、路椎旁入路其它入路鎖骨下阻滯局部麻醉藥物、劑量禁忌癥104Page 患者體位仰臥位, 頭頸部向穿刺側(cè)對(duì)側(cè)傾斜適應(yīng)癥麻醉與術(shù)后鎮(zhèn)痛，二頭肌及肱骨手術(shù)劑量、速度30-40ml 0.5%羅哌卡因注射后以連續(xù)輸注8-10ml/h速度或PCA滴注以0.2%羅哌卡因(5 mL/hour 基線，3-4 ml快速濃注并鎖上20分鐘)解剖學(xué)標(biāo)志胸鎖乳突肌(SCM) ，鎖骨，斜方肌前及中群以及環(huán)甲軟骨膜 (C6)實(shí)施方案抬頭以顯示SCM，確定并標(biāo)記SCM后側(cè)緣中斜角肌及肌間溝，在環(huán)甲狀軟骨水平與皮膚呈30進(jìn)針。105Page 106Page 為了增加操作者穩(wěn)定性，可將手術(shù)臺(tái)升高 三角肌收縮需與胸肌或鎖骨上刺激鑒別

36、（因該神經(jīng)已從臂叢分出）胸肌刺激顯示針的位置略向前（0.5 cm）鎖骨上刺激（肩后）顯示套管針的位置靠后（1cm）在送入導(dǎo)管3-4cm可能出現(xiàn)阻力，可退出導(dǎo)管，將套管針再向皮下組織穿刺3-4cm再置管。107Page 患者體位仰臥位, 頭頸部向穿刺側(cè)對(duì)側(cè)傾斜，雙手放置腹部上。醫(yī)生站在操作側(cè)對(duì)側(cè)。適應(yīng)癥麻醉，肩部手術(shù)術(shù)后鎮(zhèn)痛，康復(fù)治療劑量、速度30-40ml 0.5%羅哌卡因注射后以連續(xù)輸注8-10ml/h速度或PCA滴注以0.2%羅哌卡因(5 mL/hour背景輸注，3-4 ml單次劑量，鎖定時(shí)間20min)解剖學(xué)標(biāo)志SCM胸骨與鎖骨端，鎖骨中點(diǎn)，胸壁上緣 108Page 109選擇鎖骨上一橫

37、指、SCM胸骨頭和鎖骨頭之間進(jìn)針，針尖與SCM鎖骨頭后側(cè)緣呈15角，指向鎖骨中點(diǎn)上1cm處。留置管深度超過針尖2-3cm為宜。Page 在鎖骨上方區(qū)域進(jìn)行穿刺時(shí)，可觸及臂叢上、中、下干。推薦 在中干置管，置入容易同時(shí)可減少向脊柱、胸膜腔損傷。頸部不應(yīng)過度旋轉(zhuǎn)以避免影響解剖結(jié)構(gòu)之間關(guān)系。脂肪可使SCM三角模糊。必要時(shí)需提起鎖骨頭段SCM并在后方進(jìn)行穿刺 。穿刺前先找出胸壁上緣進(jìn)行穿刺指導(dǎo)。注意避免在皮丘浸潤(rùn)和穿刺時(shí)誤穿頸內(nèi)靜脈。 腹部活動(dòng)可提示膈神經(jīng)刺激，需重新進(jìn)行穿刺 可在穿刺前進(jìn)行影像學(xué)檢查（透視） 因穿刺損傷、導(dǎo)管位置不佳可導(dǎo)致以下并發(fā)癥包括頸內(nèi)、鎖骨下動(dòng)脈穿刺，胸膜穿刺，膈肌麻痹，Hor

38、ner綜合癥110Page 患者體位仰臥位, 頭頸部向穿刺側(cè)對(duì)側(cè)傾斜適應(yīng)癥肩部手術(shù)，包括關(guān)節(jié)鏡操作。連續(xù)斜角肌注射可助于術(shù)后物理治療鎮(zhèn)痛。劑量、速度20 mL 0.5% 羅派卡因，8-14ml/h 0.2%羅派卡因連續(xù)注射1小時(shí)。或者PCA。解剖學(xué)標(biāo)志SCM與前中斜角肌間溝。穿刺點(diǎn)在該溝最上位點(diǎn),約C6水平。 111Page 112以肌間溝頂點(diǎn)、沿身體長(zhǎng)軸方向進(jìn)針，約在2.5cm處可誘發(fā)刺激反應(yīng)，留置深度建議5cm.Page 準(zhǔn)確辨認(rèn)斜角肌間溝，頭部旋轉(zhuǎn)可嚴(yán)重扭曲解剖標(biāo)志物位置適合用于肩部手術(shù)，進(jìn)行肘部、前臂或手部手術(shù)時(shí)需加大局部麻醉藥物容量臂叢周圍有血管性、神經(jīng)性結(jié)構(gòu)，在斜角肌間區(qū)域進(jìn)行操作

39、需慎重進(jìn)行有氣胸風(fēng)險(xiǎn)，可通過控制、限制針的插入深度避免氣胸 連續(xù)斜角肌阻滯可有膈肌麻痹表現(xiàn)，較低如0.125%布比卡因同樣可顯著減少膈肌活動(dòng)和呼吸功能 ，該現(xiàn)象持續(xù)整個(gè)阻滯期間該方法不能用于無法耐受肺功能下降25%的患者 因頸椎的活動(dòng)性較大，可導(dǎo)致導(dǎo)管移位。因其導(dǎo)管深度能達(dá)5-10cm，較傳統(tǒng)穿刺更牢固、穩(wěn)定。 因?qū)Ч苡捕瓤蓪?dǎo)致周圍組織的損傷，應(yīng)密切觀察患者是否有新（非手術(shù)相關(guān)）疼痛或神經(jīng)系統(tǒng)主訴 113Page 患者體位.坐位，頭部輕度前屈適應(yīng)癥肩部手術(shù)麻醉和術(shù)后鎮(zhèn)痛劑量、速度30-40ml 0.5%羅哌卡因注射后以連續(xù)輸注8-10ml/h速度或PCA (0.2%羅哌卡因5 mL/h背景輸注

40、，3-4 ml單次劑量，鎖定時(shí)間20分鐘)解剖學(xué)標(biāo)志臂叢 (BP), 前(AS)和中斜角肌(MS) , 被椎體骨性結(jié)構(gòu)保護(hù)的椎動(dòng)脈(VA),斜方肌(TM) 和提斜角肌(SM), 膈肌(PN), 頸內(nèi)靜脈(IJV), 頸動(dòng)脈(CA), 氣管(T)114Page 115Page 116Page 117刺激導(dǎo)管導(dǎo)入。從椎體橫突外側(cè)向前下方逐漸插入。Page 118導(dǎo)管固定Page 同樣可將患者擺放為側(cè)臥位進(jìn)行操作如穿刺時(shí)出現(xiàn)感覺異常，應(yīng)仔細(xì)觀察、分析情況后再進(jìn)行應(yīng)再操作前仔細(xì)詢問病史并記錄任何既往性臂叢神經(jīng)炎或臨床前、亞臨床復(fù)雜性區(qū)域疼痛綜合癥。實(shí)際肩部病變往往表現(xiàn)為肩部疼痛，但很少有肘關(guān)節(jié)遠(yuǎn)端疼痛

41、癥狀，該情況意味著神經(jīng)病變的存在如出現(xiàn)興奮性肌肉顫搐，神經(jīng)刺激儀調(diào)制在90%)、陰部神經(jīng)阻滯 (80%)，甚至發(fā)生尿潴留。罕見并發(fā)癥包括盆腔血管或器官損傷。該入路是坐骨神經(jīng)阻滯中唯一可完全阻斷脛、腓、股后側(cè)皮支、臀上/下等神經(jīng)的方式。139Page 患者體位側(cè)臥位,半俯臥側(cè)位適應(yīng)癥膝關(guān)節(jié)水平以下（踝、足）手術(shù)麻醉、術(shù)后鎮(zhèn)痛劑量、速度30-40ml 0.5%羅哌卡因注射后以0.2%羅哌卡因連續(xù)輸注8-10ml/h速度或PCA (5 mL/hour 背景輸注，3-4 ml單次劑量，鎖定時(shí)間20min)解剖學(xué)標(biāo)志股骨大轉(zhuǎn)子，坐骨結(jié)節(jié).140Page 141Page 142Page 與傳統(tǒng)后路相比，臀

42、下入路可減少誤刺血管以及導(dǎo)管移位的可能。適用于肥胖病人。與后路相比，穿刺經(jīng)股二頭肌與半腱肌之間肌溝進(jìn)入，可減少病人穿刺痛苦。如針尖觸及股骨，應(yīng)回退并適當(dāng)調(diào)整。143Page 患者體位仰臥位，雙膝略屈曲，兩腿間夾針頭適應(yīng)癥膝關(guān)節(jié)水平以下手術(shù)麻醉與術(shù)后鎮(zhèn)痛（踝，足）劑量、速度30-40ml 0.5%羅哌卡因注射后以連續(xù)輸注8-10ml/h速度或PCA滴注以0.2%羅哌卡因(5 mL/hour 背景輸注，3-4 ml單次劑量，鎖定時(shí)間20min)解剖學(xué)標(biāo)志髕骨, 股二頭肌及股外側(cè)肌144Page 145Page 由于在腘窩水平血管來自深部股血管,往往深于坐骨神經(jīng),因此側(cè)入法可降低誤穿血管的可能.如需在大腿/小腿處加用止血帶,常需聯(lián)合股/隱神經(jīng)阻滯。146Page 147Page 患者體位俯臥位適應(yīng)癥踝、足部手術(shù)麻醉與術(shù)后鎮(zhèn)痛劑量、速度30-40ml 0.5%羅哌卡因注射后以0.2%羅哌卡因連續(xù)輸注8-10ml/h或PCA (5 mL/hour 背景輸注，3-4 ml單次劑量，鎖定時(shí)間20min)解剖學(xué)標(biāo)志坐骨神經(jīng)通常在腘窩上端高位腘