新版超聲引導(dǎo)技術(shù)應(yīng)用于區(qū)域麻醉和鎮(zhèn)痛

麻醉與超聲

Anaesthesiaandultrasound傳統(tǒng)麻醉→現(xiàn)代麻醉

traditionalanaesthesia→modernanaesthesia

藥物:單一，不良反應(yīng)多→選擇↑，安全性↑，可控性↑

技術(shù)

:盲探操作→可視操作理論

:麻醉基礎(chǔ)和臨床理論日益豐富超聲技術(shù)與麻醉

ultrasoundtechniqueandanaesthesia以其獨(dú)特優(yōu)點(diǎn)成為近年熱點(diǎn),方興未艾喻為現(xiàn)代麻醉醫(yī)生的“第三只眼睛”麻醉各領(lǐng)域廣泛應(yīng)用“Thethirdeye”foranaesthetist

第一頁，共54頁。內(nèi)容Contents

局部麻醉的發(fā)展

developmentoflocalanesthesia超聲設(shè)備和原理

ultrasoundequipmentsandprinciples超聲技術(shù)在現(xiàn)代麻醉中的應(yīng)用

applicationofultrasoundtechniqueinanesthesia

臨床麻醉

clinicalanesthesia

疼痛治療

painmanagement

危重病醫(yī)學(xué)

CriticalCareMedicine第二頁，共54頁。從古柯樹葉中提取的生物堿

AlkaloidderivedfromtheleavesofErythroxyloncoca

1860年Niemann制成純白結(jié)晶物，取名可卡因

Niemannin1860producedpurewhitecrystalswhichnamedcocaine

局麻藥物-可卡因

localanesthetic-cocaine

古柯葉foliumcocoecocaleafgukeye罌粟花poppyflower第三頁，共54頁。1884年,CarlKoller將Cocaine成功用于眼局部手術(shù)

CarlKollerinthesummerof1884appliedcocainetotheconjunctionwithsuccess可卡因

Cocaine毒性toxicity時(shí)效短shortduration

成癮性

addictionCarlKoller(1857-1944)可卡因cocaine

第四頁，共54頁。

普魯卡因procaine(1904)

–低毒性、無成癮lowtoxicity,lackofaddictiveproperties

–時(shí)效短、過敏反應(yīng)shortduration,allergicreactions

探索新的更加安全的局麻藥

(1890s～1940s)

theintroductionofsaferlocalanesthetics

地卡因amethocaine

(1937)

–強(qiáng)效、時(shí)效長potent,longduration–毒性、過敏反應(yīng)toxic,allergicreactions

局麻藥物localanesthetic

第五頁，共54頁。1943:NilsLofgren合成利多卡因

NilsLofgrensynthesizedlidocainein1943利多卡因衍生物的合成thesynthesisoflidocaine’sderivatives甲哌卡因mepivacaine(1956)布比卡因bupivacaine(1963)丙胺卡因prilocaine

(1960)羅哌卡因

ropivacaine(1980)左旋布比卡因

levobupivacaine(1993)局麻藥物localanesthetic

第六頁，共54頁。首次神經(jīng)阻滯

thefirstnerveblockWilliamBurke(theendofNov.1884)WilliamHalstedandRichardHall(theendof1885)至1900年,大部分現(xiàn)今局部麻醉技術(shù)已用于臨床

mostcurrentlyusedtechniquesofRAweredevisedby1900臂叢阻滯（腋、鎖骨上）brachialplexusblock腹腔神經(jīng)叢阻滯celiacplexusblock頭、頸部神經(jīng)阻滯nerveblockabouttheheadandneck靜脈內(nèi)局部麻醉bierblock脊麻spinalblock硬膜外阻滯epiduralblock神經(jīng)阻滯nerveblock第七頁，共54頁。傳統(tǒng)神經(jīng)定位方法conventionalmethodologyfornervelocation

解剖定位

anatomicallandmarks操作難度高difficulttoperform成功率低lowsuccessrates異感定位

paresthesiatechniques神經(jīng)損傷nervedamage成功率→

90％

successrates神經(jīng)定位方法的發(fā)展developmentfornervelocation神經(jīng)刺激器

nervestimulator

超聲引導(dǎo)定位

ultrasoundguidance

神經(jīng)定位方法

methodologyfornervelocation

Titleinhere解剖定位異感定位神經(jīng)刺激器超聲引導(dǎo)定位第八頁，共54頁。局限性周圍神經(jīng)病變裝有心臟起搏器者費(fèi)用肌群收縮致患者不適和疼痛

周圍神經(jīng)電刺激peripheralnervestimulation(PNS)

DisadvantagesAdvantages優(yōu)點(diǎn)

需患者合作程度小患者不舒適感減輕(異感→不舒適)不受溝通障礙影響可能縮短操作時(shí)間第九頁，共54頁。超聲引導(dǎo)局部麻醉

Ultrasound-guidedregionalanesthesia(UGRA)1978年LaGrange最早報(bào)道→超聲下鎖骨上臂叢阻滯

UGRAwasfirstdescribedbyLaGrandeetal.in1978

BrJAnesth,1978,50:965-967近十年來UGRA得到長足發(fā)展

UGRAdevelopedbecomeamoresignificantareaofinteresttoanesthesiologists便攜式

portable更精確

morerefined價(jià)格合理

affordable第十頁，共54頁。

原理principlesofultrasoundtechnology不同的人體解剖結(jié)構(gòu)均有各自的反射特性

differenthumananatomicalstructureshavevaryingreflectiveproperties反射（回聲）能夠被超聲探頭收集

thereflection(echo)iscollectedbytheprobe反射的信號(hào)經(jīng)放大處理后顯示在數(shù)字監(jiān)測(cè)儀上

theamplitudeofreflectedsignalisdisplayedonadigitalmonitor超聲技術(shù)原理

principlesofultrasoundtechnology第十一頁，共54頁。

組織回聲differenttypeofultrasound“高回聲”結(jié)構(gòu)－“亮”圖像（如：骨、腱）

“hyperechoic”structures－“bright”onscreen(e.g.bone,tendons)“低回聲”結(jié)構(gòu)－“暗”圖像（如：脂肪、血管）

“hypoechoic”tissues－“dark”onscreen(e.g.fat,vessels)

外周神經(jīng)一般為高回聲

peripheralnervesusuallyhaveahyperechoicappearance超聲技術(shù)原理

principlesofultrasoundtechnology第十二頁，共54頁。

高頻超聲higher-frequencyultrasound高清晰度(分辨率),低穿透力higherresolution,lowpenetration低頻超聲lower-frequencyultrasound低清晰度、高穿透力lowerimageresolution,deeperpenetration位置較淺神經(jīng)superficialnerve肌間溝、鎖骨上、腋路臂叢:10－13MHzinterscalene,supraclavicular,axillarybrachialplexus位置較深神經(jīng)deepnerve鎖骨下、腘、腰叢:5－7MHzInfraclavicularorpoplitealregion,lumbarplexus超聲技術(shù)原理-頻率

principlesofultrasound-frequency第十三頁，共54頁。超聲引導(dǎo)的外周神經(jīng)阻滯優(yōu)點(diǎn)AdvantagesofUltrasoundGuidedPeripheralNerveBlocks項(xiàng)目優(yōu)點(diǎn)定位神經(jīng)直接可視

有助于神經(jīng)定位的周圍結(jié)構(gòu)直接可視直接可見局麻藥注射時(shí)的擴(kuò)散減少局麻藥劑量安全性避免血管內(nèi)或神經(jīng)內(nèi)注射避免創(chuàng)傷病人疼痛性肌收縮阻滯效果神經(jīng)阻滯起效更快，作用更持久提高阻滯效果AdoptedfromMarhoferetal2004

第十四頁，共54頁。Ultrasound-guidedRegionalAnesthesia.Anesthesiology2006;104:368–73.NA=notapplicable.NS=notstatisticallysignificant(P≥0.05).Ref.=reference第十五頁，共54頁。Ultrasound-guidedRegionalAnesthesia.Anesthesiology2006;104:368–73.NA=notapplicable.NS=notstatisticallysignificant(P≥0.05).Ref.=reference第十六頁，共54頁。平面內(nèi)和平面外inplaneandoutofplane第十七頁，共54頁。超聲下肌間溝臂叢阻滯

ultrasoundguidedinterscalenebrachialplexusblockade頸動(dòng)脈三角肌間溝鎖骨臂叢上干臂叢中干臂叢下干胸鎖乳突肌前斜角肌短軸平面內(nèi)技術(shù)典型的臂叢三干超聲圖第十八頁，共54頁。液性暗區(qū)臂叢針尖臂叢局麻藥穿刺針在阻滯過程中的顯像臂叢完全被液性暗區(qū)包圍超聲下肌間溝臂叢阻滯

ultrasoundguidedinterscalenebrachialplexusblockade第十九頁，共54頁。Thefemoralnervewassurroundedbyafluidspace.FN:femoralnerve股神經(jīng),FA:femoralartery股動(dòng)脈,LA:localanesthetic局麻藥,IF:iliacfascia髂筋膜FALAFNIF超聲下股神經(jīng)阻滯

ultrasoundguidedfemoralnerve

blockade第二十頁，共54頁。

注射局麻藥有利于靶神經(jīng)結(jié)構(gòu)顯像

thetargetednervestructuresoftencanbemoreeasilyidentifiedfollowingtheinjectionoflocalanesthetic

第二十一頁，共54頁。

甜圈征doughnut第二十二頁，共54頁。UltrasoundImagingoftheThoracicEpiduralSpace.RegionalAnesthesiaandPainMedicine,2002,27(2):pp200–206

第二十三頁，共54頁。UltrasoundImagingoftheThoracicEpiduralSpace.RegionalAnesthesiaandPainMedicine,2002,27(2):pp200–206

Fig3.Highresolutionimagesfrommedianlongitudinal(A),paramedianlongitudinal(B)scans.Allrelevantstructuresarenamed.硬膜外腔硬膜外腔硬膜外腔第二十四頁，共54頁。UltrasoundImagingoftheThoracicEpiduralSpace.RegionalAnesthesiaandPainMedicine,2002,27(2):pp200–206

硬膜外腔Fig3.Highresolutionimagesfrommedianlongitudinal(A),paramedianlongitudinal(B)scans.Allrelevantstructuresarenamed.第二十五頁，共54頁。Caudalinjectioncanbereliablyimagedusingportableultrasound–apreliminarystudy.PediatricAnesthesia,2005,15:948–952

第二十六頁，共54頁。Real-timethree-dimensionalultrasoundforcontinuousinterscalenebrachialplexusblockade.JAnesth(2009)23:466–468第二十七頁，共54頁。Case1一般情況患者：男，25歲，65公斤，腰2骨折復(fù)位內(nèi)固定術(shù)后兩月診斷：右足跟軟組織缺損，擬行手術(shù)：右足跟清創(chuàng)+腓腸神經(jīng)加強(qiáng)皮瓣轉(zhuǎn)移術(shù)麻醉方法：坐骨神經(jīng)+股神經(jīng)阻滯腰2骨折術(shù)后超聲下坐骨神經(jīng)阻滯超聲下股神經(jīng)阻滯第二十八頁，共54頁。Case1術(shù)中情況體位：左側(cè)臥位靜脈藥物：咪唑安定，1mg；芬太尼，0.1mg生命體征平穩(wěn)，術(shù)者滿意術(shù)后鎮(zhèn)痛良好，患者滿意度高左側(cè)臥位，吸氧手術(shù)部位第二十九頁，共54頁。一般情況患者：男，86歲病史冠心病，前間壁心梗史5年高血壓病史18年腦梗史10年血肌酐升高史5年,腎性貧血；骨質(zhì)疏松史5年診斷雙下肢動(dòng)脈粥樣硬化性閉塞癥右第二足趾截趾術(shù)后，右第三足趾壞死并感染右足跟軟組織缺損擬行手術(shù)：右大腿截肢術(shù)

高齡，高危！Case2麻醉過程術(shù)前：神經(jīng)阻滯股神經(jīng)+坐骨神經(jīng)+股外側(cè)皮神經(jīng)+閉孔神經(jīng)術(shù)中鎮(zhèn)痛良好生命體征平穩(wěn)全麻？腰麻or

硬膜外？神經(jīng)阻滯？第三十頁，共54頁。一般情況患者：男，68歲，病史重度鼾癥，BMI≈40kg/m2慢性心衰擬行手術(shù)：右膝關(guān)節(jié)置換術(shù)麻醉方法術(shù)前：神經(jīng)阻滯(股神經(jīng)+坐骨神經(jīng)+股外側(cè)皮神經(jīng)+閉孔神經(jīng)術(shù)中喉罩淺麻醉維持術(shù)后患者清醒迅速，無痛避免了鼾癥病人術(shù)后拔管延遲，呼吸抑制等并發(fā)癥Case3第三十一頁，共54頁。無痛關(guān)節(jié)置換nopainsforJointReplacement

術(shù)前神經(jīng)阻滯無痛的關(guān)節(jié)置換

nopainsforJointReplacement[ImageInfo]

-Notetocustomers:ThisimagehasbeenlicensedtobeusedwithinthisPowerPointtemplateonly.Youmaynotextracttheimageforanyotheruse.術(shù)中強(qiáng)阿片藥物術(shù)后切口周圍注射局麻藥鎮(zhèn)痛泵目標(biāo)多模式鎮(zhèn)痛第三十二頁，共54頁。超聲與疼痛ultrasoundandpainmanagement第三十三頁，共54頁。疼痛治療-神經(jīng)阻滯

painmanagement-nerveblock

治療藥物drugsforpainmanagement局麻藥糖皮質(zhì)激素作用原理principles暫時(shí)阻斷痛覺傳導(dǎo)阻斷交感神經(jīng)，擴(kuò)張血管，改善局部血供消除軟組織水腫，減輕神經(jīng)受壓消除細(xì)胞因子、炎性介質(zhì)對(duì)神經(jīng)的刺激消除神經(jīng)炎癥、水腫幫助神經(jīng)修復(fù)第三十四頁，共54頁。超聲與疼痛ultrasoundandpainmanagement腰交感神經(jīng)節(jié)阻滯

lumbarsympatheticandceliacplexusblock

Kirvela等首先以超聲多普勒引導(dǎo)實(shí)行超聲可精確定位腰交感神經(jīng)干，阻滯有效率100%優(yōu)點(diǎn)：定位精確、價(jià)廉、無射線、機(jī)體影響小、良好的應(yīng)用前景Kirvel?O,etal.Ultrasonicguidanceoflumbarsympatheticandceliacplexusblock:anewtechnique.RegAnesth,1992,17(1):43-6.星狀神經(jīng)節(jié)阻滯

stellateganglionblock(SGB)Kapral超聲監(jiān)控下實(shí)施觀察到針尖和藥物的擴(kuò)散安全性提高：SGB并發(fā)癥↓

副作用↓KapralS,etal.Ultrasoundimagingforstellateganglionblock:directvisualizationofpuncturesiteandlocalanestheticspread.Apilotstudy.RegAnesth,1995,20(4):323-8.第三十五頁，共54頁。超聲與疼痛ultrasoundandpainmanagement腰交感神經(jīng)節(jié)阻滯

lumbarsympatheticandceliacplexusblock

Kirvela等首先以超聲多普勒引導(dǎo)實(shí)行超聲可精確定位腰交感神經(jīng)干，阻滯有效率100%優(yōu)點(diǎn)：定位精確、價(jià)廉、無射線、良好的應(yīng)用前景Kirvel?O,etal.Ultrasonicguidanceoflumbarsympatheticandceliacplexusblock:anewtechnique.RegAnesth,1992,17(1):43-6.星狀神經(jīng)節(jié)阻滯

stellateganglionblock(SGB)Kapral超聲監(jiān)控下實(shí)施觀察到針尖和藥物的擴(kuò)散安全性提高：SGB并發(fā)癥↓

KapralS,etal.Ultrasoundimagingforstellateganglionblock:directvisualizationofpuncturesiteandlocalanestheticspread.Apilotstudy.RegAnesth,1995,20(4):323-8.第三十六頁，共54頁。超聲與疼痛ultrasoundandpainmanagement肩部注射療法治療肩峰下滑囊炎

shoulderinjections

inthetreatmentofsubacromialbursitis兩組twogroups盲目穿刺blindgroup超聲引導(dǎo)穿刺ultrasound-guidedgroup標(biāo)準(zhǔn)standard注藥1周后肩部活動(dòng)度大小作為療效評(píng)價(jià)結(jié)果與結(jié)論resultandconclusion超聲引導(dǎo)組療效＞

對(duì)照組超聲引導(dǎo)準(zhǔn)確定位針的位置,注射時(shí)安全有效,明顯增加肩部的活動(dòng)度，是很好的輔助措施ChenMJL,etal.Ultrasound-GuidedShoulderInjectionsinthetreatmentofSubacromialBursitis.Am.J.Phys.Med.Rehabil.2006,85(1):32-5第三十七頁，共54頁。超聲與疼痛ultrasoundandpainmanagement肩部注射療法治療肩峰下滑囊炎

shoulderinjections

inthetreatmentofsubacromialbursitisFigure1Patientssitinanuprightpositionandwiththebackwellsupports,thearmsarepositionedbehindtheirbacksandwiththeelbowsbent.第三十八頁，共54頁。超聲與疼痛ultrasoundandpainmanagement崗上肌肱骨頭肩峰下滑囊崗上肌肱骨頭肩峰肩峰三角肌三角肌崗上肌肩峰下滑囊肩峰肩峰下滑囊肩峰下滑囊第三十九頁，共54頁。小關(guān)節(jié)源性疼痛painoffacetJointintheLumbarSpine小關(guān)節(jié)源性小關(guān)節(jié)功能紊亂小關(guān)節(jié)退行性變小關(guān)節(jié)的神經(jīng)支配脊神經(jīng)背支內(nèi)側(cè)支第四十頁，共54頁。UltrasoundGuidanceforFacetJointInjectionsintheLumbarSpine:Acomputedtomography-ControlledfeasibilityStudy.AnesthAnalg2005;101:579–83.

穿刺針I(yè)fmfIfmfIf:lateralfacet外側(cè)關(guān)節(jié)面mf:medialfacet中關(guān)節(jié)面

：needle穿刺針＝第四十一頁，共54頁。食道超聲心動(dòng)圖

Transesophagealechocardiography(TEE)

基本設(shè)備basicequipmentTee探頭(換能器)主機(jī)圖像記錄系統(tǒng)主要臨床應(yīng)用mainclinicalapplication血流動(dòng)力學(xué)檢測(cè)心肌缺血監(jiān)測(cè)手術(shù)效果即刻評(píng)價(jià)其他術(shù)中監(jiān)測(cè)：肺栓塞等第四十二頁，共54頁。食道超聲心動(dòng)圖

Transesophagealechocardiography(TEE)

TEEinrightatriallongaxistwo-dimensional

Pálinkásetal.CardiovascularUltrasound20064:6

doi:10.1186/1476-7120-4-6

第四十三頁，共54頁。Real-Time3-DimensionalEchocardiographyintheOperatingRoom.SeminCardiothoracVascAnesth.2008,12(4):248-64.

AML:anteriormitralleaflet二尖瓣前葉

PML:posteriormitralleaflet二尖瓣后葉

第四十四頁，共54頁。食道超聲心動(dòng)圖

Transesophagealechocardiography(TEE)

TEE在ICU的應(yīng)用applicationintheintensivecareunit對(duì)于ICU危重病人診斷和監(jiān)測(cè)，有很強(qiáng)的指導(dǎo)作用急需確診的心臟瓣膜病感染性心內(nèi)膜炎低血壓和血容量的具體評(píng)價(jià)病情危重狀態(tài)下左、右室功能評(píng)價(jià)心源性栓塞的功能診斷低氧血癥者有無卵圓孔未閉的右向左分流胸痛的鑒別診斷，特別是主動(dòng)脈夾層和心肌梗死后并發(fā)癥的鑒別心包積液、心包占位性病變、縱隔出血的診斷胸部外傷后心臟并發(fā)癥的診斷第四十五頁，共54頁。肺栓塞pulmoamyembolism,PETEE對(duì)于確診肺栓塞forconfirmationofPE靈敏度:70%

特異性:81%

70%sensitivityand81%specificityImpactofTEEinnoncardiacsurgery.InternationalAnesthesiologyClinics,2008,46:121-136.可能在肺動(dòng)脈的主要分支和右肺動(dòng)脈看到栓子maybeseeninthemainpulmonaryarteryortherightpulmonaryarteryUsefulnessofTransesophagealechocardiographytodiagnoseperioperativepulmonaryembolism.JournalofClinicalAnesthesia,2005,17:146-154

TEE與肺栓塞TEEandpulmoamyembolism第四十六頁，共54頁。TEE與肺栓塞TEEandpulmoamyembolismSinghA,FlemingN.Rightheartembolismandacuterightatrialdilationduringtotalkneearthroplasty.AnesthAnalg,2007,105(5):1224-7.Figure1.Mid-esophagealbicavalviewshowingalargehorseshoeshapedembolusintherightatriumFigure2.Mid-esophagealbicavalviewshowingtheinter-atrialseptumanditssignificantbulgingaftertourniquetrelease.第四十七頁，共54頁?？諝馑ㄈ鸻irembolismTEE是監(jiān)測(cè)心內(nèi)氣體栓子的最敏感方法。一般從經(jīng)胃短軸和四腔長軸兩個(gè)切面觀察，直徑小于2mm的栓子能清楚顯示全髖置換術(shù)(THR)右心中氣體栓子的檢出率很高靜脈空氣栓塞可能是THR心肺功能障礙的重要原因股骨假體植入是心腔內(nèi)栓子發(fā)生最明顯時(shí)段，幾乎每個(gè)患者都發(fā)生術(shù)中用TEE監(jiān)測(cè)有助于早期診斷TEE與空氣栓塞TEEandairembolism[1]王愛忠,江偉.全髖置換術(shù)與靜脈空氣栓塞.中國骨與關(guān)節(jié)損傷雜志,2008,23(4):348-350.[2]王愛忠,張衛(wèi)興,江偉.全髖置換術(shù)中經(jīng)食管超聲心動(dòng)圖監(jiān)測(cè)栓子和室壁運(yùn)動(dòng)異常的臨床研究.臨床麻醉學(xué)雜志,2008,24(5):373-375.

第四十八頁，共54頁。脂肪栓塞和空氣栓塞fatembolismandairembolism

脂肪栓塞

fatembolism

空氣栓塞airembolism

Wang