齐鲁医学连续外周神经阻滞王连主

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2021/9/301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。2021/9/302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。2021/9/303疼痛治疗骨折的术前疼痛、神经病理性疼痛、癌性疼痛等2021/9/304 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

2、/kg 最大量30ml 小儿： 0.375罗哌卡因 初始剂量： 0.5ml/kg 最大量20ml 2021/9/305 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：15min2021/9/306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2021/9/307一、连续肌间沟臂丛神经阻滞2021/9/308臂丛神经解剖分布2021/9/309C5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

3、经手内肌拇对掌小指屈2021/9/3010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N2021/9/3011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。2021/9/3012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2021/9/30132021/9/30142021/9/3015 患者仰卧位，头偏向健侧，患

4、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。2021/9/30162021/9/30172021/9/30182021/9/3019 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。2021/9/3020 二、连续股神经阻滞2021/9/3021股神经解剖起自L24，在腹股

5、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。2021/9/30222021/9/3023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2021/9/3024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2021/9/3025 全膝置换（TKA） Effect of continuous femoral nerve block in analgesia and the early rehabilit

6、ation 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 arthroplasty early.2021/9/3026 Comparison of the influences of

7、 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 intraoperative hemodynamics than PCIA, with b

8、etter pain relief,faster postoperative knee rehabilitation,less side effects,and higher patient satisfaction.2021/9/3027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 Palliat Care. 2010 Sep;16(3):

9、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 of well being.2021/9/

10、3028 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。2021/9/30292021/9/30302021/9/3031 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2021/9/3032三、连续髂筋膜间隙阻滞2021/9/3033 髂筋膜间隙解剖前界为

11、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。2021/9/30342021/9/3035 连续髂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2021/9/3036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

12、 and at all measurements in the FICB group. The study supports the use of FICB 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.2021/9/3037A Continuous Infusion Fascia Ili

13、aca 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%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2.9vs1.4，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.2021/9/3038

14、Effect of fascia iliaca compartment block with ropivacaine on early analgesia in children with development dislocation 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):2638-40.2021

15、/9/3039交叉韧带、股骨干手术 Comparison of continuous 3-in-1 and fascia Iliaca compartment blocks for postoperative analgesia: feasibility, catheter migration, distribution of sensory block, and analgesic efficacy. The authors conclude that a catheter for continuous lumbar plexus block can be placed more quick

16、ly and at lesser cost using the fascia iliaca technique than the perivascular technique with equivalent postoperative analgesic efficacy. Morau D al.2021/9/3040膝关节置换 Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: a case report and descriptio

17、n 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 fascia iliaca compartment is an effective means of providing postoperative analgesia after total knee arthroplasty when epidural analgesia is contrai

18、ndicated.2021/9/3041 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。2021/9/30422021/9/30432021/9/3044髂筋膜腔隙解剖2021/9/3045 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10cm2021/9/3046 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。2021/9/3047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