超声引导下对门诊病人的区域麻醉

Ultrasound-guidedforRegionalAnesthesiaforAmbulatorypatient

(超声引导下对门诊病人的区域麻醉)原文：MegA.Rosenblatt,M.D.

翻译：福建医大附属协和医院麻醉科规培住院医师张海梅2020/11/31introductionOutpatientsurgeriesnowaccountformorethantwo-thirdsofallsurgeriesperformedintheUnitedStatesandafterGIendoscopies,ophthalmologicprocedures,orthopedicoperationsarethenextmostfrequentlyperformed.如今在美国所有手术中在门诊执行的手术占了三分之二以上，随后的是胃肠镜检查、眼科手术、骨科手术。

Theadvantagesthatregionalanesthesia(RA)confersovergeneralanesthesia(GA),especiallyintheoutpatientsetting,arenumerous.区域麻醉的优势(RA)超过了全身麻醉(GA),尤其是在门诊病人。2020/11/32introductionSpecifically,orthopedicpatientsarethegroupofambulatorypatientswiththehighestincidence(16.1%)ofpaininthePACU.具体来说,在PACU中骨科病人是门诊病人中疼痛发生率最高的Peripheralnerveblocks(PNBs)offerpredictableintraoperativeanesthesia,aswellasprovideanalgesiaintothepostoperativeperiod,theopportunitytobypassPhaseIrecovery,andtheavoidanceofairwaymanipulations.外周神经阻滞(PNBs)提供可预测的术中麻醉,还提供术后镇痛,绕过复苏第一阶段,避免了气道处理。2020/11/33introductionUltrasound(US)imagingpermitsdirectvisualizationofperipheralnerves,needlelocationanddistributionoflocalanesthetic.超声成像能直接看到周围神经、针的位置及局麻药的分布。TheuseofUS-guidancetoperformnerveblocksisassociatedwithdecreasedtimetoonsetandqualityofblockwhichisequaltoorbetterthanPNBsperformedwithnervestimulator(NS)techniques,使用超声引导进行神经阻滞与减少起效时间相关,阻滞的效果等于或优于使用神经刺激器(NS)技术。2020/11/34introductionandtheuseofUSfacilitatestheplacementofblocksinpatientswhoareobese,maybeonanticoagulantsandthosewithchallengingexternalanatomy.超声的使用方便了肥胖病人、可能使用抗凝剂的病人、有挑战的解剖异常的病人的阻滞。2020/11/35introductionPerformingUS-guidednerveblocksrequiresanentirelynewskillsetforpractitioners.超声引导下神经阻滞要求医生掌握一项全新技能。Firstly,onemustlearntooperateultrasoundequipmentandthenusethistoidentifyanatomyasitappearsonatwo-dimensionalscreen.首先,你必须学会操作超声设备,然后使用它识别出现在二维屏幕上的解剖。Secondly,onemustbeabletosimultaneouslyusebothhands(oneholdingtheultrasoundtransducerandtheotherholdingtheblockneedle),watchthedisplayscreen,andmanipulatetheneedleintothenervesheath.其次,一个人必须能同时使用双手(一边拿着超声波换能器，一边握着阻滞针),观察显示屏,操作针使其进入神经鞘。Lastly,itisnecessarytolearntoidentifypatternsoflocalanestheticspreadthatareassociatedwithoptimalplexusblockade.最后,必须学会识别局部麻醉药扩散的模式，这与最佳神经阻滞相关。2020/11/36introductionEnlistingthesurgeontointroducetheconceptofPNBswhentheyofferpatientstheirpreoperativeinstructionswillimprovepatientacceptance.让外科医生给病人术前指导时介绍外周神经阻滞的概念,会提高病人的接受度。LocalanestheticsshouldbechosentominimizeonsettimesandlimittheuseofGAinordertopreventoperatingroomdelays.Meticulousfollow-upuntilresolutionofallblocksalongwithcommunicationwiththesurgeonscanaddtooverallsatisfaction.应选择可以缩短起效时间和限制使用全身麻醉的使用的局部麻醉药来防止手术延迟。仔细的观察直到所有的阻滞有效，并与外科医生沟通，可以增加整体满意度。2020/11/37LocalAnestheticsandAdjuvants局部麻醉剂和佐剂Localanesthetic(LA)agentsshouldbechosenaccordingtothedesireddurationofactionandtherequireddegreeofmotorblockade.局部麻醉剂选用应根据所需阻滞的持续时间和所需的运动神经阻滞深度，Aninsensateextremityinapatientwhoseproceduremaynotproducemuchpost-operativediscomfortmaybeatriskforinjurysecondarytothelossofprotectivereflextopain,orplacethepatientatrisksecondarytoalossofproprioception本体感觉—blocksofthelongestpossibledurationarenotalwaysthewisestchoice.对一个手术后可能不会有什么不适的病人让其肢体没有感觉，可能有继发损伤的风险，由于疼痛保护性反射消失或失去本体感觉，最长阻滞时间并不总是最明智的选择。2020/11/38GalindoconcludedthatmixingLAsleadstounpredictableblockadecharacteristics.Galindo得出使用混合的局部麻醉将导致不可预知的阻滞效果。Gratenstein

lookedatUS-guidedinterscalene

blockswith30mLin3differentsolutions—mepivacaine1.5%,bupivacaine0.5%

anda50:50mixtureofthetwo,andfoundthatmixingtheshortandlong-actingagentsdoesnotresultina

significantdifferenceinonsettimecomparedwitheithersolutionalone.

Gratenstein观察在超声引导下使用1.5%甲哌卡因,0.5%布比卡因和这两个药物对等混合的各30ml分别进行行肌间沟阻滞,发现短效和长效混合的这一组与在起效时间方面与单独使用一种药物相比并没有显著性差异2020/11/39WhereassomepractitionerscombineLAstodecreaseonsettimewhileprovidinglongduration,combiningchloroprocaine2%andbupivacaine0.5%causespHchangesthatcreateablockthatresemblesoneproducedbybupivacainealone.而一些医生结合使用局部麻醉以减少起效时间,同时提供长时间麻醉,将2%氯普鲁卡因和0.5%布比卡因混合引起pH值的变化导致阻滞效果类似于单独使用布比卡因。2020/11/310Localanestheticsdiffusesintonervesandtherateofdiffusionisdeterminedbytheconcentration,thereforehigherconcentrationsofLAsresultinmorerapidonsetofblockade.

局部麻醉药扩散到神经，其扩散的速率是由浓度决定的,因此越高浓度的局部麻醉药导致扩散速率越快Ropivacaine0.75%hasbeenshowntohavesimilarorshorteronsettimesforfemoral,sciaticandinterscaleneblocks,whileprovidingsignificantlylongerpostoperativeanalgesiathanmepivacaineandbupivacaine.0.75%罗哌卡因已被证明作用在股神经,坐骨神经和肌间沟神经阻滞有类似甚至更短的起效时间,同时提供术后镇痛时间明显比甲哌卡因和布比卡因长。2020/11/311Theeffectofalkalinizationofagentsonthespeedofonsetoftheblockisunclear.碱化剂对阻滞的起效速度的影响还不清楚。Ithasbeenshowntooffernoadvantageinperivascularblockswith0.5%bupivacainebutimprovementinonsetandqualityofanalgesiainaxillaryblockswith1.25%mepivacaine,andinfemoralandsciaticblockswith2%mepivacainehasbeendemonstrated.已证明使用0.5%布比卡因在血管周围阻滞并没有优势,但使用1.25%甲哌卡因行腋神经阻滞、2%甲哌卡因行股神经和坐骨神经阻滞被证实改善了起效时间及镇痛的效果。

2020/11/312Addingsodiumbicarbonate

tolidocainehasbeenshowntohavenoeffectontheonsetofaxillaryblock,andinratsithasbeenshowntodecreasetheintensityanddurationoftheblock.

在利多卡因液中加入碳酸氢钠已被证明对腋神经阻滞的起效时间上没有效果，在老鼠身上它已被证明可降低阻滞的强度和持续时间Inonestudyfentanylimprovedthesensoryblockadeachievedwithanaxillaryblockusing1.5%lidocaine,butthepHchangesitconferreddelayedtheonsetofanalgesia.Otherstudieshavenotshownefficacyofeitherfentanylormorphineintheimprovementofonsetorqualityofaxillaryblocks.在一项研究中显示在用1.5%利多卡因进行腋神经阻滞时，芬太尼可改善感觉阻滞，但它的pH值的变化导致镇痛起效时间延迟。其他研究没有表明芬太尼或吗啡在改善腋神经阻滞起效时间和效果有效，2020/11/313Clonidine,anα2-agonist,isknowntoprolongthedurationofsensoryandmotorblockade,particularlywhenaddedtolocalanestheticsofintermediateduration.可乐定，一种a2受体激动剂,众所周知，它可延长感觉和运动阻滞持续时间,特别是添加到中等时效局麻药时持续时间更长。One

studyof56patientsundergoingcarpaltunnelreleaseunderaxillaryblockwith1%lidocaineandvaryingamountsofclonidine,showedareductioninblockonsettime.一项研究56例准备行腕管减压的病人以1%利多卡因混合不同剂量的可乐定予腋神经阻滞，证实阻滞起效时间缩短。However,evenwithdosesassmallas30μg,patientsexperiencedsedation.然而,即使有剂量小至30微克,对患者都有镇静作用。Morethan50%ofpatientswerereportedtofallasleepintermittentlyat140minutesafterperformanceoftheblock.超过50%的患者报告显示在阻滞效果产生后的140分钟内都睡着了2020/11/314Recentlytheutilityofaddingdexamethasonetoupperextremityblocks.Theadditionofdexamethasone8mgto30mL

mepivacianehasbeenshowntosignificantlyprolongthedurationofasupraclavicularblock.最近使用加入地塞米松来对上肢进行阻滞。加入地塞米松8毫克至30毫升甲哌卡因中被证明能显著延长锁骨上神经阻滞的持续时间。Eightmgofdexamethasonewasshowntoprolongthedurationofactionofropivacaine(11.8vs22.2hrs)andbupivacaine(14.8vs22.4hrs)whenaddedto30mLoflocalanestheticforinterscaleneanesthesia.当8毫克的地塞米松添加到30毫升的局部麻醉剂中，对肌间沟的麻醉效果被证明可延长罗哌卡因的作用时间(11.8vs22.2小时)和布比卡因的作用时间(14.8vs22.4小时)。2020/11/315Tandoandcolleaguesfoundnodifferenceinthedurationofanalgesiabetweenadding4mgand8mgdosesofdexamethasonetointerscaleneblocksusing40mLbupivacaine.Thereexactmechanismofthisprolongationofactionisyettobeelucidated.Tando和同事们发现在40毫升布比卡因加入4或8毫克剂量的地塞米松，行肌间沟阻滞，在镇痛的持续时间上没有不同。延长作用时间的确切机制仍有待阐明。2020/11/316The5US-GuidedPNBsEveryAmbulatoryPractitionerNeedsandWhentoUseThem5种每个医师需要知道及何时使用超声引导下神经阻滞2020/11/317Masteryoftheinterscalene(ISB),supraclavicular,femoral股骨,popliteal腘肌andtransverses腹横肌abdominisplane(TAP)blockswillbeadequateforalmostalloftheneedsoftheanesthesiologistwhohasanambulatory-basedpractice.掌握肌间沟、锁骨上,股骨、腘肌和腹横肌平面的阻滞可满足门诊麻醉实践的麻醉医师几乎所有的需要。2020/11/318UpperExtremityUS-GuidedPeripheralNerveBlocks超声引导下上肢周围神经阻滞learningasimplescanningtechnique.2020/11/319

Theregiontobeblockedis

sterilelyprepped:阻滞区域消毒1)Identifythecarotidarteryandinternaljugularvein,withtheprobeinthehorizontalposition,justabovetheclavicle.确认颈动脉和颈内静脉,将探头放在水平位置,略高于锁骨。2)Movingtheprobelaterallyalongtheclavicleandaimingthebeamcaudad,towardsthefirstrib,thesubclavianarteryisidentifiedasthenextpulsatilestructurethatisvisualized.沿着锁骨向外侧横向移动探头，探头尾端方向，对着第一肋骨,即可确定跳动的结构为锁骨下动脉,这是可见的。Thepatientisplacedinthesupinepositionwithhisorherheadflatonthebed(withoutpillows)andturnedtowardsthecontralateralshoulder.病人仰卧位，去枕平卧，头转向对侧的肩膀。2020/11/320Thebrachialplexusatthelevelofthedivisionsappearsasa“bagofgrapes”locatedlateraltotheartery.臂丛的一级分支像“葡萄”样出现位于动脉的一侧。Toperformasupraclavicularblockatthatlevel,a22gaugeblockneedleisinsertedin-plane(paralleltotheprobe),untilitreachesthelocationthatisborderedbythesubclavianarterymedially,thefirstribinferiorly,andthedivisionsofthebrachialplexussuperiorlaterally--the“eightballinthecornerpocket”position.Thisblockisidealforallproceduresoftheelbowanddistally.在这样的平面上操作锁骨上神经阻滞,一个22号规格针插入平面(平行于探针),直到它到达锁骨下动脉内侧的位置，在第一肋下缘,上级部门臂丛神经外侧——“八球在角落里的口袋”位置。这阻滞对肘部及远端手术是理想的。

30-40mloflocalanestheticwillbemorethanadequatetoprovideablock.30-40毫升局部麻醉剂足够用来提供阻滞。2020/11/3213)Itisthenpossibletochoosethelargestofthenerves,appearingasaradiolucentcircleandtraceitcephalad,astheprobeiskeptinthehorizontalposition.然后你就可以选择最大的神经,出现一个射线可透过的圆，然后向头侧跟踪它,探头保持在水平位置。

WhentheC-6levelisreached,thisnerveandtheothersofthebrachialplexusareseeninaverticalorientation,betweentheanteriorandmiddlescalenemuscles.当到达颈6水平时,这根神经和其他的臂丛神经根在垂直方向可看见,在前部和中部肌肉之间的三角形。2020/11/322The22-gaugeblockneedleisinsertedeitherin-planeorout-of-planeanddirectedtowardsthepreviouslyidentifiednerve,withinthesheath.22号阻滞针平面内或平面外插入并指向之前确定的的神经鞘内神经。Theout-of-planeapproachmaybepreferabletoanin-planeoneforpractitionerswhohaveexperiencewithusingavesselfinderforcentralvenouslineplacement平面外接近的方法可能更适合于一个实践者已具备平面内借助寻找血管法置入中心静脉经验者。2020/11/323Again,30-40mloflocalanestheticwillprovideadequateanesthesia.同样的,30-40毫升的局部麻醉剂会提供足够的麻醉。Inastudylookingat170patientsundergoingshouldersurgery,SpencesoughttodescribetheideallocationtoinjectLA—eitherperi-plexus(betweenthemiddlescalenemuscleandbrachialplexus),orintra-plexus(injectionwithinthebrachialplexussheath).在一项观察170例患者接受肩膀手术,Spence寻求理想的位置注入局部麻醉剂--要么从周围神经丛(在斜角肌和臂丛之间的之中),或内部神经丛(注射在臂丛神经鞘内)。2020/11/324Afterinjecting30mLbupivacaine0.5%,theylookedforlossofshoulderabduction.在注射30毫升0.5%布比卡因后,他们检查肩关节外展的活动是否存在。Onsettimesandblockqualitywereequal,buttheintra-plexusblocksresulted

instatisticallysignificantlylongerblockduration(2.6hrs,p=0.03).起效时间和阻滞效果都是一样的,但内部神经丛阻滞导致了阻滞持续时间显著的延长(2.6小时,p=0.03)2020/11/325Datashowthatwhen5mLvs.20mlofropivacaineareusedforinISBcombinedwithGAforthesurgicalprocedure,patientshavefewerrespiratoryandothercomplicationswithnochangeinpostoperativeanalgesia.资料显示5毫升与20毫升罗哌卡因相比较用于肌间沟阻滞复合全身麻醉的手术,病人更少呼吸及其它并发症，而术后镇痛没有不同。MorerecentlythisgroupshowedthatwiththeuseofUS,theminimumeffectiveanalgesicvolumeofropivacaine0.5%inanISBrequiredtoprovideanalgesiaintheimmediatepostopperiodis0.9mL最近这个研究小组发现在超声的使用下,

0.5%罗哌卡因肌间沟阻滞提供术后即刻镇痛的最低有效的止痛剂量是0.9毫升。2020/11/326Aftertheneedletipwasdeterminedtobeintheinterscalenegroovethenerve

stimulatorwasturnedonandthelowestcurrentelicitingaresponsewasnoted.当针尖被认为是在肌间沟时，打开神经刺激器，并记录最低电流引起的反应。Thesensoryanalgesiaachievedbetweenthegroupswithresponsesat<0.5mAand>0.5mAwassimilar,thusconfirmingthatUS-guidedblocksproducesuccessfulanalgesiaregardlessofthemotorstimulationevoked.感觉神经镇痛的获得在<0.5mA和>0.5mA组是相似的,因此证实了无论运动刺激诱发与否，超声引导阻滞都可以产生满意的镇痛效果。2020/11/327

Perlasetaldescribedtheirexperiencewith510consecutiveUS-guidedsupraclavicularblocks,andreporteda94.6%successatachievingsurgicalanesthesiawithasingleattempt.Perlas等描述他们在510个病人连续超声引导下锁骨上神经的阻滞的经验，仅一次尝试就实现外科麻醉的成功率为94.6%。Complicationsincludedsymptomatichemidiaphragmaticparesis(1%),Hornersyndrome(1%),vascularpuncture(0.4%)andtransientsensorydeficit(0.4%).并发症包括膈肌麻痹症状(1%),霍纳综合征(1%)、误穿血管(0.4%)和短暂感觉障碍(0.4%)。2020/11/328Aprospectiveregistryof1,169US-guidedISBandsupraclavicularblocksforshouldersurgeriesshowsa0%incidenceofvascularpuncture,0.4%incidenceofshort-termpostoperativeneurologicsymptomsanda0%incidenceofpermanentnerveinjury.1169个超声引导下的肌间沟阻滞和锁骨上神经阻滞的肩膀手术的前瞻性研究显示血管穿刺的发生率0%，术后短期神经症状发生率0.4%,永久神经损伤发生率0%。2020/11/329SinceSauterusedMRItodefinetheanatomiclocationofthecordsoftheinfraclavicularbrachialplexus,weknowthatneedleplacementatthe“VIIIo’clock”positionadjacenttotheaxillaryarteryinthecranioposteriorquadrantandobservingsatisfactoryspreadoflocalanestheticbetweenthe“IIIo’clockandIXo’clock”positionswillpredictasuccessfulinfraclavicularblock.由于sauter使用核磁共振成像技术来明确的锁骨下臂丛的解剖位置,我们知道针位于毗邻腋动脉的“八点”位置颅后象限，观察局部麻醉在“三点和九点”位置满意的扩散将预测一次成功的锁骨下阻滞。2020/11/330MccairredescribedusingUS-guidedmedianandulnarnerveblocksatthewristtoprovideanesthesiaforendoscopiccarpaltunnelrelease.Mccairre描述了对内镜下腕管减压手术提供麻醉使用超声引导在腕部阻滞正中神经和尺神经。Throughasingleinjectionsitelocated5to10cmproximaltothewristcreaseintheanterior

forearm,bothnervesareblockedunderdirectvision,eachwith4mlof1.5%mepivacaine.通过前臂位于腕横纹近端5到10厘米的位置单次注射，在直视下两神经都可被阻滞，各需4毫升的1.5%甲哌卡因。Thisissupplementedwith1-2mloflocalanestheticatthelevelofincisioninthewristcreaseinordertoblockthepalmarisramusofthemediannerve.在腕横纹切口处可补充1-2毫升的局部麻醉剂以便阻滞正中神经的掌支。2020/11/331

LowerExtremityUSguidedPeripheralNerveBlocks超声引导下肢周围神经阻滞

Thefemoralnerveislocatedbyplacingthelinearprobeintheinguinalcrease.将线阵探头置于腹股沟折痕处可定位股神经。Itisthedensewhitestructure,lateraltothehypoecoicpulsatilefemoralarteryanddeeptoboththefascialataandfasciailiaca.它是致密白色结构,在低回声跳动性的股动脉外侧，在阔筋膜和髂筋膜的深部。2020/11/332Thiscanbeblockedwitha22gneedleinanin-orout-ofplaneapproachandasuccessfulblockisanticipatedwhenlocalanesthesiaspreadisseensurroundingthenerve.这可以被22号针使用平面内或外接近方法阻滞，当局部麻醉剂围绕神经扩散，成功的阻滞是可预期的。Thisblockisparticularlyusefulforpatientsundergoingrepairsoftheanteriorcruciateligamentorsurgicalproceduresinvolvingthepatella.Performingafasciailiacablockisanalternativetothefemoralnerveblock,andmaybemoresuccessfulforblockingthelateralfemoralcutaneousnerveandoccasionallytheobturatornerve.这阻滞在患者接受前交叉韧带修补或涉及膝盖骨的手术特别有用。行髂筋膜阻滞是股神经阻滞替代方法,可能更有效阻滞股外侧皮神经，有时还能阻滞到闭孔神经。2020/11/333

Alinedrawnbetweentheanteriorsuperioriliacspineandpubictubercleisdividedinthirds.Atthejunctionbetweenthemiddleandlateralthirdsanultrasoundprobeisplacedinatransversepositionandthefascialataandiliacaareidentified.在髂前上棘棘和耻骨结节之间划一条线分为三等分。在中外三分之一处，超声波探头放置在横向位置，阔筋膜和髂筋膜可被识别。Theneedleisplacedunderthefasciailiaca,and30mloflocalanestheticisinjected.Spreadoflocalanestheticinmedialandlateraldirectionsunderthefasciailiacaisevidenceofcorrectneedleplacement.针位于髂筋膜下,注入30毫升局部麻醉药。局部麻醉药在髂筋膜下向内侧和外侧方向扩散是针位置正确的证据。2020/11/334

Forsurgicalproceduresbelowtheknee,thesciaticnerveinthepoplitealfossacanbeblockedeitherfromaposteriororlateralapproach.对于在膝盖以下的外科手术,在腘窝处的坐骨神经可以从后侧或外侧入路法阻滞。Theposteriorapproachrequiresplacingthepatientinapronepositionandthehyperechoicnerveislocatedatthemidpointbetweenthetendonsofthebicepsfemorisandtheemitendinosus/semimembranosismuscles.后侧入路法需要将病人置于俯卧位，高回声神经位于股二头肌肌腱和半腱肌的肌肉中点之间。Thepoplitealarteryislocatedmedialanddeeptothenerve,andisanexcellentlandmarkfromwhichtobeginscanningsuperiorandlaterally.腘动脉位于神经的内侧和深部,是一个极好的开始外上方向扫描的标志点。2020/11/335

Itisessentialtoidentifythepointofdivisionofthesciaticnerveintothecommonperonealandanteriortibialnerves,andplacetheneedleproximaltothispointtoensurethatbothdivisionsareblocked.重要的是识别坐骨神经分出腘总神经和胫前神经的位置,把针位置置于此点的近侧,以确保分支也被阻滞。US-guidancehasbeenshowntoincreasesuccessofblockanddecreaseonsettimecomparedtoaNSTechnique.超声引导被证明能增加阻滞的成功及比神经刺激器技术减少起效时间。

2020/11/336

Forthelateralapproach,thepatientremainsinthesupinepositionanditishelpfultohavethepatient’slegplacedonabolster,withtheUSprobeplacedunderneath.外侧入路，病人保持仰卧位，病人的腿部垫枕，超声探头位于其下。A100mmneedleisinsertedparalleltotheprobeanddirectedtowardsthehyperechoicnerve,againinsuringthatithasnotyetdivided.100毫米针平行探头插入并指向高回声的神经,再次确认它未分叉。Foreitherapproach,30mloflocalanestheticwillensureanadequateblock.不管哪种入路,30毫升的局部麻醉药能确保足够的阻滞。2020/11/337

Toprovidecompleteanalgesiaofthelowerextremitywiththepoplitealblock,anesthesiaofthesaphenousdistribution(medialsideofthelowerextremity)isnecessary.为了提供含腘窝阻滞的完全下肢镇痛,隐神经分支的麻醉(下肢内侧)是必要的。And,inordertopreservequadricepsmusclefunction(whichwouldnotbepossiblewithafemoralnerveblock),thesaphenousnervecanbeblockedatthelevelofthetibialtuberosity.为了保留置股四头肌肌肉功能(股神经阻滞无法实现),隐神经可在胫骨粗隆水平阻滞。Thiscanbeaccomplishedbylocatingthesaphenousveinintheshortaxisview,andthendelivering5mloflocalanesthesiabothmedialandlateraltothevessel.这可以通过在短轴视图定位隐静脉实现,然后在血管的内侧和外侧给予5毫升的局部麻醉药。2020/11/338

Becauseitmaybedifficulttoidentifythesaphenousnerveatthislevel,itmaybeeasiertoidentifythenerveasittravelsdeeptothesartoriusmuscle,adjacenttoadescendingbranchofthefemoralartery.由于在这个水平可能难以识别隐神经,更容易识别的是神经穿行深入缝匠肌,与股动脉降支相邻。Withthepatient’slowerextremityexternallyrotatedatthehip,theprobeisplacedperpendiculartotheextremity7cmproximaltothepoplitealcrease.病人下肢在髋部外旋,探头垂直置于腘横纹近心端7厘米位置。Usinganin-planeapproach,10mloflocalanesthesiaisdepositeddeeptothesartoriousmuscleanteriorandsuperiortotheartery,wherethenerveisvisualized.使用平面内法,10毫升的局部麻醉药注入缝匠肌深部，动脉的前上方，此处神经可见。2020/11/339

USisnowbeingusedtoimprovethesuccessrateofPNBsnerveblocksattheankle.超声近来被用于提高踝部外周神经阻滞的成功率。Thesuralnervehasbeenshowntolieadjacenttothelessersaphenousvein.腓肠神经被证明毗邻小隐静脉。Redborgplacedhispatientsinapronepositionwithatourniquetaroundtheproximaltibia,toalloweasyidentificationofthevein,andusinga27gaugeneedleinanout-of-planetechnique,injected5mloflocalanesthetic.Redborg把他的病人置于俯卧位，止血带绑在在胫骨近端,使静脉容易识别,并且使用平面外技术27号针注入5毫升局部麻醉剂。2020/11/340

Theendpointwastoobservethespreadoflocalanesthesiacompletelyaroundthelessersaphenousvein.AlthoughtheUSblockstooklongertoperformthananatomicallybasedones(172secvs.70sec),theywereconsideredtobedenserinquality.ShealsodescribedusingUStoblockthetibialnerveattheankle.最后是观察局部麻醉药完全扩散至小隐静脉四周。尽管超声阻滞比基于解剖学上的操作(172秒和70秒)花了更长的时间,但是效果更好。她还描述了在踝部使用超声来阻滞胫神经。Again,patientswereplacedintheproneposition,andtheprobewasplacedinahorizontalplaneposteriortothemedialmalleolus.Thenervecanbeidentifiedposteriortotheposteriortibialartery.同样地,病人置于俯卧位,探头位于内踝后部水平位。神经可在胫后动脉后部被识别。2020/11/341

Theflexorhallucislongustendontravelswiththeneurovascularstructuresatthatlevelandmaylooklikethenerve;thereforetheauthorsuggestsdemonstratingmotionofthetendonwithmovementofthegreattoeinordertodifferentiateitfromthenerve.在这个水平，屈趾长肌腱走行在血管神经结构之间,可能看起来像神经,因此作者建议为了区分它与神经，可运动大脚趾来显示肌腱的活动。Using5mloflocalanestheticanddemonstratingcircumferentialspreadaroundthenerveisassociatedwithblocksuccess.使用5毫升的局部麻醉剂，并证实其围绕神经扩散，这与阻滞是否成功有关系2020/11/342

TruncalBlocks躯干阻滞TheTAPblockisgainingpopularityasamethodforpostoperativeanalgesiaforproceduresoftheabdomen,includinglaparoscopicappendectomyandcholecystectomy.腹横平面阻滞方法是作为腹部手术术后镇痛包括腹腔镜胆囊切除术及阑尾切除术已经很常见了TheblockisaccomplishedbyplacingalineararrayprobehorizontallyattheT10levelandmovinglaterallyuntilitispossibletoidentifythefollowingabdominallayers:skin/subcutaneoustissue,externalobliquemuscle,internalobliquemuscle,andtransversusabdominismuscle(belowwhichisperitonealcavity).阻滞是通过把一个线性阵列探头水平放在T10水平和横向移动直到它有可能确定以下腹部层：皮肤或皮下组织、腹外斜肌,腹内斜肌和腹横肌肌(下图这是腹膜腔)。2020/11/343

Usinga22gaugeblockneedleandanin-planeapproach,20mlof0.25%bupivacaineisdepositedononeorbothsides,dependinguponthelocationofthesurgicalincisions.用22号针，从平面内入路,根据手术切口的位置，将20毫升0.25%布比卡因注药在一边或两边。Thisblockhasbeenshowntoreduceboththeintraoperativeandpostoperativeuseofnarcoticanalgesics.US-guidancehasalsobeendescribedtoplaceilioinguinal髂腹股沟的andiliohypogastric髂腹下的blockstoprovideanalgesiafollowingoutpatientinguinalherniorrhaphy.神经阻滞已被证明可以减少术中及术后都麻醉镇痛药用量。超声引导也被用来通过髂腹股沟神经、髂腹下神经阻滞提供门诊腹股沟疝修补术后镇痛。2020/11/344Afteridentifyingtheanteriorsuperioriliacspine,theanteriorabdominalmusclelayers,andtheperitoneum,aneedleisinsertedintothefascialplanebetweentheinternalobliquemuscleandtransversusabdominismuscle.Occasionallyitispossibletoidentifytheiliohypogastricnerve.在识别髂前上棘,腹前部肌肉层,和腹膜后,将针插入腹内斜肌和腹横肌之间的筋膜层。偶尔可以看到髂腹下神经。Lastly,therectussheathblockhasbeendescribedtoblockthelowerthoracicnervesandprovideanalgesiaformidlineincisionsandproceduresaroundtheumbilicus.最后,腹直肌鞘阻滞可以当成阻滞下胸神经，为正中切口及肚脐周围书中的手术提供镇痛2020/11/345

Needlesareinserted5cmaboveandbelowtheumbilicusand5cmbilaterally,andinjecting10mloflocalanestheticineachquadrantbetweentheanteriorandposteriorrectussheaths.针插入脐上及脐下及脐部左右5厘米位置，注入10毫升的局部麻醉剂在每个象限腹直肌鞘的前部和后部之间。2020/11/346IndwellingCatheterTechniques

留置导管技术Forambulatorypractitionerswhoplaceindwellingcatheters,US-guidancehasproventoprovideanalgesiaequaltothatachievedwhenaNStechniqueisemployed,withstatisticallysignificantshortertimefromneedleplacementundertocatheterinsertionandlowercatheterinsertionpainscores.对于医生留置导管,超声引导已被证明提供镇痛的效果跟使用神经刺激技术产生的效果一样,统计学上显著缩短位于导管下部针置入的时间，降低导管置入疼痛评分。2020/11/347Forinterscalenecatheters,someadvocateaposteriorapproachtotheinterscalenegroove,whichprovidespostoperativeanalgesiaandofferstheadvantagesofavoidanceoftheexternaljugularveinandplacementofthecatheterfurtherawayfromthesurgicalfield.对于肌间沟导管来说,有些人主张从后方进入肌间沟,它能提供术后镇痛，并能避免损伤颈外静脉，而且导管放置位置可以远离手术区域

2020/11/348HowevertheuseofGAisnecessarysincethenervesofthesuperficialcervicalplexusandtheskinaroundtheshoulderarenotanesthetized.Whenplacingcathetersforforearmandhandprocedures,aninfraclavicularapproachofferstheadvantageofamoresecurepositionunderboththepectoralismajorandminormuscles.然而使用全麻是必需的,因为颈浅神经丛和肩部皮肤未能被麻醉。当为前臂和手的手术置管时，一种经锁骨下的方法在胸大和胸小肌下提供了一个更可靠的位置。2020/11/349Inthispositionthereislessleakagearoundthecatheterthanfrommoresuperficiallyplacedones(i.e.,supraclavicularandinterscalenecatheters).在这个位置在放置导管比从浅表位置放置导管更少漏(如锁骨上和肌间沟的导管)。AndUS-guidedinfraclavicularcathetersresultinhigherprimaryblocksuccessanddecreasedsecondarycatheterfailurewhencomparedtotraditionalinsertiontechniques.超声引导下引导锁骨下置管使阻滞更加成功，与传统的置管技术相比可减少二次置管的失败,2020/11/350Thereareconflictingdataregardingtheidealsolutionsforambulatorycatheters.Forexample,Leefoundthatlowconcentrationsofanestheticathigherbasalrateprovidedsuperioranalgesiatopatientswithinterscalenecatheters.关于门诊置管的溶液有争议。例如,Lee发现低浓度较高的背景速度的麻醉剂在肌间沟置管时更能为病人提供优越的镇痛。Conversely,Ilfeldshowedthatforcontinuouspopliteal-sciatic

nerveblocks,concentratedsolutionsofsmallvolumeprovidedexcellentanalgesia,withalowerincidenceofi