椎旁阻滞临床应用课件

椎旁阻滞的临床应用梅伟华中科技大学同济医学院附属同济医院麻醉科椎旁阻滞的临床应用梅伟1椎旁神经阻滞历史1905年由Sellheim首先在Leipzig报道，替代腰麻用于剖宫产术麻醉也有报道认为是在1908年Tuebingen开始的HugoSellheim(28.Dezember1871

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beiWorms;22.April1936inLeipzig)wareindeutscherGynäkologeundGeburtshelfer.椎旁神经阻滞历史1905年由Sellheim首先在Leipz2ArthurLäwen验证PVB(1911年)ArthurGeorgLäwen(6.Februar

1876inWaldheim,Sachsen;30.Januar1958inLüneburg)wareindeutscherChirurgundWegbereiterderheutigenAnästhesiologieArthurLäwen验证PVB(1911年)Arthu3Richardson,J.etal.,BrJAnaesth.1998;81(2):230-8.Richardson,J.etal.,BrJAn4ArthurLäwen的其他贡献1912年：首次联合使用硬膜外联合全麻1912年：在局麻药中加入碳酸氢钠首次采用骶管阻滞1912年：首次在手术中使用箭毒呼吸衰竭患者的辅助通气ArthurLäwen的其他贡献1912年：首次联合使用硬5MaxKappis（

1919年）KappisM.SensibilitaetundlocaleanaesthesiagebeitderBauchoelemitbesondererberuchsichtigungderSplanchnicusanaesthesia.BeitrKlinChir1919;115:161–75FujitaY.[MaxKappis,aninventorofsplanchnicnerveblock].Masui.1993Sep;42(9):1378-80.[ArticleinJapanese]MaxKappis(6.Oktober1881inTübingen;5.August1938)wareindeutscher

ChirurgMaxKappis（1919年）KappisM.Se6PVB的早期应用1920s应用极为流行：心绞痛、癌痛、股骨颈骨折、肢体缺血痛，室上性心动过速，哮喘，辅助排石，带状疱疹痛（MandelF.Paravertebralblock.NewYork:GruneandStratton,1946）1950s-1960s文献报道几乎消失1970s，阻力消失法引入后，再度流行(EasonMJ,WyattR.Paravertebralthoracicblock-areappraisal.Anaesthesia.1979;34(7):638-42.)PVB的早期应用1920s应用极为流行：心绞痛、癌痛、股骨颈7Richardson,J.etal.,AnesthAnalg.1998;87(2):373-6.Richardson,J.etal.,Anesth8Figure2.Inthepresenceofcompletenumbnessonsensoryexamination,depressionoftheS1dermatomalSSEPrangedfrom0%(A),togreaterthan50%(B),to100%(C)Dataarerepresentativeexamples.BenzonHTetal.,AnesthAnalg.1993;76(2):328-32.Figure2.Inthepresenceofc9椎旁阻滞临床应用ppt课件10PVBvs硬膜外:4-8h和48hVAS评分Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:4-8h和48hVAS评分Di11PVBvs硬膜外:吗啡量和尿潴留Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:吗啡量和尿潴留Ding,X.et12PVBvs硬膜外:PONV和低血压Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:PONV和低血压Ding,X.e13PVBvs硬膜外:失败率和肺部并发症Ding,X.etal.,PLoSOne.2014;9(5):e96233PVBvs硬膜外:失败率和肺部并发症Ding,X.14区域阻滞与术后慢性疼痛AndreaeMHandAndreaeDA.BrJAnaesth.2013;111(5):711-20区域阻滞与术后慢性疼痛AndreaeMHandAndr15椎旁神经解剖Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42椎旁神经解剖Eason,M.J.andWyatt,16椎旁神经解剖Schematicthoracicspinalnerve.AD=anteriordivision,PD=posteriordivision,C=spinalcord,SG=spinalganglion,RM=recurrentmeningeal,SC=sympatheticchain,RC=ramicommunicantes,PC=posteriorcutaneous,LC=lateralcutaneous,AC=anteriorcutaneous,P=pleura.Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42椎旁神经解剖Schematicthoracicspina17穿刺方法Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42穿刺方法Eason,M.J.andWyatt,R.18穿刺技巧Eason,M.J.andWyatt,R.Anaesthesia.1979;34(7):638-42穿刺技巧Eason,M.J.andWyatt,R.19Eason和Wyatt阻力消失法成功率Lonnqvist,P.A.etal.,Anaesthesia.1995;50(9):813-5Eason和Wyatt阻力消失法成功率Lonnqvist,20Eason和Wyatt法神经刺激器定位Naja,Z.andLonnqvist,P.A.Anaesthesia.2001;56(12):1184-8.Eason和Wyatt法神经刺激器定位Naja,Z.an21容量和感觉平面范围（针刺痛）志愿者，阻力消失法，1%利多卡因，头侧10ml（2秒推完），转向尾侧5ml（1.5秒推完）。置管15分钟后再推1%利多卡因7ml。Saito,T.etal.,ActaAnaesthesiolScand.2001;45(1):30-3容量和感觉平面范围（针刺痛）志愿者，阻力消失法，1%利多卡22容量和温度平面范围TM：鼓膜，C7：前臂内侧，T4：锁骨中线第四肋间，T10：锁骨中线脐平面，L2：大腿前中部，S2：小腿中后部Saito,T.etal.,ActaAnaesthesiolScand.2001;45(1):30-32ml利多卡因=1个节段容量和温度平面范围TM：鼓膜，C7：前臂内侧，T4：锁骨中线23剂量与容量和阻滞范围无关Cheema,S.etal,Anaesthesia.2003;58(7):684-773例慢性疼痛成人，横突上单点注射造影剂X光确认后，推注0.5%布比卡因10-15ml（60秒），9例无平面。剂量与容量和阻滞范围无关Cheema,S.etal,24超声定位平面外穿刺PVBHara,K.etal.,Anaesthesia.2009;64(2):223-5.3-11MHz线性探头（PhilipsSONOS5500）平面外技术穿刺，主要是判断深度超声定位平面外穿刺PVBHara,K.etal.,A25靶向肋间内膜平面外穿刺Marhofer,P.etal.,BrJAnaesth.2010;105(4):526-32.靶向肋间内膜平面外穿刺Marhofer,P.etal.26肋间入路靶向横突间内膜PVBBen-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.肋间入路靶向横突间内膜PVBBen-Ari,A.eta27肋间入路PVBBen-Ari,A.etal.,AnesthAnalg.2009;109(5):1691-4.肋间入路PVBBen-Ari,A.etal.,Ane28靶向横突下PVBShibata,Y.andNishiwaki,K.AnesthAnalg.2009;109(3):996-7根据Kappis技术改良（中线旁开3指，45度角向中线穿刺，触及椎旁间隙的后外侧壁骨质后注药，后被弃用），无需触及骨质，利用IICM和肋横突韧带的连续性靶向横突下PVBShibata,Y.andNishiw29肋间入路平面内穿刺PVB注药前探头和针位置Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVB注药前探头和针位置Renes,S.30肋间入路平面内穿刺PVB注药后针尖位置错误Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVB注药后针尖位置错误Renes,S.31肋间入路平面内穿刺PVBRenes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVBRenes,S.H.,eta32肋间入路平面内穿刺PVB0.75%罗哌卡因5ml+0.75%罗哌卡因10ml，置管后再给0.75%罗哌卡因5ml（总量20ml）阻滞成功率100%（三个节段）阻滞平面6（中位数）Renes,S.H.,etal.RegAnesthPainMed.2010;35(2):212-6肋间入路平面内穿刺PVB0.75%罗哌卡因5ml+0.75%33斜轴位靶向肋横突上韧带PVBLuyet,C.,etal.,BrJAnaesth.2009;102(4):534-9斜轴位靶向肋横突上韧带PVBLuyet,C.,etal34椎管内扩散Luyet,C.,etal.,BrJAnaesth.2009;102(4):534-9椎管内扩散Luyet,C.,etal.,BrJA35靶向肋横突上韧带的PVBO.RiainSCetal.,AnesthAnalg.2010;110(1):248-51靶向肋横突上韧带的PVBO.RiainSCetal.36椎旁阻滞入路KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁阻滞入路KredietAC.,etal.,Ane37椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,An38椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,An39椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,An40SCTL和iimb的异同KredietAC.,etal.,Anesthesiology2015;123:459-74SCTL和iimb的异同KredietAC.,etal41椎旁间隙的解剖KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙的解剖KredietAC.,etal.,An42椎旁间隙头侧和尾侧的边界KredietAC.,etal.,Anesthesiology2015;123:459-74椎旁间隙头侧和尾侧的边界KredietAC.,etal43肋骨平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74肋骨平面-横切面扫描KredietAC.,etal.,44横突平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74iimb=internalintercostalmembrane(green);横突平面-横切面扫描KredietAC.,etal.,45横突平面-横切面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-74imim=innermostintercostalmuscle1:20mllidocaine(15mg/ml)amedianof5dermatomes(interquartilerange,4to6).2:20mlropivacaine0.75%amedianof4or6dermatomes(range,3to7),acadaverstudy20mlinjecteddyeover3to4TPVspaces(range,1to10)with40%incidenceofepiduralspread.3:20mlmepivacaine1%adistamedianof3.5to4dermatomes(range,2to6)epiduralspreadof25%,whilethesamevolunteershadasensoryblockadeoveramedianof10dermatomes横突平面-横切面扫描穿刺法KredietAC.,eta46下关节突平面-横切面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74IAP=inferiorarticulateprocess;iimb=internalintercostalmembrane(green)暂无临床报道下关节突平面-横切面扫描KredietAC.,etal47下关节突平面-横切面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-744：暂无临床报道5：cadaverstudy,34of36needletipswerecorrectlypositionedintheTPV,epiduralspreadofdyewasnotedinsixinstances下关节突平面-横切面扫描穿刺法KredietAC.,et48肋间平面-矢状面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74iimb=internalintercostalmembrane(green)肋间平面-矢状面扫描KredietAC.,etal.,49肋间平面-矢状面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-746：13of14injectionsof1mlmethyleneblue1%resultedinspreadofdyetotheTPVspace.Thesamestudyalsoevaluatedatransversalin-planeintercostalapproach(fig.9,arrowno.1)andfoundthatmoreattemptswererequiredtosuccessfullyplacetheneedlewiththesagittaltechniquecomparedwiththetransversaltechnique:two(range,1to4)andfour(range,1to7),respectively).15肋间平面-矢状面扫描穿刺法KredietAC.,eta50OffSide靶向肋横突上韧带Abdallah,F.W.andBrull,R.

RegAnesthPainMed.2014;39(3):240-2OffSide靶向肋横突上韧带Abdallah,F.W51肋横突关节平面-矢状面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74SCTL=superiorcostotransverseligament(pink)肋横突关节平面-矢状面扫描KredietAC.,eta52肋横突关节-矢状面扫描穿刺法KredietAC.,etal.,Anesthesiology2015;123:459-747：insertionofcathetersthroughtheneedlewasfoundtobedifficultorimpossiblein6of20cathetersplaced,andahighvariabilityinspreadofinjectateoccurred,including30%epiduralspread.肋横突关节-矢状面扫描穿刺法KredietAC.,et53横突平面-矢状面扫描KredietAC.,etal.,Anesthesiology2015;123:459-74SCTL=superiorcostotransverseligament(pink)横突平面-矢状面扫描KredietAC.,etal.,54横突平面-矢状面扫描穿刺法8：目前尚无临床数据9：目前尚无临床数据KredietAC.,etal.,Anesthesiology2015;123:459-74横突平面-矢状面扫描穿刺法8：目前尚无临床数据Krediet55体会横突平面-横切面扫描穿刺法肋间平面-矢状面扫描穿刺法目标结构：穿破肋间内膜，到达横突下缺点：朝向中线穿刺，有盲区，肩胛间区不易操作，不易置管优点：平面内穿刺角度小，穿刺针清楚用于：低位胸段椎旁目标结构：穿破肋间内膜或肋横突韧带，到达肋间内膜和肋间最内肌之间缺点：穿刺角度大，针道消失困难优点：肩胛间区可操作，易于鉴别节段用于：低位和高位椎旁体会横突平面-横切面扫描穿刺法肋间平面-矢状面扫描穿刺法目标56横突平面-横切面扫描横突平面-横切面扫描57肋间平面-矢状面扫描肋间平面-矢状面扫描58节段的鉴别：12Rib节段的鉴别：12Rib590.5%Ropivacaine20ml单次平面0.5%Ropivacaine20ml单次平面60连续vs单次(Eason和Wyatt法)Catala,E.etal.,JCardiothoracVascAnesth.1996;10(5):586-8.连续vs单次(Eason和Wyatt法)Catala,61单次能达到什么效果Hill,S.E.etal.,Anesthesiology.2006;104(5):1047-53单次能达到什么效果Hill,S.E.etal.,A62单次能达到什么效果0.5%Ropivacaine30mL单次能达到什么效果0.5%Ropivacaine3063浓度和连续阻滞范围0.5%罗哌卡因20ml切皮前+20ml手术结束白色：0.2%罗哌卡因组黑色：0.5%罗哌卡因组6ml/h连续阻滞Yoshida,T.etal.,Anaesthesia.2014;69(3):231-9浓度和连续阻滞范围0.5%罗哌卡因20ml切皮前+20ml手64肝右叶切除术后镇痛的问题静脉内阿片为主镇痛的问题：镇痛效果不佳，药物代谢影响，呼吸抑制硬膜外镇痛的风险：肝叶切除术后凝血功能不良（70%术后第一天PT延长），交感阻滞肝血流增加，输血风险增加，输液量增加，（TzimasP,etal.,Anaesthesia.2013;68:628–635）PVB的可行性：病例报告研究PVB用于两例肝右叶切除术（Ho,A.M.etal.,BrJAnaesth.2004;93(3):458-61）肝右叶切除术后镇痛的问题静脉内阿片为主镇痛的问题：镇痛效果不65PVB在肝胆手术应用胆囊切除术后镇痛GieseckeK,HambergerB,JarnbergPO,KlingstedtC.Paravertebralblockduringcholecystectomy:effectsoncirculatoryandhormonalresponses.BrJAnaesth1988;61:652-656KumarCM.Paravertebralblockforpost-cholecystectomypainrelief.BrJAnaesth1989;63:129.NajaMZ,ZiadeMF,LonnqvistPA.Generalanaesthesiacombinedwithbilateralparavertebralblockade(T5-6)vs.generalanaesthesiaforlaparoscopiccholecystectomy:aprospective,randomizedclinicaltrial.EurJAnaesthesiol2004;21:489-495肝癌射频消融CulpWC,PayneMN,MontgomeryML.Thoracicparavertebralblockforanalgesiafollowinglivermassradiofrequencyablation.BrJRadiol2008;81:e23-25.经皮胆道穿刺引流CulpWC,McCowanTC,DeValdenebroM,etal.Paravertebralblock:animprovedmethodofpaincontrolinpercutaneoustranshepaticbiliarydrainage.CardiovascInterventRadiol2006;29:1015-1021肝区创伤痛HallH,LeachA.Paravertebralblockinthemanagementoflivercapsulepainafterblunttrauma.BrJAnaesth1999;83:819-821.胆道内扩张引起的疼痛CulpWC,Jr.,CulpWC.Thoracicparavertebralblockforpercutaneoustranshepaticbiliarydrainage.JVascIntervRadiol2005;16:1397-1400.PVB在肝胆手术应用胆囊切除术后镇痛66椎旁阻滞临床应用ppt课件67PVB用于肝右叶切除的解剖基础右肋下皮肤感觉神经纤维：发自T5到T11（√）肝脏交感神经纤维：来自双侧T7到T11交感神经，支配肝脏包膜和肝内血管（BerthoudHR.AnatRecADiscovMolCellEvolBiol2004;280:827-835）（√）副交感纤维：自迷走神经（×）PVB用于肝右叶切除的解剖基础右肋下皮肤感觉神经纤维：发自T68椎旁阻滞临床应用ppt课件69一般资料一般资料70舒芬太尼用量和PCA按压次数舒芬太尼用量和PCA按压次数71静息和咳嗽时疼痛评分静息和咳嗽时疼痛评分72全凭椎旁阻滞经皮肾镜全凭椎旁阻滞经皮肾镜73躯体痛：经10肋间、11肋间、肋缘下建立碎石通道内脏痛：PVB用于PCNL的解剖基础Miller’sAnesthesia.Philadelphia:ChurchillLiving