神经阻滞定位方法进展

神经阻滞定位方法进展Advance

in

Locatliza

ion

of

Nerve

Block阻滞成功率高

High

successful

ratio

安全性高

More

safety应激反应轻

Less

stress

response

降低深静脉血栓形成

Avoid

DVT恢复快

Fast

recovery生理机能稳定

stable

physical

status

病人欢迎

Welcomed

by

patients费用低

Low

cost外周神经阻滞的优点 Advantage

of

peripheral

nerve

block1

.神经阻滞定位方法Localization

methods

ofnerve

block2

.

神经刺激器与神经刺激针Nerve

s

tim

ul

at

or

and

needles3

.

下肢神经阻滞在老年重危病人中的应用Application

oflower

extremity

nerve

block

in

elderly

severe

patients内容提要

Contents解剖定位

Anatomylocation异感定位

Sensorylocation超声和放射学定位Ultrasound

and一、神经阻滞的定位方法

I.

Location

methodsofnerveblock神经解剖变异，神经分布不规则，神经不

是集中某个单一的点，解剖标记不明确或

不易辨认，因此，临床操作难度较大。Variation

and

decentralization

of

nerves,

irregular

distribution

,ambiguity

ofanatomy

landmarks,it

’

s

difficult

to

operate

in

clinic

Anatomy

location（一）解剖定位n

是否需要寻找异感尚有争议Debate

offinding

special

sensory找到“

异感”

，麻醉效果并非一定完善Unsatisfied

anesthetic

effects

w

ith

sensory

location神经分布与病人状态，可能无法引出异感Sensation

may

be

not

found

in

some

patients寻找异感可能损伤神经Maybe

damage

nerves（二）异感定位

Sensory

location（三）超声和放射学定位

Ultrasound

and

radiological

location优点

Advantages提高神经阻滞的成功率Increase

the

successful

rate

of

nerve

block观察局麻药注射后的扩散规律Observethe

distribution

of

local

anesthetics避免血管内注射的发生Avoid

intravascular

injection减少麻醉药用量Reduce

the

dosage

ofanesthetics需要特殊设备和人员技术培训Need

equipments

andtraining增加了操作步骤More

operation

steps仪器体积较大，价格昂贵Largesize

and

ex

pensive

equipment缺点

Disadvantages临床应用的超声频率为2.5~20MHzClinicalultrasoundwith

2.5~20MHz频率越高空间分辨率越好，但穿透性越差；反之亦然Higher

frequencywithbetter

spacedifferentiationratiobut

lesspenetr

ability;

vicever

sa浅表神经可用＞10MHz，而深部神经需用＜7.5MHz

，超声

定位深部神经应与局部解剖学相结合>10MHzfrequencyused

in

superficialnervesand＜7.5MHzin

deep

ones,ultrasound

shouldbeusedwithtopographyespeciallyin

deep

nerveblock

Basic

principles

of

Ultrasound超声的基本原理超声引导下神经阻滞Nerveblockguided

byultrasound1、Mid-axisobliquesurface

of

inter

scalenegroove2

、Supra-claviclecoronalobliquesur

face3

、Sub-claviclesagittalsurface4、transect

of

axilla5、transect

of

mid-humerusPerlasA,et

al.Anesthesiology

,2003;99:429.1、肌间沟中轴斜面2、锁骨上冠状斜面3、锁骨下矢状面4、腋部横断面5

、肱骨中部横断面超声探头的位置

Location

of

ultr

asoundprobeHad

zic

A,et

al.Anesthesiology

,2003;98:969.超声定位穿刺操作时，一手持探头，一手握绝缘针Onehandwith

probe,another

with

insulatedneedleCH为胸锁乳突肌锁骨头，SH

为胸骨头CH=claviclehead

of

ster

nocleidomastoid

,

SH=stern

alhead肌间沟经路定位

Interscalenelocation锁骨上经路定位

Supraclaviclelocation腋路定位

AxillarylocationInterscalene

BlockTransverse

sonogram

in

the

interscalene

region

showing

brachial

plexus

as

hypoecho

ic

nodules

(

arrows)interposed

betw

een

scalenus

anterior

(SAM

)

and

medi

us

(SMM)

m

uscles,

beneath

the

posterior

margin

ofthe

ster

nocleidomastoid

m

uscle

(SCM

)

.

CA,ca

rotid

artery;

IJ

,inter

naljugular

vein.Interscalene

BlockTransverse

sonogram

ofthe

needle

(arrow

s)

in

contact

w

ith

the

nerve

trunks

in

the

interscalene

groove

.Interscalene

BlockTransverse

sonogram

show

ing

local

anestheticspread

and

distention

(

arrows)

in

the

interscalene

groove

.Transverse

sonogram

in

the

infraclav

icular

region

showing

brachial

plexus

as

hypoecho

ic

nodules

(

Nwith

arrow)

.AA

axillary

artery;AVaxillaryvein;

PM

aMpectoralis

major

muscle

;P

MiM

pectoralis

minor

m

uscle.InfraclavicularBlock腋部径路超声图中针头位置（箭头所示）Needlepositionofaxillarynerveblock

in

sonogram

(arrows)AA:腋动脉

axillaryarteryHadzicA

,etal

.Anesthesiology

,2003;98:969.Axillary

BlockTransverse

so

nog

ram

in

the

m

id

hu

me

ral

region

showingtwo

term

inal

branches

ofthe

b

rachial

plexus

as

hypoecho

ic

nodu

les

(

N

with

arrows)

.

BAbrachial

artery

;

BMbicepsm

uscle;

H

humerus;TMtriceps

m

usc

le.A

12

-MHz

ultrasound

image

demonstrating

themuscul

ocuta

neo

us

nerve

and

surrounding

structures

.

B,bone

(

humerus);

Bi

,

bicepsmuscle;CB,

coraco

brachialis

muscle;A,

axillary

artery;

v

,

axilla

ryvein

.Themuscul

ocuta

neo

usnerve

is

found

in

thej

uncture

between

the

biceps

andcoraco

brachia

lis

muscles

.The

nerve,asdoes

the

mediannerve,a

ppears

as

aconstellation

of

hypodense

(

dar

k)

grapelikestructures

with

hyperecho

ic(bright)

rings

.

Ultrasound

-Guide

d

M

us

culo

cutaneous

Nerve

Block

•

Spence,Sites,and

Beach

1

99Muscul

ocutaneuousNerve

Block(四)神经刺激器定位Location

w

ith

nerve

s

tim

ul

at

or1.

周围神经刺激器Peripheral

nerve

s

tim

ul

at

or刺激后肌肉反应的指标客观明确Objective

and

correct

signsafterstimulation用于无法准确说明异感或定位困难病人(小儿、老年、不合作用及神智不清的病人)Used

in

pediatrics

,elderly,disoperative

and

unconscious

patients最大程度减少神经损伤Reduce

nerve

damages神经阻滞成功率较高High

successful

rate

Advantages神经刺激器的优点病人感觉触电、痛苦Electr

ic

shock

sensory

and

discomfortfeeling血管内意外注药危险Danger

in

intra-vesse

l

infusion麻醉效果难以保证Poora

nalgesia

sometime定位无客观指标No

objectivesigns成功率相对低Compa

rative

low

er

success

ratio病人感觉舒适Feel

comfort血管内意外注药少Avoid

intra-vessel

infusion麻醉镇痛效果满意Better

analgesia定位指标明确Precise

&

objective

location成功率高，并发症少Higher

success

ratio

&

ra

re

complication神经刺激器与传统异感定位的对比Comparisonof

nervestimulator

and

traditional

sensorylocation神经刺激器定位Sti

m

ul

at

or

location传统异感定位法Sensory

location世界上第一个神经刺激器

First

nerve

s

tim

ul

at

or

in

the

world1912S

tim

uplex

HNS神经刺激器S

tim

uplex

HNS

stimul

at

or采用全数字显示技术和人性化设计Digital

display

and

personal

design具有两种不同的显示方法(预设电流和实时显示)Tw

o

different

display

(initialcu

rrent

and

display

in

real

time)电流范围在0-1

mA或0-5

mA

，调节精度高Current

ranges

0-1

or

0-5mA

,

p

recise

regu

lation脉冲时间有0

.1、0.3或1

.0

ms三档可调Impu

lse

time

with

0.1

,

0

.3

,

1

.

0ms脉冲频率可设在1,2

HzImpu

lsefreq

uency

1

or

2Hz具有不同报警功能(防止电路故障和低电池量)Different

alarm

fu

nction

(

p

revent

electro

circ

uitdisorder

and

low

battery)

S

tim

uplex

HNS

S

tim

uplex

Dig

RC单人操作Operation

w

ith

single

doctor仅有一个调节按钮Only

has

one

regu

lating

button电流的设置和测量同时进行，没有一个额外的

按钮Setting

and

measuring

simultaneously黄色LED指示每一个脉冲电流Yellow

LED

indicate

every

impulsecurrent如果电流量低于设置值快速闪烁Flashing

when

the

current

below

setting

S

tim

uplex

Dig

RC•

Different

current

and

frequency

with

different

voice•

Changes

in

current,

stimulating

frequency

and

timemake

the

stimulation

more

precise

in

different

nerves•

Special

design

for

single

operation•

Skin

location

before

needle

insertion

which

be

used

in

teaching对不同电流及频率设定了不

同的声音提示,可调电流范

围，刺激频率，刺激时间,

在不同类型神经刺激时可更

为精确。其特殊的设计使操

作者可进行单人操作，在导

针刺入前还能进行体表定位，便于在教学中应用。S

tim

uplex

HN

S

II单人操作装置Device

for

single

operation“Stimulator

pen

”“神经刺激笔

”连续输出电流Continuous

electrical

cu

rrent可调输出电流范围(刻度显示数字)Regulated

current

with

digital

scale

show

ing清晰的电流极性标记Clearcurrent

polarity

marker刺激频率较短Short

stim

ulating

frequency2

.神经刺激器的要求和原理

Request

for

stimul

at

or各种神经刺激器

Nerve

s

tim

ul

at

orsHad

zicA

,etal.Anesthesiology,2003;98:969

.CC

：恒定电流

Con

stant

current

CV：恒定电压

Constant

voltage刺激波形

Stimulating

waves（1

.0mA

，1

k

Ω)升压时间与降压时间比较(1mA)Ascendingand

descending

time(

1mA)Current

maintenance

time稳定的电流输出可以增加操作的准确性，减少病人的创伤Stable

cu

rrent

output

improve

operation

veracity

and

reduce

patients

damages电流持续时间Comparisonof

error

betw

eenoutput

and

initialized

current输出电流与设定电流误差比较voltage

output生物组织阻抗不

同,设定相同电压,

可能引起电流大小

变化,据欧姆定律：

I

＝U/R，阻抗变化

时，为保证输出衡

电流，需调整电Newnerve

stim

ul

at

or

s

could

auto

-regu

late

the

resistance

and

g

uarantee

the

stable

current

while

avoid

overshootvoltageIndividual

body

is

of

different

impedance

which

causes

cu

rrent

changes

u

nderthe

samevoltage

.As

p

rovide

stable

cu

rrent,

supplementaryvoltage

sho

uld

be

given

.It

may

reach

7

0V

and

b

urn

the

patients

.压，阻抗不同，差

异很大，>70V，会造成病人灼热痛

感新型神经刺激器

具有参考电极发生

器,自动调节电阻大

小,保证输出衡定电

流，避免回路电压

过高最大电压输出Maximal

Nerve

block

w

ith

sti

mul

at

or3

.神经刺激器使用方法具体定位操作步骤

Operating

steps

in

details测试神经刺激器性能Test

the

sti

mul

at

or

before

using安置皮肤电极，保证接触良好Settlethe

skin

electrode消毒、局麻，但浅表神经不必过度浸润Sterilization,su

rface

anesthesia将局麻药充满阻滞针，接地导线接电极Fu

lfill

the

block

needle

w

ith

anesthetics

and

connect

the

earthing

electrode开启刺激器，调整参数:脉宽

0

.

1ms

，频率2Hz

，刺激

电流1

.5

mATurn

on

stim

ul

at

or

and

initialize

theparameters穿透皮肤、将穿刺针置入皮下组织Penet

rate

skinand

insert

it

into

subcutaneous

tissue电流1.5mA时引出神经支配的肌肉最大收缩后，减小电流Decrease

the

current

after

muscle

response

induced

by

1

.5

mA电流0.2~0.3mA(0.1ms)还可引出肌肉收缩时表明针头已接

近该神经,

0.1mA时可能损伤神经The

muscle

twitch

remains

at

0

.2

~0

.3

mA(

0

.1

ms)

indicates

the

approach

of

needle

to

nerve

.0

.1

mA

current

may

hurtthe

nerve

.在上述电流下，运动纤维可被0.15ms的脉冲时程选择性的刺激，不影响痛觉纤维、病人舒适，当刺激感觉神经时脉宽

应

0.15ms，患者可感觉到神经支配区域的异感Motor

nerve

may

be

selectivelystimulatedat0

.1

5ms

without

affecting

sensory

nerve

which

makes

patients

comfortable.Increasingtheimpulse

time

over

0

.

15

ms,the

patients

will

have

special

feelingat

block

area

.回抽，注入局麻药2-3ml,肌肉收缩停止Withdraw

before

injection

of

local

anesthetics2-3ml.

Muscle

twitch

w

ill

stopthen

.(

1

)刺激臂丛神经的肌肉运动反应Motor

responses

after

stimulationof

brachial

plexus

nerve外周神经支配肌肉功能FunctionPeriphera

l

n.Dominating

m.腋神经Axilla

ry

n

.三角肌

Delto

id

m

.肩关节处上臂外展

Extension

ofarm肌皮神经M

us

culo

cutaneous

n

.肱二头肌

Biceps

m.

喙肱肌Coracobrachial旋后位屈肘

Supi

nation

and

flex

ion

of

elbow正中神经Median

n

.桡侧腕屈肌

m

.flex

or

carpi

radia

lis拇短屈肌

m

.

flexor

pollic

is

brevis第I~

III指深屈肌I~

III

deep

flexor

m

.

of

finge

rs桡侧腕屈和外展

Flex

ion

a

nd

extension

ofwrist前臂旋前(屈近节指间关节)Pronation

offorear

m

andflex

ion

ofapproximateinterp

harlangeal

joint屈和外展拇指，屈第I~

III

指(屈远节指间关节)Flex

ion

andabduction

ofthum

b,flex

ion

of

I

~III

distal

inter

pharlangea

lBrachial

plexus

nerve

domination臂丛神经运动支配区域j

i

t桡神经

Radial

n

.I肱三头肌

triceps桡侧腕(短)伸肌M.extensor

carpi伸肘

Extension

of

elbow

桡侧腕伸和外展

Extensionand

abd

uction

of

wrist指伸肌

Extensor

of伸手和手背屈

Abductio

n

and

dorsal

flexion

of

handfingers指的伸展

Extension

offingers尺神经Ulna

r

n

.尺侧腕屈肌

Ulna

r

flex

or

of

wrist第IV

~V指伸屈肌IV～V

flex

or

offingers尺侧腕屈和外展

Flexion

and

abduction

ofwrist屈第IV

~V指

Flex

io

n

of

IV

~

V

fingersraa

s

rev

sdibliiMotor

response

after

stim

ulation1

.手腕尺侧偏展Ulna

r

extensio

n

of

wrist2

.掌指关节屈曲Flex

io

n

of

metacarpo

-p

harlan

geal3

.拇指内收

Add

uct

ion

ofthum

b刺激尺神经的运动反应of

ulna

r

nervejo

int应Motor

response

afterstim

ulation

of

radial

nerve1

.手腕背屈Dorsal

flex

io

n

of

wrist2.掌指关节伸展Extension

of

metacarpo

-

p

harlan

gealjoint3

.拇指外展Abduction

ofthu

m

b刺激桡神经的运动反(2)刺激腰丛与坐骨神经的肌肉运动反应Motor

responses

after

stimulationof

lumbar

plexus

and

sciatic

nerve外周神经Periphera

l

n.支配肌肉功能Dominating

m.Function胫神经Tibia

l

n.股二头肌

Femoral

biceps

m.半膜肌

m.semi

me

m

bran

osu

s半腱肌

m.sem

i

tendinosus腓肠肌

m.gast

rocnemii

足母长屈肌

m.flex

orhall

uc

is

longus趾长屈肌

m

.

flexordigitorum

longus屈膝、小腿旋外

flex

ion

of

k

nee

and

lateral

rotation

of

leg屈膝

flexion

of

k

nee伸大腿、屈小腿旋内

Extensionofthigh

,flex

ionand

sup

i

nation

of

leg跖屈

Plant

a

rflex

ion

ofankle

屈趾

Flexion

of

phala

ngesLumbar-sacral

plexus

nervedomination腰骶丛神经运动支配区域闭孔神经Obturator

n髋关节的股内收肌Internal

adduction

m

of

thigh大腿内收Adductthigh股神经Femoral

n

.股四头肌Quadriceps

m.屈髋、伸膝

Flex

ion

of

hip

and

extension

of

k

nee腓总神经CommonPe

roneal

n

.胫前肌

Anterior

tibia

l

m.趾伸肌

Digitoralex

tensor

m

.腓骨肌

Perone

al

m

.足背屈或内翻

Dorsalflex

ion

offoot

or

internal

flex

ion足背的伸、外翻和旋前Extension

,abduction

and

pro

nation

offoot.

腰丛穿刺点Punctur

epointof

lumbar

plexus髂后上棘骶裂孔

Posterior

superioriliacspineSacra

l

hiatus股骨大转子Greater

trochanter坐骨神经穿刺点

Punctur

epointof

sciaticn后路腰丛阻滞,刺激股神经与闭孔神经引起内收肌群和股四头肌收缩,髌骨上下运动Flex

ion

of

internal

add

uct

ion

m

.andquadriceps

and

u

p-and-down

movement

of

patella

can

be

i

nduced

by

stimu

lation

offemoral

and

o

bturator

n

.

in

Lu

mbar

plexusnerve

block

with

posterior

app

roach.刺激针靠近坐骨神经外

侧主要引起腓总神经支

配的肌肉收缩,表现为足

背曲,外展When

the

needle

app

roaches

the

lateral

sciatic

n

.,thecommon

pero

nea

l

n.

isstim

u

lated

and

the

foot

isdorsal

flex

io

n

and

abd

uctionWhen

the

needle

is

near

the

internal

side

of

sciatic

n

.,

the

tibia

l

n

.

is

stimulated

and

the

foot

plant

ar

flex

ion,

eversion

and

flexion

oftoes刺激针靠近坐骨神经内

侧主要引起胫神经支配

的肌肉收缩,表现为足庶

曲,足指内收Sti

mul

at

or

needles4

.神经刺激针外周神经阻滞麻醉PeripheralnerveblockMoore

DC(1965):“

NOparaesthesia

-NOanaesthesia”组织☆

没有异感,就没有麻醉(传统的神经丛阻滞麻醉方法)针斜面不绝缘Non-insulatedinobliquesurface皮肤shin组织tissue神经nervel非绝缘导管N

on-insulatedcanu

amA

绝缘导管

Insulatedcan

ula+1

+2cm无绝缘Non-insulated-2

-1

0642针尖点状不绝缘Non-insulatedonly

intipof

needle针斜面不绝缘Non-insulated

in

oblique

surface无绝缘Non

-insulated.除了针尖其余部分完全绝缘，避免针体对穿刺径路上

不必要的电流刺激Insulatedwithout

the

tip

of

needle

as

to

avoid

unnecessary

stim

ulation针尖离神经越近所需电流减小Lower

cu

rrent

needed

w

hen

approach

thenerve15

斜面针穿透组织容易、损伤小15ºoblique

surface

penetratetissue

easily

w

ith

little

damages穿刺针长度有25mm、50mm、100mm和150mmDifferent

length

of

needle

:25

,5

0,

1

00,

150

mmB/BRAUN

,S

tim

uplexA,

1

5º

s

si型Fo四按人体工学特点

设计的针柄Design

of

needlehandle针尖斜面导电Non-insulated

in

needletipStimuplex®A

needleStimuplex

®

D具有理想的针尖状电极

Ideal

needle

tip

electrode

ofS

tim

uplex

®

D特殊涂层的针杆Special

coat

of

needle

poleStim

uplex®

DStim

uplex®ACanulaforcontinuous

nerveblock导管臂丛阻滞(肌间沟和腋路)Brachial

p

lexus

nerve

block

(interscalene

and

axillary

route)腰肌间隙阻滞Lumbar

p

lexus

nerve

block股神经阻滞Femoral

nerve

block坐骨神经阻滞(Labat法和前径路)Sciatic

nerve

block

(Labat

and

anterior

route)坐骨神经远端阻滞Distal

block

of

sciatic

nerve

5

.导管技术

Can

ul

a

technique穿刺部位感染Infection

of

puncture

site潜在的菌血症，全身感染Latent

bacteremia,general

infection患者拒绝Patient

refusion导管技术禁忌症Contradictions导管脱出

Pro

lapsus

of

canul

a穿刺部位伤口感染

Infection

of

puncture

site导管断裂、打折或套成环

Rupture

or

replicateof

canu

al毒性反应

Toxicity局部血肿

Hemorrhage

edema并发症类型

Complication•Grant等报道228例，24h内置管，无并发症出现No

complication

when

canalize

within

2

4h

in

2

2

8

cases

.(

Grant)Seda等报道597例，局麻药毒性反应17例（2.9%）神经损伤3例（0.5%）

血肿1例In

5

97

cases,

1

7(

2

.9

%)

with

anestheticstoxicity

,3(

0

.5

%)

with

nerve

hurt

and

1

with

ede

maBradley等报道405例，感染1例，血肿1例，神经损伤5例，导管断裂残留

1例Bradley

reports

40

5

patients,

onewith

infection

,one

withedema,

five

with

nerve

block

and

one

with

r

uptureofcan

ula•并发症报道

Reports

ofcomplication注意神经损伤环节:手术体位，止血带应用，外科

损伤,神经牵拉等。Pay

attention

to

protect

nerve,

like

surgical

position

,application

oftourniq

uet

,operation

damage,stretch

of

nerve导管滑脱与移位多由固定和病人不当活动等产生，

在更合适的导管产品诞生前，尚无有效的解决办

法。Surge

and

dislocation

of

canul

a

is

most

caused

by

incorrect

fixation

and

patients

movement•并发症对策

Strategy

of

comp

lication在更合适的导管产品诞生前，尚无有效的解决办

法。局麻药的毒性反应存在着一定的个体差异，除了严

格遵循用药指征外，合理应用辅助药物如肾上腺素，可乐定，阿片类药物等，也是比较可行的方

法。对于解剖、生理的掌握是麻醉医师减少各并发症的

首要措施。影像学定位下神经阻滞的操作可能会减少并发症，

但其优点有待进一步研究。注意损伤环节:手术体位，止血带应用，外科损伤,

神经牵拉等。

导管滑脱与移位多由固定和病人不当活动等产生，

•

并发症对策Application

of

lower

extremity

nerve

block

in

elderly

severe

patients三、下肢神经阻滞在老年重

危病人中的应用2004年3月~2005年3月,109例重危老年患者2004

Mar～

2004

Mar,

109

elderly

severepatients腰丛+后路坐骨神经+股神经阻滞

59例Lumbar

plex

us+sciatic

n(

posterior)

+

femoral

n

.

block,

n=

59腰丛+后路坐骨神经阻滞

50例Lumbar

plex

us+sciatic

n

block,

n

=

50

方法

Methods结果

Results年龄798

(67~92)岁Aged

7

98

(67

~

92)

yr手术种类:动脉转流(87例)

，(股A-胫后A、髂-股A、股-月国A

等)，大隐静脉剥脱术、下肢动脉、静脉取栓、下肢截肢等Operation

:

artery

bypass(

n

=

8

7),

saphenecto

my

,

amputation,etc

.夹杂症：糖尿病、高血压、心脏病(心梗、房颤、心肌缺血、

频发室早、房早、心衰等)，患者有两种以上夹杂症Com

plication

:DM

,HT,heart

disease70%

以上患者麻醉前有抗凝治疗史70%patientswith

anti-coagu

lation

therapy阻滞成功率为100%Success

ratio

=10

0%无局麻药毒性反应和硬膜外阻滞等不良

反应No

toxicity

of

local

anesthetics

or

epi

dural

block手术时间5

2hOperation

duration

:

52

h局部麻醉药用量

Dosage腰丛25~40mlLum

bar

plexus

25

~

40

m

l后路坐骨神经25~4