股神經(jīng)髂筋膜隱神經(jīng)蔣嘉

1、1會計學(xué)股神經(jīng)髂筋膜隱神經(jīng)蔣嘉股神經(jīng)髂筋膜隱神經(jīng)蔣嘉Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文庫文檔分享Primary outcomes:(1) acute postoperative pain (during rest and movement)

2、(2) postoperative opioid consumption(3) quality of early postoperative rehabilitation (functional assessments)Secondary outcomes:postoperative complications (e.g., nausea, vomiting, falls), duration of hospitalization, blood loss, procedure failure, and patient withdrawalTerkawi AS, Mavridis D, Sess

3、ler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文庫文檔分享與與PCA比較比較(A ) Overall pain scores in the first 72 h duringrest(B) overall pain scores in the first 72 h during movement,(C) ov

4、erall opioid consumption in the first 72 h(D) overall range on motion in the first 72 h.Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials.Anesthesiology 2017; 126:923-37牛牛文庫文檔分享Ranking F/S

5、(6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPP AACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文庫文檔分享閉孔神經(jīng)閉孔神經(jīng)股神經(jīng)股神經(jīng)股外側(cè)皮神經(jīng)股

6、外側(cè)皮神經(jīng)隱神經(jīng)隱神經(jīng)牛牛文庫文檔分享阻滯的是什么？牛牛文庫文檔分享髂髂筋膜筋膜 外界：髂嵴內(nèi)外界：髂嵴內(nèi)側(cè)緣側(cè)緣 內(nèi)界：小骨盆內(nèi)界：小骨盆的的界線界線 向下一直延續(xù)向下一直延續(xù) 到股骨小轉(zhuǎn)子到股骨小轉(zhuǎn)子 水平水平 覆蓋腰大肌和覆蓋腰大肌和 髂肌髂肌牛牛文庫文檔分享髂髂筋膜筋膜閉孔神經(jīng)與髂肌和髂筋膜并沒有密切的聯(lián)系閉孔神經(jīng)與髂肌和髂筋膜并沒有密切的聯(lián)系閉閉 孔孔 神神 經(jīng)經(jīng)牛牛文庫文檔分享Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the in

7、guinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (2015) 27, 652657腹股溝韌帶水平腹股溝韌帶水平骶骨水平骶骨水平冠狀位冠狀位腹股溝韌帶水平髂筋膜阻滯腹股溝韌帶水平髂筋膜阻滯牛牛文庫文檔分享超超聲引聲引導(dǎo)導(dǎo)髂筋髂筋膜膜阻滯阻滯的的方方法法牛牛文庫文檔分享腹股溝韌帶上法腹股溝韌帶上法Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSupr

8、ainguinal Fascia Iliaca Technique ProvidesBenefit as an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438牛牛文庫文檔分享超超聲引聲引導(dǎo)導(dǎo)腹股腹股溝溝韌帶韌帶上上髂筋髂筋膜膜阻阻滯滯Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Ben

9、efit as an Analgesic Adjunct for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438牛牛文庫文檔分享如何提高成功率？牛牛文庫文檔分享股神經(jīng)解剖股神經(jīng)解剖股神經(jīng)股神經(jīng)牛牛文庫文檔分享股股神神經(jīng)經(jīng)超超聲影像聲影像牛牛文庫文檔分享超超聲聲探頭探頭的的最佳最佳位置位置旋股內(nèi)、外側(cè)動脈旋股內(nèi)、外側(cè)動脈牛牛文庫文檔分享 旋髂深淺動脈 必要時用多普勒調(diào)整位置 腹股溝韌帶和 腹橫紋中間位置或許最佳OGAMI K, MURATA H, SAKAI A, et al. Deep and

10、Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017)牛牛文庫文檔分享短軸，平面內(nèi)法短軸，平面內(nèi)法短軸，平面外法短軸，平面外法牛牛文庫文檔分享Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle t

11、ip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329牛牛文庫文檔分享n，Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329牛牛文庫文檔分享辨

12、辨認(rèn)不認(rèn)不清清髂筋髂筋膜膜怎么怎么辦辦？Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329GIPM：髂腰肌凹槽髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）牛牛文庫文檔分享Benoit Fanara, Je

13、an-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. Anobservational study. Eur J Anaesthesiol 2014; 31:2329髂筋膜髂筋膜GIPM:85% 髂筋膜：68%牛牛文庫文檔分享闊筋膜張肌闊筋膜張肌 股外側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)縫匠肌縫匠肌股股外側(cè)外側(cè)皮皮神經(jīng)神經(jīng)阻阻滯滯 支配：大腿前外側(cè) 適應(yīng)證：髖部手術(shù)為主 過去：髂前上棘內(nèi) 下12cm，皮下 0.51cm 變異大：以解剖標(biāo) 志為基

14、礎(chǔ)的傳統(tǒng)阻 滯技術(shù)不可靠牛牛文庫文檔分享超超聲聲引導(dǎo)引導(dǎo)股股外側(cè)外側(cè)皮皮神經(jīng)神經(jīng)阻滯阻滯 高頻探頭 掃描方式：闊筋膜張肌和縫匠肌 超聲影像：低回聲橢圓形（此處可能已經(jīng)分支） 進針路徑：平面內(nèi)或平面外 局麻藥：5ml 目標(biāo)：局麻藥在神經(jīng)周圍或 闊筋膜張肌和縫匠肌之間闊 筋膜下方擴散牛牛文庫文檔分享與收肌管阻滯？牛牛文庫文檔分享隱隱神經(jīng)神經(jīng)阻阻滯滯 股神經(jīng)的最大感覺支 支配：內(nèi)側(cè)膝關(guān)節(jié)、 髕骨下方、小腿內(nèi)側(cè) 和足內(nèi)側(cè)緣的皮膚 適應(yīng)證：膝關(guān)節(jié)手術(shù)、大隱靜脈手術(shù)、坐 骨神經(jīng)阻滯的補充 不影響股四頭肌力量 局麻藥：低濃度，510ml牛牛文庫文檔分享隱隱神經(jīng)神經(jīng)走走行行 股動脈伴行，內(nèi)下行 通過收肌管，接

15、近膝 蓋穿出 大腿中段：縫降肌深面，與股動脈伴行 膝上：縫匠肌和股內(nèi) 肌之間的收肌管內(nèi)， 與股動靜脈伴行 膝下：脛骨粗隆表面，與大隱靜脈伴行牛牛文庫文檔分享隱隱神經(jīng)神經(jīng)阻阻滯入滯入路路Subsartorial plexus block（大腿中段） Adductor Canal block（大腿遠(yuǎn)端/收肌管） Subcoutaneous infiltration block（小腿近端）牛牛文庫文檔分享牛牛文庫文檔分享收收肌肌管管收肌肌腱鍵膜管狀間隙構(gòu)成：股內(nèi)側(cè)肌、縫匠肌、長收肌和大收肌近端：股三角頂點遠(yuǎn)端：收肌管裂孔表面：股內(nèi)收膜內(nèi)容：股神經(jīng)的股內(nèi)側(cè)肌支、隱神經(jīng)、股中間皮神經(jīng)、股動脈、股靜 脈牛

16、牛文庫文檔分享牛牛文庫文檔分享起點：股三角（倒）頂點，縫匠肌與長收肌內(nèi) 側(cè)緣相交處終點：股動脈偏離縫匠肌，進入股內(nèi)側(cè)肌和大 收肌之間（收肌腱裂孔）S：縫匠：縫匠肌肌VM：股內(nèi)側(cè)：股內(nèi)側(cè)肌肌AL：長收：長收肌肌AM：大收?。捍笫占ong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245牛牛文庫文檔分享vastoadductor membraneWong WY, et al. Defining the Location of the

17、 Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245牛牛文庫文檔分享小結(jié)小結(jié)髂筋膜阻滯： 阻滯：股神經(jīng)+股外側(cè)皮神經(jīng) 腹股溝上髂筋膜阻滯（更佳）：髂前上棘、髂肌和腹橫肌 腹股溝下髂筋膜阻滯：縫匠肌和髂肌 股神經(jīng) 一般：股動脈和髂筋膜 特殊：GIPM旁結(jié)構(gòu) 外側(cè)進針平面內(nèi)法、藥液包繞、神經(jīng)前方置管 隱神經(jīng) 收肌管水平最佳：縫匠肌和股外側(cè)肌膝關(guān)節(jié)置換：股神經(jīng)聯(lián)合坐骨神經(jīng)阻滯最佳牛牛文庫文檔分享牛牛文庫文檔分享Ranking F/S (6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPP AACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37牛牛文庫文檔分享髂髂筋膜筋膜 外界：髂嵴內(nèi)外界：髂嵴內(nèi)側(cè)緣側(cè)緣 內(nèi)界：小骨盆內(nèi)界：小骨盆的的界線界線 向下一直延續(xù)向下一直延續(xù) 到