連續(xù)外周神經(jīng)阻滯精選課件

1、連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件術(shù)后鎮(zhèn)痛（PCNA）對血流動力學(xué)影響小，無需嚴(yán)密監(jiān)測，減少惡心、嘔吐、皮膚瘙癢、尿潴留，以及對凝血機(jī)制異常病人的擔(dān)憂。外周神經(jīng)阻滯可有效阻止疼痛刺激的傳入，防止中樞敏化。對運(yùn)動疼痛效果好，早期下床鍛煉?？尚凶?，可帶回家。術(shù)后鎮(zhèn)痛（PCNA）疼痛治療骨折的術(shù)前疼痛、神經(jīng)病理性疼痛、癌性疼痛等疼痛治療 連續(xù)神經(jīng)阻滯用藥手術(shù)麻醉： 成人：0.5羅哌卡因 初始劑量：0.5ml/kg 最大量30ml 小兒： 0.375羅哌卡因 初始劑量： 0.5ml/kg 最大量20ml 連續(xù)神經(jīng)阻滯用藥手術(shù)麻醉： 連續(xù)神經(jīng)阻滯用藥術(shù)后鎮(zhèn)痛與疼痛治療： 成人：0.2羅哌卡

2、因 小兒：0. 125羅哌卡因 PCNA：負(fù)荷劑量：5ml 輸注速率：2ml/h 單次劑量：0.5ml 鎖定時間：15min 連續(xù)神經(jīng)阻滯用藥術(shù)后鎮(zhèn)痛與疼痛治療：主要內(nèi)容連續(xù)肌間溝臂叢神經(jīng)阻滯連續(xù)股神經(jīng)阻滯連續(xù)髂筋膜間隙阻滯主要內(nèi)容連續(xù)肌間溝臂叢神經(jīng)阻滯一、連續(xù)肌間溝臂叢神經(jīng)阻滯一、連續(xù)肌間溝臂叢神經(jīng)阻滯臂叢神經(jīng)解剖分布臂叢神經(jīng)解剖分布C5腋神經(jīng)三角肌肩外展 C6肌皮神經(jīng)肱二頭肌肘屈曲 C7橈神經(jīng)伸肌群肩肘腕伸 C8 正中神經(jīng)屈肌群腕指屈 T1 尺神經(jīng)手內(nèi)肌拇對掌小指屈C5腋神經(jīng)三角肌肩外展腋N上臂內(nèi)側(cè)皮N和肋間臂前臂內(nèi)側(cè)皮N橈N尺N前臂外側(cè)皮N(肌皮N)正中N腋N上臂內(nèi)側(cè)皮N和肋間臂前臂內(nèi)側(cè)

3、皮N橈N尺N前臂外側(cè)皮N(連續(xù)肌間溝臂叢神經(jīng)阻滯應(yīng)用上肢橈側(cè)部、肩部和鎖骨（C4）的手術(shù)或鎮(zhèn)痛。年輕較瘦患者的尺側(cè)（T1）手術(shù)也可進(jìn)行，但需要的容積要足夠大，起效相對較慢。連續(xù)肌間溝臂叢神經(jīng)阻滯應(yīng)用上肢橈側(cè)部、肩部和鎖骨（C4）的手連續(xù)肌間溝臂叢穿刺技術(shù)穿刺點(diǎn)定位第一條線：從胸鎖乳突肌的起點(diǎn)到胸鎖乳突肌的胸骨頭第二條：從胸鎖乳突肌的起點(diǎn)到胸鎖乳突肌的鎖骨頭第三條：沿肌間溝向上第四條：環(huán)狀軟骨的水平線第三第四的交點(diǎn)向上1cm即進(jìn)針點(diǎn)連續(xù)肌間溝臂叢穿刺技術(shù)穿刺點(diǎn)定位連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件 患者仰臥位，頭偏向健側(cè)，患肢垂直貼身體一側(cè)。使用連續(xù)臂叢神經(jīng)阻滯套件，借助神經(jīng)刺激儀

4、尋找臂叢神經(jīng)，刺激儀起始強(qiáng)度為1.2mA，引發(fā)肱三、二頭肌或三角肌抽動時，將刺激強(qiáng)度減至0.3mA，仍有肌肉抽動時，回抽無血注藥置管。 患者仰臥位，頭偏向健側(cè)，患肢垂直貼身體一側(cè)。連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件 連續(xù)肌間溝臂叢神經(jīng)阻滯操作技巧頭側(cè)向45度為宜沿肌間溝平行劃線局麻充分且需切皮后進(jìn)針進(jìn)針角度不宜過大（15度），與床面平行引出肌肉收縮后將扶持針的手松開，利于觀察針的位置和角度置管忌粗暴，防止導(dǎo)管打折導(dǎo)管置入神經(jīng)干間45cm。 連續(xù)肌間溝臂叢神經(jīng)阻滯操作技巧頭側(cè)向45度為宜 二、連續(xù)股神經(jīng)阻滯 二、連續(xù)股神經(jīng)阻滯股神經(jīng)解剖起自L24，在腹股溝韌

5、帶下方進(jìn)入股三角，并分出前支和后支。后支的感覺纖維終支是隱神經(jīng)。股神經(jīng)解剖起自L24，在腹股溝韌帶下方進(jìn)入股三角，并分出前連續(xù)外周神經(jīng)阻滯精選課件股神經(jīng)分布混合神經(jīng) 感覺神經(jīng)：大腿前面、膝關(guān)節(jié)、內(nèi)踝以上小腿內(nèi)側(cè)面皮膚。 運(yùn)動神經(jīng)：股四頭肌、縫匠肌。股外側(cè)皮神經(jīng)股神經(jīng)前皮支隱神經(jīng)坐骨神經(jīng)股神經(jīng)分布混合神經(jīng)股外側(cè)皮神經(jīng)股神經(jīng)前皮支隱神經(jīng)坐骨神經(jīng)連續(xù)股神經(jīng)阻滯的應(yīng)用膝部、大腿中段的手術(shù)大腿前面軟組織探查和裂傷縫合術(shù)及膝關(guān)節(jié)鏡檢查。股骨、髕骨、膝關(guān)節(jié)、踝關(guān)節(jié)術(shù)前術(shù)后疼痛治療連續(xù)股神經(jīng)阻滯的應(yīng)用膝部、大腿中段的手術(shù) 全膝置換（TKA） Effect of continuous femoral nerve

6、 block in analgesia and the early rehabilitation 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.

7、 全膝置換（TKA） Comparison of the influences of 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 int

8、raoperative hemodynamics than PCIA, with better pain relief,faster postoperative knee rehabilitation,less side effects,and higher patient satisfaction. Comparison of the influence股骨干骨折 Low cost continuous femoral nerve block for relief of acute severe cancer related pain due to pathological fracture

9、 femur. Koshy RC al. Indian J Palliat Care. 2010 Sep;16(3):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

10、-related pain and improving the level of well being.股骨干骨折 連續(xù)股神經(jīng)阻滯技術(shù)采用長50mm的絕緣型穿刺針，腹股溝韌帶下方2.5cm、股動脈搏動點(diǎn)外側(cè)12cm為穿刺點(diǎn)，以與皮膚成40度角向頭端刺入穿刺針。通過神經(jīng)刺激器在0.3mA仍能誘發(fā)出髕骨上移運(yùn)動時，回抽無血，注藥置管。 連續(xù)股神經(jīng)阻滯技術(shù)采用長50mm的絕緣型穿刺針，腹股溝韌帶連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件 連續(xù)股神經(jīng)阻滯操作技巧清晰畫出腹股溝韌帶、股動脈和縫匠肌內(nèi)側(cè)緣構(gòu)成的三角進(jìn)針方向與股動脈平行，進(jìn)針點(diǎn)不能離腹股溝韌帶太遠(yuǎn)，縫匠肌或最近皺褶與腹股溝韌帶之間進(jìn)針

11、角度約3040度引出肌肉收縮應(yīng)以膝蓋運(yùn)動為主置管約4cm左右 連續(xù)股神經(jīng)阻滯操作技巧清晰畫出腹股溝韌帶、股動脈和縫匠肌三、連續(xù)髂筋膜間隙阻滯三、連續(xù)髂筋膜間隙阻滯 髂筋膜間隙解剖前界為腹股溝韌帶，后界為髂骨，內(nèi)側(cè)為髂恥弓。內(nèi)有髂腰肌、股外側(cè)皮神經(jīng)及股神經(jīng)通過。 髂筋膜間隙解剖前界為腹股溝韌帶，后界為髂骨，內(nèi)側(cè)為髂恥弓連續(xù)外周神經(jīng)阻滯精選課件 連續(xù)髂筋膜間隙阻滯應(yīng)用髖關(guān)節(jié)、股骨頸、股骨干、膝關(guān)節(jié)術(shù)前急性疼痛控制和術(shù)后鎮(zhèn)痛 連續(xù)髂筋膜間隙阻滯應(yīng)用髖關(guān)節(jié)、股骨頸、股骨干、膝關(guān)節(jié)術(shù)前髖部骨折 Fascia iliaca compartment blockade for acute pain contr

12、ol in hip fracture patients: a randomized, placebo-controlled trial.Foss NB al. Conclusion: Pain relief was superior at all times 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 procedur

13、e that also may reduce opioid side effects in this fragile, elderly group of patients.髖部骨折A Continuous Infusion Fascia Iliaca Compartment Block in Hip Fracture Patients: A Pilot Study 42位髖部骨折患者（5399歲間）初始劑量60ml 0.5%羅哌卡因，0.2%持續(xù)輸注，10ml/h。 與2010年平均VAS比，其術(shù)后第0天4.1vs1.7,第一天2.9vs1.4，平均住院天數(shù)5.9vs4.8. J Clin M

14、ed Res. 2012 February; 4(1): 4548. Elizabeth Dulaney-Cripe,a,f Scott Hadaway,b Ryan Bauman,c Cathy Trame et al.A Continuous Infusion Fascia IEffect of fascia iliaca compartment block with ropivacaine on early analgesia in children with development dislocation of the hip received salter arthroplasty

15、treatment 0 .2%羅哌卡因1ml/kg,最大量30ml，觀察術(shù)后1、4、24h VAS 安全、有效、持久、簡便 Wang G, Wang XL, Li SZ. Zhonghua Yi Xue Za Zhi. 2011 Oct 11;91(37):2638-40.Effect of fascia iliaca compar交叉韌帶、股骨干手術(shù) Comparison of continuous 3-in-1 and fascia Iliaca compartment blocks for postoperative analgesia: feasibility, catheter mi

16、gration, distribution of sensory block, and analgesic efficacy. The authors conclude that a catheter for continuous lumbar plexus block can be placed more quickly and at lesser cost using the fascia iliaca technique than the perivascular technique with equivalent postoperative analgesic efficacy. Mo

17、rau D al.交叉韌帶、股骨干手術(shù)膝關(guān)節(jié)置換 Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: a case report and description of a catheter technique.SR al.Anesth. 1997 Jul-Aug;22(4):372-7. Conclusion: Lumbar plexus blockade with continuous local anesthetic infusio

18、n via the fascia iliaca compartment is an effective means of providing postoperative analgesia after total knee arthroplasty when epidural analgesia is contraindicated.膝關(guān)節(jié)置換 連續(xù)髂筋膜間隙阻滯技術(shù) 沿股動脈、腹股溝韌帶、縫匠肌畫三條線，圍成一個三角形，在其外上角內(nèi)腹股溝韌帶下1.52cm距髂前上棘5cm處為穿刺點(diǎn)，局麻后將穿刺針以與皮膚成40度并指向該角的方向刺入，穿過闊筋膜出現(xiàn)第一次落空感，繼續(xù)深入通過其下方的髂筋膜時可有第二次落空感，然后注藥置管。 連續(xù)髂筋膜間隙阻滯技術(shù) 沿股動脈、腹股溝韌帶、縫連續(xù)外周神經(jīng)阻滯精選課件連續(xù)外周神經(jīng)阻滯精選課件髂筋膜腔隙解剖髂筋膜腔隙解剖