股神經(jīng)髂筋膜隱神經(jīng)蔣嘉學(xué)習(xí)教案

1、會(huì)計(jì)學(xué)1股神經(jīng)股神經(jīng)(shnjng)髂筋膜隱神經(jīng)髂筋膜隱神經(jīng)(shnjng)蔣嘉蔣嘉第一頁(yè)，共35頁(yè)。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第1頁(yè)/共34頁(yè)第二頁(yè)，共35頁(yè)。Primary outcomes:(1) acute postoperati

2、ve pain (during rest and movement)(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 with

3、drawalTerkawi 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第2頁(yè)/共34頁(yè)第三頁(yè)，共35頁(yè)。與與PCAPCA比較比較(bjio)(bjio)(A) Overall pain scores in the first 72 h duringrest(B) ove

4、rall pain scores in the first 72 h during movement,(C) overall 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 T

5、rials.Anesthesiology 2017; 126:923-37第3頁(yè)/共34頁(yè)第四頁(yè)，共35頁(yè)。Ranking F/S (6) F/O(6) LP/S (3)FIC (3) PA (2)Ranking on high-quality studiesF/SFICLPPAACBTerkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Tri

6、als. Anesthesiology 2017; 126:923-37第4頁(yè)/共34頁(yè)第五頁(yè)，共35頁(yè)。閉孔神經(jīng)閉孔神經(jīng)(shnjng)(shnjng)股神經(jīng)股神經(jīng)(shnjng)(shnjng)股外側(cè)股外側(cè)(wi c)(wi c)皮神經(jīng)皮神經(jīng)隱神經(jīng)隱神經(jīng)(shnjng)(shnjng)第5頁(yè)/共34頁(yè)第六頁(yè)，共35頁(yè)。阻滯(z zh)的是什么？第6頁(yè)/共34頁(yè)第七頁(yè)，共35頁(yè)。髂筋膜髂筋膜(jn (jn m)m) 外界：髂嵴內(nèi)側(cè)緣 內(nèi)界：小骨盆的界線 向下一直延續(xù) 到股骨小轉(zhuǎn)子(zhun z) 水平 覆蓋腰大肌和 髂肌第7頁(yè)/共34頁(yè)第八頁(yè)，共35頁(yè)。髂筋膜髂筋膜(jn (jn m)m)閉

7、孔神經(jīng)閉孔神經(jīng)(shnjng)(shnjng)與髂肌和髂筋膜并沒(méi)有密切的聯(lián)與髂肌和髂筋膜并沒(méi)有密切的聯(lián)系系閉閉 孔孔 神神 經(jīng)經(jīng)第8頁(yè)/共34頁(yè)第九頁(yè)，共35頁(yè)。Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. Journal of Clinical Anesthesia (20

8、15) 27, 652657腹股溝韌帶腹股溝韌帶(rndi)(rndi)水平水平骶骨骶骨(dg)(dg)水平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第9頁(yè)/共34頁(yè)第十頁(yè)，共35頁(yè)。超聲引導(dǎo)超聲引導(dǎo)(yndo)(yndo)髂筋膜阻髂筋膜阻滯的方法滯的方法第10頁(yè)/共34頁(yè)第十一頁(yè)，共35頁(yè)。腹股溝韌帶腹股溝韌帶(rndi)(rndi)上法上法Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSuprainguinal Fascia Iliaca Technique ProvidesBenefit a

9、s an Analgesic Adjunct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438第11頁(yè)/共34頁(yè)第十二頁(yè)，共35頁(yè)。超聲引導(dǎo)超聲引導(dǎo)(yndo)(yndo)腹股溝韌帶上髂腹股溝韌帶上髂筋膜阻滯筋膜阻滯Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct

10、 for Patients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438第12頁(yè)/共34頁(yè)第十三頁(yè)，共35頁(yè)。如何(rh)提高成功率？第13頁(yè)/共34頁(yè)第十四頁(yè)，共35頁(yè)。股神經(jīng)股神經(jīng)(shnjng)(shnjng)解解剖剖股神經(jīng)股神經(jīng)(shnjng)(shnjng)第14頁(yè)/共34頁(yè)第十五頁(yè)，共35頁(yè)。股神經(jīng)股神經(jīng)(shnjng)(shnjng)超超聲影像聲影像第15頁(yè)/共34頁(yè)第十六頁(yè)，共35頁(yè)。超聲探頭的最佳超聲探頭的最佳(zu (zu ji)ji)位置位置旋股內(nèi)、外側(cè)旋股內(nèi)、外側(cè)(wi c)(wi c)

11、動(dòng)脈動(dòng)脈第16頁(yè)/共34頁(yè)第十七頁(yè)，共35頁(yè)。 旋髂深淺動(dòng)脈 必要(byo)時(shí)用多普勒調(diào)整位置 腹股溝韌帶和 腹橫紋中間位置或許(hux)最佳OGAMI K, MURATA H, SAKAI A, et al. Deep and Superficial Circumflex Iliac Arteries and Their Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017)第17頁(yè)/共34頁(yè)第十八頁(yè)，共35頁(yè)

12、。短軸，平面短軸，平面(pngmin)(pngmin)內(nèi)法內(nèi)法短軸，平面短軸，平面(pngmin)(pngmin)外法外法第18頁(yè)/共34頁(yè)第十九頁(yè)，共35頁(yè)。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第19頁(yè)/共34頁(yè)第二十頁(yè)，共35頁(yè)。隱神經(jīng)部分與神經(jīng)其他部分可能(k

13、nng)存在隔斷平面內(nèi)由外向內(nèi)進(jìn)針，一直到神經(jīng)內(nèi)側(cè)，藥液包繞，神經(jīng)前方置管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第20頁(yè)/共34頁(yè)第二十一頁(yè)，共35頁(yè)。辨認(rèn)辨認(rèn)(binrn)(binrn)不清髂筋不清髂筋膜怎么辦？膜怎么辦？Benoit Fanara, Jean-Lu

14、c 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）第21頁(yè)/共34頁(yè)第二十二頁(yè)，共35頁(yè)。Benoit Fanara, Jean-Luc Christophe, Annie Boil

15、lot, 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(jn m)(jn m)GIPM:85% 髂筋膜(jn m)：68%第22頁(yè)/共34頁(yè)第二十三頁(yè)，共35頁(yè)。闊筋膜張肌闊筋膜張肌 股外側(cè)股外側(cè)(wi c)(wi c)皮神經(jīng)皮神經(jīng)縫匠肌縫匠肌股外側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)(shnjng)(shnjng)阻滯阻滯 支配(zhpi)：大腿前外側(cè) 適應(yīng)證：髖部手術(shù)為主 過(guò)去

16、：髂前上棘內(nèi) 下12cm，皮下 0.51cm 變異大：以解剖標(biāo) 志為基礎(chǔ)的傳統(tǒng)阻 滯技術(shù)不可靠第23頁(yè)/共34頁(yè)第二十四頁(yè)，共35頁(yè)。超聲引導(dǎo)股外側(cè)超聲引導(dǎo)股外側(cè)(wi c)(wi c)皮神皮神經(jīng)阻滯經(jīng)阻滯 高頻(o pn)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(jìn)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?chē)?闊筋膜張肌和縫匠肌之間闊 筋膜下方擴(kuò)散第24頁(yè)/共34頁(yè)第二十五頁(yè)，共35頁(yè)。與收肌管阻滯(z zh)？第25頁(yè)/共34頁(yè)第二十六頁(yè)，共35頁(yè)。隱神經(jīng)隱神經(jīng)(shnjng)(shnjng)阻滯阻滯 股神經(jīng)的最大感覺(jué)支 支配：內(nèi)側(cè)

17、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(bǔ)充 不影響股四頭肌力量(l ling) 局麻藥：低濃度，510ml第26頁(yè)/共34頁(yè)第二十七頁(yè)，共35頁(yè)。隱神經(jīng)隱神經(jīng)(shnjng)(shnjng)走行走行 股 動(dòng) 脈 伴 行 ， 內(nèi) 下 行(xixng) 通過(guò)收肌管，接近膝 蓋穿出 大腿中段：縫降肌深面，與股動(dòng)脈伴行 膝上：縫匠肌和股內(nèi) 肌之間的收肌管內(nèi)， 與股動(dòng)靜脈伴行 膝下：脛骨粗隆表面，與大隱靜脈伴行第27頁(yè)/共34頁(yè)第二十八頁(yè)，共35頁(yè)。隱神經(jīng)阻滯隱神經(jīng)阻滯(z zh)(z zh)入路入路Subsartorial plexus bl

18、ockSubsartorial plexus block（大腿中段）大腿中段） Adductor Canal Adductor Canal blockblock（大腿遠(yuǎn)端（大腿遠(yuǎn)端/ /收肌管）收肌管） Subcoutaneous infiltration Subcoutaneous infiltration blockblock（小腿近端）（小腿近端）第28頁(yè)/共34頁(yè)第二十九頁(yè)，共35頁(yè)。收肌管收肌管收肌肌腱(jjin)鍵膜管狀間隙構(gòu)成：股內(nèi)側(cè)肌、縫匠肌、長(zhǎng)收肌和大收肌近端：股三角(snjio)頂點(diǎn)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(dòng)脈、股靜 脈第29頁(yè)/共34頁(yè)第三十頁(yè)，共35頁(yè)。第30頁(yè)/共34頁(yè)第三十一頁(yè)，共35頁(yè)。起點(diǎn)：股三角（倒）頂點(diǎn)，縫匠肌與長(zhǎng)收肌內(nèi) 側(cè)緣相交處終點(diǎn)：股動(dòng)脈(dngmi)偏離縫匠肌，進(jìn)入股內(nèi)側(cè)肌和大 收肌之間（收肌腱裂孔）S：縫匠肌VM：股內(nèi)側(cè)肌AL：長(zhǎng)收肌AM：大收肌Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245第31頁(yè)/共34頁(yè)第三十二頁(yè)，共35頁(yè)。vastoadductor membran