外周神經(jīng)阻滯

1、lAnesthesia (an-iss-thee-zuh) is medicine to make you comfortable during surgery or a procedure.No painSedationMuscle relaxationWhats Peripheral Nerve Block? A peripheral nerve block is a medical procedure that involves administration of a dose of local anesthetic usually into either your arm, hand,

2、 leg, or ankle region. “Peripheral nerve block is an economical techniques that can be used not only for intraoperative anesthesia but also for perioperative analgesia without any major risks for the patients.”Graf BM, Anaesthesist 2001 May;50(5):312Avoid GA complications Less anesthetic requiredFas

3、ter wake-up/quicker recoveryFaster ambulation, dischargeN/V less commonPost-op pain minimizedAttenuated stress responseDecreased thromboembolic complications Less hemodynamic change尋證疼痛醫(yī)學(xué)尋證疼痛醫(yī)學(xué)(EBPM)的實(shí)際應(yīng)用：的實(shí)際應(yīng)用：Nerve Blocks and Patient Outcomes神經(jīng)阻滯和病人預(yù)后神經(jīng)阻滯和病人預(yù)后:與與PCA/硬膜外麻醉的硬膜外麻醉的比較比較lcompared PCA w

4、ith either continuous femoral/sciatic nerve block or epidural analgesia (Capdevila, Singelyn & Chelly et al). lPain score, side effects, motion & hospital stay. New data from IARS March 20, 2002Complications related to the toxicity of local anesthetics Nerve injury caused by needle trauma or injecte

5、d medications Infection Class 1 Healthy patient, no medical problemsClass 2 Mild systemic diseaseClass 3 Severe systemic disease, but not incapaitatingClass 4 Severe systemic disease that is a constant threat to lifeClass 5 Moribund, not expected to live 24 hours irrespective of operationAn e is add

6、ed to the status number to designate an emergency operation. An organ donnor is usually designate as Class 6 “The higher the ASA physical status classification, the more beneficial it is to use peripheral nerve blocks!”0 0101020203030404050506060% %306060GeneralSpinalPNBPeking Union Medical College

7、Hospital01020304050601234ASA% %General SpinalPNBPeking Union Medical College HospitalPatientAnesthesiologistSurgeon26449181176676SpinalOthersGeneralPNBPeking Union Medical College Hospital* Hadzic A, Vloka JD, Koorn R, Sanborn K, Shih H, Birnbach DJ. The use of regional anesthesia in ambulatory anes

8、thesia practice. Results of a national survey. Anesthesiology 1997; 3A:A22. Requirement of surgical procedureInadequate training in PNBLack of familiarity by surgeons of the benefits of PNBTime pressure from surgeons5761.367.968.670.80 0101020203030404050506060707080801957195719751975198119811990199

9、019971997age“no paresthesia, no anesthesia!”Von PerthesFirst electrical nerve stimulatorDecreased risk of nerve damageIncreased specificityIncreased reliability of the techniqueEasier approachClinical and teaching tools141154231317050100150200250300350199819992000200134%34%26%26%17%17%10%10%7%7%5%5%

10、1%1%0%0%10%10%20%20%30%30%40%40%sciaticlumbar plexuscervical plexusbrachial plexsparavertebralthree-in-oneothersPeking Union Medical College Hospital59.2%22.2%7.8%9.6%1%0%10%20%30%40%50%60%Regional =2655GA ( adults) =997GA ( peds) =350MAC = 433Local = 49ANESTHESIA TECHNIQUEJuly 13,1998 - July 13,199

11、9 ( N = 4504)Duke University Medical Center, U.S.ATYPES OF BLOCK July 13, 1998 - July 13, 1999 ( N = 3546)701674512385275251244212132743316151570100200300400500600700800InterscaleneSciaticParavertebralLumbar plexusSpinalFemoralContinuous CatheterAxillarySupraclavicularAnkleIV regionalEpiduralWristCa

12、udalInfraclavicularDuke University Medical Center, U.S.AmmHg5090130170pre-operation30min60minPNB-SPEPI-SPPNB-DPEPI-DP Zhonghuang Xu, et al. Combined lumbar plexus and sciatic nerve block with ropivacaine in the patients undergoing lower-extremity surgery: a clinical study. The Journal of Clinical An

13、esthesiology 2002; 18(5):235Onset time of the blocks0510152025MotorSensoryTime (min)EpiduralPNBDuration of the blocks0150300450600MotorSensoryTime (min)EPINER全麻全麻,硬膜外和外周神經(jīng)阻滯硬膜外和外周神經(jīng)阻滯在麻醉和鎮(zhèn)痛中的價(jià)值在麻醉和鎮(zhèn)痛中的價(jià)值?Case 1：May 16, 2001Mr. Qin，male，81yr，48KgC.C.:Intermittent claudication and pain for 3 yearsP.H.

14、:Atrial fibrillation, anticoagulation therapyDiagnosis: Left leg arterial embolism and necrosisOperation：Left amputationLocal anesthetic：0.5% Ropivacaine 35ml+1% lignocaine20mlAnesthesia Methods: Combined lumbar plexus-sciatic blockMr. Wang, male, 70yr, 65KgDiagnosis: arterial embolismP.H.: Rheumati

15、c heart diseas, mitral stenosis, tricuspid insufficiency, pulmonary hypertension, right heart failure, atrial fibrillationL.D.: Abnormal PT, PT%, INR, APTT, and APTT-R; BUN 35mg/dl; abnormal CR 1.8TBIL, DBIL, AST, and TBAOperation: amputationlCombined lumbar plexus-sciatic block Lumbar plexus: 1%lid

16、ocaine 20ml+0.5% ropivacaine 10ml Sciatic nerve: 1%lidocaine 20ml+0.5% ropivacaine 5mlDiagnosisOsteoarthritis OperationLeft Arthroscopy Post HistoryPost-appendectomy, hysterectomy, right arthroscopy;Hypertension, Coronary heart disease(Infarction), Sinus bradycardia, Multiple arteritis, Hiatus herni

17、a, Scrofula, and Duodenal ulcer.Laboratory Data Left atrial enlargement, Aortic retrograde degeneration;Lumbar vertebra retrograde degeneration, L4 dislocation, Protrusion of vertebra disc (L3-5)Drug historyNSAIDsAnesthesiaCombined lumbar plexus-sciatic blockCase3: Oct. 26, 2001lRepeated catheter pl

18、acement induced conglutination of epidural space.Peripheral Nerve Block Procedures ClassificationBasic Regional Anesthesia TechniquesIntermediate Regional Anesthesia TechniquesAdvanced Regional Anesthesia TechniquesSuperficial Cervical Plexus BlockAxillary brachial plexus blockIntravenous regional b

19、lock (Bier block) Wrist blockDigital Nerve Block Genitofemoral Block Saphenous Block Ankle BlockSpinal AnesthesiaEpidural AnesthesiaCombined Spinal-Epidural Anesthesia Deep Cervical Plexus BlockInterscalene Block Supraclavicular Interscalene BlockInfraclavicular Brachial Plexus BlockSciatic Nerve Bl

20、oc: Posterior approach Femoral Nerve BlockPopliteal Block - Intertendinous (Posterior) ApproachPopliteal Block: Lateral approachPopliteal Block: Lithotomy (supine) approachContinuous Interscalene Brachial Plexus Block Continuous infraclavicular brachial plexus blockParavertebral BlockCombined Lumbar

21、 Plexus - Sciatic BlocksContinuous Femoral Nerve BlockParafemoral TechniqueObturator BlockContinuous Sciatic Block Continuous Sciatic Block - Posterior ApproachContinuous Popliteal Nerve Block etc.lKnee surgery lPain management after lower extremity (knee) and hip surgerylExamples: knee arthroscopy,

22、 anterior cruciate ligament (ACL) repair, thigh biopsy, above knee amputation, lower extremity revascularization, etc.). 1.Pubic tubercle2.Inguinal ligament3.Anterior superior iliac spine4.Obturator nerve5.Accessory Obturator nerve6.Superior Ramus of the pubic bone7.Genitofemoral nerve8.Femoral nerv

23、e9.Sciatic nerve lLumbar plexus block Lateral decubitus position lSciatic block Same as above with a slight forward tilt.Trochanter majorPosterior superior iliac spineLumbar vertebraeThe point of insertionPosterior superior iliac spineIliac crestsPosas Compartment Blocksacral hiatusgreat trochanterP

24、oint of insertionposterior superior iliac spinePosterior ApproachlAccomplish both the lumbar plexus and posterior sciatic blocklSubcutaneous infiltrationlInfiltrate the skin at the insertion point for the sciatic blocklContact the transverse processlRedirected cephalad or caudad and advanced beyond

25、the transverse process lTwitches of the quadriceps muscle lInjection of local anesthetic with intermittent aspirationslPerpendicular or slightly caudadlInvariably first obtains twitches of the gluteus muscles, followed by the sciatic nerve stimulation神經(jīng)阻滯方式臂叢神經(jīng)阻滯腰叢神經(jīng)阻滯 坐骨神經(jīng)阻滯 腰叢+坐骨神經(jīng)阻滯椎旁神經(jīng)阻滯 目前開展的項(xiàng)目

26、目前開展的項(xiàng)目神經(jīng)刺激器定位l病人感覺舒適l血流動(dòng)力學(xué)平穩(wěn)l麻醉鎮(zhèn)痛效果滿意l盡早恢復(fù)出院l定位指標(biāo)明確l并發(fā)癥少傳統(tǒng)異感定位法l病人感覺觸電、痛苦l(xiāng)血管內(nèi)意外注藥危險(xiǎn)l麻醉效果難以保證，成功率相對(duì)低。l定位無客觀指標(biāo)。1 1、適當(dāng)鎮(zhèn)靜：適當(dāng)鎮(zhèn)靜：咪唑安定咪唑安定1 5mg1 5mg， 芬太尼芬太尼 50 200ug50 200ug2 2、定位：定位：電刺激混合神經(jīng)電刺激混合神經(jīng) 引發(fā)運(yùn)引發(fā)運(yùn)動(dòng)反應(yīng)動(dòng)反應(yīng) 注藥注藥/ /置管置管3 3、電流：電流：( (1.0mA 0.3mA)1.0mA 0.3mA)誘發(fā)最大顫誘發(fā)最大顫搐搐 給給藥藥l病人鎮(zhèn)靜：咪唑安定+芬太尼；l定位（見圖）：解剖定位 電刺

27、激定位；l確認(rèn)腰叢，進(jìn)針78cm,注藥20-30ml；l羅哌卡因首選；l并發(fā)癥：誤入硬膜外腔發(fā)生率10%。l適當(dāng)鎮(zhèn)靜：咪唑安定+芬太尼;l傳統(tǒng)后側(cè)入路（Sims位），注意體位;l刺激電流：1.0mA 0.3mA;l確認(rèn)坐骨神經(jīng)，注藥進(jìn)針方向;l羅哌卡因首選(15-25ml)。下1/3手術(shù) 15ml 坐骨神經(jīng)阻滯 腰叢神經(jīng)阻滯局麻藥給藥量手術(shù)部位 神經(jīng)阻滯法上上2/3手術(shù)手術(shù)20-25ml腰叢神經(jīng)阻滯腰叢神經(jīng)阻滯 1520ml坐骨神經(jīng)阻滯坐骨神經(jīng)阻滯 2025ml在許多臨床情形下，應(yīng)首選長(zhǎng)效局麻藥：布比卡因左旋布比卡因羅哌卡因?yàn)闇p少意外過量可能導(dǎo)致的全身毒性，左旋布比卡因、羅哌卡因優(yōu)于布比卡因。

28、l布比卡因：2.0mg/kgl羅哌卡因：3.5mg/kgl局麻藥用于外周神經(jīng)阻滯時(shí)的最大安全劑量是多少？lA ropivacaine dose of 60 to 70 ml of 0.5% appears adequate for regional anesthesia with safety, ambulation, and post-op pain relief.優(yōu)點(diǎn)l保持神志清醒l血流動(dòng)力學(xué)平穩(wěn)l便于術(shù)后鎮(zhèn)痛l盡早恢復(fù)出院l便于病人配合治療l可控的感覺運(yùn)動(dòng)神經(jīng)阻滯潛在風(fēng)險(xiǎn)潛在風(fēng)險(xiǎn)l毒性：心臟、神經(jīng)、過敏毒性：心臟、神經(jīng)、過敏l理論上存神經(jīng)損傷的機(jī)率理論上存神經(jīng)損傷的機(jī)率l穿刺部位疼痛和血

29、腫穿刺部位疼痛和血腫l某些術(shù)中不適某些術(shù)中不適l麻醉失敗的危險(xiǎn)麻醉失敗的危險(xiǎn)EBPM:nerve blocks & patient EBPM:nerve blocks & patient outcomes;outcomes;Improved understanding of lower Improved understanding of lower extremity anatomy; extremity anatomy; Increased duration of peripheral Increased duration of peripheral nerve blocks. nerve

30、blocks. l臨床麻醉（術(shù)中病人無痛苦）：重要！l術(shù)后鎮(zhèn)痛（圍術(shù)期病人無痛苦）：重要！l臨床麻醉和術(shù)后鎮(zhèn)痛是不可分隔的整體；存在的問題存在的問題：如何延長(zhǎng)外周神：如何延長(zhǎng)外周神經(jīng)阻滯鎮(zhèn)痛的作用維持時(shí)間？經(jīng)阻滯鎮(zhèn)痛的作用維持時(shí)間？可能的答案可能的答案：1.1.置管置管+ +連續(xù)給連續(xù)給藥；藥； 2.2.藥理學(xué)研究進(jìn)藥理學(xué)研究進(jìn)展展. .單次給藥針單次給藥針可置管針可置管針病人自控鎮(zhèn)痛新的給藥途徑病人自控鎮(zhèn)痛新的給藥途徑:外周神經(jīng)病人自控鎮(zhèn)痛術(shù)外周神經(jīng)病人自控鎮(zhèn)痛術(shù)P a t i e n t - C o n t r o l l e d R e g i o n a l Analgesia,PCN

31、A*外周神經(jīng)鞘內(nèi)置管；外周神經(jīng)鞘內(nèi)置管；*連接連接PCA泵（也可采用連續(xù)輸注泵（也可采用連續(xù)輸注泵）；泵）；*以局麻藥為主，也可聯(lián)合用藥。以局麻藥為主，也可聯(lián)合用藥。l手術(shù)：上肢，肩關(guān)節(jié)，；l區(qū)域阻滯：臂（頸）叢神經(jīng)阻滯（interscaleneblock；verticleinfraclavicularblock);l置入硬膜外導(dǎo)管(8-10cm)；l術(shù)后鎮(zhèn)痛用藥方案：0.2%Naropin連續(xù)輸注（泵），5-15ml/hl手術(shù)：股骨（頸）骨折手術(shù)；l外周神經(jīng)阻滯：腰叢+坐骨神經(jīng)阻滯（Psoascompartmentblock+proximalsciaticnerveblock);l置管術(shù)后鎮(zhèn)

32、痛:腰叢（8-10ml）；l鎮(zhèn)痛用藥：0.2%Naropin5-15ml/h.l手術(shù)：膝關(guān)節(jié)鏡手術(shù)；l外周神經(jīng)阻滯：腰叢+股神經(jīng)阻滯（Psoascompartmentblock+inguinalfemoralnerveblock);l置管術(shù)后鎮(zhèn)痛：股神經(jīng)置管（8-10ml）；l鎮(zhèn)痛用藥：0.2%Naropin5-15ml/h.l手術(shù)：全膝關(guān)節(jié)置換手術(shù)；l外周神經(jīng)阻滯：腰叢+坐骨神經(jīng)阻滯（Psoascompartmentblock+proximalsciaticnerveblock);l置管術(shù)后鎮(zhèn)痛：腰叢神經(jīng)置管（8-10ml）；l鎮(zhèn)痛用藥：0.2%Naropin5-15ml/h.l手術(shù)：踝關(guān)節(jié)

33、骨折復(fù)位或腳部截肢手術(shù)；l外周神經(jīng)阻滯：坐骨神經(jīng)（必要時(shí)加股神經(jīng)）阻滯（proximalsciaticnerveblock);l術(shù)后鎮(zhèn)痛：坐骨神經(jīng)（必要時(shí)加股神經(jīng)）置管l鎮(zhèn)痛用藥：0.2%Naropin5-15ml/hAlpha AgonistsAlpha Agonists: : clonidineclonidine; ;Bupivacaine loaded Bupivacaine loaded microspheresmicrospheres; ;Peptides & Peptides & proteinsproteins: CGX-1002.: CGX-1002.Alpha Agonist

34、s: 0.5-1.0 ug/kg Alpha Agonists: 0.5-1.0 ug/kg clonidineclonidine The duration of block increased by The duration of block increased by 25-60%;25-60%;Mechanisms: Mechanisms: 1).alpha mediated local 1).alpha mediated local vasoconstriction;vasoconstriction; 2).direct nerve blocking action. 2).direct

35、nerve blocking action.Casati A, et al. Anesth Analg 2000; 91:388-92Iskandar H, et al. Anesth Analg 2001; 93:771-5“Tramadol may be au sefulalternative, as adjuvant in peripheral block, with same effects of other drugs commonly used and a lower incidence of side effects.”0.75%ropivacaine 20ml with1.tr

36、amadol100ug;2.Clonidine1.5ug/kg3.Sufentanil20ug4.0.9%NaCll0.25%-0.125% bubivacaine 0.25mg/kg/hr;l0.2% ropivacaine 0.3-0.4mg/kg/hr With less motor block;lNo enhanced analgesia from the addition Of narcotics to peripheral nerveb lock;lClonidine 1ug/ml prolongs analgesia By 50% to 100% without side eff

37、ects.l可樂定可樂定(Clonidine) 1ug/ml;lProlonged analgesia by 50%-100%;lAll peripheral blocks suitable;lWithout side effects except sedation.Antonucci S. Minerva Anesthersiol 2001; Jan-Feb;67(1-2):23-7lErlacher W,etal.Clonidine as adjuvant for ropivacaine inaxillary, perivascular brachial plexus block.Can

38、J Anaesth 2001 Jul;48(6):522-5A sustained drug delivery A sustained drug delivery system:system:Bupivacaine loaded into Bupivacaine loaded into microspheresmicrospheres; ;poly-lactic-glycolic-acid;poly-lactic-glycolic-acid;InjectableInjectable & biodegradable; & biodegradable;Sensory Nerve block up

39、to 5-13 Sensory Nerve block up to 5-13 days;days;Estebe JP, et al. Anesth Analg 2001; 93:447-55Drager C, et al. Anesthesiology 1998; 89: 969-79Peptides and proteinsPeptides and proteinsIsolates from the peisonousIsolates from the peisonous tropical tropical shell;shell;The new local anesthetic, CGX-

40、1002;The new local anesthetic, CGX-1002;To allow nerve block for up to 48 To allow nerve block for up to 48 hrs;hrs;Currently being reviewed by the FDA. Currently being reviewed by the FDA. Swenson JD. New Directions in Pain Management, March 2-5, 2002, Snowbird, Utah, USAAims of Coadministration:*t

41、o reduce the latency of the block onset;*to improve the quality of the block;*to prolong the duration of analgesia;*to reduce the doses of local anesthetics.l阻滯成功的指標(biāo)客觀、明確；l適用于無法準(zhǔn)確說明異感的病人；l減少病人的不適感；l提高阻滯成功率；l減少神經(jīng)損傷。l神經(jīng)損傷的機(jī)制:lDirect nerve transection;lIntraneural injection;lIschemia caused by vasoconstrictors;lDirect toxicity of concentrat