超声在椎管内麻醉中的应用

近年来,超声在区域麻醉尤其是外周神经阻滞方面得到广泛应用,超声引导椎管内穿刺也取得了一定进展。既往研究表明,穿刺前超声检查能够提供正确的椎间隙、脊柱中线、最佳穿刺点、适当的穿刺角度以及椎管到皮肤深度等方面的信息。本文介绍椎管的超声扫查方法及图像解读,以及超声(包括穿刺前扫查定位和超声实时引导穿刺)在临床椎管内麻醉中的应用价值。     

强直性脊柱炎病人超声引导下腰硬联合麻醉一例

目的介绍1例全身麻醉存在高风险的强直性脊柱炎病人行超声引导下椎管内麻醉的经验。方法 51岁男性病人1例,拟行开放复位胫骨内固定术。既往强直性脊柱炎病史,目前腰椎骨质增生伴腰背部前屈后伸困难,胸椎成驼背畸形;颈椎强直,成前屈位,后仰困难,头部转动困难。行旁正中长轴超声引导下腰硬联合麻醉。结果超声成像发现L3/4椎板间隙存在,超声引导下椎管内麻醉顺利,术毕1周后出院,无麻醉相关并发症。结论超声引导下椎管内麻醉,极大地易化了全身麻醉存在高风险的强直性脊柱炎病人椎管内穿刺的难度。     

超声辅助下椎管内麻醉穿刺在肥胖患者中的应用

目的探讨超声辅助下椎管内麻醉穿刺在肥胖患者中的应用效果。方法选取在本院行下腹部或下肢手术,且需椎管内麻醉穿刺的74例肥胖患者,随机分为对照组和观察组,各37例。对照组采用常规人工手法定位出腰椎间隙行椎管内麻醉穿刺,观察组采用超声辅助下椎管内麻醉穿刺,对比两组腰椎间隙定位时间、穿刺时间、定位加穿刺总时间、穿刺次数、穿刺成功率及不良反应。结果观察组腰椎间隙定位时间(1.48±0.59)分钟、穿刺时间(6.79±2.17)分钟、定位及穿刺总时间(9.48±1.34)分钟和穿刺次数(1.26±0.24)次,均显著少于对照组(6.02±1.03分钟、20.31±6.02分钟、25.69±7.73分钟、2.74±1.14次),组间差异P0.05。观察组椎管内麻醉穿刺成功率(100.00%)显著高于对照组(86.49%),组间差异P0.05。观察组穿刺过程不良反应发生率(13.51%)均显著低于(58.82%)对照组,组间差异P0.05。结论肥胖患者采用超声辅助下椎管内麻醉穿刺,可有效保证穿刺效果,临床应用安全可靠。     

超声实时引导在肥胖患者腰段硬膜外麻醉中的临床应用

目的探讨超声实时引导技术在肥胖患者腰段硬膜外麻醉中的临床应用。方法 86例患者随机分为超声实时引导组(超声组)和传统定位盲探穿刺组(对照组),每组43例。超声组采用超声实时引导进行硬膜外穿刺置管;对照组采用传统的体表解剖标志进针及阻力消失法确定硬膜外间隙。记录两组麻醉前准备时间、穿刺时间、穿刺次数、术中麻醉效果及术后腰痛发生率,超声测量的硬膜外腔的深度与实际穿刺时进针深度。结果两组均成功实施硬膜外穿刺,麻醉效果均能满足手术需要。与对照组比较,超声组穿刺时间明显缩短(P<0.01),穿刺次数明显减少(P<0.05),术后腰痛发生率明显降低(P<0.05)。超声测量的硬膜外腔的深度与实际穿刺时进针深度存在显著正相关关系(r=0.861,P<0.01)。结论超声实时引导技术能提高肥胖患者硬膜外麻醉的质量和满意度,同时避免误伤周围组织,降低术后腰痛发生率,值得在临床推广应用。     

超声引导下腰麻在单侧下肢手术中的应用

<正>传统的腰麻是通过解剖标志进行定位[1]。脊柱畸形、肥胖以及年龄相关的退行性改变使得解剖标志缺失、模糊、甚至变形而增加穿刺难度[2]。近年来有学者开始探索在椎管内麻醉前,应用超声确定穿刺间隙和深度,然后采用传统技术盲法穿刺[3,4]。这种非实时超声定位辅助穿刺技术虽然比纯体表标志定位盲法有一定改进,但在穿刺时未在超声下观察针道方向和位置,存在较多局限性。由于方法 学     

超声引导下旁矢状斜位平面内与短轴平面内蛛网膜下腔穿刺入路的比较

<正>随着超声可视化技术在椎管内麻醉中的应用,椎管内麻醉的安全性与成功率得到了提高^[1]。超声引导技术可实时显示穿刺路径,观察麻醉药物扩散情况,提高椎管内穿刺的准确率与成功率^[2-4]。目前超声引导下蛛网膜下腔穿刺入路主要有3种：旁矢状斜位、短轴位和斜轴位入路^[5],其中旁矢状斜位^[6]和短轴入路^[7-8]的应用较广泛。旁矢状斜位入路因具有较好的成像质量,是目前常用的引导入路,但对体位要求较高(右利手的操作者需要患者左侧卧位)。     

超声显像-椎管内麻醉辅助新技术

<正>椎管内麻醉是临床上常用的麻醉方式,目前常用的椎管内穿刺方法是盲穿法,即根据患者的解剖定位决定穿刺间隙,并通过间接的证据或者主观的感觉来判断椎管内穿刺或置管是否到位。然而因个体解剖结构的变异或退化,以及主观感觉的不准确性,传统的椎管内穿刺常出现阻滞不全、失败甚至引起严重的并发症等。目前超声在外周神经阻滞方面应用广泛,因为相对于解剖定位以及神经刺激仪法,超声     

超声在脊髓麻醉中腰椎间隙定位的研究进展

脊髓麻醉是麻醉的一种重要方法,穿刺点的选择和准确定位是规避麻醉并发症和影响麻醉成功的重要环节。然而人工触诊方法在腰椎间隙定位中缺乏稳定性和准确性。近年,超声技术发展迅速,实现了腰椎图像的可视化,尤其是对解剖学穿刺困难的患者有更精准的定位,大大提高了椎管内穿刺的成功率和准确性。     

超声引导精索阻滞在睾丸摘除及取精术中的应用

<正>精索神经阻滞是睾丸手术重要的麻醉方法,但由于传统的解剖定位盲探精索神经阻滞成功率低,潜在风险(局麻药误入血管、血肿形成及刺穿输精管等)较大,有时不得不选择椎管内麻醉或全身麻醉。但是全麻术后患者往往容易出现疼痛、恶心、呕吐及康复较慢等不良反应,而采用椎管内麻醉,部分患者由于年龄较大,脊柱骨质增生等因素导致脊髓或硬膜外麻醉穿刺困难,且椎管内麻醉对血流动力学影响较     

25 G细针侧隐窝入路单次腰麻在老年下肢骨折手术中的应用

正椎管内麻醉由于操作简单、麻醉效果确切及对生理干扰小,是老年下肢骨折手术首选的麻醉方法。由于老年患者常见腰椎骨质增生、韧带钙化并多有服用抗凝药物史,给常规正中入路麻醉穿刺操作带来困难,反复穿刺又可增加椎管内血肿及神经损伤的风险。本研究采用L3~4间隙小关节内缘25G细针侧隐窝入路穿刺行单次腰麻,观察该方法的可行性与安全性,以期为临床提供参考。资料与方法一般资料本研究经医院伦理委员会批准(20150725),     

Real‐time ultrasound‐guided spinal anesthesia in patients with a challenging spinal anatomy: two case reports

Spinal anesthesia may be challenging in patients with poorly palpable surface landmarks or abnormal spinal anatomy. Pre‐procedural ultrasound imaging of the lumbar spine can help by providing additional anatomical information, thus permitting a more accurate estimation of the appropriate needle insertion site and trajectory. However, actual needle insertion in the pre‐puncture ultrasound‐assisted technique remains a ‘blind’ procedure. We describe two patients with an abnormal spinal anatomy in whom ultrasound‐assisted spinal anesthesia was unsuccessful. Successful dural puncture was subsequently achieved using a technique of real‐time ultrasound‐guided spinal anesthesia. This may be a useful option in patients in whom landmark‐guided and ultrasound‐assisted techniques have failed.     

Ultrasound and local anaesthesia. Part III: ultrasound and neuroaxial local anaesthesia

The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia.This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques.The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented.We review all presently available data on the prediction of the puncture depth.The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm.Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31.The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels.The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved.The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.     

A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients

Purpose

The present study was conducted to examine if preinsertion lumbar ultrasound scanning helps with performance of spinal puncture, as a tool for decreasing the number of puncture attempts and spinal procedure time and increasing the success rate. We hypothesized that ultrasound can facilitate neuraxial blockade, particularly in pregnant women with difficult topographic anatomy.

Methods

One hundred (50 lean, BMI <30 kg/m², and 50 obese, BMI ≥30 kg/m²) parturients scheduled for cesarean delivery were divided into ultrasound and control groups. Subarachnoid block was performed with prepuncture ultrasound examination in lean parturients (group 1, n = 25) and in obese parturients (group 2, n = 25), and subarachnoid block was performed without prepuncture ultrasound examination in lean parturients (group 3, n = 25) and in obese parturients (group 4, n = 25). The number of puncture attempts and puncture levels were recorded.

Results

A lower number of puncture attempts and fewer puncture levels were detected in ultrasound (US) groups (p < 0.001). First attempt success rate under US guidance was 92 % in comparison to 44 % using a conventional technique in obese parturients (p < 0.001). In 52 % of the lean patients and in 54.2 % of the obese patients, the intercristal line was at the L3–L4 and at the L2–L3 interspace, respectively. The duration of spinal procedure was shorter in US groups (22 vs. 52 s, p = 0.031). We found a high correlation between ultrasound and needle depth (r = 0.709, p < 0.001).

Conclusions

We found a high level of success in the prepuncture ultrasound-determined insertion point. The ultrasound imaging technique can be a reliable guide to facilitate spinal anesthesia, especially in obese parturients.     

Ultrasound-guided epidural block

Epidural block is performed with surface landmark guidance and loss of resistance technique. Ultrasound visualization of the spinal column and surrounding structures gives additional anatomical information, which could make the block easier and safer. Previous studies revealed that there is strong correlation between the depth of the epidural space measured using ultrasound and the depth of the needle inserted. In order to obtain an image of the spinal canal, the ultrasound probe is positioned at the interspace of spinous processes in transverse and longitudinal planes. The dura mater is identified as an echogenic structure inside the spinal canal. Prepuncture ultrasound examination offers useful information for epidural block such as puncture point and depth as well as angle to the epidural space.     

超声引导与透视引导下膝下动脉逆行穿刺在下肢动脉闭塞双向成形术中应用对比研究

目的 比较超声引导下膝与透视引导下穿刺动脉逆行穿刺在下肢动脉闭塞双向成形术中的成功率及并发症。方法 回顾性分析首都医科大学附属北京世纪坛医院自2016年5月至2019年5月因下肢动脉闭塞行双向开通术的67例病人资料,根据逆穿引导方法的不同分为超声组和透视组,其中超声组32例,透视组35例,分析两组穿刺成功率、手术成功率、通畅率及相关并发症情况。结果 67例病人逆行穿刺均获得成功,超声组在平均穿刺时间及穿刺次数上均明显少于透视组（P＜0.05）;两组术后Rutherford分级较术前均明显改善,同时,ABI值较术前均明显升高（P＜0.05）;超声组与透视组6个月的一期通畅率分别为80％和76.5％,12个月的一期通畅率分别为71.4％和73.3％,两组间通畅率比较差异无统计学意义;常见并发症为穿刺点出血、血肿及穿刺血管痉挛,两组间并发症发生率差异无统计学意义。结论 超声引导下穿刺较透视引导下穿刺可以明显缩短穿刺时间及减少穿刺次数,有临床应用价值。     

Spinal blocks

Every anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single-injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow-up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.     

Subarachnoid anesthesia: 100 years of an established technique

Over the 100 years since the introduction of spinal anesthesia into clinical practice, this technique, like most others, has enjoyed varying degrees of popularity. The attraction of spinal anesthesia is easy to identify: a relatively simple technique is used to inject a very small amount of drug into a readily identifiable body compartment to provide deep anesthesia. However, the apparent simplicity of spinal anesthesia is as much as weakness as a strength, given that the technique can be put to use with relatively little understanding of its problems, which are what underlie the shifts in popularity that spinal anesthesia has suffered over the years. In addition to reviewing the history of spinal anesthesia and the local anesthetics and adjuvant drugs administered by this route, we discuss single-dose and continuous spinal injection, combined spinal-epidural technique, and spinal anesthesia for outpatient settings. The problems typical of dural puncture and placement of local anesthetics and adjuvant drugs into the intrathecal space are also reviewed.     

超声引导与透视引导下膝下动脉逆行穿刺在下肢动脉闭塞双向成形术中应用对比研究

目的 比较超声引导下膝与透视引导下穿刺动脉逆行穿刺在下肢动脉闭塞双向成形术中的成功率及并发症。方法 回顾性分析首都医科大学附属北京世纪坛医院自2016年5月至2019年5月因下肢动脉闭塞行双向开通术的67例病人资料,根据逆穿引导方法的不同分为超声组和透视组,其中超声组32例,透视组35例,分析两组穿刺成功率、手术成功率、通畅率及相关并发症情况。结果 67例病人逆行穿刺均获得成功,超声组在平均穿刺时间及穿刺次数上均明显少于透视组（P＜0.05）;两组术后Rutherford分级较术前均明显改善,同时,ABI值较术前均明显升高（P＜0.05）;超声组与透视组6个月的一期通畅率分别为80％和76.5％,12个月的一期通畅率分别为71.4％和73.3％,两组间通畅率比较差异无统计学意义;常见并发症为穿刺点出血、血肿及穿刺血管痉挛,两组间并发症发生率差异无统计学意义。结论 超声引导下穿刺较透视引导下穿刺可以明显缩短穿刺时间及减少穿刺次数,有临床应用价值。     

穿刺引导架在CT介入治疗中的应用

目的探讨穿刺引导架在CT导向活检和介入治疗中的应用。方法对468例患者应用穿刺引导架行CT引导介入活检或治疗,其中110例接受穿刺活检,358例接受穿刺治疗;胸部病变192例,腹部病变276例,病灶大小2～15cm。穿刺前行CT薄层扫描确定皮肤进针点、确定双向进针角度α、θ和深度d等数据,放置穿刺引导架,局麻后将穿刺针刺人皮肤,调整穿刺针体与CT机架（α）定位激光线重合,穿刺角度为θ。CT扫描确认穿刺针瞄准病灶靶点,将穿刺针刺入至进针深度,命中靶点。结果总体穿刺命中率为100％,一步命中率为96．79％,定位扫描开始至穿刺命中平均8．4min;胸部穿刺气胸发生率为1．56％。结论穿刺引导架应用于CT介入诊疗,使操作准确、安全、便捷,值得推广。     

全麻与腰麻无管化经皮肾镜碎石取石术治疗肾结石的比较

目的探讨全麻与腰麻无管化经皮肾镜碎石取石术(PCNL)治疗肾结石的临床效果。方法前瞻性分析2017年8月至2017年12月我院65例行无管化经皮肾镜钬激光碎石取石术的患者的临床资料,术前采用随机数字表将患者分为全麻组与腰麻组,其中术中发生严重出血需留置肾造瘘管共12例被删除。最终53例行无管化PCNL的患者被纳入研究,其中全麻组28例,腰麻组25例,统计分析两组患者结石的基本特征、术中及术后的参数。结果两组患者在年龄、性别、体质量指数、结石大小、结石位置、手术时间、住院天数、穿刺针数、穿刺位置、血红蛋白下降、出院当天视觉模拟疼痛评分(VAS)及残石率差异无统计学意义(P>0.05),但腰麻组术后的第一天的VAS评分[(4.4±1.8)vs(6.4±2.0),P<0.05]及曲马多镇痛需求量[(56±36) mg vs (112±44) mg,P<0.05]显著小于全麻组。结论腰麻行无管化PCNL是全麻下无管化PCNL的良好替代方案,与全麻相比,腰麻术后疼痛更轻,减少了无管化PCNL患者术后镇痛需求。