臂丛神经阻滞在动静脉内瘘成形术中的应用

目的观察臂丛神经阻滞在动静脉内瘘成形术中的效果。方法拟行动静脉内瘘成形术患者152例,随机均分为臂丛神经阻滞组和局部浸润麻醉组。臂丛神经阻滞组手术中采用臂丛神经阻滞法进行麻醉,局部浸润麻醉组术中给予局部浸润麻醉法。比较两组术中VAS疼痛评分、术中血管直径、术后4h内瘘血流量、手术时间、术后24h和术后2年的手术成功率及麻醉安全性。结果臂丛神经阻滞组VAS疼痛评分、手术时间明显低于局部浸润麻醉组(P0.01);臂丛神经阻滞组术中动脉直径、术中静脉直径和内瘘血流量明显高于局部浸润麻醉组(P0.01)。臂丛神经阻滞组术后24h手术成功率为98.68%,与局部浸润麻醉组的92.11%差异无统计学意义;但臂丛神经阻滞组术后2年手术成功率为88.16%,明显高于局部浸润麻醉组的75.00%(P0.05)。两组均未见明显药物不良反应。结论臂丛神经阻滞可减轻术中疼痛,提高动静脉内瘘成形术手术成功率。     

实时B超定位垂直锁骨下喙突入路臂丛阻滞麻醉

目的介绍在超声定位下行锁骨下喙突入路臂丛麻醉的安全性和阻滞范围。方法对40例手术的患者，应用B超在患侧喙突内下处探到腋动脉第2段，将超声探头置于腋动脉的正上方（前胸壁的点），测量该点与喙突的距离、腋动脉的深度及其同胸膜的位置关系。其中20例上肢手术患者在B超引导下进行锁骨下臂丛神经阻滞。结果B超不能清楚地显示锁骨下臂丛的结构，但选择喙突内下2cm作为锁骨下臂丛阻滞的穿刺点是合理的。在该点腋动脉第2段的深度，左侧是2．84cm，右侧是2．78cm。穿刺点到胸膜的水平距离，左侧为8．1mm，右侧为7．7mm。腋动脉的深度和穿刺点到胸膜的距离均同病人的体重呈正相关。20例B超实时定位下行锁骨下臂丛神经阻滞的麻醉效果达95％，臂丛发出7根神经的阻滞率为40％，但其中5根神经（肌皮、正中、尺、桡、前臂内侧皮神经）的阻滞率为85％。结论在B超定位的帮助下，锁骨下入路臂丛阻滞麻醉可以达到上肢广泛区域的阻滞并可避免气胸的并发症。     

超声引导经锁骨上窝进针在喙突旁臂丛神经阻滞中的应用

目的评价经锁骨上窝进针在超声引导下喙突旁臂丛神经阻滞中的临床效果。方法选择实施前臂或手部手术的患者60例,男33例,女27例,18～60岁,BMI 18.5～28.0kg/m2,ASAⅠ—Ⅲ级。随机分为两组:锁骨下进针组(A组)和锁骨上窝组(B组),每组30例,实施超声引导下喙突旁臂丛神经阻滞,分别从锁骨下进针(A组)和锁骨上窝进针(B组),在腋动脉周围注射0.5%罗哌卡因20ml。记录操作时间、调针次数、起效时间、注药后15min感觉阻滞评分、阻滞成功率和并发症发生率。结果与A组比较,B组操作时间明显缩短(P0.05);两组调整针次数、起效时间、注药后15min感觉阻滞评分、阻滞成功率和并发症发生率差异无统计学意义。结论经锁骨上窝进针实施超声引导喙突旁臂丛神经阻滞,操作期间更短,效果确切,不增加并发症的发生率。     

超声引导锁骨上与锁骨下入路臂丛阻滞效果的比较

目的 比较超声引导锁骨上入路和锁骨下入路臂丛阻滞的效果.方法 择期上肢手术患者120例,性别不限,年龄18～80岁,ASA分级Ⅰ-Ⅲ级,采用随机数字表法,将患者随机分为2组(n=60):锁骨上入路组(SCB组)和锁骨下入路组(ICB组).局麻药采用0.375％罗哌卡因与1％利多卡因混合液(含1∶200000肾上腺素)分别行锁骨上或锁骨下臂丛阻滞,0.5 ml/kgo分别记录阻滞操作时间、麻醉维持时间及麻醉成功情况,注药完毕后每5 min测定腋神经、桡神经、正中神经、尺神经、肌皮神经、前臂内侧和臂内侧皮神经的阻滞情况及不良反应、并发症的发生情况,直至30 min.结果 与SCB组比较,ICB组麻醉成功率、尺神经、前臂内侧皮神经和臂内侧皮神经阻滞有效率升高,穿刺过程中异感发生率降低,阻滞操作时间延长(P＜0.05).两组均无严重并发症发生.结论 超声引导锁骨下入路臂丛阻滞的效果优于锁骨上入路.     

上肢手术病人超声引导锁骨上臂丛神经阻滞的效果

目的探讨上肢手术病人超声引导锁骨上臂丛神经阻滞的效果。方法拟在锁骨上臂丛神经阻滞下行上肢手术病人120例,ASA Ⅰ-Ⅲ级,随机分为3组(n=40):超声引导组(U组)、神经刺激器组(N组)、传统方法组(T组)。局麻药为0．75％罗哌卡因与2％利多卡因等容量混合液,剂量为0．4ml·kg-1。记录肌皮神经、桡神经、正中神经、尺神经阻滞的起效时间,并评价其阻滞完善率; 评定手术全程的麻醉效果(优、良、差),记录并发症。结果 U组4根神经阻滞完善率均接近100％ (P>0．05),N组和T组尺神经的阻滞完善率均低于肌皮神经和桡神经(P<0．05)。与T组比较,U 组和N组正中神经阻滞完善率均较高,麻醉优良率较高,起效时间均较短(P<0．05或0．01)。与N组比较,U组尺神经阻滞完善率和麻醉优等率较高,起效时间较短(P<0．01)。T组穿刺过程中有3例误入血管,3组均无严重并发症。结论上肢手术病人超声引导锁骨上臂丛神经阻滞较神经刺激器辅助和传统方法下的阻滞效果更好,起效时间更短,在临床上具有推广应用价值。     

逆行锁骨下臂丛神经阻滞的临床应用

目的探讨逆行锁骨下臂丛神经阻滞(BPB)的效果。方法择期行上肢手术的患者90例随机分为三组,每组30例。在外周神经刺激器引导下行逆行锁骨下(A组)、肌间沟(B组)或锁骨上(C组)BPB穿刺,注入0.5%罗哌卡因40ml。记录感觉神经阻滞完善时间、不良反应。A组记录穿刺针进针深度,与矢状面、冠状面角度。结果A组感觉神经阻滞效果优于B、C组(P<0.05或P<0.01)。A组臂内侧皮、前臂内侧皮、正中、尺神经阻滞完善时间快于B组(P<0.01)。A组颈浅神经阻滞完善时间较B组慢(P<0.01)。A组不良反应与并发症明显少于B、C组(P<0.01)。结论逆行锁骨下BPB的感觉神经阻滞效果优于肌间沟法或锁骨上法。     

Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children

Background: Supraclavicular brachial plexus blocks are not common in children because of risk of pneumothorax. However, infraclavicular brachial plexus blocks have been described in paediatric patients both with nerve stimulation and ultrasound (US)‐guidance. US‐guidance reduces the risk of complications in supraclavicular brachial plexus blocks in adults. Objective: To compare the success rate, complications and time of performance of US‐guided supraclavicular vs infraclavicular brachial plexus blocks in children. Material and methods: Eighty children, 5–15 years old, scheduled for upper limb surgery were divided into two randomized groups: group S (supraclavicular), n = 40, and group I (infraclavicular), n = 40. All blocks performed were exclusively US‐guided, by a senior anaesthesiologist with at least 6 months of experience in US‐guided blocks. For supraclavicular blocks the probe was placed in coronal‐oblique‐plane in the supraclavicular fossa and the puncture was in‐plane (IP) from lateral to medial. For infraclavicular blocks the probe was placed parallel and below the clavicle and the puncture was out‐of‐plane. Ropivacaine 0.5% was administered up to a maximum of 0.5 ml·kg^?1 until appropriate US‐guided‐spread was achieved. Block duration and volumes of ropivacaine used (mean±1SD) in the supraclavicular approach were recorded. Success rate (mean ± 1 SD, 95%confidence interval), complications rate and time to perform the block (two‐tailed Student′s test) were recorded both for supraclavicular and infraclavicular approaches. Results: In the US‐guided supraclavicular brachial plexus blocks, the duration of the sensory block was 6.5 ± 2 h and of the motor block was 4 ± 1 h. The volume of ropivacaine used in this group was 6 ± 2 ml. In group I, 88% of blocks achieved surgical anaesthesia without any supplemental analgesia compared with 95% in group S (P = 0.39; difference=7%; 95% CI: ?10% to 24%). Failures in group I were because of arterial puncture and insufficient ulnar or radial sensory block. Failures in group S were because of insufficient ulnar sensory block. No pneumothorax or Horner’s syndrome was recorded in either group. The mean time (SD) to perform the block was in group I: 13 min (range 5–16) and in group S: 9 min (range 7–12); the 95% CI for this difference was 2–6 min and was statistically significant (P < 0.05). Conclusions: (i) Ultrasound‐guided supraclavicular and infraclavicular brachial plexus blocks are effective in children. (ii) There has been no pneumothorax in 40 US‐guided supraclavicular brachial plexus blocks performed by anaesthesiologists already trained in US‐guided regional anaesthesia using an IP technique in children ≥5 years old. (iii) In this study, the supraclavicular approach of the brachial plexus was faster to perform than the infraclavicular one.     

Upper extremity surgery in younger children under ultrasound-guided supraclavicular brachial plexus block: a case series

Purpose  

Supraclavicular brachial plexus block is considered to be one of the most effective anesthetic procedures for upper extremity surgeries. Its major drawback is placement of the needle, with inaccurate placement, especially in children, being a risk factor for pneumothorax and vascular puncture and failure of the procedure. Ultrasound-guided needle placement may reduce the risk of complications and increase the accuracy of the block, particularly in pediatric patients. Little has been published on the efficacy and safety of ultrasound-guided supraclavicular block in children based on practical experience, and there has been no published report on its usage in younger children (<6 years old).     

Upper extremity surgery in younger children under ultrasound-guided supraclavicular brachial plexus block: a case series

Purpose  

Supraclavicular brachial plexus block is considered as one of the most effective anesthetic methods for upper extremity surgeries. Its major drawback, especially in children, is the risk of pneumothorax, vascular puncture, and failure of the procedure due to inaccurate placement of the needle. Ultrasound-guided needle placement may reduce the risk of complications and increase the accuracy of block, particularly in pediatric patients. There are few published experiences about the efficacy and safety of ultrasound-guided supraclavicular block in children and to our knowledge, it seems that there is no published report about its usage in younger children (less than 6 years of age).     

超声引导下肋锁间隙和喙突入路锁骨下臂丛神经阻滞在前臂或手部术中效果的比较

目的比较超声引导下肋锁间隙(CCS)臂丛神经阻滞与超声引导下喙突入路锁骨下臂丛神经阻滞在前臂或手部术中临床麻醉效果。方法选取拟行前臂或手部手术患者58例,男33例,女25例,年龄18~70岁,ASAⅠ~Ⅲ级,随机分为超声引导下CCS臂丛神经阻滞组(A组)和超声引导下喙突入路锁骨下臂丛神经阻滞组(B组)。分别给予0.5%罗哌卡因20 ml,记录臂丛神经深度,神经阻滞操作时间,注射局麻药后5、10、20、30 min臂丛神经分支(正中神经、尺神经、桡神经、肌皮神经)感觉阻滞和运动阻滞情况,神经阻滞持续时间,以及麻醉相关不良反应等。结果 A组臂丛神经深度(2.0±1.2)cm,明显浅于B组(3.5±1.8)cm(P0.05);A组神经阻滞操作时间(2.0±1.5)min,明显短于B组(4.0±1.5)min(P0.05);注射局麻药后5、10 min A组正中神经、尺神经、桡神经、肌皮神经的感觉阻滞率均明显高于B组(P0.05);注药后10 min A组尺神经、桡神经、肌皮神经的运动阻滞率明显高于B组(P0.05),其余时点两组运动阻滞率差异无统计学意义。两组无一例呼吸困难、恶心呕吐、耳鸣等不良反应。结论超声引导下肋锁间隙臂丛神经阻滞较喙突入路锁骨下臂丛神经阻滞深度浅,神经阻滞穿刺操作时间更短,其感觉阻滞和运动阻滞起效更快。     

Ultrasound-guided brachial plexus block in a patient with multiple glomangiomatosis

BACKGROUND AND OBJECTIVES: Glomangiomas are rare, vascular tumors consisting of an afferent artery, arteriovenous canal, neuro-reticular elements, collagen, and efferent veins, and are most often located in the soft tissue of the upper extremities. We describe how the use of ultrasound-guided nerve blockade altered the anesthetic management of a patient with multiple glomangiomatosis undergoing elective forearm surgery. ULTRASOUND FINDINGS: A 32-year-old man was scheduled for excision of painful glomangiomas from the ulnar aspect of his right wrist, with exploration of his ulnar nerve. The anesthetic concerns included (1) morbid obesity, (2) chronic pain syndrome and opioid intolerance, (3) a potentially difficult airway, and (4) obstructive sleep apnea. Ultrasound-guided supraclavicular blockade was the proposed anesthetic of choice. Ultrasound scan of the supraclavicular fossa revealed numerous vascular lesions surrounding the divisions of the brachial plexus. Color Doppler imaging confirmed these pulsatile lesions to be vascular in origin. Even under two-dimensional ultrasound guidance, we believed that the risk of vascular puncture and unintentional intravascular injection of local anesthetic was high, and therefore we abandoned the supraclavicular approach. A successful ultrasound-guided axillary brachial plexus blockade was performed uneventfully. CONCLUSIONS: Although multiple glomangiomatosis is a rare disease, this case illustrates the invaluable contribution that ultrasound has made to modern, regional anesthetic practice, especially for patients with aberrant anatomy in whom traditional nerve-localization techniques could result in serious complications.     

穿刺针导引技术在超声引导下臂丛神经阻滞中的应用

目的设计超声引导下臂丛神经阻滞时的穿刺针导引器,并在体外和临床上验证其效果。方法自制一个穿刺针导引器,其主要部分是一个双层的扇形不锈钢薄片。选择80例在臂丛神经阻滞下行上肢手术的患者,随机分为自由手组和导引组,每组40人。由四位麻醉医师实施在超声引导下臂丛神经阻滞(锁骨上入路),每位医师完成20例,10例用自由手技术,10例用穿刺针导引器引导技术。记录穿刺针的主观可视性、阻滞完成时间、临床效果以及麻醉医师和患者对臂丛神经阻滞的满意度。结果导引组的针的主观可视性显著优于自由手组(P<0.05);导引组的阻滞完成时间明显短于自由手组(P<0.01);麻醉医师使用导引技术的满意度高于使用自由手技术(P<0.05)。结论使用穿刺针引导技术更容易完成超声引导下臂丛神经阻滞。     

超声引导下锁骨上入路单靶点或三靶点注射法臂丛神经阻滞的效果

目的 比较超声引导下锁骨上入路单靶点和三靶点注射法与传统解剖定位法臂丛神经阻滞的效果.方法 择期拟行上肢手术患者90例,性别不限,ASA Ⅰ或Ⅱ级,随机分为3组(n=30):单靶点组(S组)超声引导下锁骨上臂丛神经周围注射21 ml局麻药;三靶点组(T组)超声引导下在锁骨上臂丛神经与锁骨下动脉相接位置的下方注射7 ml局麻药,再2次(各7 ml)调整穿刺针的位置形成以臂丛神经为中心的扇形注射;传统解剖定位组(A组)取锁骨中点上1 cm左右为穿刺点,注射21 ml局麻药.局麻药为0.375%罗哌卡因和1%利多卡因的混合液.记录各组操作时间和尺神经、正中神经、桡神经支配区域痛觉消失时间及镇痛持续时间;评价各神经支配区域的阻滞程度及切皮时的麻醉效果,观察并发症的发生情况.结果 与A组相比,T组操作时间延长,尺神经分支配区域痛觉消失时间缩短,S组和T组麻醉效果满意率升高,镇痛持续时间延长,尺神经、正中神经的阻滞完全率升高(P＜0.05);与T组相比,S组操作时间缩短,尺神经分支配区域痛觉消失时间延长(P＜0.05);三组桡神经阻滞完全率差异无统计学意义(P＞0.05).A组刺破血管4例,轻度局麻药中毒1例,S组和T组未见并发症发生.结论 与传统解剖定位法相比,超声引导下锁骨上臂丛神经阻滞的单靶点和三靶点注射法麻醉效果较好、镇痛持续时间较长,且并发症较少;三靶点注射法的操作时间较单靶点注射法长,但对尺神经的阻滞较快且完全.     

超声引导下两种锁骨下臂丛神经阻滞入路对膈肌麻痹的影响

目的比较超声引导下肋锁间隙入路和喙突旁入路锁骨下臂丛神经阻滞对膈肌麻痹程度的影响。方法选择择期行右手或右前臂手术患者60例,男36例,女24例,年龄18~65岁,体重50~80kg,BMI 18~28kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为两组:肋锁组(C组)和喙突组(P组),每组30例。C组行超声引导下肋锁间隙0.375%罗哌卡因30ml锁骨下臂丛神经阻滞;P组行超声引导下喙突旁0.375%罗哌卡因30ml锁骨下臂丛神经阻滞。记录操作时间、感觉和运动阻滞起效时间、感觉和运动功能恢复时间和不良反应包括Horner综合征、损伤血管、局麻药中毒、气胸、呼吸困难、神经损伤的发生情况。采用M型超声分别对平静呼吸和深呼吸状态下阻滞前、阻滞后30min的膈肌移动度进行测量并记录。结果 C组感觉和运动阻滞起效时间均明显短于P组(P0.05)。两组操作时间、感觉和运动功能恢复时间差异无统计学意义。阻滞后30min深呼吸测量下C组膈肌部分麻痹率明显高于P组(43.3%vs 13.3%,P0.05)。平静呼吸下C组与P组膈肌麻痹程度差异无统计学意义。两组无一例出现Horner’s综合征、损伤血管、局麻药中毒、气胸、神经损伤并发症。结论超声引导下肋锁间隙入路锁骨下臂丛神经阻滞较喙突旁入路起效时间短,但更易引起膈肌麻痹。     

超声引导下臂丛神经阻滞在全麻患者中的应用

目的 评估超声引导下肌间沟臂丛神经阻滞(ISBPB)在全麻患者中应用的效果.方法 选择择期全麻下单侧卜肢手术患者60例,随机均分成三组.三组采用同种方案麻醉诱导,丙泊酚术中麻醉维持速率为75 μg·kg-1·min-1,根据MAP监测值调整雷米芬太尼注药速度以维持MAP波动在基础值的10%～20%范围之内.Ⅰ组插管后在超声引导下于患侧肌间沟穿刺并同定20G静脉留置针;Ⅱ组按常规方法完成操作,两组均注入0.375%罗哌卡因20 ml后连接微量注射泵以5 ml/h速度输注0.375%岁哌卡因直至手术结束;Ⅲ组不实施臂丛阻滞.比较Ⅰ、Ⅱ组神经阻滞操作时间、术中麻醉药物用量及术后疼痛情况.结果 Ⅰ组患者术中雷米芬太尼用量低于Ⅱ、Ⅲ组(P<0.05或P<0.01),呼之睁眼时间Ⅰ组短于Ⅲ组(P<0.05),Ⅰ组拔管后5、10 min的VRS明显低于Ⅱ、Ⅲ组(P<0.05或P<0.01).结论 超声引导下ISBPB在全麻患者中应用效果确实,可显著减少镇痛药物用量.     

超声引导下肌间沟联合腋路臂丛神经阻滞用于患儿上肢手术

目的评估超声引导下肌间沟联合腋路臂丛神经阻滞用于患儿上肢手术的麻醉效果。方法 52例ASAⅠ或Ⅱ级拟行单侧上肢手术患儿,随机均分为超声引导下肌间沟联合腋路臂丛神经阻滞组(U组)和传统体表定位肌间沟联合腋路臂丛神经阻滞组(N组)。局麻药为0.2%盐酸罗哌卡因,总量为1ml/kg。肌间沟入路和腋路分别给予局麻药总量的一半。观察两组注入局麻药后5、10、15min的桡神经、尺神经、正中神经和肌皮神经的阻滞情况、阻滞效果及不良反应。结果注入局麻药后5、10、15min时U组桡神经阻滞有效率明显高于N组,注入局麻药后10、15min时U组尺神经和正中神经阻滞有效率明显高于N组(P0.01或P0.05)。U组麻醉优良率为26例(100%),明显高于N组20例(76.9%)(P0.05)。结论超声引导下肌间沟联合腋路臂丛神经阻滞用于患儿上肢手术安全可行。     

罗哌卡因混合碳酸利多卡因与等效浓度罗哌卡因用于逆行锁骨下臂丛神经阻滞效果的比较

目的 比较罗哌卡因混合碳酸利多卡因与等效浓度罗哌卡因用于逆行锁骨下臂丛神经阻滞的效果.方法 择期行上肢手术患者60例,ASA分级Ⅰ或Ⅱ级,年龄18～64岁,体重49～ 98 kg,均在超声引导下行逆行锁骨下臂丛神经阻滞.采用随机数字表法,将患者随机分为2组(n＝30),A组应用0.35％罗哌卡因30ml,B组应用0.233％罗哌卡因和0.346％碳酸利多卡因混合液30 ml.于麻醉给药后每隔5 min记录臂丛神经各分支的阻滞效果(感觉阻滞效果评估采用针刺法,运动阻滞效果评估采用Bromage分级),记录感觉和运动阻滞起效时间、麻醉给药后30 min时感觉与运动阻滞有效情况和并发症的发生情况.结果 两组臂丛神经各分支的感觉和运动阻滞起效时间及阻滞有效率比较差异无统计学意义(P＞0.05).两组均未见严重并发症发生.结论 罗哌卡因混合碳酸利多卡因与等效浓度罗哌卡因行逆行锁骨下臂丛神经阻滞效果相似,提示碳酸利多卡因不能增强罗哌卡因的臂丛神经阻滞效应.     

垂直锁骨下臂丛神经阻滞两种穿刺点定位方法的比较

目的比较垂直锁骨下臂丛神经阻滞两种定位方法的准确性和安全性。方法择期上肢手术患者110例，ASAⅠ或Ⅱ级，随机分为2组（n=55）：K组采用Kilka介绍的定位方法行垂直锁骨下臂丛神经阻滞，穿刺点位于肩峰腹侧突与胸骨颈静脉切迹连线（K线）的中点；G组采用Greher介绍的定位方法行垂直锁骨下臂丛神经阻滞，根据K线的长度对Kilka定位方法的穿刺点予以校正。所有穿刺成功患者给予0．5％罗哌卡因40ml。记录两种方法的试穿次数、进针深度和注药后正中、桡、尺、腋、肌皮和前臂内侧皮神经阻滞的起效时间，观察有无刺破血管、气胸等并发症。结果K组和G组首次穿刺成功率分别为50．9％和14．5％（P〈0．01），前3次试穿总成功率分别为83．6％和47．3％（P〈0．01），放弃率分别为7．3％和10．9％（P〉0．05）。穿刺成功的100例进针深度平均为35（25—49）mm。K组发生刺破血管2例，G组发生刺破血管1例、局麻药中毒1例。结论就成功率而言，Kilka方法是一种较好的穿刺点定位方法，适用于成年患者垂直锁骨下臂丛神经阻滞，进针深度不超过50mm.