Interscalene block using ultrasound guidance: impact of experience on resident performance

Background: We evaluated the weekly progress of anesthesiology residents performing an interscalene block with ultrasound guidance (UG) for block success rates and for the specific time intervals: (i) time to image the brachial plexus and (ii) time from insertion of the block needle until motor stimulation occurred. Our primary objective was to characterize the influence of experience over the course of the regional anesthesia rotation on the performance of a UG interscalene block by anesthesiology residents.
Methods: Residents conducted an interscalene block with UG under the supervision of attending anesthesiologists experienced in this technique. Block efficacy, time intervals required to perform the block, and acute complications were recorded. We compared success rates over the course of the rotation, and analyzed process time data with respect to trainee level of experience, week of the trainee rotation, and patient body habitus.
Results: Twenty-one trainees conducted 222 blocks over a consecutive 7-month period. Block success rate was 97.3%, and did not change significantly over the course of the 4-week rotation. Total block time and imaging time significantly decreased over the 4-week rotation, while the needle insertion-to-stimulation time did not change. Slower imaging time was predicted by obesity.
Conclusion: The success rates for a UG interscalene block provided by supervised residents were initially high, and remained so throughout the 4-week rotation. Trainees required less time to image the nerves and to perform the block over the course of the rotation.     

超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果

目的 评价超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果.方法 择期在椎管内麻醉下行单侧腹股沟疝成形术病人40例,年龄18 ～ 79岁,BMI＜ 30 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将病人分为2组(n=20):生理盐水对照组(C组)和超声引导下腹横肌平面阻滞组(B组),B组术毕在超声引导下行腹横肌平面阻滞,注入0.375％罗哌卡因20 ml,C组给予等容量生理盐水.术后当视觉模拟评分(VAS评分)≥4分时静脉注射曲马多,分别于术后4、6、24、48 h时记录静态和动态VAS评分,分别于术后24、48 h时测定阻滞侧温觉阻滞平面,记录术后病人镇痛总体满意度评分和排气时间,记录腹横肌平面阻滞相关不良反应的发生情况.结果 C组有4例病人使用曲马多镇痛,B组无一例病人需补救镇痛;与C组比较,B组术后VAS评分降低,镇痛总体满意度评分升高(P＜ 0.05或0.01),排气时间差异无统计学意义(P＞0.05);B组术后24 h时阻滞侧温觉平面阻滞率为80％,术后48 h时阻滞侧无一例病人存在温觉阻滞平面;C组术后24、48 h时无一例病人存在温觉阻滞平面.B组未见腹横肌平面阻滞相关不良反应.结论 超声引导下腹横肌平面阻滞用于腹股沟疝成形术病人术后镇痛的效果较好,且安全性较高.     

超声引导下髂筋膜腔隙阻滞对全髋关节置换术患者术后镇痛的效果

目的 评价超声引导下髂筋膜腔隙阻滞对全髋关节置换术患者术后镇痛的效果.方法 择期行全髋关节置换术患者36例,年龄54～82岁,体重48～72 kg,ASA分级Ⅰ～Ⅲ级,采用随机数字表法,将其随机分为2组(n=18):生理盐水组(NS组)和罗哌卡因组(R组).手术结束后30 min内行患侧超声引导下髂筋膜腔隙阻滞.R组髂筋膜腔隙注射0.25％罗哌卡因30 ml;NS组注射等容量生理盐水.阻滞完成后,采用0.01 mg/ml芬太尼行PCIA,无背景输注,PCA量2ml,锁定时间15 min.于阻滞前即刻(T0)、阻滞后3 h(T1)、6 h(T2)、8 h(T3)、12 h(T4)、24 h(T5)、48 h(T6)和72 h(T7)时,记录静态VAS评分;于T4、T5、T6和T7时,记录被动运动VAS评分;于T5、T6和T7时,记录主动运动VAS评分.记录阻滞后0～12h、12～24 h、24～48 h、48～ 72 h各时段内芬太尼用量.记录术后不良反应的发生情况.结果 与NS组比较,R组T1～T7时静态VAS评分、T4～T7时被动运动VAS评分和T5～T7时主动运动VAS评分均降低,各时段芬太尼用量减少(P＜0.05).两组不良反应发生率差异无统计学意义(P＞0.05).结论 全髋关节置换术患者超声引导下髂筋膜腔隙阻滞的镇痛效果好,安全性良好.     

椎板后阻滞对乳腺癌改良根治术病人术后镇痛效果的影响

目的探讨椎板后阻滞(RLB)对乳腺癌改良根治术病人术后镇痛效果的影响。方法乳腺癌改良根治术病人50例,随机分为两组:椎板后阻滞组(RLB组)和对照组(C组)。RLB组病人在手术结束后行手术侧椎板后阻滞,注入0.5%罗哌卡因20 ml。两组术后均使用静脉自控镇痛(PCIA)。记录术后24小时内PCIA舒芬太尼总用量、有效按压次数及补救镇痛例数。记录术后2、4、6、12、24小时的静息视觉模拟评分(VAS)和Ramsay镇静评分及不良反应的发生情况。结果 RLB组术后24小时内PCIA舒芬太尼总用量和有效按压次数分别为(20±4)μg和(13±4)次,C组分别为(29±3)μg和(19±3)次,两组比较差异有统计学意义(P<0.05),两组补救镇痛率比较差异无统计学意义(P>0.05)。RLB组术后4、6、12小时的静息VAS评分分别为(1.9±0.5)、(2.1±0.5)和(1.9±0.7)分,C组分别为(2.6±0.6)、(2.5±0.5)和(2.3±0.5)分,两组比较差异有统计学意义(P<0.05),两组各时点Ramsay镇静评分比较差异无统计学意义(P>0.05)。RLB组术后恶心、呕吐发生率为16%,低于C组的44%,差异有统计学意义(P<0.05),两组术后头晕、皮肤瘙痒和呼吸抑制等发生率比较差异无统计学意义(P>0.05),RLB组未见阻滞相关并发症发生。结论椎板后阻滞能用于乳腺癌改良根治术,不仅可以减少术后阿片类药物用量,提高术后镇痛效果,还可以降低术后恶心、呕吐的发生率。     

Interscalene brachial plexus block for outpatient shoulder arthroplasty: Postoperative analgesia, patient satisfaction and complications

Background:

Shoulder arthroplasty procedures are seldom performed on an ambulatory basis. Our objective was to examine postoperative analgesia, nausea and vomiting, patient satisfaction and complications of ambulatory shoulder arthroplasty performed using interscalene brachial plexus block (ISB).

Materials and Methods:

We prospectively examined 82 consecutive patients undergoing total and hemi-shoulder arthroplasty under ISB. Eighty-nine per cent (n=73) of patients received a continuous ISB; 11% (n=9) received a single-injection ISB. The blocks were performed using a nerve stimulator technique. Thirty to 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected perineurally after appropriate muscle twitches were elicited at a current of less than 0.5% mA. Data were collected in the preoperative holding area, intraoperatively and postoperatively including the postanesthesia care unit (PACU), at 24h and at seven days.

Results:

Mean postoperative pain scores at rest were 0.8 ± 2.3 in PACU (with movement, 0.9 ± 2.5), 2.5 ± 3.1 at 24h and 2.8 ± 2.1 at seven days. Mean postoperative nausea and vomiting (PONV) scores were 0.2 ± 1.2 in the PACU and 0.4 ± 1.4 at 24h. Satisfaction scores were 4.8 ± 0.6 and 4.8 ± 0.7, respectively, at 24h and seven days. Minimal complications were noted postoperatively at 30 days.

Conclusions:

Regional anesthesia offers sufficient analgesia during the hospital stay for shoulder arthroplasty procedures while adhering to high patient comfort and satisfaction, with low complications.     

Continuous ultrasound-guided sacral intervertebral block for postoperative analgesia in neonates

A sacrococcygeal teratoma and a sacral agenesis represent a contraindication to a caudal block. We report two cases where the optimal use of ultrasound helped place a sacral intervertebral catheter in two neonates. Radiological and ultrasound studies of the sacrum and spine should be available before performing the procedure.     

超声引导髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞在老年患者髋关节置换术术后镇痛中的作用

目的 观察超声引导下髂筋膜腔隙与髂腹下/髂腹股沟神经联合阻滞在老年患者全髋关节置换术术后镇痛的作用. 方法 选择2015年1月～2015年11月全身麻醉下行单侧前外侧入路全髋关节置换术的患者50例,年龄61～75岁,ASA分级Ⅱ、Ⅲ级,采用随机数字表法将患者分为两组(每组25例):单纯髂筋膜间隙阻滞组(单纯组)和髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞组(复合组).手术结束后即刻行患侧超声引导下神经阻滞.单纯组于髂筋膜腔隙注射0.3％罗哌卡因30 ml;复合组分别于髂筋膜腔隙与髂腹下/髂腹股沟注射0.3％罗哌卡因15 ml.记录患者一般情况,术后6、12、18、24 h患者静息及运动VAS评分,超声成像时间,穿刺注药时间,患者自控镇痛(patient controlled analgesia,PCA)芬太尼累计用量及术后镇痛相关副作用的发生情况. 结果 两组患者一般情况差异无统计学意义(P＞0.05).两组患者术后各时点静息VAS评分差异均无统计学意义(P＞0.05).复合组运动VAS评分在术后6 h [(3.8±0.9)分]和12 h[(3.6±1.3)分]时点较单纯组[(5.5±11)分和(5.3±1.0)分]降低(P＜0.05);在术后18h和24 h时点,2组运动VAS评分差异均无统计学意义(P＞0.05).两组患者超声成像时间和穿刺注药时间差异均无统计学意义(P＞0.05).复合组PCA芬太尼累计用量[(0.54±0.03) mg]较单纯组[(0.69±0.05) mg]降低(P＜0.05).两组患者术后镇痛相关副作用发生率差异无统计学意义(P＞0.05). 结论 在老年患者髋关节置换术后,超声引导髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞可安全、有效地用于术后镇痛,显著缓解患者甲早期的运动疼痛同时减少芬太尼用量.     

Interscalene plexus block for arthroscopy of the hurnero-scapular joint

Interscalene plexus block was performed in nine patients subjected to shoulder arthroscopy. The operating conditions, including muscle relaxation, were fully adequate in all patients (after additional local anaesthesia of the skin in four patients). With the exception of one patient who experienced temporary hoarseness (probably due to a concomitant block of the recurrent laryngeal nerve), no side effects were found and the patients tolerated the surgical procedure well. Interscalene block might be a suitable alternative to general anaesthesia for shoulder arthroscopy. However, additional local anaesthesia at the site where the arthroscope is to be inserted is frequently required.     

The efficacy of paravertebral block using a catheter technique for postoperative analgesia in thoracoscopic surgery: a randomized trial

Objective: The analgesic scheme combining paravertebral block (PVB) and intravenous non-steroidal anti-inflammatory drug (NSAID) has proven to be effective for postoperative pain control after thoracotomy. The hypothesis tested in this study was that this policy was also suitable to improve pain control after video-assisted thoracic surgery (VATS). Methods: This was a prospective randomized study on 40 patients submitted to three-ports’ VATS for pneumothorax or solitary pulmonary nodule. The sample size was calculated to detect one point of minimum pain score difference with 80% statistical power. Patients were randomly assigned to two groups: (1) paravertebral block group (PVB) (n = 20) – At the end of surgery, a catheter was placed in patients in the thoracic paravertebral space under camera control; they received a bolus of 15 ml of local anesthetic (ropivacaine 0.2%) every 6 h, combined with endovenous metamizol (1 g); and (2) alternate NSAIDs group (AN) (n = 20) – They were treated with paracetamol (1 g) combined with metamizol (1 g) every 6 h. Subcutaneous meperidine (synthetic opioid) was employed as rescue drug. Both groups were comparable in terms of age, sex, pathology, and co-morbidity. Pain level was measured with the visual analog scale (VAS) at 1, 6, 24, and 48 h. Results: No side effects related to any of the two analgesic techniques were noted. Two patients needed rescue meperidine in the AN group, and none in the PVB group. VAS scores were the following: PVB group, VAS 1 h: 1.4 ± 0.8, VAS 6 h: 3.4 ± 1.2, VAS 24 h: 2.6 ± 1.0, VAS 48 h: 2.2 ± 0.9, and mean VAS: 2.4 ± 1.3; AN group, VAS 1 h: 2.8 ± 1.0, VAS 6 h: 4.9 ± 1.3, VAS 24 h: 3.9 ± 1.4, VAS 48 h: 3.3 ± 1.0, and mean VAS: 3.8 ± 1.4. VAS scores were significantly lower at any time in the PVB patients (p < 0.01). Conclusions: The analgesic regimen combining PVB and NSAID provided an excellent level of pain control. Thoracoscopy assisted positioning of the paravertebral catheter is simple and effective, and allows direct visualization of correct delivery of local anesthetic. It represents a valuable addition to any VATS procedure.     

Supraclavicular continuous peripheral nerve block in a wounded soldier: when ultrasound is the only option

The complex nature of combat-related injuries requires frequentoperative interventions and prolonged analgesic therapy. Theapplication of continuous peripheral nerve block (CPNB) hasbeen an important anaesthetic tool in the management of combatsoldiers wounded from the current conflicts. The severe, destructivenature of combat injuries makes placement of CPNB difficultor impossible using more common neurostimulation approaches.The use of ultrasound technology has improved our success inplacing CPNB in the presence of such injuries. We report theapplication of ultrasound technology in placing CPNB in a combat-injuredsoldier, whose injuries precluded other CPNB options.     

超声引导下腹横肌平面阻滞用于下腹部手术术后镇痛的效果

目的观察超声引导下腹横肌平面(TAP)阻滞用于下腹部手术术后镇痛的临床效果。方法选择下腹部手术患者90例,年龄25~55岁,随机分为三组,每组30例。A组行超声引导下单侧TAP阻滞;B组行舒芬太尼PCIA;C组行舒芬太尼+罗哌卡因PCEA。所有患者均在腰-硬联合麻醉下完成手术。观察并记录术后2、4、8、16、24h的VAS疼痛评分,及术后镇痛相关的不良反应。结果与A组比较,B组在术后2、4、8、16h的VAS疼痛评分明显升高(P0.05);C组在术后24h的VAS疼痛评分明显降低(P0.05)。与A组比较,B组恶心呕吐、皮肤瘙痒、嗜睡明显增多(P0.05);C组恶心呕吐、下肢感觉及运动异常、尿潴留明显增多(P0.05)。结论超声引导下腹横肌平面阻滞可有效缓解下腹部手术后24h内的疼痛,且无明显不良反应。     

罗哌卡因-曲马多骶管阻滞在小儿尿道下裂成形术后的镇痛效果观察

目的观察罗哌卡因复合曲马多骶管阻滞与单独应用罗哌卡因、曲马多,对小儿尿道下裂成形术后镇痛时间、疼痛评分、镇痛次数、睡眠质量满意度和并发症的影响。探讨罗哌卡因复合曲马多和单独应用曲马多、罗哌卡因能否提供满意的术后镇痛。方法选取自2012年6月～2013年2月于我院行尿道下裂成形术的患儿66名,美国麻醉医师协会（ASA）分级Ⅰ级,年龄1岁-6岁,采用完全随机设计的方法分为3组（每组22例）：0．2％罗哌卡因1ml／kg组（L组）、0．2％罗哌卡因1ml／kg＋曲马多1．5mg／kg组（LT组）、0．9％氯化钠1ml／kg＋曲马多1．5mg／kg组（T组）。麻醉维持均采用骶管阻滞复合全凭七氟醚吸入全麻。观察并记录镇痛维持时间（骶管阻滞到术后第1次镇痛给药的时间）,术毕患儿清醒1、2、4、6、12、24h三点疼痛评分,术后24h镇痛次数,睡眠质量满意度评估,并发症等。结果镇痛时间比较,LT组（14．5±2．5）h比其他两组明显延长（P〈0．05）。3组疼痛评分在2h前差异无统计学意义,2h到6hT组与L组、LT组比较,差异有统计学意义（P〈0．05）。T组与LT组、L组比较,术后24h所需镇痛次数明显加（P〈0．05）。术后寒战发生率L组为18％,而LT组、T组为0。3组患儿术毕清醒均未出现运动神经阻滞,呕吐次数也无明显增加。LT组100％的患儿父母对患儿术后24h睡眠质量满意度为优和良。结论0．2％罗哌卡因1ml／kg复合曲马多1．5mg／kg骶管阻滞用于6岁以下小儿尿道下裂成形术后镇痛是安全、有效的,可有效镇痛（14．5±2．5）h,并发症少且能有效减少术后寒战的发生。     

腹横肌平面阻滞在腹部手术术后镇痛中的应用

背景 腹横肌平面（transversus abdominis plane block,TAP）阻滞技术是一项近几十年发展起来的新型的局部神经阻滞技术,它可以减少术后镇痛阿片类药物的用量,继而减少其相关副作用,提高患者总的满意度. 目的 介绍TAP阻滞技术,探讨其在腹部手术术后镇痛中的应用. 内容 就TAP阻滞的解剖基础、操作方法、临床效果、并发症及尚待解决的问题等方面进行综述,为临床研究及应用提供参考. 趋向 TAP阻滞技术,被证实在很多手术的术后镇痛应用中是安全、有效的,有着广阔的应用前景.     

Prolonged peridural block for postoperative analgesia in heart surgery patients

Prolonged peridural blockade with trimekain used in 1000 cardiosurgical patients is shown to be an effective prophylactic measure against postoperative complications. This method should not be widely used in patients with blood circulation insufficiency.     

腹横肌平面阻滞在乳房再造术后镇痛中的临床研究

目的：探讨腹横肌平面阻滞在腹壁皮瓣乳腺癌患者乳房再造术后镇痛的临床效果。方法回顾性分析腹横肌平面阻滞置管间断注射局部麻醉药术后镇痛和术后患者自控静脉镇痛48 h 镇痛效果、阿片类药物的使用量及术后镇痛相关并发症的发生率。结果腹横肌平面阻滞组术后镇痛效果与患者自控静脉镇痛组相当,但阿片类药物使用量和术后镇痛相关并发症发生率却远低于患者自控静脉镇痛组。结论腹壁皮瓣乳腺癌患者乳房再造术后应用腹横肌平面阻滞置管镇痛可提供与传统术后镇痛方法相当的镇痛效果,同时又具有传统术后镇痛方法所不具备的优势,值得临床应用。     

腹横肌平面阻滞用于剖宫产术后镇痛的效果评价:Meta分析

目的 采用Meta分析的方法评价腹横肌平面阻滞(transversus abdominis plane block,TAPB)在剖宫产术后镇痛的安全性及有效性. 方法 检索PubMed 、OVID、EMBASE、Cochrane图书馆,检索时间从建库至2015年3月.收集剖宫产术后镇痛使用TAPB的随机对照临床试验.采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan5.2软件进行Meta分析. 结果 共纳入12项研究,包括663例患者,其中TAPB组342例,对照组321例.与对照组比较,TAPB组患者术后12h活动时VAS评分明显降低[加权均数差(weighted mean difference,WMD)=-0.61,95％置信区间(confidence interval,CI):-1.13～-0.09,P＜0.05]、术后24 h吗啡累积消耗量减少(WMD=-22.78,95％CI:-24.49～-21.07,P＜0.05)以及TAPB组患者需首次给予补救镇痛的时间延长(WMD=148.22,95％CI:86.57～209.86,P＜0.05),并且TAPB组患者恶心呕吐[比值比(OR)=0.23,95％CI:0.12～0.44,P＜0.05]及过度镇静(OR=0.29,95％CI:0.12～0.67,P＜0.05)的发生率较低. 结论 TAPB可能是剖宫产患者术后镇痛的一种较好的选择.     

小儿骶管复合用药对术后镇痛的影响

目的观察小儿骶管复合用药对术后镇痛的影响。方法80例1～4岁患儿随机分为四组,每组20例。在静脉麻醉后行1%利多卡因1ml/kg骶管阻滞:Ⅰ组局麻药中不加其他药,Ⅱ组加芬太尼2μg/kg,Ⅲ组局麻药中加新斯的明2μg/kg,Ⅳ组局麻药中加曲马多2mg/kg。术后给予芬太尼护师控制泵注镇痛(NCA)治疗。分别于术后1、2、4、6、24h观察镇痛和镇静评分,记录镇痛时间(初次NCA)、NCA芬太尼用量、不良反应及出院时间。结果Ⅳ组的镇痛时间(510.7±64.9)min,长于Ⅰ组的(174.5±39.3)min、Ⅱ组的(291.7±50.8)min和Ⅲ组的(242.0±62.8)min(P0.01)。但Ⅳ组术后恶心呕吐的发生率高于其他三组(P0.05)。结论2mg/kg曲马多复合1%利多卡因1ml/kg行小儿骶管阻滞的术后镇痛效果较好,但其恶心呕吐发生率也有所增加。     

阻力消失法定位髂筋膜间隙的准确性:超声法评价

目的 应用超声技术评价阻力消失法定位髂筋膜间隙的准确性.方法 拟行髋部手术患者175例,在髂前上棘和耻骨结节间连线中外1/3交界处向尾端旁开2 cm处进针,当感觉到2次突破感后,给予0.5％罗哌卡因30 ml,经超声辨认药液扩散部位确定准确穿刺情况,并记录给药后20min感觉阻滞有效情况.结果 经超声确定,应用阻力消失法定位髂筋膜间隙准确率56.6％.穿刺错误部位构成情况:髂筋膜浅层25例、髂腰肌内51例;准确定位于髂筋膜间隙的阻滞有效率为98.0％,而定位错误时阻滞有效率为82.9％.结论 阻力消失法不能准确定位髂筋膜间隙.     

胸椎旁神经阻滞和竖脊肌平面阻滞用于胸腔镜肺叶切除术术后镇痛效果的Meta分析

目的:通过Meta分析方法评价超声引导下胸椎旁神经阻滞（thoracic paravertebral nerve block, TPVB）和竖脊肌平面阻滞（erector spinae plane block, ESPB）用于胸腔镜肺叶切除术术后镇痛的效果。方法:计算机检索PubMed、Web of Science、C...