压力波形监测在硬膜外麻醉穿刺置管中的研究进展

在传统盲探穿刺的基础上,近年来提出一种新的压力波形监测方法用于硬膜外麻醉。相比较于临床普遍采用的阻力消失法以及超声引导、计算机断层扫描、介入造影等新兴的辅助硬膜外麻醉的穿刺方法,大量研究表明压力波形监测方法可作为硬膜外麻醉穿刺成功的客观指征,可全程实时监测硬膜外麻醉过程,安全可靠,简便实用。文章回顾压力波形监测方法在硬...     

压力图像与回流性状双指征法辅助硬膜外腔定位麻醉的准确性与可行性研究

目的 探讨压力图像与回流液相双指征法辅助硬膜外麻醉定位与监测的准确性与可行性.方法 择期硬膜外麻醉患者1 200例,ASA Ⅰ～Ⅲ级,年龄、体重、性别不限.根据硬膜外穿刺节段分为6组(每组200例):颈组(C4～5/C5～6/C6～7,C组),胸Ⅰ组(T3～4/T4～5,T1组),胸Ⅱ组(T8～9/T9～10,T2组)...     

压力波形联合回流液相双指征监测法定位硬膜外麻醉的临床应用

背景 硬膜外穿刺技术临床上广泛用于颈部、胸腹部、下肢手术的麻醉与疼痛治疗.现行传统硬膜外麻醉操作为一种盲探性穿刺置管技术,单独依靠操作者的感觉和经验及简单的试验方法评判麻醉成功与否,难以做到精确可控,而麻醉状态无客观指征监测,麻醉失败原因常无法得知.目的 为改进现行盲探方法,探求硬膜外麻醉的可视化指征的可行性.内容 自2006年以来,经不断深入研究,以“压力波形联合回流液相双指征法”用于辅助硬膜外麻醉,达到了可视化指征,辅助硬膜外麻醉定位与监测,效果理想.至今已在临床成功应用万例以上(内蒙古医学院附属医院完成硬膜外麻醉1万余例/年,约占麻醉总例数的50％).趋向 目前此项技术已常规应用于临床并加以推广,现予以介绍,以期建立新型硬膜外麻醉操作流程,从而使麻醉全程达到严谨、规范、安全、可靠,进一步提高硬膜外麻醉的安全有效性.     

压力波形法与阻力消失法在硬膜外穿刺术中的应用比较

目的 比较压力波形法与阻力消失法在硬膜外穿刺术中的成功率.方法 择期腹部外科手术拟行硬膜外麻醉患者400例,随机均分为压力波形组(P组)和阻力消失组(C组).所有患者均采用直入法进针.P组在连续压力监测下施行穿刺;C组采用常规阻力消失法施行硬膜外穿刺.记录两组硬膜外穿刺时间、置管完成时间、穿刺成功率等,并记录压力波形变化.结果 两组硬膜外穿刺时间、置管完成时间差异无统计学意义.P组穿刺成功率显著高于C组(100％ vs.94％,P＜0.01).P组在针尖突破黄韧带时压力波形出现直线返折,继而出现正弦波形,确认针尖进入硬膜外腔.结论 硬膜外穿刺中采用压力波形监测有助于提高穿刺成功率,且不延长操作时间.     

压力囊泡指示器指导硬膜外穿刺的效果

目的 评价压力囊泡指示器指导硬膜外穿刺的效果.方法 试验Ⅰ:拟行硬膜外穿刺的患者32例,常规硬膜外穿刺成功后,穿刺针针尾连接压力传感器,测定硬膜外间隙压力.试验Ⅱ:拟行硬膜外穿刺的患者70例,应用压力囊泡指示器指导硬膜外穿刺.囊泡瘪掉后暂停穿刺,依据传统临床指征判断穿刺针是否到达硬膜外腔.记录压力囊泡指示器指导硬膜外穿刺成功情况.结果 硬膜外间隙压力为(10±4)cm H2O;完成压力囊泡指示器指导硬膜外穿刺患者70例,均符合操作要求,并经临床证实穿刺成功,成功率100%.结论 压力囊泡指示器可辅助硬膜外穿刺,准确判断穿刺针尖到达硬膜外间隙,具有临床应用价值.     

硬膜外阻滞注药速度与硬膜外腔压力及扩散关系的研究

为了探讨硬膜外腔持续输注和单次推注后硬膜外腔压力与扩散的关系，我们测定了输注和推注后硬膜外腔压力。１５例择期下肢手术患者随机分为输注组（ｎ＝７）和推注组（ｎ＝８）。在侧卧位下于Ｌ１－２和Ｌ２－３行硬膜外穿刺，穿刺针分别连接压力传感器和微泵导管或注射器，以１ｍｌ／分或１ｍｌ／３秒速度向硬膜外腔注入２％利多卡因１２ｍｌ，持续描记压力曲线和 ＥＣＧⅡ １４分钟，改平卧位，于１５和３０分钟测阻滞范围。结果显示两组硬膜外峰压（Ｐ＜０．００５）和峰压时间（Ｐ＜０．００５）极其不同，而最大阻滞范围无明显差别（Ｐ＞０．０５），但输注组朝下以上侧阻滞范围差明显大于推注组（Ｐ＜０．０２）。两组硬膜外腔压与阻滞范围都无相关性。作者认为输注和推注给药后硬膜外腔压力不同，但对扩散无影响。     

硬膜外腔盐水冲洗逆转硬膜外麻醉所致的运动阻滞

硬膜外麻醉术后较长时间的运动阻滞常导致病人焦虑和排尿困难,且由于病人不能活动而给护理工作带来较大的困难。在这种情况下,人们希望通过采用能促进硬膜外麻醉消退的治疗措施来逆转或拮抗运动阻滞。笔者经硬膜外导管向硬膜外腔注入生理盐水,观察硬膜外腔盐水冲洗是否可逆转或消除硬膜外麻醉术后的运动阻滞。硬膜外麻醉术后较长时间的运动阻滞常导致病人焦虑和排尿困难,且由于病人不能活动而给护理工作带来较大的困难。在这种情况下,人们希望通过采用能促进硬膜外麻醉消退的治疗措施来逆转或拮抗运动阻滞。笔者经硬膜外导管向硬膜外腔注入生理盐水,观察硬膜外腔盐水冲洗是否可逆转或消除硬膜外麻醉术后的运动阻滞。     

腰麻穿刺针用于硬膜外腔穿刺的体会

自1998年以来,笔者对100例疑经硬膜外腔注药治疗疼痛的病人,采用7G腰穿针施行硬膜外腔穿刺,同期与应用18G Tuohy针作硬膜外腔穿刺者进行观察比较。现报告如下。     

硬膜外腔侧隐窝穿刺的研究

目的：设计一种新进路，使消炎镇痛液更集中地作用于病变神经根，或将胶原酶直接注射到突出的椎间备用上而摆脱大型Ｘ线机的限制，更简便有效地治疗腰腿痛。方法：通过解剖学研究、腰椎Ｘ线摄片和ＣＴ摄片分析，设计邮经椎板外切迹或小关节内缘进路到达硬膜外脸侧隐并将其应用临床。根据感觉平面的测定，疗效的评定和部分病例穿刺过程中的ＣＴ扫描观察，确认该地路的安全性和可行性。结果：应用椎板外切迹进路行硬膜外腔侧隐穿刺１７     

预充回流试验法预防硬膜外局麻药毒性反应与提高阻滞成功率的临床研究

目的 观察探讨预充回流试验法用于预防硬膜外局麻药毒性反应与提高硬膜外阻滞成功率的可行性.方法 择期硬膜外麻醉手术患者2 000例,所有患者均左侧卧位,采用直入法穿刺进针,以气泡压缩法确认进入硬膜外腔后,硬膜外腔内留置导管5 cm,导管末端连接装有盐水的玻璃注射器.对照1 ml/2 s的推注力度,测试导管阻力,同时硬膜外腔内导管退至3 cm.回抽玻璃注射器无脑脊液或血液,即硬膜外腔预充注入生理盐水3 ml,观察1 min玻璃注射器内有无问流液.观察回流液性状(-清;+微红;++显红;+++深红;++++血性)5 min,回流液性状为(+++)以下,给予试验量、维持量完成手术.观察记录麻醉全程回流液性状,麻醉效果和并发症发生情况.结果 预充回流液与麻醉效果存在相关关系.1例患者手术开始42 min发现回流液为血液,停止硬膜外注药,有效避免了局麻药毒性反应.所有患者均未出现神经、脊髓损伤,有1例患者术毕回流液为血液.结论 预充回流试验法可作为硬膜外麻醉成功的可靠指征,有效避免局麻药毒性反应,及时监测、处理硬膜外血肿的发生.     

Clinical evaluation of a simple epidural pressure sensor

Summary The Plastimed^® epidural pressure sensor was evaluated in 35 patients, twenty-eight of whom were suffering from head injury. In seven patients simultaneous intraventricular pressure measurements were obtained. The epidural pressure sensor was only functioning satisfactorily in approximately 2/3 of the patients, while it was malfunctioning or not functioning in the remainder. In seven comparable IVP/EDP studies significant differences up to 25 mm Hg were noted. In three patients IVP was greater than EDP. In two patients the opposite was true. No significant complications were observed.These unsatisfactory results have made us abandon the technique and resort to intraventricular or subarachnoidal pressure measurements.     

Clinical evaluation of a new epidural pressure monitor

Summary Comparative measuring of epidural pressure using the Spiegelberg probe 1 and ventricular fluid pressure was carried out in 15 neurosurgical intensive-care patients. Deviations in both directions were established, with a trend toward overestimating ventricular pressure in epidural pressure measuring (r=0.77). Individual pulsations, spontaneous wave courses and therapy-induced pressure changes were reflected without delays. There were no complications observed with probe implantation periods for up to 6 days. The system has been shown to be mechanically stable and easy to implant. We believe the device to be fit for trend monitoring of intracranial pressure. As with other epidural pressure monitoring systems, false assessments of ventricular pressure may lead to wrong decisions as to the required therapy.     

Effects of osmotic pressure on intrathecal and epidural lidocaine anesthesia

Lidocaine (1%), either in plain distilled water or in 10% dextrose, was intrathecally or epidurally administered to urethane-chloralose anesthetized cats. Electrical stimulation was applied to the gracile tract at a cervical level, and the resultant antidromic compound action potentials were recorded from the sural nerve. Lidocaine dissolved in plain distilled water was more effective than lidocaine dissolved in 10% dextrose solution in suppressing the compound action potentials. Lidocaine-free plain distilled water or dextrose solution caused partial suppression of the compound action potentils. The suppression was more marked following plain distilled water application than following application of 5% or 10% dextrose.     

Effects of rapid inhalation induction with sevoflurane-oxygen anesthesia on epidural pressure in humans

In this study, we chose sevoflurane as the volatile anesthetic for rapid inhalation induction (RII) and investigated its usefulness. We also assessed how RII with sevoflurane affected epidural pressure, and compared RII with rapid intravenous induction by thiopental on epidural pressure. The results were as follows: RII with 5% sevoflurane had a shorter induction time compared with published results on RII with other volatile anesthetics like halothane and isoflurane, and was accompanied by fewer complications. When RII with sevoflurane was attempted, epidural pressure increased significantly upon exhalation to residual volume just before induction and during laryngoscopy and endotracheal intubation compared with the preinduction value. There was induction methods during laryngoscopy and endotracheal intubation. Epidural pressure measurements are reportedly useful in monitoring intracranial pressure. Consequently, in patients with increased intracranial pressure, exhaling to residual volume and increasing arterial blood pressure during laryngoscopy and endotracheal intubation should be avoided. The results of this study suggest that RII with 5% sevoflurane in itself is safe and useful, and that it is unlikely to increase intracranial pressure as compared with rapid intravenous induction by thiopental. A part of this study was presented at The 40th annual meeting of the Japan Society of Anesthesiology, 1993     

Estimation of cerebrospinal fluid pressure via lumbar epidural space by equilibration method

By introducing water into the lumbar epidural space from a vertically held tube under gravity, we measured lumbar epidural pressure (EDP) when the water meniscus no longer declined. In principle, the pressure of either side of dura mater had become equal at this time which is referred to as the equilibrium point. EDP measured in this way was consistently 1–3 mmHg lower than lumbar cerebrospinal fluid pressure (CSFP) not only immediately after the equilibrium point, but also for 5 min after the equilibrium point had been reached. Both EDP and CSFP responded sensitively to the manipulations of CSFP during this period. We suggest that this method may provide a means to continuously monitor CSFP by EDP.