超声联合神经刺激仪引导后入路臂丛神经阻滞的效果

对于肥胖、强直性脊柱炎和需要术后连续臂丛神经阻滞镇痛的的患者,神经刺激仪引导的后路臂丛神经阻滞是前外侧入路难以实施时的另一选择[1].虽然此种方法有其独特的优势,但是仍然存在误伤血管及神经并发症等风险.超声技术已广泛用于引导神经阻滞,超声联合神经刺激仪引导后入路臂丛神经阻滞能否降低上述风险尚有待研究.本研究拟探讨超声联合神经刺激仪引导后入路臂丛神经阻滞的效果.     

超声联合神经刺激仪引导实施老年病人臂丛神经阻滞的临床研究

目的 评估超声联合神经刺激仪引导实施老年病人臂丛神经阻滞的优缺点及安全性.方法 75例ASAⅡ或Ⅲ级择期实施上肢手术的65岁以上老年病人,随机均分为三组:超声联合神经刺激仪定位组(US组);超声引导组(U组);神经刺激仪定位组(S组).记录各组臂丛神经阻滞的各项评价指标.结果 三组局麻药用量差异均无统计学意义.US组和U组阻滞操作时间、阻滞起效时间、阻滞完善时间均短于S组(P＜0.05),辅助用药例数、并发症发生率均低于S组(P＜0.05);US组阻滞起效时间、阻滞完善时间均短于U组(P＜0.05),三组均无病人改全麻.结论 超声联合神经刺激仪引导实施肌间沟臂丛神经阻滞成功率高,并发症少,对病人影响小,用于老年病人安全有效.     

神经刺激仪定位下联合臂丛神经阻滞的临床观察

单一臂丛阻滞常导致阻滞不全,联合臂丛神经阻滞来提高麻醉效果.但传统阻滞方法的成功率受操作者的经验、患者的合作程度及能否及时、准确地讲述异感部位等多种因素影响,故临床上阻滞不全甚至失败的情况还会发生.我院于2007年开始运用周围神经刺激仪(TOF-WatchSX)进行肌间沟、腋路联合臂丛神经定位,减少了操作的盲目性和有效地控制了药量现报道如下.     

神经刺激仪引导后入路臂丛神经阻滞的可行性

神经刺激仪引导下臂丛神经阻滞是上肢手术常用的麻醉方法,常规采用肌间沟入路法,该入路穿刺路径较短,不利于术后连续臂丛神经阻滞镇痛的实施,而对于肥胖或强直性脊柱炎患者,肌间沟难以定位,不宜采用.后入路臂丛神经阻滞骨性解剖标志明显,易于定位,且穿刺路径相对较长,有利于术后连续臂丛神经阻滞镇痛时导管的固定[1].本研究拟探讨神经刺激仪引导后入路臂丛神经阻滞的可行性.     

神经刺激仪定位腋路臂丛神经阻滞的临床观察

近年来神经刺激仪定位技术在区域阻滞中应用广泛,它以电刺激诱发出的特定肌肉收缩为指标,阻滞成功率高.本研究在神经刺激仪定位下行腋路臂丛神经阻滞用于显微手外科手术,并与传统法腋路臂丛神经阻滞麻醉效果进行比较.     

神经刺激仪引导下两点和四点腋路臂丛神经阻滞效果的比较

目的 在神经刺激仪引导下,比较0.25%左旋布比卡因用于两点和四点腋路臂丛神经阻滞的临床效果.方法 64例拟在臂丛神经阻滞下行择期手术的患者,随机均分为两组:Ⅰ组注射0.25%左旋布比卡因9 ml阻滞肌皮神经,并注射0.25%左旋布比卡因27 ml,随机阻滞正中神经,尺神经或桡神经三支中的一支;Ⅱ组分别注射0.25%左旋布比卡因9 ml,阻滞上述四支神经.阻滞后30 min观察对肌皮、正中、尺和桡神经的感觉和运动阻滞效果.记录臂丛神经阻滞实施时间、手术时间、止血带使用时间、手术等待时间等指标.术后随访患者,记录臂丛神经阻滞的镇痛时间.结果 两组患者在性别、年龄、体重、手术部位、手术时间、止血带使用时间等方面差异无统计学意义.Ⅰ组所需的臂丛神经阻滞实施时间(平均6.2 min)较Ⅱ组(平均12.8 min)明显缩短(P＜0.05),但是Ⅰ组的首次臂丛神经阻滞成功率明显低于Ⅱ组(P＜0.05).在臂丛神经阻滞30 min后,两组患者对肌皮神经的感觉和运动阻滞评分差异无统计学意义;Ⅰ组患者尺、桡、正中神经的感觉和运动阻滞评分明显高于Ⅱ组(P＜0.05).结论 在神经刺激仪引导下的臂丛神经两点阻滞效果明显低于四点阻滞,由于实施两点法的许多患者需要追加神经阻滞,因此并不能够缩短患者的手术等待时间.     

超声联合神经刺激仪引导下闭孔神经阻滞效果的临床研究

目的通过比较超声联合神经刺激仪引导及单纯神经刺激仪引导下闭孔神经阻滞(ONB),探讨超声联合神经刺激仪引导ONB的可行性及先进性。方法需行ONB的经尿道膀胱肿瘤电切术(TURBT)患者60例,男女不限,年龄39~77岁,BMI 19~30kg/m2,随机均分为神经刺激仪组(S组)和超声联合神经刺激仪组(US组),S组患者在神经刺激仪引导下经典入路行ONB;US组患者在超声联合神经刺激仪引导下行ONB。神经阻滞过程中记录两组患者穿刺中最高VAS评分、穿刺一针成功率、穿刺内收肌收缩时间间隔、穿刺次数、穿刺深度、阻滞后大腿内收肌力、成功率及并发症等指标。结果两组患者ONB成功率、阻滞后大腿内收肌力、并发症发生率差异无统计学意义;一针成功率US组明显高于S组(P0.01);US组最高VAS评分明显低于,穿刺内收肌收缩时间间隔明显短于,诱发收缩穿刺次数明显少于,穿刺深度明显浅于S组(P0.05)。结论与经典入路神经刺激仪引导下ONB比较,超声联合神经刺激仪引导下ONB定位更准,操作更快,患者痛苦更小。     

超声联合神经刺激仪引导神经阻滞在膝关节镜术中的应用

目的研究分析膝关节镜手术过程中采用超声联合神经刺激仪引导坐骨神经、股神经神经阻滞麻醉的效果及临床价值。方法选取2017年1月至2019年3月本院收治的拟行膝关节镜手术治疗患者共76例,按照数字表法随机分为A、B两组。其中A组38例,行超声、神经刺激仪联合导引下神经阻滞麻醉;B组38例,行硬膜外麻醉。结果 B组患者T0、T1、T3、T6均少于A组患者,而B组患者T4显著少于A组患者(P0.05);A组与B组患者T7时的平均动脉压、心率以及T8、T9、T10时心率均无明显差异(P0.05),B组患者T8、T9、T10时的平均动脉压水平值显著小于A组患者(P0.05);A组患者麻醉后不良反应情况显著少于B组患者(P0.05)。结论超声联合神经刺激仪引导坐骨神经、股神经阻滞麻醉在膝关节镜手术过程中具有较好的麻醉效果,且麻醉后的不良反应情况较少,麻醉操作相对更为简单,血流动力学受干扰小,患者治疗舒适度更高,适合临床选择应用。     

三种定位方法行臂丛神经阻滞的效果比较

目的探讨三种定位方法行臂丛神经阻滞的效果。方法选择择期上肢手术患者120例,随机均分成三组:超声引导组(A组)、神经刺激器组(B组)、传统方法组(C组),局麻药为2%盐酸氯普鲁卡因30ml。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;评定麻醉效果(优、良、差),记录并发症。结果 A组神经阻滞起效时间较短,而C组起效时间较长,A组和B组明显短于C组,且A组短于B组(P<0.01)。A组神经阻滞完善率均接近100%,明显高于B组和C组(P<0.05或P<0.01)。麻醉效果优等率A组为95%,B组为75%,C组为47.5%,A组明显高于B、C组(P<0.05或P<0.01)。A、B组各有1例,C组有3例并发症,但三组均未出现严重并发症。结论超声引导下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良好,起效时间更短,提高了麻醉安全性和有效性。     

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.     

超声引导喙突处锁骨下臂丛神经阻滞与逆行锁骨下臂丛神经阻滞的比较

目的 比较超声引导喙突处锁骨下臂丛神经阻滞与逆行锁骨下臂丛神经阻滞的临床麻醉效果.方法 拟行前臂或手部手术患者60例,随机分为两组,分别行超声引导下喙突处锁骨下臂丛神经阻滞(观察组)和超声引导逆行锁骨下臂丛神经阻滞(对照组),每组30例.记录麻醉成功率、麻醉操作时间、持续时间及并发症发生例数、各臂丛神经的起效时间.结果 对照组尺神经、前臂内侧皮神经起效时间较观察组短(P＜0.05).对照组有5例Homer's综合征,1例误入血管.结论 超声引导喙突处锁骨下臂丛神经阻滞和逆行锁骨下臂丛神经阻滞均是可行有效的区域麻醉方法.     

超声引导锁骨下臂丛神经阻滞不同入路的临床效果

目的比较超声引导锁骨下臂丛神经阻滞锁骨中点入路与喙突入路的临床效果。方法选择拟行前臂及手外科手术患者60例,男32例,女28例,年龄18~70岁,体重50~70kg,ASAⅠ或Ⅱ级。将患者随机分为两组,每组30例。M组行超声引导锁骨中点入路臂丛神经阻滞(一点法),C组行超声引导喙突入路臂丛神经阻滞(两点法),阻滞药物均为1%盐酸利多卡因与0.375%盐酸罗哌卡因混合液20ml,C组分2次,每次注入10ml。记录麻醉操作时间、阻滞起效时间、麻醉维持时间、阻滞完成后5min(T_0)、10min(T_1)、15min(T_2)、20min(T_3)、25min(T_4)、30min(T_5)患者的感觉运动阻滞情况以及不良反应。结果 M组麻醉操作时间明显短于C组(P0.05);两组患者阻滞起效时间与麻醉维持时间差异无统计学意义;T_0和T_1时M组尺神经的感觉阻滞效果明显优于C组(P0.05);T_0时C组肌皮神经的感觉阻滞效果明显优于M组(P0.05);T_5时两组患者的感觉和运动阻滞情况差异无统计学意义。结论超声引导锁骨中点入路与喙突入路均可安全用于臂丛神经阻滞,锁骨中点入路操作时间更短,更易掌握。     

Restricted infraclavicular distribution of the local anesthetic solution after infraclavicular brachial plexus block

BACKGROUND AND OBJECTIVES: The distribution of local anesthetic after different approaches for brachial plexus anesthesia could be responsible for the varying rates of side effects, such as phrenic block, hoarseness, and Horner's syndrome associated with each approach. We compared the distribution of local anesthetic within the neurovascular space in infraclavicular block with that of interscalene and supraclavicular block. METHODS: In a prospective analysis using fluoroscopy, we studied the distribution of a solution of local anesthetic containing radiologic contrast medium in 18 patients. Six patients received an interscalene block, another 6 patients received a perpendicular supraclavicular block, and another 6 patients, a perpendicular coracoid block. RESULTS: Distribution of the anesthetic solution in the interscalene and supraclavicular groups extended to both supraclavicular and infraclavicular spaces in all patients. This distribution was significantly different (P <.05) compared with that of the infraclavicular group. In this group, the solution remained below the clavicle in every patient. CONCLUSIONS: Spread of the local anesthetic from the infraclavicular space after infraclavicular coracoid block appears to be limited to below the level of the clavicle. Conversely, local anesthetic solution passes below the clavicle in all patients given interscalene or supraclavicular blocks.     

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。     

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。     

Comparison of two different techniques for brachial plexus block: infraclavicular versus axillary technique

BACKGROUND: Brachial plexus block via the axillary approach is problematic in patients with limited arm mobility. In such cases, the infraclavicular approach may be a valuable alternative. The purpose of our study was to compare axillary and infraclavicular techniques for brachial plexus block in patients undergoing arm or forearm surgery. METHODS: After institutional approval and informed consent were obtained, 30 patients (ASA physical status I or II) scheduled for forearm and hand surgery under brachial plexus anesthesia were included in the study. Patients were randomly allocated into two groups. Brachial plexus block was performed via the axillary approach in the Group A patients and via the infraclavicular approach in the Group I patients using a peripheral nerve stimulator. All blocks were performed with a total dose of 40 ml 0.375% bupivacaine. RESULTS: In each nerve territory (radial, ulnar, median, and musculocutaneous), the mean values of the degree and the duration of the sensory block and motor block were not significantly different between the two groups (P > 0.05). Inadvertent vessel puncture was significantly more frequent in the axillary approach (P < 0.05). CONCLUSION: Brachial plexus block performed via the infraclavicular approach is as safe and effective as the axillary approach. Infraclavicular approach may be preferred to the axillary approach when the upper arm mobility is impaired or not desired.     

Vertical infraclavicular technique of brachial plexus block

In comparison to preceding infraclavicular methods, vertical infraclavicular blockade of the brachial plexus (VIP), as described by Kilka et al. in 1995, has quickly established itself because of the high success rates and comparatively low risks. Users define the blockade success achieved at around 85 %. However, this figure includes a more or less large number of patients who require supplementary analgesia/sedation and/or sleep induction in addition to pre-medication. Such a combined procedure, VIP plus analgesia/sedation is sometimes problematic e. g. in geriatric patients with a number of additional diseases. This patient group in particular could possibly profit from VIP without additional medication. Based initially on purely clinical observations, the following study reports on a method to improve the success rate of VIP blockade (operability) without additional analgesia and/or sedation. Altogether 499 patients were included in a retrospective study. In 88 patients (Group 1), the method of Kilka et al. was strictly applied. In a second Group (99 patients) the determined puncture site was moved 1 cm laterally. In Group 3 (312 patients), elicitation of a response to stimulation of the fasciculi of the brachial plexus was examined. This was performed by multiple punction, as a rule lateral to the puncture site of Kilka et al. In this group, the total dose of anesthetic (identical in all groups) was divided into 2 - 3 single doses. The pre-operative data of the patients in all groups were comparable. In the course of the VIP (Group 1), the method was changed in 13 patients (14.8 %) with incomplete blockade and after initial modification (Group 2), this was necessary in 12 patients (12.1 %). By means of targeted stimulation of individual sections of the brachial plexus (Group 3), the rate of incomplete blockade could be reduced to 8.3 %. The clearly improved blockade success was achieved without an increase in complications. In contrast to other authors, we came to the conclusion that the success rate was considerably higher when the anaesthetist had several years of experience. In the case of the authors of this study (longest experience), only 3.7 % of the plexus blocks were incomplete. For the use of VIP in practice it can be concluded that the optimal puncture site is often somewhat lateral to that defined by Kilka et al. By means of multiple stimulation with the aim of locating the individual fasciculi of the brachial plexus, the success of blockade, in terms of operability with unchanged low complication rates, can be considerably improved without the need for additional analgesics and/or sedation.