上腹部手术对肺功能的影响

为探讨手术与麻醉对肺功能的影响，对２５例上腹部手术（ＵＡＳ）患者术后肺功能的掼害和恢复进行了连续观察。手术前后分别用肺功能测定仪测量肺通气功能和血气，并于不同体位（坐位和仰卧位）测量功能余气量（ＦＲＣ）。结果显示：ＵＡＳ后呼吸频率（Ｒ）增加，潮气量（ＶＴ）减少，分钟通气量（ＶE）无明显改变。术后肺活量（ＶＣ）和用力肺活量（ＦＶＣ）等明显下降，手术当天ＦＶＣ为术前的２７．１％，至术后第７天恢复至术前６９．６％。ＰａＯ２术前为１０．５７±１．４６ｋＰａ，术后第Ｊ、３天分别为９．６１±１．４５和９．６９±１．３８ｋＰａ，同期肺泡一动脉血氧分区差［Ｐ（Ａ－ａ）ＤＯ２］梯度增加。硬膜外阻滞术后坐位时ＦＲＣ无明显改变，仰卧位时在术后第１、７天分别为术前的７５．４％和９５．８％。麻醉和手术时间越长，肺功能损害越重。本文证实ＵＡＳ后肺功能严重受损，气体交换障碍，术后坐位时ＦＲＣ无明显改变，仰卧位时减少。     

不同体位不同麻醉平面对剖宫产病人呼吸功能的影响

３１例ＡＳＡⅠ～Ⅱ级择期剖宫产病人术前坐、卧位肺功能测定：卧位时ＦＶＣ、ＦＶ１．０、ＦＶ３．０、ＭＢＣ、ＥＲＶ显著降低（Ｐ＜０．０１）。ＩＲＶ显著增加（Ｐ＜０．０１），ＶＣ、ＦＶ０．５、ＭＭＦ有降低（Ｐ＜０．０５）。不同麻醉平面麻醉前后肺功能比较，低平面组（Ｔ８以下）ＦＶＣ、ＶＣ、ＦＶ１．０、ＦＶ３．０、ＭＢＣ仍继续下降，而高、中平面组呈上升趋势或变化不大。观测结果提示由坐位改为平卧位，通气贮备和肺容量明显降低，Ｔ４以下阻滞平面对通气贮备和肺容量无明显影响；吸气肌未被阻滞时，腹肌的松弛有使肺通气贮备回升的趋势。     

超声引导下选择性神经阻滞在肩关节镜术后镇痛的临床应用

目的 对比研究超声引导下C5神经根联合锁骨上神经阻滞与肌间沟臂丛神经阻滞在肩关节镜手术后镇痛的临床应用价值。方法 采用前瞻性随机对照研究,将我院2017年3月至2018年12月收治的60例进行单侧肩关节镜手术的病人纳入研究。按照随机数字表法分为观察组（超声引导选择性C5神经根联合锁骨上神经阻滞）和对照组（超声引导下肌间沟臂丛神经阻滞）。两组均在超声引导下完成神经阻滞后实施全身麻醉,均采取相同的全身麻醉药物诱导及维持。记录并比较两组病人术后3、6、9、12 h静息疼痛视觉模拟量表（visual analogue scale, VAS）评分,屈肘、屈腕肌力评分,术后30 min膈肌麻痹程度、霍纳综合征的发生率及病人满意度等指标。结果 两组静息VAS评分在各时间点的差异均无统计学意义（P均＞0.05）。与对照组比较,观察组膈肌麻痹程度显著降低（P＜0.05）,屈肘、屈腕肌力显著增高（P＜0.05）,霍纳综合征的发生率显著降低（P＜0.05）,病人满意度显著增高（P＜0.05）。结论 在肩关节镜手术中,肌间沟臂丛神经阻滞和选择性C5神经根联合锁骨上神经阻滞均能有效缓解术后疼痛,但选择性神经阻滞对病人的膈肌麻痹程度、屈肘及屈腕肌力影响小,能显著降低霍纳综合征的发生率,更有利于病人术后功能锻炼,达到早日康复的目的。     

两种容量罗哌卡因用于超声引导下肌间沟臂丛神经阻滞对膈肌麻痹的影响

目的探讨在超声引导下使用0.375%罗哌卡因20 ml或30 ml行肌间沟臂丛神经阻滞的效果及对膈肌麻痹的影响。方法选择拟在超声引导下行肌间沟臂丛神经阻滞的右侧前臂手术患者54例,男39例,女15例,年龄18～65岁,ASAⅠ或Ⅱ级,随机分为A组(0.375%罗哌卡因20 ml)和B组(0.375%罗哌卡因30 ml),每组27例。记录臂丛各分支神经阻滞起效时间和痛觉阻滞情况,使用超声测量并记录麻醉前、注药后15、30 min时平静呼吸和用力呼吸时膈肌移动度以及RR,记录神经阻滞相关不良反应。结果两组臂丛分支神经痛觉阻滞完全率差异无统计学意义。与A组比较,B组桡神经、腋神经、尺神经阻滞起效时间明显缩短(P0.05);注药后30 min,B组RR明显增快(P0.01),平静呼吸和用力呼吸时膈肌移动度均明显减少(P0.05),膈肌麻痹率明显升高(P0.05)。结论采用20 ml和30 ml的0.375%罗哌卡因在超声引导下行肌间沟臂丛神经阻滞均能达到理想麻醉效果,但20 ml对膈肌麻痹影响更小。     

改良型锁骨上臂丛神经阻滞的临床观察

臂丛神经阻滞麻醉是上肢手术最常用的麻醉方法，在基层医院被广泛应用。臂丛神经阻滞的入路很多，临床上采用的传统方法有三种：肌间沟法、锁骨上法和腋路法。肌间沟法和腋路法易出现阻滞不全，锁骨上法虽阻滞完善但易出现气胸等并发症。自1998年以来，我们采用改良型锁骨上臂丛神经阻滞，即经中斜角肌下端外缘入路行臂丛神经阻滞，效果良好。１资料与方法１．１一般资料选择ASAI-II级，年龄18～45岁，上肢手术病人150例，随机分成改良组，肌间沟组和锁骨上组，每组50例。三组病人均术前30min肌注苯巴比妥钠0.1克、阿托品0.5毫克。臂丛神…     

超声引导下腋神经阻滞的研究进展

上肢手术镇痛方案包括全麻和臂丛神经阻滞.阿片类药物是控制中、重度疼痛的首选全麻药物,能有效缓解疼痛,但会产生急性不良反应,如呼吸抑制及恶心呕吐等.臂丛神经阻滞能减少甚至避免全麻药物的使用.臂丛神经阻滞途径包括肌间沟、锁骨上、锁骨下及腋路等入路.Urmey等[1]研究表明,肌间沟入路100％会造成膈神经阻滞,锁骨上与锁骨...     

相同浓度不同容量罗哌卡因超声引导锁骨上臂丛神经阻滞对膈肌麻痹的影响

目的观察超声引导锁骨上臂丛神经阻滞(supraclavicular brachial plexus block,SCBPB)使用相同浓度不同容量罗哌卡因对膈肌麻痹的影响。方法选择拟行右上肢骨折术后取内固定装置术的患者72例,男32例,女40例,年龄18~65岁,ASA I或II级。随机分为两组:0.375%罗哌卡因20ml组(A组)和0.375%罗哌卡因30ml(B组),每组36例。所有患者在超声引导下行锁骨上臂丛神经阻滞,记录臂丛各主要神经根的感觉阻滞、运动阻滞的起效时间和持续时间,并观察两组患者不良反应的发生情况。采用M型超声测量阻滞前、阻滞后30min时两组平静呼吸和用力呼吸的膈肌移动度,通过观察膈肌移动度的变化来反映膈肌麻痹情况,并计算膈肌麻痹率。结果两组患者感觉阻滞起效时间、感觉阻滞和运动阻滞持续时间差异均无统计学意义。B组运动阻滞起效时间明显短于A组(P0.05)。阻滞后30min A组和B组分别有12例(33.3%)和22例(61.1%)患者出现膈肌麻痹,B组膈肌麻痹率明显高于A组(P0.05)。结论 0.375%罗哌卡因20 ml与30ml在超声引导下行锁骨上臂丛神经阻滞均可达到理想的臂丛阻滞效果,0.375%罗哌卡因20 ml引起膈肌麻痹较少。     

膈肌厚度比在肌间沟臂丛神经阻滞致膈肌麻痹中的诊断价值

目的 评价膈肌厚度比(DTI)在肌间沟臂丛神经阻滞导致膈肌麻痹中的诊断价值。方法 选择择期行肱骨中段、桡骨骨折内固定或取内固定术的患者51例,男27例,女24例,年龄18～64岁,BMI 18～30 kg/m²,ASAⅠ或Ⅱ级。所有患者采用0.5%罗哌卡因20 ml在超声引导下行肌间沟臂丛神经阻滞。以用力呼吸时膈肌移动度(DE)作为标准将患者分为两组：麻痹组(n=11,DE≥25%)和非麻痹组(n=40,DE<25%)。记录阻滞前、阻滞后15 min阻滞侧DE、吸气末膈肌厚度(DTei)、呼气末膈肌厚度(DTee)、用力肺活量(FVC)、第一秒用力呼气容积(FEV₁)、SpO₂,感觉、运动阻滞时间和恢复时间,并记录芬太尼用量,给药24 h内恶心、呕吐、声音嘶哑、头痛、霍纳综合征、低血压、呼吸困难等不良反应发生情况。绘制受试者工作特征(ROC)曲线,分析DTI、FVC下降幅度对诊断臂丛神经阻滞所致急性膈肌麻痹的曲线下面积(AUC)和95%可信区间(CI)、界值、敏感性和特异性。结果 两组阻滞前DE、DTI、FVC、F...     

中斜角肌前缘入路臂丛阻滞对ETCO_2和SpO_2的影响

中斜角肌前缘入路臂丛阻滞对ＥＴＣＯ＿２和ＳｐＯ＿２的影响李茂源，王丽江，孙彦，何光华，曹莉作者比较观察中斜角肌入路臂丛阻滞前后呼气末二氧化碳（ＥＴＣＯ２）、脉搏。血氧饱和度（ＳｐＯ２）、分钟通气量（ＶＥ）、呼吸频率（ｆ）和潮气量（ＶＴ）的变化，报道如...     

俯卧位下地心引力及机械性干涉对脊柱手术呼吸功能影响的临床研究

作者测定了５５例脊柱手术患者术前仰卧位、俯卧位，麻醉后俯卧位和术毕仰卧位的呼吸频率（ｆｒｅｑｕｅｎｃｙ，ｆ）、潮气量（ｔｉｄａｌｖｏｌｕｍｅ，ＶＴ）、每分通气量（ｍｉｎｕｔｅｖｏｌｕｍｅ，ＭＶ）、血氧饱和度（ｐｕｌｓｅｏｘｙｇｅｎｓａｔｕｒａｔｉｏｎ，ＳｐＯ２）和呼气终末ＣＯ２分压（ｅｎｄｔｉｄａｌＰＣＯ２，ＰｅｔＣＯ２）。结果发现，麻醉后俯卧位的ＶＴ、ＭＶ、ＳｐＯ２明显低于术前仰卧位（Ｐ值＜０．０５）；ｆ、ＰｅｔＣＯ２明显高于术前仰卧位（Ｐ值＜０．０５）。若改为先将患者置于手术体位，再麻醉，其呼吸功能则比较平稳（Ｐ值＞０．０５）。作者认为，俯卧位对呼吸功能的影响主要来自地心引力（重力）和机械干涉两方面因素。并提出：（１）此类手术应先将患者置于手术体位，再麻醉；（２）安置俯卧位时，应取髂前上棘、耻骨结节部和锁骨区为身体的负重点；（３）麻醉平面应控制在Ｔ６；（４）术中应常规吸氧；（５）慎用麻醉辅助药。     

A case report of hemidiaphragmatic paresis caused by interscalene brachial plexus block

A 76-yr-old woman was scheduled for left upper extremity orthopedic procedure. Preoperative examinations were within normal limits except forced vital capacity. Interscalene brachial plexus block with 0.25% bupivacaine 15 ml, was performed under general anesthesia. Her intraoperative course was uneventful. She, however, complained of the dyspnea after removal of a tracheal tube, and Spo2 dropped to 89%. A chest X-ray demonstrated the elevation of hemidiaphragm. She was diagnosed as ipsilateral hemidiaphragmatic paresis, treated with oxygen inhalation under deep breathing for approximately one hour, and then transferred to the common ward. We conclude that respiratory movement should be carefully observed following interscalene brachial plexus block especially in geriatric patients.     

Ultrasound-guided interscalene brachial plexus block in a child with acute upper respiratory infection

The brachial plexus is commonly blocked at the interscalene level for shoulder and proximal humeral surgery. There are only a few publications about the interscalene technique in pediatric patients for a peripheral nerve block. Ultrasound-guided peripheral nerve block has become increasingly more popular for pediatric patients because of high success rates and safety concerns. We used ultrasound-guided interscalene brachial plexus block in an 18-month-old child with an acute upper respiratory infection who had a supracondylar fracture of the humerus.     

Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics.

We studied the effects of unilateral hemidiaphragmatic paresis caused by interscalene brachial plexus block on routine pulmonary function in eight patients. In an additional four patients, we studied changes in chest wall motion during interscalene block anesthesia by chest wall magnetometry. Ipsilateral hemidiaphragmatic paresis, as diagnosed by ultrasonography, developed in all patients within 5 min of interscalene injection of 45 mL of 1.5% mepivacaine with added epinephrine and bicarbonate. Large decreases in all pulmonary function variables were measured in every patient. Forced vital capacity and forced expiratory volume at 1 s decreased 27% +/- 4.3% and 26.4% +/- 6.8%, respectively (P = 0.0001). Peak expiratory and maximum midexpiratory flow rates were also significantly reduced. Interscalene block caused changes in pulmonary function and chest wall mechanical motion that were similar to those published in previous studies on patients with hemidiaphragmatic paresis of pathological or surgical etiology. Interscalene block probably should not be performed in patients who are dependent on intact diaphragmatic function and in those patients unable to tolerate a 25% reduction in pulmonary function.     

Spirometry, blood gas analysis and ultrasonography of the diaphragm after Winnie's interscalene brachial plexus block

Ten patients with healthy lungs were subjected to radiology, sonography, spirometry and blood gas analysis before and after an interscalene brachial plexus block prior to shoulder surgery. Winnie's interscalene block induced ipsilateral hemidiaphragmatic paresis that was confirmed by radiology and sonography. Changes in forced expiratory vital capacity (FVC), forced expiratory volume (FEV1) and peak expiratory flow rate (PEFR) were significant and PaO2 declined by an average of 1.3 kPa. These changes should not cause further clinical symptoms in sitting patients with unaffected lungs. In patients with pulmonary disease, this method of nerve block should be limited to cases for which there is a clear indication.     

Interscalene brachial plexus block for scapular and upper chest pain due to cervical radiculopathy: a randomized controlled clinical trial

BackgroundAnimal experiments have shown that one of the pathways for pain originating from the cervical spine is the sympathetic trunk. However, there have been few reports regarding the cervical pain pathway and efficacy of interscalene brachial plexus block for upper limb, scapular and chest pain originating in the cervical spine in clinical cases. The purpose of the present study was to clarify the efficacy of interscalene brachial plexus block for upper limb, scapular and chest pain.MethodsPatients (137 men and 223 women) who had cervical radicular pain were studied. The intensity of upper limb, scapular and chest pain was measured by using a VAS before injection and at 5 min and 7 days after injection. To evaluate the efficacy of interscalene brachial plexus block, patients with cervical radicular pain who had received NSAIDs for at least 2 weeks were randomized to interscalene brachial plexus block or control block groups. VAS scores were compared to assess the effects of injection and the pain pathway.ResultsThe average VAS score for upper limb pain with or without scapular and chest pain was significantly reduced by interscalene brachial plexus block compared with control block at 5 min and 7 days after injection. After interscalene brachial plexus block, 89 patients reported symptoms of stellate ganglion block versus no patients after control block. Scapular and chest pain was significantly reduced in the patients with stellate ganglion block compared to those without stellate ganglion block.ConclusionsInterscalene brachial plexus block is useful for upper limb, scapular and chest pain due to disorders of the cervical spine. The scapular and chest pain pathway is more likely to be interrupted by an interscalene brachial plexus block that causes a stellate ganglion block compared to an interscalene brachial plexus block without stellate ganglion block.     

Pleural effusion and chest pain after continuous interscalene brachial plexus block

Objective: We describe a unique case of a patient who experienced atelectasis of the lower lobe of the left lung and pleural effusion manifested by chest pain after continuous interscalene brachial plexus block for postoperative analgesia.Case Report: A 45-year-old man with no respiratory disease was scheduled for left shoulder arthroscopy for rotator cuff repair under interscalene brachial plexus block and sedation. A continuous interscalene brachial plexus block provided postoperative analgesia. On the first postoperative day, the patient reported left-sided chest pain. The chest x-ray showed elevation of the left hemidiaphragm associated with a left lower lobe atelectasis and a minor pleural effusion. After catheter removal, clinical and radiologic signs resolved within few days without sequela.Conclusion: If chest pain presents after interscalene brachial plexus block, early postoperative chest x-ray is recommended to rule out pneumothorax, atelectasis, and/or pleural effusion secondary to ipsilateral phrenic block.     

Sedation with target-controlled propofol infusion during shoulder surgery under interscalene brachial plexus block in the sitting position: report of a series of 140 patients

BACKGROUND AND OBJECTIVE: The aim of this study was to assess target-controlled propofol infusion as a technique of sedation for shoulder surgery under interscalene brachial plexus block in the sitting position and to evaluate the effect of sedation on hypotensive/bradycardic events during this procedure. METHODS: One hundred and forty patients undergoing elective shoulder surgery in the sitting position under interscalene brachial plexus block (with 30 mL of ropivacaine 0.75%) were prospectively enrolled. All patients were premedicated with hydroxyzine 1 mg kg(-1), none received beta-blockers. No patients were given atropine except for the patients who experienced a vasovagal event either during the block procedure or intravenous catheter placement. The target-controlled propofol infusion was started immediately after positioning the patient on the operating table. The initial target concentration was 1 microg mL(-1). The infusion rate was adjusted every 15 min by increasing or decreasing the target concentration by 0.2 microg mL(-1) steps to maintain the patient rousable to verbal commands (score of 3 on Wilson sedation scale). The following parameters were assessed: minimal, maximal, optimal target concentration, respiratory and haemodynamic parameters, total propofol dose, additional alfentanil needs, occurrence of hypotensive/bradycardic events, complications. Results are mean +/- SD. Statistical analysis used t-test and chi2-tests. RESULTS: The optimal propofol target concentration was 0.8 mug mL(-1). No respiratory complications or conversion to general anaesthesia was reported. Two patients experienced transient and inconsequential intraoperative agitation. The incidence of hypotensive/bradycardic events during the procedure was 5.7% (eight patients). CONCLUSION: Target-controlled propofol infusion (0.8-0.9 microg mL(-1)) following hydroxyzine premedication is a safe and effective technique for sedation when combined with interscalene brachial plexus block during shoulder surgery in the sitting position.     

Respiratory effects of low-dose bupivacaine interscalene block

In this double-blind study, interscalene brachial plexus (ISBP) block was performed in 11 volunteers using 10 ml of either 0.25% (n = 6) or 0.5% (n = 5) bupivacaine with epinephrine 1:200,000. Diaphragmatic excursion, respiratory function and neural function were assessed for 90 min. Our results showed that hemidiaphragmatic excursion declined significantly after block in the 0.5% group and paradoxical movement during inspiration was more common than in the 0.25% group. Forced vital capacity and forced expiratory volume in 1 s declined significantly in the 0.5% group (mean 74.6 (SD 13.0)% and 78.2 (19.9)% of baseline, respectively) but not in the 0.25% group. Sensory anaesthesia in the upper limb was found consistently in both groups, although biceps paralysis occurred earlier after 0.5% bupivacaine. We conclude that ISBP block using 10 ml of 0.25% bupivacaine provided upper limb anaesthesia to pinprick in C5-6 dermatomes with only occasional interference with respiratory function.      

超声引导下臂丛神经阻滞在上肢手术中的临床观察和经验

目的　研究超声引导臂丛神经阻滞相对于传统盲探下臂丛神经阻滞的优越性和实践经验。方法　选取我院采用超声引导臂丛神经阻滞上肢手术20例（超声引导组）,同时选择同期采用盲探异感法臂丛神经阻滞（盲探臂丛阻滞组）20例,比较两组患者各生理指标、生命体征变化、神经阻滞效应和并发症。结果　超声引导组患者的麻醉起效时间、镇痛维持时间、成功率均优于盲探臂丛阻滞组,两组比较差异有统计学意义（P<0.05）;盲探臂丛阻滞组的并发症高于超声引导组,但其差异没有统计学意义（P>0.05）。结论　超声引导下臂丛神经阻滞有助于使麻药准确注入至最佳位置,提高麻醉质量。