超聲和神經(jīng)刺激儀雙重引導(dǎo)

1、超聲和神經(jīng)刺激儀雙重引導(dǎo)鎖骨上臂叢神經(jīng)阻滯,佛山市中醫(yī)院劉曉捷 醫(yī)學(xué)碩士,（特別鳴謝 羅富榮博士）,三甲中醫(yī)院佛山市創(chuàng)傷急救中心,病床2400多張年手術(shù)3.5萬臺(tái),骨傷科15個(gè)病區(qū)國(guó)家中醫(yī)藥管理局的重點(diǎn)?？撇〈?000張年手術(shù)2萬多臺(tái),問題一：為什么神經(jīng)阻滯？,神經(jīng)阻滯的優(yōu)勢(shì),全身影響小鎮(zhèn)痛時(shí)間長(zhǎng),骨科術(shù)前移動(dòng)改變體位時(shí)的鎮(zhèn)痛不受術(shù)后使用抗凝劑的限制充分控制疼痛以便及早活動(dòng),羅富榮博士于2

2、010年德國(guó)進(jìn)修學(xué)習(xí),本人于2012年北京積水潭醫(yī)院進(jìn)修學(xué)習(xí),問題二：為什么要雙重引導(dǎo)？,神經(jīng)阻滯的定位技術(shù),神經(jīng)刺激儀：電生理定位，較精確，深淺皆宜，但同一神經(jīng)多點(diǎn)注射有顧慮。超聲成像儀：影像學(xué)定位，淺部好于深部，可同一神經(jīng)多點(diǎn)注射，減少用藥。減少鄰近組織結(jié)構(gòu)損傷。,Nysora.com,問題三：如何選擇不同入路？,高士濂，實(shí)用解剖圖譜,Mehrkens, Peripheral regional anaesthesia,Pro

3、nation of the forearm,Supination of the forearm,And elbow,Ulnar inclination and flexion of the wrist,,Flexion of 4th and 5th fingers,臂叢阻滯,肌間溝鎖骨上鎖骨下腋路,,頭端,尾端,根、干,束,神經(jīng),膈神經(jīng),氣胸,深在,分散,臂叢阻滯,,肌間溝：C5、6、7或上干、中干支配區(qū)，尤其肩部和上臂的手術(shù)，

4、但尺神經(jīng)失敗率高。,Nysora.com,臂叢阻滯,鎖骨上：臂叢神經(jīng)最為集中，除肩部手術(shù)外上肢手術(shù)。但氣胸風(fēng)險(xiǎn)大。,集中，所以效率高,Nysora.com,臂叢阻滯,鎖骨下：除肩部手術(shù)外上肢手術(shù)。,Nysora.com,臂叢阻滯,腋路：除肩部手術(shù)外上肢手術(shù)。,Nysora.com,問題四：局麻藥的選擇？,Ropivacaine: a review of its use in regional Anaesthesia and a

5、cute pain management.,Thus ropivacaine, with its efficacy, lower propensity for motor block and reduced potential for CNS toxicity and cardiotoxicity, appears to be an important option for regional anaesthesia and

6、for the management of postoperative and labour pain.,Drugs. 2005;65(18):2675-717.,Some current controversies in paediatric regional anaesthesia,Conversely, continuous infusion of ropivacaine offers the safest th

7、erapy.,Curr Opin Anaesthesiol. 2006 Jun;19(3):301-8.,問題五：局麻藥的用量？,外周神經(jīng)阻滯的種類,按區(qū)域分為小神經(jīng)阻滯和大神經(jīng)阻滯：小神經(jīng)阻滯是指單一神經(jīng)（如橈神經(jīng)、尺神經(jīng)）的麻醉大神經(jīng)阻滯是指兩條或多條相互獨(dú)立的神經(jīng)或神經(jīng)叢麻醉或者在近端阻滯比較大的神經(jīng)（如股神經(jīng)或坐骨神經(jīng)）,《米勒麻醉學(xué)》第7版927,小神經(jīng)阻滯,,《米勒麻醉學(xué)》第7版940,大神經(jīng)阻滯,劑量以70kg成