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1、,朝阳医院超声麻醉疼痛周,髂筋膜、股神经和 隐神经/收肌管阻滞,膝关节置换镇痛,Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37,膝关节置换镇痛,Primary outcomes: (1) acute postoperative pain (during re
2、st and movement) (2) postoperative opioid consumption (3) quality of early postoperative rehabilitation (functional assessments) Secondary outcomes: postoperative complications (e.g., nausea, vomiting, falls), duration of hospitalization, blood loss, procedure failure, and patient withdrawal Terkawi
3、 AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta- analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37,与PCA比较,(A) Overall pain scores in the first 72 h duringrest (B) overall pain scores in the first 72 h during mov
4、ement, (C) overall opioid consumption in the first 72 h (D) overall range on motion in the first 72 h.,Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37,Ran
5、king F/S (6) F/O(6) LP/S (3) FIC (3) PA (2) Ranking on high- quality studies F/S FIC LP PA ACB,Terkawi AS, Mavridis D, Sessler DI, et al. Pain Management Modalities after Total Knee Arthroplasty. A Network Meta-analysis of 170 Randomized Controlled Trials. Anesthesiology 2017; 126:923-37,闭孔神经 股神经,股外
6、侧皮神经,隐神经,髂筋膜阻滞,阻滞的是什么？,髂筋膜, 外界：髂嵴内 侧缘 内界：小骨盆 的界线 向下一直延续 到股骨小转子 水平 覆盖腰大肌和 髂肌,髂筋膜,闭孔神经与髂肌和髂筋膜并没有密切的联系,闭 孔 神 经,髂筋膜阻滞的扩散范围（MRI）,Swenson JD, Davis JJ, et al. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturato
7、r nerve. Journal of Clinical Anesthesia (2015) 27, 652657,腹股沟韧带水平,骶骨水平,冠状位,腹股沟韧带水平髂筋膜阻滞,超声引导髂筋膜阻滞的方法,腹股沟韧带下法 寻找缝匠肌和髂肌 药液扩散：缝匠肌和髂肌之间 阻滞：股神经、股外侧皮神经？,超声引导髂筋膜阻滞,腹股沟韧带上法,Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-GuidedSuprainguinal Fascia Iliaca Technique ProvidesBenefit as an Analgesic Adju
8、nct forPatients Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438,超声引导腹股沟韧带上髂筋膜阻滞, 寻找髂前上棘、髂肌、腹横肌 药液扩散：腹横肌和髂肌之间 阻滞：股神经、股外侧皮神经、髂腹股沟神经,Bullock WM, Yalamuri SM, Gregory SH, et al. Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct for Patients
9、 Undergoing Total Hip Arthropla. J Ultrasound Med 2017; 36:433438,股神经阻滞,如何提高成功率？,股神经解剖,股神经,股神经超声影像, 腹股沟水平 股动脉外侧，髂筋膜深部，髂肌表面 高回声，宽而扁，椭圆形 深度：13cm,超声探头的最佳位置,旋股内、外侧动脉,超声探头的最佳位置, 旋髂深浅动脉 必要时用多普 勒调整位置 腹股沟韧带和 腹横纹中间位,置或许最佳,OGAMI K, MURATA H, SAKAI A, et al. Deep and Superficial Circumflex Iliac Arteries and T
10、heir Relationship to the Ultrasound-Guided Femoral Nerve Block Procedure: A Cadaver Study. Clinical Anatomy 30:413420 (2017),进针点？药液？置管位置？,短轴，平面内法,短轴，平面外法,进针点？药液？置管位置？,Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An o
11、bservational study. Eur J Anaesthesiol 2014; 31:2329,进针点？药液？置管位置？,Topographic view of the terminal branches of the femoral nerve ACN： anterior cutaneous nerve MCN：medial cutaneous nerve PMN：pectineus muscle nerve; RFMN：rectus femoris muscle nerve SMN：Sartorius muscle nerve SN：saphenous nerve VIMN：va
12、stus intermedius muscle nerve VLMN：vastus lateralis muscle nerve VMMN：vastus medialis muscle nerve 隐神经部分与神经其他部分可能存在隔断 平面内由外向内进针，一直到神经内侧，药液包绕，神经前方置管,Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study.
13、 Eur J Anaesthesiol 2014; 31:2329,辨认不清髂筋膜怎么办？,Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329,GIPM：髂腰肌凹槽（a groove formed by the iliac and lateral psoas muscles）,股
14、神经阻滞寻找GIPM旁结构,Benoit Fanara, Jean-Luc Christophe, Annie Boillot, et al. Ultrasound guidance of needle tip position for femoral nerve blockade. An observational study. Eur J Anaesthesiol 2014; 31:2329,髂筋膜,GIPM:85% 髂筋膜：68%,阔筋膜张肌 股外侧皮神经 缝匠肌,股外侧皮神经阻滞, 支配：大腿前外侧 适应证：髋部手术 为主 过去：髂前上棘内 下12cm，皮下 0.51cm 变异大：以解
15、剖标 志为基础的传统阻 滞技术不可靠,超声引导股外侧皮神经阻滞, 高频探头 扫描方式：阔筋膜张肌和缝 匠肌 超声影像：低回声椭圆形 （此处可能已经分支） 进针路径：平面内或平面外 局麻药：5ml 目标：局麻药在神经周围或 阔筋膜张肌和缝匠肌之间阔 筋膜下方扩散,隐神经阻滞,与收肌管阻滞？,隐神经阻滞, 股神经的最大感觉支 支配：内侧膝关节、 髌骨下方、小腿内侧 和足内侧缘的皮肤 适应证：膝关节手术 、大隐静脉手术、坐 骨神经阻滞的补充 不影响股四头肌力量 局麻药：低浓度， 510ml,隐神经走行, 股动脉伴行，内下行 通过收肌管，接近膝 盖穿出 大腿中段：缝降肌深 面，与股动脉伴行 膝上：缝匠
16、肌和股内 肌之间的收肌管内， 与股动静脉伴行 膝下：胫骨粗隆表面 ，与大隐静脉伴行,隐神经阻滞入路 Subsartorial plexus block（大腿中段） Adductor Canal block（大腿远端/收肌管） Subcoutaneous infiltration block（小腿近端）,收肌管,收肌肌腱键膜管状间隙,构成：股内侧肌、缝匠 肌、长收肌和大收肌 近端：股三角顶点 远端：收肌管裂孔 表面：股内收膜 内容：股神经的股内侧 肌支、隐神经、股中间 皮神经、股动脉、股静 脉,收肌管相关肌肉,收肌管超声,起点：股三角（倒）顶点，缝匠肌与长收肌内 侧缘相交处 终点：股动脉偏离缝匠
17、肌，进入股内侧肌和大 收肌之间（收肌腱裂孔） S：缝匠肌VM：股内侧肌AL：长收肌AM：大收肌 Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245,股内收膜,vastoadductor membrane,Wong WY, et al. Defining the Location of the Adductor Canal Using Ultrasound.Reg Anesth Pain Med 2017;42: 241245,小结 髂筋膜阻滞： 阻滞：股神经+股外侧皮神经 腹股沟上髂筋膜阻滞（更佳）：髂前上棘、髂肌和腹横肌 腹股沟下髂筋膜阻滞：缝匠肌和髂肌 股神经 一般：股动脉和髂筋膜 特殊：GIPM旁结构 外侧进针平面内法、药液包绕、神经前方置管 隐神经 收肌管水平最佳：缝匠肌和股外侧肌 膝关节置换：股神经联合坐骨神经阻滞最佳,