一、神经阻滞的定位方法
I. Ana tom y location 异感定位 Se nsory location 超声和放射学定位 Ultrasound and
（一）解剖定位
An atom y loc ati on
神经解剖变异，神经分布不规则，神经不 是集中某个单一的点，解剖标记不明确或 不易辨认，因此，临床操作难度较大。
B asi c p rin ci pl es of U ltrasou n d
临床应用的超声频率为2.5~20MHz
Clinical ultrasound with 2.5~20MHz
频率越高空间分辨率越好，但穿透性越差；反之亦然
Higher frequency with better space differentiation ratio but less penetrability; vice ver sa
（二）异感定位 Sensory location
n 是否需要寻找异感尚有争议 Debat e of finding specia l sensory 找到“ 异感” ，麻醉效果并非一定完善 Unsa t is fied an est hetic effect s w ith s ens ory loca t ion 神经分布与病人状态，可能无法引出异感 Sensa tion ma y b e not foun d in som e pat ien ts 寻找异感可能损伤神经 M a ybe da ma ge nerves
缺点 Di sadvan tag es
需要特殊设备和人员技术培训 Nee d equipm ents and training 增加了操作步骤 M ore operation steps 仪器体积较大，价格昂贵 Large size and ex pensive e quipme nt
超声的基本原理
Tran sverse sonogra m show ing loca l a nest het ic spread a nd distent ion ( arrow s ) in t he int ersca lene groove.
Infraclavicular Block
Tr ans verse son og ram i n th e i n fr acl avic ul ar reg io n sh ow i ng b rach i al pl exu s as hyp oec ho ic n od u les ( N w i th arro w ) . AA axi ll ary arter y; A V axi l lar y vei n; P M aM p ecto ral is ma jor m usc le ; P M i M pec toral i s m in or m us cle .
Musculocutaneuous Nerve Block
A 12 -M Hz u ltra sou n d im age d emo nstr atin g th e mu sc ul oc uta neo us n erve an d su rro un d in g stru ctu res . B, b on e ( hu m eru s); Bi , b ic eps mu sc le; CB, cor aco bra ch ial i s mu sc le; A, axi ll ary arter y; v, axi l la ry vei n . Th e mu sc ul oc uta neo us n erve is fou nd i n th e j u nc ture b etwe en th e b ic eps an d co raco br ach ia li s mu scl es. The n erve, a s d oes th e m edi an n erve, a pp ears as a c on stel la tio n of hyp od ens e ( dar k) gr apel i ke stru ctu res w ith hyp erec ho ic (b ri gh t) ri n gs. Ul tras ou nd Gu id ed M us cu lo cu tane ou s N erve Bl oc k • S p enc e, S ite s, an d Beac h 1 99
（三）超声和放射学定位
Ul trasoun d and radi olo gic al l ocation
优点 Advantages
提高神经阻滞的成功率 Inc rea se t he s ucc es sful rat e of nerv e bloc k 观察局麻药注射后的扩散规律 Observe t he dist ribut ion of loca l anest het ics 避免血管内注射的发生 Av oid int rav as cula r inject ion 减少麻醉药用量 Reduce the dosage of a nest het ics
( 四 ) 神经刺激器定位
Location w ith nerve sti mulator
1. 周围神经刺激器
P eripheral nerve stimul ator
神经刺激器的优点 Advantages
刺激后肌肉反应的指标客观明确 Objectiv e and cor rect si gn s after stimu lation 用于无法准确说明异感或定位困难病人 ( 小儿、老年、不合作用及神智不清的病人) Used i n pedi atri cs, el derl y, di soperati ve and un co nsci ous patients 最大程度减少神经损伤 Reduce n er ve damages 神经阻滞成功率较高 High successful rate
内容提要 Con ten ts
1.神经阻滞定位方法 Localization m ethods of nerve block 2. 神经刺激器与神经刺激针 N erve stim ulator and needles 3. 下肢神经阻滞在老年重危病人中的应用 Application of low er extrem ity ne rve block in elderly severe patients
腋部径路超声图中针头位置（箭头所示）
Needle position of axillar y ner ve block in sonogr am (ar r ows)
AA: 腋动脉 axillary ar tery
Hadzic A, et al. Anesthesiology,2003;98:969.
外周神经阻滞的优点
Advantage of peripheral nerve block
阻滞成功率高 High successful ratio 安全性高 More safety 应激反应轻 Less stress response 降低深静脉血栓形成 Avoid DVT 恢复快 Fast recovery 生理机能稳定 stable physical status 病人欢迎 Welcomed by patients 费用低 Low cost
神经阻滞定位方法进展
Adva nce in Locatli za ion of N erve B lock
杭燕南
Ya nna n Ha ng M .D. Depa rt men t of An est hesiology R en Ji Hospit al Sha ngh ai Sec ond M edic al Univers it y Sha ngha i 2 00001
Interscalene Block
Tran sverse sonogra m of t he n eedle (a rrow s) in con ta ct w ith t he n erve t run ks in t he int ersc alene groove.
Interscalene Block
Vari ation and d ecen trali zati on of nerves, ir regu lar d istri bu tion , am b ig ui ty of anatom y l an dm ark s, it’s d iffi cu lt to op er ate i n c li ni c
Perlas A, et al. Anesthesiology,2003;99:429.
肌间沟经路定位
Interscalene location
Hadzic A, et al. Anesthesiology,2003;98:969.
超声定位穿刺操作时，一手持探头，一手握绝缘针 One hand with probe, another with insulated needle CH为胸锁乳突肌锁骨头，SH 为胸骨头 CH=clavicle head of ster nocleidomastoid, SH=sternal head
Axillary Block
Tr ansv er se so nog ram in th e m id hu mer al r egion show in g t w o ter m inal br an ches of t he b rach ial plex u s as h y poech oic n odu les ( N w ith arrow s ). B A br achial ar t er y ; B M bicep s m uscle; H h um er us; TM tr icep s m u sc le.
超声引导下神经阻滞
Nerve block guided by ultrasound