图15:超声解剖示意图与平面内进针行腋神经阻滞
小贴士
肥胖患者肩关节阻滞挑战性很大,肩胛上神经和腋神经的超声显像可能不清晰。
锁骨高耸,颈部变短的患者,可能会影响肩胛上神经在锁骨上窝的识别和选择性阻滞,这些患者,选择后路肩胛上神经阻滞可能更好。
为了优化冈上窝肩胛上神经的超声成像,调整探头的倾斜度,旋转探头,使探头的外侧端位于肩峰上方,内侧端位于肩胛冈上方。
专家点评
北京医院的张宏业教授对肩关节手术的神经阻滞研究颇深,在今年北京医院麻醉科举办的的第八届气道管理和围术期超声应用论坛中,他对肩关节手术的神经阻滞总结为以下几点:
- 肌间沟臂丛阻滞仍然是肩关节手术镇痛的金标准,但其常见的副作用是同侧膈神经阻滞。
- 从近端到远端,臂丛和膈神经的距离越来越远,HDP(半膈麻痹)的几率也会降低。
- 研究证实喙突旁锁骨下臂丛(20ml) 后路肩胛上神经阻滞(10ml),以及肋锁间隙臂丛神经阻滞(20ml),镇痛效果与肌间沟臂丛相当,且未出现HDP。
- 研究证实前路肩胛上神经阻滞(15ml),可以更好保留肺功能,前路肩胛上神经阻滞(10ml)可以更好保留握力,患者更满意,是否可以避免HDP需要证实。
原文链接:
https://app.nysora.com/courses/shoulder-block/lessons/anatomy-21/
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