超声引导下对门诊病人的区域麻醉(双语)

Local Anesthetics and Adjuvants 局部麻醉剂和佐剂
Local anesthetic (LA) agents should be chosen according to the desired duration of action and the required degree of motor blockade. 局部麻醉剂选 用应根据所需阻滞的持续时间和所需的运动神经阻滞深度， An insensate extremity in a patient whose procedure may not produce much postoperative discomfort may be at risk for injury secondary to the loss of protective reflex to pain, or place the patient at risk secondary to a loss of proprioception本体感 觉—blocks of the longest possible duration are not always the wisest choice. 对一个手术后可能不会有什么不适的病人让其 肢体没有感觉，可能有继发损伤的风险，由于 疼痛保护性反射消失或失去本体感觉，最长阻 滞时间并不总是最明智的选择。
introduction
• Specifically, orthopedic patients are the group of ambulatory patients with the highest incidence (16.1%) of pain in the PACU. • 具体来说,在PACU中骨科病人是门诊病人中疼痛发生率最高 的 • Peripheral nerve blocks (PNBs) offer predictable intraoperative anesthesia, as well as provide analgesia into the postoperative period, the opportunity to bypass Phase I recovery, and the avoidance of airway manipulations. • 外周神经阻滞(PNBs)提供可预测的术中麻醉,还提供术后镇痛, 绕过复苏第一阶段,避免了气道处理。
The effect of alkalinization of agents on the speed of onset of the block is unclear. 碱化剂对阻滞的起效速度的影响还不清楚。 It has been shown to offer no advantage in perivascular blocks with 0.5% bupivacaine but improvement in onset and quality of analgesia in axillary blocks with 1.25% mepivacaine,and in femoral and sciatic blocks with 2% mepivacaine has been demonstrated. 已证明使用0.5%布比卡因在血管周围阻滞并没有优势,但使用 1.25%甲哌卡因行腋神经阻滞、 2%甲哌卡因行股神经和坐骨神 经阻滞被证实改善了起效时间及镇痛的效果。
introduction
• Enlisting the surgeon to introduce the concept of PNBs when they offer patients their preoperative instructions will improve patient acceptance. • 让外科医生给病人术前指导时介绍外周神经阻滞的概念,会提高病人的接 受度。 • Local anesthetics should be chosen to minimize onset times and limit the use of GA in order to prevent operating room delays. Meticulous follow-up until resolution of all blocks along with communication with the surgeons can add to overall satisfaction.应选择可以缩短起效时间和限制 使用全身麻醉的使用的局部麻醉药来防止手术延迟。仔细的观察直到所 有的阻滞有效，并与外科医生沟通，可以增加整体满意度。
introduction
• and the use of US facilitates the placement of blocks in patients who are obese, may be on anticoaternal anatomy. • 超声的使用方便了肥胖病人、可能使用抗凝剂的病人、有挑 战的解剖异常的病人的阻滞。
introduction
• Ultrasound (US) imaging permits direct visualization of peripheral nerves, needle location and distribution of local anesthetic. • 超声成像能直接看到周围神经、针的位置及局麻药的分布。 • The use of US-guidance to perform nerve blocks is associated with decreased time to onset and quality of block which is equal to or better than PNBs performed with nerve stimulator (NS) techniques, • 使用超声引导进行神经阻滞与减少起效时间相关 ,阻滞的效果 等于或优于使用神经刺激器(NS)技术。
introduction
• Performing US-guided nerve blocks requires an entirely new skill set for practitioners. • 超声引导下神经阻滞要求医生掌握一项全新技能。 • Firstly, one must learn to operate ultrasound equipment and then use this to identify anatomy as it appears on a two-dimensional screen. • 首先,你必须学会操作超声设备,然后使用它识别出现在二维屏幕上的解剖。 • Secondly, one must be able to simultaneously use both hands (one holding the ultrasound transducer and the other holding the block needle), watch the display screen,and manipulate the needle into the nerve sheath. • 其次,一个人必须能同时使用双手(一边拿着超声波换能器，一边握着阻滞 针),观察显示屏,操作针使其进入神经鞘。 • Lastly, it is necessary to learn to identify patterns of local anesthetic spread that are associated with optimal plexus blockade. • 最后,必须学会识别局部麻醉药扩散的模式，这与最佳神经阻滞相关。
Local anesthetics diffuses into nerves and the rate of diffusion is determined by the concentration, therefore higher concentrations of LAs result in more rapid onset of blockade. 局部麻醉药扩散到神经，其扩散的速率是由浓度决定的,因此 越高浓度的局部麻醉药导致扩散速率越快 Ropivacaine 0.75% has been shown to have similar or shorter onset times for femoral, sciatic and interscalene blocks, while providing significantly longer postoperative analgesia than mepivacaine and bupivacaine. 0.75%罗哌卡因已被证明作用在股神经,坐骨神经和肌间沟神经 阻滞有类似甚至更短的起效时间,同时提供术后镇痛时间明显 比甲哌卡因和布比卡因长。
Galindo concluded that mixing LAs leads to unpredictable blockade characteristics. Galindo得出使用混合的局部麻醉将导致不可预知的阻滞 效果。 Gratenstein looked at US-guided interscalene blocks with 30 mL in 3 different solutions—mepivacaine 1.5%, bupivacaine0.5% and a 50:50 mixture of the two, and found that mixing the short and long-acting agents does not result in a significant difference in onset time compared with either solution alone.
Ultrasound-guided for Regional Anesthesia for Ambulatory patient (超声引导下对门诊病人的区域麻醉)
原文：Meg A. Rosenblatt, M.D. 翻译：福建医大附属协和医院麻醉科规培 住院医师 张海梅
introduction
Outpatient surgeries now account for more than two-thirds of all surgeries performed in the United States and after GI endoscopies, ophthalmologic procedures, orthopedic operations are the next most frequently performed. 如今在美国所有手术中在门诊执行的手术占了三分之二以上， 随后的是胃肠镜检查、眼科手术、骨科手术。 The advantages that regional anesthesia (RA) confers over general anesthesia (GA), especially in the outpatient setting, are numerous. 区域麻醉的优势(RA)超过了全身麻醉(GA),尤其是在门诊病人。
Gratenstein观察在超声引导下使用1.5%甲哌 卡因, 0.5%布比卡因和这两个药物对等混合的 各30 ml分别进行行肌间沟阻滞,发现短效和长 效混合的这一组与在起效时间方面与单独使用 一种药物相比并没有显著性差异
Whereas some practitioners combine LAs to decrease onset time while providing long duration, combining chloroprocaine 2% and bupivacaine 0.5% causes pH changes that create a block that resembles one produced by bupivacaine alone. 而一些医生结合使用局部麻醉以减少起效时间, 同时提供长时间麻醉,将2%氯普鲁卡因和0.5%布 比卡因混合引起pH值的变化导致阻滞效果类似 于单独使用布比卡因。