1、1髂腹下神经阻滞（范文 2篇）以下是网友分享的关于髂腹下神经阻滞的资料 2 篇，希望对您有所帮助，就爱阅读感谢您的支持。髂腹下神经阻滞（1）髂腹股沟-髂腹下神经阻滞在儿科麻醉中的应用万帆 郑利民北京大学深圳医院麻醉科 深圳市 518036Application of ilioinguinal/iliohypogastric nerve block in pediatric anesthesiaWAN Fan ,ZHENG Li-minDepartment of Anesthesiology, Shenzhen Hospital, Beijing University of Medical Sc
2、iences,Shenzhen 518036 ,ChinaAbstract : Ilioinguinal/iliohypogastric nerve block(IINB) 2can provide satisfactory anesthesia and effective postoperative pain relief. It is widely used in inguinal incision surgery, especially suitable for pediatric day surgery. IINB technique is save, effective and ea
3、sy to perform, compared with general and spinal anesthesia, patients receiving IINB have shorter recovery times, decreased anesthesia- complications, and better postoperative pain management. Therefore, IINB is a proper choice for pediatric anesthesia and analgesia.Key words: ilioinguinal/iliohypoga
4、stric nerve; nerve block; pediatric anesthesia摘要 髂腹股沟-髂腹下神经阻滞具有麻醉效果确切，对患者全身影响小和术后镇痛时间长等优点，尤其适合小儿腹股沟区手术的麻醉和镇痛。现就其应用解剖、操作方法、临床应用等方面进行综述。关键词 髂腹股沟- 髂腹下神经；神经阻滞；儿科麻醉由于日间手术和门诊手术在小儿手术中的比例日益增多，局部麻醉在小儿外科手术中的应用受到重视。髂腹股沟-髂腹下神经阻滞(Ilioinguinal/Iliohypogastric Nerve Block, IINB)简单实用，安全有效，在小儿腹股沟区手术的麻醉和3镇痛方面受到重视。本文就
5、 IINB 在小儿腹股沟区手术中的应用现况及前景作一综述。1 应用解剖髂腹下神经(Iliohypogastric Nerve ,IHN)与髂腹股沟神经(Ilioinguinal Nerve ,IIN) 是腰从的分支均行走于腹股沟区。IHN 源于 T12、L1，出腰大肌外缘，经肾后面和腰方肌前面行向外下，在髂嵴上方进入腹内斜肌和腹横肌之间，继而在腹内、外斜肌间前行，终支在腹股沟管浅环上方穿腹外斜肌腱膜至皮下;其皮支分布于臀外侧、腹股沟区及下腹部皮肤,肌支支配腹壁肌。IIN 源于L1，在髂腹下神经的下方与之并行，走行方向与该神经略同，终支分布于腹股沟和阴囊前部（或大阴唇前部）皮肤，肌支支配腹壁肌。
6、这两支神经在髂前上棘内侧近处穿出腹内斜肌，位于腹外斜肌腱膜深面。 图 11、脐；2、腹内斜肌；3、腹横肌；4、腹股沟疝；5、腹股沟浅环；6、腹外斜肌；7、IINB 进针点位于脐与髂前上棘连线外 1/48、髂前上棘；49、髂腹下神经；10、髂腹股沟神经但 IIN 和 IHN 在腹股沟区的解剖变异相当普遍。Al-dabbagh 在 110 例成人腹股沟疝修补术中观察了 IHN 和IIN 的走向，发现如教科书所描述的仅占 41.8%,其余 58.2%存在变异。包括：IIN 在未出外环前向下外成锐角，占18.18%；IIN 在外环外侧位于腹外斜肌腱膜浅面，占16.36%；在精索前面 IIN 与 IHN
7、 仍为一干，而后分开，占 21.82%；两神经之一缺如，占 7.27%；两神经之一有副支，占 2.73%；IIN 起自生殖股神经，占 1.82%。这些变异可导致 IINB 的成功率下降，阻滞不全；在行腹股沟区手术时，易被损伤，术后可出现腹股沟区感觉异常，缺失或后遗神经痛的症状。2 临床应用2.1 适应症IINB 作为一种简单而实用的麻醉方法，主要适用于小儿腹股沟区手术，如：腹股沟疝修补，睾丸下降固定及精索静脉曲张高位结扎术等，尤其适用于小儿日间手术麻醉和术后镇痛。1、3212.2 药物选择2.2.1 局麻药的选择IINB 临床常用的布比卡因最常用，小儿单次注射的最大5推荐剂量不应超过 2.5m
8、g/kg。配方有：0.25%布比卡因，0.3-0.5ml/kg；0.5%布比卡因，0.25ml/kg。左旋布比卡因具有与布比卡因相似的作用，但心脏与中枢神经系统毒性低，更适合小儿局部麻醉。与布比卡因41相比，罗哌卡因尚无一明确的小儿应用极量，可能比布比卡因略高，安全性更好。Dalens 5报道，用 3mg/kg 的罗哌卡因给小儿实施单次 IINB 可获得满意的术后镇痛，且安全性高，无毒性反应，游离血浆峰浓度低于成人的毒性阈值。Ala-Kokko 等 6分别用同等剂量的 0.75%罗哌卡因和 0.5%布比卡因在小儿进行 IINB，比较它们的药代动力学变化，发现布比卡因组的血浆峰浓度明显高于罗哌卡
9、因组，且达峰时间及分布半衰期明显比罗哌卡因组短，说明布比卡因更易从注射部位吸收，血浆浓度高于罗哌卡因。原因可能与布比卡因的脂溶性较高，具有扩血管作用有关，而罗哌卡因有一定的缩血管作用；此外，同等剂量的 0.5%布比卡因，其容积为 0.75%罗哌卡因的 1.5 倍。2.2.2 辅助药物的应用早先的研究表明局麻药液中添加 a2-受体激动剂可乐定，可延长外周神经阻滞、术后镇痛的作用时间。可乐定用于小儿脊麻及硬膜外麻醉，可显著延长感觉阻滞时间。Ivani等发现将 2gkg 的可乐定加入 0.2%罗哌卡因行 IINB 可6获得比骶麻更优的术后镇痛效果，但 Kaabachi 等将1gkg 的可乐定加入 0
10、.25%布比卡因用于小儿 IINB，与单纯 0.25%布比卡因比较，并未增加镇痛效能，延长术后镇痛时间，而且还出现一过性血压下降。可乐定对周围神经的作用机制尚未明确，其与局麻药配伍应用于小儿局部麻醉尚需进一步研究。2.3 操作方法Bahr 法（1979 年） ，在髂前上棘与脐之间作一连线，均IINB 有 3 种穿刺方法： Von分为四等份，在髂脐连线的外 1/4 处穿刺进针，直接深达腹外斜肌腱膜注入局麻药，随后退至皮下呈扇形浸润；Sethna 和 Berde 法（1989 年） ，进针点应在髂前上棘内下方各 10mm 交界处；Schulte-Steinbery 法（1990 年） ，穿刺点应恰
11、好在髂前上棘内下方，偏内的距离应取决于病人的大小，大约是 5mm10mm。针缓慢深入，直至穿过腹外斜肌腱膜时阻力消失可体会到特定的突破感，将局麻药注入腹内、外斜肌之间。尽管 IINB 安全有效，操作简单，但失败率也可高达 1025%。Boon 认为对不同年龄组小儿IIN、IHN 解剖结构、空间位置理解不当是导致阻滞失败的主要原因。他在解剖直视下对上述三种方法的准确性进行了比较，发现：Von Bahr 法所描述的进针点离神经最远，主要靠扇形注射时局麻药扩散产生作用；而 Sethna 和7Berde 法的所有进针点均在腹股沟韧带的下方；Schulte-Steinbery 法被认为是三种方法中最准确
12、的，最靠近神经的。根据直视下解剖得出的结论是，在新生儿和婴幼儿行 IINB时，进针点要比早先认为的更靠近髂前上棘，可选在髂前上棘与脐连线上靠近髂前上棘约2.5 mm 处。2387图 21、髂前上棘；2、髂腹下神经；3、髂腹股沟神经；4、脐；5、腹横肌；6、腹内斜肌；7、腹外斜肌；A、Von Bahr 法进针点；B 、假定理想的进针点；C、Schulte-Steinbery 法进针点；D、Sethna 和 Berde 法进针点“两点法”就是在“一点法”Lim 等就 IINB 阻滞的“一点法”和“两点法”进行了比较。的基础上，在腹股沟韧带中点外上 0.5cm 进针达腹外斜8肌腱膜注入余下 2/3
13、的局麻药。发现“两点法”较“一点法”操作难度增加，而成功率并未提高。近年来超声技术在神经阻滞中得到应用1093, Willschke 等11 在超声介导下行 IINB 阻滞，证实它不仅可直观的探测到神经、血管等结构，还可观察局麻药注射后的扩散规律、分布情况，从而减少局麻药用量，提高神经阻滞定位的成功率，降低血管内注射、神经损伤等不良事件的发生。2.4 效益分析及效果评价2.4.1 效益分析在合理应用基础麻醉和辅助药的情况下，小儿腹股沟区手术可在 IINB 下完成。它联合全麻或麻醉监测护理(Monitored Anesthesia Care, MAC)与单纯全麻相比，具有对患儿全身影响小、术后恢
14、复快和镇痛时间长的优点，可减少阿片类药物的应用及其副作用，缩短住院时间、节省住院费用。Song 等12比较了 IINB-MAC、全麻和脊麻 3种麻醉方法对腹股沟疝修补术病人的影响： IINB-MAC 组病人住院时间最短，出院时疼痛评分最低，在随后的 24 小时满意度最高，麻醉总费用最低。对于接受单侧腹股沟疝修补术的门诊病人，IINB-MAC 性价比最高，在术后恢复时间、病人舒适度、相关费用等方面最优。2.4.2 术后镇痛9IINB 对术后镇痛尚有争议。Jovivonen 等13报道，术前IINB 的镇痛作用仅持续至术后 6 小时左右，并未显示出长时间的镇痛作用。从理论上讲，IINB 可阻止伤害
15、性刺激传入中枢，避免中枢敏感化，发挥超前镇痛的作用，但Moiniche 等 14发现，术前阻滞与术后阻滞相比，在术后镇痛方面并无明显优越性。2.4.3 与骶麻比较许多研究者并未发现两者的麻醉效能有显著差异，更有观点认为在婴幼儿，IINB 更优于骶麻 。Cross and Barrett 315认为两种麻醉作用时间相似，镇痛作用可持续至术后6 小时16以上，而 IINB 易于实施，且局麻药的总剂量和并发症的风险低于骶麻。Markham期排尿是 IINB 明显优于骶麻之处。但 IINB 时布比卡因吸收明显快于骶麻，Smith17认为：早的研究发现体重在 10-15kg 的小儿，使用 0.25mlk
16、g 0.5%的布比卡因进行 IINB 时，血浆浓度会显著增高，故在婴幼儿中，局麻药的用量应更加慎重。另外，IINB 并不能有效抑制术中牵拉精索或腹膜，及对睾丸操作时引起的疼痛，联合生殖股神经阻滞可减轻上述刺激，但 Sasaoka 等繁琐。Somri 等 1918认为临床意义不大，且操作比较了 IINB 和骶麻在睾丸固定术中血浆儿茶酚胺水平的变化，10发现 IINB 组血浆肾上腺素、去甲肾上腺素浓度均高于骶麻组，说明骶麻能较 IINB 更有效地抑制牵拉精索、腹膜和睾丸刺激。2.5 并发症及对策一般来说，IINB 是相当安全的。常见并发症有：（1）一过性的股神经阻滞，发生率为8.8% 20。 （2
17、）局麻药中毒，由于局麻药在 IINB 时吸收过快，可导致过高的血浆浓度，故每个患儿应根据体重仔细计算药量，尤其是婴幼儿用量应相对保守；应注意将计算准确无误的药量放入一个注射器内，操作时反复回抽，缓慢注射，减少注射阻力。 （3）其它罕见的还有腹壁穿透、肠损伤21等，穿刺时应缓慢进针，仔细体会解剖层次。综上所述，IINB 操作相对简单实用，对患儿全身影响小，安全有效，为小儿腹股沟区手术的麻醉提供了一种良好的选择。参考文献1 Johr M. Regional Techniques for Pediatric Day Surgery. Techniques in Regional Anesthesia
18、 and Pain Management.2000,4(1):38-44.2 Al-dabbagh A.K.R. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat 2002,24(2):102-107.113 Boon JM, Bosenberg AT, Abrahams PH, et al. Anatomical considerations of the pediatric ilioinguinal/iliohypogastric
19、nerve block. Pediatric Anesthesia 2005,15(5):371-377.4 Gunter JB, Gregg T, Varughese AM, et al. Levobupivacaine for ilioinguinal/iliohypogastric nerve block in children. Anesth Analg 1999,89(3):647-649.5 Dalens B, Ecoffey C, Joly A, et al. Pharmacokinetics and analgesic effect of ropivacaine followi
20、ng ilioinguinal/iliohypogastric nerve block in children. Paediatr Anaesth 2001,11(4):415-420.6 Ala-Kokko TI, Karinen J, Raiha E, et al. Pharmacokinetics of 0.75% ropivacaine and 0.5%bupivacaine after ilioinguinal/iliohypogastric nerve block in children. Br J Anaesth 2002,89(3):438-441.7 Ivani G, Con
21、io A, De Negri P et al. Spinal versus peripheral effects of adjunct clonidine: comparison of the analgesic effect of a ropivacaine-clonidine mixture when administered as a caudal or ilioinguinal/iliohypogastric nerve blockage for inguinal surgery in children. Paediatr Anaesth 2002,12(8):680-684.8 Ka
22、abachi O, Zerelli Z, Mehhamem M, et al. Clonidine 12administered as adjuvant for bupivacaine in ilioinguinal/iliohypogastric nerve block dose not prolong postoperative analgesia. Paediatr Anaesth 2005,15(7):586-590.9 Lim SL, Ng Sb A, Tan GM. Ilioinguinal and iliohypogastric nerve block revisited: si
23、ngle shot versus doube shot technique for hernia repair in children. Paediatr Anaesth 2002,12(3):255-260. 10 Marhofer P, Greher M and Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005,94(1):7-17.11 Willschke H, Marhofer P, Bosenberg A et al. Ultrasonography for ilioinguinal/il
24、iohypogastric nerve blocks in children. Br J Anaesth 2005,95(2):226-230.12 Song D, Greilich NB, White PF et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000,91(4):876-881.13 Toivonen J, Permi J and Rosenberg PH. Analgesia and discharge
25、 following preincisional Ilioinguinal and iliohypogastric nerve block combined with general or spinal anaesthesia for inguinal herniorrhaphy. Acta Anesthsiol Scand 2004,48(4):480-485.14 Moiniche S, Kehlet H, Dahl JB. A quqlitative and 13quantitative systematic review of preemptive analgesia. Anesthe
26、siology 2002,96(3):725-741.15 Cross GD, Barrett RF. Comparison of two regional techniques for postoperative analgesia in children following herniotomy and orchidopxy. Anaesthesia 1987,42(8):845-849.16 Markham SJ, Tomlinson J, Hain WR.Ilioinguinal nerve blocks in children-a comparison with caudal blo
27、ck for intra and postoperative analgesia. Anaesthesia 1986,41(11):1098-1103.17 Smith T, Moratin P, Wulf H. Smaller children have greater bupivacaine plasma concentrations after ilioinguinal block. Br J Anaesth 1996,76(3):452-455.18 Sasaoka N, Kawaguchi M, Yoshitani K et al. Evaluation of genitofemor
28、al nerve block, in addition to ilioinguinal and iliohypogastric nerve block, during inguinal hernia repair in children. Br J Anaesth 2005,94(2):243-246.19 Somri M, Gaitini LA, Vaida sj et al. Effect of ilioinguinal nerve block on the catecholamine pasma levels in orchidopexy: comparison with caudal
29、epidural block. Paediatr Anaesth 2002,12(9):791-797.20 Lipp A, Woodcock J, Hensman B et al. Leg weakness is a complication of ilio-inguinal block in children. Br J 14Anaesth 2004,92(2):273-274.21 Amory C, Mariscal A, Guyot E et al. Is ilioinguinal/iliohypogastric nerve block always totally safe in c
30、hildren? Paediatr Anaesth 2004,14(4):365-366.髂腹下神经阻滞（2）BJA Advance Access published April 17, 2009British Journal of Anaesthesia Page 1of 5doi:10.1093/bja/aep067Ultrasound-guided transversus abdominis plane block:description of a new technique and comparison with conventional systemicanalgesia durin
31、g laparoscopic cholecystectomy A. A. El-Dawlatly 1, A. Turkistani 1, S. C. Kettner 2, A.-M. Machata 2, M. B. Delvi 1, A. Thallaj 1,S. Kapral 2and P. Marhofer 2*Department of Anaesthesia and Intensive Care Medicine, King Saud University, College of Medicine, Riyadh, Saudi Arabia. 2Department of Anaes
32、thesia, Intensive Care Medicine and Pain Therapy, Medical15University of Vienna, Waehringer Guertel 18-20, A-1090Vienna, Austria*Correspondingauthor. E-mail:peter.marhofermeduniwien.ac.atBackground. The transversus abdominis plane (TAP) block is usually performed by landmark-based methods. This pros
33、pective, randomized, and double-blinded study was designed to describe a method of ultrasound-guided T AP block and to evaluate the intra-and postoperative analgesic efcacyin patients undergoing laparoscopic cholecystectomy under general anaesthe-sia with or without T AP block.Methods. Forty-two pat
34、ients undergoing laparoscopic cholecystectomy were randomized to receive standard general anaesthetic either with (GroupA, n 21) or without T AP block (GroupB, n 21). Ultrasound-guided bilateral T AP block was performed with a high frequent linear ultrasound probe and an in-plane needle guidance tec
35、hnique with 15ml bupivacaine 5mg ml 21on each side. Intraoperative use of sufentanil and postoperative demand of morphine using a patient-controlled analgesia device were recorded.Results. Ultrasonographic visualization of the relevant 16anatomy, detection of the shaft and tip of the needle, and the
36、 spread of local anaesthetic were possible in all cases where a T AP block was performed. Patients in Group A received signicantlymore intraoperative sufentanil and postoperative morphine compared with those in Group B mean(SD ) 8.6(3.5)vs 23.0(4.8)m g, P , 0.01, and 10.5(7.7)vs 22.8(4.3)mg, P , 0.0
37、5.Conclusions. Ultrasonographic guidance enables exact placement of the local anaesthetic for T AP blocks. In patients undergoing laparoscopic cholecystectomy under standard general anaesthetic, ultrasound-guided T AP block substantially reduced the perioperative opioid consumption. Br J Anaesth 200
38、9Keywords :anaesthetic techniques, regional; equipment, ultrasound machines; surgery, laparoscopyAccepted for publication:February 26, 20091Although laparoscopic cholecystectomy is considered to be a minimally invasive surgical procedure with lower perioperative pain scores compared with open proced
39、ures, it is associated with signicantlevels of postoperative pain. 12Usually, standard general anaesthetic is given to patients 17undergoing laparoscopic cholecystectomy.However, the use of neuraxial anaesthesia 35or of intra-peritoneal local anaesthesia 6has been shown to increase the efcacyof peri
40、operative pain therapy and reduce the consumption of opioid drugs. Peripheral regional anaes-alternative to central blocks or high-dose intraperitoneal anaesthesia. The transversus abdominis plane (TAP)block involves the sensory nerve supply of the anteriorlateralabdominal wall, where the T712interc
41、ostal nerves, the ilioinguinal and iliohypogastric nerves, and the lateral cutaneous branches of the dorsal rami of L13are blocked with an injection of local anaesthetic between theThe study was performed at the Department of Anaesthesia and Intensive Care Medicine, King Saud University, College ofE
42、l-Dawlatly et al.internal oblique abdominal muscle (IOAM)and the trans-verse abdominal muscle (TAM).7TAP blocks are per-formed for indications such as Caesarean delivery, 8bowel surgery, 9or retropubic prostatectomy. 10Despite the encouraging initial results, the TAP block is not well 18described in
43、 the literature in terms of block technique, success rates, or local anaesthetic plasma levels. So far, the block is performed by so-called pop89or double-pop7methods in the anatomical area of the Petittri-angle, which is located between the iliac crest, the latissi-mus dorsi, and external oblique a
44、bdominal muscles (EOAM).Consequently, inadvertent needle positions with subsequent severe complications are described. 11Direct ultrasonographic visualization of the anatomy involved and the spread of local anaesthetic could serve as an alternative technique to perform a TAP block. Only anec-dotal r
45、eports are available about the use of ultrasound for TAP blocks. 1213Therefore, we designed a prospective, ran-domized, and double-blinded study to describe the feasibility of ultrasound-guided TAP block and to compare the efcacyof ultrasound-guided TAP blocks for laparoscopic cholecys-tectomy as a
46、part of a concept for balanced anaesthesia with the conventional method of standard general anaesthesia.After induction of general anaesthesia, bilateral TAP block was performed under ultrasonographic guidance with a SonoSite M-Turbo transportable ultrasound device 19(SonoSiteTM , Bothell, WA, USA)
47、and a linear 613MHz ultrasound transducer. Once the EOAM, IOAM, and TAM were visualized at the level of the anterior axillary line between the 12th rib and the iliac crest (Fig.1), the punc-ture area and the ultrasound probe were prepared in a sterile manner. Then, the block was performed with a 21G
48、 90mm Facette tip needle and an injection line (PolymedicTM by tenema, Z.I. des Amandiers, France) rea-lizing an in-planeultrasound-guided technique as illus-trated in Figure 2. Once the tip of the needle was placed in the space between the IOAM and TAM and negative aspiration, 15ml bupivacaine 5mg
49、ml 21was administered under direct ultrasonographic guidance (Fig.3). The con-tralateral block was performed equally.Skin incision was given in both study groups 15min after the TAP block. The four ports for the laparoscopic procedure were placed below umbilicus, on the right side and on the left side of the abdominal wall. The subsequent surgical procedure was performed routinely followingtheMethodsAfter approval by the Ethics Committee of the King Saud 20University in Riyadh (SaudiArabia) and
