本文選題：超聲 + 胸椎旁間隙　； 參考：《南方醫(yī)科大學(xué)》2014年博士論文

【摘要】：研究背景與目的 近年來隨著認(rèn)識的深入,區(qū)域阻滯為多模式鎮(zhèn)痛治療方案重要的組成成分已被廣泛接受。Kairaluoma研究發(fā)現(xiàn)圍術(shù)期運(yùn)用胸椎旁神經(jīng)阻滯可降低術(shù)后急性疼痛發(fā)生率,同時也可減少術(shù)后一年內(nèi)慢性疼痛的發(fā)生。另一項(xiàng)Exadaktylos的研究提示在乳腺癌術(shù)后36個月腫瘤復(fù)發(fā)率的觀察中,胸椎旁神經(jīng)阻滯組低于全麻組,這再次引發(fā)大家對胸椎旁神經(jīng)阻滯的重視。胸椎旁間隙是一個與相應(yīng)椎體相鄰的橫截面近似楔形的潛在解剖間隙,該間隙內(nèi)側(cè)通過椎間孔與硬膜外間隙相通,外側(cè)與肋間間隙相通。通過注射局部麻醉藥,可阻滯通過此間隙的感覺、運(yùn)動、交感神經(jīng),從而達(dá)到同側(cè)軀體的鎮(zhèn)痛與麻醉的目的。同時注射的藥液可沿此間隙向上和向下擴(kuò)散,故通過一個注射點(diǎn)能夠產(chǎn)生多個節(jié)段范圍的麻醉。開展這項(xiàng)技術(shù)的最初目的是為了減少椎管內(nèi)阻滯時潛在的血腫、脊髓損傷、感染等嚴(yán)重并發(fā)癥及在硬膜外阻滯困難、失敗時提供備選方案,然而通過回顧性研究發(fā)現(xiàn)：胸椎旁神經(jīng)阻滯可提供與硬膜外阻滯相當(dāng)?shù)逆?zhèn)痛療效,而且相比之下可維持更好的氧合通氣指標(biāo),并減少低血壓、尿潴留等相關(guān)并發(fā)癥。胸椎旁神經(jīng)阻滯的療效明確使該項(xiàng)技術(shù)越來越多運(yùn)用于胸科、乳腺、上腹部手術(shù)圍術(shù)期的麻醉鎮(zhèn)痛和胸部區(qū)域的疼痛診療中。 早期胸椎旁神經(jīng)阻滯采用體表標(biāo)志解剖定位,運(yùn)用阻力消失法或壓力監(jiān)測定位法,成功率均不理想,并發(fā)癥發(fā)生率高。采用刺激針連接神經(jīng)刺激儀穿刺亦存在操作的盲目性,不能避免血管內(nèi)穿刺,而且在并存糖尿病等疾病時,存在神經(jīng)傳導(dǎo)障礙,神經(jīng)刺激儀的有效性受到影響。 超聲技術(shù)運(yùn)用于區(qū)域阻滯麻醉是近年臨床麻醉新開展的技術(shù)熱點(diǎn),超聲與其它X線、CT、MRI磁共振等影像技術(shù)相比,具有無X射線暴露、輕便、快捷、準(zhǔn)確等優(yōu)點(diǎn)。在臨床麻醉工作中超聲技術(shù)能協(xié)助確認(rèn)阻滯靶點(diǎn)并了解其相鄰組織結(jié)構(gòu),同時能確定穿刺針路徑并實(shí)時引導(dǎo)穿刺。胸椎旁間隙是一個與脊柱硬膜外間隙毗鄰的潛在間隙,前端與胸膜、肺臟及胸部大血管緊密相鄰,操作時容易導(dǎo)致穿刺損傷。超聲技術(shù)的可視化、實(shí)時化為我們解決上述難題提供強(qiáng)有力的臨床診療工具。 超聲技術(shù)對于初步接觸者尤其是剛開始學(xué)習(xí)麻醉技能的初學(xué)者,掌握這項(xiàng)技術(shù)需要較長的學(xué)習(xí)過程。有研究表明,利用現(xiàn)代化的科技手段如計(jì)算機(jī)圖像技術(shù)、模擬器虛擬教學(xué)等手段均能提高心肺復(fù)蘇急救技能的學(xué)習(xí)效率,提高治療有效率,同時在模擬氣管插管,模擬腔鏡手術(shù)中也證實(shí)了有效性。因此我們擬將其運(yùn)用于超聲引導(dǎo)的神經(jīng)阻滯教學(xué)中,以探討其有效性、可重復(fù)性,努力提高學(xué)習(xí)效率。 本研究目的在于對以下四個方面問題進(jìn)行探討：①胸椎旁間隙超聲解剖特征及優(yōu)化穿刺路徑的研究；②超聲引導(dǎo)胸椎旁間隙置管對肺部腫瘤介入手術(shù)術(shù)后鎮(zhèn)痛安全性的研究；③超聲引導(dǎo)胸椎旁神經(jīng)阻滯對胸部創(chuàng)傷急性疼痛治療有效性的觀察；④超聲引導(dǎo)行胸椎旁神經(jīng)阻滯的學(xué)習(xí)曲線探討,分析學(xué)習(xí)規(guī)律,為制定培訓(xùn)細(xì)則提供參考依據(jù)。 [方法] 1.胸椎旁間隙超聲解剖特征及優(yōu)化穿刺路徑的研究：選擇擇期行開胸手術(shù)患者進(jìn)行研究。分組：旁矢狀切面掃描阻滯組(Paramedian Sagittal scan,S組)，，斜軸位橫斷面掃描阻滯組(Transverse scan,T組)。在胸椎旁間隙進(jìn)行掃描,記錄超聲圖像特征及解剖變化。分辨椎旁肌群、橫突、肋橫突上韌帶、胸膜及胸膜下的肺臟組織,采用超聲引導(dǎo)平面內(nèi)(in plane)穿刺法,引導(dǎo)針突破肋橫突上韌帶進(jìn)入胸椎旁間隙,回抽無血后在超聲監(jiān)測下分次緩慢注射局部麻醉藥。觀察阻滯操作時間、麻醉起效時間、麻醉效果優(yōu)良率,并發(fā)癥發(fā)生率4個指標(biāo)。比較兩種阻滯方法的有效性、安全性。 2.超聲引導(dǎo)胸椎旁間隙置管對肺部腫瘤介入手術(shù)術(shù)后鎮(zhèn)痛安全性的研究,對超聲引導(dǎo)胸椎旁間隙置管方法進(jìn)行探討,運(yùn)用X射線斷層掃描對藥物的擴(kuò)散進(jìn)行觀察：選擇行經(jīng)皮肺部腫瘤介入射頻消融治療患者,全麻前運(yùn)用斜軸位掃描(Transverse scan)外側(cè)肋間入路,采用超聲引導(dǎo)平面內(nèi)(in plane)穿刺法,引導(dǎo)穿刺置管。分次推注含造影劑(Iohexol碘海醇)的局麻藥(0.5%羅哌卡因)共20mL。觀察麻醉平面及效果,評估含造影劑局部麻醉藥在CT橫斷位胸椎旁間隙擴(kuò)散情況,同時通過CT冠狀位重建,測量藥物擴(kuò)散的節(jié)段數(shù)。從而評價超聲實(shí)時引導(dǎo)的胸椎旁神經(jīng)阻滯及置管法的安全性,有效性。 3.觀察超聲引導(dǎo)下行胸椎旁間隙置管,羅哌卡因復(fù)合舒芬太尼溶液聯(lián)合胸椎旁持續(xù)患者自控鎮(zhèn)痛,在多發(fā)肋骨骨折患者的鎮(zhèn)痛有效性及對患者生活質(zhì)量的影響。選擇單側(cè)多發(fā)肋骨骨折患者25例,超聲引導(dǎo)下行胸椎旁間隙成功置管后,予0.2%羅哌卡因含5μg/ml腎上腺素,復(fù)合0.25pg/ml舒芬太尼0.1ml/kg/h持續(xù)鎮(zhèn)痛治療,同時口服塞來昔布200mg每日兩次,觀察并記錄VAS評分和Barthel指數(shù)評分,并觀察胸椎旁阻滯對循環(huán)的影響及其他不良反應(yīng)。 4.超聲引導(dǎo)下行胸椎旁神經(jīng)阻滯的學(xué)習(xí)曲線探討：回顧分析2013年1月～2013年9月由5名麻醉科住院醫(yī)生完成的超聲引導(dǎo)下行胸椎旁神經(jīng)阻滯的90例手術(shù)病人臨床資料,按手術(shù)時間先后順序分為6組,每組15例,比較各組的阻滯操作時間、麻醉起效時間、麻醉優(yōu)良率、并發(fā)癥發(fā)生率4個指標(biāo)的差異。評估超聲引導(dǎo)胸椎旁阻滯的臨床學(xué)習(xí)曲線。 [結(jié)果] 1.胸椎旁間隙超聲影像學(xué)的解剖特征：超聲技術(shù)可清晰顯示椎體橫突輪廓,及橫突旁肋橫突上韌帶,胸椎旁間隙,胸膜,胸膜滑動征,胸膜下肺組織。從穿刺針接觸皮膚至注藥完畢所需時間旁矢狀切面掃描組(Paramedian Sagittal scan,S組)平均需要10.2±2.62min:斜軸位橫斷面掃描組(Transverse scan,T組)阻滯操作時間平均需要7.5±2.07min；兩組比較有顯著差異(P0.05)；超聲測量穿刺點(diǎn)至胸椎旁間隙深度： S組為52±6.6mm, T組為73±9.7mm,兩組差異顯著。實(shí)際穿刺深度：S組為62±6.8mm,T組為8±9.7mm,兩組差異顯著。引導(dǎo)穿刺時調(diào)整穿刺針針道的次數(shù)：S組為3.3±1.46次,T組為2.1±1.29次,P值為0.009,有統(tǒng)計(jì)學(xué)差異。穿刺時遇到骨質(zhì)次數(shù)：S組1.9±1.37次,T組0.7±0.8次,P=0.002,有統(tǒng)計(jì)學(xué)差異。穿刺時有阻力消失感(例,%)：S組2例(10%),T組1例(5%)。S組有1例(5%)穿刺時損傷血管形成血腫；T組無發(fā)現(xiàn)有血管損傷。兩組麻醉效果均為優(yōu)良,S組麻醉效果優(yōu)者有11例,良者有9例；T組麻醉效果優(yōu)者有13例,良者有7例。旁矢狀切面掃描組有6例(30%)穿刺部位疼痛,余無氣胸和局麻藥中毒等報(bào)道。 2.超聲引導(dǎo)胸椎旁間隙置管藥物擴(kuò)散的觀察：通過針刺法測定阻滯平面均數(shù)為6.2±0.9個節(jié)段的脊神經(jīng),注藥部位感覺阻滯分布：頭側(cè)2.1±0.7個節(jié)段和尾側(cè)4.1±0.7個節(jié)段,自注藥點(diǎn)尾側(cè)節(jié)段多于頭側(cè)節(jié)段數(shù)(P=0.000)。通過CT冠狀位重建,藥物彌散的節(jié)段數(shù)平均為3.4±1.0個節(jié)段,注藥部位藥物彌散分布：注藥部位頭側(cè)1.2±0.6個和尾側(cè)2.3±0.8個節(jié)段,自注藥點(diǎn)尾側(cè)大于頭側(cè)(P=0.001)。感覺減退總的平面節(jié)段數(shù)大于藥液彌散節(jié)段數(shù),有統(tǒng)計(jì)學(xué)意義(P=0.000)。含造影劑局部麻醉藥在CT橫斷位胸椎旁間隙擴(kuò)散情況：結(jié)果顯示藥液集聚在椎旁,接近椎間孔和神經(jīng)根區(qū)域的最多,占47%；藥物集聚在椎體椎旁水平,接近交感神經(jīng)干占28%；藥物集聚在椎旁,位于椎間孔外側(cè)及肋間隙占18%；還有部分藥物集聚在椎旁的肌群內(nèi)占7%。 3.與阻滯前比較,阻滯后的SBP、DBP、MAP、HR、SpO2值變化均不明顯,差異無統(tǒng)計(jì)學(xué)意義。靜息狀態(tài)下在阻滯后較阻滯前疼痛明顯緩解,疼痛評分明顯下降(P0.05)。咳嗽咳痰時阻滯后與阻滯前比較疼痛評分也明顯下降(P0.05)。在相同時間點(diǎn)咳嗽咳痰時與靜息時比較疼痛感差異不明顯�；颊叱鲈寒�(dāng)天、出院后1個月、3個月電話隨訪VAS評分,靜息和咳嗽時均低于3分,且無麻木、疼覺敏感等不適。阻滯前的Barthel指數(shù)顯示患者日常生活能力為中至重度功能障礙；在阻滯之后24h、48h的Barthel指數(shù)評分為輕度功能障礙,能獨(dú)立完成部分日�；顒�,與阻滯前比較日常生活活動能力改善(P0.05)。出院后1個月,3個月電話隨訪Barthel指數(shù)評分與出院當(dāng)日比較有進(jìn)一步改善(P0.05)。 4.90例患者按手術(shù)時間先后順序分為6組,比較組間麻醉阻滯操作時間,后期所需時間短于前期所需時間,有顯著差異(F=54.39,P0.001)。組間麻醉起效時間比較(P=0.682),麻醉優(yōu)良率比較(P=0.791)無統(tǒng)計(jì)學(xué)差異。阻滯操作時間隨著麻醉例數(shù)增加呈下降趨勢,曲線擬合效果良好決定系數(shù)R2=0.757。曲線函數(shù)圖可以看到初學(xué)者在初期陡直下降后自30例起開始趨于平緩進(jìn)入平臺期。 [結(jié)論] 1.超聲技術(shù)可為胸椎旁間隙的形態(tài)學(xué)提供新的觀察方法,超聲能清晰顯示其周圍組織關(guān)系。此外,高頻超聲可實(shí)時引導(dǎo)穿刺針進(jìn)行神經(jīng)阻滯,麻醉效果優(yōu)良。斜軸位掃描外側(cè)肋間入路平面內(nèi)法,其穿刺不良事件少,患者滿意度更高。 2.超聲技術(shù)可用于引導(dǎo)胸椎旁間隙置管,導(dǎo)管位置多位于椎旁間隙接近椎間孔、神經(jīng)根。胸椎旁間隙置管可為單側(cè)肺部手術(shù)提供良好的鎮(zhèn)痛,20毫升局麻藥可提供均數(shù)6個感覺減退平面,自注藥點(diǎn)尾側(cè)大于頭側(cè)并大于實(shí)際藥液彌散節(jié)段數(shù)。藥液可在椎旁間隙沿椎體上下擴(kuò)散,也可沿肋間隙擴(kuò)散,部分經(jīng)過椎間孔擴(kuò)散到硬膜外腔隙。 3.超聲引導(dǎo)下行胸椎旁間隙置管,羅哌卡因復(fù)合舒芬太尼持續(xù)胸椎旁間隙鎮(zhèn)痛用于多發(fā)肋骨骨折患者效果好,可改善患者日常生活能力且副作用少。 4.學(xué)習(xí)超聲引導(dǎo)下行胸椎旁神經(jīng)阻滯是個漸進(jìn)的過程,無超聲引導(dǎo)神經(jīng)阻滯操作經(jīng)驗(yàn)的麻醉醫(yī)師行超聲引導(dǎo)胸椎旁阻滯的學(xué)習(xí)曲線為30例。
[Abstract]:Research background and purpose
In recent years, with the deepening of understanding, regional block as an important component of multimodal analgesic therapy has been widely accepted by the.Kairaluoma study. It is found that peri thoracic paravertebral block can reduce the incidence of acute postoperative pain and also reduce the occurrence of chronic pain within one year after operation. Another Exadaktylos study suggests In the observation of the recurrence rate of the 36 months after breast cancer, the paravertebral block group was lower than the general anesthesia group, which again caused attention to the paravertebral block again. The paravertebral space is a potential dissecting space of approximately wedge-shaped cross section adjacent to the corresponding vertebral body. The medial interspace through the intervertebral space passes through the intervertebral foramen and extradural space. The side of the intercostal space interconnects. By injecting a local anesthetic, it can block the sensation, movement, and sympathetic nerve through this space, so as to achieve the purpose of analgesia and anesthesia in the same side of the body. At the same time, the injection of the liquid can spread up and down along the gap, so the technique can be used to produce multiple segments of the anesthetic through an injection point. The initial aim was to reduce the potential hematoma, spinal cord injury, infection, and other severe complications, such as the epidural block, and the alternative options when the intradural block was blocked. However, a retrospective study found that paraspinal nerve block could provide an analgesic effect comparable to that of epidural block, and can be maintained better than that of the epidural block. The effect of the paravertebral block is clearly made more and more used in the chest, the breast, the peri operation of the breast, and the pain diagnosis and treatment of the chest region.
The early thoracic paravertebral nerve block using the body surface marker anatomic location, using the method of resistance disappearance or pressure monitoring and positioning, the success rate is not ideal and the incidence of complications is high. The puncture of the stimulation needle connected to the nerve stimulator also has the blindness of operation, and it can not avoid the intravascular puncture, and there is a neural transmission in the coexistence of diabetes and other diseases. The effectiveness of the neurostimulator is affected by obstruction.
Ultrasound technique used in regional anesthesia is a new technical hotspot in clinical anesthesia in recent years. Compared with other imaging techniques, such as ultrasound and other X-ray, CT, and MRI magnetic resonance imaging techniques, it has the advantages of no X ray exposure, light, quick, accurate and so on. In clinical anesthesia, ultrasound technique can assist in identifying the block target and understanding its adjacent tissue structure, and simultaneously can The paravertebral space is a potential gap adjacent to the spinal epidural space. The front-end is closely adjacent to the pleura, the lungs and the large blood vessels of the chest. The operation can easily lead to puncture injury. The visualization of ultrasonic technology provides a powerful clinical tool for solving the above problems.
It is shown that the use of modern technology such as computer image technology and simulator virtual teaching can improve the learning efficiency of cardiopulmonary resuscitation skills and improve the effectiveness of treatment. At the same time, it is also proved to be effective in simulated tracheal intubation and simulated endoscopic surgery. Therefore, we intend to apply it to the teaching of ultrasound guided nerve block in order to explore its effectiveness, repeatability and improve the learning efficiency.
The purpose of this study is to discuss the following four aspects: (1) the ultrasonic anatomical characteristics of the paravertebral space and the study of the optimization of the puncture path; (2) the study of the safety of the paravertebral space by ultrasound guided intervertebral space catheterization for the postoperative analgesia of the pulmonary tumor; and (3) the treatment of acute pain in the thoracic trauma by ultrasound guided thoracic paravertebral blockade Observation of effectiveness. 4. Learning curve of thoracic paravertebral nerve block guided by ultrasound and analysis of learning rules, so as to provide reference for making training rules.
[method]
The ultrasonic anatomical features of the 1. paravertebral space and the optimization of the puncture path: select the patients undergoing elective thoracotomy. Group: parasagittal section scan block group (Paramedian Sagittal scan, S), oblique axis transverse section block group (Transverse scan, T group). The paravertebral space was scanned in the paravertebral space, and the characteristics of ultrasonic images were recorded and the characteristics of the ultrasound images were recorded and The paravertebral muscle group, the transverse process, the transverse process, the ligament of the transverse process, the lung tissue under the pleura and the pleura, the ultrasound guided in plane puncture method, the guide needle break through the ligaments of the transverse process to the paravertebral space, and the local anesthetic after the ultrasonic monitoring. There were 4 indexes of time, the excellent and good rate of anesthetic effect and the incidence of complications. The efficacy and safety of the two methods were compared.
2. ultrasound guided paravertebral space catheterization was used to study the safety of postoperative analgesia after interventional surgery for pulmonary tumor. Ultrasound guided catheterization of the paravertebral space was explored. The diffusion of drugs was observed by X ray tomography: percutaneous pulmonary tumor interventional radiofrequency ablation was selected and oblique axis scan was used before general anesthesia (Tran Sverse scan) on the lateral intercostal approach, using the ultrasound guided plane (in plane) puncture method to guide the puncture and catheterization. The anesthetic level and effect of the local anesthetic (0.5% ropivacaine) containing contrast agent (iodipivacaine) were injected into a total of 20mL. (0.5% ropivacaine). The diffusion of the local anesthetic in the paravertebral space of the CT transverse position and the CT crown were evaluated. In order to evaluate the safety and effectiveness of real-time ultrasound guided thoracic paravertebral nerve block and catheterization, we measured the number of segments of drug diffusion.
3. ultrasound guided paravertebral space catheterization, ropivacaine combined with sufentanil combined with paravertebral continuous patient controlled analgesia, analgesic effectiveness and quality of life in patients with multiple ribs fracture. 25 cases of unilateral multiple rib fractures were selected and the paravertebral space was successfully placed under supersonic guidance to 0. 2% ropivacaine containing 5 g/ml adrenaline, combined with 0.25pg/ml sufentanil 0.1ml/kg/h for continuous analgesia, and two times a day with celecoxib 200mg, observed and recorded the VAS score and the Barthel index score, and observed the effects of paravertebral block on circulation and other adverse reactions.
Study on the learning curve of paravertebral nerve block under 4. ultrasound guidance: a retrospective analysis of the clinical data of 90 patients undergoing ultrasound guided thoracic paravertebral block from 5 anesthesiologists from January 2013 to September 2013, and divided into 6 groups according to the order of operation time, 15 cases in each group, and compared the anesthesia time of each group. The difference between the 4 indicators of intoxication onset time, the excellent rate of anesthesia and the incidence of complications were evaluated.
[results]
1. ultrasound imaging features of the paravertebral space: ultrasound technique can clearly display the outline of the transverse process of the vertebral body, the ligament of the transverse process of the parapleura, the paravertebral space, the pleura, the pleural slipping sign, the lower pleural lung tissue. The average paracental scan group (Paramedian Sagittal scan, S) from the puncture needle to the end of the injection The average needs of the 10.2 + 2.62min: oblique axial scan group (Transverse scan, T group) block operation time averaged 7.5 + 2.07min; the two groups were significantly different (P0.05); the puncture point to the paravertebral space depth: S group was 52 + 6.6mm, T group was 73 + 9.7mm, and the two groups were significantly different. The actual puncture depth was 62 + 6.8mm. 8 + 9.7mm, the two groups had significant differences. The number of needle channels adjusted to puncture needle was 3.3 + 1.46 times, T group was 2.1 + 1.29 times, and P was 0.009, there were statistical differences. There were 1.9 + 1.37 times in S group, 0.7 + 0.8 times in group T, P=0.002, with statistical difference. There were 3.3 cases (10%) in:S group, and T group 1 cases when piercing. In group.S, there were 1 cases (5%) injured blood vessels and hemangioma, no vascular injury was found in group T. The anesthetic effect of two groups was excellent, group S was anesthetized in 11 cases, good in 9 cases, and in group T, there were 13 cases of anesthetic effect and 7 cases. There were 6 cases (30%) puncture site pain in parasagittal section scan group, no pneumothorax and intoxication of local anesthetics. Avenue.
The observation of the drug diffusion of 2. ultrasound guided paravertebral space catheterization: the spinal nerve was measured by acupuncture at 6.2 + 0.9 segments by acupuncture. The distribution of sensory block in the injection site: 2.1 + 0.7 segments at the cephalic side and 4.1 + 0.7 segments at the tail side, and the end segment of the injection point was more than the number of the cephalic segments (P=0.000). The drug was reconstructed by CT coronal position. The average number of diffuse segments was 3.4 + 1 segments, and the distribution of drugs at the injection site was 1.2 + 0.6 and 2.3 + 0.8 segments at the tail side. The end side of the injection point was larger than the head side (P=0.001). The total number of plane segments in the sensory degeneration was larger than the number of dispersive segments of the liquid medicine (P=0.000). The local anesthetics containing contrast agents were transverse to CT. The diffusion of paravertebral space in the intervertebral space: the results showed that the liquid was gathered around the vertebra, near the intervertebral foramen and the nerve root area, accounting for 47%. The drugs gathered at the vertebral paravertebral level and nearly 28% of the sympathetic trunk; the drugs gathered at the paravertebral, located in the lateral and intercostal spaces of the intervertebral foramen and the intercostal space of 18%, and some of the drugs gathered in the paravertebral muscles of 7. It is.
3. compared with pre block, the changes of SBP, DBP, MAP, HR, and SpO2 were not significant. The pain was significantly relieved and the pain score decreased significantly (P0.05) in the resting state after block anesthesia. The pain scores of cough expectoration and before block were also significantly decreased (P0.05). At the same time, cough expectoration at the same time point. On the day of discharge, the patient was discharged on the day of discharge, 1 months after discharge and 3 months after the hospital was followed up with VAS scores, while resting and coughing were lower than 3, without numbness and pain sensitivity. The pre block Barthel index showed that the patient's daily living ability was moderate to severe dysfunction; and after block, 24h, 48h Barthel index The score was mild dysfunction, it was able to perform some daily activities independently and compared with the daily living activity before block (P0.05). 1 months after discharge, the Barthel index score of the 3 month follow-up telephone was further improved than that of the day of discharge (P0.05).
4.90 patients were divided into 6 groups according to the order of operation time. The time of anesthesia block operation between the groups was compared with the time required in the later period. There were significant differences (F=54.39, P0.001). The time of anesthesia initiation was compared (P=0.682), and the comparison of the excellent rate of anesthesia (P=0.791) was not statistically significant. The time of block operation was increased with the number of anesthetic cases. The decline trend, the curve fitting effect good determination coefficient R2=0.757. curve function diagram can see the beginner in the initial steep descent after 30 cases began to gradually become flat into the platform period.
[Conclusion]
1. ultrasound technique can provide a new observation method for the morphology of the paravertebral space, and the ultrasound can clearly show the surrounding tissue. In addition, high frequency ultrasound can guide the puncture needle for nerve block in real time, and the effect of anesthesia is excellent. The oblique axis scan of the lateral intercostal approach is less and the patient's satisfaction is higher.
2. ultrasound technique can be used to guide the paravertebral space and catheterization. The position of the catheter is located near the intervertebral space. The nerve root and the paravertebral space tube can provide good analgesia for unilateral pulmonary surgery. The 20 ml anesthetic can provide 6 sensory hypothictic planes. The end of the injection point is larger than the head side and is larger than the number of the actual dispersive segments. The liquid can diffuse along the vertebral body in the paraspinal space, and can also diffuse along the intercostal space, and partly spread through the intervertebral foramen to the epidural space.
3. ultrasound guided paravertebral space catheterization, ropivacaine combined with sufentanil continuous paravertebral space analgesia for multiple ribs fracture patients with good results, can improve the patient's daily life ability and less side effects.
4. learning ultrasound guided paravertebral block is a gradual process, and the anesthesiologist without the experience of ultrasound-guided nerve block operation is guided by ultrasound guided thoracic paravertebral block

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R614

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