躯干神经阻滞

躯干神经阻滞在胸腹手术中的应用肖颖胸壁手术镇痛方式的比较•胸段硬膜外•胸椎旁神经阻滞•PECSBlockRiskpotential胸壁神经支配IntercostalnervesensorydistributionNeuralinnervationofchestwall硬膜外阻滞胸椎旁阻滞前锯肌平面阻滞（肋间神经侧皮支）肋间神经阻滞胸骨旁肋间神经阻滞(肋间神经前皮支)ThoracicParavertebralBlockThoracicParavertebralBlockThoracicParavertebralBlockThoracicwallblock:PECS1+PECS2+PECS3NeuralinnervationofanteriorchestwallandbreastSupraclavicularnerveC3-C4NeuralinnervationofanteriorchestwallandbreastLateralpectoralnerveC5-C7MedialpectoralnerveC8-T1NeuralinnervationofanteriorchestwallandbreastLongthoracicnerveC5-C7NeuralinnervationofanteriorchestwallandbreastThoracodorsalnerveC6-C8NeuralinnervationofanteriorchestwallandbreastLateralintercostalcutaneoousnerveT2-T6AnteriorintercostalcutaneoousnerveT2-T6NeuralinnervationofanteriorchestwallandbreastThoracicwallblock:PECS1+PECS2+PECS3•Indication:postoperativeAnalgesiaPECS1:BreastexpanderorsubpectoralprosthesesPECS2:+PECS1:Tumorresection,Mastectomy+axillarylymphnodeclearancePECS3+PECS1:Mastectomy+axillarylymphnodeclearance+reconstructionBlancoR,Anaesthesia.2011Sep;66(9):847-8BlancoRetal,RevEspAnestesiolReanim.2012Nov;59(9):470-5BlancoRetal,Anaesthesia2013,68,1107–1113Thoracicwallblock:PECS1+PECS2+PECS3•PECS1:interfascialplanebetweenpectoralismajorandminorN.pectoralesmedialis+lateralis(M.pectoralismajor)BlancoR,Anaesthesia.2011Sep;66(9):847-8BlancoRetal,RevEspAnestesiolReanim.2012Nov;59(9):470-5BlancoRetal,Anaesthesia2013,68,1107–1113GeorgThiemeVerlagPECS1PECS1PECS1:InjectionThoraxwallblock:PECS1+PECS2+PECS3•PECS1N.pectoralesmedialis+lateralis(M.pectoralismajor)•PECS2LateralcutaneousbranchofthoracicintercostalneervenerveT2-T6+N.thoracicuslongus(M.serratusanterior)BlancoR,Anaesthesia.2011Sep;66(9):847-8BlancoRetal,RevEspAnestesiolReanim.2012Nov;59(9):470-5BlancoRetal,Anaesthesia2013,68,1107–1113GeorgThiemeVerlagM.serratusanteriorGeorgThiemeVerlagPECS2PECS2:Zielregionmediallateral4.Rib5.Rib3.RippePleuraPleuraM.pectoralismajorM.pectoralisminorM.SerratusanteriorPECS2PECS2InjectionUltrasoundblock.comPECS2:sensoryBlockadeThoracicwallblock:PECS1+PECS2+PECS3•PECS1N.pectoralesmedialis+lateralis(M.pectoralismajor)•PECS2R.cutaneilateralisderR.anterioresderSpinalnervenT2-T6+N.thoracicuslongus(M.serratusanterior)•PECS3LateralcutaneousbranchofthoracicintercostalneervenerveT2-T6+N.thoracodorsalis(M.latissimusdorsi)BlancoR,Anaesthesia.2011Sep;66(9):847-8BlancoRetal,RevEspAnestesiolReanim.2012Nov;59(9):470-5BlancoRetal,Anaesthesia2013,68,1107–1113GeorgThiemeVerlagGeorgThiemeVerlagPECS3PECS3:sensoryBlockadeBlancoRetal,Anaesthesia2013,68,1107–1113腹壁手术术后镇痛方式的比较•胸段硬膜外•胸椎旁神经阻滞•QudratusLumborumBlockadeandTAPRiskpotentialQudratusLumborumBlockN.spinalisPutz/Pabst:Sobotta.AtlasderAnatomiedesMenschen,21.Aufl.Urban&Fischer,2000R.cutaneuslateralisR.cutaneusanteriorQuadratuslumborumB.TABB.RectussheathB.ClassicalTAPSubcostalTAPQuadratusLumborumBlockRectussheathBlockQudratusLumborumBlockadeBlancoR.RegAnaesthPainMed2007;32(Suppl1):130HebbardPD,JCanAnesth(2009)56:618–620M.erectorspinaeM.psoasM.QuadratuslumborumRectussheathB.TAPB.QuadratuslumborumB.Ultrasound-GuidedTransmuscularQuadratusLumborumBlockadeQuadratuslumborumBlockadeTransmuscularQuadratuslumborumBlockadeM.psoasM.QuadratuslumborumTransversusAbdominisplaneblockadeventralposterioranteriordorsalWirbelkörperM.psoasProcesstransversusM.erectorspineM.QuadratuslumborumTansversusAbdominsPlaneBlockadeUltrasound-GuidedTransversusAbdominsPlaneBlockUltrasound-GuidedTransversusAbdominsPlaneBlockUltrasound-GuidedTransversusAbdominsPlaneBlockade