中英双语：超声引导下锁骨下臂丛神经阻滞Duke

本文由“麻醉新超人”授权转载

翻译：高   寒 徐州医科大学2020级麻醉学研究生  

审校：赵林林 徐州医科大学附属医院麻醉科

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The infraclavicular brachial plexus block is an extremely effective and reliable technique for anesthetizing the upper limb. It's a favorite of many longtime regionalists and in this video will discuss the anatomy, sono-anatomy and the technique for blocking the brachial plexus in the infraclavicular fossa.

锁骨下臂丛神经阻滞是一种极为有效和可靠的上肢麻醉技术。它是许多长期从事区域麻醉工作的人的最爱，在本视频中，我们将讨论锁骨下臂丛神经阻滞的解剖、超声解剖和技术。

If we consider the region just south of the clavicle and medial to the coracoid process, we see the brachial plexus forms three chords, that lie in close proximity to the axillary artery. They're named for their relation to the artery, and so we have the lateral cord, the posterior cord, and the medial cord. Their intimate relation with the artery means that the infraclavicular is essentially a perivascular technique.

如果我们观察锁骨以下、喙突内侧的区域，我们会看到臂丛形成三束，它们位于腋动脉的附近。它们因与动脉的位置关系而被命名，因此有外侧束、后束和内侧束。它们与动脉的密切关系意味着锁骨下阻滞基本上是一种血管周围技术。

To effectively visualize and block the plexus, we’ll want the patient’s supine with the head of the bed slightly elevated. The head is turned to the contralateral side, and the arm is abducted to 90 degrees. The operator can approach the patient from the ipsilateral side or from the head of the bed, depending on ergonomics and the location of the ultrasound machine.

为了有效地观察和阻断神经丛，我们希望病人仰卧，床头略微抬高，头转向对侧，手臂外展至90度。操作者可以从同侧或从床头接近病人，这取决于是否符合人体工程学以及超声机的位置。

The transducer is placed in a parasagital orientation, just caudad to the clavicle and just medial to the coracoid process. These two structures are in green here. This should get you an image like this. Here we see the pec major and minor muscles, and beneath those are the axillary artery and vein. The artery is going to be our main focus. Clustered around the artery are the three chords, the lateral and posterior typically on the cephalad side and the medial wedged between the artery and vein.

探头对准肩胛骨方向，正好在锁骨的尾部和喙突的内侧。这两个结构在这里用绿色标出。你可以得到如下图像：在这里我们看到胸大肌和胸小肌，下面是腋动脉和静脉。动脉将是我们的主要关注点。围绕着动脉的是三束，外侧束和后束通常在头侧，而内侧束则夹在动脉和静脉之间。

The goal of the block is to advance the needle from the cephalot aspect through the pec muscles and land the needle tip just deep to the artery at the 6 o'clock position.

神经阻滞的目的是将针从头侧穿过胸肌，并使针尖在 6 点钟位置深入动脉。

Things are clustered tightly here, and you’ll want to make good use of hydrodissection to keep those cords clear of the needle path. And it's often the case that you can see your artery well, but don't have a clear image of any of the cords. The great thing about this block is it doesn't matter if you put your local at 6 o'clock, you'll be in great shape. We’ll typically use between 20 and 30 ml of local depending on the patient's size and the pattern of spread.

这里的结构聚集得很紧密，你需要好好利用水分离来使三束避开阻滞针。通常情况下，你可以很好地看到动脉，但不能看清三束的清晰图像。这种阻滞方法的好处是，如果你把针头放置放在6点钟方向也没有关系，你会得到很好的图像。我们通常会使用20至30毫升的局麻药，这取决于病人的体型和扩散方式。

Here's an example of why it's not crucial to see the cords. I can maybe see the lateral cord in this image, but I wouldn't bet my life on it. That's okay, because my goal is to hit that 6 o'clock spot. You can see the local lifting the artery up and spreading in a u-shaped pattern. This is what you want to see.

这里有一个例子，说明为什么看到三束并不重要。在这张图片中，我也许能看到外侧束，但我不能保证。这没关系，因为我的目标是6点钟的位置。你可以看到局麻药把动脉抬起来，并以U形模式展开。这就是你想要看到的。

Okay, so here we see the axillary artery underneath the pec minor muscle, we can appreciate what looks like the lateral cord on the cephalad. The needle passes through the pec major and pec minor muscles, annd hydrodissection lifts the pec fascia of the artery. We want to scrape the paint off the artery passing very close to it tangentially, while we continue to hydro dissect. There the needle tip is deep to the artery, and we get immediate flow after passing through that fascial layer. Our aim is to see local anesthetic directly underneath the artery with no intervening structures or layers.

好的，所以在这里我们看到了胸小肌下面的腋动脉，我们可以看到头侧看起来像外侧束的东西。针头穿过胸大肌和胸小肌，水分离提升了动脉的胸肌筋膜。我们像刮掉动脉的油漆一样从切线方向靠近动脉，同时继续进行水分离。针尖深入到动脉下方，在通过该筋膜层后，我们立即注射局麻药。我们的目的是在动脉的正下方看到局部麻醉药，并且没有任何结构或筋膜层次的干扰。

Like the supraclavicular, this is a spinal of the arm, meaning you block nearly the entire upper limb with one caveat. At this location, you don't reliably get the suprascapular nerve, which branches off the superior trunk. And for that reason, the interclavicular approach is not ideal for shoulder surgery. Everything else is fair game, though arm, elbow, forearm, and hand.

与锁骨上臂丛神经阻滞一样，这也是手臂的“腰麻”，意味着你几乎阻断了整个上肢。但有一点需要注意的是，在这个位置，你不能可靠地获得肩胛上神经阻滞，该神经是上肢主干的分支。由于这个原因，锁骨下入路不是肩部手术的理想选择。其他部位都是一样的，包括整个手臂、肘部、前臂和手。

The infraclavicular approach is a favorite of many. For one principal reason, It's a single injection one and done. If you put 30 ml of local anesthetic immediately deep to the artery, you have a 100.0 percent success rate, or at least very close. This is because you only have three chords, and they all lie in the same neurovascular plane as the artery.

锁骨下臂丛神经阻滞是许多人的首选。主要原因之一是它只需一次注射就能完成。如果你把30毫升的局部麻醉药注射到动脉深处，你有100.0%的成功率，或者至少非常接近。这是因为在这里臂丛神经只有三束，而且三束都位于和动脉一样的神经血管鞘内。

The supraclavicular brachial plexus block by comparison, tends to fail occasionally with a single corner pocket injection, and it often requires two or even three separate needle passes and aliquots of local anesthetic to get a good effect. The other plus relates to catheters, because the catheter is going through two fairly thick muscles. It holds well and doesn't move compared to a supraclavicular location, where the place is shallow and the patient's neck is moving constantly. The chest wall is also more comfortable place to have a catheter dressing compared to the neck.

相比之下，锁骨上臂丛神经阻滞，偶尔会因为单一的角落口袋内注射而失败，而且往往需要两次甚至三次单独进针和等量的局部麻醉药才能获得良好的效果。另一个好处是与导管有关，因为导管要穿过两块相当厚的肌肉。与锁骨上位置相比，它保持得很好，而且不会移动，而锁骨上的位置很浅，病人的脖子在不断移动。并且与颈部相比，胸壁也是放置导管敷料的更舒适的地方。

Here are some inffraclavicular tips.

First, there are a lot of vessels in this part of the body, so watch for where your needle travels. The two that are most at risk are the thorac acromial artery or its branches and the cephalic vein. These typically lie in the plane between the two pec muscles. So it's a good idea to check for them before planning your needle trajectory.

这里有一些锁骨下阻滞的小方法：

首先，这里有很多血管，所以要注意你的针头所经过的地方。最危险的两条是胸肩峰动脉及其分支和头静脉。这些通常位于两块胸肌之间的平面内。因此，在规划进针轨迹之前，最好检查它们。

Second, it's a common novice error to inadvertently let the probe slide medial or lateral making it challenging to find your landmarks. As long as you keep the narrow pec minor muscle on the screen, you should be in good shape. Here's our nice view. When the probe slides medial we lose pec minor end up very close to the chest wall. Going the other way, we pass by our optimal view, and then end up losing the artery as we begin to see more deltoid and shoulder structures. Keeping both pec muscles on the screen anchors your image in the right place.

第二，一个常见的新手错误就是不经意间使探头向内或外滑动，使其难以找到标志物。在屏幕上保持看到狭窄的胸小肌，你就可以得到好图像。这是我们得到的清晰图像。当探头向内侧滑动时，胸小肌在接近胸壁的方向消失。反过来向外侧移动探头，我们经过最佳视图，当我们开始看到更多的三角肌和肩膀结构时，动脉消失在屏幕里。当同时看到胸大肌和胸小肌时就是你的最佳图像。

And lastly, a criticism of the infraclavicular approach is that it's relatively steep and deep, which makes it difficult to see the needle at times. Heel toeing the probe, so the beam is angled more towards the head may only change the angle by 10 to 15 degrees, but this vastly improves the likelihood you'll see your needle. Alternatively, we'll pull out the curvilinear probe sometimes, especially for patients with a lot of pec muscle. The fan shaped angle of the beam can improve needle visualization, especially in heavy patients.

最后，锁骨下入路的一个意见是，它相对较陡峭和深，这使得有时很难看到针头。将探头向脚部倾斜，使声束更多地朝向头部，这可能只会改变10至15度的角度，但这大大地提高了你看到针的可能性。另外，我们有时也会用曲阵探头，特别是对胸肌发达的病人。声束的扇形角度可以提高针头的可视性，特别是对于体重大的病人。

And finally, the retroclavicular or RAPTIR approach can provide excellent needle visualization due to the flattened trajectory.

For an in-depth discussion of the RAPTIR(retroclavicular approach to the infraclavicular region), check out this video.

最后，由于轨迹平坦，锁骨后或RAPTIR入路可以很好地看到阻滞针。

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