| BACKGROUND&OBJECTIVEThoracic paravertebral block(TPVB) is injected local anesthetic into the wedge-shaped gap beside thoracic spine. The gap connected the epidural space through the foramen and communicated with the outside of the intercostal space connected. By injecting a local anesthetic, can block nerve by sensory, motor, sympathetic, so as to achieve the purpose of the ipsilateral somatic analgesia and anesthesia. Local drug can diffusion into upward and downward along the gap, therefore injected a dose of local anesthetics can produce anesthesia range plurality of segments. The technology to carry out the intention is to reduce the incident of potential spinal hematoma, spinal cord injury, infection and other serious complications,and provide alternative solutions in difficult epidural failed. A retrospective study found that Thoracic paravertebral block could provide analgesia efficacy compare to the thoracic epidural block, but in contrast to maintain better oxygenation index ventilation and reduce complications. In recent years, along with a deeper understanding, regional anesthesia is an important component of multimodal analgesia is widely accepted. Thoracic paravertebral block is clear effectly and used increasingly in chest area and upper abdominal area surgery.Early thoracic paravertebral block is used anatomical landmarks, by the feeling of loss resistance or pressure monitor, its success rate is not ideal.the use of nerve stimulator with stimulater needle is also belong to blindness operation. Diabetes with nerve pathological and other diseases cause its efficiency is affected.Ultrasound technology used in regional anesthesia is hot new technology in recent years, anesthesia, Compared with X-ray, CT, MRI imaging techniques, ultrasound had no no X-ray exposure,convenient and fast at the same time. The use of ultrasound in clinical anesthesia to help determine the puncture target and real-guided nerve block.Ultrasound technology allows visualization of target block, the needle can be determined simultaneously and in real time route guidance.Thoracic paravertebral space close to the spinal epidural space,adjacent to the pulmonary pleura closely. Ultrasound technology can let us visualize in real time and minimize complications.For initial contact ultrasound technology, especially for residents to master this technique requires a long learning process. Studies have shown that the use of modern technological means:computer graphics technology, the virtual simulator technology can improve skill efficiency in learning CPR, improve treatment efficiency. While also useful in learning intubation and laparoscopic surgery.Simulators for teaching ultrasound-guided nerve block also demonstrate its repeatability, improve the learning efficiency.In this study, using high-frequency ultrasound imaging technology,we aim to address the4issues as follows:①Sonoanatomy character research of thoracic paravertebral space and optimized puncture path;②To observed ultrasound guided thoracic catheter and its safety used in postoperative analgesia in lung cancer interventional surgery;③To observed ultrasound guided thoracic paravertebral block to cure acute pain by trauma;④To evaluate the learing curve when studying ultrasound guided thoracic paravertebral block,and provide a reference for training.[METHODS]1. Sonoanatomy character research of thoracic paravertebral space and optimized puncture path:Forty elective thoracic surgery patients were studied. Grouping: Paramedian Sagittal scan,(S group), Transverse scan,(T group). After thoracic paravertebral space scan, ultrasound image were recorded. Distinguish paraspinal muscles, transverse, transverse ligament ribs, pleura, and lung pleura.Under ultrasound guidance using in plane method guide the needle, and break though the superior costotransverse ligament.Inject local anesthetic slowly. Observation block operating time, the onset time of anesthesia, anesthesia excellent rate, complication rate.Comparison of two methods of blocking, which is more effective and safety.2. By next thoracic ultrasound-guided catheterization method to explore space, the use of X-ray tomography drug diffusion observed:Select interventional percutaneous radiofrequency ablation of lung cancer patients before anesthesia using oblique axial scanning (Transverse scan) lateral rib between approach, using ultrasound guidance in the plane (in plane) puncture, guided catheterization. Graded push the contrast agent (Iohexol Iohexol) and local anesthetic (0.5%ropivacaine) of20mL. Observe the effects of anesthesia and to assess the number of local anesthetics containing contrast agents in CT segmental thoracic transverse position beside the spread gap, through CT coronal reconstruction, measuring drug diffusion. To evaluate the real-time ultrasound-guided thoracic catheter method next block and the safety and effectiveness.3.Observed beside ultrasound guided thoracic catheter clearance, beside ropivacaine solution combined thoracic sufentanil continuous infusion, multiple rib fractures in patients with analgesic effectiveness and impact on quality of life in patients with unilateral multiple rib fractures25patients, ultrasound-guided thoracic next downside gap after successful catheter, to0.2%ropivacaine with0.5μg/ml epinephrine complex0.25μg/ml sufentanil O.lml/kg/h sustained analgesic treatment, while oral celecoxib200mg twice daily, observe and record the VAS score and Barthel Index score, and observe the effect on the next cycle arrest thoracic clearance and other adverse reactions.4. ultrasound guided thoracic gap next block learning curve to explore: Retrospective analysis of January2013-September2013low of five years of the completion of the attending anesthesiologist ultrasound guided gap next block90cases of thoracic surgery patients clinical data comparing arrest operation time, anesthesia onset time differences, anesthesia excellent rate, complication rate four indicators. Assessment of ultrasound-guided thoracic block beside clinical learning curve.[RESULTS]1. Anatomical characteristics of thoracic ultrasound imaging gap next: High-frequency ultrasound can clearly show the outline of the vertebral transverse process, and adjacent transverse ribs transverse ligament, pleura, pleural sliding sign, and lung tissue.The time required for the injection is on average10.2±2.62min(Paramedian Sagittal scan, S group),7.5±2.07min (Transverse scan, T group) There was a significant difference between the two groups (P<0.05);Thoracic ultrasound to measure the puncture point to the space depth:(52±6.6) mm in S group,(73±9.7) mm in T group; difference was significant. The actual puncture depth:62±6.8mm in S group,80±9.7mm in T group; difference was significant. The number of needle tract adjustments:3.3±1.46times in S group,2.1±1.29times in T group, P=0.009.The times when bone puncture:1.9±1.37times in S group,0.7±0.8times in T group, P=0.002, statistically significant. There LOR (eg,%) puncture:There were2patients (10%) in S group,1patients (5%) in T group. There were1patients (5%) in S group with angiogenesis hematoma after pucture injury; Two anesthetic effects are excellent,In S group there were11cases in excellent,9cases in benign;In T group there were13cases in excellent,7cases in benign. In S group6patients (30%)called puncture site pain, no pneumothorax and local anesthetic toxicity werer reported.2. To observed ultrasound guided thoracic catheter and its safety used in postoperative analgesia in lung cancer interventional surgery:Spinal nerve block plane mean6.2±0.9segments by acupuncture measuring, injection site sensory block distribution:2.1±0.7cephalic segments and4.1±0.7caudal segments, caudal from the injection point is greater than the cephalic (P=0.000). By CT coronal reconstruction, drugs diffusion several sections average3.4±1.0segments, injection site drugs dispersed:injection site cephalic1.2±0.6segments, and caudal2.3±0.8segments, since, caudal injection point is greater than the cephalic (P=0.001). Hypoesthesia number of segments is greater than the number of segments diffusion (P=0.000) statistically was significant. In contrast agent containing a local anesthetic Axial thoracic CT gap beside the spread:The results showed that the liquid concentrate in the paraspinal, and up near the nerve root foramen region,47%; drugs accumulate in paraspinal vertebral level, close to sympathetic trunk,28%; drugs accumulate in the paraspinal, located outside the intervertebral foramen and intercostal space,18%; still part of the drug concentration in the paraspinal muscles accounted for7%.3. Compared with the previous block, SBP, DBP, MAP, HR, SpO2value changes are not significant, the difference was not statistically significant. In the resting state after the blockede pain scores decreased significantly (P<0.05). In the cough and sputum state pain score was significantly decreased (P<0.05). The same point of time when the cough and sputum compared with resting pain score no significant difference. Patients discharged from hospital the same day, one month after discharge, three months telephone follow-up VAS scores at rest and coughing were less than3, and no numbness, pain and discomfort felt sensitive. Befor block Barthel index display patients with moderate to severe dysfunction.After block24h,48h Barthel index score display mild dysfunction, patient complete part of their daily activities independently, comparing with the previous block activities of daily living the ability to improve (P<0.05). Barthel Index score comparison further improvemen1month, three months after discharge (P<0.05).4.90patients divided into six groups by surgery chronologically, between groups operating time of anesthesia, time is shorter than the time required for the early, there is a significant difference (F=54.39, P<0.001). The onset time between the two groups and compare rates anesthetic excellent had no statistical difference between the groups (P=0.682, P=0.791). Operation time decreases while number of cases increased and showed a downward trend, curve fitting to good effect coefficient of determination R2=0.757. Beginners curve function diagram can be seen after the initial steep decline from30cases begun to flatten out into a plateau.[CONCLUSION]1. Ultrasound technology provides a new method for the observation of thoracic paravertebral gap, can clearly show the relationship between the surrounding tissue-In addition, high-frequency ultrasound can guided needle puncture real-time, to provide excellent analgesia. Oblique axial scanning with lateral intercostal approach offter higher patient satisfaction and less harmful happen.2. Ultrasound can be used to guide the thoracic paravertebral gap catheter, the catheter position is located close to the paravertebral space foramen nerve root. Thoracic catheter next to the gap provides good analgesia in unilateral lung surgery. Twenty milliliters local drug can provide six hypoesthesia segments and the hypoesthesia segments is greater than the plane of drug dispersion.The drug can diffusion along the paravertebral space, can spread along the intercostal space also, and there are some drug diffusion into the epidural space through the intervertebral foramina.3.Ultrasound guided paravertebral gap catheter follow with patient control analgesia used ropivacaine combined with sufentanil provided excellent analgesic effect and improve patients’ daily lives and fewer side effects.4. Thoracic ultrasound guided learning gap next block is a gradual process, the number of cases after the completion of30cases become familiar with ultrasound-guided thoracic paravertebral gap block, block operations to shorten the time and improve anesthesia excellent rate. |
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