| Objective:With the development of ultrasonic technique, the method of location and block of nerve has great change. The clinical application of ultrasonic technique in supraclavicuar brachial plexus block has a unique advantage, the technology currently just started in china. The purpose of this study was to lean more about of anatomy of adult supraclavicuar brachial plexus and its adjacent relationshipsMethods:Part one:one hundred subjects scheduled for surgery. With tradition methods, supraclavicuar brachial plexus above clavicular midpoint1-1.5cm was located. A portable ultrasound system with a linear6to13MHz transducer was used. The transducer was parallel the clavicle and close to the midpoint of clavicle and was perpendicular to the skin. The best cross-sectional ultrasonogram of subclavian artery, brachial plexus and first rib.was find. The radius of supraclavicuar brachial plexus, the distance of skin to supraclavicuar brachial plexus, first rib, pleur and the horizontal distance beween the midpoint of supraclavicuar brachial plexus and the midpoint of subclavian artery were measured. The actual surface position of supraclavicuar brachial plexus was located by ultrasonography. The relationship beween supraclavicuar brachial plexus and subclavian artery and the relationship beween supraclavicuar brachial plexus and external jugular vein.and the relationship beween the location of supraclavicuar brachial plexus by tradition methods and the actual surface position of supraclavicuar brachial plexus by ultrasonography were observed. The multi-factor correlations between the distance of the skin to supraclavicular brachial plexus, the fist rib, pleur and weight, height, age, neck length, neck circumference was analysed.Part two:sixty subjects scheduled for upper extremity surgery. We use portable ultrasound systems with a linear6to13MHz transducer. The transducer was parallel the clavicle and close to the midpoint of clavicle. The transducer is perpendicular to the skin. The best cross-sectional ultrasonogram of the right subclavian artery, brachial plexus and first rib was. fund. Puncture point far away from the transducer1.5cm. The16G trocar was inserted adjacent to the brachial in region of the first rib, subclavian artery and brachial plexus by ultrasound-guided in plane technology and water separation technology was used to expand to open a gap with1%lidocaine10ml. The sleeve of trocar was fastened and the stylet of trocar was exited. Epidural catheter through the sleeve of trocar was inserted adjacent to the brachial in region of the first rib, subclavian artery and brachial plexus. With20G needles, brachial plexus was block by multi-target injection with0.4%ropivacaine+1%lidocaine20ml by ultrasound-guided in plane technology.2ml saline was injected via the epidural catheter to observe and to adjust the loaction of epidural catheter after surgery. If the catheter deviated from and could’t be adjusted to adjacent to the target nerves around, according to the method of the previous to repeatedly place the catheter and the times of repeatedly placed catheter was been record. According to different concentrations of ropivacaine by epidural catheter, the patients were randomly divided into two groups,0.2%ropivacaine group,0.3%ropivacaine group The basis dose of electronic infusion pump:was5ml/h, patient-controlled doses was5ml, lockout time30min.in two groups. The standard of auxiliary analgesic:VAS<4, given no painkillers, VAS4-7, given dynastat injection40mg (daily total does not exceed80mg), VAS≥7given pethidine hydrochloride injection100mg (daily dosage of not more than600mg, the time interval should not be less than4hours). The surgery time, the VAS score values of postoperative8h,12h,16h,20h,24h,32h,40h,48h, the highest VAS score values of postoperative1,2d, the total dosage of dynastat injection and pethidine hydrochloride injection, the times of PCA and complications2days after surgery was recorded in two groups Postoperative analgesia satisfaction of patients, was evaluated.Results:Part one:The radius of the supraclavicular brachial plexus was0.38cm (0.33～0.45). The distance of skin to supraclavicular brachial plexus, the first rib the pleur was0.72cm (0.59～0.91),1.68cm (1.66-1.94), and2.01cm (1.74～2.25). The horizontal distance beween the midpoint o supraclavicular brachial plexus and the midpoint of subclavian artery was0.59cm (0.45～0.72). Subclavian artery as a reference, supraclavicular brachial plexus in its lateral was25%, in its top-outside was59%, in its above was15%and divided into about two stocks was1%. The actual surface location of supraclavicular brachial with ultrasound as a reference, the external jugular vein overlaped with its was27%, in its lateral horizontal distance0～1cm was28%, in its lateral horizontal distance>1cm was9%, in its medial horizontal distance0～1cm was13%,17%, in its medial horizontal distance>lcm was6%, and without in a ultrasound plane was17%. The actual surface location of supraclavicular brachial with ultrasound as a reference, the location of supraclavicular brachial plexus by traditional methods overlaped with its was35%, in its lateral was64%, in its medial was1%. The location of supraclavicular brachial plexus by traditional methods was0.65cm (0.00～1.00) lateral of actual surface location of supraclavicular brachial with ultrasound. There was a multi-factor correlation between the distance of skin to supraclavicular brachial plexus, the first rib, the pleur, and weight, height, neck circumference, neck length, but without age.Part two:27subjects (45%) had rerepeatedly inserted catheter in two groups. The VAS score of two groups was no significant difference in8-12h and after24h after surgery (P>0.05). The VAS score of0.3%ropivacaine group was significantly lower than0.2%ropivacaine group in16-20h after surgery (P<0.05). The highest VAS score of0.3%ropivacaine group was significantly lower than0.2%ropivacaine group in1d after surgery (P<0.05). The highest VAS score of two groups in8～12h after surgery was no significant difference (P>0.05). The total dosage of dynastat injection of0.3%ropivacaine group was significantly less than0.2%ropivacaine group in2d after surgery (P<0.05). The total dosage of pethidine hydrochloride injection of two groups was no significant difference in2d after surgery. The patient satisfaction of0.3%ropivacaine group was higher than0.2%ropivacaine group (P<0.05). The number of PAC of0.3%ropivacaine group was significantly less than0.2%ropivacaine group in2d after surgery (P<0.05). There were no punctured subclavian artery, local anesthetic toxicity, Horner syndrome, hoarseness, difficulty in breathing in two groups of subjects. There were two subjects with puncture site redness, heat, pain, but no systemic reactions. There are ten subjects with liquid exudation. There were twelve subjects with catheter off. There are twelve subjects with paresthesia, dysesthesia.Conclusions:Part one:There is a multi-factor correlation between the distance of skin to supraclavicular brachial plexus, the first rib, the pleur, and weight, height, neck circumference, neck length, but without age; Subclavian artery as a reference, supraclavicular brachial plexus in its top-outsider is most. The actual surface location of supraclavicular brachial with ultrasound as a reference, the location of supraclavicular brachial plexus by traditional methods in its lateral is most. The location of external jugular vein in the horizontal distance0-lcm of the position of supraclavicular brachial is most.Part two:As result of the VAS score, under the conditions of the basis dose of electronic infusion pump is5ml/h, patient-controlled doses is5ml, lockout time30min, both0.2%ropivacaine and0.3%ropivacaine groups have some analgesic effect, but0.3%ropivacaine group better than the0.2%ropivacaine group in16-20h after surgery. The patient satisfaction of0.3%ropivacaine group is higher than0.2%ropivacaine group. The total dosage of dynastat injection of0.3%ropivacaine group is significantly less than0.2%ropivacaine group. The number of PAC of0.3%ropivacaine group is significantly less than0.2%ropivacaine group. |
