Neuburger M, Kaiser H, Ass B, Franke C, Maurer H
Abteilung für Anaesthesie, BG Unfallklinik Murnau.
Anaesthesist. 2003 Jul;52(7):619-24. doi: 10.1007/s00101-003-0526-7. Epub 2003 Jul 10.
The vertical infraclavicular blockade of the brachial plexus (VIP) according to Kilka et al.is a technique which has gained more importance over the past years. This method distinguishes itself from other periclavicular techniques by a very low risk of pneumothorax (0.2%), which seems to be increased with asthenic patients.
In the study presented we examined 52 patients undergoing a vertical infraclavicular blockade of the brachial plexus, for an alternative method to determine the puncture point. With 31 of the 52 patients, who had a small distance (<20 cm) between the landmarks jugulum and anterior process of the acromion, the puncture point was moved 0.3 cm in a lateral direction for each centimeter less than 20 cm. Additionally we determined the "finger-point", i.e. the medial margin of the anesthetist's index finger, placed in the gap between the M. deltoideus and M. pectoralis with the finger tip touching the clavicle.
In 54% of the patients, the "finger-point" corresponded to the measured puncture point. In 46% of the patients, these points varied by a maximum of 1 cm in the lateral or medial direction. In 53% of the patients, the plexus could be found at the measured puncture point,which applied especially to the patients with a small distance between the leading points (<20 cm) and as a consequence a lateralized puncture point. If a correction of the puncture point was necessary to find the plexus, the correction by skin movement would always be in the direction of the "finger-point".
As a consequence, we assume that if the distance between the leading points jugulum and ventral process of acromion is smaller than 20 cm, the puncture point for a vertical infraclavicular blockade of the brachial plexus should be lateralized as described above; additionally, the "finger-point" should be determined in order to verify the puncture point and to finally give an idea of the direction, in case of a possible need for correcting the puncture point.
根据基尔卡等人的方法，臂丛神经锁骨下垂直阻滞（VIP）是一种在过去几年中变得越来越重要的技术。该方法与其他锁骨周围技术的不同之处在于气胸风险非常低（0.2%），而在体质虚弱的患者中这种风险似乎会增加。
在本研究中，我们检查了52例行臂丛神经锁骨下垂直阻滞的患者，以寻找一种确定穿刺点的替代方法。在52例患者中，有31例患者的胸骨颈静脉切迹与肩峰前突之间的距离小于20厘米，每比20厘米少1厘米，穿刺点就向外侧移动0.3厘米。此外，我们确定了“指尖点”，即麻醉医生食指的内侧边缘，将食指置于三角肌和胸大肌之间的间隙中，指尖触及锁骨。
在54%的患者中，“指尖点”与测量的穿刺点相对应。在46%的患者中，这些点在外侧或内侧方向上的最大差异为1厘米。在53%的患者中，在测量的穿刺点处可以找到神经丛，这尤其适用于引导点之间距离较小（<20厘米）且因此穿刺点偏向外侧的患者。如果需要校正穿刺点以找到神经丛，通过皮肤移动进行的校正总是朝着“指尖点”的方向。
因此，我们认为，如果胸骨颈静脉切迹与肩峰腹侧突之间的距离小于20厘米，臂丛神经锁骨下垂直阻滞的穿刺点应如上所述偏向外侧；此外，应确定“指尖点”以验证穿刺点，并在可能需要校正穿刺点时最终了解校正方向。
