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连续外周神经阻滞:已发表证据的综述。

Continuous peripheral nerve blocks: a review of the published evidence.

机构信息

Clinical Investigation, University of California San Diego, 200 West Arbor Dr., MC 8770, San Diego, CA 92103-8770, USA.

出版信息

Anesth Analg. 2011 Oct;113(4):904-25. doi: 10.1213/ANE.0b013e3182285e01. Epub 2011 Aug 4.

Abstract

A continuous peripheral nerve block, also termed "perineural local anesthetic infusion," involves the percutaneous insertion of a catheter adjacent to a peripheral nerve, followed by local anesthetic administration via the catheter, providing anesthesia/analgesia for multiple days or even months. Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of lightweight, portable pumps permits ambulatory infusion as well. This technique's most common application is providing analgesia after surgical procedures. However, additional indications include treating intractable hiccups; inducing a sympathectomy and vasodilation to increase blood flow after a vascular accident, digit transfer/replantation, or limb salvage; alleviating vasospasm of Raynaud disease; and treating peripheral embolism and chronic pain such as complex regional pain syndrome, phantom limb pain, trigeminal neuralgia, and cancer-induced pain. After trauma, perineural infusion can provide analgesia during transportation to a distant treatment center, or while simply awaiting surgical repair. Catheter insertion may be accomplished using many possible modalities, including nerve stimulation, ultrasound guidance, paresthesia induction, fluoroscopic imaging, and simple tactile perceptions ("facial click"). Either a nonstimulating epidural-type catheter may be used, or a "stimulating catheter" that delivers electrical current to its tip. Administered infusate generally includes exclusively long-acting, dilute, local anesthetic delivered as a bolus only, basal only, or basal-bolus combination. Documented benefits appear to be dependent on successfully improving analgesia, and include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic requirements, opioid-related side effects, and sleep disturbances. In some cases, patient satisfaction and ambulation/functioning may be improved; an accelerated resumption of passive joint range-of-motion realized; and the time until discharge readiness as well as actual discharge from the hospital or rehabilitation center achieved. Lastly, postoperative joint inflammation and inflammatory markers may be decreased. Nearly all benefits occur during the infusion itself, but several randomized controlled trials suggest that in some situations there are prolonged benefits after catheter removal as well. Easily rectified minor complications occur somewhat frequently, but major risks including clinically relevant infection and nerve injury are relatively rare. This article is an evidence-based review of the published literature involving continuous peripheral nerve blocks.

摘要

连续外周神经阻滞,也称为“神经周围局部麻醉输注”,涉及将导管经皮插入外周神经附近,然后通过导管给予局部麻醉,从而提供多天甚至数月的麻醉/镇痛。连续外周神经阻滞可以在医院环境中进行,但使用轻便、便携式输液泵也可以进行门诊输液。该技术最常见的应用是在手术后提供镇痛。然而,其他适应症包括治疗顽固性呃逆;在血管意外、手指转移/再植或肢体保全、雷氏病血管痉挛以及治疗外周栓塞和慢性疼痛(如复杂性区域疼痛综合征、幻肢痛、三叉神经痛和癌性疼痛)后,引起交感神经切断和血管扩张以增加血流量。在创伤后,神经周围输注可以在运往遥远的治疗中心或等待手术修复的过程中提供镇痛。导管插入可以通过多种可能的方式完成,包括神经刺激、超声引导、感觉异常诱导、荧光镜成像和简单的触觉感知(“面部咔哒声”)。可以使用非刺激型硬膜外导管,也可以使用向其尖端输送电流的“刺激导管”。输注的药物通常包括仅长效、稀释的局部麻醉剂,仅推注、仅基础或基础-推注组合。已记录的益处似乎取决于成功改善镇痛,包括降低基础/突破/动态疼痛、补充镇痛需求、阿片类相关副作用和睡眠障碍。在某些情况下,可能会改善患者满意度和活动/功能;加速实现被动关节活动范围的恢复;以及达到出院准备时间和实际从医院或康复中心出院的时间。最后,术后关节炎症和炎症标志物可能减少。几乎所有的益处都发生在输注过程中,但几项随机对照试验表明,在某些情况下,导管取出后也会有较长时间的益处。轻微并发症易于纠正,且较为常见,但包括临床相关感染和神经损伤在内的重大风险相对罕见。本文是对涉及连续外周神经阻滞的已发表文献的循证综述。

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