超声引导下颈丛神经阻滞后同侧膈肌不完全麻痹的发生率：前瞻性观察研究
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Incidence of hemi‑diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study
背景与目的
颈丛神经阻滞(CPB)穿刺点定位于胸锁乳突肌和椎前筋膜之间的颈后间隙。膈神经从C3~C5腹侧支发出后，斜行于椎前筋膜下的前斜角肌表面。因此，根据椎前筋膜的通透情况，CPB期间，膈神经可能会受到局麻药的影响。这项研究探讨了CPB是否会影响膈神经，并导致同侧膈肌不完全麻痹。
方 法
本项前瞻性观察研究共纳入20名接受腋下单切口、机器人辅助右侧甲状腺切除术的患者。患者全麻苏醒前，在C4~5椎间隙谨慎进行CPB(0.25%罗哌卡因0.2ml/kg)，不穿透椎前筋膜。分别于麻醉前(基线)、CPB后30min和60min用M型超声测量阻滞侧的膈肌运动。根据与基线水平进行对比所得的膈肌运动百分比，将膈肌不完全麻痹分为三个等级：无膈肌麻痹(>75%)、同侧部分膈肌不完全麻痹(25-75%)、同侧全部膈肌不完全麻痹(<25%)。
结 果
CPB后60分钟内，没有患者出现同侧部分或全部膈肌不完全麻痹。
结 论
于C4-5椎间隙使用0.2ml/kg 0.25%罗哌卡因施行CPB不会导致同侧膈肌不完全麻痹。这意味着CPB对膈神经的影响不明显。
原始文献来源及摘要
Kim HY, Soh EY, Lee J, et al. Incidence of hemi‑diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study.[J].J Anesth. 2020 Mar 31. doi: 10.1007/s00540-020-02770-2.
Abstract
Purpose：An intermediate cervical plexus block (CPB) targets the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. The phrenic nerve descends obliquely on the surface of the anterior scalene muscle beneath the prevertebral fascia after originating from the C3–C5 ventral rami. Therefore, the phrenic nerve can be affectedby a local anesthetic during an intermediate CPB, depending on the permeability characteristics of the prevertebral fascia. This study investigated whether an intermediate CPB affects the phrenic nerve, inducing hemidiaphragmatic paresis.
Methods: In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2 ml/kg) was performed at the C4–5 intervertebral level carefully, without penetrating the prevertebral fascia, before the patient emerged from general anesthesia. Diaphragmatic motions of the block side were measured by M-mode ultrasonography at three time points: before anesthesia (baseline) and at 30 and 60 min after the intermediate CPB. Hemi-diaphragmatic paresis was divided into three grades, depending on the percentage of diaphragm movement compared to the baseline: none (> 75%), partial paresis (25–75%), and complete paresis (< 25%).
Results: No patient showed any partial or complete ipsilateral hemi-diaphragmatic paresis within 60 min after the intermediate CPB.
Conclusion: Intermediate CPB using 0.2 ml/kg of 0.25% ropivacaine at the C4–5 intervertebral level did not cause ipsilateral hemidiaphragmatic paresis. This may imply that the effect of the intermediate CPB on the phrenic nerve is not significant.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：牛振瑛 编辑：冯玉蓉 审校：曹莹