Information
¿øÁ¦ Ultrasound-guided Regional Anesthesia for Surgery on Extremities
°¢ ½Å°æÀ» ÃÊÀ½ÆÄ·Î °üÂûÇÒ ¶§ landmark°¡ µÇ´Â Á¶Á÷±¸Á¶¸¦ ÃÖ´ëÇÑ ÀÏ·¯½ºÆ®¸¦ ÀÌ¿ëÇØ Ç¥ÇöÇÏ·Á°í ÇÏ¿´´Ù. ±âº»ÀûÀ¸·Î ÀÌ Ã¥Àº »çÁö¿¡¼ Ä¡·á¼ú±â¸¦ ½ÃÇàÇϱâ À§ÇÑ regional blockÀ» Á¦ÇÑµÈ ±¹¼Ò¸¶ÃëÁ¦ ¿ë·®À¸·Î ½ÃÇàÇϱâ À§ÇÑ °üÁ¡¿¡¼ ±â¼úµÇ¾î, ¸ðµç ¸»ÃʽŰæÀ» µ¿µîÇÏ°Ô ´Ù·çÁö´Â ¸øÇß´Ù.
»ó´çÈ÷ À¯¿ëÇÑ ÃÊÀ½ÆÄ ¿µ»ó°ú ÇغÎÇÐÀû ¸ð½Äµµ, ±×¸®°í ½ÇÁ¦Àû ¡®Tip¡¯µéÀÌ Ã³À½ ¹è¿ì´Â ÀÇ»ç »Ó ¾Æ´Ï¶ó °æÇèÀڵ鵵 ¸¸Á· ÇÒ ¸¸Å dzºÎÇÏ°Ô ¼ö·ÏµÇ¾î ÀÖ´Ù. ½ÇÁ¦ ¿µ»ó¿¡ »öÀ» ÀÔÇô ±¸Á¶¹°À» ±¸ºÐÇÑ À̹ÌÁö, probe¸¦ ¿òÁ÷ÀÌ´Â °æ·Î¸¦ ±×¸° À̹ÌÁö, ±×¸®°í ÇϳªÀÇ ½Å°æÀ» ¿©·¯ ´Ù¸¥ ¹æÇâ¿¡¼ ½ºÄ³´×ÇÑ ¿µ»ó µîÀº ÀÚÄ© È¥¶õ½º·´°Ô ´À²¸Áú ¼ö ÀÖ´Â 3Â÷¿øÀû ±¸Á¶¸¦ ºü¸£°í Á¤È®ÇÏ°Ô ÀÌÇØÇϴµ¥ Å« µµ¿òÀÌ µÈ´Ù.
Contents
¥°Àå Regional blockÀÇ Áغñ
US guided regional blockÀÇ ¸Å·Â • 2
°ß°üÀý Å»±¸ Á¤º¹ 2
Àü¿Ï °ñÀý Ä¡·á 2
Á·°üÀý, Á·ºÎ ¼ö¼ú 3
Àΰø½½°üÀýġȯ¼ú ÈÄ ÅëÁõ Á¶Àý 5
¼ö¼ú ÈÄ È¸º¹±âÀÇ ÅëÁõ Á¶Àý 5
ÀÓ»ó ½ÇÀü ÀÀ¿ë 6
ÃÊÀ½ÆÄ ÀåÄ¡ÀÇ ¼±Åà • 7
ÀûÇÕÇÑ ÃÊÀ½ÆÄ ±â±â´Â? 7
Probe ¼±Åà 7
±â±â Á¶ÀÛ ¹æ¹ý 9
¿µ»ó ó¸® 9
ÃÊÀ½ÆÄÀÇ Æ¯¼º°ú °Ë»ç ¹æ¹ý • 10
Echogenecity 10
Anisotropy & fibrillar pattern 10
¸»ÃʽŰæ°ú ±Ù¸·ÀÇ ±¸Á¶ • 13
¸»ÃʽŰæÀÇ ±¸Á¶¿Í paraneural sheath 13
¸»ÃʽŰæÀÇ ±âº»ÀûÀÎ ÃÊÀ½ÆÄ ¼Ò°ß 15
±Ù¸·ÀÇ ±âº»ÀûÀÎ ±¸Á¶ 17
»çÁö ¸»ÃʽŰæÀÇ Á¸Àç ¾ç»ó°ú ÃÊÀ½ÆÄ °Ë»ç ¹æ¹ý • 18
3°¡Áö ÀÌ»óÀÇ ±ÙÀ°, ±Ù¸·, »À »çÀ̸¦ Åë°úÇÏ´Â °æ¿ì 18
2°³ ±ÙÀ° »çÀ̸¦ Åë°úÇÏ´Â °æ¿ì 20
±ÙÀ°³»¿¡ Á¸ÀçÇÏ´Â ¸»ÃʽŰæ 21
°ñ°£¸·À» µû¶ó ÁÖÇàÇÏ´Â ¸»ÃʽŰæ 22
ÇǺνŰæ cutaneous nerve 23
½Å°æ ½ºÄµ ¹æ¹ý(ÃÑ·Ð) • 25
Regional blockÀÇ ½ÇÆпøÀÎ 25
Pre-scanÀÇ Á߿伺 25
¸»ÃÊ½Å°æ ½ºÄµÀÌ ¾î·Á¿î ÀÌÀ¯ 26
½Å°æ ½ºÄµ ¹æ¹ý 26
´ÜÃà ½ºÄµ(ÁßÃß ¡ê ¸»ÃÊ) 26
½Å°æÀ» ãÀ» ¼ö ¾ø´Â °æ¿ì 27
Regional block Áغñ • 30
Regional blockÀÇ Áغñ¹° 30
Block ½ÃÇà Àü check list 31
Ropivacaine 31
ÃÊÀ½ÆÄ À¯µµÇÏ ÃµÀÚ ¹æ¹ý • 32
õÀÚ ¹æ¹ý 32
Needle ¿µ»ó 33
NeedleÀÇ Á¾·ù 34
½Ã¼ú ½Ã ÀÚ¼¼ 35
¹«±Õ óġ 36
õÀÚ Àü ÁÖÀÇ»çÇ× 36
õÀÚ Áß ÁÖÀÇ»çÇ× 37
Block needle°ú bevelÀÇ ¹æÇâ 38
Hydrodissection technique 39
ÁÖÀÔ ¼ø¼ 39
In-plane¿¡¼ needleÀÌ º¸ÀÌÁö ¾ÊÀ» ¶§ 40
US guided regional blockÀÇ ÀûÀÀÁõ°ú ±Ý±â • 41
ÀûÀÀÁõÀÇ ¹üÀ§ 41
±Ý±â/ÇÕº´Áõ 41
±¹¼Ò¸¶ÃëÁ¦/block ÇÕº´Áõ°ú ´ëÃ¥ • 45
±¹¼Ò¸¶ÃëÁ¦ÀÇ Á¾·ù¿Í ±âº»Àû ¾à¸® 45
BlockÀÇ ÇÕº´Áõ 46
Regional block ¿¬½À • 54
ÃÊÀ½ÆÄ Áø´Ü ÀåÄ¡ 54
¸®½ºÅ©°¡ Àû°í, È¿°úÀûÀÎ ¼ú±â¿Í ÀûÀÀÁõ 55
Regional blockÀÇ ÈçÇÑ ÀûÀÀÁõ 56
¥±Àå ¸»ÃʽŰæÀÇ ½ºÄµ Å×Å©´Ð
»óÁö
Á¤Á߽Űæ median nerve • 60
¼·Ð 60
ÇغΠ60
Axilla~upper arm • 60 / Proximal forearm¡¤AIN; anterior interosseous nerve • 60 / Mid-forearm • 60 / Distal to wrist joint • 60
Á¤Á߽Űæ median nerveÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 61
Scan technique
Axilla~upper arm
»ó¿Ïµ¿¸Æ°ú ÇÔ²² ÁÖÇàÇÏ´Â ¶ìÇü ±¸Á¶¹°À» ã´Â´Ù. • 62 / »ó¿Ïµ¿¸Æ°ú Á¤Á߽ŰæÀº »ó¿ÏºÎ¿¡¼ ±³Â÷ÇÑ´Ù. • 64 / Median nerve at axilla • 65 / Median nerve block at axilla • 66
at elbow~forearm
¿ì¼± mid-forearm¿¡¼ median nerve¸¦ ã´Â´Ù. • 68 / at proximal forearm • 69 / Àü°ñ°£ ½Å°æ AIN; anterior interosseous nerve • 70 / at forearm~wrist • 72 / Palmar branch of median nerve • 73 / at carpal tunne • 74
ô°ñ½Å°æ ulnar nerve • 76
¼·Ð 76
ÇغΠ76
Brachial plexus~upper arm • 76 / Forearm • 76 / Wrist joint • 76
ô°ñ½Å°æ(ulnar nerve)ÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 77
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
at axilla~upper arm
ô°ñ½Å°æÀº »ó¿Ï Áß¾Ó¿¡¼ ½ºÄµÇÑ´Ù. • 78 / ô°ñ½Å°æÀº »ó¿Ï»ïµÎ±Ù ±Ù¸·ÀÇ ³»ÃøÀ» µû¶ó ÁÖÇàÇÑ´Ù. • 79 / ô°ñ½Å°æÀ» ãÀº ÈÄ ¾×¿Í±îÁö ½ºÄµÇÑ´Ù. • 80 / Axillary block • 81
at forearm
Àü¿Ï Áß¾Ó°ú ¿øÀ§ºÎ »çÀÌ¿¡¼ ô°ñ½Å°æÀ» ½ºÄµÇÑ´Ù. • 82 /ô°ñ½Å°æÀº ôÃø¼ö±Ù±¼±Ù FCU ÇϺÎ, ô°ñµ¿¸ÆÀÇ ³»ÃøÀ» ÁÖÇàÇÑ´Ù. • 83 / Dorsal cutaneous branch of ulnar nerve • 84 / at wrist joint • 85
¿ä°ñ½Å°æ radial nerve • 86
¼·Ð 86
ÇغΠ86
Axilla~upper arm • 86 / Elbow joint~forearm • 86
¿ä°ñ½Å°æ radial nerveÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 87
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
at axilla~proximal upper arm
¾×¿ÍºÎ¿¡¼´Â ¿ä°ñ½Å°æÀÇ À±°ûÀ» °üÂûÇϱ⠾î·Æ´Ù. • 88 / »ó¿Ï»ïµÎ±ÙÀÇ ³»ÃøµÎ¿Í ÀåµÎ »çÀÌ¿¡¼ »ó¿Ï°ñ ¹èÃø¸éÀ¸·Î ÁÖÇàÇÑ´Ù. • 89 / Axillary block • 90
at distal upper arm~elbow joint
ÁÖ°üÀý Á¤¸é¿¡¼, »ó¿Ï°ñ ¼ÒµÎ°¡ ¿ä°ñ½Å°æÀÇ landmarkÀÌ´Ù. • 92 / Radial nerve rescue block • 93 / »ó¿Ï ¿øÀ§ºÎ¿¡¼ ½ºÄµÇÒ ¶§¿¡´Â ÁÖ°üÀý ±¼°î ¹× °ß°üÀý ³»È¸Àü elbow flexion & shoulder IR ÀÚ¼¼·Î • 94 / »ó¿Ï Áß¾Ó¿¡¼ ¿øÀ§ºÎ·Î, ¿ä°ñ½Å°æ¿¡¼ ºÐÁöµÇ´Â ÈÄÀü¿ÏÇǽŰæ PACN; posterior antebrachial cutaneous nerveÀ» ½ºÄµÇÑ´Ù. • 95
at elbow~forearm
¿ä°ñ½Å°æ õÁö superficial branch of radial nerve´Â ¿ä°ñµ¿¸Æ/Á¤¸Æ radial a. & v.°ú ÇÔ²² ÁÖÇàÇÑ´Ù. • 96 / ÈÄ°ñ°£½Å°æ PIN; posterior interosseous nerve ½ºÄµ • 98 / ȸ¿Ü±Ù supinatorÀ» Åë°úÇÏ´Â PINÀ» ã¾Æ³½´Ù. • 99 /Àü¿Ï¿¡¼ PINÀÇ ÁÖÇà • 100
±ÙÇǽŰæ MCN; musculocutaneous nerve • 104
¼·Ð 104
ÇغΠ104
Axilla~upper arm • 104
±ÙÇǽŰæ MCNÀÇ ÁÖÇà°ú °¨°¢Áö¹è 105
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
¾×¿Í¿¡¼´Â ³»Ãø Àü¹æ medial/anterior, ÁÖ°üÀý¿¡¼´Â ¿ÜÃø Àü¹æ lateral/anterior • 106 / ¾×¿ÍºÎ¿¡¼´Â Á¤Á߽ŰæÀÇ ¿ÜÃø/±ÙÀ° ³»¿¡ ÁÖÇàÇÏ´Â ±ÙÇǽŰæÀ» °üÂûÇÑ´Ù. • 107 / »ó¿Ï Áß¾ÓºÎÅÍ ¿øÀ§ºÎ¿¡¼ ±ÙÇǽŰæ main stemÀ» °üÂûÇÑ´Ù. • 108 / »ó¿Ï°ñ/»ó¿ÏÀ̵α٠½ºÄµ • 108 /
MCN block • 109 / Àü¿ÏÀÇ ¿ÜÃøÀü¿ÏÇÇ½Å°æ • 110
³»ÃøÀü¿ÏÇǽŰæ MACN; medial antebrachial cutaneous nerve
³»Ãø»ó¿ÏÇǽŰæ(MBCN; medial brachial cutaneous nerve) • 112
¼·Ð 112
ÇغΠ112
³»ÃøÀü¿ÏÇǽŰæ(MACN) ³»Ãø»ó¿ÏÇǽŰæ(MBCN)ÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 113
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
»ó¿Ï Áß¾Ó¿¡¼ ôÃøÇǺÎÁ¤¸Æ basilic veinÀ» È®ÀÎÇÑ´Ù. • 114 / ôÃøÇǺÎÁ¤¸Æ°ú ÇÔ²² ÁÖÇàÇÏ´Â ³»ÃøÀü¿ÏÇǽŰæÀ» È®ÀÎÇÑ´Ù. • 115 / ¾×¿ÍºÎÅÍ »ó¿Ï Á߾Ӻο¡¼ blockÀ» ½ÃÇàÇÑ´Ù. • 115 / ÁÖ°üÀýºÎÅÍ Àü¿Ï±îÁö ½ºÄµÇÑ´Ù. • 115
»ó¿Ï½Å°æÃÑ brachial plexus
»ç°¢±Ù°£(interscalene)¡¤¼â°ñ»óºÎ(suprascapular) • 116
¼·Ð 116
ÇغΠ116
»ó¿Ï½Å°æÃÑ brachial plexusÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 117
¾Ó¿ÍÀ§ supineº¸´Ù Ãø¿ÍÀ§ side lying¿¡¼ blockÀÌ ¿ëÀÌÇÏ´Ù. • 117
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
Supraclavicular block
Supraclavicular block ½Ã¿¡´Â ¼â°ñ ÇϺθ¦ µé¿©´Ùº¸µíÀÌ probe¸¦ ´í´Ù. • 118 / Supraclavicular block ½Ã¿¡´Â ¼â°ñÇϵ¿¸Æ°ú 1¹ø ´Á°ñ »çÀ̸¦ targetÀ¸·Î ÇÑ´Ù. • 119 / Transverse cervical artery¿¡ ÁÖÀÇÇϸç õÀÚÇÑ´Ù. • 119
Interscalene block
Interscalene block ½Ã¿¡µµ, ¼â°ñ »óºÎ¿¡¼ ½ºÄµÀ» ½ÃÀÛÇÏ¿© ±ÙÀ§ºÎ·Î À̵¿ÇÑ´Ù. • 120 / ½Å°æ±ÙÀÇ levelÀ» È®ÀÎÇÒ ¶§¿¡´Â C6 Ⱦµ¹±â transverse process°¡ ±âÁØÀÌ µÈ´Ù. • 121 / Ãß°ñµ¿¸Æ verterbral arteryÀÇ ÇغÎÇÐÀû º¯ÀÌ¿¡ ÁÖÀÇÇÑ´Ù. • 122 / ¾î±ú °üÀý ¼ö¼ú ½Ã targetÀº C5, C6 • 122 / Superficial plexus block • 123
¥²Àå ¸»ÃʽŰæÀÇ ½ºÄµ Å×Å©´Ð
ÇÏÁö
´ëÅð½Å°æ femoral nerve ¿ÜÃø´ëÅðÇǽŰæ LFCN • 126
¼·Ð 126
´ëÅð½Å°æ • 126 / ¿ÜÃø´ëÅðÇǽŰæ LFCN; lateral femoral cutaneous nerve • 126
ÇغΠ126
´ëÅð½Å°æ femoral nerveÀÇ ÁÖÇà°ú °¨°¢Áö¹è 127
¿ÜÃø´ëÅðÇǽŰæ LFCNÀÇ ÁÖÇà°ú °¨°¢Áö¹è 127
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
Femoral nerve block
´ëÅ𵿸ÆÀÇ ¿ÜÃø¡¤½ÉÃþ¿¡¼ Àå¿ä±Ù ±Ù¸·ÀÇ À±°ûÀ» °üÂûÇÑ´Ù. • 128 / Femoral nerve block • 129
LFCN; lateral femoral cutaneous nerve block
´ëÅð ±ÙÀ§ºÎ 1/3¿¡¼ ã¾Æ³»¸é °£´ÜÇÏ´Ù. • 130 / Ä«Å×ÅÍ À¯Ä¡ • 131 / ³«»ó¿¡ ÁÖÀÇÇÒ °Í • 131
º¹Àç½Å°æ saphenous nerve
´ëÅð½Å°æÀÇ ºÐÁö branch of femoral nerve • 132
¼·Ð 132
ÇغΠ132
º¹Àç½Å°æ saphenous nerveÀÇ ÁÖÇà°ú °¨°¢Áö¹è 133
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
´ëÅð Á߾ӺΠmid-thigh
ºÀ°ø±Ù sartoriusÀÇ ÁÖÇàÀ» ÃßÀûÇÑ´Ù. • 134 / ´ëÅ𵿸Æ/Á¤¸ÆÀ» °üÂûÇϱ⠾î·Á¿î ÀÌÀ¯ • 134 / ´ëÅ𵿸ơ¤ºÀ°ø±Ù¡¤³»Ãø±¤±ÙÀ¸·Î ÀÌ·ç¾îÁø ¿µ¿ªÀ» ã´Â´Ù. • 135
ÇÏÅð ±ÙÀ§ºÎ proximal lower-leg
¸ÕÀú ¹«¸ ³»Ãø, °æ°ñ ÈÄ¿¬ posterior marginÀ» ½ºÄµÇÑ´Ù. • 136 / º¹Àç½Å°æ saphenous nerve°ú ´ëº¹ÀçÁ¤¸Æ greater saphenous veinÀº ºÀ°ø±Ù ±Ù¸· sartorius fasciaÀ¸·Î ºÐ¸®µÇ¾î ÀÖ´Ù. • 137 /
ÇÏÅð ±ÙÀ§ºÎ¿¡¼ º¹Àç½Å°æ Â÷´Ü saphenous nerve block at proximal lower-leg • 137
Æó¼â½Å°æ obturator nerve • 138
¼·Ð 138
ÇغΠ138
Æó¼â½Å°æ obturator nerveÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 139
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
±ÙÀ°À» »çÀÌ¿¡ µÎ°í, µÎ ÃþÀ¸·Î ÁÖÇàÇÏ´Â °í¿¡ÄÚ À̹ÌÁö¸¦ ã´Â´Ù. • 140 / Obturator nerve block • 141
Á°ñ½Å°æ sciatic nerve
°æ°ñ½Å°æ(tibial nerve)¡¤ÃѺñ°ñ½Å°æ(common peroneal nerve) • 142
¼·Ð 142
ÇغΠ142
°ñ¹Ý at pevis • 142 / °ñ¹Ý~´ëÅð pelvis~thigh • 142 / ´ëÅðºÎ at thigh • 142 / ½½¿ÍºÎ at popliteal fossa • 142
°æ°ñ½Å°æ tibial nerveÀÇ ÁÖÇà°ú °¨°¢Áö¹è 143
ÃѺñ°ñ½Å°æ common peroneal nerveÀÇ ÁÖÇà°ú °¨°¢ Áö¹è 144
ÈÄ´ëÅðÇǽŰæ PFCNÀÇ ÁÖÇà°ú °¨°¢Áö¹è 144
Á°ñ½Å°æ Â÷´Ü sciatic nerve blockÀÇ Á¢±Ù ¹æ¹ý 145
ÃÊÀ½ÆÄ ½ºÄµ Å×Å©´Ð
Parasacral approach
Á°ñ½Å°æÀº parasacral area¿¡¼ »ó´çÈ÷ ½ÉºÎ¿¡ À§Ä¡ÇÑ´Ù. 146 / Parasacral approachÀÇ ÀåÁ¡°ú ´ÜÁ¡ • 147
Subgluteal approach
Á°ñ°áÀý ischial tuberosity°ú ´ëÀüÀÚ greater trochanter°¡ landmark • 148 / Á°ñ½Å°æÀº ´ëµÐ±Ù ÇϺο¡ Á¸ÀçÇÑ´Ù. • 149
Popliteal approach
½½¿Íµ¿¸Æ/Á¤¸ÆÀÇ Ç¥Ãþ¿¡ ÁÖÇàÇÏ´Â °æ°ñ½Å°æÀ» ½ºÄµÇÑ´Ù. • 150 / ºñ°ñ½Å°æÀ» ã´Â´Ù. • 152 / °æ°ñ½Å°æ¡¤ÃѺñ°ñ½Å°æ tibial nerve¡¤common peroneal neve ºÐÁöºÎÀ§¿¡¼ blockÇÑ´Ù. • 154
ÃѺñ°ñ½Å°æ common peroneal nerve
½Éºñ°ñ½Å°æ deep peroneal nerveÀº Àü°æ°ñµ¿¸Æ anterior tibial artery¿Í ÇÔ²² ÁÖÇàÇÑ´Ù. • 156 / õºñ°ñ½Å°æ superficial peroneal nerveÀº ÇÏÅð lower-leg ¾à 1/3¿¡¼ ±Ù¸·À» ¶Õ°í ÇÇÇÏ·Î ³ª¿Â´Ù. • 156
°æ°ñ½Å°æ tibial nerve
°æ°ñ½Å°æÀº ÈÄ°æ°ñÁ¤¸Æ posterior tibial vein¿¡ Á¢ÇØ ÀÖ´Ù. • 157 / Á·±Ù°ü tarsal tunnel¿¡¼ ºñ±³Àû ½±°Ô °üÂûµÈ´Ù. • 157
ºñº¹½Å°æ sural nerve
¼Òº¹ÀçÁ¤¸Æ lesser saphenous vein°ú ÇÔ²² ÁÖÇàÇÑ´Ù. • 157
2018-11-23 ¿ÀÀü 10:10:46, Á¶È¸¼ö : 3473
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