文献 超声引导下胸骨旁浅、深肋间平面封闭的最佳方法：一项尸体研究

Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study

超声引导下胸骨旁浅、深肋间平面封闭的最佳方法：一项尸体研究

Introduction The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2–T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum.

胸骨旁肋间平面(PIP)封闭T2-T6肋间神经的最佳方法尚未阐明。这项试验性身体研究旨在确定在超声引导下浅层和深层PIP阻断后，在第二至第六肋间实现一致染料扩散的最佳注射技术。我们还研究了胸横肌在第一至第六肋间的存在及其超声识别的一致性，以及胸廓内动脉相对于胸骨外侧缘的位置。

Methods Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded.

方法超声引导下单次、二次或三次注射浅层或深层PIP阻滞剂治疗24例(每例3个半胸)。所有技术的染料总量为20毫升。解剖时记录第1~6肋间的染料分布、各肋间胸横肌的存在及胸廓内动脉至胸骨外侧缘的距离。

Results The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block.

结果在第2~6肋间始终可见胸横肌，在第2~5肋间超声诊断胸横肌与胸横肌的符合率>80%。胸内动脉位于胸骨交界处和肋软骨交界处中点的内侧，沿第二至第六肋间。浅层PIP阻断后的染料扩散比深层PIP阻断更局部化。

For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively.

对于这两种方法，注射次数越多，染料分布越广。第2、4、5肋间浅层阻滞后染色的肋间间隙数为5.3±1.2个，第3、5肋间深层阻滞后染色的肋间间隙数为5.7±0.6个水平。

Conclusion Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.

结论浅入路二、四、五肋间三次注射，深入路三、五肋间二次注射是PIP阻滞的最佳方法。

Ultrasound scanning to identify the transversus thoracis muscles

To identify the transversus thoracis muscles by ultrasound scan, a 6–13 MHz linear ultrasound probe (LOGIQ F8; GE Healthcare, Wauwatosa, Wisconsin, USA) was placed in the parasagittal plane between the sternal border and the costochondral junction. AS and PLe conjointly scanned for the presence of the transversus thoracis muscle at each intercostal space from the first to sixth intercostal levels. The transversus thoracis muscle was recorded as being identified by sonography when both investigators agreed that the transversus thoracis muscle was visualized.

为了通过超声扫描识别胸横肌，将一个6~13 MHz的线性超声探头(LOGIQ F8；GE Healthcare，美国威斯康星州沃瓦托萨)放置在胸骨边缘与肋软骨交界处之间的矢状面上。AS和PLE联合扫描从第一到第六肋间的每个肋间间隙是否存在胸横肌。当两位研究人员都同意胸横肌被可视化时，胸横肌被记录为通过超声被识别。

Superficial PIP block→A.B

浅层PIP阻滞   

Deep-plane block→C.D

深层PIP阻滞

1. Presence of the transversus thoracis muscle and sonographic identification 

胸横肌的存在和超声鉴别

The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces on both sides of the thorax.The visualization of the transversus thoracis muscles by ultrasonography was practically obvious at the second to fifth intercostal spaces. Thus, the percent agreement between these two outcomes was acceptable or higher than 80% at the second to fifth intercostal spaces (table 1).胸横肌始终位于胸腔两侧的第二至第六肋间。

超声对胸横肌的显示在第2~5肋间明显。因此，在第二到第五肋间间隙，这两种结果之间的百分比一致性是可接受的或高于80%(表1)。

2. Location of the internal thoracic artery in relation to the length of costal cartilage

胸内动脉的位置与肋软骨长度的关系

At all intercostal spaces, the internal thoracic artery was located within 20 mm from the lateral border of the sternum. The horizontal distance from the lateral border of the sternum to the costochondral junction was progressively longer at the lower intercostal spaces. Thus, the fraction of the length from the internal thoracic artery to the lateral sternal border and the length of the costal cartilage was gradually smaller at the lower intercostal spaces (table 2). These fractions at the second to sixth intercostal spaces were less than 0.5.在所有肋间，胸廓内动脉位于胸骨外侧缘20 mm以内。肋间下间隙胸骨外侧缘至肋软骨交界处的水平距离逐渐变长。因此，从胸内动脉到胸骨外侧缘的长度和肋软骨的长度在肋间下部逐渐变小(表2)。在第二至第六肋间间隙，这些分数小于0.5。

3. Dye spreading following the superficial approach of PIP block.

PIP块表面处理后的染料扩散

The superficial plane block resulted in localized dye staining at the intercostal spaces where the dye was injected (figure 2A–D).浅平面阻滞导致注入染料的肋间间隙出现局限性染料染色(图2A-D)。

4.Dye spreading following the deep approach of PIP block. PIP深层阻滞的染料扩散

A single injection technique of the deep-plane block, either at the third or the fourth intercostal space, resulted in uncertain dye spreading over two to six levels of the adjacent intercostal spaces (table 4 and figure 2E,F). Double injections, either at the second and fourth or third and fifth intercostal spaces, provided wider dye distribution (figure 2G,H). Dye spread over the first to sixth intercostal spaces was more consistently achieved by the injections at the third and fifth intercostal spaces

深平面块的单次注射技术，无论是在第三或第四肋间空间，导致不确定的染料扩散到相邻肋间空间的两到六个水平(表4和图2E，F)。在第二和第四肋间或第三和第五肋间两次注射可提供更广泛的染料分布(图2G，H)。通过在第三和第五肋间注射染料，染料在第一到第六肋间扩散的效果更稳定

文章：差劲先生

排版：肉肉