Izithi zezikhali zokunqula kanye nezisebenziso zazo zokusebenza kwemithombo

Ukubonakala Kwesikhombisa Sesifundo Sokuqinisa: Isikhundla, Isithembiso Sezinyawo, Nokusebenza Kwehub

Kwesibezela (Quincke) vs. Kwezinyawo Ezisemthandweni (Whitacre, Sprotte): Isithembiso Sezinyawo Sisiphikisana Kanjani Nokuphatha Kwesidura Nokuthi Kukhona Ukuthi Kusenziwa Ukuphuma Kwesifundo

Amaphutha amathathu (ama-Quincke) aqondisa izinyathelo ezimhlophe zokukhupha izihlalo sezindiza, ngakho-ke amaphutha amahle okukhupha—njengezika-Whitacre nezika-Sprotte—ayikhubaza kakhulu. Lokhu kubalulekile kakhulu kubonakala kuzindiza: amaphutha ama-Quincke ayakha izihlalo ezingafuni ukubuyela emuva, okuvamisa ukushukuma kwesifundo se-cerebrospinal (CSF) nokwakha kwezinkinga zokukhala kwesikhumba emuva kokukhupha kwezindiza (PDPH) ngokuphakanyiswa kwe-1.5–2× kunamaphutha amahle okukhupha. Umthombo wokufunda okuhlanganisiweyo wabonisa ukuthi isivinini sokukhala kwesikhumba emuva kokukhupha kwezindiza siphakanyiswe ku-9.6% ngezika-Quincke kodwa siphakanyiswe ku-4.1% ngezika-Whitacre kumshini wokukhupha kwezindiza—lokhu kubonakala njengesibonelo esingasemthwakweni wase-Amerika wokufunda kwezindiza nezinkinga zokukhala (ASRA) njengesibonelo esisodwa kwezinhlangano zokusebenza kahle. Amaphutha amahle okukhupha ayena futhi ayabona izinkokhelo ezizenzile kakhulu ekukhuphweni kwezindiza, okusiza ukuthi umsebenzi wokubona ukuthi ‘ukuphupha’ kwenzeke ngokuphakeme ngaphandle kokukhulula ukubuyela emuva kwezindiza. Isibonelo sesikhathi sokusebenza siyisodwa: ubunzima obuhlaka obungakhiyeli ukukhupha kwezindiza buphakamisa ubuciko bezindiza nokuthi abantu bakholelwe kakhulu.

Ukukhetha Kwesikhala Sokubonwa Ngokuphakanyiswa: Ukubalansisa Isivinini Sesandla, Ukuqonda Kwesikhala Somzimba, Nokuphepha Kwabantu Ngeminye Imisebenzi

Ukukhetha kwesikhala kufanele kubalane nezinhlongo zokusuka kweziflow—ezihlanganiselwe ngolwazi lukaPoiseuille—nezinhlongo zamzimba nesizinda sezinhloso zomsebenzi. Izinombolo ezinkulu zesikhala zibonisa izikhala ezingaphansi: izikhala zesikhala 25G–29G zihlula ukuthi bakhokele isikhundla sokuzwa okungabiyo kwezincitha futhi zihlula ukuthi bakhokele ukuthi kuhlanjwe amasili okusuka kweCSF, kodwa zihlula ukuthi bakhokele isivinini, ikakhulukazi emasilini amaningi njengebupivacaine yokuqondisa. Ngokuvamile, izikhala ezingaphezulu (isibhalo: 22G) zihlula ukuthi bakhokele isivinini futhi ukuthi bakhokele ukuthi kubonwa ngokuphepha ukuthi kuhlanjwe, kodwa zihlula ukuthi bakhokele ukuthi kubhekwe ngokuphepha kwePDPH. Izindlela zokubonwa ngokwemfanekiso zihlula ukuthi zibonise le ndlela yokubalansisa:

Ukukhetha ukuguquka okungafanele kunezindlela eziphathelene ngokupheleleyo: abadokotela bavuma ukuthi kukhona ukuphulula kwemithombo yokuqondwa kwe-CSF ngokuphakeme kwe-32% ngezinkambo ezingaphansi kwe-22G emaqhinga amahlanu ase-Spinal. Ukufunda kwe-CDC kwezinhlobo zomsebenzi kusuka ku-500 iminyaka yabadokotela kuvumela ukuthi ukukhetha ukuguquka okuhambisana ne-viscosity kunciphisa ukungasebenzi kwezinhlobo futhi ukugcina isiqu esikhulu. Izikhombiso zezindawo zokusebenza ezihlanganisa ukufundisa ngokuguquka okuhambisana nezinhlobo zokusebenza zizocincisha ukugcina isiqu sokunqamuka ngokuphakeme kwe-50% ngeminyaka emithathu—kubonisa ukuthi ukucacisa ukuguquka kwezinkambo akuyiyo inkimbinkimbi yokuqhubeka, kodwa yilokho okuphakeme kakhulu ekubhekiseni isibopho.

Izinkambo Zokusebenza Kwe-Spinal Anesthesia: Ukukhetha Ngokwesibonelo Sokubheka Ukufika Kwesi-CSF Nokubheka Isibopho

Ukulinganisa Amaphuzu: I-Quincke, I-Whitacre, Ne-Sprotte Needles Ekufikeni Kwesi-CSF Nokubhekwa Kwesi-Post-Dural Puncture Headache

Umbono wendlela yomshini—akasiqondi kuphela ukuthi yisipho—uyadetermina ubukhulu bokuphumelela kwenkqubo nokuthi kungakhathalelwa ngokwesibindi ekubeni kufanele kususwe kumsebenzi wokugcina isikhathi. Amashini ase-Quincke ayenza amashele aphakathi okwesikhathi esihle, esihle, esithi kususwa kwe-PDPH kusukela ku-10–15% kwabantu abangaphansi kwe-40, ngokwesiqinisekiso sase-ASRA. Ngaphandle kwalokho, amashini ase-Whitacre ne-Sprotte—oba zilahlekile—ayisula amafibrile okwesikhathi kodwa ayikhiya, futhi ayisula i-PDPH ku-<5% kuzo zonke izindawo. Kuyisidingo sokuthi, amaphuzu akhombisa ukuthi akukho ph difference esikhundleni sokuthi kususwa kwe-CSF phakathi kwe-Quincke, Whitacre, ne-Sprotte amashini kuzo zonke izinkambo zokusebenzisa (22–27G); zonke zifika kwe-CSF ephakathi kwe-95% yezinyathelo lapho zisebenziswa ngendlela ephakathi. Kodwa, umsindo wokuhambisa we-Sprotte uyakhulisa ukususwa kwe-CSF ngokushesha kancane—lokhu kuyisiphumo esikhulu kubantu abanenqanaba eliphezulu le-BMI noma abanenqanaba ezindaweni eziningi. Noma ukubona kwe-CSF kungaqondi kancane ngokwesikhathi sokunqamuka kwe-pencil-point ngokuba umsindo wokuhambisa uyinkanana, lokhu akakhiphe ukuthi kuyizinkinga zokuphumelela noma ukuthi kungabhalwe. Ukuthi kuyisidingo sokuthi kususwa kwe-mashini angalahlwa kuyisidingo sokuthi kususwa kwe-spinal anesthesia: kuyathola ukuthi kuyasebenza ngokufanele kodwa kuyasula ukuthi kungakhathalelwa ngokwesibindi okungakwazi ukuthi kususwe.

Amaphathi okukhanyisa kwe-Epidural ne-Regional Anesthesia: Amaphathi ka-Tuohy, amaphathi okuphakamisa ngaphakathi kwesikhundla, namaphathi okukhanyisa kwe-Nerve Block okwenzelwe ngokuzimela

Ukukhanyisa kwe-Epidural ne-Regional kuyasebenza ngamaphathi akhiwe ngokuzimela ukusiza kumathuba okwesikhundla okuhambisana nokuthi yiliphi isikhundla esithile kanye nokuthi yiliphi isiphumo sokusebenza. Amaphathi ka-Tuohy—okuyinto ekubonisa ukuthi inqaba yayo ibe yendlela yokugcina, ayikhiqi, noma yiliphi indlela yokugcina—kusiza ukuthi amaphathi ayo abe yinkambo yokukhanyisa ngokuphephile kwe-Epidural space. Ukuphakamisa ngaphakathi kwesikhundla kuyisebenzisa amaphathi okuphakamisa ngokuzimela ukukhupha ukuthi amaphathi ayodlula ngaphakathi kwe-midline ligamentous resistance, okuyisivumelwano esihle kubantu abanemibala yomhlango we-spine. Amaphathi okukhanyisa kwe-Nerve Block ayakhetha ukuthi iphakathi liyinyani kanye nokuthi i-bevel angle iyahlukahluka (isibhalo: i-short-bevel yamaphathi okukhanyisa kwe-superficial blocks, i-long-bevel yamaphathi okukhanyisa kwe-deep plexus) ukuthi kwenzeke ukuthi amaphathi ayodlula ngaphakathi kwe-nerve ngokuphephile futhi ukuthi kunciphise ukuthi amaphathi ayodlula ngaphakathi kwe-nerve. Ngokuphakathi kwezinye zonke izinhlobo, ukusebenza okuphephile kuyincazelo yokuqondisa ukuthi iphakathi liyayifanele, ukuthi iphakathi liyayiqinisekile ngokuphephile, nokuthi ukuthi umsebenzi wawo uyayiqinisekile ngokuphephile—izincazelo eziqukethe ukuthi ziyavumelwa ngokwesikhundla se-ASTM F2101 sokuthi iphakathi liyayifanele kanye nokuthi inqaba yayo iyayigcina ngokuphephile.

Ukugoba Kwezinaliti ZaseTuohy Nendlela Yokulahlekelwa Ukuphikiswa: I-Biomechanics Yendawo Yendawo Yokufaka I-Epidural

I-Tuohy needle's 1015° distal curvature isebenza imisebenzi emibili ebalulekile ngokwemvelo: okokuqala, iqondisa i-epidural catheter kude ne-dura lapho iphuma, inciphisa ukuphuma okungahlosiwe kwe-dural nge-~ 30% uma kuqhathaniswa nezinye izindlela eziqondile; okwesibili, Ngesikhathi sokulahleka kokumelana (LOR), ukucindezela okuqhubekayo kusirinji egcwele usawoti kuveza ukumelana kwe-ligamentum flavum okuhambisana nokwehla okuphawulekayo nokungazelelwe kokumelana endaweni ye-epidural, evame ukuba ngamasentimitha angu-4-6 ukusuka ekungeneni Lesi senzakalo sokuthinta sihlobene kakhulu nokujula okuqinisekiswe yi-ultrasound kumacala angu-92%, ngokwezifundo zamuva zokuqinisekisa ezinezindawo eziningi. Ukugoba kuqinisekisa ukuthi ikathathitha iyaqhubeka ngemva kokugcina isikhala se-epidural kunokuthi siphambene noma sidlule ku-dural, okwenza kube yinto engathandeki nje kuphela, kodwa ingxenye eyenziwe ngokuphepha yomkhuba wanamuhla we-neuraxial.

Uhlaka Lokwenza Izinqumo Ezingokomtholampilo Lokukhetha Inalithi Ye-Anesthesia

Ukukhetha inaliti yokwehlisa izinga elifanele kudinga ukuhlanganiswa okuhlelekile kwe-gauge, i-geometry ye-tip, kanye nesimo senqubohhayi izici ezihlukile. Ukuphakama kwe- gauge kushintsha ngokuya ngamasu: izinaliti ezibanzi ze-1618G ziboniswa ukulethwa kwe- epidural bolus okusheshayo noma i-air-injection LOR ezigulini ezingenazinhlalakahle ze-hemodynamically, lapho ukunciphisa ukuhlukaniswa kwemithambo yegazi nokuqinisekisa Nokho, uma kuziwa ekuhlolweni kokwelashwa kokwelashwa komgogodla, i-geometry yomkhawulo ilawula ukuthatha izinqumo: imiklamo ye-atraumatic (Whitacre, Sprotte) inciphisa i-PDPH ngo-40% uma iqhathaniswa ne-Quincke, ngokuhlaziywa okuhlangan Ukwelashwa kwe-anesthesiology (2022). Ukukhombisa kwe-ultrasound ngokwesikhathi sokusebenza kusobala ukukhetha—kunciphisa ukungafiki kuphela kwesikhathi esokuqala ngama-4–8 ngabantu abanemithambo eminingi noma abanemithambo yasezansi, ngokwesiqephu se-ASRA sokuqinisekisa ukusebenza kwe-ultrasound. Uma kubhalwa ngokuhambisana nezilingo zokukhetha ubude bokushaya nokuthi izindlela zokuphatha izinto ezibonakalayo zokuzihlukanisa izinto, lezi zizindlela eziphathelene nezindaba zokusebenza kuzocimba ukunakekelwa kwezinyawo ngaphezu kwe-0.05%. Ekugcineni, ukukhetha ukushaya kuyizindlela zokuphatha ezinamandla: eyayisisekelwe kwe-physics, iyavumiswa ngamadatha okuphatha, futhi iyasebenziswa ngokuzimisela ukuze kwenziwe ukuthula nokusebenza kahle.

Imibuzo Evame Ukubuzwa

Ukuchaza kwe-Quincke kunye ne-Whitacre kuyiphi?

Izikhathi ze-Quincke zinezinyawo ezinkulu ezifanele ukufaka izinyawo zezinyawo, ngakho-ke i-Whitacre zinezinyawo ezingaphinde zizilungiselela ukuthi zihlukanise izinyawo ngokomlando, kunciphisa ukuthi kubhekwe izinyawo futhi kunciphisa isivumelwano sokufaka izinyawo (PDPH).

Kungani ukukhetha igauge kubalulekile kwezikhathi zokuphatha?

Ukukhetha kwe-gauge kubalansisa ukudluliswa kwe-fluid, ukukhathazeka kwe-tissue, nokuhlanganisa izinhlaka zokusebenza. Amagauge amancane kunciphisa ukugqibela kwe-tissue nokuphuma kwe-CSF, ngakho-ke amagauge amaningi akwakha ukudluliswa kwe-fluid nokuthembeka kwe-aspiration kodwa kakhulu kunciphisa isikhundla sokuphuma kwe-PDPH.

Ukuthi i-Tuohy needle iyaphinda yisikhundla sezinkampani zepidural njani?

Isihlango sesihlango se-Tuohy sokuqala sokugcina isikhundla sokuphuma kwe-dura, sikwenza ukuthi ikatheter ibe yisikhundla esifanayo ngaphakathi kwe-epidural canal, futhi sithuthukisa ukudluliswa kwe-anesthetic ngokufanayo, okuyabuyisa isikhundla sokusebenza nokuthembeka.

Izincongo zokukhetha izinhlobo zezincampani ezizimisele njani?

Izincongo zezincampani ezizimisele, njenge-Whitacre ne-Sprotte, zicisha isikhundla sokuphuma kwe-dura, zilondoloza ubunzima bwe-dura, futhi zinikeza isikhundla sokubona ngokufanayo, okuyabuyisa isikhundla sokuphila kwabantu basebenzi nezinhlobo zokuthembeka kwebhizinisi emsebenzini.

Ukuthi i-ultrasound guidance iyasebenza njani ekulandeleni kwe-needle?

Ukukhombisa kwe-ultrasound kukhuthaza ukuphepha kwesikhathi sokufaka isikhombisa, ikakhulu kubantu abanemitha emnyama noma abanemiphumela yokuqondana, kususa izimboni zokufika kwe-1st pass futhi kuzimisa izinkinga njengezinkinga zokugcina amaswidi.