外科學(xué)課件：椎管內(nèi)麻醉

NeuraxialAnesthesia

椎管內(nèi)麻醉BriefSpinal,epidural,andcaudalneuraxialblocksresultinsympatheticblockade,sensoryanalgesia,oranesthesiaandmotorblockade,dependingonthedose,concentration,orvolumeoflocalanesthetic,afterinsertionofaneedleintheplaneoftheneuraxis.——Miller’sAnesthesiaBriefSpinalAnesthesia蛛網(wǎng)膜下腔麻醉(簡稱脊麻)EpiduralAnesthesia硬膜外麻醉CaudalAnesthesia

骶管麻醉CombinedSpinalandEpiduralAnesthesia

聯(lián)合阻滯IndicationsSurgicalprocedurecanbeaccomplishedwithasensorylevelofanesthesiathatdoesnotproduceadversepatientoutcomes.最基本適應(yīng)證：足夠保證外科操作的麻醉平面不產(chǎn)生有害結(jié)果ContraindicationsAbsoluteLocalizedinfectionatskinpuncturesite.Generalizedsepsis.CoagulopathyIncreasedintracranialpressure.RelativeHypovolemia.Centralnervoussystemdisease.Chronicbackpain.SegmentalLevelRequiredforSurgerySkindermatomescorrespondingtorespectivesensoryinnervationbyspinalnerves.SegmentalLevelRequiredforSurgeryOperativeSiteLevelLowerextremitiesT12HipT10Vagina,uterusT10Bladder,prostateT10LowerextremitieswithtourniquetT8Testis,ovariesT8LowerintraabdominalT6OtherintraabdominalT4SuggestedminimumcutaneouslevelsforspinalanesthesiaAnatomySpinecurve(supineposition)Highest:C3andL3Lowest:T5andS4AnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮膚→皮下組織→棘上韌帶→棘間韌帶→黃韌帶→硬膜外腔→硬脊膜和蛛網(wǎng)膜→蛛網(wǎng)膜下腔）AnatomySpinalcordends:Adult:atL1-2.Newborn:ataboutL3By2yrsofage:nearL1AnatomyThreeinterlaminarligamentsbindthevertebralprocessestogetherSupraspinousligament棘上韌帶Interspinousligament

棘間韌帶Ligamentumflavum黃韌帶，阻力增加AnatomySpinalcordisinvestedinthreemeningesDuramater（硬脊膜）Arachnoid（蛛網(wǎng)膜）Piamater（軟脊膜）AnatomyCSF（腦脊液）Totalvolume:120~150mLSpinalsubarachnoidspace:25~30mLpH7.35Specificgravity1.003~1.009AnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮膚→皮下組織→棘上韌帶→棘間韌帶→黃韌帶→硬膜外腔→硬脊膜和蛛網(wǎng)膜→蛛網(wǎng)膜下腔）AnatomyEpiduralspacecontainsNerverootsbloodvesselsFatConnectivetissueAnatomy—CaudalSacralsurfaceanatomy.Anequilateraltrianglecanbedrawntoconnecttheposteriorsuperioriliacspinesandthesacralhiatus.Itcanbeusefulinconfirmingpalpationofthesacralhiatus(骶裂孔).PhysiologyNeuralblockadeEasilyblockedautonomicfibers—sensoryfibers—motorfibersLevelofblockadeautonomicblockadeextendsabovesensoryblockadeby2~4segmentssensoryblockadeextendsabovemotorblockadeby1~4segmentsPhysiologyEpiduralneuralblockadeLocalanestheticplacedintheepiduralspaceactsdirectlyonthespinalnerveroots（脊神經(jīng)根）

locatedinthelateralpartofthespace.Theonsetoftheblockisslowerthanwithspinalanesthesia,andtheintensityofthesensoryandmotorblockisless.PhysiologyCardiovascular（交感神經(jīng)被阻滯）Hypotension

：sympatheticblockadeRiskfactorsforbradycardiabaselinebradycardiauseofbetablockersage<50sensorylevelaboveT-6PhysiologyRespiratoryPhrenicnerve（膈神經(jīng)）:C3~C5UsuallyaspinallevelofT4doesnotresultinimpairedventilation,butrespiratorycompromisemayhappeninpatientswithlimitedrespiratoryreserveorhigherspinallevels.Technique—SpinalAnesthesiaSpinalneedle

QuinckeSprotteWhitacareTechnique—SpinalAnesthesiaPatientpositionlateralpositionsittingpositionTechnique—SpinalAnesthesiaProcedure定位：TheL2-3,L3-4,orL4-5interspacesarecommonlyusedforspinalanesthesia.皮丘：Raiseaskinwhealwith1%lidocaineanda25Gneedleatthespinalpuncturesite.Technique—SpinalAnesthesiaApproaches

正入法

Midlineapproach

側(cè)入法

（少用）

Paramedianapproaches

避開鈣化韌帶Technique—SpinalAnesthesiaTechnique—SpinalAnesthesiaDeterminantsoflevelofspinalblockadeControllableFactorsDose(volume×concentration)（劑量）Siteofinjectionalongtheneuraxis（穿刺點）Baricityofthelocalanestheticsolution（比重）Postureofthepatient（體位）FactorsNotControllableVolumeofcerebrospinalfluidDensityofcerebrospinalfluidTechnique—SpinalAnesthesiaBaricityoflocalanestheticsolution

局麻藥的比重Localanestheticsolutionscanbedescribedashyperbaric（重比重）,hypobaric（輕比重）,orisobaric（等比重）

inrelationtothespecificgravityofCSF(1.003~1.009).Technique—EpiduralAnesthesiaEpiduralneedles18GHustead17GTuohyTechnique—EpiduralAnesthesiaApproaches胸段：棘突疊瓦狀腰段：棘突較平行Technique—EpiduralAnesthesia進(jìn)入硬膜外腔的判斷阻力消失法（loss-of-resistance）懸滴法（hanging-drop）通常置入硬膜外管2.5-5cmTechnique—EpiduralAnesthesia試驗劑量判斷導(dǎo)管位置是否在硬膜外腔？是否入血？了解局麻藥物擴(kuò)散情況藥物劑量身高注藥速度硬膜外腔通暢性（年齡、懷孕、既往麻醉史）粘連、靜脈充盈、結(jié)締組織Technique—Combinedspinal-epiduralanesthesia（脊麻-硬膜外聯(lián)合阻滯）優(yōu)點：起效快效果確切可連續(xù)給藥術(shù)后鎮(zhèn)痛Complications—SpinalAnesthesiaNeurologicPostduralpunctureheadache（硬膜穿破后頭痛）

Caudaequinasyndrome（馬尾綜合征）Neurologicinjury（神經(jīng)損傷）CardiovascularHypotensionBradycardiaComplications—SpinalAnesthesiaRespiratoryDyspnea/ApneaUrinaryretentionNauseaandvomitingInfectionComplications—EpiduralAnesthesiaUnintentionalsubarachnoidinjectionTotalspinalanesthesia（全脊髓麻醉）Intravascularinjection

（血管內(nèi)注射，局麻藥中毒）PostduralpunctureheadacheDirectspinalcordinjuryEpiduralhematoma(硬膜外血腫）Epiduralabscess