局部麻醉英文

1、局部麻醉英文Clinical Anesthesia General AnesthesiaRegionalAnesthesiaTopical anesthesiaPeripheral nerve blockLocal infiltration anesthesiaSpinal & Epidural Anesthesia一、Nerve BlocksDrug-Local anestheticsServer complication-the toxicity of LAAnatomy and TechniqueLOCAL ANESTHETICS(LA)十八世紀(jì)中，人們咀嚼古柯葉感受舒適感和增加耐力18

2、60年，從古柯葉中發(fā)現(xiàn)了可卡因1884年，可卡因先后用于眼部局麻手術(shù)、頜神經(jīng)阻滯、脊髓麻醉、硬膜外麻醉和蛛網(wǎng)膜下腔阻滯麻醉1905年發(fā)現(xiàn)普魯卡因、丁卡因、利多卡因、布比卡因等，可卡因因其成癮性高和安全性低而被淘汰。Lidocaine BupivacaineRopivavaineProcaineTetracaine酰胺類局麻藥酯類局麻藥extremely stablerelatively unstablehydrolyzed in plasmaby the cholinesteraseenzymesundergo enzymatic degradation in the liverChemica

3、l stabilityBiotransformationLidocaine利多卡因 Bupivacaine布比卡因Ropivavaine羅派卡因Procaine普魯卡因Tetracaine的卡因Local anesthetics of Peripheral nerve blockDrug dose concentration durationRopivacaine 150200mg 0.20.5% 612h Bupivacaine 150mg 0.20.5% 612hLidocaine 400mg 0.51% 13hThe toxicity of Local anesthetics Reaso

4、nOverdoseIntravascular injectionRapid systemic absorption of local anesthetic from rich blood supply areaPatient statusCNS ExcitationCNS DepressionDizzinessTinnitus Feelings of drowsinessMuscle TwitchingConsciousnessConvulsionsRespiratory DepressionRespiratory ArrestCentral Nervous System ToxicityCN

5、S Conduction PathwaysInhibitory PathwaysExcitatoryPathwaysLACNS ExcitationCNS Depression BP Heart rate Cardiac ArrestCardiovascular System ToxicityBP Heart rateCardiovascular SystemexcitationCardiovascular SystemdepressionDirect Cardiac EffectsDirect Peripheral Vascular EffectsNegative inotropic act

6、ionFastconducting tissues Highconcentrations vasodilation. Low concentrationsvasoconstrictionCardiovascular SystemdepressionLA CNS excitationCardiovascular SystemexcitationExcessive doses of LASystemic absorption of LA intravascular injection of LATest doses of LA Premedication PreventionIncipient t

7、oxic reactions: Stop administering LA,ventilation supportCNS excitation : Sedativetreatment,BenzodiazepineConvulsion Thiopental :therapy Convulsion Succinylcholine: Intubation maintaining adequate ventilation Cardiovascular System depression : supported by using IV fluids and vasopressorsCardiac arr

8、est : Cardiopulmonary resuscitationTreatmentAnatomy and TechniqueUpper extremity blocks Brachial plexus blockadeLower extremity blocks Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve BlocksBlocks of the head and neckBlocks of the thorax and abdomen Upper extremity blocks Brachial plexu

9、s blockade正中神經(jīng)肌皮神經(jīng)腋神經(jīng)橈神經(jīng)正中神經(jīng)肌皮神經(jīng)正中神經(jīng)橈神經(jīng)尺神經(jīng)橈神經(jīng)正中神經(jīng)Interscalene BlockInterscalene BlockThe block can be performed with the patients hand, arm ,upper arm, shoulder and clavicle surgeryThe ulnar nerve blockade is often incompletelow risk of pneumothoraxLA solution into the epidural and subarachnoid spac

10、esAxillary BlockAxillary BlockNo pneumothoraxAxillary block is unsuitable for surgical procedures on the upper arm or shoulder Supraclavicular BlockSupraclavicular BlockThe block can be performed with the patients arm in any positionProvide excellent anesthesia for elbow, forearm, and hand surgeryhi

11、gh risk of pneumothoraxLower extremity blocks- Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve BlocksThe major branches of Lumbar Plexus :Femoral nerveLateral femoral cutaneous nerveObturator nerveSaphenous nerveThe sciatic nerveLumbar Plexus Nerve BlocksComplicationsHematoma- Avoid mu

12、ltiple needle insertions, particularly in anticoagulated patientsVascular puncture Local anesthetic toxicity Total Spinal Anesthesia Sciatic Nerve BlocksSurface landmarks ComplicationsHematoma: Avoid multiple needle insertions, particularly in anticoagulated patientsLocal anesthetic toxicityFemoral

13、Nerve BlocksVAN:VeinArteryNerveComplicationsVascular Puncture Nerve Injury Local anesthetic toxicity二、Spinal & Epidural AnesthesiaSpinal & Epidural AnesthesiaAnatomyTechniqueFactors affecting blocking region ComplicationIndications & ContraindicationsANATOMYSubarachnoid space -Spinal AnesthesiaEpidu

14、ral space-Epidural AnesthesiaTECHNIQUESpinal anesthesia:L3L4, or L4L5 spacesSpinal anesthesia VolumeRate of injectionDensity of LA PatientpositionEpidural anesthesiaPuncture SiteVolumeRate of injectionFactors affecting blocking regionFactors affecting blocking regionSpinal anesthesia VolumeRate of i

15、njectionDensity of LA Patient positionEpidural anesthesiaPuncture SiteVolumeRate of injectionComplicationImportant complicationsSevere hypotension The toxicity of LA Total spinal anesthesia Headache after anesthesiaNerve injury Spinal & Epidural AnesthesiaSympathetic blockvagus nerve surgery operati

16、onvasodilatation1. HypotensionSensoryanalgesiaMotor blockCirculating blood volumeHeartrateSever hypotensionThe incidence and severity of hypotensionare related to: Level of the block Physical status of the patientIV fluids Treatment: Fluid InfusionEphedrine Administration, 5 to 10 mg IV.Atropine , 0

17、.3 to 0.5mg IV Severe hypotension HypoxiaUnconsciousnessCardiac arrestMost spinal never were blocked2. Total Spinal AnesthesiaEpidural puncture needle or catheter in the subarachnoid spacePreventionConfirm the catheter is in epidural space before LA injectionTest doses of local anesthetics must be u

18、sedThe patient must be monitored carefully during the processTreatmentMaintainingAdequate ventilationTracheal intubation mechanical ventilationMaintaining stablehemodynamic statusIV fluid Atropine Ephedrine Cardiopulmonary resuscitation (CPR)AgeYounger more frequentGenderFemales malesNeedle sizeLarg

19、er smallerNo. dural puncturesMore with multiple punctures3 Headache after anesthesiaTreatmentBed rest Analgesics Hydration Wearing of a tight abdominal binder Increases epidural pressure Decreases the amount of leaking CSF.5. Nerve injury Epidural hematomaEpidural abscess Spinal never root trauma:pr

20、essure on the cord or spinal roots by a needle point produces excruciating painAdhesive arachnoiditisIndications & ContraindicationsIndicationsSpinal anesthesia ：Operation time is 2-3hcoeliac, lower limbs, perineal operationEpidural anesthesia: abdominal, neck, limbs operationcoeliac,lower limbs, pe

21、rineal operationContraindications Patient refusalCoagulopathy Skin or soft tissue infection at the proposed site of needle insertion Severe hypovolemia Preexisting neurologic diseaseLack of anesthesiologist experienceBLOOD TRANSFUSIONBLOOD TRANSFUSIONIndications for TransfusionComplication of transf

22、usionAutologous transfusionIncreasing vascular volume Supply RBCIncreasing PlasmaalbumenIncreasing coagulation factorsAcute AnaemiaDysfunction of coagulationSerious infectionChronic AnaemiaIndications for Transfusionincrease oxygen-carrying capacity Blood transfusionsincrease blood volumeIV Fluid Ac

23、ute Anaemiaindications for blood transfusions?ASA Practice GuidelinesHb 100 g/L Transfusion is rarely Hb 100g/L Transfusion is rarely indicated Hb 70g /L TransfusionHb 70100g/L Transfusion should be based on the patients risk for complications of inadequat oxygenationTransfus Med Rev. 2002 Jul;16(3)

24、:187-99. Transfusion triggers: a systematic review of the literature USA（輸血指征：文獻(xiàn)的系統(tǒng)回顧）檢索了OVID Medline數(shù)據(jù)庫，近期期刊目錄庫，Cochrane數(shù)據(jù)庫，和已發(fā)表文獻(xiàn)目錄。觀察死亡率，心臟相關(guān)事件發(fā)生率，發(fā)病率，和住院時間沒有受影響。結(jié)論：在有限的已經(jīng)發(fā)表的證據(jù)支持在不合并嚴(yán)重心臟疾病的患者中采用限制性輸血。Crit Care. 2007 Jun 19;11(3):142Transfusion trigger in critically ill patients: has the puzzle be

25、en completed?重癥患者輸血指南：問題完全解決了嗎？在穩(wěn)定的危重病患兒采用以70g/L血色素為輸血底限的限制輸血方法能減少用血而不影響預(yù)后。該研究證實，試圖通過輸RBC來提高組織氧供是沒有多大臨床優(yōu)勢的。Complication of transfusionImmunoreactionNon-immunoreactionHemolytic transfusion reactionAllergic reactionsNonhemolytic transfusion reactions Fever reactionsAcute Hemolytic Transfusion Reaction

26、Delay Hemolytic Transfusion ReactionTransfusion-Induced Immuno-depressionTransfusion-Related Acute Lung Injurymyocardial injuryImmunoreactionAcute hemolytic transfusion reactionA fatal reactions ， mortality rate 20% to 60%The renal and coagulation systems are affected ABO-incompatible The reaction c

27、an occur from infusion of as little as 10 mL of bloodSigns and Symptoms The classic signs and symptoms chills feverchest or flank pain nauseaThe signs in general anesthesiableeding hypotension hemoglobinuriaDelayed hemolytic transfusion reactionunexplained fever and anaemia 7 to 14 days after a transfusionRh-incompatiblerarely deathNon-immunoreactionHepatitisIn the 1940s