局部麻醉英文課件

1、Zhang LanDepartment of Anesthesiology of West China HospitalRegional Anesthesia Zhang LanRegional Anesthesia Clinical Anesthesia General AnesthesiaRegionalAnesthesiaTopical anesthesiaPeripheral nerve blockLocal infiltration anesthesiaSpinal & Epidural AnesthesiaClinical General AnesthesiaRe一、Nerve B

2、locksDrug-Local anestheticsServer complication-the toxicity of LAAnatomy and Technique一、Nerve BlocksDrug-Local anestLOCAL ANESTHETICS(LA)LOCAL 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1860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。十八世紀(jì)中，人們咀嚼

3、古柯葉感受舒適感和增加耐力1905年發(fā)現(xiàn)Lidocaine BupivacaineRopivavaineProcaineTetracaine酰胺類局麻藥酯類局麻藥Lidocaine Procaine酰胺類局麻藥酯類局麻藥extremely stablerelatively unstablehydrolyzed in plasmaby the cholinesteraseenzymesundergo enzymatic degradation in the liverChemical stabilityBiotransformationLidocaine利多卡因 Bupivacaine布比卡因R

4、opivavaine羅派卡因Procaine普魯卡因Tetracaine的卡因extremely relatively hydrolyze局部麻醉英文Local anesthetics of Peripheral nerve blockDrug dose concentration durationRopivacaine 150200mg 0.20.5% 612h Bupivacaine 150mg 0.20.5% 612hLidocaine 400mg 0.51% 13hLocal anesthetics of PeripherThe toxicity of Local anesthetic

5、s The toxicity of Local anestheReasonOverdoseIntravascular injectionRapid systemic absorption of local anesthetic from rich blood supply areaPatient statusReasonOverdoseCNS ExcitationCNS DepressionDizzinessTinnitus Feelings of drowsinessMuscle TwitchingConsciousnessConvulsionsRespiratory DepressionR

6、espiratory ArrestCentral Nervous System ToxicityCNS CNS DizzinessConsciousnessCNS Conduction PathwaysInhibitory PathwaysExcitatoryPathwaysLACNS ExcitationCNS Depression CNS Conduction Inhibitory ExciBP Heart rate Cardiac ArrestCardiovascular System ToxicityBP Heart rateCardiovascular Systemexcitatio

7、nCardiovascular SystemdepressionBP Cardiovascular System ToxiDirect Cardiac EffectsDirect Peripheral Vascular EffectsNegative inotropic actionFastconducting tissues Highconcentrations vasodilation. Low concentrationsvasoconstrictionCardiovascular SystemdepressionLA CNS excitationCardiovascular Syste

8、mexcitationDirectDirect Negative FastHighExcessive doses of LASystemic absorption of LA intravascular injection of LATest doses of LA Premedication PreventionExcessive doses of LAPreventioIncipient toxic reactions: Stop administering LA,ventilation supportCNS excitation : Sedativetreatment,Benzodiaz

9、epineConvulsion Thiopental :therapy Convulsion Succinylcholine: Intubation maintaining adequate ventilation Cardiovascular System depression : supported by using IV fluids and vasopressorsCardiac arrest : Cardiopulmonary resuscitationTreatmentIncipient toxic reactions:TreaAnatomy and TechniqueAnatom

10、y 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 Upper extremity blocks Brachial plexus blockadeUpper extremity b

11、locks Brachi局部麻醉英文正中神經(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)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)尺局部麻醉英文Interscalene BlockInterscalene 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 p

12、neumothoraxLA solution into the epidural and subarachnoid spacesInterscalene BlockThe block cAxillary BlockAxillary BlockAxillary BlockNo pneumothoraxAxillary block is unsuitable for surgical procedures on the upper arm or shoulder Axillary BlockNo pneumothoraxSupraclavicular BlockSupraclavicular Bl

13、ockSupraclavicular BlockThe block can be performed with the patients arm in any positionProvide excellent anesthesia for elbow, forearm, and hand surgeryhigh risk of pneumothoraxSupraclavicular BlockThe blockLower extremity blocks- Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve Blocks

14、Lower extremity blocks- Lumba局部麻醉英文The major branches of Lumbar Plexus :Femoral nerveLateral femoral cutaneous nerveObturator nerveSaphenous nerveThe major branches of Lumbar The sciatic nerveThe sciatic nerveLumbar Plexus Nerve BlocksLumbar Plexus Nerve Blocks局部麻醉英文ComplicationsHematoma- Avoid mult

15、iple needle insertions, particularly in anticoagulated patientsVascular puncture Local anesthetic toxicity Total Spinal Anesthesia ComplicationsHematoma- Avoid mSciatic Nerve BlocksSciatic Nerve BlocksSurface landmarks Surface landmarks ComplicationsHematoma: Avoid multiple needle insertions, partic

16、ularly in anticoagulated patientsLocal anesthetic toxicityComplicationsHematoma: Avoid mFemoral Nerve BlocksFemoral Nerve BlocksVAN:VeinArteryNerveVAN:ComplicationsVascular Puncture Nerve Injury Local anesthetic toxicityComplicationsVascular Puncture二、Spinal & Epidural Anesthesia二、Spinal & Epidural

17、AnesthesiSpinal & Epidural AnesthesiaAnatomyTechniqueFactors affecting blocking region ComplicationIndications & ContraindicationsSpinal & Epidural AnesthesiaAANATOMYANATOMY局部麻醉英文Subarachnoid space -Spinal AnesthesiaEpidural space-Epidural AnesthesiaSubarachnoid space -Spinal An局部麻醉英文TECHNIQUETECHNI

18、QUE局部麻醉英文Spinal anesthesia:L3L4, or L4L5 spacesSpinal anesthesia:局部麻醉英文局部麻醉英文局部麻醉英文Spinal anesthesia VolumeRate of injectionDensity of LA PatientpositionEpidural anesthesiaPuncture SiteVolumeRate of injectionFactors affecting blocking regionSpinal anesthesia Epidural aneFactors affecting blocking re

19、gionSpinal anesthesia VolumeRate of injectionDensity of LA Patient positionEpidural anesthesiaPuncture SiteVolumeRate of injectionFactors affecting blocking regComplicationComplicationImportant complicationsSevere hypotension The toxicity of LA Total spinal anesthesia Headache after anesthesiaNerve

20、injury Important complicationsSevere Spinal & Epidural AnesthesiaSympathetic blockvagus nerve surgery operationvasodilatation1. HypotensionSensoryanalgesiaMotor blockCirculating blood volumeHeartrateSever hypotensionSpinal & Epidural SympathetiThe incidence and severity of hypotensionare related to:

21、 Level of the block Physical status of the patientIV fluids The incidence and severity of Treatment: Fluid InfusionEphedrine Administration, 5 to 10 mg IV.Atropine , 0.3 to 0.5mg IV Treatment: Fluid InfusionSevere hypotension HypoxiaUnconsciousnessCardiac arrestMost spinal never were blocked2. Total

22、 Spinal AnesthesiaEpidural puncture needle or catheter in the subarachnoid spaceSevere hypotension Most spinalPreventionConfirm the catheter is in epidural space before LA injectionTest doses of local anesthetics must be usedThe patient must be monitored carefully during the processPreventionConfirm

23、 the catheterTreatmentMaintainingAdequate ventilationTracheal intubation mechanical ventilationMaintaining stablehemodynamic statusIV fluid Atropine Ephedrine Cardiopulmonary resuscitation (CPR)TreatmentMaintainingTracheal iAgeYounger more frequentGenderFemales malesNeedle sizeLarger smallerNo. dura

24、l puncturesMore with multiple punctures3 Headache after anesthesiaAgeGenderNeedle sizeNo. dural TreatmentBed rest Analgesics Hydration Wearing of a tight abdominal binder Increases epidural pressure Decreases the amount of leaking CSF.TreatmentBed rest Increases 5. Nerve injury Epidural hematomaEpid

25、ural abscess Spinal never root trauma:pressure on the cord or spinal roots by a needle point produces excruciating painAdhesive arachnoiditis5. Nerve injury Epidural hematIndications & ContraindicationsIndications & ContraindicationIndicationsSpinal anesthesia ：Operation time is 2-3hcoeliac, lower l

26、imbs, perineal operationEpidural anesthesia: abdominal, neck, limbs operationcoeliac,lower limbs, perineal operationIndicationsSpinal anesthesia ：Contraindications Patient refusalCoagulopathy Skin or soft tissue infection at the proposed site of needle insertion Severe hypovolemia Preexisting neurol

27、ogic diseaseLack of anesthesiologist experienceContraindications Patient refuBLOOD TRANSFUSIONBLOOD TRANSFUSION局部麻醉英文局部麻醉英文BLOOD TRANSFUSIONIndications for TransfusionComplication of transfusionAutologous transfusionBLOOD TRANSFUSIONIndications Increasing vascular volume Supply RBCIncreasing Plasmaa

28、lbumenIncreasing coagulation factorsAcute AnaemiaDysfunction of coagulationSerious infectionChronic AnaemiaIndications for TransfusionIncreasing Supply Increasing Iincrease oxygen-carrying capacity Blood transfusionsincrease blood volumeIV Fluid Acute Anaemiaindications for blood transfusions?increa

29、se Blood increase IV FluASA Practice GuidelinesHb 100 g/L Transfusion is rarely Hb 100Chinese Health Ministry practice Guidelines of transfusion 2000Hb 100g/L Transfusion is rarely indicated Hb 70g /L TransfusionHb 70100g/L Transfusion should be based on the patients risk for complications of inadeq

30、uat oxygenationChinese Health Ministry practiTransfus Med Rev. 2002 Jul;16(3):187-99. Transfusion triggers: a systematic review of the literature USA輸血指征：文獻的系統(tǒng)回憶Transfus Med Rev. 2002 Jul;16(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

31、采用限制性輸血。檢索了OVID Medline數(shù)據(jù)庫，近期期刊目錄庫，CocCrit Care. 2007 Jun 19;11(3):142Transfusion trigger in critically ill patients: has the puzzle been 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。Crit Care. 2007 Jun 19;11(3):1Complication of transfusionI

32、mmunoreactionNon-immunoreactionComplication of transfusionImmHemolytic transfusion reactionAllergic reactionsNonhemolytic transfusion reactions Fever reactionsAcute Hemolytic Transfusion ReactionDelay Hemolytic Transfusion ReactionTransfusion-Induced Immuno-depressionTransfusion-Related Acute Lung I

33、njurymyocardial injuryImmunoreactionHemolytic Allergic reactionsNoAcute hemolytic transfusion reactionA fatal reactions ， mortality rate 20% to 60%The renal and coagulation systems are affected ABO-incompatible The reaction can occur from infusion of as little as 10 mL of bloodAcute hemolytic transf

34、usion Signs and Symptoms The classic signs and symptoms chills feverchest or flank pain nauseaThe signs in general anesthesiableeding hypotension hemoglobinuriaSigns and Symptoms The classicDelayed hemolytic transfusion reactionunexplained fever and anaemia 7 to 14 days after a transfusionRh-incompatiblerarely deathDelayed hemolytic transfusion Non-immunoreactionNon-immunoreactionHepatitisIn the 1940s ,viral hepatitis was recognized as a major complication of transfusion.Now, th