局部麻醉英文课件

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)十八世纪中，人们咀嚼古柯叶感受舒适感和增加耐力1860年，从古柯叶中发现了可卡因1884年，可卡因先后用于眼部局麻手术、颌神经阻滞、脊髓麻醉、硬膜外麻醉和蛛网膜下腔阻滞麻醉1905年发现普鲁卡因、丁卡因、利多卡因、布比卡因等，可卡因因其成瘾性高和安全性低而被淘汰。十八世纪中，人们咀嚼

3、古柯叶感受舒适感和增加耐力1905年发现Lidocaine BupivacaineRopivavaineProcaineTetracaine酰胺类局麻药酯类局麻药Lidocaine Procaine酰胺类局麻药酯类局麻药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罗派卡因Procaine普鲁卡因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经肌皮神经腋神经桡神经正中神经肌皮神经正中神经桡神经尺神经桡神经正中神经正中神经肌皮神经腋神经桡神经正中神经肌皮神经正中神经桡神经尺局部麻醉英文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输血指征：文献的系统回忆Transfus Med Rev. 2002 Jul;16(检索了OVID Medline数据库，近期期刊目录库，Cochrane数据库，和已发表文献目录。观察死亡率，心脏相关事件发生率，发病率，和住院时间没有受影响。结论：在有限的已经发表的证据支持在不合并严重心脏疾病的患者中

31、采用限制性输血。检索了OVID Medline数据库，近期期刊目录库，CocCrit Care. 2007 Jun 19;11(3):142Transfusion trigger in critically ill patients: has the puzzle been completed?重症患者输血指南：问题完全解决了吗？在稳定的危重病患儿采用以70g/L血色素为输血底限的限制输血方法能减少用血而不影响预后。该研究证实，试图通过输RBC来提高组织氧供是没有多大临床优势的。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