重医大临床麻醉学教案10椎管内麻醉

授课教案课程名称临床麻醉学年级授课专业麻醉学系教师职称授课方式大课学时4题目章节第十章椎管内麻醉教材名称根据《临床麻醉学》椎管内麻醉章节改编为英文作者房秀生，刘新伟出版社版次第一版教学目的要求.蛛网膜下腔阻滞：熟悉腰麻的作用机理及其对生理的影响。掌握腰麻的适应证，禁忌证与并发证。熟悉腰麻的平面调节和用药基本方法。了解穿刺要点。.硬膜外阻滞。熟悉硬膜外阻滞的作用机理及其对生理的影响，掌握硬膜外麻醉的适应证，禁忌证，平面调节和麻醉管理。理解其穿刺要点，注药方法，掌握硬膜外麻醉的并发证。教学难点.椎管的解剖，穿刺层次，注药部位。.椎管内麻醉对生理的影响。.影响腰麻平面的因素及平面的调节。.术后头痛的原因与处理。.硬膜外麻醉注药原则.全脊椎麻醉的产生与预防，处理。教学重点.椎管的解剖，穿刺层次，注药部位。.腰麻与硬膜外麻醉对生理影响。.腰麻与硬膜外麻醉的适应证与并发症。.腰麻与硬膜外麻醉的区别外语要求掌握椎管内麻醉章的英文关键词，能基本听懂全英文讲课，血rathecalanesthesia;epiduralanesthesia;spinalanesthesia;cerebrospinalfluid(CSF).学法段教方手讲授及多媒体教学。经考资料《Clinicalanesthesia》ByGE.Morgan.(Textbookofanesthesia》教研十.届、同意教学组长：教研室主任：20年月日Steps:Keepingtheairwaypatency,maintainingadequateventilationandgivingoxygen.Supportingcirculation:Infusionofintravenousfluidsquickly.UsevasopressorsbyIV.Ifcardiacarrestoccurs,CPRmustbeimmediatelyperformed.PreventionofTSAstrictlyusingthetestdoseoflocalanesthetic,aspirationthecatheterbeforeinjection.carefullyobservingpatientafterinjectedlocalanesthetic..ToxicreactionReasonsintravascularinjection.absorptionofexcessiveamountsofanesthetic.Clinicalcharacteristicsnumbnessortinglingoftongue・tinnitus,lingualsensations&lightheaded.consciousnesslost.convulsion.PreventionlOminlOminlOminaspiratingtheneedleorcatheter,usingtestdose.lOminobservingearlysignsoftoxicity.Managementoxygeninhale・patencyairway.sedative&anti-convulsionagents,keepingcirculationstable.4.HypotensionManagementcrystalloidorcolloidsolution.IVInfusionephedrine15-30mgIV.atropine0.25-0.5mgIV.Oxygeninhale.NauseaorvomitingReasons

hypotensionlOminlOminlOminvisceralmanipulationhypoxemialOminManagementManagementincreasefluidtransfusioninhaleoxygendrugusage:atropine,efedrina,antiemetics.RespiratorydepressionReasonshighlevelofepiduralanesthesia.ClinicalsignsSO2%decreased,tidalvolumedecreased,orapnea.Managementavoidhighblocklevel.decreaseanestheticdrugconcentration.oxygeninhale&respiratorysupport.Postoperativecomplications1.HeadacheReasonfollowingduratap.Managementlyinginbed.liquidinfusion.sedative&analgesiaagents.epiduralbloodpatch.NeurologicinjuryReasonsPuncturetraumatospinalroot,nervefibersorspinalcord.nerveinjuryresultfromthedirecteffectoflocalanesthetics.ManagementPrevention.ConsulatationneurologicphysicianEpiduralhematomaReasonbleedingabnormalcoagulationordisorder・

puncturetrauma.bleedingManagementpost-operationpatientvisiting.chooseindicationpatient.perfectpuncturetechnique.EpiduralabscesslOminlOminlOminReasonspuncturesiteinfectious.lOminunsterilizedepiduralpack.practitionerunsterilizedperformance.Managementantibacterialagents.decompressionoflaminectomyIndicationsandcontraindicationsIndicationsoperationofchestwall.majorabdominaloperation.gynecologyandobstetrics.lowerextremitysurgeryurologicsurgery・ContraindicationslOminlOminlOminpatientrefusal.lOminlocalinfectionatthesiteofpuncture.severehemorrhageorshock.severehypovolemia.coagulopathyoranticoagulanttherapy.severecardiovasculardiseasespreexistingneurologicdiseasessepticemia.DifferentiationbetweenSpinal&EpiduralAnesthesiaEpiduralC-SepiduralLargeupper&lowerSinge&ContinuouswithcatheterEpiduralC-SepiduralLargeupper&lowerSinge&ContinuouswithcatheterSAB<L2subarachnoidsmallTransectionSingle小结思考题及预习预习.硬膜外麻醉与腰麻对身体的生理影响？小结思考题及预习预习.硬膜外麻醉与腰麻对身体的生理影响？.硬膜外麻醉与腰麻的相同点与不同点？.椎管内麻醉后头疼的机制与预防，处理。.椎管内麻醉的适应症与并发症。复合麻醉与联合麻醉.学习椎管内麻醉对身体的生理影响。.掌握腰麻的用药，麻醉平面的调节，并发症与适应证。腰麻后头痛的预防与处理。.掌握硬膜外麻醉的注药方法与意义。麻醉平面的调节。术中与术后并发症。全脊椎麻醉的预防与临床表现与处理。.熟悉腰麻与硬膜外麻醉的比较。教学内容辅助手段

时间分配多媒体

教学内容辅助手段

时间分配多媒体

lOmin多媒体

lOminIntrathecalAnesthesia多媒体

lOminIntrathecalanesthesia.Intrathecalanesthesiaresultinsympatheticblock,sensoryanalgesia,andmotorblock(dependingondose,concentration,orvolumeoflocalanesthetic)bylocalanestheticisinjectedintosubarachnoidspace(spinalanesthesia)ortheepiduralspace(epiduralanesthesia)andbathesthenerverootsinthesubarachnoidspaceorepiduralspace,respectivelyIntrathecalblockisdividedintotwoclassesSubarachnoidblock(spinalblock):Localanestheticisinjectedintosubarachnoidspace.Epiduralblock:Localanestheticisinjectedintotheepiduralspace.AnatomyVertebralcolumn7cervical(C),12thoracic(T),5lumbar(L),5sacral(S)fusedasthesacrum,4smallcoccygealvertebra(Co)thatformthecoccyxlOminVERTEBRAlOminThevertebralarchenclosesthevertebralforamen,eachvertebralarchhastwoparts,thatispedicle(root)andlamina.Pedicleshavelargenotchesontheirinferiorsurfaceandsmallernotchesontheirsuperiorsurface.Notchesfromadjacentvertebraeformintervertebralforamina,throughwhichnerverootsexitthespinalcolumn.Sacrum&Coccyx:Thesacralhiatusleadsintothesacralcanal,theinferiorendofthevertebralcanal.LigamentumofvertebralcolumnSupraspinousligamentInterspinousligamentLigamentumflavum(theyollowligament)SpinalcordspinalcordextendsfromtheforamenmagnumtothelevelofLIinadults.Theanteriorandposteriornerverootsateachspinalleveljoinoneanother.Caudaequina(horse'stail).

Spinalmeningesspinalcordspinalduramaterarachnoidmater■一spinalpiamaterSpinalspaceEpiduralspaceSubduralspaceSubarachnoidspaceSpinalnervesdermatomicdistributionT2manubriumofsternumT4-…nipplT6--xiphoidprocessT8-…betweenT6&T10T10…navelT12…pubicsymphysisPhysiologicEffectsofIntrathecalAnesthesiaNerveblockadesequenceSympathetic-sensory-motor-sheathednerve.DifferentialnerveblockadelevelSympatheticblockadethatmaybetwosegmentslevelhigherthanthesensoryblock,whichinturnistwosegmentshigherthanthemotorblockade.RespiratorysystemLowspinalblockorlowepiduralblockMotorblockadeextendingtotherootsofHighthoraciclevelblockadecancauseisamarkeddecreaseinvitalcapacity.CardiovascularsystemDecreasebloodpressure.ReductionincardiacoutputandcardiacRespiratorysystemLowspinalblockorlowepiduralblockMotorblockadeextendingtotherootsofHighthoraciclevelblockadecancauseisamarkeddecreaseinvitalcapacity.CardiovascularsystemDecreasebloodpressure.ReductionincardiacoutputandcardiacBradycardia.(blockT1-T4).GastrointestinalsystemIncreaseintestinalcontraction.Nausea,retchingorvomiting:hasnoeffectontherespiratorysystem,thephrenicnerves(C3-5)causesapnea,lossofintercostalmuscleactivity,therecontractility.lOmin(spinalblockorsubarachnoidblock,SAB)SABisatypeofregionalanesthesia,whichisachievedbyinjectingalocalanestheticintothelumbarsubarachnoidspace.ThetermforSABlevelBlocklevelhigherT4ishighlevelSABBlocklevellowerT10islowlevelSABBlockregiononlycovertheperineum&buttockissaddleblockBlockonlyoccurinunilaterallowerextremityisunilateralblock.lOminLocalanestheticsforSABSolutionbaricity:lOmin(ThespecificgravityofCSFis1.003-1.009at37℃.)HyperbaricsolutionAdditionofglucose5%or10%toalocalanestheticsolutionproducesasolutionwithspecificgravityof1.024orgreater,thissolutionisheavierthanCSF・AhypobaricsolutionLighterthanCSF,itcanbemadebythepowderanestheticplusofsterilewaterorthepureanestheticsolution.Anisobaric(plain)solution;AnestheticagentsaremixedwithCSF.Localanestheticsolution:(hyperbaricwithepinephrine)Procaine5%solution+5%glucose.Dosage:100-150mg.Duration:45-90minTetracaine1%solution1ml+10%glucose1ml+3%efedrina1mL(1+1+1solution).Dosage:10-12mg.Duration:120-240minBupivacaine0.75%solution+5-10%glucoseDosage:10-15mg.Duration:100-150minlOminlOminlOminVasoconstrictorsEpinephrine&phenylephrinelOminBothagentsappeartodecreasetheuptakeandclearanceoflocalanestheticsfromCSF.

Additionofvasoconstrictorsinlocalanestheticsolutioncanprolongthedurationofspinalanesthesia.Dosage:Epinephrine(0.1-0.2mg).Assessingblockadelevel:•Thesensorylevelofblockadecanbeassessedwithpinprickorice,thelevelofsympathectomyisassessedbymeasuringskintemperature.Thecompleteblockofmotornervesismanifestedinabilitytomovethelegsorfoot.FactorsaffectingspreadofhyperbaricspinalsolutionPatienfsposition"saddleblock^keepingthepatientsittingfor3-5minafterinjectionofl-2mlofhyperbaricsolution.lateralposition.^unilateralblockskeepingthepatientonDrugdosage&solutionvolume・lateralposition.3.4.5.Speedofinjection.Therateofinjectionis1ml/5sec.Lumberpuncturesite.Needlebeveldirection.SABlevelmanagement3.4.5.Speedofinjection.Therateofinjectionis1ml/5sec.Lumberpuncturesite.Needlebeveldirection.SABlevelmanagement(Hyperbaricsolution)ComplicationsofSAB1.HypotensionReasons:vesselsdilatation;increasedbloodpooling;decreasedreturntoheart.Cardiaccontractilitydecreased.bloodflowlOminAugmentedby:HypovolemiaChangesinpositionBradycardiaTreatmentfluidsPrevention:Useofcrystalloidorcolloid10-20ml/kgforvolumefluids10-20ml/kgforvolume10-20ml/kgforvolumeloadingpre-lumberpuncture.10-20ml/kgforvolumeIncreasefluidadministration.Maskoxygeninhale.Drug:Ephedrine10-15mgIV.Bradycardia

Reasons:blockthecardiacSpinalblocklevelhigherthanT4,whichmaysympatheticacceleratorfibers(Tl-T4),thenbradycardiamayoccur.blockthecardiacSABdoesnotblockthevagalnerve.Unopposedvagaltoneincreasedisanotherreasonforbradycardia.TreatmentAtropine0.25-0.5mgiv.Ephedrine15-30mgiv.NauseaandvomitingReasonsincreasedvagaltonehypotensionOperationexplorationHypoxemiaTreatment:CheckBP&HRlOminlOminlOminAtropine0.25-0.5mg.iv.lOminEphedrine15mg-30mg.iv.Maskoxygeninhale4.Headache(post-duralpunctureheadache,PDPH)Theincidencerateisabout20-30%.Headachemayoccurafterduralpuncture,presumablysecondarytothetearintheduraandthatresultfromdecreasedintracranialpressureasCSFleakfromtheduraldefect,whichmaycausetractiononthemeningesandcranialnerves.ClinicalcharacteristicsTheonsettimein12-72hours.persistforupto1-6weeks.Theheadacheisaggravatedbysittingorstanding.Relievedorlessenedbylyingdownflat.Travenousororalfluidadministration.epiduralbloodpatchtreatmentlOminlOminlOminasalinebolusepiduralspaceinjectionsedative&analgesicagentlOminUrinaryretentionReasons

BlockofS2-S4rootfibersdecreasesurinarybladdertoneandinhibitsthevoidingreflex.Associatedwiththesurgicalprocedure.Urinaryretentionisusuallytemporary.Persistentbladderdysfunctionmaybeaseriousneuralinjury.Treatment:aurethralcatheterinsertedNeurologiccomplicationsCaudaequinasyndromeMeningitisArachnoiditisCranialnervepalsyIndications&ContraindicationsIndicationslowerabdomenoperation.perineumoperation.lowerlimbsoperation.ContraindicationsInfectionatthesiteofpuncture.Bleedingdiathesisorcoagulopathy.Severehypovolemia.Severecardiovasculardiseases.Severespinaldeformity.Preexistingneurologicdiseases.lOminIntracranialhighpressureEpiduralAnesthesiaConceptlOminEpiduralanesthesiaisachievedbyinjectingalocalanestheticintotheepiduralspace,whichblocksthespinalnerveroots,producingregionalanesthesia.Epiduralblockmethodsasingle-shotinjectivetechniques.acontinuousinfusion&intermittentbolustechniques.lOmin“Acatheterinserttotheepiduralspaceforcontinuousinfusionorintermittentbolusinjection.”EpiduralanestheticagentslOminLidocaine

short-tointermediate-actingagent.concentrationof1.5-2.0%withadrenaline1:200,000.anesthesiaduration90-150min.totaldosagelimited400mginadult.Bupivacainelong-actinglocalanesthetic.usedin0.5%or0.75%withadrenalin1:200,000.onsettimeis10-15min・durationisabout200-260min.dosagelimited150mginadult.3.RopivacainenewamidelocalanestheticwithalesscardiactoxicitythanbupivacainelOminslowonsettimeandlonganesthesiaduration.lOminuse0.5%or0.75%withl:200,000orwithoutadrenalin.Dosagelimited150-200mginadultAdministrationoflocalanestheticThequantityoflocalanestheticneedforepiduralanesthesiaisrelativelylargercomparedwithspinalanesthesia.Significanttoxicitycanoccurifthisamountofanestheticisinjectedsubarachnoidspaceorintravascular.Safeguardsaretheepiduraltestdoseandincrementaldosing(ormaindose).TestdoseAim:todetectwhethersubarachnoidinjectiontodetectwhetherintravascularinjectionMethod:3-4mlof2%lidocainewith1:200,000epinephrine(5ug/ml)isinjectedtoepiduralspace,ifinjectedintosubarachnoidspace,thatwillproducespinalanesthesiarapidly.The15ug-20ugofepinephrine,ifinjectedintravascularly,anoticeableincreaseinheartrateproduced.IncrementaldoseIncrementaldoseisaveryeffectivemethodofavoidingseriouscomplication.After5minoftestdosegiven,thereisnosystemtoxicity&nosignsofspinalanesthesiaoccursthentheincrementaldosecanbeinjectedintoepiduralspace.FactorsaffectingblockinglevelofanesthesiaVolume:inadults,1-2mloflocalanestheticpersegmenttobeblockedisagenerallyacceptedguideline