外科学课件：椎管内麻醉

NeuraxialAnesthesia

椎管内麻醉NeuraxialAnesthesia

椎管内麻醉BriefSpinal,epidural,andcaudalneuraxialblocksresultinsympatheticblockade,sensoryanalgesia,oranesthesiaandmotorblockade,dependingonthedose,concentration,orvolumeoflocalanesthetic,afterinsertionofaneedleintheplaneoftheneuraxis.——Miller’sAnesthesiaBriefSpinal,epidural,andcauBriefSpinalAnesthesia蛛网膜下腔麻醉(简称脊麻)EpiduralAnesthesia硬膜外麻醉CaudalAnesthesia

骶管麻醉CombinedSpinalandEpiduralAnesthesia

联合阻滞BriefSpinalAnesthesiaIndicationsSurgicalprocedurecanbeaccomplishedwithasensorylevelofanesthesiathatdoesnotproduceadversepatientoutcomes.最基本适应证：足够保证外科操作的麻醉平面不产生有害结果IndicationsSurgicalprocedureContraindicationsAbsoluteLocalizedinfectionatskinpuncturesite.Generalizedsepsis.CoagulopathyIncreasedintracranialpressure.RelativeHypovolemia.Centralnervoussystemdisease.Chronicbackpain.ContraindicationsAbsoluteRelatSegmentalLevelRequiredforSurgerySkindermatomescorrespondingtorespectivesensoryinnervationbyspinalnerves.SegmentalLevelRequiredforSSegmentalLevelRequiredforSurgeryOperativeSiteLevelLowerextremitiesT12HipT10Vagina,uterusT10Bladder,prostateT10LowerextremitieswithtourniquetT8Testis,ovariesT8LowerintraabdominalT6OtherintraabdominalT4SuggestedminimumcutaneouslevelsforspinalanesthesiaSegmentalLevelRequiredforSAnatomySpinecurve(supineposition)Highest:C3andL3Lowest:T5andS4AnatomySpinecurve(supineposAnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮肤→皮下组织→棘上韧带→棘间韧带→黄韧带→硬膜外腔→硬脊膜和蛛网膜→蛛网膜下腔）AnatomySkin→subcutaneoustiAnatomySpinalcordends:Adult:atL1-2.Newborn:ataboutL3By2yrsofage:nearL1AnatomySpinalcordends:AnatomyThreeinterlaminarligamentsbindthevertebralprocessestogetherSupraspinousligament棘上韧带Interspinousligament

棘间韧带Ligamentumflavum黄韧带，阻力增加AnatomyThreeinterlaminarligAnatomySpinalcordisinvestedinthreemeningesDuramater（硬脊膜）Arachnoid（蛛网膜）Piamater（软脊膜）AnatomySpinalcordisinvesteAnatomyCSF（脑脊液）Totalvolume:120~150mLSpinalsubarachnoidspace:25~30mLpH7.35Specificgravity1.003~1.009AnatomyCSF（脑脊液）AnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮肤→皮下组织→棘上韧带→棘间韧带→黄韧带→硬膜外腔→硬脊膜和蛛网膜→蛛网膜下腔）AnatomySkin→subcutaneoustiAnatomyEpiduralspacecontainsNerverootsbloodvesselsFatConnectivetissueAnatomyEpiduralspacecontainAnatomy—CaudalSacralsurfaceanatomy.Anequilateraltrianglecanbedrawntoconnecttheposteriorsuperioriliacspinesandthesacralhiatus.Itcanbeusefulinconfirmingpalpationofthesacralhiatus(骶裂孔).Anatomy—CaudalSacralsurfacePhysiologyNeuralblockadeEasilyblockedautonomicfibers—sensoryfibers—motorfibersLevelofblockadeautonomicblockadeextendsabovesensoryblockadeby2~4segmentssensoryblockadeextendsabovemotorblockadeby1~4segmentsPhysiologyNeuralblockadePhysiologyEpiduralneuralblockadeLocalanestheticplacedintheepiduralspaceactsdirectlyonthespinalnerveroots（脊神经根）

locatedinthelateralpartofthespace.Theonsetoftheblockisslowerthanwithspinalanesthesia,andtheintensityofthesensoryandmotorblockisless.PhysiologyEpiduralneuralblocPhysiologyCardiovascular（交感神经被阻滞）Hypotension

：sympatheticblockadeRiskfactorsforbradycardiabaselinebradycardiauseofbetablockersage<50sensorylevelaboveT-6PhysiologyCardiovascular（交感神经被PhysiologyRespiratoryPhrenicnerve（膈神经）:C3~C5UsuallyaspinallevelofT4doesnotresultinimpairedventilation,butrespiratorycompromisemayhappeninpatientswithlimitedrespiratoryreserveorhigherspinallevels.PhysiologyRespiratoryTechnique—SpinalAnesthesiaSpinalneedle

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

正入法

Midlineapproach

侧入法

（少用）

Paramedianapproaches

避开钙化韧带Technique—SpinalAnesthesiaTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaDeterminantsoflevelofspinalblockadeControllableFactorsDose(volume×concentration)（剂量）Siteofinjectionalongtheneuraxis（穿刺点）Baricityofthelocalanestheticsolution（比重）Postureofthepatient（体位）FactorsNotControllableVolumeofcerebrospinalfluidDensityofcerebrospinalfluidTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaBaricityoflocalanestheticsolution

局麻药的比重Localanestheticsolutionscanbedescribedashyperbaric（重比重）,hypobaric（轻比重）,orisobaric（等比重）

inrelationtothespecificgravityofCSF(1.003~1.009).Technique—SpinalAnesthesiaTechnique—EpiduralAnesthesiaEpiduralneedles18GHustead17GTuohyTechnique—EpiduralAnesthesiTechnique—EpiduralAnesthesiaApproaches胸段：棘突叠瓦状腰段：棘突较平行Technique—EpiduralAnesthesiTechnique—EpiduralAnesthesia进入硬膜外腔的判断阻力消失法（loss-of-resistance）悬滴法（hanging-drop）通常置入硬膜外管2.5-5cmTechnique—EpiduralAnesthesiTechnique—EpiduralAnesthesia试验剂量判断导管位置是否在硬膜外腔？是否入血？了解局麻药物扩散情况药物剂量身高注药速度硬膜外腔通畅性（年龄、怀孕、既往麻醉史）粘连、静脉充盈、结缔组织Technique—EpiduralAnesthesiTechnique—Combinedspinal-epiduralanesthesia（脊麻-硬膜外联合阻滞）优点：起效快效果确切可连续给药术后镇痛Technique—Combinedspinal-epComplications—SpinalAnesthesiaNeurologicPostduralpunctureheadache（硬膜穿破后头痛）

Caudaequinasyndrome（马尾综合征）Neurologicinjury（神经损伤）CardiovascularHypotensionBradycardiaComplications—SpinalAnestheComplications—SpinalAnesthesiaRespiratoryDyspnea/ApneaUrinaryretentionNauseaandvomitingInfectionComplications—SpinalAnestheComplications—EpiduralAnesthesiaUnintentionalsubarachnoidinjectionTotalspinalanesthesia（全脊髓麻醉）Intravascularinjection

（血管内注射，局麻药中毒）PostduralpunctureheadacheDirectspinalcordinjuryEpiduralhematoma(硬膜外血肿）EpiduralabscessComplications—EpiduralAnestPostduralpunctureheadache

（硬膜穿破后头痛）保守治疗卧床休息，平卧位补液（静脉或口服）镇痛药（非甾体类抗炎药）咖啡因，茶碱硬膜外血补丁(EpiduralBloodPatch)Postduralpunctureheadache

（硬Intravascularinjection

（血管内注射，局麻药中毒）CNS：头晕、耳鸣、口舌麻痹、意识障碍、抽搐、昏迷CVS：传导障碍、心肌抑制、血管扩张RS:

呼吸暂停Intravascularinjection

（血管内预防血管内注射给药前回抽！只使用推荐剂量控制药物浓度控制给药速度注意观察病人：早期发现！预防血管内注射给药前回抽！治疗血管内注射CPR进一步呼吸循环支持治疗血管内注射CPREpiduralhematoma(硬膜外血肿）高危人群（凝血功能异常）血小板数目、功能异常凝血因子异常穿刺不顺利，粗暴预防询问用药史、相关症状实验室检查（血小板数目和凝集，PT，INR）补充凝血因子、血小板Epiduralhematoma(硬膜外血肿）高危人群（Epiduralhematoma(硬膜外血肿）及时发现：腰痛马尾综合症相应部位感觉运动异常影像学确诊尽快手术减压Epiduralhematoma(硬膜外血肿）及时发现：ReferenceMiller’sAnesthesia,7thedition.ClinicalAnesthesiaProceduresoftheMassachusettsGeneralHospital,7thEdition.《现代麻醉学》.第三版.ReferenceMiller’sAnesthesia,NeuraxialAnesthesia

椎管内麻醉NeuraxialAnesthesia

椎管内麻醉BriefSpinal,epidural,andcaudalneuraxialblocksresultinsympatheticblockade,sensoryanalgesia,oranesthesiaandmotorblockade,dependingonthedose,concentration,orvolumeoflocalanesthetic,afterinsertionofaneedleintheplaneoftheneuraxis.——Miller’sAnesthesiaBriefSpinal,epidural,andcauBriefSpinalAnesthesia蛛网膜下腔麻醉(简称脊麻)EpiduralAnesthesia硬膜外麻醉CaudalAnesthesia

骶管麻醉CombinedSpinalandEpiduralAnesthesia

联合阻滞BriefSpinalAnesthesiaIndicationsSurgicalprocedurecanbeaccomplishedwithasensorylevelofanesthesiathatdoesnotproduceadversepatientoutcomes.最基本适应证：足够保证外科操作的麻醉平面不产生有害结果IndicationsSurgicalprocedureContraindicationsAbsoluteLocalizedinfectionatskinpuncturesite.Generalizedsepsis.CoagulopathyIncreasedintracranialpressure.RelativeHypovolemia.Centralnervoussystemdisease.Chronicbackpain.ContraindicationsAbsoluteRelatSegmentalLevelRequiredforSurgerySkindermatomescorrespondingtorespectivesensoryinnervationbyspinalnerves.SegmentalLevelRequiredforSSegmentalLevelRequiredforSurgeryOperativeSiteLevelLowerextremitiesT12HipT10Vagina,uterusT10Bladder,prostateT10LowerextremitieswithtourniquetT8Testis,ovariesT8LowerintraabdominalT6OtherintraabdominalT4SuggestedminimumcutaneouslevelsforspinalanesthesiaSegmentalLevelRequiredforSAnatomySpinecurve(supineposition)Highest:C3andL3Lowest:T5andS4AnatomySpinecurve(supineposAnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮肤→皮下组织→棘上韧带→棘间韧带→黄韧带→硬膜外腔→硬脊膜和蛛网膜→蛛网膜下腔）AnatomySkin→subcutaneoustiAnatomySpinalcordends:Adult:atL1-2.Newborn:ataboutL3By2yrsofage:nearL1AnatomySpinalcordends:AnatomyThreeinterlaminarligamentsbindthevertebralprocessestogetherSupraspinousligament棘上韧带Interspinousligament

棘间韧带Ligamentumflavum黄韧带，阻力增加AnatomyThreeinterlaminarligAnatomySpinalcordisinvestedinthreemeningesDuramater（硬脊膜）Arachnoid（蛛网膜）Piamater（软脊膜）AnatomySpinalcordisinvesteAnatomyCSF（脑脊液）Totalvolume:120~150mLSpinalsubarachnoidspace:25~30mLpH7.35Specificgravity1.003~1.009AnatomyCSF（脑脊液）AnatomySkin→subcutaneoustissue→supraspinousligament→interspinousligament→ligamentumflavum→epiduralspace→duramaterandarachnoid→subarachnoidspace

（皮肤→皮下组织→棘上韧带→棘间韧带→黄韧带→硬膜外腔→硬脊膜和蛛网膜→蛛网膜下腔）AnatomySkin→subcutaneoustiAnatomyEpiduralspacecontainsNerverootsbloodvesselsFatConnectivetissueAnatomyEpiduralspacecontainAnatomy—CaudalSacralsurfaceanatomy.Anequilateraltrianglecanbedrawntoconnecttheposteriorsuperioriliacspinesandthesacralhiatus.Itcanbeusefulinconfirmingpalpationofthesacralhiatus(骶裂孔).Anatomy—CaudalSacralsurfacePhysiologyNeuralblockadeEasilyblockedautonomicfibers—sensoryfibers—motorfibersLevelofblockadeautonomicblockadeextendsabovesensoryblockadeby2~4segmentssensoryblockadeextendsabovemotorblockadeby1~4segmentsPhysiologyNeuralblockadePhysiologyEpiduralneuralblockadeLocalanestheticplacedintheepiduralspaceactsdirectlyonthespinalnerveroots（脊神经根）

locatedinthelateralpartofthespace.Theonsetoftheblockisslowerthanwithspinalanesthesia,andtheintensityofthesensoryandmotorblockisless.PhysiologyEpiduralneuralblocPhysiologyCardiovascular（交感神经被阻滞）Hypotension

：sympatheticblockadeRiskfactorsforbradycardiabaselinebradycardiauseofbetablockersage<50sensorylevelaboveT-6PhysiologyCardiovascular（交感神经被PhysiologyRespiratoryPhrenicnerve（膈神经）:C3~C5UsuallyaspinallevelofT4doesnotresultinimpairedventilation,butrespiratorycompromisemayhappeninpatientswithlimitedrespiratoryreserveorhigherspinallevels.PhysiologyRespiratoryTechnique—SpinalAnesthesiaSpinalneedle

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

正入法

Midlineapproach

侧入法

（少用）

Paramedianapproaches

避开钙化韧带Technique—SpinalAnesthesiaTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaDeterminantsoflevelofspinalblockadeControllableFactorsDose(volume×concentration)（剂量）Siteofinjectionalongtheneuraxis（穿刺点）Baricityofthelocalanestheticsolution（比重）Postureofthepatient（体位）FactorsNotControllableVolumeofcerebrospinalfluidDensityofcerebrospinalfluidTechnique—SpinalAnesthesiaTechnique—SpinalAnesthesiaBaricityoflocalanestheticsolution

局麻药的比重Localanestheticsolutionscanbedescribedashyperbaric（重比重）,hypobaric（轻比重）,orisobaric（等比重）

inrelationtothespecificgravityofCSF(1.003~1.009).Technique—SpinalAnesthesiaTechnique—EpiduralAnesthesiaEpiduralneedles18GHustead17GTuohyTechnique—EpiduralAnesthesiTechnique—EpiduralAnesthesiaApproaches胸段：棘突叠瓦状腰段：棘突较平行Technique—EpiduralAnesthesiTechnique—EpiduralAnesthesia进入硬膜外腔的判断阻力消失法（loss-of-resistance）悬滴法（hanging-drop）通常置入硬膜外管2.5-5cmTechnique—EpiduralAnesthesiTechnique—EpiduralAnesthesia试验剂量判断导管位置是否在硬膜外腔？是否入血？了解局麻药物扩散情况药物剂量身高注药速度硬膜外腔通畅性（年龄、怀孕、既往麻醉史）粘连、静脉充盈、结缔组织Technique—EpiduralAnesthesiTechnique—Combinedspinal-epiduralanesthesia（