上海交大医学院仁济临床医学院
五年制、七年制
上海交大医学院仁济临床医学院麻醉科
黄貞玲、何振洲
Intrathecal Anesthesia (椎管内麻醉)
掌握：
1. 全脊麻定义及其治疗方法。
2. 脊麻麻醉平面的调节
熟悉：
1. 脊麻的并发症
2. 脊麻适应症及禁忌症
了解：
1. 硬膜外阻滞并发症
2. 脊麻-硬膜外联合
重点：1. 全脊麻定义及其治疗方法。
2. 脊麻麻醉平面的调节
难点：椎管解剖和生理
Topics
I Intrathecal Anatomy and physiology (椎管解剖和生理)
II Spinal Anesthesia (蛛网膜下阻滞)
III Epidural Anesthesia (硬膜外阻滞)
IV Combined Spinal-epidural? (脊麻-硬膜外联合)
V Combined general-epidural? (全麻-硬膜外联合)
椎管内麻醉定义：将局麻药注入椎管的蛛网膜下腔或硬膜外腔,脊神经根受到阻滞或暂时麻痹使该脊神经所支配的相应区域产生麻醉作用
Similarities: sympathetic block, sensory analgesia, motor block
Differences: physiologic and pharmacology
I Intrathecal anatomy and? physiology
1. Anatomy
(1)Vertebral column (vertebrarium)(脊柱) ?(2)Vertebra (脊椎) ?(3)Ligament (韧带) (4)Spinal cord(脊髓) (5)Three memberanes (脊膜)
2. Physiology
(1)Spinal canal (2)Epidual space (3)Spinal nerve roots
II. Spinal Anesthesia
定义:局麻药注入蛛网膜下腔产生的阻滞作用,称为蛛网膜下腔阻滞,又称脊麻或腰麻。
1. Physiology
2. Technique: (1) Position:lateral Puncture site :L3-4, L4-5
Puncture approach:midline(正中) paramedian(正中旁的)
Identification of spinal canal- escape of CSF
(2)Factors influencing distribution of local anesthetics in cerebrospinal fluid
- Patient characteristics: Age, height, weight, position
- Technique of injection: Site and rate of injection, Direction of needle
- Characteristics of anesthetic solutin: Amount of anesthetic, concentration of anesthetic, volume injected, addition of vasoconstrictors
3. Clinical use of local anesthetics for spinal anesthesia
4.Indication
1)Lower abdominal surgery 2)Gynecologic surgery 3) Obstetric surgery 4)Herniorrhaphies 5) Lower limb surgery 6) Urologic surgery 7) Perineal and rectal surgery
5.Contraindication
1) Patient refusal 2) Uncorrected hypovolemia 3) Uncorrected coagulopathy 4) Bacteremia Infection at lumbar puncture site 5) Anatomic abnormalities that makelumbar puncture impossible 6) Elevated intracranial pressure 7) Certain neurologic disorders
6.Complications
1) Arterial hypotension and its management 2) Postdural puncture headache
treatment: A. analgetic therapy, bedrest and hydration; B. epidural saline infusion; C.epidural blood patch
3) Extensive spread of spinal anesthesia? 4) Backache? 5) Nausea and vomiting
6) The failed spinal 7) Major neurologic sequelae
III. Epidural Anesthesia
定义：局麻药注入硬脊膜外所产生的阻滞作用称为硬膜外阻滞
1. Physiology
2. Technique
(1) Puncture site, Puncture approach: midline(正中) or paramedian(正中旁的)
Identification of epidural space: loss of resistance
(2) Factors influence the sensory level of anesthesia: site; catheter placement and volume of local anesthetics; ?patient position and condition
3. Drugs :1) Local anesthetics 2) Epidural opioids – postoperative pain 3) Test doses rule out intravascular or subarachnoid injection
4. Caudal anesthesia
5. Indication
6. Contraindication
7. Complications
1) local anesthetic toxicity
2) unintentional subarachnoid injection
- reason
- signs and symptoms: dyspnea à respiratory arrest hypotension à cardiac arrest
- management: vasopressor, endotracheal intubation; positive pressure ventilation
- prevention: use of adequate test dose; pumpback repeatly
3) unintentional subdural injection
4) postdural puncture headache
5) neurologic damage
8. Epidural versus spinal anesthesia
IV. Combined spinal-epidural Anesthesia
定义：将脊麻和硬膜外两种技术同时应用以增强麻醉效果，称脊麻-硬膜外联合阻滞
TV. Combined general anesthesia with epidural Anesthesia
定义：将全麻和硬膜外两种技术同时应用以增强麻醉效果，称全麻-硬膜外联合阻滞
Questions
1.Complication of spinal anesthesia
2.Factors influencing the sensory distribution of spinalanesthesia
3.Indication and Contraindication of spinal anesthesia
4.Definication and treatment of totol anesthesia
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