1、Zhang LanDepartment of Anesthesiology of West China HospitalRegional Anesthesia Clinical Anesthesia General AnesthesiaRegionalAnesthesiaTopical anesthesiaPeripheral nerve blockLocal infiltration anesthesiaSpinal&Epidural Anesthesia一、一、Nerve BlocksDrug-Local anestheticsServer complication-the toxicit
2、y of LAAnatomy and TechniqueLOCAL ANESTHETICS(LA)十八世纪中，人们咀嚼十八世纪中，人们咀嚼古柯叶古柯叶感受舒适感和增加耐力感受舒适感和增加耐力18601860年，从古柯叶中发现了可卡因年，从古柯叶中发现了可卡因18841884年，可卡因先后用于眼部局麻手术、颌神经阻滞、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脊髓麻醉、硬膜外麻醉和蛛网膜下腔阻滞麻醉19051905年发现年发现普鲁卡因、丁卡因、利多卡因、普鲁卡因、丁卡因、利多卡因、布比卡因布比卡因等，可卡因因其成瘾性高和安全性等，可卡因因其成瘾性高和安全
3、性低而被淘汰。低而被淘汰。Lidocaine BupivacaineRopivavaineProcaineTetracaine酰胺类局麻药酰胺类局麻药酯类局麻药酯类局麻药extremely stablerelatively unstablehydrolyzed in plasmaby the cholinesteraseenzymesundergo enzymatic degradation in the liverChemical stabilityBiotransformationLidocaine利多卡因利多卡因 Bupivacaine布比卡因布比卡因Ropivavaine罗派卡因罗派卡
4、因Procaine普鲁卡因普鲁卡因Tetracaine的卡因的卡因Local anesthetics of Peripheral nerve blockDrug dose concentration durationRopivacaine 150200mg 0.20.5%612h Bupivacaine 150mg 0.20.5%612hLidocaine 400mg 0.51%13hThe toxicity of Local anesthetics wOverdosewIntravascular injectionwRapid systemic absorption of local ane
5、sthetic from rich blood supply areawPatient statusCNS ExcitationCNS DepressionDizzinessTinnitus Feelings of drowsinessMuscle TwitchingConsciousnessConvulsionsRespiratory DepressionRespiratory ArrestCentral Nervous System ToxicityCNS Conduction PathwaysInhibitory PathwaysExcitatoryPathwaysLACNS Excit
6、ationCNS Depression BP Heart rate Cardiac ArrestCardiovascular System ToxicityBP Heart rateCardiovascular SystemexcitationCardiovascular SystemdepressionDirect Cardiac EffectsDirect Peripheral Vascular EffectsNegative inotropic actionFastconducting tissues Highconcentrations vasodilation.Low concent
7、rationsvasoconstrictionCardiovascular SystemdepressionLA CNS excitationCardiovascular Systemexcitation Excessive doses of LA Systemic absorption of LA intravascular injection of LA Test doses of LA Premedication Prevention Incipient toxic reactions:Stop administering LA,ventilation support CNS excit
8、ation:Sedativetreatment,Benzodiazepine Convulsion Thiopental:therapy Convulsion Succinylcholine:Intubation maintaining adequate ventilation Cardiovascular System depression:supported by using IV fluids and vasopressors Cardiac arrest:Cardiopulmonary resuscitationTreatmentAnatomy and TechniqueUpper e
9、xtremity 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 Brachial plexus blockade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Interscalene BlockInter
10、scalene BlockThe block can be performed with the patients hand,arm,upper arm,shoulder and clavicle surgeryThe ulnar nerve blockade is often incompletelow risk of pneumothoraxLA solution into the epidural and subarachnoid spacesAxillary BlockAxillary Block No pneumothorax Axillary block is unsuitable
11、 for surgical procedures on the upper arm or shoulder Supraclavicular BlockSupraclavicular Block The block can be performed with the patients arm in any position Provide excellent anesthesia for elbow,forearm,and hand surgery high risk of pneumothoraxLower extremity blocks-Lumbar Plexus Nerve Blocks
12、 Sciatic Nerve Blocks Femoral Nerve Blocks The major branches of Lumbar Plexus:Femoral nerve Lateral femoral cutaneous nerve Obturator nerve Saphenous nerveThe sciatic nerveLumbar Plexus Nerve BlocksComplications Hematoma-Avoid multiple needle insertions,particularly in anticoagulated patientsVascul
13、ar puncture Local anesthetic toxicity Total Spinal Anesthesia Sciatic Nerve BlocksSurface landmarks Complications Hematoma:Avoid multiple needle insertions,particularly in anticoagulated patients Local anesthetic toxicityFemoral Nerve BlocksVAN:VeinArteryNerveComplications Vascular Puncture Nerve In
14、jury Local anesthetic toxicity二、二、Spinal&Epidural Anesthesia Anatomy Technique Factors affecting blocking region Complication Indications&ContraindicationsANATOMYSubarachnoid space-Spinal AnesthesiaEpidural space-Epidural AnesthesiaTECHNIQUESpinal anesthesia:L3L4,or L4L5 spacesSpinal anesthesia Volu
15、meRate of injectionDensity of LA PatientpositionEpidural anesthesiaPuncture SiteVolumeRate of injectionFactors affecting blocking regionFactors affecting blocking region Spinal anesthesia Volume Rate of injection Density of LA Patient positionEpidural anesthesiaPuncture SiteVolumeRate of injectionCo
16、mplicationImportant complicationsSevere hypotension The toxicity of LA Total spinal anesthesia Headache after anesthesiaNerve injury Spinal&Epidural AnesthesiaSympathetic blockvagus nerve surgery operationvasodilatation1.HypotensionSensoryanalgesiaMotor blockCirculating blood volumeHeartrateSever hy
17、potensionThe incidence and severity of hypotensionare related to:Level of the block Physical status of the patientIV fluids Treatment:Fluid InfusionEphedrine Administration,5 to 10 mg IV.Atropine,0.3 to 0.5mg IV Severe hypotension HypoxiaUnconsciousnessCardiac arrestMost spinal never were blocked2.T
18、otal Spinal AnesthesiaEpidural puncture needle or catheter in the subarachnoid space Confirm the catheter is in epidural space before LA injection Test doses of local anesthetics must be used The patient must be monitored carefully during the processMaintainingAdequate ventilationTracheal intubation
19、 mechanical ventilationMaintaining stablehemodynamic statusIV fluid Atropine Ephedrine Cardiopulmonary resuscitation(CPR)AgeYounger more frequentGenderFemales malesNeedle sizeLarger smallerNo.dural puncturesMore with multiple puncturesTreatmentBed rest Analgesics Hydration Wearing of a tight abdomin
20、al binder Increases epidural pressure Decreases the amount of leaking CSF.5.Nerve injury Epidural hematoma Epidural abscess Spinal never root trauma:pressure on the cord or spinal roots by a needle point produces excruciating pain Adhesive arachnoiditisIndications&ContraindicationsIndicationsSpinal
21、anesthesia：Operation time is 2-3hcoeliac,lower limbs,perineal operationEpidural anesthesia:abdominal,neck,limbs operationcoeliac,lower limbs,perineal operationContraindications Patient refusal Coagulopathy Skin or soft tissue infection at the proposed site of needle insertion Severe hypovolemia Pree
22、xisting neurologic disease Lack of anesthesiologist experienceBLOOD TRANSFUSION Indications for Transfusion Complication of transfusion Autologous transfusionIncreasing vascular volume Supply RBCIncreasing PlasmaalbumenIncreasing coagulation factorsAcute AnaemiaDysfunction of coagulationSerious infe
23、ctionChronic Anaemiaincrease oxygen-carrying capacity Blood transfusionsincrease blood volumeIV Fluid Acute AnaemiaHb 100 g/L Transfusion is rarely Hb 100g/L Transfusion is rarely indicated Hb 70g/L TransfusionHb 70100g/L Transfusion should be based on the patients risk for complications of inadequa
24、t oxygenation Transfus Med Rev.2002 Jul;16(3):187-99.Transfusion triggers:a systematic review of the literature USA输血输血指征：文献的系统回忆指征：文献的系统回忆 检索了检索了OVID MedlineOVID Medline数据库，近期期刊目录库，数据库，近期期刊目录库，CochraneCochrane数据数据库，和已发表文献目录。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。受影响。结论
25、：在有限的已经发表的证据支持在不合并严重心脏疾病的结论：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采用限制性输血。患者中采用限制性输血。Crit Care.2007 Jun 19;11(3):142 Transfusion 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？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在稳定的危重病患儿采用以70g/L血色素为输血底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。限的限制输血方法能减少用血而不影响预
26、后。该研究证实，该研究证实，试图通过输试图通过输RBC来提高组织氧供是没来提高组织氧供是没有多大临床优势的有多大临床优势的。Complication of transfusionImmunoreactionNon-immunoreactionHemolytic transfusion reactionAllergic reactionsNonhemolytic transfusion reactions Fever reactionsAcute Hemolytic Transfusion ReactionDelay Hemolytic Transfusion ReactionTransfusi
27、on-Induced Immuno-depressionTransfusion-Related Acute Lung InjuryImmunoreactionAcute hemolytic transfusion reaction A 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 bloodSigns and S
28、ymptoms The classic signs and symptoms chills feverchest or flank pain nauseaThe signs in general anesthesiableeding hypotension hemoglobinuriaDelayed hemolytic transfusion reaction unexplained fever and anaemia 7 to 14 days after a transfusion Rh-incompatible rarely deathNon-immunoreactionHepatitis
29、 In the 1940s,viral hepatitis was recognized as a major complication of transfusion.Now,the incidence of posttransfusion hepatitis B has dramatically decreased.90%posttransfusion hepatitis is caused by the hepatitis C virus.Acquired Immunodeficiency Syndrome AIDS is most frequently transmitted by in
30、timate homosexual contact and intravenous drug abuse Whole blood,plasma,blood cellular products,or clotting factors can transmit AIDS.The antibodies of the AIDS virus(human immunodeficiency virus type 1 HIV-1)has dramatically reduced the incidence of transfusion-transmitted AIDS.Preoperative autolog
31、ous blood donation(PABD)Acute normovolemic hemodilutionIntraoperation&postoperation blood recoveryAutologous Transfusion References 外科学外科学7年制规划教材年制规划教材 2002年第一版年第一版 ANESTHESIA(Miller)2000 Fifth Edition重点掌握重点掌握 常用局部麻醉药的平安剂量及极量常用局部麻醉药的平安剂量及极量 局部麻醉药毒性反响的临床表现、预防及处理局部麻醉药毒性反响的临床表现、预防及处理 全脊椎麻醉的临床表现、预防及处理全脊椎麻醉的临床表现、预防及处理 臂丛神经阻滞的几种入路的优缺点及可能出现的并发症？臂丛神经阻滞的几种入路的优缺点及可能出现的并发症？输血的适应症输血的适应症
