1、 脊柱手术的麻醉脊柱手术的麻醉椎间盘问题椎间盘问题 脊椎滑脱脊椎滑脱需要手术治疗的脊柱问题需要手术治疗的脊柱问题 椎管狭窄椎管狭窄脊柱侧凸脊柱侧凸驼背驼背脊髓肿瘤脊髓肿瘤需要手术治疗的脊柱问题需要手术治疗的脊柱问题硬膜外血肿和脓肿硬膜外血肿和脓肿,外伤外伤手术操作手术操作椎板切开术椎板切开术椎板切除术椎板切除术椎间盘摘除术椎间盘摘除术手术操作手术操作融合和固定融合和固定内固定术内固定术术前评估术前评估 气道评估气道评估:张口度张口度 是否有困难插管史是否有困难插管史 头颈活动度头颈活动度 颈椎的稳定性颈椎的稳定性 与外科医生沟通是必须的与外科医生沟通是必须的麻醉注意事项麻醉注意事项呼吸系统呼吸
2、系统 病史病史:关注肺功能是否有损害关注肺功能是否有损害 体检体检:肺部感染的体征；肺部感染的体征；严重的脊柱畸形严重的脊柱畸形 胸部胸部X X线线 肺功能检查肺功能检查:脊柱侧凸脊柱侧凸 血气分析血气分析心血管系统心血管系统 病史病史:高血压高血压,糖尿病糖尿病,充血性心力衰竭充血性心力衰竭,冠心病冠心病 体检体检:充血性心力衰竭体征充血性心力衰竭体征 心电图心电图 应激试验应激试验/心超心超 实验室检查（推荐）实验室检查（推荐）基本检查基本检查 可选检查可选检查气道气道 颈椎侧位片颈椎侧位片 CT CT 扫描扫描 肺部肺部 胸片胸片 肺功能检查肺功能检查 血气分析血气分析 (支气管扩张试验
3、支气管扩张试验)肺功能检查肺功能检查 (FEV1,FVC)(FEV1,FVC)肺弥肺弥散功能检查散功能检查心血管心血管 心电图心电图 多巴酚丁胺应激多巴酚丁胺应激 EchoEcho 超声心动图超声心动图 潘生丁潘生丁/铊铊 扫描图扫描图血液检查血液检查 CBC,electrolytes,Cr CBC,electrolytes,Cr 肝功能检查肝功能检查 BUN,PT/PTT BUN,PT/PTT Albumin,calcium(Albumin,calcium(肿瘤疾病肿瘤疾病)神经系统评估神经系统评估整个神经系统评估都应记录在案整个神经系统评估都应记录在案1.1.颈椎手术的病人颈椎手术的病人,
4、麻醉科医生有责任在插管和放置体位时避免进一步麻醉科医生有责任在插管和放置体位时避免进一步的损伤的损伤2.2.肌肉萎缩增加术后反流误吸的风险肌肉萎缩增加术后反流误吸的风险 3.3.脊髓损伤的程度和时间与围术期出现心血管和呼吸系统功能紊乱密切相脊髓损伤的程度和时间与围术期出现心血管和呼吸系统功能紊乱密切相关（小于关（小于 3 3 周周,脊髓休克症状仍可出现；脊髓休克症状仍可出现；3 3周后可能出现自主神经反周后可能出现自主神经反射失调射失调麻醉技巧麻醉技巧诱导诱导:麻醉诱导的选择麻醉诱导的选择:i.v.or inhalation?i.v.or inhalation?病人的医疗状况病人的医疗状况 气
5、道气道 颈椎稳定性颈椎稳定性 肌松药的选择肌松药的选择:Succinylcholine or NDNMBs?Succinylcholine or NDNMBs?病人的医疗状况病人的医疗状况 气道气道 返流误吸返流误吸 术中监测术中监测麻醉技巧麻醉技巧插管插管 Awake or asleep?Awake or asleep?清醒气管插管清醒气管插管:返流误吸可能返流误吸可能 插管后行神经评估插管后行神经评估:不稳定颈椎不稳定颈椎 颈部稳定装置颈部稳定装置:halo traction:halo traction Direct or fiber-optic laryngoscopy?Direct o
6、r fiber-optic laryngoscopy?直接喉镜插管直接喉镜插管:包括可视喉镜等包括可视喉镜等 纤支镜纤支镜:畸形畸形:上胸段和颈部上胸段和颈部 颈托固定的病人颈托固定的病人 解剖异常解剖异常:小下颌畸形，张口度小小下颌畸形，张口度小 上胸段和颈部手术的插管流程上胸段和颈部手术的插管流程麻醉维持麻醉维持 维持稳定的麻醉深度维持稳定的麻醉深度 避免因麻醉深度的突然改变而引起的血压波动避免因麻醉深度的突然改变而引起的血压波动 Common practice:0.5 MAC Iso or sevo Common practice:0.5 MAC Iso or sevo continuo
7、us infusion of propofol continuous infusion of propofol continuous remifentanyl or bolus opioids continuous remifentanyl or bolus opioids麻醉苏醒麻醉苏醒 拔管拔管:完全清醒完全清醒 对指令有反应对指令有反应 气道自我保护恢复气道自我保护恢复 麻醉技巧麻醉技巧脊柱手术中的特殊挑战脊柱手术中的特殊挑战体位体位术中监测术中监测脊髓损伤脊髓损伤术后失明或视力低下术后失明或视力低下 (POVL)(POVL)体位体位Prone position for C-spine
8、procedure 俯卧位引起的麻醉中的问题俯卧位引起的麻醉中的问题 气道气道:气管导管扭曲或移位气管导管扭曲或移位 长时间手术导致上呼吸道水肿长时间手术导致上呼吸道水肿 血管血管:上肢动脉和静脉阻塞上肢动脉和静脉阻塞 股静脉扭曲，股静脉扭曲，DVPDVP 腹腔内压腹腔内压:硬膜外静脉压硬膜外静脉压 出血出血神经神经:臂丛神经牵拉和受压臂丛神经牵拉和受压 尺神经受压尺神经受压:尺嘴鹰骨受压尺嘴鹰骨受压 腓总神经受压腓总神经受压:压迫腓骨小头压迫腓骨小头 股外侧皮神经损伤股外侧皮神经损伤:压迫髂嵴压迫髂嵴头和颈头和颈:头颈屈曲或伸展过度头颈屈曲或伸展过度 眼部受压眼部受压:视网膜损伤视网膜损伤
9、眼睛缺乏润滑和覆盖眼睛缺乏润滑和覆盖:角膜角膜 靠枕可能引起框上神经受压和损伤靠枕可能引起框上神经受压和损伤.颈部过度扭曲颈部过度扭曲:臂丛神经损伤臂丛神经损伤 颈动脉受压颈动脉受压 坐位 颈部椎板切除术病人手术应检查颈部活动情况颈部椎板切除术病人手术应检查颈部活动情况 应用坐位行颈部椎板切除术的比例逐渐增多应用坐位行颈部椎板切除术的比例逐渐增多 坐位手术的缺点为静脉气栓的危险性增加坐位手术的缺点为静脉气栓的危险性增加 坐位手术病人应防止神经、皮肤损伤坐位手术病人应防止神经、皮肤损伤 注意颈部过度前屈可阻塞气道注意颈部过度前屈可阻塞气道 给病人以适当液体补充，且逐渐改变体位有助于给病人以适当液
10、体补充，且逐渐改变体位有助于 防止低血压。防止低血压。并发症 静脉气栓是脊柱手术严重并发症之一是脊柱手术严重并发症之一表现为无法解释的低血压、呼气末氮气水平升高表现为无法解释的低血压、呼气末氮气水平升高早期诊断和处理可提高存活率早期诊断和处理可提高存活率 脊髓功能监测脊髓功能监测截瘫是脊柱手术最严重的并发症截瘫是脊柱手术最严重的并发症常用唤醒试验和神经生理功能监测常用唤醒试验和神经生理功能监测 术中监测术中监测 唤醒试验唤醒试验Wake-up testWake-up test 体感诱发电位体感诱发电位SSEPsSSEPs 动作诱发电位动作诱发电位MEPsMEPs Lightening anes
11、thesia at an appropriate point during the Lightening anesthesia at an appropriate point during the procedure and observing the patients ability to move to procedure and observing the patients ability to move to command.It evaluates the gross functional integrity of the command.It evaluates the gross
12、 functional integrity of the motor pathway.It was first described in 1973.motor pathway.It was first described in 1973.麻醉要求麻醉要求:简单和快速简单和快速 确切和快速拮抗药确切和快速拮抗药 温柔唤醒温柔唤醒 试验过程中无痛试验过程中无痛 No recall No recall唤醒试验唤醒试验Wake-up testWake-up test麻醉基数麻醉基数:吸入麻醉药吸入麻醉药 咪唑安定咪唑安定 丙泊酚丙泊酚 瑞芬太尼瑞芬太尼 缺点缺点:需要患者配合需要患者配合 插拔气管导管
13、插拔气管导管 实践实践 延长手术时间延长手术时间 不能评估感觉不能评估感觉通路通路唤醒试验唤醒试验Wake-up testWake-up testSSEPsSSEPs1.The most common neurophysiological method for 1.The most common neurophysiological method for monitoring the intra-operative spinal functional integrity monitoring the intra-operative spinal functional integrity2.Th
14、e stimulus applied to the peripheral N(tibial or ulnar)2.The stimulus applied to the peripheral N(tibial or ulnar)3.The recording electrodes placed:cervical region,scalp,or3.The recording electrodes placed:cervical region,scalp,or epidural space during surgery epidural space during surgery4.Baseline
15、 data obtained after skin incision4.Baseline data obtained after skin incision5.Responses are recorded intermittently during surgery5.Responses are recorded intermittently during surgery6.6.A reduction in the amplitude by 50%and an increase in the A reduction in the amplitude by 50%and an increase i
16、n the latency by 10%are considered significant.latency by 10%are considered significant.Typical tracing and L-10Typical tracing and L-101.1.SSEPs provides an indirect way of monitoring adjacent motor pathways SSEPs provides an indirect way of monitoring adjacent motor pathways because more acute imp
17、airment affects function of many adjacent pathways,because more acute impairment affects function of many adjacent pathways,not just the posterior column.However,this cannot be guaranteed.not just the posterior column.However,this cannot be guaranteed.2.The blood supply of the corticospinal motor tr
18、acts2.The blood supply of the corticospinal motor tracts differs from that of differs from that of the dorsomedial sensory tracts.It is possible to have normalthe dorsomedial sensory tracts.It is possible to have normal SSEPsSSEPs recordings throughout surgery,but to have a paraplegicrecordings thro
19、ughout surgery,but to have a paraplegic patient patient postoperatively.postoperatively.lSatisfactory monitoring of early cortical SSEPs is possible with Satisfactory monitoring of early cortical SSEPs is possible with 0.51.0 MAC isoflurane,desflurane and sevoflurane.0.51.0 MAC isoflurane,desflurane
20、 and sevoflurane.lNitrous oxide potentiates the depressant effect of volatile anestheticsNitrous oxide potentiates the depressant effect of volatile anestheticslIntravenous anesthetics generally affect SSEPs less than inhaled Intravenous anesthetics generally affect SSEPs less than inhaled anestheti
21、csanestheticslEtomidate and ketamine increases cortical SSEP amplitudeEtomidate and ketamine increases cortical SSEP amplitudelClinically unimportant changes in SSEP latency and amplitude after the Clinically unimportant changes in SSEP latency and amplitude after the administration of opioidsadmini
22、stration of opioids麻醉药和麻醉药和 SSEPsSSEPslEliminating NEliminating N2 2O from the background anesthetic has been shown O from the background anesthetic has been shown to improve cortical amplitude sufficiently to make monitoring to improve cortical amplitude sufficiently to make monitoring more reliabl
23、emore reliablelSSEP latency will take 58 min to stabilize after the step SSEP latency will take 58 min to stabilize after the step changes in volatile anesthetic concentrationchanges in volatile anesthetic concentrationlAdding etomidate,propofol or opioids is preferable to Adding etomidate,propofol
24、or opioids is preferable to beginning Nbeginning N2 2O or increasing volatile anesthetic concentrations O or increasing volatile anesthetic concentrations when anesthetic depth is inadequatewhen anesthetic depth is inadequatelIf a volatile anesthetic is nevertheless needed rapidly,If a volatile anes
25、thetic is nevertheless needed rapidly,sevoflurane permits faster SSEP recovery after the acute need sevoflurane permits faster SSEP recovery after the acute need for volatile anesthetic has been resolvedfor volatile anesthetic has been resolvedlIt is critical to avoid sudden changes in volatile anes
26、thetic It is critical to avoid sudden changes in volatile anesthetic depth or bolus administration of intravenous anesthetics during depth or bolus administration of intravenous anesthetics during surgical manipulations that could jeopardize the integrity of surgical manipulations that could jeopard
27、ize the integrity of the neural pathways being monitoredthe neural pathways being monitoredMEPsMEPsMotor cortex stimulated by Motor cortex stimulated by electrical or magnetic meanselectrical or magnetic meansMyogenic responsesMyogenic responsesNeurogenic responses:Neurogenic responses:peripheral N
28、or spinal cordperipheral N or spinal cord麻醉药和麻醉药和 MEPsMEPslInhalational anesthetics suppress myogenic MEPs in a dose-Inhalational anesthetics suppress myogenic MEPs in a dose-dependent mannerdependent mannerlPaired pulses or a train of pulses cannot overcome the Paired pulses or a train of pulses ca
29、nnot overcome the suppressive effectssuppressive effectslShould be avoided,or limited to a very low concentration during Should be avoided,or limited to a very low concentration during the monitoring of myogenic MEPsthe monitoring of myogenic MEPslN2O appears to be less suppressive than other inhale
30、d agents.N2O appears to be less suppressive than other inhaled agents.Moderate doses of up to 50%N20 have been used successfully to Moderate doses of up to 50%N20 have been used successfully to supplement other agents during myogenic MEP monitoring.supplement other agents during myogenic MEP monitor
31、ing.lFentanyl,etomidate,and ketamine have little or no effect on Fentanyl,etomidate,and ketamine have little or no effect on myogenic MEP and are compatible with intra-operative recording.myogenic MEP and are compatible with intra-operative recording.lBenzodiazepines,barbiturates,and propofol also p
32、roduce marked Benzodiazepines,barbiturates,and propofol also produce marked depression of myogenic MEP.However,successful recordings have depression of myogenic MEP.However,successful recordings have been obtained during propofol anesthesia by controlling serum been obtained during propofol anesthes
33、ia by controlling serum propofol concentrations and increasing stimuli rates.propofol concentrations and increasing stimuli rates.lMyogenic MEPs are affected by the level of neuromuscular Myogenic MEPs are affected by the level of neuromuscular blockadeblockadelBy adjusting a continuous infusion of
34、muscle relaxant to By adjusting a continuous infusion of muscle relaxant to maintain one or two twitches in a train of four,reliable MEP maintain one or two twitches in a train of four,reliable MEP responses have been recordedresponses have been recordedlMotor stimulation can elicit movement,and thi
35、s can interfere Motor stimulation can elicit movement,and this can interfere with surgery in the absence of neuromuscular blockadewith surgery in the absence of neuromuscular blockadelPhysiologic factors such as temperature,systemic bloodPhysiologic factors such as temperature,systemic blood pressur
36、e,PaO pressure,PaO2 2,and PaCO,and PaCO2 2 can alter SEPs/MEPs and must be can alter SEPs/MEPs and must be controlled during intra-operative recordingscontrolled during intra-operative recordings麻醉药和麻醉药和 MEPsMEPs脊髓损伤脊髓损伤1.1.手术和麻醉引起的神经损伤并不局限于手术部位手术和麻醉引起的神经损伤并不局限于手术部位 2.2.不良的手术体位可能导致截瘫和四肢瘫痪不良的手术体位可能导致
37、截瘫和四肢瘫痪 3.3.神经损伤最多见还是在手术部位神经损伤最多见还是在手术部位 危险因素危险因素:手术种类和手术时间的长短手术种类和手术时间的长短 脊髓血供（灌注压）脊髓血供（灌注压）潜在的脊柱病理改变潜在的脊柱病理改变 术中神经组织的受压程度术中神经组织的受压程度 脊髓损伤脊髓损伤预防预防:仔细放置体位仔细放置体位 维持维持 SCPP:SCPP=MAP CSFP SCPP:SCPP=MAP CSFP 降低降低CSFP CSFP，脑脊液引流，脑脊液引流 维持维持MAP MAP?保持收缩压保持收缩压 90 mm Hg 90 mm Hg 药物药物:?:?甲强龙甲强龙,门冬氨酸抑制剂门冬氨酸抑制剂
38、 (氯胺酮氯胺酮,镁镁)防止血肿形成防止血肿形成 仔细止血仔细止血 术前停用抗血小板药物术前停用抗血小板药物 术后立即使用肝素治疗术后立即使用肝素治疗脊髓损伤脊髓损伤术后失明术后失明Post-operative visual loss(POVL)Post-operative visual loss(POVL)POVL POVL 罕见但是灾难性罕见但是灾难性 1/1100 1/1100 俯卧位手术俯卧位手术原因原因:视神经缺血视神经缺血 (ION)(81%)(ION)(81%)视网膜中央动脉阻塞视网膜中央动脉阻塞 (13%)(13%)不明原因不明原因 (6%).(6%).病因病因:原因不明，但是
39、和视网膜和或视神经血流灌注直接相关眼灌注压眼灌注压Ocular perfusion pressure(OPP):Ocular perfusion pressure(OPP):OPP=MAP-IOP.OPP=MAP-IOP.OPP OPP :MAP MAP and/or and/or IOP IOP 危险因素危险因素:病人因素病人因素:肥胖肥胖 高血压高血压 糖尿病糖尿病 贫血贫血 手术因素手术因素:长时间手术长时间手术 大量失血大量失血 俯卧位俯卧位 低血压低血压 水中毒水中毒 视神经缺血视神经缺血 (ION)(ION)1.1.临床表现临床表现:框周水肿框周水肿,视网膜中央凹出现樱桃红斑点，视
40、网膜中央凹出现樱桃红斑点，单侧失明单侧失明2.2.病因病因:直接眼球压迫直接眼球压迫 3.3.可预防可预防视网膜中央动脉阻塞视网膜中央动脉阻塞脊柱侧弯 呼吸功能呼吸功能 呼吸功能改变主要为通气呼吸功能改变主要为通气/血流比例失调导致低氧血流比例失调导致低氧血症血症 年龄增长，由于代偿功能下降，而出现二氧化碳分年龄增长，由于代偿功能下降，而出现二氧化碳分压升高压升高 长期低氧血症、高二氧化碳分压，使肺血管收缩，长期低氧血症、高二氧化碳分压，使肺血管收缩，导致肺血管不可逆性改变和肺动脉高压导致肺血管不可逆性改变和肺动脉高压 脊柱侧弯 心血管功能心血管功能 右心室肥厚，肺血管发生高血压性改变右心室肥
41、厚，肺血管发生高血压性改变 还可伴有先天性心脏疾患。还可伴有先天性心脏疾患。术前评估术前评估 发现并存的心肺疾患和病变程度发现并存的心肺疾患和病变程度 应检查有无神经功能缺陷应检查有无神经功能缺陷 还应了解有无气管插管困难还应了解有无气管插管困难脊柱侧弯 麻醉处理麻醉处理 应考虑包括手术体位应考虑包括手术体位 手术时间较长，血液和液体的替代治疗手术时间较长，血液和液体的替代治疗 维护脊髓功能的完整维护脊髓功能的完整 防治静脉气栓防治静脉气栓 麻醉期间给予适当监测和保持静脉畅通十分重要。麻醉期间给予适当监测和保持静脉畅通十分重要。失血失血 减少出血和输血的措施包括合适体位、术中自体血减少出血和输
42、血的措施包括合适体位、术中自体血回收、行控制性低血压术、术中血液稀释等。回收、行控制性低血压术、术中血液稀释等。脊髓外伤病人的麻醉脊髓外伤病人的麻醉脊髓外伤约一半发生于颈椎水平脊髓外伤约一半发生于颈椎水平对疑有脊髓损伤的病人应快速检查神经系统功能对疑有脊髓损伤的病人应快速检查神经系统功能同时应立即检查有无呼吸功能不全、气道梗阻肋骨骨折、胸部和颌面部同时应立即检查有无呼吸功能不全、气道梗阻肋骨骨折、胸部和颌面部外伤外伤 脊髓外伤病人的麻醉脊髓外伤病人的麻醉气管插管气管插管 急性颈椎损伤最主要的死亡原因是呼吸衰竭急性颈椎损伤最主要的死亡原因是呼吸衰竭 在可能的情况下，应在确定病人上、下肢随意运动的
43、前提下进行静脉置在可能的情况下，应在确定病人上、下肢随意运动的前提下进行静脉置管、全麻诱导、气管插管和摆放体位管、全麻诱导、气管插管和摆放体位 脊髓外伤病人的麻醉脊髓外伤病人的麻醉 维护脊髓完整维护脊髓完整 应维持良好的脊髓供血，应避免过度通气，应用神应维持良好的脊髓供血，应避免过度通气，应用神经生理监测经生理监测 呼吸功能支持呼吸功能支持 心血管功能支持心血管功能支持 损伤部位以下的交感性血管张力丧失损伤部位以下的交感性血管张力丧失 避免应用琥珀胆碱避免应用琥珀胆碱 在损伤后在损伤后48h48h内应用琥珀胆碱是安全的；在脊髓损内应用琥珀胆碱是安全的；在脊髓损伤后伤后4 4周至周至5 5个月血清钾升高最为明显个月血清钾升高最为明显 脊髓外伤病人的麻醉脊髓外伤病人的麻醉 控制体温控制体温 脊髓损伤平面以下体温变化与交感张力分离，导致脊髓损伤平面以下体温变化与交感张力分离，导致体温随环境温度而变化体温随环境温度而变化 自主反射增强自主反射增强 表现特征为严重的阵发性高血压、心动过缓、心律表现特征为严重的阵发性高血压、心动过缓、心律失常失常 损害平面以下的皮肤血管收缩，损害平面以上的皮损害平面以下的皮肤血管收缩，损害平面以上的皮肤血管扩张肤血管扩张 Thank YouThank You感谢下感谢下载载
