1、武汉大学中南医院 王焱林Table 1.Most Common Adverse Outcomes*Adverse Outcome%of Claims Median Payment Range of PaymentDeath 29$417,880$438-22,344,000Nerve Damage 19 127,000 489-13,395,750Perm Brain Damage 9 1,480,058 7,400-44,776,000Airway Trauma 7 89,961 43-2,625,000Eye Damage 4 145,900 46-4,147,000Injury to N
2、ewborn 4 829,016 4,933-19,656,000Stroke 3 370,000 8,750-30,967,685Pneumothorax 3 75,600 574-17,370,000Back Pain 3 38,500 2,800-2,540,000Headache 3 23,970 1,096-1,089,000Aspiration Pneumonitis 3 350,000 714-4,290,000Myocardial Infarction 2 258,000 9,450-2,254,250Burn,thermal 2 63,640 5,580-2,875,000S
3、kin Reaction 2 27,068 608-1,360,000Awareness 1 51,480 924-1,050,000Meningitis 1 122,850 5,700-1,080,000N=8495*Total payments by defendants,excluding legal costs,adjusted to 2007 dollars2009 ASA 年会：年会：Refresher Course布比卡因布比卡因“心脏毒性心脏毒性”反应反应n1979年报道年报道bupicacaine的心脏毒性反应的心脏毒性反应（心律失常，循环衰竭，心搏停止）（心律失常，循环衰竭
4、，心搏停止）n1983年年10月月Albright向美国向美国FDA和和LSAC(life support advisory committee)递交递交49份有关份有关bupivacine 过去过去10年使用中年使用中21死亡报告死亡报告n其中主要是剖腹产硬膜外使其中主要是剖腹产硬膜外使0.75%bupivacainenFDA禁止美国医院剖腹产硬膜外使用禁止美国医院剖腹产硬膜外使用 0.75%bupivacaineAlbright GA.Anesthesiology 1979;15 285-287nSeveral sources of evidence suggest that sudden
5、 cardiac arrest during spinal or epidural anesthesia is an ongoing and significant source of risk in current anesthesia practicenIn a recent review of high severity injuries associated with regional anesthesia claims in the 1990s,Lee found 30 claims in which death occurred.n近期文献：41例完整记录的蛛网膜下腔或硬膜外麻醉突
6、发心搏骤停死亡病例，死亡原因为循环系统原因（迷走神经反射如牵拉、恐惧、运动员心脏等）而非呼吸抑制n高位交感阻滞导致外周血管张力难以恢复高位交感阻滞导致外周血管张力难以恢复,血液回流血液回流减少减少nThe critical threshold is regained only after the administration of exogenous epinephrine or vasopressin.Rosenberg also found that non-spinalized animals have a significant increase in endogenous epine
7、phrine and norepinephrine at 1 and 3 minutes after cardiac arrest,but spinalized animals do not show this response.n研究提示：椎管内麻醉期间心搏骤停复苏时尽早使用研究提示：椎管内麻醉期间心搏骤停复苏时尽早使用肾上腺素或血管紧张素恢复外周血管张力是复苏成败肾上腺素或血管紧张素恢复外周血管张力是复苏成败的关键的关键nAn in-depth analysis of claims for nerve injury 1990-227 cases 1999-610 cases神经损伤神经损伤
8、n脊髓损伤脊髓损伤n9090年代占赔偿案例年代占赔偿案例25%25%n8080年代占赔偿案例年代占赔偿案例10%10%n7070年代占赔偿案例年代占赔偿案例5%5%n区域麻醉导致神经损伤的最常见原因是椎管内血肿区域麻醉导致神经损伤的最常见原因是椎管内血肿spinal or epidural hematoma(43/103 cases;41%).n4343例赔偿案例中例赔偿案例中,32(74%)与凝血异常有关与凝血异常有关 either from anticoagulant therapy(30 cases)or intrinsic coagulopathy(2 cases).Ruppen W,
9、et al.Anesthesiology 2006;105(2):394-9-Davies JM,et al.Anesthesiology 2009;110(1):131-9-Davies JM,et al.Anesthesiology 2009;110(1):131-9瑞典1990-1999：450000例epidural发生严重神经损伤127例2000年法国12例（9女3男）椎管内阻滞后发生严重且持续时间长的神经根和脊髓并发症Anesth Analg 2007;104:975979Denise Wedel:2003 ASA Refresher course lecturesDenise W
10、edel:2003 ASA Refresher course lecturesDenise Wedel:2003 ASA Refresher course lecturesVandermeulen E.Best Pract Res Clin Anaesthesiol 2010;24(1):121-31Vandermeulen E.Best Pract Res Clin Anaesthesiol 2010;24(1):121-31Vandermeulen E.Best Pract Res Clin Anaesthesiol 2010;24(1):121-31蛛网膜下腔与硬膜外麻醉的神经蛛网膜下腔
11、与硬膜外麻醉的神经并发症因素并发症因素l注射药物毒性注射药物毒性l穿刺针或置管不当导致直接神经组织穿刺针或置管不当导致直接神经组织损伤损伤l感染感染l缺血或肿物压迫引起脊髓损伤缺血或肿物压迫引起脊髓损伤50Rosalia Perez-Castro,Anesth Analg 2009,108:997-1007Pollock JE.Transient neurologic symptoms:etiology,riskfactors,and managementReg Anesth Med 2002;27:5816Johnson ME.Potential neurotoxity of spinal anesthesia with lidocaine.Mayo Clin Proc 2000;75:921-32Rosalia Perez-Castro Anesth Analg 2009,108:997-1007超声引导下行神经阻滞超声引导下行神经阻滞Thank you for your attention!
