外科40椎管内麻醉医学课件.ppt

Physiology Respiratory Phrenic nerve（膈神经）: C3~C5 Usually a spinal level of T4 does not result in impaired ventilation, but respiratory compromise may happen in patients with limited respiratory reserve or higher spinal levels. Technique — Spinal Anesthesia Spinal needle ? Quincke Sprotte Whitacare Technique — Spinal Anesthesia Patient position lateral position sitting position Technique — Spinal Anesthesia Procedure 定位：The L2-3, L3-4, or L4-5 interspaces are commonly used for spinal anesthesia. 皮丘：Raise a skin wheal with 1% lidocaine and a 25G needle at the spinal puncture site. Technique — Spinal Anesthesia Approaches 正入法 Midline approach 侧入法 （少用） Paramedian approaches 避开钙化韧带 Technique — Spinal Anesthesia Technique — Spinal Anesthesia Determinants of level of spinal blockade Controllable Factors Dose (volume × concentration)（剂量） Site of injection along the neuraxis（穿刺点） Baricity of the local anesthetic solution（比重） Posture of the patient（体位） Factors Not Controllable Volume of cerebrospinal fluid Density of cerebrospinal fluid Technique — Spinal Anesthesia Baricity of local anesthetic solution 局麻药的比重 Local anesthetic solutions can be described as hyperbaric（重比重）, hypobaric（轻比重）, or isobaric（等比重） in relation to the specific gravity of CSF (1.003~1.009). Technique — Epidural Anesthesia Epidural needles 18G Hustead 17G Tuohy Technique — Epidural Anesthesia Approaches 胸段：棘突叠瓦状 腰段：棘突较平行 Technique — Epidural Anesthesia 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2.5-5cm Technique — Epidural Anesthesia 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 — Combined spinal-epidural anesthesia（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 Complications — Spinal Anesthesia Neurologic Postdural puncture headache（硬膜穿破后头痛） Caudaequina syndrome（马尾综合征） Neurologic injury（神经损伤） Cardiovascular Hypotension Bradycardia Complica