局部麻醉英文课件

Zhang Lan Department of Anesthesiology of West China Hospital Regional Anesthesia Zhang Lan Department of AnesthClinical Anesthesia General Anesthesia Regional Anesthesia Topical anesthesia Peripheral nerve block Local infiltration anesthesia Spinal&Epidural Anesthesia Clinical Anesthesia General 一、一、Nerve Blocks Drug-Local anesthetics?Server complication-the toxicity of LA Anatomy and Technique 一、Nerve Blocks Drug-Local anesLOCAL ANESTHETICS(LA)LOCAL 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?1860年，从古柯叶中发现了可卡因?1884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 1905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、布比卡因等，可卡因因其成瘾性高和安全性低而被淘汰。低而被淘汰。?十八世纪中，人们咀嚼古柯叶感受舒适感和增加耐力?1860Lidocaine Bupivacaine Ropivavaine Procaine Tetracaine 酰胺类局麻药 酯类局麻药 Lidocaine Bupivacaine Ropivavextremely stable relatively unstable hydrolyzed in plasma by the cholinesterase enzymes undergo enzymatic degradation in the liver Chemical stability Biotransformation Lidocaine 利多卡因 Bupivacaine 布比卡因 Ropivavaine 罗派卡因 Procaine 普鲁卡因 Tetracaine 的卡因 extremely stable relatively 局部麻醉英文课件Local anesthetics of Peripheral nerve block Drug dose concentration duration Ropivacaine 150200mg 0.20.5%612h Bupivacaine 150mg 0.20.5%612h Lidocaine 400mg 0.51%13h Local anesthetics of PeripherThe toxicity of Local anesthetics The toxicity of Local anestheReason?Overdose?Intravascular injection?Rapid systemic absorption of local anesthetic from rich blood supply area?Patient status Reason?Overdose?IntravasculaCNS Excitation CNS Depression Dizziness Tinnitus Feelings of drowsiness Muscle Twitching Consciousness Convulsions Respiratory Depression Respiratory Arrest Central Nervous System Toxicity CNS Excitation CNS DepressioCNS Conduction Pathways Inhibitory Pathways Excitatory Pathways LA CNS Excitation CNS Depression?CNS Conduction Pathways InhibBP?Heart rate?Cardiac Arrest Cardiovascular System Toxicity BP Heart rate Cardiovascular System excitation Cardiovascular System depression BP?Heart rate?Cardiac ArreDirect Cardiac Effects Direct Peripheral Vascular Effects Negative inotropic action Fast conducting tissues High concentrations vasodilation.Low concentrations vasoconstriction Cardiovascular System depression LA CNS excitation Cardiovascular System excitation Direct Cardiac Effects Direct?Excessive doses of LA?Systemic absorption of LA?intravascular injection of LA?Test doses of LA?Premedication Prevention?Excessive doses of LA?System?Incipient toxic reactions:Stop administering LA,ventilation support?CNS excitation :Sedativetreatment,Benzodiazepine?Convulsion Thiopental:therapy Convulsion Succinylcholine:Intubation maintaining adequate ventilation?Cardiovascular System depression :supported by using IV fluids and vasopressors?Cardiac arrest :Cardiopulmonary resuscitation Treatment?Incipient toxic reactions:Anatomy and Technique Anatomy and Technique Upper extremity blocks Brachial plexus blockade Lower extremity blocks Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve Blocks Blocks of the head and neck Blocks of the thorax and abdomen Upper extremity blocks Upper extremity blocks Brachial plexus blockade Upper extremity blocks Brachi 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 正中神经 肌皮神经 腋神经 桡神经 正中神经 肌皮神经 正局部麻醉英文课件Interscalene Block Interscalene Block Interscalene Block?The block can be performed with the patients hand,arm,upper arm,shoulder and clavicle surgery?The ulnar nerve blockade is often incomplete?low risk of pneumothorax?LA solution into the epidural and subarachnoid spaces Interscalene Block?The blockAxillary Block Axillary Block Axillary Block?No pneumothorax?Axillary block is unsuitable for surgical procedures on the upper arm or shoulder Axillary Block?No pneumothoraSupraclavicular Block Supraclavicular Block Supraclavicular 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 pneumothorax Supraclavicular Block?The bloLower extremity blocks-Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve Blocks Lower extremity blocks-Lumba?The major branches of Lumbar Plexus:?Femoral nerve?Lateral femoral cutaneous nerve?Obturator nerve?Saphenous nerve?The major branches of Lumbar The sciatic nerve The sciatic nerve Lumbar Plexus Nerve Blocks Lumbar Plexus Nerve Blocks 局部麻醉英文课件Complications?Hematoma-Avoid multiple needle insertions,particularly in anticoagulated patients Vascular puncture?Local anesthetic toxicity?Total Spinal Anesthesia Complications?Hematoma-AvoidSciatic Nerve Blocks Sciatic Nerve Blocks Surface landmarks Surface landmarks Complications?Hematoma:Avoid multiple needle insertions,particularly in anticoagulated patients?Local anesthetic toxicity Complications?Hematoma:AvoidFemoral Nerve Blocks Femoral Nerve Blocks VAN:Vein Artery Nerve VAN:Vein Artery Nerve Complications?Vascular Puncture?Nerve Injury?Local anesthetic toxicity Complications?Vascular Punctu二、二、Spinal&Epidural Anesthesia 二、Spinal&Epidural AnesthesiSpinal&Epidural Anesthesia?Anatomy?Technique?Factors affecting blocking region?Complication?Indications&Contraindications Spinal&Epidural Anesthesia ANATOMY ANATOMY 局部麻醉英文课件Subarachnoid space -Spinal Anesthesia Epidural space-Epidural Anesthesia Subarachnoid space-Spinal An局部麻醉英文课件TECHNIQUE TECHNIQUE 局部麻醉英文课件Spinal anesthesia:L3L4,or L4 L5 spaces Spinal anesthesia:L3L4,or L局部麻醉英文课件局部麻醉英文课件局部麻醉英文课件Spinal anesthesia Volume Rate of injection Density of LA Patientposition Epidural anesthesia Puncture Site Volume Rate of injection Factors affecting blocking region Spinal anesthesia Volume RateFactors affecting blocking region?Spinal anesthesia?Volume?Rate of injection?Density of LA?Patient position?Epidural anesthesia?Puncture Site?Volume?Rate of injection Factors affecting blocking regComplication Complication Important complications Severe hypotension The toxicity of LA Total spinal anesthesia Headache after anesthesia Nerve injury Important complications SevereSpinal&Epidural Anesthesia Sympathetic block vagus nerve surgery operation vasodilatation 1.Hypotension Sensory analgesia Motor block Circulating blood volume Heart rate Sever hypotension Spinal&Epidural AnesthesiThe incidence and severity of hypotension are related to:Level of the block Physical status of the patient IV fluids The incidence and severity of Treatment:Fluid Infusion Ephedrine Administration,5 to 10 mg IV.Atropine,0.3 to 0.5mg IV Treatment:Fluid Infusion EphSevere hypotension Hypoxia Unconsciousness Cardiac arrest Most spinal never were blocked 2.Total Spinal Anesthesia Epidural puncture needle or catheter in the subarachnoid space Severe hypotension Hypoxia UPrevention?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 process Prevention?Confirm the cathetTreatment Maintaining Adequate ventilation Tracheal intubation mechanical ventilation Maintaining stable hemodynamic status IV fluid Atropine Ephedrine Cardiopulmonary resuscitation(CPR)Treatment Maintaining AdequateAge Younger more frequent Gender Females males Needle size Larger smaller No.dural punctures More with multiple punctures 3 Headache after anesthesia Age Younger more frequent GeTreatment Bed rest Analgesics Hydration Wearing of a tight abdominal binder Increases epidural pressure Decreases the amount of leaking CSF.Treatment Bed rest Analgesics5.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 arachnoiditis 5.Nerve injury?Epidural hemIndications&Contraindications Indications&ContraindicationIndications Spinal anesthesia：Operation time is 2-3h coeliac,lower limbs,perineal operation Epidural anesthesia:abdominal,neck,limbs operation coeliac,lower limbs,perineal operation Indications Spinal anesthesia Contraindications?Patient refusal?Coagulopathy?Skin or soft tissue infection at the proposed site of needle insertion?Severe hypovolemia?Preexisting neurologic disease?Lack of anesthesiologist experience Contraindications?Patient reBLOOD TRANSFUSION BLOOD TRANSFUSION 局部麻醉英文课件局部麻醉英文课件BLOOD TRANSFUSION?I ndications for Transfusion?Complication of transfusion?Autologous transfusion BLOOD TRANSFUSION?IndicationIncreasing vascular volume Supply RBC Increasing Plasma albumen Increasing coagulation factors Acute Anaemia Dysfunction of coagulation Serious infection Chronic Anaemia Indications for Transfusion Increasing vascular volume increase oxygen-carrying capacity Blood transfusions increase blood volume IV Fluid Acute Anaemia indications for blood transfusions?increase oxygen-carrying capaASA Practice Guidelines Hb 100 g/L Transfusion is rarely Hb 10Chinese Health Ministry practice Guidelines of transfusion（2000）Hb 100g/L Transfusion is rarely indicated Hb 70g/L Transfusion Hb 70100g/L Transfusion should be based on the patients risk for complications of inadequat oxygenation Chinese Health Ministry practi?Transfus Med Rev.2002 Jul;16(3):187-99.?Transfusion triggers:a systematic review of the literature USA（输血指征：文献的系统回顾）指征：文献的系统回顾）?Transfus Med Rev.2002 Jul;16?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，Cochrane数据数据库，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，和住院时间没有受影响。受影响。?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。?检索了OVID Medline数据库，近期期刊目录库，Co?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？?在稳定的危重病患儿采用以 70g/L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。?该研究证实，试图通过输RBC来提高组织氧供是没有多大临床优势的。?Crit Care.2007 Jun 19;11(3):Complication of transfusion Immunoreaction Non-immunoreaction Complication of transfusion ImHemolytic transfusion reaction Allergic reactions Nonhemolytic transfusion reactions Fever reactions Acute Hemolytic Transfusion Reaction Delay Hemolytic Transfusion Reaction Transfusion-Induced Immuno-depression Transfusion-Related Acute Lung Injury myocardial injury Immunoreaction Hemolytic transfusion reactAcute 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 blood Acute hemolytic transfusion Signs and Symptoms The classic signs and symptoms chills fever chest or flank pain nausea The signs in general anesthesia bleeding hypotension hemoglobinuria Signs and Symptoms The classiDelayed hemolytic transfusion reaction?unexplained fever and anaemia 7 to 14 days after a transfusion?Rh-incompatible?rarely death Delayed hemolytic transfusion Non-immunoreaction Non-immunoreaction Hepatitis?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.Hepatitis?In the 1940s,viralAcquired Immunodeficiency Syndrome?AIDS is most frequently transmitted by intimate 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.Acquired Immunodeficiency Synd?Preoperative autologous blood donation(PABD)?Acute normovolemic hemodilution?Intraoperation&postoperation blood recovery Autologous Transfusion?Preoperative autologous bloodPreoperative autologous blood donation(PABD)Preoperative autologous bloodAcute normovolemic hemodilution Acute normovolemic hemodilutioIntraoperation&postoperation blood recovery Intraoperation&postoperation局部麻醉英文课件局部麻醉英文课件References?外科学7年制规划教材 2002 年第一版?ANESTHESIA(Miller)2000 Fifth Edition References?外科学7年制规划教材 2002年重点掌握重点掌握?常用局部麻醉药的安全剂量及极量?局部麻醉药毒性反应的临床表现、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？?输血的适应症 重点掌握?常用局部麻醉药的安全剂量及极量?局部麻醉药毒性