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1、Zhang LanDepartment of Anesthesiology of West China Hospital,Regional Anesthesia,Zhang LanRegional Anesthesia,Clinical Anesthesia,General Anesthesia,RegionalAnesthesia,Topical anesthesia,Peripheral nerve block,Local infiltration anesthesia,Spinal & Epidural Anesthesia,Clinical General AnesthesiaRe,一
2、、Nerve Blocks,Drug-Local anestheticsServer complication-the toxicity of LAAnatomy and Technique,一、Nerve BlocksDrug-Local anest,LOCAL ANESTHETICS(LA),LOCAL ANESTHETICS(LA),十八世纪中，人们咀嚼古柯叶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、脊髓麻醉、硬膜外麻醉和蛛网膜下腔阻滞麻醉,1905年发现普鲁卡因、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
3、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1905年发现,Lidocaine BupivacaineRopivavaine,ProcaineTetracaine,酰胺类局麻药,酯类局麻药,Lidocaine Procaine酰胺类局麻药酯类局麻药,extremely stable,relatively unstable,hydrolyzed in plasmaby the cholinesteraseenzymes,undergo enzymatic degradation in the liver,Chemical stability,Biotransformation,Lid
4、ocaine利多卡因 Bupivacaine布比卡因Ropivavaine罗派卡因,Procaine普鲁卡因Tetracaine的卡因,extremely relatively hydrolyze,局部麻醉英文,Local anesthetics of Peripheral nerve block,Drug dose concentration durationRopivacaine 150200mg 0.20.5% 612h Bupivacaine 150mg 0.20.5% 612hLidocaine 400mg 0.51% 13h,Local anesthetics of Periphe
5、r,The toxicity of Local anesthetics,The toxicity of Local anesthe,Reason,OverdoseIntravascular injectionRapid systemic absorption of local anesthetic from rich blood supply areaPatient status,ReasonOverdose,CNS Excitation,CNS Depression,DizzinessTinnitus Feelings of drowsinessMuscle Twitching,Consci
6、ousnessConvulsionsRespiratory DepressionRespiratory Arrest,Central Nervous System Toxicity,CNS CNS DizzinessConsciousness,CNS Conduction Pathways,Inhibitory Pathways,ExcitatoryPathways,LA,CNS Excitation,CNS Depression,CNS Conduction Inhibitory Exci,BP Heart rate Cardiac Arrest,Cardiovascular System
7、Toxicity,BP Heart rate,Cardiovascular Systemexcitation,Cardiovascular Systemdepression,BP Cardiovascular System Toxi,Direct Cardiac Effects,Direct Peripheral Vascular Effects,Negative inotropic action,Fastconducting tissues,Highconcentrations vasodilation.,Low concentrationsvasoconstriction,Cardiova
8、scular Systemdepression,LA,CNS excitation,Cardiovascular Systemexcitation,DirectDirect Negative FastHigh,Excessive doses of LASystemic absorption of LA intravascular injection of LATest doses of LA Premedication,Prevention,Excessive doses of LAPreventio,Incipient toxic reactions: Stop administering
9、LA,ventilation supportCNS excitation : Sedativetreatment,BenzodiazepineConvulsion Thiopental :therapy Convulsion Succinylcholine: Intubation maintaining adequate ventilation Cardiovascular System depression : supported by using IV fluids and vasopressorsCardiac arrest : Cardiopulmonary resuscitation
10、,Treatment,Incipient toxic reactions:Trea,Anatomy and Technique,Anatomy and Technique,Upper extremity 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
11、blocks,Upper extremity blocks Brachial plexus blockade,Upper extremity blocks Brachi,局部麻醉英文,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中神经桡神经尺,局部麻醉英文,Interscalene Block,Interscalene Block,Interscalene Block,The block can be performed with the patients hand, arm ,upper a
12、rm, shoulder and clavicle surgeryThe ulnar nerve blockade is often incompletelow risk of pneumothoraxLA solution into the epidural and subarachnoid spaces,Interscalene BlockThe block c,Axillary Block,Axillary Block,Axillary Block,No pneumothoraxAxillary block is unsuitable for surgical procedures on
13、 the upper arm or shoulder,Axillary BlockNo pneumothorax,Supraclavicular Block,Supraclavicular Block,Supraclavicular Block,The block can be performed with the patients arm in any positionProvide excellent anesthesia for elbow, forearm, and hand surgeryhigh risk of pneumothorax,Supraclavicular BlockT
14、he block,Lower extremity blocks- Lumbar Plexus Nerve Blocks Sciatic Nerve Blocks Femoral Nerve Blocks,Lower extremity blocks- Lumba,局部麻醉英文,The major branches of Lumbar Plexus :Femoral nerveLateral femoral cutaneous nerveObturator nerveSaphenous nerve,The major branches of Lumbar,The sciatic nerve,Th
15、e sciatic nerve,Lumbar Plexus Nerve Blocks,Lumbar Plexus Nerve Blocks,局部麻醉英文,Complications,Hematoma- Avoid multiple needle insertions, particularly in anticoagulated patientsVascular puncture Local anesthetic toxicity Total Spinal Anesthesia,ComplicationsHematoma- Avoid m,Sciatic Nerve Blocks,Sciati
16、c Nerve Blocks,Surface landmarks,Surface landmarks,Complications,Hematoma: Avoid multiple needle insertions, particularly in anticoagulated patientsLocal anesthetic toxicity,ComplicationsHematoma: Avoid m,Femoral Nerve Blocks,Femoral Nerve Blocks,VAN:VeinArteryNerve,VAN:,Complications,Vascular Punct
17、ure Nerve Injury Local anesthetic toxicity,ComplicationsVascular Puncture,二、Spinal & Epidural Anesthesia,二、Spinal & Epidural Anesthesi,Spinal & Epidural Anesthesia,AnatomyTechniqueFactors affecting blocking region ComplicationIndications & Contraindications,Spinal & Epidural AnesthesiaA,ANATOMY,ANAT
18、OMY,局部麻醉英文,Subarachnoid space -Spinal AnesthesiaEpidural space-Epidural Anesthesia,Subarachnoid space -Spinal An,局部麻醉英文,TECHNIQUE,TECHNIQUE,局部麻醉英文,Spinal anesthesia:L3L4, or L4L5 spaces,Spinal anesthesia:,局部麻醉英文,局部麻醉英文,局部麻醉英文,Spinal anesthesia VolumeRate of injectionDensity of LA Patientposition,Epi
19、dural anesthesiaPuncture SiteVolumeRate of injection,Factors affecting blocking region,Spinal anesthesia Epidural ane,Factors affecting blocking region,Spinal anesthesia VolumeRate of injectionDensity of LA Patient position,Epidural anesthesiaPuncture SiteVolumeRate of injection,Factors affecting bl
20、ocking reg,Complication,Complication,Important complications,Severe hypotension The toxicity of LA Total spinal anesthesia Headache after anesthesiaNerve injury,Important complicationsSevere,Spinal & Epidural Anesthesia,Sympathetic block,vagus nerve,surgery operation,vasodilatation,1. Hypotension,Se
21、nsoryanalgesia,Motor block,Circulating blood volume,Heartrate,Sever hypotension,Spinal & Epidural Sympatheti,The incidence and severity of hypotensionare related to:,Level of the block Physical status of the patientIV fluids,The incidence and severity of,Treatment:,Fluid InfusionEphedrine Administra
22、tion, 5 to 10 mg IV.Atropine , 0.3 to 0.5mg IV,Treatment: Fluid Infusion,Severe hypotension HypoxiaUnconsciousnessCardiac arrest,Most spinal never were blocked,2. Total Spinal Anesthesia,Epidural puncture needle or catheter in the subarachnoid space,Severe hypotension Most spinal,Prevention,Confirm
23、the catheter is in epidural space before LA injectionTest doses of local anesthetics must be usedThe patient must be monitored carefully during the process,PreventionConfirm the catheter,Treatment,MaintainingAdequate ventilation,Tracheal intubation mechanical ventilation,Maintaining stablehemodynami
24、c status,IV fluid Atropine Ephedrine,Cardiopulmonary resuscitation (CPR),TreatmentMaintainingTracheal i,AgeYounger more frequent,GenderFemales males,Needle sizeLarger smaller,No. dural puncturesMore with multiple punctures,3 Headache after anesthesia,AgeGenderNeedle sizeNo. dural,Treatment,Bed rest
25、Analgesics Hydration Wearing of a tight abdominal binder,Increases epidural pressure Decreases the amount of leaking CSF.,TreatmentBed rest Increases,5. Nerve injury,Epidural hematomaEpidural abscess Spinal never root trauma:pressure on the cord or spinal roots by a needle point produces excruciatin
26、g painAdhesive arachnoiditis,5. Nerve injury Epidural hemat,Indications & Contraindications,Indications & Contraindication,Indications,Spinal anesthesia ：Operation time is 2-3hcoeliac, lower limbs, perineal operation,Epidural anesthesia: abdominal, neck, limbs operationcoeliac,lower limbs, perineal
27、operation,IndicationsSpinal anesthesia ：,Contraindications,Patient refusalCoagulopathy Skin or soft tissue infection at the proposed site of needle insertion Severe hypovolemia Preexisting neurologic diseaseLack of anesthesiologist experience,Contraindications Patient refu,BLOOD TRANSFUSION,BLOOD TR
28、ANSFUSION,局部麻醉英文,局部麻醉英文,BLOOD TRANSFUSION,Indications for TransfusionComplication of transfusionAutologous transfusion,BLOOD TRANSFUSIONIndications,Increasing vascular volume,Supply RBC,Increasing Plasmaalbumen,Increasing coagulation factors,Acute Anaemia,Dysfunction of coagulation,Serious infection
29、,Chronic Anaemia,Indications for Transfusion,Increasing Supply Increasing I,increase oxygen-carrying capacity,Blood transfusions,increase blood volume,IV Fluid,Acute Anaemia,indications for blood transfusions?,increase Blood increase IV Flu,ASA Practice Guidelines,Hb 100 g/L Transfusion is rarely Hb
30、 60 g/L TransfusionHb 60100g/L Transfusion should be based on the patients risk for complications of inadequate oxygenation,ASA Practice GuidelinesHb 100,Chinese Health Ministry practice Guidelines of transfusion 2000,Hb 100g/L Transfusion is rarely indicated Hb 70g /L TransfusionHb 70100g/L Transfu
31、sion 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：文献的系统回忆,Transfus Med Rev. 2002 Jul;16(,检索了OVID Medline数据库，近期期刊目录库，Cochrane数
32、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。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。,检索了OVID Medline数据库，近期期刊目录库，Coc,Crit Care. 2007 Jun 19;11(3):142Transfusion 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
33、提高组织氧供是没有多大临床优势的。,Crit Care. 2007 Jun 19;11(3):1,Complication of transfusion,ImmunoreactionNon-immunoreaction,Complication of transfusionImm,Hemolytic transfusion reaction,Allergic reactions,Nonhemolytic transfusion reactions,Fever reactions,Acute Hemolytic Transfusion Reaction,Delay Hemolytic Trans
34、fusion Reaction,Transfusion-Induced Immuno-depression,Transfusion-Related Acute Lung Injurymyocardial injury,Immunoreaction,Hemolytic Allergic reactionsNo,Acute hemolytic transfusion reaction,A fatal reactions ， mortality rate 20% to 60%The renal and coagulation systems are affected ABO-incompatible
35、 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 feverchest or flank pain nausea,The signs in general anesthesiableeding hypotension hemoglobinuria,Signs and Symptoms The classic,Delayed hemolyti
36、c transfusion reaction,unexplained fever and anaemia 7 to 14 days after a transfusionRh-incompatiblerarely 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 pos
37、ttransfusion hepatitis B has dramatically decreased. 90 % posttransfusion hepatitis is caused by the hepatitis C virus.,HepatitisIn the 1940s ,viral h,Acquired Immunodeficiency Syndrome,AIDS is most frequently transmitted by intimate homosexual contact and intravenous drug abuseWhole blood, plasma,
38、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 normo
39、volemic hemodilutionIntraoperation & postoperation blood recovery,Autologous Transfusion,Preoperative autologous blood,Preoperative autologous blood donation (PABD),Preoperative autologous blood,Acute normovolemic hemodilution,Acute normovolemic hemodilutio,Intraoperation & postoperation blood recovery,Intraoperation & postoperation,局部麻醉英文,局部麻醉英文,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年第一,重点掌握,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平安剂量及极量,
