ClinicalAnaesthesiology临床麻醉学课件

《ClinicalAnaesthesiology临床麻醉学课件》由会员分享，可在线阅读，更多相关《ClinicalAnaesthesiology临床麻醉学课件（75页珍藏版）》请在装配图网上搜索。

1、ClinicalAnaesthesiology临床麻醉学Clinical AnaesthesiologyQiu Wei FanAssociate professorDepartment of AnaesthesiologyRui Jin HospitalShanghai Second Medical UniversityClinicalAnaesthesiology临床麻醉学Local Anaesthetic techniquesnFeatures of local anaesthesianMethods of local anaesthesianComplications of local

2、anaesthesia nRegional block equipmentnSpinal, epidural, & caudal blocksnPeripheral nerve blocksClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedication PurposenEstablish rapport with the patientnObtain a history and perform a physical examinationsnOrder a special investigationsnAssess t

3、he risks of anaesthesia and surgery and if necessary postpone or cancel the date of surgerynInstutite preoperative managementnPrescribe premedication and the anaesthesia managementClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedicationRoutine preoperative anaesthetic evaluationHistoryn

4、Current problemnOther known problemsnMedication historyClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedication Medication historynAllergiesnDrug intolerancesnPresent therapy Prescription NonprescriptionnNontherapeutic Alcohol TobacconIllicitClinicalAnaesthesiology临床麻醉学Preoperative asse

5、ssment and premedicationnPrevious anaesthetics, surgery, and obstetric deliverriesnFamily historynReview of organ systemsnLast oral intakeClinicalAnaesthesiology临床麻醉学 Preoperative assessment and premedication Review of organ systemsnGeneralnRespiratorynCardiovascularnRenalnGastrointestinalnHematolog

6、icClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedication Review of organ systemsnNeurologicnEndocrinenPsychiatricnOrthopedicnDermatologicClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedication Physical examinationnVital signsnAirwaynHeartnLungsnExtremitiesnNeurologic exa

7、minationClinicalAnaesthesiology临床麻醉学Preoperative assessment and premedicationLaboratory evaluationnHematocrit or hemoglobin concentrationAll menstruating womenAll patients over 60 years of ageAll patients who are likely to experience significant blood loss and may require transfusionnSerum glucose a

8、nd creatinine (or blood urea nitrogen) concentration: all patients over 60 years of agenElectrocardiogram: all patients over 40 years of agenChest radiogram: all patients over 60 years of ageClinicalAnaesthesiology临床麻醉学ASA classificationnIA normal healthy patient other than surgical pathology- witho

9、ut systemic disease.nII A patient with mild systemic disease no functional limitations.nIIIA patient with moderate to severe systemic disturbance duo to medical or surgical disease- some functional limitation but not incapacitating.ClinicalAnaesthesiology临床麻醉学ASA classificationnIV A patient with sev

10、ere systemic disturbance which poses a constant threat to life and is incapacitating. nVA moribund patient not expected to survive 24 hours with or without surgery.nEIf the case is an emergency, the physical status is followed by the letter “E”-, “IIE”.ClinicalAnaesthesiology临床麻醉学American Society of

11、 Anaesthesiologists classification and perioperative mortality rates Class Mortality Rate I 0.06-0.08%II 0.27-0.4%III 1.8-4.3%IV 7.8-23%V 9.4-51%ClinicalAnaesthesiology临床麻醉学DocumentationnInformed ConsentnThe preoperative notenThe intraoperative anaesthesia recordnThe postoperative notesClinicalAnaes

12、thesiology临床麻醉学Local Anaesthetic techniques Features of local anaesthesianPreservation of consciousnessnThe quality of early postoperative analgesianSimplicity of administrationnSympathetic blockade attenuation of the stress response nMinimal depression of ventilationClinicalAnaesthesiology临床麻醉学Loca

13、l Anaesthetic techniques Methods of local anaesthesianSurface anaesthesianLocal infiltration nField blocknRegional blocks (Spinal, epidural, & caudal blocks)nPeripheral nerve blocksClinicalAnaesthesiology临床麻醉学 Complications of local anaesthesianLocal anaesthetic toxicity( Systemic toxicity): Cardiov

14、ascular, Respiratory， Cerebral and Immunologic nHypotensionnMotor blockadenPneumothoraxnUrinary retentionnNeurological complicationsnEquipment problemsClinicalAnaesthesiology临床麻醉学Local anaesthetic toxicitySystemic toxicity Cardiovascular: Cardiac dysrhythmia or circulatory collapse is often the pres

15、enting sign of local anaesthetic overdose during anaesthesia.ClinicalAnaesthesiology临床麻醉学 Local anaesthetic toxicitySystemic toxicity Respiratory: Lidocaine depresses hypoxic drive. Apnea can result from phrenic and intercostal nerve paralysis or depression of the medullary respiratory center.Clinic

16、alAnaesthesiology临床麻醉学Local anaesthetic toxicity Systemic toxicity Cerebral: Early symptoms are circumoral numbness, tongue paresthesia, and dizziness. Sensory complaints may include tinnitus and blurred vision.Excitatory signs often precede central nerve system depression.ClinicalAnaesthesiology临床麻

17、醉学Local anaesthetic toxicity Systemic toxicity Immunologic: True hypersensitivity reactions to local anaesthetic agents- as distinct from systemic toxicity due to excessive plasma concentration- are quite uncommon.ClinicalAnaesthesiology临床麻醉学Regional block equipmentnSpinal needles (26G)nPencil-point

18、 24G needlesnCathetersnLabel syringesnA short length of tubingnNerve stimulatorsnLocal anaesthetic drugsClinicalAnaesthesiology临床麻醉学Complications of local anaesthesia HypotensionnSympathetic blockadenTotal spinal blockadenVasovagal attacknAnaphylactoid reactionClinicalAnaesthesiology临床麻醉学Regional bl

19、ocknSubarachnoid block(SAB): Spinal anaesthesianExtradural nerve block: Epidural anaesthesia may be performed in the sacral(caudal block), lumbar, thoracic or cervical regions. ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAna

20、esthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学ClinicalAnaesthesiology临床麻醉学蛛网膜

21、下腔阻滞联合硬脊膜外腔阻滞蛛网膜下腔阻滞联合硬脊膜外腔阻滞ClinicalAnaesthesiology临床麻醉学Regional BlockPhysiology:Somatic BlackadeVisceral blackadeCardiovascularPulmonaryGastrointestinalLiverUrinary tractMetabolic & EndocrineClinicalAnaesthesiology临床麻醉学Physiology effects of SABDifferential nerve blockadenSympathetic fibres blockns

22、ensory blocknMotor blockClinicalAnaesthesiology临床麻醉学Physiology effects of SABRespiratory systemnRoots of the phrenic nerves: apnoeanThoracic level: loss of intercostal muscle activity, decrease in vital capacity, reduction in cardiac output and pulmonary artery pressure, and increased ventilation/pe

23、rfution imbalance, resulting in a decrease in arterial oxygen tension (PaO2)ClinicalAnaesthesiology临床麻醉学Physiology effects of SABCardiovascular systemnDenervation of the sympathetic outflow tracts (T1-L2): dilatation of resistance and capacitance vessels and results in hypotensionnBradycardia: vasov

24、agal syndrome; block of the cardiac sympathetic fibresClinicalAnaesthesiology临床麻醉学Physiology effects of SABGastrointestinal system Sympathetic denervation and unopposed parasympathetic action : a constricted gut with increased peristaltic activity (nausea, retching or vomiting)ClinicalAnaesthesiolog

25、y临床麻醉学Physiology effects of extradural block The physiological effect of extradural blockade are similar to those following subarachnoid block.ClinicalAnaesthesiology临床麻醉学Spinal anaesthesia：IndicationsnLower extremitiesnHipnPerineumnLower abdomennLumber spineType of surgery: Urology, Gynaecology, Ob

26、stetrics and any surgical procedure on the lower limbs or perineum. Urologic endoscopic surgery, Rectal surgery, repair of hip fracture, obstetrics, orthopedic, Inguinal hernia repair, etc.ClinicalAnaesthesiology临床麻醉学 Spinal anaesthesia： ContraindicationsAbsolute:SepsisBacteremiaSkin infection at in

27、jection siteHypovolemiaCoagulopathyTherapeutic anticoagulationDemyelating central nerve system diseaseIncreased intracranial pressurePsychosis or dementiaLack of consentClinicalAnaesthesiology临床麻醉学Spinal anaesthesia： ContraindicationsRelativePeripheral neuropathyMini-dose” heparinAspirin or other an

28、tiplatelet drugsPrior lumbar spine surgeryChronic back painCertain cardiac lesionsPsychologic or emotional instabilityUncooperative patients Prolonged surgerySurgery of uncertain durationSurgical team resistance to awake patientsClinicalAnaesthesiology临床麻醉学Patient preparationnConsentnPhysical examin

29、ationnLaboratory TestsnPremedicationClinicalAnaesthesiology临床麻醉学Equipment & SafetynGeneral Preparation: MonitoringnAdministration of GA if necessarynResuscitation equipmentnRegional equipmentClinicalAnaesthesiology临床麻醉学Patient positionnSitting positionnLateral positionnProne positionClinicalAnaesthe

30、siology临床麻醉学T e c h n i q u e ： N e e d l e TechniquenMidline TechniquenParamedian TechniqueClinicalAnaesthesiology临床麻醉学Factors influencing spinal anaesthesianAgents: Procaine, Tetracaine, Lidocaine, BupivacainenDosagenVasoconstrictorsnSpecific Gravity: Hyperbaric technique, Hypobaric technique, Iso

31、baric techniquenPosturenIntra-abdominal PressurenSpinal CurvaturenPrior Surgery of SpinenAge nObesitynPregnancynSpread of the agent nRedistributionClinicalAnaesthesiology临床麻醉学Spinal anaesthesia： ComplicationsnPain on injectionnBackachenHeadachenUrinary RetentionnMeningitis and meningismnVascular inj

32、urynNerve injury: Cranial nerve palsynHigh spinal anaesthesianTransverse myelitis and cauda equina syndromeClinicalAnaesthesiology临床麻醉学 Epidural anaesthesia ：Indications Specific IndicationsHip and knee surgeryLow extremity RevascularizationObstetric deliveriesPostoperative managementClinicalAnaesth

33、esiology临床麻醉学 Epidural anaesthesia ： Contraindications Epidural anaesthesia shares the contraindications discussed in the section on spinal anaesthesia.ClinicalAnaesthesiology临床麻醉学Applied Physiology for Epidural AnaesthesianSegmental BlockadenDifferential BlockadeClinicalAnaesthesiology临床麻醉学Table Ag

34、ents for epidural anaesthesianAgent Concentration Onset Sensory BlockMotor BlocknChloroprocaine 2% Fast AnalgesicMild to moderate 3% Fast Dense Densenlidocvaine 1% IntermediateAnalgesic Minimal 1.5% Dense Mild to moderate 2% Intermediate Dense DensenMepivacaine 1% Intermediate Analgesic Minimal 2% I

35、ntermediateDense Dense nPrilocaine 2% Fast Dense Minimal 3% Fast Dense DensenBupivacaine 0.25% Slow Analgesic Minimal 0.375-0.5% Slow Dense Mild to moderaten 0.75% Slow Dense Moderate to denseClinicalAnaesthesiology临床麻醉学Technique of Epidural AnaesthesianA) SafetynB) Preparation of the patientInforme

36、d consentPreoperative evaluationLaboratory assessmentPremedicationnC）Equipment: The epidural needleClinicalAnaesthesiology临床麻醉学Technical performance of a blockIdentification of the epidural space: nLoss of resistance technique;nHanging drop techniqueClinicalAnaesthesiology临床麻醉学Level selectednLumbar

37、epidural anaesthesia: Midline technique, paramedian techniquenThoracic epidural anaesthesia: Midline technique, paramedian techniquenCervical epidural anaesthesia: Midline techniqueClinicalAnaesthesiology临床麻醉学Strategies for injection of the anaesthetic agentnA test dosenIncremental dosingClinicalAna

38、esthesiology临床麻醉学Choice of local anaestheticnAgent Concentration Onset Sensory Block Motor BlocknChloroprocaine 2% Fast Analgesic Mild to moderate 3% Fast Dense Densenlidocvaine 1% Intermediate Analgesic Minimal 1.5% Dense Mild to moderate 2% Intermediate Dense DensenMepivacaine 1% Intermediate Anal

39、gesic Minimal 2% Intermediate Dense Dense nPrilocaine 2% Fast Dense Minimal 3%Fast Dense DensenBupivacaine 0.25% 0.25% Slow Analgesic Minimal n 0.375-0.5% 0.375-0.5% Slow Dense Mild to moderaten 0.75% 0.75% Slow Dense Moderate to denseClinicalAnaesthesiology临床麻醉学Factors that affect epidural anaesthe

40、sianDosagenPatient AgenWeight & HeightnPosturenVasoconstrictorsnpH adjustment of local anaesthesianFailure of epidural blockClinicalAnaesthesiology临床麻醉学Epidural anaesthesia Complications(Intraoperative)nDural tapnTotal spinal anaesthesia Profound hypotension ApnoeanMassive extradural block and subdu

41、ral blocknIntravenous toxititynHypotensionnShiveringnNausea/ vomitingClinicalAnaesthesiology临床麻醉学Epidural anaesthesia Complications(Postoperative)nHeadachenInfectionnExtradural haematomanNeurological complicationsClinicalAnaesthesiology临床麻醉学Caudal anaesthesia IndicationsnObstetric patients, for vagi

42、nal deliveriesnSurgery related to the sacral area (anorectal and vaginal procedures).ClinicalAnaesthesiology临床麻醉学Caudal anaesthesia: Contraindications The contraindications for caudal anaesthesia are the same as for any central block.ClinicalAnaesthesiology临床麻醉学 Caudal anaesthesia Complications The

43、complications of caudal block are essentially the same as those associated with epidural and spinal block.ClinicalAnaesthesiology临床麻醉学Differences between subarachniod and extradural blocknDose of drug employednRate of onsetnIntensity of blocknPattern of blockSubarachniod Extradural blockSmall LargeF

44、ast SlowComplete anaesthesia Not complete anaesthesiaCord transection DermatomalClinicalAnaesthesiology临床麻醉学Peripheral nerve blocksUpper limb blocksnBrachial plexus blocknAxillary blocknSupraclavicular blocknInterscalene blockClinicalAnaesthesiology临床麻醉学Peripheral nerve blocksLower limb blocksnSciat

45、ic nerve blocknFemoral nerve blocknMid tarsal blockClinicalAnaesthesiology临床麻醉学QuestionnWhat are the complication of local anaesthesia?nWhat are the features of local anaesthetic toxicity?nWhat are the absolute contraindications to subarachnoid block and extradural block?ClinicalAnaesthesiology临床麻醉学QuestionnWhat are the major differences between subarachnoid block and extradural block?nHow do you take the history from a patient?nWhat are the methods for identifying the epidural space?ClinicalAnaesthesiology临床麻醉学Any Questions?Thank you !