椎管内麻醉课件

anesthesia
1905 H. Braun (Germany): procaine spinal anesthesia 1907 Barker (United Kingdom): hyperbaric procaine (glucose); hypobaric procaine (alcohol) 1930 Jones (United Kingdom): dibucaine spinal anesthesia 1935 Sise (USA): tetracaine spinal anesthesia 1940 Lemmon (USA): continuous spinal anesthesia 1945 Tuohy (USA): continuous spinal anesthesia 1945 Prickett (USA): report on neurologic safety of intrathecal epinephrine to prolong spinal anesthesia
Dose (mg)
Duration (min)a
Drug and concentration
Procaine (5%)
To L4 To T10 To T4
50– 100– 75 150
150– 200
With 0.2 mg Plain epinephrine
40–55 60–75
Lidocaine (5%)
椎 管 内 解 剖
椎 管 内 解 剖
椎 管 内 解 剖
Specific gravity
Volume
CSF pressure (lumbar)
Composition of cerebrospinal fluid 1.006 (1.003-1.009) (at 37°C) 120–150 ml (25–35 ml spinal space) 60–80 mm H20 (in horizontal position)
不同腔
隙，使脊神经所支配的相应区域产生麻醉作用， 包括蛛网膜下腔阻滞麻醉和硬膜外阻滞麻醉两种 方法，后者还包括骶管阻滞。局麻药注入蛛网膜 下腔，主要作用于脊神经根所引起的阻滞称为蛛 网膜下腔阻滞，通称为脊麻；局麻药在硬膜外间 隙作用于脊神经， 使相应节段的感觉和交感神
pH
7.32 (7.27–7.37) (cisternal pH follows blood; lumbar pH lags
behind)
PC02 HC03¯ Sodium Calcium Phosphorus Magnesium Chloride Proteins (lumbar)
48 mm Hg 23 mEq/L 133–145 mEq/L 2–3 mEq/L 1.6 mg/dl 2.0–2.5 mEq/L 15–20 mEq/L 23–38 mg/dl ( permeability to protein in lumbar area)
1954 Wooly and Roe (United Kingdom): report of paraplegia in association with spinal anesthesia
1954 1965
Dripps and Vandam (USA): study demonstrating absence of neurologic sequelae Re-emergence of use of spinal anesthesia
2. 旁入法 于棘突间隙中点旁开1.5cm处作 局部浸润。穿刺针与皮肤成75度对准棘突 间孔刺入，经黄韧带及硬脊膜而达蛛网膜 下腔。本法可避开棘上及棘间韧带，特别 适用于韧带钙化的老年病人或脊椎畸形或 棘突间隙不清楚的肥胖病人。
针尖进入蛛网膜下腔后，拔出针芯即有脑 脊液流出
Drugs for spinal anesthesia
经完全被阻滞，运动神经纤维部分地丧失功能， 这种麻醉方法称为硬膜外阻滞。
椎管内麻醉
硬膜外 腰硬联合 阻滞
蛛网膜 下腔阻
滞
History of spinal anesthesia
1885 J.L. Corning (New York Neurologist):? epidural;? spinal; cocaine for pain relief 1891 Quincke (Germany): lumbar puncture 1899 August Bier (Germany): first cocaine spinal anesthesia in six patients 1899 Matas (New Orleans), Tuff ier (France), Tait and Caglieri (San Francisco): cocaine spinal
椎 管 内 解 剖
脊 髓 及 硬 膜 囊 的 位 置
三蛛网膜下腔阻滞
（一）分类
1. 给药方式 单次 连续 2. 麻醉平面 高 T4---T10 中 低 3. 局麻药的比重 重 轻 等比重
腰麻穿刺术
穿刺方法 穿刺点用0.5%~1%普鲁卡因作皮 内、皮下和棘间韧带逐层浸润。
1. 直入法 用左手拇、示两指固定穿刺点皮 肤。将穿刺针在棘突间隙中点，与病人背部 垂，针尖稍向头侧作缓慢刺入，并仔细体会 针尖处的阻力变化。当针穿过黄韧带时，有 阻力突然消失“落空”感觉，继续推进常有 第二个“落空”感觉，提示已穿破硬膜与蛛 网膜而进入蛛网膜下腔。如果进针较快，常 将黄韧带和硬膜一并刺穿，则往往只有一次 “落空”感觉。
25– 50–75 75–100 60–70 60–70 50
Tetracaine (0.5%) 4–6 6–10 12–16 60–90 120–180
Bupivacaine (0.75%)b
4–8 8–12
14–20 90– 110
90–110
a For a given local anesthetic in spinal anesthesia the larger mg dose, the longer the duration of surgical anesthesia (e.g., a 16 mg dose of tetracaine will have a duration of two– to three times longer than a 4 mg dose, either plain or with epinephrine.