区域神经阻滞麻醉并发症201208131

脊髓麻醉和硬膜外麻醉期间突发心搏骤停


高位交感阻滞导致外周血管张力难以恢复,血液回流 减少 The critical threshold is regained only after the administration of exogenous epinephrine or vasopressin. Rosenberg also found that non-spinalized animals have a significant increase in endogenous epinephrine and norepinephrine at 1 and 3 minutes after cardiac arrest, but spinalized animals do not show this response. 研究提示：椎管内麻醉期间心搏骤停复苏时尽早使用 肾上腺素或血管紧张素恢复外周血管张力是复苏成败 的关键
Nerve Damage
Perm Brain Damage Airway Trauma Eye Damage Injury to Newborn Stroke Pneumothorax Back Pain Headache Aspiration Pneumonitis Myocardial Infarction Burn, thermal Skin Reaction Awareness Meningitis
Nerve Blocks


In 1880, Halsted and Hall (U.S)reported Cocaine for peripheral nerve injection 。 In 1885, Corning reported prolonging the effect of Cocaine with Esmarch bandage blocking local circulation
19
9 7 4 4 3 3 3 3 3 2 2 2 1 1
127,000 489 - 13,395,750
1,480,058 7,400 - 44,776,000 89,961 43 - 2,625,000 145,900 46 - 4,147,000 829,016 4,933 - 19,656,000 370,000 8,750 - 30,967,685 75,600 574 - 17,370,000 38,500 2,800 - 2,540,000 23,970 1,096 - 1,089,000 350,000 714 - 4,290,000 258,000 9,450 - 2,254,250 63,640 5,580 - 2,875,000 27,068 608 - 1,360,000 51,480 924 - 1,050,000 122,850 5,700 - 1,080,000


其中主要是剖腹产硬膜外使0.75%bupivacaine

FDA禁止美国医院剖腹产硬膜外使用 0.75%bupivacaine
Albright GA. Anesthesiology 1979; 15 285-287
Table 1. Most Common Adverse Outcomes*
Adverse Outcome Death % of Claims 29 Median Payment Range of Payment $ 417,880 $ 438 - 22,344,000

神经系统损伤
索赔案件中第二大类损伤是周围神经系统或脊髓 损伤 An in-depth analysis of claims for nerve injury 1990---227 cases 1999---610 cases 索赔案例占1990年的15％，占1999年的16％ 尺神经损伤、臂丛损伤及腰骶部神经根损伤占50％
神经传导阻滞麻醉分类



硬膜外阻滞 蛛网膜下腔麻醉 神经及神经丛阻滞
颈丛神经阻滞 臂丛神经阻滞 上肢神经阻滞 下肢神经阻滞 躯干及会阴神经wenku.baidu.com滞

布比卡因“心脏毒性”反应
1979年报道bupicacaine的心脏毒性反应 （心律失常，循环衰竭，心搏停止） 1983年10月Albright向美国FDA和LSAC(life support advisory committee)递交49份有关 bupivacine 过去10年使用中21死亡报告
N=8495 *Total payments by defendants, excluding legal costs, adjusted to 2007 dollars
脊髓麻醉和硬膜外麻醉期间突发心搏骤停


健康成人在按常规方法实施麻醉过程中突发 心搏骤停 详尽分析：
阻滞平面T4以上，交感神经阻滞平面高 多使用镇静剂 脊麻后30分钟突发 约半数患者血流动力学和呼吸稳定；

立即心肺复苏，但肾上腺素在事件发生平均
7分钟才开始使用
脊髓麻醉和硬膜外麻醉期间突发心搏骤停



Several sources of evidence suggest that sudden cardiac arrest during spinal or epidural anesthesia is an ongoing and significant source of risk in current anesthesia practice In a recent review of high severity injuries associated with regional anesthesia claims in the 1990’s, Lee found 30 claims in which death occurred. 近期文献：41例完整记录的蛛网膜下腔或硬膜外麻 醉突发心搏骤停死亡病例，死亡原因为循环系统原 因（迷走神经反射如牵拉、恐惧、运动员心脏等） 而非呼吸抑制