new喉罩與神經(jīng)阻滯

1、外周神經(jīng)阻滯與喉罩,北京協(xié)和醫(yī)院 黃宇光,現(xiàn)狀與個體化麻醉選擇,,滿足病人生活質(zhì)量需要：“全程無痛”；適應(yīng)日間手術(shù)“短、平、快”的節(jié)奏：“手術(shù)快通道”： 71%（USA 2001） > 75% (USA 2002)；日益增多的高齡、重危病人與麻醉的對策。,10th World Congress on Pain, Aug.17-22,2002, San Dieg

2、o,USA,社會老年化與麻醉,2010-2030（美國）>65歲人口數(shù)達(dá)75%2050年（美國）85歲人口將為1995年四倍需手術(shù)的老年人口增長率 > 人口增長率,中國人均壽命The Average Age of Chinese（From Ministry of Health P.R. China）,老年患者對麻醉藥比年輕人敏感30%-50% Schnider TW, Minto CF, Shafer

3、SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology 1999;90:1502-16.,老年人、心功能差： PROPOFOL< 2.0mg/Kg,老年人病理生理改變,老年人心功能和腎功能的變化,圖2. 不同人種的年齡對第1秒時間肺活量（FEV1）的影響,常見不良反應(yīng)及其對策,,不良反應(yīng)發(fā)生率,麻醉方法的

4、選擇,吸入麻醉,靜脈麻醉,靜吸復(fù)合麻醉,硬膜外/神經(jīng)阻滯與全麻復(fù)合,麻醉鎮(zhèn)痛方法和領(lǐng)域,用于：全身麻醉； 區(qū)域麻醉； 術(shù)后鎮(zhèn)痛； 腫瘤鎮(zhèn)痛； 良性疼痛、、、,,,Medical Center of Duke University, U.S.A,Kirchmair L, et al. Ultrasound Guidance for the

5、Psoas Compartment Block: an Imaging Study.,Anesth & Analg 2002; 94: 706-10IARS Meeting, March 16-20, 2002, San Diego,New Approach to Peripheral Nerve Block超聲引導(dǎo)的外周神經(jīng)阻滯技術(shù)Ultrasound Guided peripheral nerve block,超聲/神

6、經(jīng)刺激法用于區(qū)域阻滯優(yōu)點(diǎn),阻滯成功的指標(biāo)客觀、明確；無需病人表達(dá)異感；減少病人的痛苦；提高阻滯成功率；減少神經(jīng)損傷。,神經(jīng)叢刺激定位原理,涂覆絕緣材料的針桿僅在針尖一點(diǎn)導(dǎo)電,縱座標(biāo):刺激電流橫座標(biāo):離神經(jīng)的距離,,,,Plexusanesthesia-Electrical Nervestimulation & Cathetertechnique-,外周神經(jīng)阻滯與重危病人下肢手術(shù),外周神經(jīng)阻滯改善鎮(zhèn)痛，減少嗎啡的需求

7、；包括腰叢和坐骨神經(jīng)阻滯等；鎮(zhèn)靜、神經(jīng)刺激器定位；1 % 利多卡因 20 ml + 0.5 % 羅哌卡因 20 ml;安全、有效，便于術(shù)后鎮(zhèn)痛。,北京協(xié)和醫(yī)院病例報告:高齡、心肺功能差、 抗凝治療、脊柱病變（強(qiáng)脊）等,LMA（Laryngeal Mask Airway) 概述,1983年由英國Brain發(fā)明 由通氣管和通氣罩兩部分組成介于氣管導(dǎo)管和面罩之間的通氣工具無創(chuàng)性、刺激小和操作簡便的通氣裝置,Advant

8、ages of LMA,More secure than a face mask --通氣效果好，低氧血癥發(fā)生率低； --用于輔助和控制呼吸更方便; --能提供更好的手術(shù)條件,提高安全性。Less complications than endotracheal intubations --與氣管插管比并發(fā)癥少，無須喉鏡顯露聲門; --無導(dǎo)管插入等強(qiáng)刺激，應(yīng)激反應(yīng)輕；分泌物少； --術(shù)后肺不張、肺炎等

9、并發(fā)癥少； --插入容易；無需使用肌松藥，能保留自主呼吸Use in difficult airway?。鳛榫o急氣道使用,分類,LMA Classic? 　　 LMA Unique?　　　　 LMA Fastrach? LMA ProSeal? 　　　　　　 LMA Flexible?,The LMA Classic?,first introduced in the

10、 U.K. in 1988 widest range of sizes (8 種，嬰兒至成人）；often used in spontaneously breathing patients； controlled ventilation up to 20 cm H20,The LMA-Unique?,Proven performance Convenient, single-use, disposable Economical

11、 ; Easy to use Packaged sterile, ready for use,The LMA Flexible?,Suitable for head and neck procedures Airway tube may be positioned away from surgical field without loss of seal Wire-reinforced tube resists kinking a

12、nd cuff dislodgment Available in three pediatric and three adult sizes,Flexible Reinforced LMA,Adenotonsillectomy (William PJ et al; BJA 1993; 70:30)Intranasal surgery (Webster AC et al; AA 1999; 88:421) - safe, st

13、able protected airway during anesthesia - smoother emergence from anesthesia than ETT,The LMA Fastrach?,Designed to facilitate tracheal intubation with an endotracheal tube (ETT). Used in anticipated or unexpected

14、difficult airway situations and for cardiopulmonary resuscitation,The LMA ProSeal?,Introducer Cuff-Deflator,Drain tube (soft and flexible),15 mm proximalconnector,,,1. Protection against regurgitation

15、,2. Passage of a gastric tube,3. Prevention of gastric insufflation,4. Detection of malposition,Five functions of drain tube,5. Guide to insertion – bougie or gastric tube,Induction for LMA Insertion,Adequate level to ob

16、tund laryngeal reflex - propofol 2-2.5 mg/kg > thiopental (CJA 1993; 40 : 816) - midazelam 3-5 mg - inhalational agents (sevoflurane)Muscle relaxant are unnecessaryInsertion techniques,Seal and openingwi

17、th periglottis,Seal and openingwith hypopharynx,,,LMA in Place,Hold the LMA airway with the index finger at the cuff/tube junction.,,,Deflation tool,Index Finger Technique (LMA ProSeal? ),Deflate the cuff and apply a

18、water-soluble lubricant to the posterior surface. Hold the LMA ProSeal? like a pen in the dominant hand, with the index finger placed at the junction of the cuff and the two tubes,,,,Press the tip of the cuff upward aga

19、inst the hard palate and flatten the cuff against it,Using the index finger to guide the LMA ProSeal?, press backward toward the other hand, which exerts counter-pressure (do not use force).,Advance the LMA ProSeal? into

20、 the hypopharynx until a definite resistance is felt. Hold the outer end of the airway tube while removing the index finger.,Neck and epigastricauscultation,LMA ProSeal? Selection Guidelines,LMA- Positive Pressure Ven

21、tilation,Devitt JH et al; Anesthesiology 1994; 80:550,Gynecological laparoscopy,Laparoscopic cholecystectomy,105 kg maleTV 600 mlPAP 26 cm H2O,Nasal surgery,PLMA和腰叢+坐骨神經(jīng)阻滯聯(lián)合應(yīng)用于下肢手術(shù)麻醉,2004-9月~2005-4月,麻醉選擇理由：,選擇椎管內(nèi)麻醉可能

22、的困難：病人高齡，心肺合并疾病較多骨折/體位、硬膜外穿刺有困難服用阿司匹林或其他 NSAIDs史,LMA的優(yōu)點(diǎn)－與氣管插管比較,使用簡便，無需肌松劑和喉鏡禁忌使用喉鏡和氣管插管著易于耐受，心血管反應(yīng)輕術(shù)后肌松恢復(fù)不全和再插管困難者可避免氣管插管并發(fā)癥可重復(fù)使用,喉罩對下肢神經(jīng)阻滯的補(bǔ)益,提供術(shù)中充分鎮(zhèn)靜;保證氣道通暢，提供充分氧合;有利于手術(shù)、麻醉體位的擺放;某些手術(shù)下肢神經(jīng)阻滯平面不夠時， 可提供安全、有效

23、的麻醉補(bǔ)充.,一般資料,平均年齡：75.6±11.3yr （55~85yr）37例（16F/21M）體重：64.4±16.5 Kg術(shù)前診斷：股骨粗隆間骨折14例股骨頸骨折10例股骨干粉碎性骨折5例坐骨結(jié)節(jié)囊腫1例股骨頸骨折術(shù)后取釘7例,既往病史：,Step1：喉罩放置,建立靜脈通路常規(guī)監(jiān)測ECG、BP和SPO2；面罩吸氧。咪唑安定1－2mg和異丙酚（1.5-2mg/Kg), 意識消失后置入

24、喉罩：型號：PLMATM，size 4進(jìn)行肺部及喉部聽診，確認(rèn)喉罩位置異丙酚1－4mg/kg/ h維持如必要，行機(jī)械通氣。,Step2：腰叢及坐骨神經(jīng)阻滯實(shí)施,體位：側(cè)臥穿刺定位：后路腰叢及坐骨神經(jīng)阻滯方式：神經(jīng)刺激器（B/BRAUN Stimuplex-DIG）定位外周神經(jīng)阻滯局麻藥：0.4%羅哌卡因復(fù)合1%利多卡因用量：腰叢神經(jīng) 34.3 ml±3.3ml， 坐骨神經(jīng) 19.6

25、 ml±4.9ml）,腰叢神經(jīng)阻滯定位,坐骨神經(jīng)定位,Propofol 150mg/hr靜脈連續(xù)輸注術(shù)中單次給予芬太尼50ug,術(shù)中血流動力學(xué)平穩(wěn)血管活性藥物使用情況：以維持血壓心率波動于±20％以內(nèi)為目標(biāo)，共計使用阿托品2次、麻黃素3次、硝酸甘油2次,術(shù)后隨訪37例患者均無麻醉相關(guān)并發(fā)癥，所有患者及家屬對麻醉及術(shù)后鎮(zhèn)痛表示滿意。,體會:,此種復(fù)合技術(shù)四肢手術(shù)麻醉可行可滿足手術(shù)需要提高老年重危病人的安全性

26、加快病人術(shù)后恢復(fù)提供有效術(shù)后鎮(zhèn)痛,World Record!,THANKS for your attention…,LMA的適應(yīng)癥（1）作為常規(guī)通氣道,最適于自主呼吸的短小和門診手術(shù)眼科和耳鼻等淺表手術(shù)拔牙、扁桃體摘除等口腔手術(shù)使用面罩困難者需反復(fù)麻醉插管者局部阻滯麻醉支氣管鏡檢查避免氣管插管不良反應(yīng) 術(shù)后應(yīng)用,LMA的適應(yīng)癥 （2）處理氣道困難,代替氣管插管不適宜插管時維持術(shù)中通氣要求避免插管反應(yīng)插管失敗后暫

27、時（緊急）維持通氣插管困難,LMA的適應(yīng)癥 （2）處理氣道困難,協(xié)助氣管內(nèi)插管經(jīng)喉罩盲插氣管導(dǎo)管首次成功率 >75％，總成功率 >90％經(jīng)喉罩引入探條插管成功率約90％經(jīng)喉罩引導(dǎo)纖支鏡插管成功率100％,LMA的適應(yīng)癥 （3）用于急救復(fù)蘇,較面罩有效較氣管插管操作簡便不需喉鏡操作者不需嚴(yán)格培訓(xùn)成功率高 無經(jīng)驗者首次插入成功率80％，再次插入達(dá)98％可用于狹窄的事故現(xiàn)場,飽食，腹內(nèi)壓過高，有嘔吐

28、返流誤吸高度危險，習(xí)慣性嘔吐返流史病人。 咽喉部存在感染或其它病理改變的病人。 術(shù)中須持續(xù)正壓通氣，通氣壓力需大于25cmH2O的慢性呼吸道疾病病人。 呼吸道出血的病人。 有潛在呼吸道梗阻的病人，如氣管受壓軟化、咽喉部腫瘤、膿腫血腫等。,禁忌證,并發(fā)癥,咽痛、吞咽困難和聲音嘶啞： 常見于女性、老年和多次嘗試插入的病人 氣道的密閉性：正壓通氣時易漏氣，漏氣程度與手術(shù)時間、體位、頸部緊張度、通氣阻力、通氣壓力等因素有關(guān)。正壓

29、通氣時，氣道內(nèi)壓不應(yīng)超過20cmH2O。肥胖或肺順應(yīng)性降低的病人，多需較高的氣道壓(>20cmH2O)。出現(xiàn)漏氣現(xiàn)象和氣體進(jìn)胃誘發(fā)嘔吐的危險氣體入胃：喉罩可能覆蓋部分食管口，致正壓通氣時出現(xiàn)胃膨脹和反流現(xiàn)象，尤其當(dāng)食管下段括約肌張力減退時。 返流誤吸 介于氣管導(dǎo)管和面罩之間；關(guān)鍵在于術(shù)前禁食；,Insertion is similar to that using the index finger The thumb shou

30、ld be used to extend the head just prior to completing insertion.,Fingers should be extended over head allowing the thumb to pass further inward .Hold the outer end of the airway tube while removing the thumb.,,,,Introd

31、ucer Technique(LMA ProSeal? ),Completely deflate the cuff of the mask. Place Introducer tip into strap at the junction of the cuff and two tubes. Fold the tubes around the Introducer and fit the proximal end of the air

32、way tube in the matching slot.,Airway tube fitsinto the proximalslot,,Drain tube isfree at the side,,Apply a water-soluble lubricant on the posterior surface of the cuff. With the head extended and the neck flexed, c

33、arefully flatten the mask tip against the hard palate,Keep the Introducer blade close to the chin and rotate the LMA ProSeal? inward in one smooth circular movement following the curve of the Introducer.,Advance into the

34、 hypopharynx until a definite resistance is felt.Before removing the Introducer, hold the LMA ProSeal? tube with the non-dominant hand to stabilize the tube.The tip should be firmly pressed against the upper esophageal

35、 sphincter.,What is the risk of aspiration with the LMA? airway?,The guidelines to minimize risk of aspiration:Carefully select the patient and surgical procedure according to approved indications and contraindications.

36、 Avoid inadequate anesthesia upon insertion of the LMA and during surgery. Avoid lubrication of anterior surface, excessive lubrication, or use of lidocaine gels containing nonaqueous solvents or silicones. Ensure ade

37、quate neuromuscular reversal prior to termination of general anesthesia. Avoid gastric distention (minimize peak airway pressures, avoid inadequate paralysis and routinely place a gastric tube when anesthetizing small i

38、nfants).,Why do I have trouble inserting the LMA? device?,Inadequate anesthesia. Suboptimal head/neck position. Incorrect mask deflation. Failure to press the LMA? airway into the palatopharyngeal curve during inserti

39、on. Lack of water-soluble lubricant.Using a mask that has surpassed its useful life of 40 insertions.,How do I manage an air leak with the LMA? airway?,An air leak may have several causes:Prior to insertion, be sure t

40、he LMA? device is in proper working orderInadequate anesthesia can cause an air leak around the mask of the LMA? device. Check the position of the LMA? cuff and reinsert or replace, as necessary. High airway pressures

41、 can cause the mask to leak.,Rules for Positive Pressure,Largest size of LMA possible Standard insertion techniqueTidal volume : 6-8 ml/kgAirway pressure : 15-30 cmH20Inflate to only 60 cm H2O intracuff pressureAusc

42、ultation of neckReverse nm block while still deepRemoval only when fully awake,How long can I leave the LMA? airway in place?,The LMA? airway may be safe for elective procedures in healthy patients lasting 4 to 8 hours

43、 in the hands of experienced users. If the LMA? airway is used for prolonged periods, the respiratory function must be closely monitored, and a heat and moisture exchanger should be used.Maintained intracuff pressures

44、at 60 cm H2O. Nitrous oxide diffusion tends to cause a rise in intracuff pressure in the LMA? cuffs made of silicone.,Can I remove the LMA? airway with the cuff inflated?,Provided the patient is awake and airway reflexes

45、 have returned, cuff deflation prior to removal is not essential. In some situations, clinicians prefer to remove the LMA? with cuff inflated, primarily to remove secretions that collect on top of the cuff. If intubati

46、on has been performed, removal of the LMA? airway with the cuff inflated may inadvertently dislodge or move the endotracheal tube.,Should I insert a gastric tube every time? Can I leave it in place for the duration of th

47、e procedure?,The drain tube has been designed primarily as a passive drainage channel and as an indicator of correct mask placement. Use of a gastric tube is a clinical decision, depending on many variables, including t

48、he nature of the case and the surgeon.,,Bertini et al. Regional Anesthesia & Pain Medicine 1999; 24(6): 514-518,,,,,,WulfH,et al. Clinical usefulness, safety, and plasma concentration of ropivacaine 0.5% for inguinal

49、 hernia repair in regional anesthesia.Reg Anesth Pain Med 2001 Jul-Aug; 26(4): 348-51,0.5% 羅哌卡因 60 to 70 ml ；外周神經(jīng)阻滯安全、有效；術(shù)后鎮(zhèn)痛滿意； 可行走。,Continuous Plexus and Peripheral Nerve Blocks for Postoperative AnalgesiaSpencer

50、 S. Liu, MD, and Francis V. Salinas, MDDepartment of Anesthesiology, Virginia Mason Medical Center; and University of Washington, Seattle, WashingtonAnesth Analg 2003; 96:263-72,,Klein SM.Beyond the Hospital:Continu

51、ous peripheral Nerve Blocks at home. Anesthesiology 96(6):1283, 2002,術(shù)后嚴(yán)重疼痛的發(fā)生率為40-70%;連續(xù)外周神經(jīng)阻滯值得考慮;減低疼痛評分，減少阿片類藥的需求；病人滿意；促進(jìn)家庭（at home) 病人的盡早康復(fù)。,不置管的情況下如何延長外周神經(jīng)阻滯的時間 ( 1 ),新型局麻藥CGX-1002：神經(jīng)阻滯達(dá) 48 hrs;正接受FDA的審批.,Swe

52、nson JD. New Directions in Pain Management, March 2-5, 2002, Snowbird, Utah, USA,可樂定(Clonidine) 1ug/ml;延長鎮(zhèn)痛 50%-100%;適合所有外周神經(jīng)阻滯；無明顯副作用，有輕度鎮(zhèn)靜.,Antonucci S. Minerva Anesthersiol 2001; Jan-Feb;