脊柱手术的麻醉课件,1,脊柱手术的麻醉,脊柱手术的麻醉课件,2,椎间盘问题,脊椎滑脱,需要手术治疗的脊柱问题,脊柱手术的麻醉课件,3,椎管狭窄,脊柱侧凸,驼背,脊髓肿瘤,需要手术治疗的脊柱问题,硬膜外血肿和脓肿,外伤,脊柱手术的麻醉课件,4,手术操作,椎板切开术,椎板切除术,椎间盘摘除术,脊柱手术的麻醉课件,5,手术操作,融合和固定,内固定术,脊柱手术的麻醉课件,6,术前评估,气道评估: 张口度 是否有困难插管史 头颈活动度 颈椎的稳定性 与外科医生沟通是必须的,麻醉注意事项,脊柱手术的麻醉课件,7,呼吸系统 病史: 关注肺功能是否有损害 体检: 肺部感染的体征； 严重的脊柱畸形 胸部X线 肺功能检查: 脊柱侧凸 血气分析 心血管系统 病史: 高血压,糖尿病, 充血性心力衰竭, 冠心病 体检: 充血性心力衰竭体征 心电图 应激试验/心超,脊柱手术的麻醉课件,8,实验室检查（推荐） 基本检查 可选检查 气道 颈椎侧位片 CT 扫描 肺部 胸片 肺功能检查 血气分析 (支气管扩张试验) 肺功能检查 (FEV1, FVC) 肺弥散功能检查 心血管 心电图 多巴酚丁胺应激 Echo 超声心动图 潘生丁/铊 扫描图 血液检查 CBC, electrolytes,Cr 肝功能检查 BUN, PT/PTT Albumin, calcium (肿瘤疾病),脊柱手术的麻醉课件,9,神经系统评估 整个神经系统评估都应记录在案 1. 颈椎手术的病人, 麻醉科医生有责任在插管和放置体位时避免进一步的损伤 2. 肌肉萎缩增加术后反流误吸的风险 3. 脊髓损伤的程度和时间与围术期出现心血管和呼吸系统功能紊乱密切相关（小于 3 周, 脊髓休克症状仍可出现； 3周后可能出现自主神经反射失调,脊柱手术的麻醉课件,10,麻醉技巧,诱导: 麻醉诱导的选择: i.v. or inhalation ? 病人的医疗状况 气道 颈椎稳定性 肌松药的选择: Succinylcholine or NDNMBs ? 病人的医疗状况 气道 返流误吸 术中监测,脊柱手术的麻醉课件,11,麻醉技巧,插管 Awake or asleep? 清醒气管插管: 返流误吸可能 插管后行神经评估: 不稳定颈椎 颈部稳定装置: halo traction Direct or fiber-optic laryngoscopy? 直接喉镜插管: 包括可视喉镜等 纤支镜: 畸形: 上胸段和颈部 颈托固定的病人 解剖异常: 小下颌畸形，张口度小,脊柱手术的麻醉课件,12,上胸段和颈部手术的插管流程,脊柱手术的麻醉课件,13,麻醉维持 维持稳定的麻醉深度 避免因麻醉深度的突然改变而引起的血压波动 Common practice: 0.5 MAC Iso or sevo continuous infusion of propofol continuous remifentanyl or bolus opioids 麻醉苏醒 拔管: 完全清醒 对指令有反应 气道自我保护恢复,麻醉技巧,脊柱手术的麻醉课件,14,脊柱手术中的特殊挑战,体位,术中监测,脊髓损伤,术后失明或视力低下 (POVL),脊柱手术的麻醉课件,15,体位,Prone position for C-spine procedure,脊柱手术的麻醉课件,16,俯卧位引起的麻醉中的问题 气道: 气管导管扭曲或移位 长时间手术导致上呼吸道水肿 血管: 上肢动脉和静脉阻塞 股静脉扭曲， DVP 腹腔内压:硬膜外静脉压 出血 神经: 臂丛神经牵拉和受压 尺神经受压: 尺嘴鹰骨受压 腓总神经受压: 压迫腓骨小头 股外侧皮神经损伤: 压迫髂嵴 头和颈: 头颈屈曲或伸展过度 眼部受压: 视网膜损伤 眼睛缺乏润滑和覆盖: 角膜 靠枕可能引起框上神经受压和损伤. 颈部过度扭曲: 臂丛神经损伤 颈动脉受压,脊柱手术的麻醉课件,17,坐位,颈部椎板切除术病人手术应检查颈部活动情况 应用坐位行颈部椎板切除术的比例逐渐增多 坐位手术的缺点为静脉气栓的危险性增加 坐位手术病人应防止神经、皮肤损伤 注意颈部过度前屈可阻塞气道 给病人以适当液体补充，且逐渐改变体位有助于 防止低血压。,脊柱手术的麻醉课件,18,并发症 静脉气栓,是脊柱手术严重并发症之一 表现为无法解释的低血压、呼气末氮气水平升高 早期诊断和处理可提高存活率,脊柱手术的麻醉课件,19,脊髓功能监测,截瘫是脊柱手术最严重的并发症 常用唤醒试验和神经生理功能监测,脊柱手术的麻醉课件,20,术中监测,唤醒试验Wake-up test 体感诱发电位SSEPs 动作诱发电位MEPs,脊柱手术的麻醉课件,21,Lightening anesthesia at an appropriate point during the procedure and observing the patients ability to move to command. It evaluates the gross functional integrity of the motor pathway. It was first described in 1973. 麻醉要求: 简单和快速 确切和快速拮抗药 温柔唤醒 试验过程中无痛 No recall,唤醒试验Wake-up test,脊柱手术的麻醉课件,22,麻醉基数: 吸入麻醉药 咪唑安定 丙泊酚 瑞芬太尼 缺点: 需要患者配合 插拔气管导管 实践 延长手术时间 不能评估感觉通路,唤醒试验Wake-up test,脊柱手术的麻醉课件,23,SSEPs,1. The most common neurophysiological method for monitoring the intra-operative spinal functional integrity 2. The stimulus applied to the peripheral N (tibial or ulnar) 3. The recording electrodes placed: cervical region, scalp, or epidural space during surgery 4. Baseline data obtained after skin incision 5. Responses are recorded intermittently during surgery A reduction in the amplitude by 50% and an increase in the latency by 10% are considered significant.,脊柱手术的麻醉课件,24,Typical tracing and L-10,SSEPs provides an indirect way of monitoring adjacent motor pathways because more acute impairment affects function of many adjacent pathways, not just the posterior column. However, this cannot be guaranteed. 2. The blood supply of the corticospinal motor tracts differs from that of the dorsomedial sensory tracts. It is possible to have normal SSEPs recordings throughout surgery, but to have a paraplegic patient postoperatively.,脊柱手术的麻醉课件,25,Satisfactory monitoring of early cortical SSEPs is possible with 0.51.0 MAC isoflurane, desflurane and sevoflurane. Nitrous oxide potentiates the depressant effect of volatile anesthetics Intravenous anesthetics generally affect SSEPs less than inhaled anesthetics Etomidate and ketamine increases cortical SSEP amplitude Clinically unimportant changes in SSEP latency and amplitude after the administration of opioids,麻醉药和 SSEPs,脊柱手术的麻醉课件,26,SSEPs 监测意义,Eliminating N2O from the background anesthetic has been shown to improve cortical amplitude sufficiently to make monitoring more reliable SSEP latency will take 58 min to stabilize after the step changes in volatile anesthetic concentration Adding etomidate, propofol or opioids is preferable to beginning N2O or increasing volatile anesthetic concentrations when anesthetic depth is inadequate If a volatile anesthetic is nevertheless needed rapidly, sevoflurane permits faster SSEP recovery after the acute need for volatile anesthetic has been resolved It is critical to avoid sudden changes in volatile anesthetic depth or bolus administration of intravenous anesthetics during surgical manipulations that could jeopardize the integrity of the neural pathways being monitored,脊柱手术的麻醉课件,27,MEPs,Motor cortex stimulated by electrical or magnetic means,Myogenic responses,Neurogenic responses: peripheral N or spinal cord,脊柱手术的麻醉课件,28,麻醉药和 MEPs,Inhalational anesthetics suppress myogenic MEPs in a dose-dependent manner Paired pulses or a train of pulses cannot overcome the suppressive effects Should be avoided, or limited to a very low concentration during the monitoring of myogenic MEPs N2O appears to be less suppressive than other inhaled agents. Modera