NEW喉罩与神经阻滞

外周神经阻滞与喉罩北京协和医院黄宇光现状与个体化麻醉选择满足病人生活质量需要：“全程无痛”；适应日间手术“短、平、快”的节奏：“手术快通道”：71%（USA2001）>75%(USA2002)；日益增多的高龄、重危病人与麻醉的对策。10thWorldCongressonPain,Aug.17-22,2002,SanDiego,USA社会老年化与麻醉2010-2030（美国）>65岁人口数达75%2050年（美国）85岁人口将为1995年四倍需手术的老年人口增长率>人口增长率中国人均寿命

TheAverageAgeofChinese

（FromMinistryofHealthP.R.China）老年患者对麻醉药比年轻人敏感30%-50%

SchniderTW,MintoCF,ShaferSL,etal.Theinfluenceofageonpropofol

pharmacodynamics.Anesthesiology1999;90:1502-16.老年人、心功能差：

PROPOFOL<2.0mg/Kg老年人病理生理改变老年人心功能和肾功能的变化图2.不同人种的年龄对第1秒时间肺活量（FEV1）的影响常见不良反应及其对策

不良反应发生率麻醉方法的选择吸入麻醉静脉麻醉静吸复合麻醉硬膜外/神经阻滞与全麻复合麻醉镇痛方法和领域用于：全身麻醉；区域麻醉；术后镇痛；肿瘤镇痛；良性疼痛、、、MedicalCenterofDukeUniversity,U.S.AKirchmairL,etal.UltrasoundGuidanceforthePsoasCompartmentBlock:anImagingStudy.Anesth&Analg2002;94:706-10IARSMeeting,March16-20,2002,SanDiegoNewApproachtoPeripheralNerveBlock超声引导的外周神经阻滞技术UltrasoundGuidedperipheralnerveblock超声/神经刺激法用于区域阻滞优点阻滞成功的指标客观、明确；无需病人表达异感；减少病人的痛苦；提高阻滞成功率；减少神经损伤。神经丛刺激定位原理涂覆绝缘材料的针杆仅在针尖一点导电纵座标:刺激电流横座标:离神经的距离Stimulation1,0

>

0,3mAInjection40-50mlLACatheter(0,45x0,85mm)3cmPlexusanesthesia-ElectricalNervestimulation

&

Cathetertechnique-外周神经阻滞与重危病人下肢手术外周神经阻滞改善镇痛，减少吗啡的需求；包括腰丛和坐骨神经阻滞等；镇静、神经刺激器定位；1%利多卡因20ml+0.5%罗哌卡因20ml;安全、有效，便于术后镇痛。北京协和医院病例报告:高龄、心肺功能差、抗凝治疗、脊柱病变（强脊）等LMA（LaryngealMaskAirway)概述1983年由英国Brain发明由通气管和通气罩两部分组成介于气管导管和面罩之间的通气工具无创性、刺激小和操作简便的通气装置AdvantagesofLMAMoresecurethanafacemask

--通气效果好，低氧血症发生率低；

--用于辅助和控制呼吸更方便;

--能提供更好的手术条件,提高安全性。Lesscomplicationsthanendotrachealintubations

--与气管插管比并发症少，无须喉镜显露声门;

--无导管插入等强刺激，应激反应轻；分泌物少；

--术后肺不张、肺炎等并发症少；

--插入容易；无需使用肌松药，能保留自主呼吸Useindifficultairway

－作为紧急气道使用分类

LMAClassic™LMAUnique™

LMAFastrach™

LMAProSeal™LMAFlexible™TheLMAClassic™firstintroducedintheU.K.in1988widestrangeofsizes(8

种，婴儿至成人）；oftenusedinspontaneouslybreathingpatients；

controlledventilationupto20cmH20

TheLMA-Unique™ProvenperformanceConvenient,single-use,disposableEconomical;EasytousePackagedsterile,readyforuseTheLMAFlexible™SuitableforheadandneckproceduresAirwaytubemaybepositionedawayfromsurgicalfieldwithoutlossofsealWire-reinforcedtuberesistskinkingandcuffdislodgmentAvailableinthreepediatricandthreeadultsizesFlexibleReinforcedLMAAdenotonsillectomy(WilliamPJetal;BJA1993;70:30)Intranasalsurgery(WebsterACetal;AA1999;88:421)-safe,stableprotectedairwayduringanesthesia-smootheremergencefromanesthesiathanETTTheLMAFastrach™Designedtofacilitatetrachealintubationwithanendotrachealtube(ETT).Usedinanticipatedorunexpecteddifficultairwaysituationsandforcardiopulmonaryresuscitation

TheLMAProSeal™IntroducerCuff-Deflator

Draintube(softandflexible)15mmproximalconnector1.Protectionagainstregurgitation2.Passageofagastrictube3.Preventionofgastricinsufflation4.DetectionofmalpositionFivefunctionsofdraintube5.Guidetoinsertion–bougieorgastrictubeInductionforLMAInsertionAdequateleveltoobtundlaryngealreflex-propofol2-2.5mg/kg>thiopental(CJA1993;40:816)-midazelam3-5mg-inhalationalagents(sevoflurane)MusclerelaxantareunnecessaryInsertiontechniquesSealandopeningwithperiglottisSealandopeningwithhypopharynxLMAinPlaceHoldtheLMAairwaywiththeindexfingeratthecuff/tubejunction.DeflationtoolIndexFingerTechnique

(LMAProSeal™)

Deflatethecuffandapplyawater-solublelubricanttotheposteriorsurface.HoldtheLMAProSeal™likeapeninthedominanthand,withtheindexfingerplacedatthejunctionofthecuffandthetwotubesPressthetipofthecuffupwardagainstthehardpalateandflattenthecuffagainstitUsingtheindexfingertoguidetheLMAProSeal™,pressbackwardtowardtheotherhand,whichexertscounter-pressure(donotuseforce).AdvancetheLMAProSeal™intothehypopharynxuntiladefiniteresistanceisfelt.Holdtheouterendoftheairwaytubewhileremovingtheindexfinger.NeckandepigastricauscultationLMAProSeal™SelectionGuidelines

MaskSize

PatientSelectionGuidelines*MaximumCuffInflationVolume(Air)MaximumSizeGastricTubeSalemSump1½Infants5-10kgupto7ml10

French8

French2children10-20kgupto10ml10

French8

French2½Children20-30kgupto14ml14

French12

French3Children30-50kgupto20ml16French

14French4Adults50-70kgupto30ml16French14French

5Adults70-100kgupto40ml18French16FrenchLMA-PositivePressureVentilationDevittJHetal;Anesthesiology1994;80:550Gynecological

laparoscopyLaparoscopiccholecystectomy105kgmaleTV600mlPAP26cmH2ONasalsurgeryPLMA和腰丛+坐骨神经阻滞联合应用

于下肢手术麻醉2004-9月~2005-4月麻醉选择理由：选择椎管内麻醉可能的困难：病人高龄，心肺合并疾病较多骨折/体位、硬膜外穿刺有困难服用阿司匹林或其他NSAIDs史LMA的优点－与气管插管比较使用简便，无需肌松剂和喉镜禁忌使用喉镜和气管插管着易于耐受，心血管反应轻术后肌松恢复不全和再插管困难者可避免气管插管并发症可重复使用喉罩对下肢神经阻滞的补益提供术中充分镇静;保证气道通畅，提供充分氧合;有利于手术、麻醉体位的摆放;某些手术下肢神经阻滞平面不够时，可提供安全、有效的麻醉补充.一般资料平均年龄：75.6±11.3yr（55~85yr）37例（16F/21M）体重：64.4±16.5Kg术前诊断：股骨粗隆间骨折14例股骨颈骨折10例股骨干粉碎性骨折5例坐骨结节囊肿1例股骨颈骨折术后取钉7例既往病史：高血压13例糖尿病11例冠心病：心肌缺血6例，陈旧性心梗3例心电图异常者（早搏9例、ST-T改变16例、束支传导阻滞5例）呼吸系统：哮喘3例，慢阻肺7例，肺部感染2例，肺功能检查异常6例下肢深静脉血栓2例神经精神：脑梗塞3例，老年性精神障碍4例。其它：糖尿病2例，贫血1例，低蛋白血症1例。Step1：喉罩放置建立静脉通路常规监测ECG、BP和SPO2；面罩吸氧。咪唑安定1－2mg和异丙酚（1.5-2mg/Kg),意识消失后置入喉罩：型号：PLMATM，size4进行肺部及喉部听诊，确认喉罩位置异丙酚1－4mg/kg/h维持如必要，行机械通气。Step2：腰丛及坐骨神经阻滞实施体位：侧卧穿刺定位：后路腰丛及坐骨神经阻滞方式：神经刺激器（B/BRAUNStimuplex-DIG）定位外周神经阻滞局麻药：0.4%罗哌卡因复合1%利多卡因用量：腰丛神经34.3ml±3.3ml，坐骨神经19.6ml±4.9ml）腰丛神经阻滞定位坐骨神经定位Propofol150mg/hr静脉连续输注术中单次给予芬太尼50ug术中血流动力学平稳血管活性药物使用情况：以维持血压心率波动于±20％以内为目标，共计使用阿托品2次、麻黄素3次、硝酸甘油2次术后随访37例患者均无麻醉相关并发症，所有患者及家属对麻醉及术后镇痛表示满意。

体会:此种复合技术四肢手术麻醉可行可满足手术需要提高老年重危病人的安全性加快病人术后恢复提供有效术后镇痛WorldRecord!THANKSforyourattention…LMA的适应症（1）作为常规通气道最适于自主呼吸的短小和门诊手术眼科和耳鼻等浅表手术拔牙、扁桃体摘除等口腔手术使用面罩困难者需反复麻醉插管者局部阻滞麻醉支气管镜检查避免气管插管不良反应术后应用LMA的适应症（2）处理气道困难代替气管插管不适宜插管时维持术中通气要求避免插管反应插管失败后暂时（紧急）维持通气插管困难LMA的适应症（2）处理气道困难协助气管内插管经喉罩盲插气管导管首次成功率>75％，总成功率>90％经喉罩引入探条插管成功率约90％经喉罩引导纤支镜插管成功率100％

LMA的适应症（3）用于急救复苏较面罩有效较气管插管操作简便不需喉镜操作者不需严格培训成功率高无经验者首次插入成功率80％，再次插入达98％可用于狭窄的事故现场饱食，腹内压过高，有呕吐返流误吸高度危险，习惯性呕吐返流史病人。咽喉部存在感染或其它病理改变的病人。术中须持续正压通气，通气压力需大于25cmH2O的慢性呼吸道疾病病人。呼吸道出血的病人。有潜在呼吸道梗阻的病人，如气管受压软化、咽喉部肿瘤、脓肿血肿等。禁忌证并发症咽痛、吞咽困难和声音嘶哑：常见于女性、老年和多次尝试插入的病人气道的密闭性：正压通气时易漏气，漏气程度与手术时间、体位、颈部紧张度、通气阻力、通气压力等因素有关。正压通气时，气道内压不应超过20cmH2O。肥胖或肺顺应性降低的病人，多需较高的气道压(>20cmH2O)。出现漏气现象和气体进胃诱发呕吐的危险气体入胃：喉罩可能覆盖部分食管口，致正压通气时出现胃膨胀和反流现象，尤其当食管下段括约肌张力减退时。返流误吸介于气管导管和面罩之间；关键在于术前禁食；InsertionissimilartothatusingtheindexfingerThethumbshouldbeusedtoextendtheheadjustpriortocompletinginsertion.Fingersshouldbeextendedoverheadallowingthethumbtopassfurtherinward.Holdtheouterendoftheairwaytubewhileremovingthethumb.IntroducerTechnique(LMAProSeal™)Completelydeflatethecuffofthemask.PlaceIntroducertipintostrapatthejunctionofthecuffandtwotubes.FoldthetubesaroundtheIntroducerandfittheproximalendoftheairwaytubeinthematchingslot.AirwaytubefitsintotheproximalslotDraintubeisfreeatthesideApplyawater-solublelubricantontheposteriorsurfaceofthecuff.Withtheheadextendedandtheneckflexed,carefullyflattenthemasktipagainstthehardpalateKeeptheIntroducerbladeclosetothechinandrotatetheLMAProSeal™inwardinonesmoothcircularmovementfollowingthecurveoftheIntroducer.Advanceintothehypopharynxuntiladefiniteresistanceisfelt.BeforeremovingtheIntroducer,holdtheLMAProSeal™tubewiththenon-dominanthandtostabilizethetube.Thetipshouldbefirmlypressedagainsttheupperesophagealsphincter.WhatistheriskofaspirationwiththeLMA™airway?

Theguidelinestominimizeriskofaspiration:Carefullyselectthepatientandsurgicalprocedureaccordingtoapprovedindicationsandcontraindications.AvoidinadequateanesthesiauponinsertionoftheLMAandduringsurgery.Avoidlubricationofanteriorsurface,excessivelubrication,oruseoflidocainegelscontainingnonaqueoussolventsorsilicones.Ensureadequateneuromuscularreversalpriortoterminationofgeneralanesthesia.Avoidgastricdistention(minimizepeakairwaypressures,avoidinadequateparalysisandroutinelyplaceagastrictubewhenanesthetizingsmallinfants).WhydoIhavetroubleinsertingtheLMA™device?Inadequateanesthesia.Suboptimalhead/neckposition.

Incorrectmaskdeflation.

FailuretopresstheLMA™airwayintothepalatopharyngealcurveduringinsertion.

Lackofwater-solublelubricant.Usingamaskthathassurpasseditsusefullifeof40insertions.

HowdoImanageanairleakwiththeLMA™airway?Anairleakmayhaveseveralcauses:Priortoinsertion,besuretheLMA™deviceisinproperworkingorderInadequateanesthesiacancauseanairleakaroundthemaskoftheLMA™device.CheckthepositionoftheLMA™cuffandreinsertorreplace,asnecessary.Highairwaypressurescancausethemasktoleak.RulesforPositivePressureLargestsizeofLMApossibleStandardinsertiontechniqueTidalvolume:6-8ml/kgAirwaypressure:15-30cmH20Inflatetoonly60cmH2OintracuffpressureAuscultationofneckReversenmblockwhilestilldeepRemovalonlywhenfullyawakeHowlongcanIleavetheLMA™airwayinplace?

TheLMA™airwaymaybesafeforelectiveproceduresinhealthypatientslasting4to8hoursinthehandsofexperiencedusers.IftheLMA™airwayisusedforprolongedperiods,therespiratoryfunctionmustbecloselymonitored,andaheatandmoistureexchangershouldbeused.Maintainedintracuffpressuresat60cmH2O.NitrousoxidediffusiontendstocauseariseinintracuffpressureintheLMA™cuffsmadeofsilicone.CanIremovetheLMA™airwaywiththecuffinflated?Providedthepatientisawakeandairwayreflexeshavereturned,cuffdeflationpriortoremovalisnotessential.Insomesituations,cliniciansprefertoremovetheLMA™withcuffinflated,primarilytoremovesecretionsthatcollectontopofthecuff.Ifintubationhasbeenperformed,removaloftheLMA™airwaywiththecuffinflatedmayinadvertentlydislodgeormovetheendotrachealtube.ShouldIinsertagastrictubeeverytime?CanIleaveitinplaceforthedurationoftheprocedure?

Thedraintubehasbeendesignedprimarilyasapassivedrainagechannelandasanindicatorofcorrectmaskplacement.Use