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产科麻醉：穿刺要点总结

2021-12-29 2021CAA年会《每日会讯》 郭麻笔记

产科麻醉麻醉
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目前剖宫产应用最普遍的是腰硬联合麻醉或单次腰麻，穿刺及给药的每一个细节都会影响到剖宫产麻醉的质量，而腰麻穿刺椎间隙的选择还在理论上与神经并发症有一定的关联。

目前剖宫产应用最普遍的是腰硬联合麻醉或单次腰麻，穿刺及给药的每一个细节都会影响到剖宫产麻醉的质量，而腰麻穿刺椎间隙的选择还在理论上与神经并发症有一定的关联。因此，若要获得满意的剖宫产麻醉效果，需从定位与穿刺开始。

一 椎管内穿刺间隙定位的技巧
脊柱侧面观具有生理性的前凸：颈椎和腰椎，生理性的后凸：胸椎和骶椎。妊娠因素使腰椎代偿性的前凸更加明显，增加了腰段穿刺的困难。L2-3穿刺脑脊液的引出率最高，平卧位L3椎体是腰椎的最高点，因此注药后药物易向头端扩散，L3-4穿刺注药后药物易向尾端扩散，所以，临床上腰麻于L2-3穿刺头端方向注药能取得更好的麻醉效果。因脊髓圆锥绝大多数终止于L1-2椎体平面，从理论上而言，腰麻穿刺于L2-3、L3-4、L4-5均是安全可行的。文献报道：30%的脊髓圆锥终止于L1的上缘，60%的脊髓圆锥终止于L1的下缘，10%的脊髓圆锥终止于L2-3间隙，甚至终止的更低，或脊髓栓系等情况。另外，麻醉医生的实际穿刺间隙有可能高于拟穿刺间隙，两侧髂嵴最高点连线称为jacoby线或Tuffier线（T线）。T线与腰椎的定位关系并不恒定，文献报道不一，T线经过第三、四腰椎间隙、经过腰3-4棘突间隙、经过腰4椎体棘突、经过L4-5椎体间隙等均有报道。T线因孕妇松动的骨盆倾斜而上移！50%定位向头一个间隙5%偏上两间隙。文献表明：拟穿刺L3-4，实际准确穿刺于L3-4的占38%，穿刺在L2-3的占58%，穿刺在L1-2的占4%。一方面，脊髓圆锥终止的位置可能低于L1-2的水平，另一方面，麻醉医生实际穿刺的位置可能高于定位的间隙。提示临床医生穿刺的时候针的下面有可能有神经组织、脊髓圆锥。但这并不限制大家行腰椎穿刺，理论上腰麻穿刺于L2-3、L3-4、L4-5均是安全可行的。只要操作者具有丰富的理论知识，加之娴熟的穿刺技巧，就可避免穿刺性的神经损伤。
二 椎管内穿刺一针痛的技巧
经验丰富的麻醉医生在整个椎管内穿刺过程中，应该做到一针痛的技术，即只应该在局部浸润进针皮肤的时候让患者感受到一次疼痛。进针应在皮内，注射后隆起的皮丘可见十余个汗毛孔，然后垂直进针，边进针边注射局部麻醉药（无需回抽），进针到深部时可做扇形注射，2%利多卡因2~3 ml足矣。临床上常见的错误做法是：进针在皮下脂肪层，注射后形成一个局部隆起，这样既起不到局部麻醉作用，又影响间隙的触摸，而且很多人是一次进针到底，然后边退针边注射，若此，在整个途径中并没有进行局部浸润，患者则会出现反射性体动。
三 椎管内穿刺的技巧
腰椎横截面硬膜外间隙与蛛网膜下隙的解剖关系，就相当于大圆套小圆的关系。在行腰--硬联合麻醉穿刺时，操作者务必做到垂直正中进针，穿刺命中硬膜外间隙以后腰麻针向前推进，很容易刺中蛛网膜下隙。临床常见的错误是在皮肤进针时带有一定角度，但操作者不易发现，差之毫厘、谬之千里，当进针到深处时，此角度偏差就变得越来越大，有可能穿刺针较容易命中硬膜外间隙，但腰穿针就有可能刺入蛛网膜下隙的边缘或与蛛网膜下隙擦肩而过，临床常见现象为腰穿针进针时发生异感或脑脊液引流不畅或脑脊液无法引出，皆因穿刺方向发生了偏差所致。目前临床上用的腰穿针均为笔尖式侧开口的穿刺针，侧开口距针尖1.0~1.1 mm的距离，侧开口的宽度1.1~1.2 mm，所以为了取得回抽脑脊液效果理想及给药后麻醉效果满意，应将穿刺针突破后再向前娴熟、轻柔地推进，将侧开口完全置入到蛛网膜下隙，方停止进针。如此，才能保证腰麻药百分之百的注入到蛛网膜下隙，保障麻醉的满意率。
四 腰麻药物配置及给药的技巧

Barbotage注射法是往复回抽推注方法。Barbotage注射法可以产生注射局部的湍流现象，起到脊髓冲刷的作用，可以使局部麻醉药扩散更广、起效更快，麻醉效果更完善。所以，用Bbt注射法可以适当减少局部麻醉药的给药剂量。举例说明：剖宫产拟给予1%罗哌卡因12 mg，先抽取1%罗哌卡因1.2 ml，然后用脑脊液回抽稀释到2.4 ml（达到0.5%的给药浓度），推注到1 ml再回抽到1.5 ml，然后推注到0.5 ml再回抽到1 ml，继而推注到0.25 ml再回抽到0.5 ml，然后全部推注完毕。

来源：2021CAA年会《每日会讯》

转自：郭麻笔记

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    2022-02-16 ms8000000480388769

    学习

    0

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    2022-01-10 oooodoctor

    已学习

    0

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    2022-01-04 尹乔

    学习

    0

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    2021-12-31 rgjl

    #穿刺#

    0

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    2021-12-30 查查佳佳

    球新增病例如预期一样，快速上升，昨

    0

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    2021-12-30 D-House

    学习了

    0

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