【正文】 n 228 cases.(Grant) ? Seda等報(bào)道 597例，局麻藥毒性反應(yīng) 17例（ %）神經(jīng)損傷 3例（ %）血腫 1例 ? In 597 cases,17(%) with anesthetics toxicity, 3(%) with nerve hurt and 1 with edema ? Bradley等報(bào)道 405例，感染 1例，血腫 1例，神經(jīng)損傷 5例，導(dǎo)管斷裂殘留 1例 ? Bradley reports 405 patients, one with infection, one with edema, five with nerve block and one with rupture of canula ? 并發(fā)癥對(duì)策 Strategy of plication ? 注意神經(jīng)損傷環(huán)節(jié) :手術(shù)體位，止血帶應(yīng)用，外科損傷 ,神經(jīng)牽拉等。 ? Pay attention to protect nerve, like surgical position, application of tourniquet, operation damage, stretch of nerve ? 導(dǎo)管滑脫與移位多由固定和病人不當(dāng)活動(dòng)等產(chǎn)生，在更合適的導(dǎo)管產(chǎn)品誕生前，尚無(wú)有效的解決辦法。 ? Surge and dislocation of canula is most caused by incorrect fixation and patients movement ? 并發(fā)癥對(duì)策 ? 注意損傷環(huán)節(jié) :手術(shù)體位，止血帶應(yīng)用，外科損傷 ,神經(jīng)牽拉等。 ? 導(dǎo)管滑脫與移位多由固定和病人不當(dāng)活動(dòng)等產(chǎn)生，在更合適的導(dǎo)管產(chǎn)品誕生前，尚無(wú)有效的解決辦法。 ? 局麻藥的毒性反應(yīng)存在著一定的個(gè)體差異，除了嚴(yán)格遵循用藥指征外，合理應(yīng)用輔助藥物如腎上腺素，可樂(lè)定，阿片類藥物等，也是比較可行的方法。 ? 對(duì)于解剖、生理的掌握是麻醉醫(yī)師減少各并發(fā)癥的首要措施。 ? 影像學(xué)定位下神經(jīng)阻滯的操作可能會(huì)減少并發(fā)癥，但其優(yōu)點(diǎn)有待進(jìn)一步研究。 三、下肢神經(jīng)阻滯在老年重危病人中的應(yīng)用 Application of lower extremity nerve block in elderly severe patients 方法 Methods ? 2022年 3月 ~2022年 3月 ,109例重危老年患者 ? 2022 Mar～ 2022 Mar, 109 elderly severe patients ? 腰叢 +后路坐骨神經(jīng) +股神經(jīng)阻滯 59例 ? Lumbar plexus+sciatic n(posterior)+ femoral n. block, n=59 ? 腰叢 +后路坐骨神經(jīng)阻滯 50例 ? Lumbar plexus+sciatic n block, n=50 結(jié)果 Results ? 年齡 79?8 (67~92)歲 Aged 79?8(67~92) yr ? 手術(shù)種類 :動(dòng)脈轉(zhuǎn)流 (87例 )， (股 A脛后 A、髂 股 A、股 月國(guó)A等 )，大隱靜脈剝脫術(shù)、下肢動(dòng)脈、靜脈取栓、下肢截肢等 Operation: artery bypass(n=87), saphenectomy, amputation,etc. ? 夾雜癥：糖尿病、高血壓、心臟病 (心梗、房顫、心肌缺血、頻發(fā)室早、房早、心衰等 )， 患者有兩種以上夾雜癥 Complication: DM, HT,heart disease ? 70%以上患者麻醉前有抗凝治療史 70% patients with anticoagulation therapy ? 阻滯成功率為 100% ? Success ratio=100% ? 無(wú)局麻藥毒性反應(yīng)和硬膜外阻滯等不良反應(yīng) ? No toxicity of local anesthetics or epidural block ? 手術(shù)時(shí)間 5?2h ? Operation duration: 5?2h ? 局部麻醉藥用量 Dosage ? 腰叢 25~40ml Lumbar plexus 25~40ml ? 后路坐骨神經(jīng) 25~40ml Sciatic n block (Posterior approach) 25 ~40ml ? 前路股神經(jīng) 15~20ml Femoral n block (Anterior approach) 15~20ml ? 總量 80ml Total dosage less 80ml ? 76%患者耐受良好，少量鎮(zhèn)靜劑 Good tolerance 76%, minority need sedation ? 少數(shù) 患者需加用喉罩 靜脈麻醉 Minority patients need LMAVein anesthesia ? 術(shù)中血流動(dòng)力學(xué)平穩(wěn) ? Stable hemodynamic perioperative ? 血流動(dòng)力學(xué)不僅受麻醉操作的影響，更與其存在的基礎(chǔ)疾病有關(guān)，夾雜心血管疾病患者，處理應(yīng)格外小心 ? Anesthetic operation and bined diseases all affect the hemodynamic changes. Pay attention to such patients with high risks. ? 70%患者術(shù)前、術(shù)中或術(shù)后需抗凝治療，且手術(shù)時(shí)間較長(zhǎng)，為椎管內(nèi)麻醉的禁忌癥 ? 70% patients are contraindicated to epidural block as anticoagulation therapy and long operation duration ? 全身麻醉蘇醒延長(zhǎng)、增加呼吸并發(fā)癥，部分患者需在手術(shù)后呼吸支持 ? General anesthesia will prolong the recovery, cause more respiratory plications. Someone need postoperative respiratory support 討論 Discuss ? 低濃度、高容量局麻藥給藥方法 ? Low concentration and large volume anesthetics method ? 術(shù)前常規(guī)靜注咪達(dá)唑侖 1~2mg、芬太尼~ ? Premedication: midazolam1~2mg,~mg, iv ? 手術(shù)醫(yī)師和病人麻醉滿意率 90% ? Satisfactory ratio over 90% ? 部分因手術(shù)時(shí)間長(zhǎng)或手術(shù)范圍等原因加用喉罩靜脈麻醉的患者，全麻藥用量很少，患者清醒時(shí)間明顯縮短，所有患者均在 1h內(nèi)送返病房 ? Some patients bined venous anesthesia for long operation duration or additional operation fields need less anesthetics paring to the single general anesthesia, which reduce the stay time in PACU ? 老年重?；颊呦轮中g(shù)時(shí)使用神經(jīng)刺激器輔助神經(jīng)阻滯的成功率高、血流動(dòng)力學(xué)平穩(wěn)、術(shù)后并發(fā)癥少 ? Lower extremity nerve block is of high successful rate,stable hymodynamic and seldom plications with nerve stimulator in elderly severe patients 結(jié)論 Conclusion 注意點(diǎn) precaution ? 夾雜癥的治療和處理 ? Treatment and management of plication ? 阻滯前使用適量的靜脈鎮(zhèn)靜、鎮(zhèn)痛藥物 ? Sedation and analgesia before operation ? 局麻藥容積多是經(jīng)驗(yàn)性的 ? The volume of local anesthetics is by experience ? 下肢缺如患者刺激器定位反應(yīng)較差 ? Bad response in patients without lower extremity