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1、Topic of the Day I(for Interns and CA-2s)Oct 26 - Discuss unilateral epidural block - explain this result形成单侧硬膜外阻滞的原因Discussion point.A unilateral anesthetic block may result from the administration of local anesthetic in the epidural space secondary to the plica mediana dorsalis, a connective tissu
2、e band in the epidural space that extends in a vertical direction between the ligamentum flavum and dura mater dividing the epidural space in half. 由于背正中皱襞的存在，在硬膜外腔注入局部麻醉药后可造成单侧阻滞。背正中皱襞作为连接黄韧带和硬膜的带状结缔组织在硬膜外腔垂直延伸，并把其一分为二。Oct 27 - Compare sympathetic, motor p. 182, 183; Miller RD: Anesthesia, 5th ed.
3、Philadelphia, Churchill Livingstone, 2000; p. 1513-1514, 1497.Spinal Anesthetic SEs脊髓麻醉的并发症Some side effects associated with spinal anesthesia include hypotension, bradycardia, postdural puncture headache, total spinal, nausea, urinary retention, backache, neurologic sequelae, and hypoventilation.脊髓
4、麻醉的并发症包括低血压，心动过缓，硬膜穿破后头痛，全脊麻，恶心，尿潴留，腰背痛，神经病学结局和低通气。References. Stoelting RK, Miller RD: Basics of Anesthesia, 4th ed. Philadelphia, Churchill Livingstone, p. 176. Miller RD: Anesthesia, 5th ed. Philadelphia, Churchill Livingstone, 2000; pp. 1506-1507. Oct 29 - Discuss the dx and management of an acc
5、idental dural puncture意外穿破硬膜的诊断与处理Discussion point.Accidental puncture of the dura mater during attempted localization of the epidural space can be recognized by the anesthesiologist by the appearance of cerebrospinal fluid in the hub of the epidural needle. The flow of cerebrospinal fluid from the
6、large-bore needle is rapid and continuous. Cerebrospinal fluid is wann, distinguishing it from saline used for the loss of resistance technique for localization of the epidural space. Cerebrospinal fluid will also dipstick test positive for glucose. Once accidental dural puncture during attempted ep
7、idural anesthesia has occurred, the anesthesiologist may convert to a spinal anesthetic. Alternatively, the needle may be removed and reattempt an epidural anesthetic at another interspace. The development of a postdural puncture headache after accidental dural puncture with an 18-gauge epidural nee
8、dle is likely, given the size of the hole in the dura mater produced by the relatively large needle. For this reason the patient should be informed about the possibility of a postdural puncture headache and should be instructed as to whom to contact for evaluation and treatment should a postdural pu
9、ncture headache occur.（前面重复，不作叙述）一旦意外穿破硬膜，麻醉医生可改行脊髓麻醉。另外一种方法是拔出穿刺针后在另一个间隙试行硬膜外麻醉。假如硬膜破口正是 18G 硬膜外穿刺针所造成的，意外穿破硬膜就极有可能发生硬膜穿破后头痛。因此应该告知病人发生硬膜穿破后头痛的可能性，而且应说明一旦出现硬膜穿破后头痛病人可联系哪位医生进行评估和治疗。References. Stoelting RK, Miller RD: Basics of Anesthesia, 4th ed. Philadelphia, Churchill Livingstone, 2000; p. 182; M
10、iller RD: Anesthesia, 5th ed. Philadelphia, Churchill Livingstone, 2000; p. 1513-1514. Oct 30 - Discuss caudal anesthesia - anatomy, technique, etc.骶管麻醉相关的解剖、技术及其他Discussion points.To facilitate the administration of a caudal anesthetic the adult patient should be in the prone position, whereas the
11、pediatric patient may be in the lateral decubitus position.The sacral hiatus is located between the sacral cornua approximately 5 cm from the tip of the coccyx.For the administration of a caudal anesthetic the needle is first introduced through the sacrococcygeal ligament perpendicular to the skin.
12、After contact with the sacrum, the needle is withdrawn slightly and redirected at a slightly reduced angle about 2 cm into the caudal canal. The needle is then appropriately placed for the administration of the local anesthetic for caudal epidural anesthesia.Confirmation that the needle tip is appro
13、priately placed in the caudal canal for the administration of local anesthetic can be made by injecting about 5 mL of saline or air. If the needle is subcutaneously placed, subcutaneous air or a subcutaneous bulge will appear overlying the tip of the needle. Aspiration on the needle before injection
14、 would result in the appearance of cerebrospinal fluid in the syringe if the needle were erroneously placed in the subarachnoid space.为了有助于骶管麻醉的实施，成年人应该采取俯卧位，而小儿则可采取侧卧位。骶管裂孔位于距尾骨尖端约 5 cm 的两侧骶角之间。实施骶管麻醉时，穿刺针首先垂直刺过皮肤和骶尾韧带，触及骶骨后，针回退少许后稍放低，重新推进 2 cm 进入骶管腔，然后适当固定穿刺针以注射局麻药。为了确认针尖是否位于骶管腔，可注射 5ml 生理盐水或空气。如果
15、针位于皮下，可在针尖上面覆有一皮下气肿或皮下隆起。如果针误入蛛网膜下腔，注射前可回抽出脑脊液。References. Stoelting RK, Miller RD: Basics of Anesthesia, 4th ed. Philadelphia, Churchill Livingstone, 2000; p. 183; Miller RD: Anesthesia, 5th ed. Philadelphia, Churchill Livingstone, 2000; p. 1508, 1511-1512, 1525. Topic of the Day II(for CA-2s and C
16、A-3s)Oct 26 - Discuss adrenal insufficiency and supplemental periop steroids肾上腺皮质功能不全和围术期替代治疗Discussion points:Adrenocortical insufficiency can be due to the destruction of the adrenal cortex by cancer, tuberculosis, or hemorrhage; to deficiency in adrenocorticotropic hormone; or to the prolonged exogenous administration of corticosteroids. The adrenal cortex of the adrenal gland synthesizes glucocorticoids, mineralocorticoids, and androgens. Cortisol, a glucocorticoid, is essential for the
