ContraindicationstoSpinalAnesthesia
脊髓麻醉禁忌症
作者
AdrianChinandAndrevanZundert
Thereareabsoluteandrelativecontraindicationstospinalanesthesia(seeTable1).Absolutecontraindicationsincludepatientrefusal;infectionatthesiteofinjection;severe,uncorrectedhypovolemia;trueallergytoanyofthedrugs;andincreasedintracranialpressure,exceptincasesofpseudo–tumorcerebri(idiopathicintracranialhypertension).HighintracranialpressureincreasestheriskofuncalherniationwhenCSFislostthroughtheneedle.Spinalanesthesiaisalsocontraindicatedwhentheoperationisexpectedtotakelongerthanthedurationofthenerveblockorresultinbloodlosssuchthatthedevelopmentofseverehypovolemiaislikely.
脊髓麻醉有绝对和相对的禁忌症（见表1）。绝对禁忌症包括患者拒绝；注射部位感染；严重，未纠正的低血容量；对任何药物真正过敏；颅内压升高，除了假性脑肿瘤（特发性颅内
高压）。当脑脊液通过穿刺针丢失时，颅内高压会增加颞叶钩回疝的风险。当手术预期持续时间超过神经阻滞的时间或因失血从而可能发展为严重的低血容量时，脊髓麻醉也是禁忌的。
TABLE1.Contraindicationstospinalanesthesia.
表1.脊髓麻醉的禁忌症
AbsoluteContraindications绝对禁忌症
?Patientrefusal患者拒绝
?Infectionatthesiteofinjection穿刺点感染
?Uncorrectedhypovolemia未纠正的低血容量
?Allergy过敏
?Increasedintracranialpressure颅内压增加
RelativeContraindications相对禁忌症
?Coagulopathy凝血病
?Sepsis脓*症
?Fixedcardiacoutputstates固定的心输出量状态
?Indeterminateneurologicaldisease不确定的神经系统疾病
Coagulopathy,previouslyconsideredanabsolutecontraindication,maybeconsidereddependingonthelevelofderangement.Anotherrelativecontraindicationofspinalanesthesiaissepsisdistinctfromtheanatomicsiteofpuncture(eg,chorioamnionitisorlowerextremityinfection).
Ifthepatientisonantibioticsandthevitalsignsarestable,spinalanesthesiamaybeconsidered.Spinalanesthesiaisrelativelycontraindicatedincardiacdiseaseswithfixedcardiacoutput(CO)states.Aorticstenosis,onceconsideredtobeanabsolutecontraindicationforspinalanesthesia,doesnotalwaysprecludeacarefullyconductedspinalanesthetic.
凝血病，以前被认为是绝对禁忌症，可根据紊乱的程度进行考虑。脊髓麻醉的另一个相对禁忌症是远离于解剖穿刺点的脓*症（如绒毛膜羊膜炎或下肢感染）。
如果患者服用抗生素治疗且生命体征稳定，可考虑脊髓麻醉。脊髓麻醉对于心输出量固定的心脏疾病是相对禁忌症的。主动脉瓣狭窄，曾经被认为是脊髓麻醉的绝对禁忌症，并不总是排除仔细进行的脊髓麻醉。
Indeterminateneurologicaldiseaseisarelativecontraindication.Multiplesclerosisandotherdemyelinatingdiseasesarechallenging.Invitroexperimentssuggestthatdemyelinatednervesaremoresusceptibletolocalanesthetictoxicity.However,noclinicalstudyhasconvincinglydemonstratedthatspinalanesthesiaworsenssuchneurologicdiseases.Indeed,withtheknowledgethatpain,stress,fever,andfatigueexacerbatethesediseases,astress-freecentralneuraxialnerveblock(CNB)maybepreferredforsurgery.
不确定的神经系统疾病是一种相对的禁忌症。多发性硬化症和其他脱髓鞘性疾病具有挑战性。体外实验表明，脱髓鞘神经对局麻药*性易感。然而，没有临床研究令人信服地证明脊髓麻醉会恶化这种神经系统的疾病。事实上，知道了疼痛，压力，发热和疲劳加剧这些疾病，无压力下的中枢轴索神经阻滞(CNB)可能是手术的首选。
Spinalanesthesiaintheimmuno