胸科病人手术的麻醉.ppt

1,Anesthesia for Thoracic Surgery,Zhao-Qiong Zhu, M.D. Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi , Guizhou,563003, China,2,胸科手术的麻醉 遵义医学院麻醉学教研室 朱昭琼,3,要 求,掌握剖胸及侧卧位时呼吸、循环病理生理的改变 掌握剖胸手术病人麻醉前的估计和方法及麻醉的基本要求 熟悉单肺通气的生理变化、及单肺通气的术中管理 熟悉常见胸科手术的麻醉处理,4,第一节 剖胸及侧卧位时对呼吸、 循环的影响(p 119),剖胸所引起的病理生理改变自主呼吸时 1 剖胸侧通气与肺血流比例失调肺内分流 （hypoxic pulmonary vasoconstriction; HPV有限，并受麻醉药及扩管药抑制） 2 反常呼吸（paradoxical respiration) 摆动气 死腔增大 3 纵隔移位 纵隔摆动(mediastinal swaying ),5,剖胸及侧卧位时对呼吸、循环的影响,4 心排出量降低 其原因（1）（2）（3） 5 心律失常 其原因（纵隔摆动时对部位神经的刺激、通气功 能紊乱、 VAQ比失常、PaO2和PaCO2) 6 体热的散失,6,侧卧位对呼吸生理的影响,清醒状态下侧卧位 (function residual capacity;FRC下降 VAQ比 基本正常) 全麻下侧卧位 FRC下降 VAQ比失常：下侧肺VAQ下降， 上侧肺VAQ升高,7,第二节 麻醉前评估与准备,必要性（胸科手术术后肺部并发症发生率较高） 肺部并发症最常见 围术期死亡率居第二位 肺功能异常者并发症是正常者23倍 （切除肺病变，肺通气面积；手术操作肺损伤，出血、水肿；术后痛疼，分泌物坠积或肺不张 etc.),8,Preoperative evaluation,Patients for thoracic surgery should undergo the usual preoperative assessment as detailed in Chapter 1. Any patient undergoing elective thoracic surgery should be carefully screened for underlying bronchitis or pneumonia and treated appropriately before surgery. Diagnostic procedures such as bronchoscopy and lung biopsy（活检） may be intended for persistent infection. Infection beyond an obstructing lesion（损害）may not resolve（解决） without surgery.,9,In patients with tracheal stenosis（狭窄）, the history should focus on symptoms or signs of positional dyspnea, static versus dynamic airway collapse, and evidence of hypoxemia. The history may also suggest the probable location of the lesion. Arterial blood gas (ABG) determinations may help to clarify the severity of underlying pulmonary disease but are not routinely necessary. Pulmonary function tests are useful in assessing the pulmonary risk of lung resection. Both exercise function (maximal oxygen uptake O2max) and spirometry (forced expiratory volume in 1 second) have been used to stratify risks of resection. In marginal cases, split-function radionuclide scans and ventilation/perfusion ( ) scans can determine the relative contribution of each lung and individual lung regions.,Preoperative evaluation,10,Cardiac function should be assessed if there is question of the relative contribution of cardiac and pulmonary disease in the patients functional impairment. Echocardiography can estimate pulmonary artery pressure and right ventricular function. Imaging studies, such as chest radiography, computed tomography (CT), and magnetic resonance imaging, are useful to determine the presence of tracheal deviation, the location of pulmonary infiltrates, effusion or pneumothorax, and the involvement of adjacent structures in the disease.,Preoperative evaluation,11,Tracheal tomography or three-dimenional reconstruction from CT is used to assess the caliber of stenotic airways and can be used to predict the size and length of the endotracheal tube that will be appropriate for the patient. Severe airway stenosis（狭窄）observed preoperatively may change the anesthetists plans for induction and intubation.,Introduction,Preoperative evaluation,12,麻醉前评估,一般情状： 吸烟、年龄、肥胖、手术时间 临床病史和体征: 有无呼吸困难、哮喘、咳嗽、咳痰、胸痛、吞咽困难 气管受压移位、液气胸、异常呼吸音 胸部拍片、CT 肺功能测定及血气分析:,13,肺功能测定,屏气试验 吹气试验 肺功能测定: “平板运动试验” 临床常用的指标（TVC、FEV1、FVC、FEV1/ FVC、MVV） 肺活量60 通气储备量70 FEV1/FVC60 有术后呼吸功能不全的可能,14,FVC45mmHg、RV/TLV(余气量/肺总量） 50%，全肺切除术后风险,15,全肺切病人术前肺功能测定最低限度应合以下标准： （1） FEV1 2L 、 FEV1/ FVC 50% （2）MVV 80L/min或50%预计值 （3）RV/TLC 0.8L 不附合上述标准应行分侧肺功能测定 （4）平肺动脉压 45mmHg肺叶切除术的要求可稍低 运动时最大氧摄取量（VO2max 20L/(kg.min),16,血气分析,PaO2 了解肺的氧合情况 PaCO2 肺通气功能 A-aDO2 肺换气功能,17,Preoperative sedation should be given carefully to patients with tracheal or pulmonary disease. 1.Heavy sedation may impair postoperative deep breathing, coughing, and airway protection. 2.Patients with poor pulmonary function will be more prone to hypoxemia when their respiratory drive（呼吸动力） is suppressed. When sedating these patients, it is wise to monitor oxygenation and administer supplemental oxygen.,Preoperative preparation,18,3. In the presence of airway obstruction, sedation must be carefully balanced. Oversedation may profoundly（深深地) suppress ventilation, but an anxious patient may make exaggerated(夸大的, 夸张的) respiratory efforts. In this case, the increased turbulence may cause worsened airway obstruction, leading to increased anxiety. Benzodiazepines, reassuring(安慰的)words, careful monitoring, and an expeditious(迅速的）start to the procedure is the best approach.,Preoperative preparation,19,Preoperative preparation,Aspiration（吸引） prophylaxis（预防）, with an oral histamine-2 receptor antagonist and metoclopramide（胃复安), should be considered in patients undergoing major thoracic surgery. Patients with esophageal disease should be considered at high risk for aspiration.,20,麻醉前准备,停止吸烟 控制肺部感染，尽力减少痰量 保持气道通畅，防治支气管痉挛 控制感染外，常用的解痉和扩张支气管药： 1）氨茶碱 2）肾上腺糖皮质激素 3）色甘酸钠 4）2受体激动药 锻炼呼吸功能 低浓度氧吸入 对并存的心血管方面情况进行处理,21,第三节 胸科手术麻醉的特点与 处理,一、胸科手术麻醉的基本要求 消除或减轻纵隔摆动与反常呼吸 避免肺内物质的扩散 负压吸引的注意事项：1）适当麻醉深度 2）吸引时间 3）负压和相对无菌操作 4）吸引要及时 支气管插管,22,保持Pa02和PaCO2于基本正常水平 尽力缩小VAQ比失常：1）高浓度氧吸入，通气量10ml/kg；定时膨胀塌陷肺，术侧肺以不完全肺萎陷为宜 2）保持生理范围内的PaCO2。如出现PaCO2增高，不宜增大每次通气量，可适当增加每分钟的通气频率 PETCO2和SPO2监测 减轻循环障碍 1）增加输液量 2）维持较高CVP 3）适当麻醉深度 4）适当估计出血量。全肺切避免肺水肿 保持体热,23,二、 One-lung ventilation单肺通气,慨念 适应症 湿肺 支气管胸膜瘘 胸腔镜手术 肺叶全肺部手术(相对适应症),24,(一)单肺通气的生理变化,非通气侧肺产生肺内分流 通气侧肺VA/Q 异常 若缺氧性肺血管收缩（HPV）反应良好，双肺分流量约20-25 若缺氧性肺血管收缩受损，双肺分流量约 25 若非通气侧肺病变越严重，分流量越小 单肺通气均有不同程度的肺内分流 （单肺通气时，PaO2在67.5-70mmHg可接受）,25,单肺通气时呼吸管理,处理的原则： 减少非通气侧的肺血流和避免通气肺的肺不张和肺泡顺应性降低,26,呼吸管理具体方法,尽可能采用双肺通气 在由双肺通气改为单肺通气时，应先手控 通气量不能过低或过高，一般10ml/kg 适当增加呼吸频率（比正常增加20 ） 应监测PETCO2和SPO2及血气分析 如发现低氧血症或PaO2 ，其处理：,27,1）停用氧化亚氮 2）检查操作、导管、吸引 3）术侧肺通气；非通气肺内可用纯氧吹胀，然后关闭呼吸口，约20分钟重复一次 4）通气侧适当用PEEP呼吸，压力 5cmH2O 5）如前处理无效，SPO2，通知术者双肺通气 6）术者可压迫或钳夹术侧肺动脉 7. 单肺通气恢复双肺通气时，进行手法通气，首先使非通气肺膨胀，进行手法通气,28,第四节 常见胸科手术麻醉处理,肺部手术 静脉通道 体位 测压 关胸前应检查有无漏气、肺是否膨胀 接水封瓶并再次膨肺,29,(一)肺叶切除,对于无肺内物质扩散或堵塞危险的病例，一般均可在气管内插管全麻下完成 “湿肺”病人，插双腔支气管导管将病肺与健肺隔离 肺大泡的病人注意：麻醉前肺大泡已破裂，应先作闭式引流；警惕肺大泡可能破裂，作间歇正压必须用较低的压力,30,肺切除术,选用双腔支气管导管插管 在术者切除全肺组织前应将支气管导管退回