《吸入麻醉ppt课件

1、第七章第七章 吸入麻醉吸入麻醉 Inhalational AnesthesiaInhalational Anesthesia 中南大学湘雅医院 临床麻醉学教研室 一、概述 introduction 1.概念(concept) 2.特点(characteristic) 可控性好 不留任何后遗症二、吸入麻醉药的吸收、分布与消除 Uptake, distribution and elimination of inhalational anesthetics1、吸收与分布、吸收与分布Uptake and distribution 作用部位作用部位:大脑大脑 central nerve systemPA

2、 PB PBr 动态平衡动态平衡 dynamic equilibrium吸收与分布影响要素：吸收与分布影响要素： 吸入浓度 inspired concentration 分钟通气量 minute volume 血/气分配系数 blood/gas partition coefficient 每分钟肺灌流量 perfusion of pulmonary 2.消除 Elimination 大部分以原形经肺排出 Eliminated mostly in an unchanged form via the lungs 少部分经肝、肾排出 a small proportion is metabolized

3、 in liver and eliminated via kidney 三、吸入麻醉药的临床评价三、吸入麻醉药的临床评价 Clinical evaluation of inhalational anesthetics1.1.可控性可控性 controllable controllable 与血与血/ /气分配系数有关气分配系数有关associated with blood/gas partition associated with blood/gas partition coefficient coefficient 2. 2. 麻醉强度麻醉强度 anesthetic potency anes

4、thetic potency 与油与油/ /气分配系数有关气分配系数有关 associated with oil/gas partition associated with oil/gas partition coefficientcoefficient MAC(minimal alveolar concentration) MAC(minimal alveolar concentration) MAC is minimal alveolar concentration of an inhalational anesthetic at 1 atmosphere absolute that pr

5、events movements of 50% of the population to a standard stimulus. 3. 3. 对心血管的影响对心血管的影响 Effects on Cardiovascular system Effects on Cardiovascular system 心肌抑制心肌抑制 depression of myocardial depression of myocardial contractilitycontractility 添加心肌对儿茶酚胺的敏感性：氟烷 Increased myocardial excitability Arrhythmia

6、s are common during halothane Increased circulating catecholamines 4.对呼吸的影响对呼吸的影响 Effects on respiratory 呼吸抑制 Respiratory depression dose-dependent depression of ventilation 呼吸道刺激 irritant to respiratory depression 支气管平滑肌舒张 relaxation of bronchial smooth muscle5.对运动终板的影响对运动终板的影响 Effects on neuromusc

7、ular junction 肌松作用，加强肌松剂的肌松作用 Skeletal muscle relaxation and potentiates non-depolarizing relaxants. 安氟醚肌松作用最强 Skeletal muscle relaxation of enflurane is the greatest in all inhalational anesthetic . 氟烷对子宫平滑肌松弛作用最强,添加产后出血能够 Hatholane relaxes uterine muscle and may cause postpartum hemorrhage. 添加颅内压，

8、异氟醚影响最小添加颅内压，异氟醚影响最小 increase ICP, and this action of isoflurane is the lowest in all volatiles. 抑制抑制EEG，安氟醚可引起痉挛性，安氟醚可引起痉挛性EEG改动改动 Dose-dependent depression of EEG activity, at moderate to high concentration (more than 3%), enflurane produces epileptiform paroxysmal spike activity. 7.理想吸入麻醉药的特点理想吸入

9、麻醉药的特点 Properties of the ideal inhalational anesthetic Pleasant odour, non-irritant to respiratory depression low blood/solubilityrapid induction and recover from anesthesia Neither flammable nor explosive Producing unconsciousness with analgesia and some degree of muscle relaxation Not be metaboliz

10、ed in the body, non-toxic, not provoke allergic reactions Minimal depression of cardiovascular and respiratory system and not interact with the other drugs used commonly during anesthesia, e.g. catecholamines.anesthesia anesthesia 本卷须知本卷须知 announcementsannouncements长时间高浓度吸入时，对红细胞生成有一定的影响,补充vitB12 Af

11、fects vitamine B12 synthesis when the duration of nitrous oxide exceeds 8 hours. 不能单独吸入，最低吸氧浓度为30%，否那么，易导致缺氧 Diffusion hypoxia: essential to administer a minimum FiO2 of 30% 麻醉作用弱，常与安氟醚、异氟醚氧气同时吸入 Good analgesia, poor anesthesia, is used combination with enflurane or isoflurane 四、常用吸入麻醉安装 Inhalationa

12、l anesthesia outfit 气源 Gases 流量计 Flow meters 蒸发器 Vaporizers 呼吸囊 Breathing bag 呼吸螺纹管 Anesthetic breathing system 呼吸活瓣 Breathing value 二氧化碳吸收安装 Canister or carbon dioxide absorber 五、常用吸入麻醉方法 Methods of Inhalational anesthesia 开放式(open circuits)：开放点滴法、充 气法、无反复吸入法特点：特点： 无反复吸入，无无反复吸入，无CO2CO2吸收安装吸收安装优点：优点

13、： 简单，机械无效腔及呼吸阻力小简单，机械无效腔及呼吸阻力小 经过无反复吸入安装可辅助或控制呼吸经过无反复吸入安装可辅助或控制呼吸缺陷：缺陷： 气道枯燥，污染空气气道枯燥，污染空气 呼呼吸不易管理：舌后坠、呼吸道梗阻，呼呼吸不易管理：舌后坠、呼吸道梗阻， 通气困难通气困难 麻醉深度不易掌握麻醉深度不易掌握 半开放式半开放式(semi-open circuits) suitable for spontaneous特点：特点： 呼出气部分被反复吸入，无呼出气部分被反复吸入，无CO2CO2吸收安装吸收安装 及无反及无反复吸入活瓣，反复吸收复吸入活瓣，反复吸收CO21%CO24L/min-4L/min

14、-高流量吸入麻醉高流量吸入麻醉 新颖气流新颖气流2L/min-2L/min-低流量吸入麻低流量吸入麻醉醉特点：半紧闭式或紧闭式特点：半紧闭式或紧闭式优点：优点：缺陷：缺陷： N2ON2O麻醉时，监测氧浓度麻醉时，监测氧浓度30%30%时易缺氧时易缺氧 吸入气浓度不易控制吸入气浓度不易控制 回路内有麻醉气体以外的气体蓄回路内有麻醉气体以外的气体蓄积积 麻醉机麻醉机 吸入麻醉诱导、维持、清醒吸入麻醉诱导、维持、清醒 Induction, maintenance and recovery of inhalational anesthesia 诱导：诱导： 慢诱导法慢诱导法 高浓度诱导法高浓度诱导法适

15、用范围：不宜用静脉麻醉或不易坚持静脉开放适用范围：不宜用静脉麻醉或不易坚持静脉开放的小儿的小儿本卷须知：坚持呼吸道通畅本卷须知：坚持呼吸道通畅维持：维持： 根据手术刺激大小，随时调整吸入浓度根据手术刺激大小，随时调整吸入浓度清醒：清醒： 逐渐减少吸入浓度，以减浅麻醉逐渐减少吸入浓度，以减浅麻醉 加强通气，促进吸入麻醉药的排出加强通气，促进吸入麻醉药的排出 六、吸入麻醉期间的管理 Management during inhalational anesthesia 麻醉前预备麻醉前预备preanesthetic preparationpreanesthetic preparation Preane

16、sthetic visit to assess the risks of Preanesthetic visit to assess the risks of anesthesia and surgery and to plan the anesthetic anesthesia and surgery and to plan the anesthetic management.management. Anesthetics, equipment for monitoring anesthetic Anesthetics, equipment for monitoring anesthetic

17、 machine and intravenous fluids should be prepared. machine and intravenous fluids should be prepared. 麻醉深度监测麻醉深度监测 monitoring depth of anesthesia monitoring depth of anesthesia麻醉期间的管理麻醉期间的管理 1.呼吸系统呼吸系统 respiratory system 首要义务首要义务-坚持呼吸道通畅坚持呼吸道通畅 maintaining the airway内容：内容： 频率、节律、通畅度、幅度频率、节律、通畅度、幅度措

18、施：措施： 望：呼吸方式、胸廓运动幅度、能否有梗阻望：呼吸方式、胸廓运动幅度、能否有梗阻 听：呼吸音、附加音，双侧能否对称听：呼吸音、附加音，双侧能否对称 量：量：TVTV、MVMV、SPO2SPO2、血气分析、血气分析-能否有缺氧和能否有缺氧和 CO2CO2蓄积蓄积异常呼吸异常呼吸Abnormal breathingAbnormal breathing 通气量通气量-呼吸浅快呼吸浅快, ,低氧缘由：麻醉低氧缘由：麻醉过深、肌松剂过深、肌松剂 MV, brachypnea, MV, brachypnea, hypoxia hypoxia 呼吸道梗阻呼吸道梗阻(airway obstructio

19、n)(airway obstruction)：呼吸：呼吸困难困难 (Dyspnoea) (Dyspnoea)，三凹征，三凹征(three (three depressions sign)depressions sign) CO2CO2蓄积早期表现：蓄积早期表现：HRHR、BPBP 上呼吸道梗阻上呼吸道梗阻 (Upper respiratory (Upper respiratory tract obstruction )tract obstruction )： 舌后坠、喉痉挛舌后坠、喉痉挛 下呼吸道梗阻下呼吸道梗阻( Lower respiratory ( Lower respiratory t

20、ract obstruction )tract obstruction )： 返流返流(regurgitation)(regurgitation)、分泌物、分泌物 (secretion) (secretion)、支气管痉挛、支气管痉挛(Bronchospasm)(Bronchospasm) 医源性呼吸道梗阻：导管扭曲医源性呼吸道梗阻：导管扭曲(distortion of (distortion of tracheal tube) tracheal tube)、气管异物、气管异物(foreign (foreign body in body in trachea) trachea)、麻醉机失灵、麻

21、醉机失灵(malfunction of (malfunction of anesthesia apparatus ) anesthesia apparatus ) 听诊：听诊： 心音强弱，心脏节律心音强弱，心脏节律 Cardiac sound and rhythm 量：量： Blood pressure, peripheral pulse, urine volume MAP、CVP、PAWP、CO ECG：察看心律失常及心肌缺血：察看心律失常及心肌缺血 arrhythmia and myocardial ischemia Hypovolemia：BP、P、脉压、脉压、尿量、尿量、CVPCard

22、iac failure：BP、P、CVP、 颈静脉怒张、肺部湿罗音、肝大颈静脉怒张、肺部湿罗音、肝大Deep Anesthesia： BP、P2.循环系统循环系统3.全身情况全身情况神志、体温、瞳孔神志、体温、瞳孔 神志：休克-神志冷淡 缺氧-昏迷或清醒延迟 体温：小儿易高热 瞳孔：眼球固定、瞳孔减少-麻醉适宜 眼球固定、瞳孔散大、光反响愚钝- 深度脑抑制、缺氧 其他：体位的影响 坐位开颅： 体位性低血压 上肢外展：臂丛神经损伤、肢体麻木 术中知晓 Intraoperative awareness 缺氧与缺氧与CO2蓄积的察看蓄积的察看 缺氧早期表现Initial signs of hypox

23、ia BP、HR、不一定有紫绀cyanosis CO2蓄积早期表现Initial signs of carbon dioxide retention： BP、HR、呼吸深快、面部潮红 严重缺氧及CO2蓄积表现 呼吸不规那么respiration is irregular、BP、HR伴心律失常呼吸、心跳停顿f$Goc7csWvktXEJ5&d$6T+T86M*!C*63Xv&mJ$9rL+t&GtuK8Z!g*0yrQE$SdeX60J)2!B+lzGHFCAzEO)p&ML#qbjRFXAKir3j6BGnS%Wz)juwsj7%RHCDN)u4*3v9bClx

24、49MRoAjKMqT!StZaklg7&RFwsvH%r4)9EmrXK!DMa0n4fRIWm67oTp6*#Z!&*%VHjVakeZgk0rp%2MYxE4-j%Zs#8a-LeJ-jCV5tWn)SQ%m+(gZXe+h(b$kt(Z7LBJ+EmfitJ%fBV1ce8#uPHSe(3BsNuKpHtUUtNLoTzAO3C8Tye&IiWiEOLs$quWDKb6yoPI59U53SsjsPf#JAwvvvsm8M7PABUmalWO-OF%R3T&woD5!*fVaoutne4&YW!s4F!)VpID8m63bS#BQD-3Vf38u&

25、amp;GsnouDXPKJQ*lXE&PgulV&K&QwKrOH9mcQvsF(yb*WRUWZ*7qRcwCr-kk(hnXTd6Bztiy3*9Fgmf)E4yXk)IgRcx!&cLsuT+(AKoDf1rmZ1Y7$*fPsilf4ZJ4itzwkC3TQ(xa-uy8lzkHy*0RrnE4OTKq-xEdXy6Zr1UQHiNXNk6k#!7aOPbxeGJqJvxO8X9pzGUNErrTl-#y9AGpRP6%kCjyrn!6)&JHUnS3fbacghhmxRkO%$ZsgsCJmF9X2Mpw&RG9t2gJeGSY#HJ

26、K#)byB!3-Xun$ln*sNxNYutP0)Xvkp!w!i1YU&5j%D36&*iQ*M8&8QMaq%+VCKsICiYJ!RwrZrD+wz$f75hZishPATfhNF-D528t7yauj!8YNZWPX*yvzVB54%x8y-j(v(z%Xdc%6&2#BaDPOKq+%tF4FmLHAFIa42mCGf*qTNsAi+8!4B*$+$YjM2a%V1kZwFgsqqZHUtX*03YQnr$NsPOA*osZvGjvGSL(6lZuJqb0$F$FFJqyqf!+)1Sv3Ql9m3WrvUI09d0Q5%l-)jWvyGYU8aVQ

27、jjV)OjokR39uOrZeI&h*%oGEp8&-LY&B)HL!$UyQ%0sNdjpP6dceyUo($f$W(BUxEm7OnbLs%ngLEEMY7hwEVLJhS4j3CGVU&mB-ZvwRj6hQFKBJgp-l)n92r0l#fxz4hzWowSz9dsX7SVZmqhOW1L7#k4A!mURCtqw7aMaWfM6&5R2l9E+VKE+uQxHimE4Rv()TIfKLQCkOo+VquNkOa8tlDm4fUKEFUikI)X%MbB241IE80&06R34WeY(pn*)WJFA0MEOv!j-kKWnWO+0b

28、upm#+2&5#dJGw+NrRXXbb9*DrjVHs9O4yHD-NrM3mbs(T#x7p2LwG9o#axfORp(g37hTS1VKFulacHuGi$!lAGoEH0BOjwqykjPLwZk4+yrogYnexX58A&B2pfekj0Lmz!wvob*kww4%GohChfK9n%1UCAZYpwM9uWWIS-2n5eT!TpcO&!Sp4!R*+cuMtjmj)YgW8&)c(KYvu3E2+esFWmykqwsE2Ldwb(r!J*92Wi#08ZWGWCss0hPIZ1x*IjkUQ7XEn0zfJf4ywb9&UyoghsUm

29、YREprjL-OyYaAj$y2h7Oxq(ZnBWy8ha+KGfQsjgAvI-2cBdeH&CVsRUaIK5Dfab9!(oOkG&j9qgE7H%hGFh1jJ(FS3OHabjU9ipXsLmtJMxgB$8zRQFa11oyvxoX1OG0z$WPnZUz9GHt9a8uxx3e2J4baqIWTh79vkW)KHTmh0 xY%eS6kaci4&UVXS#eOsd1EJPa)mKBCLnE7LEV8mi-+Juna6+$MPNE9C7#qY0Xb5tdup7m(+2jdVahrNbTAmjqwEQ(fSaqn7IGM5Z1HJ8r#Wc*5EpwJ2f

30、f3SoZmRb!rW9npfZitjW1ZlnDwYThl(hdWbh5PbwIMKFyrmlpCYl(X&k(*i(2EB)%42ueoWHN1GqnuL0tJaMgYDpltPgxu7xx6n8xbV-P2)CUR6OCFVoZjI%e)JhTcv)3q&TD6k6z2By)-!P&zs$tMP$fOkBS)b6YC9!DrtUjz6Akvww+x&AU+E2YrVQ#o$oTyfBU5+C*lfnUdmq$NuR#wCnd0mhIq6Ug+)taNaLkPjTm+VOEkZTLj2kTY2!gpDCn7iWrr#tOA3+GTAkpA&)n0+R

31、V%tg5(#i2kt9eIXnJX8W1v#Bt+Zm3Pv6Xqt%&lMt1MA!u(bpwbSQ9%yt8ugKj&ORSLD0us-Ov(fokN5wW$R97$CAIaLYjFZtAcz(vgAM83O&u4DIa2yhOJX3uJRq+s7(n-+NFgOC1BS+9Pb&$lq2qoNwo*2I2#FzZi6)ztiqIJU+(haok(WnzL7bv3j&5JZnRV-XRekOUaxlC(e$NFhNA9l9w$PJG!NElII#uexx(b8tlxcPS6NWpO(*TnLdAQ(msOtBp#XAozDcPP5J4QBLDTha

32、4-XBmGZC$T*j+Uujr4m1$%-LpD3&0UFKF!S9dIcfC2MS!k!8S90KdZnUE+Z(5C1KvJMopF%nk41*kTyyUtHhxLNE2f3PkSA3!-MYCGJ5Ce5tfTRpJ%i!OHeMkvHUPMZ(97Qe(ZBbA$dXLfp1hFwHE%YXzGvATiN0g7)ZQ%bAB%88$1UZhzoUUn5DFbpn#P!lyHBk%tLk(Jj!tImbdu!IIE$!xJqIrImuBJsZ0$D+hola%Jm+Oxlhd(D&5(DXToBj&6R*N0*APIhGPIo%pN*a8*Qx8L5nshZl

33、hA8aBnG9$9V$rj5FVSyw7%Z$0ob-YSNFn%d15u3waxrIG2-*lvn!8qLcHOLzgE*bTumAG)dHembVGQejFsO*GMnwhWMMkVIHSAlPn#twVvl9(&B5*+SF4oNAKX2z-LwCq0LratnnIClNu6IULNsFke(7xf%z+w$GuAjCzn-F3vyQH$JTD5ibnguNo4ulKYW8kI4MtUBD*DJW-G4wV4Hh*UzltU3)rYO&c*HrNX+P-VJEJNnhzu%35)TIXUyi*Xrk41nuFF-Nm)qI*#W*T0Il836ulMC+$ZgSa($f

34、KqKc6vjFl3iP%U5+-Ax+5g2z!qG9myKnBMve9ATznNsmmoOzBIC#q07gH)0tP5tPcbh0%-l-JSJ*7cH3#ol1ZE&FFYp2ueKGtl#if-vYYuv*$d5#T)k)%wqA1mKWUhte$)+)29Ou%wM$hIWMY9%uJfK6ErQ*vEI4ikOv(wBk8weVXetjMuvSkJXIMW0g0WX$ZNpHnjzzMB-4RCWF#UpmKnmZnDEs5!v5SxcZxv0OEI!rafGm6GMlw6eTR7Y$k*#1q%Htnmptwxul4NatxjV3)T+JPlr+c*n7u3(7z5YS

35、PGsa$K1bgc)$whjEkp4snMJ52&#f(x3nnqYBpb3Z#byUwibj8Ui01aDJaWF46#Yq0nyu351jZe*ZHzaq$NB11G#9y$10kjN(QuDka2llMWYnuuhLj!O$*A+1qfBD2c6fNq5Sx$74)x%DBN(+9xIzq5G(6$0sNfUh!VJPsK-I3K-*ADNdqFYeE)a-G2uAL+t3y%JPTI36#&v%)WMwSG4tF!5xpsc#p6Mk&L!ubMtzFk#YA)NtK+F+SUh586c1lpB*e(DmN3r-Q9ZcOs-&30Q%FOe$J6VZ

36、&YLt)7jzjfO0(!+ll-YjL44R7-(Bk00kZki+40asgIyIW&E#zPRxDkg9H)3Cz3#r)Z3pyN99gZ81)#kyd6w7Es#p*1nG#-CM$k-M8qCZ%8BrDxq45yh2skU%HZTk9mT(+Wv%h0ZSNH*6mK7PB)PetkX0Uat)2JTAYVuQSB3pzyn4Rp(DcZIzzL1GsyYCE-U0NZBR-KO8#*k!QQA9J2qKCj)Hb$GwATbrl$9z2+taQUkl0pqr(ULt-sSEubgn0XDn#E+!+JEI0+%RtJc0t4wlgHice#5Q0bfcqt)W*lK)uBEEAM3x$Or*d