全麻期间严重并发症的预防和治疗下载PowerPoint演示文稿

1、Chapter 14prevention and treatment of serious complications during general anesthesiaIntroductionComplications of anesthesia involve three aspects：1. Patients condition2. Diathesis of anesthetist3. Influence and fault of anesthetics、 anesthetic apparatus and correlated instrument Serious Complicatio

2、ns during General Anesthesia Respiratory tract obstruction Respiratory depression Hypotension and Hypertension Myocardial ischemia Hyperthermia and Hypothermia Awarenss and Delay of Awake Cough、Singultus、Postoperative vomiting、 Postoperative pulmonary infection Malignant hyperthermiaRespiratory Obst

3、ruction 一、Glossocoma： 1Aetiology： 2Liability factor：1Justo major of corpus linguae2Short and stout3Short neck4Lymphadenosis of throat posterior wall5Hypertrophy of tonsilsRespiratory Obstruction 3Clinical features： 4Management：1Side lying、2Head hypsokinesis、3Lift submaxilla、4Oropharyngeal parichnos

4、Nasopharyngeal parichnosRespiratory Obstruction 二、Airway obstruction by secretion、 purulent sputum、blood and foreign object 1Aetiology：1Inhalation of stimulant anesthetic，2Bronchiectasis、pulmonary abscess、 pulmonary tuberculous cavityRespiratory Obstruction3Operation of cavum nasopharyngeum、 oral ca

5、vity、Harelip4Desquamation of tooth or artifcal teeth 2Management：1Sufficient belladonna premedication2Intubation3Suck respiratory tract4Pull out dentium vacillatia or artifcal teetRespiratory Obstruction 三、Regurgitation and Aspiration 1Aetiology：Anticholinergic agent Morphine General anaesthetics Mu

6、scle relaxant 2Clinical features：1Bronchospasm2Tachypnea and dyspnea3Moist rales4Sever hypoxiaRespiratory Obstruction 3Management：1Fasting： Adult：8h before anesthesia Children： milk and solid diet liquid 36 m 8h 3hRespiratory Obstruction2Preoperative administration of an H2-receptor antagonistcimeti

7、dine or ranitidineto decrease further secretion of additional acid.3Application of gastric decompression by a wide- bore nasogastric tube; Preparing for suction 4Full stomach/high level ileus：awake intubation5Rapid - sequence induction and intubation without positive - pressure ventilation before in

8、tubation.Respiratory Obstruction6Application of cricoid compression to control regurgitation of gastric contents7Extubation when the patient is fully awake8Aspiration： Head down position，suck vomitus Bronchial antispasmodic and antibiotics Respiration support Lavage of trachea using 0.9%NaClRespirat

9、ory Obstruction四、Malposition of catheter、Obstruction of lumina、Anaeshetic machine failure 1. Aetiology：Catheter twist Block by sputum Corrugated tube twist Malfunction of respiration valve 2. Management：Examine position of catheter Respiratory sound Breathing circuit Respiration valveRespiratory Obs

10、truction五、Trachea Compression1. Aetiology：tumor of neck or mediastinum hematoma 、edema calidum2. Management：六、Inflam affection of pharyngo-oral cavity、 Larynx tumer、Allergia laryngeal oedema1. Aetiology：peritonsillar abscess、 Larynx tumor pharynx posterior wall abscess2. Management：Respiratory Obstr

11、uction七、Laryngospasm and Bronchospasm一Laryngospasm：1. Aetiology：pharyngeal vagus nerve excitability2. Evoked reasons：1hyoxemia、hypercapnia、secretion、intubation oropharynx parichnos、laryngoscope2light anesthesia3. Clinical features4. ManagementRespiratory Obstruction 5. Prevention：avoid light anesthe

12、sia、hypoxia carbon dioxide accumulation 二Bronchospasm： 1. Aetiology： 1Tracheal intubation、aspiration、suck sputum2Operation stimulate3Thiopental Sodium、Morphine 2. Clinical features： 3. Management：Respiratory depression 一、Central Respiratory depression 1Aetiology：anesthetics、hyperventilation narcotic

13、 analgesics 、 inflate lung unduly 2Management：1Anesthetics reduce depth of anesthesia2Narcotic analgesics Naloxone3Hyperventilation、inflate lung undulyVTRespiratory depression 二、Peripheral Respiratory depression 1. Aetiology：muscle relaxant hypopotassemia general anaesthesia + epidural block 2. Mana

14、gement：1Muscle relaxant Neostigmine Bromide2Hypopotassemia supply potassium in time3Spinal nerve block waitRespiratory depression 三、Respiration Management 1. Effective ventilation 2. Select of ventilation mode：1Assistor respiration2Controlled respiration Hypotention and Hypertension 一、Hypotension 1H

15、ypotension： 20% or 80mmHg 2Aetiology：1anesthesia aspects2operation aspects3patient aspectsHypotention and Hypertension 3Prevention：1Insufficient body fluid sufficiently supply2Severe anaemia3Severe mitral valve stenosis4Myocardial ischemia maintain blood pressureHypotention and Hypertension 5 Myocar

16、dial infarction 6 Congestive heart failure 7 BBB、sick sinus syndrome pacemaker 8 Hypopotassemia 9 Atrial fibrilation 80120 bpm 10Using long-term corticosteroidHypotention and Hypertension 4Management： 1Reduce depth of anesthesia 2Transfusion，Ephedrine 3Severe coronary heart disease support cardiac p

17、ump function 4Drag internal organs stop operative procedure 5Adrenal insufficiency large dose of dexamethasone 6Cardiac arrestcardiac resuscitationHypotention and Hypertension 二、Hypertension 1Hypertension： 2Aetiology： 1Anesthesia aspects 2Operation aspects 3Patient aspectsHypotention and Hypertensio

18、n 3. Prevention：1Sufficient premedication2Phaeochromocytoma、hyperthyroidism3Intubation enhance anesthesia surface anaesthesia or -receptor blocker4Avoid hypoxia and carbon dioxide accumulationHypotention and Hypertension5Craniocerebral operationsdroperidol6Operation stress compound with epidural blo

19、ck 4Management：1Increase depth of anesthesia2 or -Receptor blocker vascular smooth muscle relaxant3Ventilatory capacity、FiO2Myocardiac Ischemia 一、Correlative physiological knowledge 1. Oxygen consumption of myocardium：1HR2myocardial contractility3intraventricular pressure 2. Coronary Perfusion Press

20、ure = AOP IMP AOP- aortic pressure IMP- intramyocardial pressureMyocardiac Ischemia二、Diagnostic method：ECG 1. Cardiac conduction abnormality 2. Arhythmia 3. Q wave，R wave progressive step down 4. S-T l mm or 2 mm 5. T wave is low、bidirection or inversionMyocardiac Ischemia三、Aetiology 1. Tension、fear

21、、pain 2. Hypotension or hypertension 3. Myocardial contractility suppression and vessel distension by anesthetic 4. Hypoxia 5. Tachyrhythmia or ArhythmiaMyocardiac Ischemia四、Management 1. Maintain the balance of Oxygen supply- demand 2. Delay selective operation 3. Monitor：ECG、MAP、CVP、CO、 SVR、Urine

22、volume 4. -receptor blocker or calcium channel blocker 5. Analgesia using morphine 6. General anaesthesia + epidural blockHYPERTHERMIA AND HYPOTHERMIA 一、Heat Production and Elimination 1Heat Production： 2Heat Elimination： 1Radiation： 60% 2Conduction：3% 3Cconvection：12% 4Evaporation：25% HYPERTHERMIA

23、AND HYPOTHERMIA 二、Normal Thermoregulation ： 1. Thermoregulatory control system：1Cold-response thresholds：36.5,vasoconstriction2Warm-response thresholds：37,sweat 2. Thermoregulation during General Anesthesia：1warm-response thresholds：1 to 382cold-response thresholds：2 to 34.5 3. Responses in infants

24、and the elderlyHYPOTHERMIA 三、Hypothermia：core temperature 282无菌单覆盖过于严密3开颅手术在下视丘附近操作4large dosage of atropine5Response to transfusions 6Ventilation：循环紧闭法HYPERTHERMIA 2Influence of Hyperthermia1Basal metabolic rate2Metabolic acidosis、hyperkaliemia hyperglycosemia3 40convulsion 3PreventionAwarenss and

25、Delay of Awake 一、Awarenss 1. Neurophysiology of Awarenss 2. Anaesthetic technique1N2O-O2- Muscle relaxant2Fentanyl - Diazepam3Thiopental or Thiopental - KetamineAwarenss4N2O- Fentanyl5Etomidate - Fentanyl6Procaine combined anesthesia 3. Management：1Avoid light anaesthesia2Monitor brain stem auditory

26、 evoked potentialBSAEPPRST记分系统 指标 体征 分值 收缩压mmHg 对照值 + 15 0 对照值 + 30 2 心率次/min 对照值 + 15 0 对照值 + 30 2 汗液 无 0 皮肤潮湿 1 可见汗珠 2 泪液 分开眼睑泪液不多 0 分开眼睑泪液过多 1 闭眼有泪液流出 2Delay of Awake 二、Delay of Awake： 30min 1. Aetiology：1Influence of Anaesthetic： Premedication Inhalation Anaesthetic Narcotic Analgesic Muscle Rel

27、axantDelay of Awake2Respiratory depression： Narcotic Analgesic and Muscle Relaxant Hypocapnia Hypercarbia Kaliopenia Overdose of Transfusion Complications of operation Severe metabolic acidosisDelay of Awake3Severe Complications ： massive bleeding serious cardiac arrhythmias acute myocardial infarct

28、ion rupture of intracranial aneurysm cerebral hemorrhage cerebral embolism4Long time of hypotension and hypothermia 5Cerebral vessels affection before operationDelay of Awake 2. Management：1Aspect of Anaesthetic technique2corresponding management3 dehydration：encephaledema intracranial hypertension4

29、hypothermia - warm5long-term hypotension6primary cerebral diseaseCough、Singultus、Postoperative vomiting and postoperative pulmonary infection 一、Cough 1. Degree of cough1轻度：阵发性腹肌紧张和屏气2中度：阵发性腹肌紧张、屏气，颈后仰、 下颌僵硬、紫绀3重度：腹肌、颈肌、支气管平滑肌阵发性 强力持续性痉挛，上半身翘起、 长时间屏气、严重紫绀Cough 2. Harmful effects of cough1腹内压剧增内脏外膨、胃内

30、容物反流、 伤口及组织撕裂2颅内压剧增，对原有颅内病变者可致 脑出血或脑疝3血压剧增伤口渗血、心脏作功、 甚至诱发心衰Cough 3Evoked reasons of cough：1Barbiturates2Cold volatility anaesthetics and secretion of trachea3Intubate and suck sputum under light anaesthesia4Aspiration Cough 4Management：1Sufficient muscle relaxant2Diazepam and Droperidol3Aspiration b

31、alloon tracheal catheter、 gastrointestinal decompressionSingultus 二、Singultus： 1. Evoked reasons：1强烈牵拉内脏、直接刺激膈肌及膈神经2全麻诱导时将大量气体压入胃内 2. Harmful effects of cough： 3. Management：1Sufficient muscle relaxant2Postoperation Diazepam and Droperidol acupuncture of endoclosure cavePostoperative vomiting 三、Post

32、operative vomiting 1. Aetiology：1role of anaesthetics inhalation anesthetic：ether methoxyflurane enflurane isoflurane N2O sevoflurane intravenous anesthetic2category of operation3conditions of patients Postoperative vomiting 2. Harmful effects of cough：1pain、wound dehiscence：2vomit aspiration or asp

33、hyxiation3Water-Electrolyte unbalance and Acid-Base unbalance 3. ManagementPostoperative pulmonary infection 四、Postoperative pulmonary infection一Pathogenic bacteria：二Aetiology： 1. Aerosolizer pollution 2. Intubation、incision of trachea、 endotracheal anesthesia 3. Aspiration 4. Surgery 5. Abuse medic

34、ationPostoperative pulmonary infection三Clinical manifestation 1. Sings and symptoms 2. Examination of bacteriology1Smear of sputum and bacterial culture2Hemoculture 3. Chest X-rayPostoperative pulmonary infection四Diagnostic criteria 1. Fever、rales，X-ray 2. Pathogenic bacteria 3. Hemoculture：positive

35、 4. Secretion of lower respiratory tract 5. Secretion of respiratory tract、serum 、 and other body fluid Postoperative pulmonary infection五Treatment： 1. antibiotics 2. immunotherapy 3. upportive treatmentMalignant HyperthermiaMalignant hyperthermiaMH: an eerie and erratic metabolic mayhem, is a clini

36、cal syndrome that in its classic form occurs during anesthesia with a potent volatile agent such as halothane and the depolarizing muscle relaxant succinylcholine, producing rapidly increasing temperatureby as much as 1 /5 minand extreme acidosis. incidence was 1:1.610104，mortality rate was 73%Malig

37、nant Hyperthermia一、Evoked reasons：halothane、ethoxyflurane enflurane、scoline、 chloropromazine lidocaine、bupivacaine二、Clinical Syndromes： 1. Temperature increases: exceed 43 2. Whole-body rigidity occurs Malignant Hyperthermia3. Myocardial function is severely altered4. Increased serum levels of CK my

38、oglobinuria 5. Contractile response6. PaCO2 may exceed 100 mm Hg, and pHa may be less than 7.00Malignant Hyperthermia三、Treatment:1. Discontinue all anesthetic agents and hyperventilate with 100% oxygen.2. Control fever by iced fluids, surface cooling, cooling of body cavities with sterile iced fluid

39、s, and a heat exchanger with a pump oxygenator3. Administer bicarbonate2 to 4 mEq/kgMalignant Hyperthermia4. Repeat administration of dantrolene： 2mg/kg，5l0 min repeat5. Treatment of hyperkalemia :10u insulin6. Monitor urinary output : mannitol 0.5g/kg frusemide l mg/kg7. Corticosteroids8. ICU: moni

40、tor and treat for 48h病历报道一般资料：女患，15岁，2004年4月23日拟行 脊柱侧弯矫形术，无其他既往史术前药：鲁米那、阿托品麻醉诱导：咪唑安定、芬太尼、万可松、 异丙酚，插管顺利麻醉维持：异氟烷 + 芬太尼 + 万可松监测：ECG、MAP、SpO2、PETCO2手术过程： 手术3小时后 PETCO2 ： 到60 mmHg，并持续 心率： 至150160 bpm 体温：最高41.3 血气：pH 110 mmHg K+ 5.6 mmol/L 、Ca2+ 1.27 mmol/L 肌酸激酶 1775 u/L 血压：至70/40mmHg左右 双肺呼吸音及麻醉机未见明显异常疑诊：

41、恶性高热措施：立即停用吸入麻醉药，更换呼吸机回路 降温毯物理降温 多巴胺、去氧肾上腺素维持血压2h后：体温至37 血气：pH 6.85、PaCO2 80 mmHg BE -19mmol/L 尿量 80 ml/h为进一步处理转入ICU ICU情况： 瞳孔3mm、光反射存在、球结膜轻度水肿 体温：37.0左右，继续降温，持续肛温监测 心率130bpm、血压91/56mmHg、CVP 20 mmHg 血气：PaCO2 41 mmHg 尿量：当日正常、次日少尿，很快无尿 肾功：血肌酐：97 umol/L333 umol/L 尿素氮：升至19.2mmol/L生化：GOT 5022 u/L、GPT 200

42、25 u/L、 LDH 7733u/L、血乳酸3.9凝血功能：凝血酶原时间 31s 局部凝血活酶时间107s 血小板在40000/L左右肌酶谱：乳酸脱氢酶 22500 u/L 肌酸激酶 20000 u/L 肌酸激酶同工酶 610 u/L ICU处理： 1持续肛温监测，降温毯37左右2监测血液动力学，维持有效血液循环3机械通气4镇静：咪唑安定、芬太尼持续泵入5肾衰6小时内给予血液滤过6促进肝功恢复：凯西来、美能、甘利欣7TPN营养支持胃肠道营养转归：48小时：循环及内环境根本稳定 肺部通气氧合良好术后4日：顺利脱离呼吸机、拔管术后7日：下肢深静脉血栓抗凝术后14日：生化：GOT 92.6 u/L

43、、GPT 51.7 u/L 凝血功能正常术后16日：肾功恢复，尿量1050 ml/h术后17日：体温正常、生命体征稳定躁 动 一原因： 1.疼痛：术毕未及时镇痛，为躁动重要因素，多年轻人2.低氧血症、高碳酸血症、胃胀气、尿潴留3.术前、术中用药：1东莨菪碱、吩噻嗪、巴比妥未用麻醉性镇痛药2异丙酚、依托咪酯3氯胺酮噩梦、幻觉等尤单用 苯二氮卓类药可减轻或消除4.脑疾患、精神病史是术后发生谵妄、躁动的危险因素 二预防和处理:1.维持适宜的麻醉深度、术后充分镇痛2.保持充分通气、供氧，维持血流动力学稳定3.防止不良刺激，保持环境安静 4.减少或即时拔除各种有创性导管和引流管5.定时变动体位利于改善呼

44、吸功能 防止长时间固定体位的不适6.定时血气分析，以免低氧血症或二氧化碳潴留7.防止因躁动引起的自身伤害，必要时适当应用镇静药 急性肺不张 急性肺不张：骤然出现肺段、肺叶或一侧肺的萎陷通气功能丧失 是手术后严重并发症之一，尤多见于全身麻醉之后 大面积肺不张呼吸功能代偿缺乏严重缺氧而致死 一危险因素：1.病人因素：(1)围手术期病人存在急性呼吸道感染 (2)呼吸道急性或慢性梗阻 (3)慢性气管炎 (4)吸烟 (5)肥胖 (6)老年病人，肺容量小、呼吸肌障碍或受限 (7)中枢性/梗阻性睡眠-呼吸暂停综合征2.术后危险因素：呼吸道分泌物多，引流或排出不畅； 胸或上腹部大手术； 切口疼痛； 镇痛药应用

45、不当； 应用抑制中枢神经系统药物 二发生机制1.压迫：(1)麻醉呼吸肌张力消失FRC (2)平卧位腹内压增高/腹内容物增大膈肌向头移位 FRC血液从胸腔向腹腔转移压迫性肺不张2.小气道早期闭合其远侧气体吸收肺泡萎陷、肺不张 尤其吸纯氧时3. PS产生减少、失活、代谢障碍肺泡萎陷三临床表现：1.小面积肺不张，无明显临床病症或体征，易被忽略2.急性大面积肺不张气急、咳嗽、发绀， 小水泡音，呼吸音和语颤消失 急性循环功能障碍四预防：1.术前禁烟23w2.有急性呼吸道感染的病人，至少应延期手术23w3.术前有明显危险因素的应延期手术，57天呼吸道治疗4.慢支、慢阻肺：1术前胸部理疗(体位引流、胸壁叩击

46、) 气道梗阻、排痰能力2训练深呼吸和咳嗽增加肺容量5.保持气道通畅，防止长时间固定潮气量，应定时吹张肺6.应用空气-O2吸入，防止吸入纯O27.术毕尽早清醒，充分恢复自主呼吸，拔管前反复吸痰8.ICU中定时变换病人体位，鼓励咳嗽和早期离床活动9.术后减少或防止麻醉镇痛药神经阻滞 EA局麻药 小剂量麻醉镇痛药五处理：消除梗阻原因，预防感染，复张萎陷肺1.积极鼓励病人咳嗽排痰，或诱导发生呛咳2. 纤支镜检查，明确梗阻部位、原因，吸痰、取异物3.明显低氧血症机械通气FiO20.6 辅以PEEP1015cmH2O 肺泡复张4.其他：雾化吸入、祛痰药、支气管扩张药、激素等5.根据痰液细菌培养结果和药敏实

47、验，选用有效的抗生素 张力性气胸 一病因：1.麻醉操作：(1)辅助或控制呼吸时气道压力过高 有先天性缺陷或病变(肺气肿 支扩、肺大泡)肺泡破裂(2)喉镜和气管插管时损伤咽后壁(3)臂丛N、肋间N、椎旁N阻滞时伤及胸膜、肺组织(4)有创性中心静脉监测(颈内或锁骨上、下静脉)2.手术操作：(1)气管造口术、甲状腺切除术、颈部广泛解剖(2)肾切除术、腹腔镜手术损伤脏层或壁层胸膜(3)一侧胸内手术损伤对侧胸膜，没及时发现和修补 二临床表现：1.轻度可无病症2. 1/5肺组织丧失通气功能呼吸急促困难、发绀、心动过速3.一侧或两侧肺萎陷V/Q严重失衡极端呼吸困难，大量未氧合 血液掺杂于动脉血内显著发绀和低

48、氧血症4.患侧胸内高压纵隔推向健侧心脏移位、腔静脉回心血流受阻 CO排血量 严重低血压、休克5.全麻下首先发现的体征可能是心动过速和低血压，不易与麻醉过 深或低血容量区别；但因受压肺顺应性下降气道阻力6.血气：PaO2 、PaCO2 7.不立即解除张力性气胸，可在短时间因呼吸循环衰竭而致死三处理：1.支持呼吸、循环2. 粗针头患侧锁骨中线第2或第3肋间进行穿刺抽气3.抽气后仍不缓解或需屡次抽气胸腔闭式引流 促进萎陷肺复张4.应积极预防感染 脑 血 管 意 外 围术期脑血管意外：缺血性-80%，脑血管供血缺乏或血流太少 出血性-20%，脑实质出血、蛛网膜下腔出血 全麻下脑血管意外，不易及时发现，

49、多麻醉后苏醒延迟、意识障碍，或相关病理部位的功能受损所反映出特殊体征时才引起临床注意和诊断。一缺血性卒中 ：1.病因：(1)动脉粥样硬化：颅外和颅内动脉粥样硬化狭窄、闭塞、或斑块 物质栓塞远端脑血管缺血性脑卒中(2)心源性栓子：心律失常(房颤)、瓣膜与腔结构异常促进血栓形 成、栓子脱落栓塞脑血管缺血性脑卒中 房颤头数月栓塞危险性最高，第1个月几率可达1/3(3)血管炎：原发性中枢神经系统动脉炎、感染性血管炎局灶性或 多灶性脑缺血缺血性脑卒中(4)血液粘稠度：脑血流与血液粘稠度呈负相关 BBC增多症、Hct 50%、血小板增多症血液粘稠 度脑血流(5)高凝状态：癌症(尤肾上腺癌)、妊娠、产褥期处

50、于高凝状态 纤维蛋白原、凝血异常、血小板聚集脑血流(6)其他：脂肪栓子、气栓脑血管栓塞和缺血性病变 2.诊断：(1)表现：神经系统病症，取决于被阻血管部位、累及脑组织范围 脑A主干梗阻迅速意识障碍、昏迷 或偏瘫、癫痫、失语和病理性反射(2)超声心动图、脑影像学(CT、MRl)和脑血管造影术3.预防：(1)控制血压：高血压是卒中最危险因素，收缩压可能是直接原因 160/95mmHg卒中危险性比正常高4倍术前控制血压(2)房颤或心脏瓣膜病人心脏科医生会诊，以确定是否抗凝治疗 二出血性卒中：颅内出血1.原因： 动脉瘤、脑血管畸形、高血压性动脉粥样硬化性出 血，全身出血性素质2.诊断：CT、MRI，假设CT未见出血腰穿具有诊断意义3.预防：控制高血压、保持血