全身麻醉的实施SectiononeAdministrationof课件

1、全身麻醉的实施及并发症 Administration of general anesthesia & prophylaxis and treatment of complications长江大学临床医学院外科教研室目的要求掌握全麻的基本概念及基本要求。 熟悉全麻的诱导、维持和苏醒期的特点及管理期注意事项。 了解全麻深浅的判断、临床常用的判断麻醉深浅的监测指标。第一节 全身麻醉的实施Section one Administration of general anesthesia General anesthesia is a state of reversible loss of conscio

2、usness for the purpose of carrying out surgery.This is achieved by:Analgesia Amnesia Immobility Loss of consciousnessSkeletal muscle relaxation全身麻醉的基本特征通过呼吸道吸入、静脉注射、肌肉注射或直肠灌注等方式使麻醉药进入体内，利用麻醉药对中枢神经系统产生的抑制作用，可逆地改变中枢神经系统中的某些功能，从而达到神志消失、（手术时）无痛的目的。A controllable and reversible loss of consciousness indu

3、ced by intoxication of the central nervous system. Lowered sensitivity to external stimuli (hyporeflexia), analgesia, unconsciousness, muscle relaxation, and amnesia are significant features of general anesthesia. 全身麻醉方法分类 吸入麻醉 Inhalational Anesthesia 静脉麻醉 Intravenous Anesthesia 一、麻醉诱导Induction of a

4、nesthesiaDefinition Induction of anesthesia produces an unconscious patient with depressed reflexes who is entirelydependent on the anesthetist for maintenance of homeostatic mechanisms and safety.诱导前的准备 preparationPreoperative evaluationsIntravascular volumeIntravenous (IV) accessPreoperative medic

5、ationsMonitoringResuscitation equipment & drugs诱导方法 Induction techniquesIV inductionInhalational inductionIntramuscular injection of ketamine or oral midazolam：used in uncooperative patients or young children二、全身麻醉的维持 Maintenance of anesthesiaDefinition Maintenance begins when the patient is suffici

6、ently anesthetized to provide analgesia,unconsciousness, and muscle relaxation for surgery. Vigilance on the part of the anesthetist is required to maintain homeostasis (vital signs, acid-base balance, temperature, coagulation, and volume status) and regulate anesthetic depth.麻醉维持方法 Maintenance of a

7、nesthesiavolatile agents with minimal opioidIn a nitrous oxideopioid relaxant techniqueIV anesthesia： uses the continuous infusion or repeated boluses of a short-acting hypnotic drug (e.g., propofol) with or without opioids (e.g., remifentanil) and a muscle relaxant.Combinations of the above methods

8、 are often usedGeneral anesthesia can be combined with a regional anesthetic techniqueGuedel 乙醚麻醉分期三、全身麻醉深度的判断 Judgement of anesthetic depthMAC的概念和意义0.6MAC意识消失1MAC50患者不发生体动反应1.2-1.3MAC95%患者对切皮刺激无反应1.7MAC完全抑制插管时心血管反应第二节：全身麻醉的并发症及其处理 prophylaxis and treatment of complications一、反流与误吸 Regurgitation&Aspi

9、ration原因吞咽及咳嗽反射丧失、贲门松弛胃内容物过多并发症呕吐与误吸-胃内容物反流-窒息吸入性肺炎一、反流与误吸 Regurgitation&Aspiration处理头低位引流气管插管肺部盥洗抗菌消炎二、上呼吸道梗阻upper airway obstruction原因 舌后坠、咽喉部分泌物、喉痉挛预防 禁食和胃排空 处理 对症处理三、下呼吸道梗阻 lower airway obstruction 原因支气管痉挛、支气管分泌物阻塞预防 对既往有呼吸道慢性炎症或支气管哮喘使的病人应仔细了解其过去发病的情况;避免应用可诱发支气管痉挛的药物，阻断起到的反射 处理 对症处理四、通气不足，二氧化碳潴留

10、原因药物导致中枢性或外周的呼吸抑制，并辅助呼吸或控 制呼吸的分钟通气量不足严重支气管痉挛导致肺泡通气量不足预防 加强呼吸监测，保持足够的通气处理增加潮气量或提高呼吸频率舒张支气管平滑肌，解除支气管痉挛，提高肺泡通气量必要时给予相应的拮抗药物五、低氧血症 HypoxiaEtiologies Inadequate oxygen supply HypoventilationVentilation-perfusion inequalitiesRight-to-left cardiac shuntReduction in oxygen-carrying capacityLeftward shift of

11、 the hemoglobin-oxygen dissociation curveTreatmentManual ventilation with 100% oxygen should be begun to assess pulmonary compliance.The breathing circuit, ventilator, and anesthesia machine should be checked for leaks.Adequate oxygen delivery to the patient should be confirmed with an in-line oxyge

12、n analyzer.Others六、高血压 Hypertension原因高血压、甲亢等病人麻醉过浅通气不足、二氧化碳潴留疼痛、低氧血症与高碳酸血症术中补液过多和升压应用不当麻醉苏醒期拔管处理解除诱因，降压治疗保证麻醉深度必要时，小量、分次地给予血管扩张剂七、低血压 Hypotension原因麻醉过深失血过多并血容量补充不当手术直接刺激迷走神经或牵拉内障反射性地兴奋迷走神经过敏反应，肾上腺皮质功能低下心肌收缩功能障碍处理减浅麻醉，补充血容量必要时停止手术刺激，或暂停手术八、心律失常arrhythmia原因麻醉深浅不当，手术刺激高血压、低血压、二氧化碳潴留或缺氧病人自身疾病（如：心功能不全）处理

13、保证适宜的麻醉深度，减少刺激消除诱因，对症处理必要时，辅助药物治疗九、高热、抽搐和惊厥hyperpyrexia,hyperspasmia, eclampsia 原因小儿的体温调节中枢未发育健全药物诱发处理积极控制体温，作降温处理（重点是病人头部）病人抽搐时立即提高吸入氧浓度，并静脉注射米达唑仑等排除麻醉药物（如：琥珀胆碱）引起的恶性高热十、心肌缺血 Myocardial ischemiaEtiology Myocardial ischemia is the result of an imbalance between myocardial oxygen supply and consumpti

14、on and, if untreated, may lead to MIClinical featuresHemodynamic instability and ECG changes may occur with ischemia.ST segment depression greater than 1 mm or T-wave inversion may indicate subendocardial ischemia.Other indicators of ischemia include: a. Hypotension. b. Changes in central filling pr

15、essures or cardiac output. c. Regional wall motion abnormalities as detected with transesophageal echocardiography.TreatmentHypoxemia and anemia should be corrected.-Adrenergic antagonists decrease myocardial oxygen consumption.Nitroglycerin reduces ventricular diastolic pressure and volume through

16、venodilation and thus decreases myocardial oxygen demand.Phenylephrine or norepinephrine to improve myocardial perfusion pressure.positive inotropes such as dopamine dobutamine or norepinephrine are indicated.Aspirin, heparinization, thrombolytic therapy, angioplasty, and coronary revascularization

17、may be considered in selected patients十一、苏醒延迟 postponed resurgence 原因麻醉药物过量呼吸或循环功能恶化低温肝肾功能严重水、电解质紊乱糖代谢异常处理 对症处理 十二、术中知晓 intraoperative awareness Awareness during anesthesia refers to a patient experiencing an intraoperative event and recalling the event postoperative. EtiologyAwareness is associated

18、 with a poor anesthetic technique, the use of low concentration of volatile anesthetic agents and breathing system disconnec- tions and leaks. Significant degrees of intraoperative awareness occur only in patients who have received a muscle relaxant.术中知晓的预防(prevention)避免麻醉过浅(avoiding the light anesthesia) 监测脑电