非住院病人的麻醉

非住院病人的麻醉第1页/共34页非住院病人的麻醉OutpatientAnesthesia第2页/共34页BenefitsofAmbulatorySurgeryPatientpreference,especiallychildrenandelderlyLackofdependenceonavailabilityofhospitalbedsGreaterflexibilityinschedulingoperationsLowmorbidityandmortalityLowerincidenceofinfection第3页/共34页LowerincidenceofrespiratorycomplicationsHighervolumeofpatients(greaterefficiency)ShortersurgicalwaitinglistsLoweroverallproceduralcostsLesspreoperativetestingandpostoperativemedicationBenefitsofAmbulatorySurgery第4页/共34页PatientSelectionDurationofsurgeryLessthan90minutesPatientcharacteristicsMalignanthyperthermiasusceptibilityObserveforatleast4hourspostoperativelyExtremesofageAgealoneshouldnotbeconsideredadeterrentintheselection第5页/共34页ContraindicationstoOutpatientSurgerySerious,potentiallylife-threateningdiseasesthatarenotoptimallymanaged(ASAⅢ～Ⅳ):brittlediabetes,unstableangina,symptomaticasthmaMorbidobesitycomplicatedbyhemodynamicorrespiratoryproblemsDrugtherapy:monoamineoxidaseinhibitors;acutesubstanceabuse第6页/共34页ContraindicationstoOutpatientSurgeryEx-prematureinfantslessthan60weekspostconceptualageLackofaresponsibleadultathometocareforthepatientontheeveningaftersurgery第7页/共34页第8页/共34页PreoperativePreparationAimedatreducingtherisksinherentinambulatorysurgery,improvingpatientoutcome,andmakingthesurgicalexperiencepleasantforthepatientandfamily第9页/共34页PreoperativePreparationPrepatationshouldminimizepatientanxietythrough

pharmacologicandnon-pharmacologic

meansandshouldreducepotentialpostoperativeproblemsbyuseofappropriatepremedication第10页/共34页NonpharmacologicPreparation第11页/共34页PharmacologicprepatationAnixolysisandsedationAnalgesicsPreventionofnauseaandvomitingPreventionofaspirationpneumonitis第12页/共34页Nothing-by-mouthGuidelines第13页/共34页AnetheticTechniquesQuality,safety,efficiency,andthecostofdrugsandequipmentareimportantconsiderationsinchoosingananesthetictechniqueforoutpatientsurgery第14页/共34页AnetheticTechniquesTheabilitytodeliverasafeandcost-effectivegeneralanestheticwithminimalsideeffectsandrapidrecoveryiscriticalinabusyoutpatientsurgeryunitGeneralanesthesiaremainsthemostwidelyusedanesthetictechniqueformanagingambulatorysurgery第15页/共34页SpecificconsideratinsinGeneralAnesthesiaAirwaymanagementIntravenousanestheticdrugsInhaledanestheticdrugsAnalgesicsMusclerelaxantsReversalofdrugeffects第16页/共34页RegionalanesthesiaMonitoredanesthesiacare(MAC)第17页/共34页DischargeCriteriaVitalsignsAmbulationNauseaandvomitingPainSurgicalbleeding第18页/共34页麻醉后监测治疗室PostanestheticCareUnit(PACU)第19页/共34页主要任务收治对象当日全麻病人术后未苏醒者非全身麻醉后病人情况尚未稳定者麻醉后神经功能未恢复者目的监护和治疗病人在麻醉恢复过程中所出现的生理功能紊乱与ICU的区别麻醉苏醒期的监护和治疗，短时间、一般性的麻醉恢复第20页/共34页PACU处理的常见问题呼吸道梗阻通气不足低氧血症低血压高血压心律失常恶心、呕吐低温神志观察第21页/共34页离开恢复室的标准呼吸循环神志椎管内麻醉平面稳定第22页/共34页PACU的设置和管理设置足够的照明足够的空间足够的装备必备的药物管理第23页/共34页呼吸道梗阻上呼吸道梗阻舌后坠上呼吸道分泌物聚积咽或喉梗阻喉头水肿下呼吸道梗阻呼吸道分泌物、呕吐物、血液和脓液等阻塞下呼吸道支气管痉挛第24页/共34页麻醉苏醒期终止给予麻醉药物至病人清醒的时间，可分为下面四个时相感觉和运动功能逐步恢复出现自主呼吸，并能逐渐自行调控呼吸道反射恢复清醒第25页/共34页第26页/共34页Sveralintravenousanestheticsforuseduringambulatoryanesthesia第27页/共34页第28页/共34页第29页/共34页第30页/共34页Intermidiaterecoveryafterpropofol,desflurane(±N2O),orpropofol-desfluraneanesthesia第31页/共34页Postoperativenauseaafterpropofol,deflurane,orprofofol-defluraneanesthesia第32页/共34页RiskFact