1、全身麻醉的實施及并發(fā)癥 Administration of general anesthesia & prophylaxis and treatment of complications長江大學(xué)臨床醫(yī)學(xué)院外科教研室目的要求掌握全麻的基本概念及基本要求。 熟悉全麻的誘導(dǎo)、維持和蘇醒期的特點及管理期注意事項。 了解全麻深淺的判斷、臨床常用的判斷麻醉深淺的監(jiān)測指標。第一節(jié) 全身麻醉的實施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過呼吸道吸入、靜脈注射、肌肉注射或直腸灌注等方式使麻醉藥進入體內(nèi)，利用麻醉藥對中樞神經(jīng)系統(tǒng)產(chǎn)生的抑制作用，可逆地改變中樞神經(jīng)系統(tǒng)中的某些功能，從而達到神志消失、（手術(shù)時）無痛的目的。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. 全身麻醉方法分類 吸入麻醉 Inhalational Anesthesia 靜脈麻醉 Intravenous Anesthesia 一、麻醉誘導(dǎo)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.誘導(dǎo)前的準備 preparationPreoperative evaluationsIntravascular volumeIntravenous (IV) accessPreoperative medic

5、ationsMonitoringResuscitation equipment & drugs誘導(dǎo)方法 Induction techniquesIV inductionInhalational inductionIntramuscular injection of ketamine or oral midazolam：used in uncooperative patients or young children二、全身麻醉的維持 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.麻醉維持方法 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、全身麻醉深度的判斷 Judgement of anesthetic depthMAC的概念和意義0.6MAC意識消失1MAC50患者不發(fā)生體動反應(yīng)1.2-1.3MAC95%患者對切皮刺激無反應(yīng)1.7MAC完全抑制插管時心血管反應(yīng)第二節(jié)：全身麻醉的并發(fā)癥及其處理 prophylaxis and treatment of complications一、反流與誤吸 Regurgitation&Aspi

9、ration原因吞咽及咳嗽反射喪失、賁門松弛胃內(nèi)容物過多并發(fā)癥嘔吐與誤吸-胃內(nèi)容物反流-窒息吸入性肺炎一、反流與誤吸 Regurgitation&Aspiration處理頭低位引流氣管插管肺部盥洗抗菌消炎二、上呼吸道梗阻upper airway obstruction原因 舌后墜、咽喉部分泌物、喉痙攣預(yù)防 禁食和胃排空 處理 對癥處理三、下呼吸道梗阻 lower airway obstruction 原因支氣管痙攣、支氣管分泌物阻塞預(yù)防 對既往有呼吸道慢性炎癥或支氣管哮喘使的病人應(yīng)仔細了解其過去發(fā)病的情況;避免應(yīng)用可誘發(fā)支氣管痙攣的藥物，阻斷起到的反射 處理 對癥處理四、通氣不足，二氧化碳潴留

10、原因藥物導(dǎo)致中樞性或外周的呼吸抑制，并輔助呼吸或控 制呼吸的分鐘通氣量不足嚴重支氣管痙攣導(dǎo)致肺泡通氣量不足預(yù)防 加強呼吸監(jiān)測，保持足夠的通氣處理增加潮氣量或提高呼吸頻率舒張支氣管平滑肌，解除支氣管痙攣，提高肺泡通氣量必要時給予相應(yīng)的拮抗藥物五、低氧血癥 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、高血壓 Hypertension原因高血壓、甲亢等病人麻醉過淺通氣不足、二氧化碳潴留疼痛、低氧血癥與高碳酸血癥術(shù)中補液過多和升壓應(yīng)用不當麻醉蘇醒期拔管處理解除誘因，降壓治療保證麻醉深度必要時，小量、分次地給予血管擴張劑七、低血壓 Hypotension原因麻醉過深失血過多并血容量補充不當手術(shù)直接刺激迷走神經(jīng)或牽拉內(nèi)障反射性地興奮迷走神經(jīng)過敏反應(yīng)，腎上腺皮質(zhì)功能低下心肌收縮功能障礙處理減淺麻醉，補充血容量必要時停止手術(shù)刺激，或暫停手術(shù)八、心律失常arrhythmia原因麻醉深淺不當，手術(shù)刺激高血壓、低血壓、二氧化碳潴留或缺氧病人自身疾病（如：心功能不全）處理

13、保證適宜的麻醉深度，減少刺激消除誘因，對癥處理必要時，輔助藥物治療九、高熱、抽搐和驚厥hyperpyrexia,hyperspasmia, eclampsia 原因小兒的體溫調(diào)節(jié)中樞未發(fā)育健全藥物誘發(fā)處理積極控制體溫，作降溫處理（重點是病人頭部）病人抽搐時立即提高吸入氧濃度，并靜脈注射米達唑侖等排除麻醉藥物（如：琥珀膽堿）引起的惡性高熱十、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、蘇醒延遲 postponed resurgence 原因麻醉藥物過量呼吸或循環(huán)功能惡化低溫肝腎功能嚴重水、電解質(zhì)紊亂糖代謝異常處理 對癥處理 十二、術(shù)中知曉 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.術(shù)中知曉的預(yù)防(prevention)避免麻醉過淺(avoiding the light anesthesia) 監(jiān)測腦電