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首页 吸入麻醉

吸入麻醉.ppt

吸入麻醉

mzk0734
2011-08-24 0人阅读 举报 0 0 暂无简介

简介:本文档为《吸入麻醉ppt》,可适用于自然科学领域

第七章吸入麻醉InhalationalAnesthesia第七章吸入麻醉InhalationalAnesthesia一、概述(introduction)概念(concept)特点(characteristic)一、概述(introduction)概念(concept)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,distributionandeliminationofinhalationalanesthetics二、吸入麻醉药的吸收、分布与消除Uptake,distributionandeliminationofinhalationalanesthetics、吸收与分布Uptakeanddistribution作用部位:大脑centralnervesystemPAPBPBr动态平衡dynamicequilibrium吸收与分布影响因素:吸收与分布影响因素:吸入浓度inspiredconcentration分钟通气量minutevolume血气分配系数bloodgaspartitioncoefficient每分钟肺灌流量perfusionofpulmonary消除Elimination●大部分以原形经肺排出Eliminatedmostlyinanunchangedformviathelungs●少部分经肝、肾排出asmallproportionismetabolizedinliverandeliminatedviakidney消除Elimination●大部分以原形经肺排出Eliminatedmostlyinanunchangedformviathelungs●少部分经肝、肾排出asmallproportionismetabolizedinliverandeliminatedviakidney三、吸入麻醉药的临床评价Clinicalevaluationofinhalationalanesthetics三、吸入麻醉药的临床评价Clinicalevaluationofinhalationalanesthetics可控性controllable●与血气分配系数有关associatedwithbloodgaspartitioncoefficient麻醉强度anestheticpotency●与油气分配系数有关associatedwithoilgaspartitioncoefficient●MAC(minimalalveolarconcentration)MACisminimalalveolarconcentrationofaninhalationalanestheticatatmosphereabsolutethatpreventsmovementsofofthepopulationtoastandardstimulusMACisminimalalveolarconcentrationofaninhalationalanestheticatatmosphereabsolutethatpreventsmovementsofofthepopulationtoastandardstimulus对心血管的影响EffectsonCardiovascularsystem●心肌抑制depressionofmyocardialcontractility●增加心肌对儿茶酚胺的敏感性:氟烷●增加心肌对儿茶酚胺的敏感性:氟烷IncreasedmyocardialexcitabilityArrhythmiasarecommonduringhalothaneIncreasedcirculatingcatecholamines●呼吸抑制Respiratorydepressiondosedependentdepressionofventilation●呼吸道刺激irritanttorespiratorydepression●支气管平滑肌舒张relaxationofbronchialsmoothmuscle对呼吸的影响Effectsonrespiratory●呼吸抑制Respiratorydepressiondosedependentdepressionofventilation●呼吸道刺激irritanttorespiratorydepression●支气管平滑肌舒张relaxationofbronchialsmoothmuscle对运动终板的影响Effectsonneuromuscularjunction对运动终板的影响Effectsonneuromuscularjunction●肌松作用增强肌松剂的肌松作用Skeletalmusclerelaxationandpotentiatesnondepolarizingrelaxants●安氟醚肌松作用最强Skeletalmusclerelaxationofenfluraneisthegreatestinallinhalationalanesthetic●氟烷对子宫平滑肌松弛作用最强,增加产后出血可能Hatholanerelaxesuterinemuscleandmaycausepostpartumhemorrhage●增加颅内压异氟醚影响最小increaseICP,andthisactionofisofluraneisthelowestinallvolatiles●抑制EEG安氟醚可引起痉挛性EEG改变DosedependentdepressionofEEGactivity,atmoderatetohighconcentration(morethan),enfluraneproducesepileptiformparoxysmalspikeactivity对颅内压及EEG的影响EffectsonICPandEEG理想吸入麻醉药的特点Propertiesoftheidealinhalationalanesthetic理想吸入麻醉药的特点PropertiesoftheidealinhalationalanestheticPleasantodour,nonirritanttorespiratorydepressionlowbloodsolubilityrapidinductionandrecoverfromanesthesiaNeitherflammablenorexplosiveProducingunconsciousnesswithanalgesiaandsomedegreeofmusclerelaxationNotbemetabolizedinthebody,nontoxic,notprovokeallergicreactionsMinimaldepressionofcardiovascularandrespiratorysystemandnotinteractwiththeotherdrugsusedcommonlyduringanesthesia,egcatecholamines优点:●毒性小对循环系统抑制轻lowtoxicity,lightdepressionofcardiovascularsystem●呼吸道无刺激nonirritanttorespiratorydepression●适用于危重病人suitableforseriouslyillpatient●诱导和苏醒快rapidinductionandrecoverfromanesthesia气体麻醉药氧化亚氮anestheticgasnitrousoxide注意事项announcements注意事项announcements●长时间高浓度吸入时对红细胞生成有一定的影响,补充vitBAffectsvitamineBsynthesiswhenthedurationofnitrousoxideexceedshours●不能单独吸入最低吸氧浓度为否则易导致缺氧Diffusionhypoxia:essentialtoadministeraminimumFiOof●麻醉作用弱常与安氟醚、异氟醚氧气同时吸入Goodanalgesia,pooranesthesia,isusedcombinationwithenfluraneorisoflurane四、常用吸入麻醉装置Inhalationalanesthesiaoit四、常用吸入麻醉装置Inhalationalanesthesiaoit气源Gases流量计Flowmeters蒸发器Vaporizers呼吸囊Breathingbag呼吸螺纹管Anestheticbreathingsystem呼吸活瓣Breathingvalue二氧化碳吸收装置Canisterorcarbondioxideabsorber五、常用吸入麻醉方法MethodsofInhalationalanesthesia㈠开放式(opencircuits)):开放点滴法、充气法、无重复吸入法五、常用吸入麻醉方法MethodsofInhalationalanesthesia㈠开放式(opencircuits)):开放点滴法、充气法、无重复吸入法特点:●无重复吸入无CO吸收装置优点:●简单机械无效腔及呼吸阻力小●通过无重复吸入装置可辅助或控制呼吸缺点:●气道干燥污染空气●呼呼吸不易管理:舌后坠、呼吸道梗阻通气困难●麻醉深度不易掌握㈡半开放式(semiopencircuits)suitableforspontaneous㈡半开放式(semiopencircuits)suitableforspontaneous特点:●呼出气部分被重复吸入无CO吸收装置及无重复吸入活瓣重复吸收CO<缺点:●吸入气流量大(分钟通气量的倍),吸入气流量小时→CO蓄积Freshgasflowratemustbeveryhigh(atleasttimesAlveolarminutevolumetopreventrebreathing)临床常用“T”管装置:特点:●呼出气部分被重复吸入无CO吸收装置及无重复吸入活瓣重复吸收CO<缺点:●吸入气流量大(分钟通气量的倍),吸入气流量小时→CO蓄积Freshgasflowratemustbeveryhigh(atleasttimesAlveolarminutevolumetopreventrebreathing)临床常用“T”管装置:●优点:呼吸阻力及无效腔小●适用于Kg以下儿童尤其是新生儿、婴幼儿●可保留自主呼吸亦可辅助或控制呼吸㈢半紧闭式semiclosedcircuits㈢半紧闭式semiclosedcircuits特点:●循环式麻醉机呼出气部分重复吸入部分通过CO吸收装置优点:●麻醉深度可控不易产生CO蓄积缺点:●麻醉药浪费大空气污染重●呼低流量和吸入氧浓度低时→缺氧㈣紧闭式closedcircuitorcirclesystemistheonlytruecircuitasanestheticgasesarerecycled㈣紧闭式closedcircuitorcirclesystemistheonlytruecircuitasanestheticgasesarerecycled特点:●循环回路呼出气全部重复吸入有CO吸收装置低流量exhaledalveolargasisrebreathedentirely优点:●CO排出完全●麻醉深度易控制低流量吸入节约麻醉药和氧气●便于呼吸管理可监测气道压机潮气量●保持气道湿润及维持体温减少空气污染缺点:●结构复杂●活瓣失灵→CO蓄积呼吸道完全梗阻●婴幼儿不宜使用㈤低流量吸入麻醉InhalationalanesthesiawithLowflowrate㈤低流量吸入麻醉InhalationalanesthesiawithLowflowrate概念:新鲜气流>Lmin高流量吸入麻醉新鲜气流<Lmin低流量吸入麻醉特点:半紧闭式或紧闭式优点:缺点:●NO麻醉时监测氧浓度<时易缺氧●吸入气浓度不易控制●回路内有麻醉气体以外的气体蓄积●麻醉机㈥吸入麻醉诱导、维持、苏醒Induction,maintenanceandrecoveryofinhalationalanesthesia㈥吸入麻醉诱导、维持、苏醒Induction,maintenanceandrecoveryofinhalationalanesthesia诱导:慢诱导法高浓度诱导法适用范围:不宜用静脉麻醉或不易保持静脉开放的小儿注意事项:保持呼吸道通畅维持:根据手术刺激大小随时调整吸入浓度苏醒: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六、吸入麻醉期间的管理Managementduringinhalationalanesthesia六、吸入麻醉期间的管理Managementduringinhalationalanesthesia㈠麻醉前准备preanestheticpreparation●Preanestheticvisittoassesstherisksofanesthesiaandsurgeryandtoplantheanestheticmanagement●Anesthetics,equipmentformonitoringanestheticmachineandintravenousfluidsshouldbeprepared㈡麻醉深度监测monitoringdepthofanesthesia㈢麻醉期间的管理呼吸系统respiratorysystem首要任务保持呼吸道通畅maintainingtheairway呼吸系统respiratorysystem首要任务保持呼吸道通畅maintainingtheairway内容:频率、节律、通畅度、幅度措施:望:呼吸方式、胸廓运动幅度、是否有梗阻听:呼吸音、附加音双侧是否对称量:TV、MV、SPO、血气分析是否有缺氧和CO蓄积异常呼吸Abnormalbreathing●通气量↓呼吸浅快,低氧(原因:麻醉过深、肌松剂)MV↓,brachypnea,hypoxia●呼吸道梗阻(airwayobstruction):呼吸困难(Dyspnoea)三凹征(threedepressionssign)●CO蓄积早期表现:HR↑、BP↑上呼吸道梗阻(Upperrespiratorytractobstruction):舌后坠、喉痉挛下呼吸道梗阻(Lowerrespiratorytractobstruction):返流(regurgitation)、分泌物(secretion)、支气管痉挛(Bronchospasm)●医源性呼吸道梗阻:导管扭曲(distortionoftrachealtube)、气管异物(foreignbodyintrachea)、麻醉机失灵(malfunctionofanesthesiaapparatus)异常呼吸Abnormalbreathing●通气量↓呼吸浅快,低氧(原因:麻醉过深、肌松剂)MV↓,brachypnea,hypoxia●呼吸道梗阻(airwayobstruction):呼吸困难(Dyspnoea)三凹征(threedepressionssign)●CO蓄积早期表现:HR↑、BP↑上呼吸道梗阻(Upperrespiratorytractobstruction):舌后坠、喉痉挛下呼吸道梗阻(Lowerrespiratorytractobstruction):返流(regurgitation)、分泌物(secretion)、支气管痉挛(Bronchospasm)●医源性呼吸道梗阻:导管扭曲(distortionoftrachealtube)、气管异物(foreignbodyintrachea)、麻醉机失灵(malfunctionofanesthesiaapparatus)循环系统听诊:心音强弱心脏节律Cardiacsoundandrhythm量:Bloodpressure,peripheralpulse,urinevolumeMAP、CVP、PAWP、COECG:观察心律失常及心肌缺血arrhythmiaandmyocardialischemiaHypovolemia:BP↓、P↑↑、脉压↓、尿量↓、CVP↓Cardiacfailure:BP↓、P↑↑、CVP↑、颈静脉怒张、肺部湿罗音、肝大DeepAnesthesia:BP↓、P↓循环系统全身情况神志、体温、瞳孔全身情况神志、体温、瞳孔神志:●休克神志淡漠●缺氧昏迷或苏醒延迟体温:小儿易高热瞳孔:●眼球固定、瞳孔缩小麻醉适宜●眼球固定、瞳孔散大、光反应迟钝深度脑抑制、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、肢体麻痹术中知晓Intraoperativeawareness缺氧与CO蓄积的观察缺氧与CO蓄积的观察缺氧早期表现InitialsignsofhypoxiaBP↑、HR↑↑、不一定有紫绀(cyanosis)CO蓄积早期表现Initialsignsofcarbondioxideretention:BP↑、HR↑、呼吸深快、面部潮红严重缺氧及CO蓄积表现呼吸不规则(respirationisirregular)、BP↓、HR↓伴心律失常→呼吸、心跳停止

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