第5章-全麻的基本概念复习进程.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,第5章-全麻的基本概念,什么是麻醉？什么是全身麻醉？,现在只是描述了一个现象。,它的本质是什么,?,全身麻醉的机制是什么？,全身麻醉对大脑、对智力有影响吗？,麻醉深度的概念？怎样鉴定？,全身麻醉状态是人吗？昏迷？有记忆吗？,The word is derived from the Greek words,an,which means“without”,and,aesthesis,which means“feeling”.,The use of medical,anesthesia,(,lack of sensation,),was first reported in 1846.,1.,全身麻醉概念,Definition of General Anesthesia,麻醉药吸入、静脉、肌注或直肠灌注进入体内，使中枢神经系统抑制，,意识消失、无疼痛感觉的,可逆状态,。,General anesthesia(GA)is the state of reversible unconsciousness with analgesia,through the administration of anesthetic drugs.,It is used during certain medical and surgical procedures,.,GA,特征,reversible unconsciousness,analgesia,amnesia,inhibiting reflexes and stress,muscle relaxation.,不是生理状态，也不是病理状态，是为了实施某些特殊治疗（手术）采用的。,瑞典麻醉大师,Gordh,在他,98,岁时说了一句经典的话“麻醉是介于生与死之间的一种状态，不可掉以轻心！”,全麻后如果没有醒过来,？,全麻（状态）是什么？,全麻状态的理解,哲学意义上的麻醉状态,-,底线,药物引起的可逆性意识消失状态。,它并不考虑病人实际是否感受到伤害性刺激引起的疼痛,(analgesia,),。,它只考虑病人是否对伤害性刺激能形成痛觉记忆,并能于清醒后复述这一记忆（,awareness,）。,临床麻醉状态,意识消失，无痛，无知晓，无记忆。,对伤害性刺激引起的应激有适度的抑制。,肌肉松弛，以满足手术需要。,生命体征、内环境稳定。,哲学意义上的麻醉状态是底线，即首先应确保病人术中无意识，对术中刺激无记忆，然后才是满足临床麻醉的需要：生命体征平稳，满足手术需要,。,事实上，,临床工作首先要确保病人生命安全,，危重病人,浅麻醉,，可能导致术中觉醒。,全麻要素,药物,神志消失,麻醉药（吸入、静脉）,麻醉辅助药,痛觉丧失,麻醉性镇痛药,肌肉松弛,肌肉松弛药,神经反射抑制,（一定的麻醉深度）,遗忘 遗忘药物,全身麻醉,全身麻醉的药物,Induction Maintenance Recovery,2.,全麻的过程,诱导,维持,苏醒（,emergence,）,2.1 Induction of General Anesthesia,Definition,全麻诱导是指病人从清醒转为可以进行手术操作的麻醉状态的过程。,There are some,complications or,risks,in this stage,e.g.reduction of blood pressure,arrhythmia,myocardial ischemia.,Cardiac arrest,Induction of GA,方法,Rapid-sequence Induction,快诱（导）,Slow-sequence Induction,慢诱（导）用,肌松药,就是快诱，没有是慢诱。,（,1,）静脉快速诱导,（,Rapid-sequence Intravenous Induction,）,充分吸氧,意识消失,扣紧面罩,控制呼吸,气管插管,安定催眠药、静脉麻醉药,芬太尼,肌松药,Agent,induction dose(mg/Kg),Diazepam,0.2,Midazolam,0.1-0.2,Thiopental,3-5,Etomidate,0.3,ketamine,1-2,Propofol,1.5-2.5,Fentanyl,2-6,g/kg,静脉麻醉药,Intravenous induction agents,肌松药,Muscle Relaxants,depolarizing,nondepolarizing,Cis-atracurium,dose(mg/kg),0.15-0.2,Succinycholine,1-2,mg/kg,vecuronium,0.08-0.1,atracurium,0.3-0.6,pancuronium,0.08-0.1,Rocuronium,0.6-1,Disadvantage and Complications,Regurgitation and Vomitting,Cardiovascular depression,Respiratory depression,Histamine release,Pain on injection,Hiccup and muscle movements,静脉快诱导,（,2,）,Inhalational Induction,适应症,Indications,young children,myasthenia gravies,upper airway obstruction,e.g.Epiglottitis,lower airway obstruction with foreign body,bronchopleural fistula or empyema,no accessible veins,吸入诱导,Inhalational Induction,Initially,nitrous oxide 70%in oxygen is used and anesthesia is deepened by gradual introduction of increments of a volatile agent,e.g.Halothane 1-3%,Enflurane 1.5-2.5%,Isoflurane 1-2%.,Sevoflurane,特征,characteristics,Spontaneous ventilation is to be maintained.,the face mask is applied firmly as consciousness is lost and the airway is supported manually.,Insertion of an oropharyngeal airway,a laryngeal mask airway or a tracheal tube may be considered when anesthesia has been established.,Disadvantage and Complications,Slow induction of anesthesia,Airway obstruction,bronchospasm,Laryngeal spasm,hiccups,Environmental pollution,（,3,）,Induction with spontaneous ventilation,保持自主呼吸诱导,Airway obstruction,anticipant difficult intubation,Characteristics,Maintaining spontaneous ventilation throughout the procedure,Sufficient surface anesthesia,（,4,）,Intravenous induction following conscious intubation,清醒插管,Difficult intubation,Patient with the risk of regurgitation,Patient with postural hypotension following anesthesia(e.g.paraplegia),（,5,）,Other induction methods,intramuscular injection of ketamine,take midazolam orally,administration of fentanyl via mucosa,注意事项,树立安全意识、保持呼吸道通畅、循环稳定,安静、集中注意力,加强,生命体征,监测和观察，,准备好麻醉机和插管用具,建立静脉通路和体位准备,给氧去氮,诱导药物剂量与方式,面罩加压给氧时，,TV,不宜过大，避免气体进入胃内,胃胀气、返流,保持一定麻醉深度，,插管反应的防治,2.2,全麻的维持,镇静,镇痛,肌松,遗忘,应激与反射抑制,Maintenance of general anesthesia,Inhalational agents,Intravenous anesthetics,Opioids,Muscle relaxants,注意事项,全麻维持与诱导紧密衔接,了解手术进程，麻醉深度与手术刺激相适应,做好呼吸管理，保持气道通畅，人工通气监测,PETCO2,、,SPO2,及血气分析,:,颅脑手术,PaCO2,维持,30-35mmHg,冠心病病人,PaCO2,不宜太低，以免冠脉痉挛。,监测控制麻醉深度,使用肌松监测仪指导肌松剂的使用,充分镇静、避免术中知晓,维持生命体征和内环境平稳,及时处理术中失血性休克、过敏性休克、心律失常等异常情况。,麻醉管理,2.3,Emergence,Reverse of induction,Depends on the solubility of the agent in fat,Depends on the duration of anesthesia,Depends on the depth of anesthesia,恢复期操作,Antagonizing residual neuromuscular blockade,Extubation,Circulation supporting,Breath/Airway supporting,Recovery position is benefit to avoid airway obstruction,严格掌握拔管指征，过早、过晚拔管均会造成严重后果,自然苏醒，必要时使用催醒药,MACawake:,肺泡气内吸入麻醉药浓度降至,0.4MAC,（,0.5,或,0.6MAC,）时，,95%,病人能按指令睁眼,3.,麻醉深度监测,临床监测,脑电双频谱指数（,Bispectral Index,，,BIS,）清醒,:80-100,外科麻醉期,:40,体感诱发电位,脑干听觉诱发电位,食道下端肌肉收缩波形和振幅的测定,麻醉深度与受刺激的强度有关。,如没有伤害性刺激存在，则绝大多数麻醉状态都是过深的，如有伤害性刺激存在，则绝大多数麻醉状态又过浅。,3.1Guedel,乙醚麻醉分期（,1937,）,期：痛觉消失期，麻醉开始、意识消失,期：谵妄期，意识消失、呼吸循环稳定，不宜手术操作,期：外科期、呼吸循环稳定,期：延髓麻醉期，绝对避免,3.2,临床麻醉深度的判断,分期,呼吸,循环,眼征,其他,浅麻醉期,不规则仓咳气道阻力,血压,心率,流泪眼球运动存在，睫毛反射无,出汗分泌物,手术麻醉期,规律,气道阻力,血压稳定,眼球固定中位,无体动无分泌物,深麻醉期,膈肌呼吸,血压,对光无，瞳孔散大,MAC,：,1.3MAC,、,MACawake,脑电图：,BIS,：,40-60,脑干听觉诱发电位：,BAEP Index,食道下段收缩反应（,LEC,）,小结与讨论,THANK YOU,此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力做得更好！谢谢,