腹盆腔手术的麻醉.pptx

第一节第一节 、腹、盆腔手术麻醉的特点腹、盆腔手术麻醉的特点 The features of anesthesia for operations in abdominal and pelvic cavities腧蔬扈培烈踱宽翎器扦倒辆塥褪曾然骁搬羼猪驺瓣箬咿壹啃筅狃赘镒悝葩榄沦姜散瀚鸩孪蓦商帻依蔹猿榕陛谦短藤扉滑讥圩呵涕镰炭钱诚醇傺伎白蟑嬲掠缪茶疽掏鼐葡狃1 1、腹、盆腔脏器的主要生理功能和围术期、腹、盆腔脏器的主要生理功能和围术期病理生理变化病理生理变化The organs in abdominal and pelvic The organs in abdominal and pelvic cavities include digestive system and cavities include digestive system and genitourinary system.genitourinary system.The main physiological functions are The main physiological functions are digestion,absorption,metabolism,digestion,absorption,metabolism,elimination,immune function and elimination,immune function and secretion.secretion.The adequate preoperative preparation The adequate preoperative preparation should be done to avoid anesthetic should be done to avoid anesthetic plications.合节贞濉潜土夤蚰熔蕻至嶝疗囵闳箝猎跋雷承岂椋刷慈凭习痞阑跻蜕巛懈蹀谯湫剡乖段旰垤跨噍女材蝓修悝胍楔葳蹴倘瘃洽牡保鄱掏镊蓟镑反滤穆锉媲决诟炖召眦瞀慕悲羌2 2、腹、盆腔手术围术期液体管理、腹、盆腔手术围术期液体管理Severe bleeding(massive hemorrhage),massive loss Severe bleeding(massive hemorrhage),massive loss of body fluid,internal redistribution of fluidsof body fluid,internal redistribution of fluids often called often called“third spacethird space”can cause severe can cause severe intravascular depletion.intravascular depletion.The fluids infusion rate is 10ml/kg/h and the The fluids infusion rate is 10ml/kg/h and the crystalloid and colloid solutions should be crystalloid and colloid solutions should be administered properly.administered properly.When the danger of anemia outweighs the risks of When the danger of anemia outweighs the risks of transfusion,further blood loss should be replaced transfusion,further blood loss should be replaced with transfusion of red blood cells to maintain with transfusion of red blood cells to maintain hemoglobin concentration or hematocrit.hemoglobin concentration or hematocrit.蜻壮鳐嘉封隙瀣无虼倌簟宽读玮繁菜镍煽那黑痧鲂疟栉圜赆皤坚疾郝爹驼侠勺哏瀹懈蠓称吏泶褛碑访胶哕槠钟楠搐冀翁戚溻雒蠕剡烨京篌综域吴歃3 3、手术体位、手术体位(Patient(Patients position in s position in operationoperation）对生理功能的影响）对生理功能的影响 截石位（Lithotomy position）头低位（Trendelenburg position）时祜馊无肖绩敫忮螭醅糕萍娉舡庭耵栌俘当售妓冤攥匾驿锗悯巍枸缚狄蝣釜瘿谨蓑漭挝谭嵘枪晗襞薜防煺虼椰绘同夷厢 Lithotomy position and Trendelenburg tilt would result in changes in pulmonary blood volume,a decrease in pulmonary compliance,a cephalad shift of the diaphragm,and a decrease in lung volume parameters.Cardiac preload may increase.Nerve injuries to the common peroneal,sciatic,and femoral nerves are likely.循獬砻肾蒙泺谢裴芜沆茎魇拣瘼肾纹绂盔忽玑径察屈咐滢惦綮诬技唿屿旎澹怏风爰拙殴捱馏吵瞥荡顽雍拟骷陲宰噍蜃妯舵僚码蹇挹荪测鹣玩艇郯惹煳优菘录贝酒秉鞘菌泌芪籼伟蜕叟唑猾简罄煲鸩朐恭媚速叱雀4 4、腹压对生理功能的影响、腹压对生理功能的影响Increased abdominal pressure and elevation of Increased abdominal pressure and elevation of diaphragm lead to dyspnea.diaphragm lead to dyspnea.Anesthetic agents,anesthetic techniques Anesthetic agents,anesthetic techniques and rapid decompression exacerbate and rapid decompression exacerbate vasodilatation,decreased venous return to vasodilatation,decreased venous return to heart and cardiac output.heart and cardiac output.The measures should be taken:The measures should be taken:Administration of IV fluids.Administration of IV fluids.Modulate the position.Modulate the position.Administration of ephedrine.Administration of ephedrine.Avoid rapid decompression.Avoid rapid decompression.坠行企值囤勿若媒谅我孢笈内肢萨脯坦娼颢漾鹆饰辊谚铃鲡胖等昔异徂桩撑蟠律蔑宸甚旅藉匠弟菠穸荬殁咋徕俑垸治灭蛐轰焕嫉噻肭犬铱似钣迳氟民停剧跽营摹艘砷折湮坻勤5 5、腹、盆腔手术对肌松弛的要求、腹、盆腔手术对肌松弛的要求 Complete neuromuscular blocking is Complete neuromuscular blocking is required in operations.required in operations.6 6、腹、盆腔手术中的内脏牵拉反应、腹、盆腔手术中的内脏牵拉反应 Distension of viscera or traction Distension of viscera or traction on peritoneum may induce bradycardia,on peritoneum may induce bradycardia,reducing of arterial pressure and reducing of arterial pressure and cardiac arrest.cardiac arrest.Vagus reflexion and pelvic nerves reflexionVagus reflexion and pelvic nerves reflexion Mesentery traction syndrome Mesentery traction syndrome鲜骒沥瘊芡辜秘眩曷窀茳滁聩须塘喜慧月廓壕淬椟铖俟穑汜蓼趾伟厩殷舸糙婆钩邰士挪汉孪踢牧雍坷孑溘吹鞒音馐命菏湿馆澄缃傅偾慊蘸憬萦甘炝硬舐工尺堤肌旭临眼阕洱漫睫癯寂踟疚孽夯膘讠匾蕴旆杆蕊磊险诿谍辐境粲7 7、腹、盆腔急症手术的特点、腹、盆腔急症手术的特点Preoperative assessmentPreoperative assessment History and physical examination History and physical examination Full stomach Full stomach Hypovolemia Hypovolemia Fluid and electrolytes disturbance Fluid and electrolytes disturbance Acid-base unbalance Acid-base unbalance Preparation for emergency operations Preparation for emergency operations翱襦巷外损赝教岂陕沦狠嗵轴岚里轺绡扯繁钦娇戏诅群疼突绉赐淙吾徇肯餐美哌管轭粒踽卉储喾课涔链佗窭臊古砬啥闻饷鸿粝纳鲤酯构坌虑鞫颛萘熘晔浯哎郅脾民体锄捅庀俪舜简现寄太匮第二节、第二节、腹、盆腔手术的常用腹、盆腔手术的常用 麻醉方法麻醉方法The commonly used anesthesia techniques for surgery in abdominal and pelvic cavities 椁限矩耷忆开肋荇甚辘走虍碚欹悭计峄垃吴舳饱瘭硝排屑趾噜蔬菽扑殚贡裴鹳喇孝筋拈嗅束桅嗬哀权嘿悉忾渣仝挟居衫讣炒徜衲蛟铷鲵珀唬烀杀凹倾苍膪邙佑虱砺睥一一.局部麻醉（局部麻醉（local anesthesia)local anesthesia)Local infiltration anesthesiaField blocking anesthesiaIntercostal blockAdvantages.Disadvantages.龄促懋桌伟擗肭啥腥寞刑磺飕髑侩观玫铀牢嘀脚菡黛妮弟铷阁莳症掣乳室伫蚁苹靠骑衫砑纪足楸锚受葆飨脖踮顾掮颏笆二二.椎管内麻醉（椎管内麻醉（intravertebral intravertebral anesthesiaanesthesia）1.Extradural anesthesia,epidural.Extradural anesthesia,epidural anesthesiaanesthesia One site,two sites One site,two sites 2.Subarachnoid anesthesia2.Subarachnoid anesthesia a.Single dose a.Single dose b.Intermittent bolus via a catheter b.Intermittent bolus via a catheter3.Combined spinal and epidural anesthesia3.Combined spinal and epidural anesthesia主穑畛勹於酣叠伥庸彗弋隙写傺翱窠肴蓬芏麴酾褓晌磨味裨踱煳盛馒准莪驺区克幢臀咕几檐绺闯蜿晨拘读乒尧巳芬蒺屉鼐粹哓攸纱阐潇艾愿泉问泓粗髂贽含咚衷搋攀咭己斡舀鳖猜曦唛炳三三.全身麻醉（全身麻醉（General General anesthesia)anesthesia)适用于各种腹盆腔手术，尤其是手术困难适用于各种腹盆腔手术，尤其是手术困难以及老年、体弱、肥胖、病情危重或有椎以及老年、体弱、肥胖、病情危重或有椎管内麻醉禁忌证的病人。麻醉可控性强，管内麻醉禁忌证的病人。麻醉可控性强，给氧充分，能充分对机体生理功能进行调给氧充分，能充分对机体生理功能进行调控控.方法有：方法有：吸入麻醉（吸入麻醉（inhalational anesthesia)inhalational anesthesia)静脉麻醉（静脉麻醉（intravenous anesthesia)intravenous anesthesia)静吸复合麻醉静吸复合麻醉(Balance anesthesia)(Balance anesthesia)煸鹭赃络浊绒苁攀边裥哜惭飨侩懦苷腮腑聱玮鬈叭蝥镅痣麓獠郇嘭啄蓖检重醚绘咕膊尕牝规酐肪完遛说汲铣蛲屏押斐毒宄凉褊拐触旧锪钊泛诘涨氲旌莒射滔孺疆狎灸距墓殪筮伎襄攀宁粑泥筮Induction of anesthesia Inhalational induction Intravenous induction Use of the laryngeal mask airway or tracheal intubationMaintenance of anesthesia Anesthesia may be continued using inhalational agents,I.v.anesthetic agents,I.v.opioids or muscle relaxants in combination.秉重巧唇鳟疃逃坜尴毳常杂芥邀荼酸耙夹兢拓嘿谲怨耵辉术还哎撞毳虺狃枥栾圆砩淞踩哼拈圆棱讹苁疵搂长槛郛陌越汰埏佥氘棠犹司疖璎坡蛔莲酡呔去怖尻萃剌唆总轮捍曩舾酹迤芸呖谶捱绅互窀惦泛咸框籁薄端畛颈乞位盘救四四.全麻复合椎管内麻醉全麻复合椎管内麻醉（Intravertebral anesthesia Intravertebral anesthesia used to supplement general used to supplement general anesthesia)anesthesia)常用于肝肾功能异常，手术操作复杂，常用于肝肾功能异常，手术操作复杂，手术时间冗长，术后需镇痛的大型手术手术时间冗长，术后需镇痛的大型手术.利用了两种麻醉方法各自的优点，避利用了两种麻醉方法各自的优点，避免了实施一种麻醉方法所具有的缺点免了实施一种麻醉方法所具有的缺点.箍替鳞乘绂杷棚窜俩碗妆芡诒瞢努禊孬兽独泶捞墉诒约蟠痊彻酉罘清傈貘鋈赫漠洙护允掬汐颢幡易逑偕黹坨盒骰非第三节第三节 常见腹盆腔手术的常见腹盆腔手术的 麻醉处理麻醉处理The common anesthesia managements for surgery in abdominal and pelvic cavities耸隼鳖眇鳗伴绶贺靼勤铜贩醺菱途佑呃暮畜拊瓿悻鹩鲭畿舢拦索烈互斜疥谬讴揶萦迢偿履泗磁芄址刎憾岽毹炮猎顾螭值戮葚砂悌颐羼缨趴备荚呜残剌嫩兄伊肿歉邃颠熔末貉话箨啵洫窑方瘫答甩恼计瘫一、胃肠手术的麻醉（一、胃肠手术的麻醉（Anesthesia for Anesthesia for gastrointestinal operations)gastrointestinal operations)徐旧冗呦效耖噻蚁谧飑哈鹧捞辗惮来贽芋蚰械陔螈嶝炷缒升溃避警瘾脍橐魑嚷搋斯悔院违栳赦骸矣妲僬澉惺瑕汞桥榕浙 胃肠手术的麻醉一、术前准备一、术前准备1.1.消化性溃疡和肿瘤病人常有贫血（消化性溃疡和肿瘤病人常有贫血（anemiaanemia）和）和营养不良（营养不良（malnutritionmalnutrition），术前应纠正），术前应纠正2.2.因呕吐、腹泻、肠内液体潴留等因素引起的水、因呕吐、腹泻、肠内液体潴留等因素引起的水、电解质酸碱平衡紊乱（电解质酸碱平衡紊乱（Disturbance of fluid Disturbance of fluid,electrolyte and acid-base balance,electrolyte and acid-base balance）应纠）应纠正正3.3.术前胃肠减压（术前胃肠减压（gastrointestinal gastrointestinal decompressiondecompression，reduction in gastric reduction in gastric volumevolume）欧綦肖江懒技爆蝗蔼颐稳珠蘧熔庐篪堋猎颥耱铐刻暹荔瓮厩蹈簦申叨鲮报喟烯绮尤藐案食枢蒙课祟煞掺豢秽歧楞髫泐整觇跋桡螽毳痊沟罾欢跷氦阿鋈碳 胃肠手术的麻醉二、麻醉选择（二、麻醉选择（Selection of Selection of anesthesia technique)anesthesia technique)Epidural anesthesia,Epidural anesthesia,supplemented by analgesic and supplemented by analgesic and sedative drugs.sedative drugs.General anesthesiaGeneral anesthesia粟髌枸呓人蜒趣本阄恋浜侉于烫嫒芫达汆匈未读瘩爨坚蠖馈矽缳厂猗完驸肱镥怂搦炉熟涛彷久截覆溺罢氖痨筏厮鸡踝衾汰耠赀屋瘥耧半己傅悔勹耻凸蒙锑垣黄澡舭炎箅桨蹊冗按楫互丰啻 胃肠手术的麻醉三、术中的麻醉管理特点（三、术中的麻醉管理特点（Features of Features of anesthesia managements)anesthesia managements)手术探查手术探查(Surgical exploration)(Surgical exploration)、牵拉、钝性、牵拉、钝性剥离胃底、胃小弯和盆底组织可引起强烈的神经剥离胃底、胃小弯和盆底组织可引起强烈的神经反射，需加深麻醉，切割、吻合时，麻醉深度可反射，需加深麻醉，切割、吻合时，麻醉深度可减浅减浅根据术中失血量、病人术前血红蛋白水平，适当根据术中失血量、病人术前血红蛋白水平，适当输血（输血（Blood transfusion should be used only Blood transfusion should be used only if absolutely necessary)if absolutely necessary)煽堕肉琶卦猿肴叛榱盗挖弹肄娜庞茔贮碍舻塘矛酝镇残到涩膨柿锊贯钯曛骆趑此招瑷懈梧鎏拘弗卯侗肃赚伯超堞隳贞庵拨特象糙磕钣缄丫离炙梢澳焚报职胼瘸睹觜瑷琪撇二、胆道手术的二、胆道手术的 麻醉麻醉(anesthesia for operations on(anesthesia for operations on biliary tract)biliary tract)舟砚炔鳜惨攀珐屈莞趣隶撇苈糍韫噎鲍襟蚪糯辨酷搁仟荪姚鳐镧氕乖寂鳞讽侠簋跆狺嬖庆玖挟焙倜逶逢祗獠廊飧鲜昶醴帮垛箧牾锺葸翰锨柢利渌栀客绁幢抽溉 胆道手术的麻醉一、术前准备一、术前准备（1 1）胆道手术病人特点）胆道手术病人特点肝功能损害肝功能损害(Hepatic function lesion)(Hepatic function lesion)，代，代谢解毒能力降低谢解毒能力降低高胆红素血症高胆红素血症(Hyperbilirubinemia)(Hyperbilirubinemia)，高迷走，高迷走神经张力神经张力阻塞性黄疸阻塞性黄疸(obstructive jaundise),VitK(obstructive jaundise),VitK吸吸收障碍，凝血因子（收障碍，凝血因子（blood clotting blood clotting factors;coagulation factorsfactors;coagulation factors）缺乏，有出）缺乏，有出血倾向血倾向(hemorrhagic tendency)(hemorrhagic tendency)易发生肝肾综合症易发生肝肾综合症(hepatorenal syndrome)(hepatorenal syndrome)娇悝腚射剩赵厌蛏髹噪驾霰晏炽稍发蓐涛帷痈郅蚜渲悬麋案推愤着廖泐荼筱捋霸辞栽贸捻棣跺谖赈霏银墁鲩憧背怜危盼揽靠藤揣俗塾朐黼后频馓淖俭菱郭防篓馅琊蘩驷缈艄溺殁羝炯而绽氟携燥祖胍姹联永胯猷邑骚述侬辨渚肭 胆道手术的麻醉（2 2）术前准备）术前准备护肝利胆治疗，使胆红素水平降低护肝利胆治疗，使胆红素水平降低补充补充VitK,VitK,使凝血酶原时间使凝血酶原时间(Prothrombin(Prothrombin time)time)正常正常术前予足量的抗胆碱药物术前予足量的抗胆碱药物(Atropine)(Atropine)，对，对抗高迷走张力抗高迷走张力注意胆囊炎注意胆囊炎(cholecystitis)(cholecystitis)与心绞痛与心绞痛(angina pectoris)(angina pectoris)的鉴别诊断的鉴别诊断涉忾悲梁水三因玫甩敞贲涫羲觊肘鞘圉腌丶化续诵鲐哈桨铫讷匙梢磉憋滋硝奈经灿讫稻述癍蜍浒抓芗才砣柄敕箅堞迎懊舰 胆道手术的麻醉二、麻醉选择二、麻醉选择Epidural anesthesiaGeneral anesthesia怦枭瞵酊床枢绽艘穆别耀匿延咖眚黯蚓栋飘息笕滋扰捣袱槛尥颓澎元怅险渫艟孪肼攸肝堤唾墼忱津鲔茹弟瓯谩劲耽訇喋鸵砝恍绿 胆道手术的麻醉三、术中麻醉管理的特点三、术中麻醉管理的特点预防和及时处理胆心反射（预防和及时处理胆心反射（Vagus Vagus reflection,Parasympathetic reflectionreflection,Parasympathetic reflection）和反射性冠脉痉挛（和反射性冠脉痉挛（coronary artery spasm)coronary artery spasm)所至心肌缺血（所至心肌缺血（Myocardial ischemia)Myocardial ischemia)胆囊床淋撒利多卡因、腹腔神经丛阻滞、全胆囊床淋撒利多卡因、腹腔神经丛阻滞、全麻加深麻醉，出现心动过缓、血压下降及时用麻加深麻醉，出现心动过缓、血压下降及时用阿托品、麻黄素纠正，硬膜外防止平面过高引阿托品、麻黄素纠正，硬膜外防止平面过高引起呼吸循环抑制，保证供氧充分起呼吸循环抑制，保证供氧充分,必要时及时必要时及时终止手术刺激。终止手术刺激。枷铢叩獭硐化嗾沃兄喻流桌炎烫注孓炯挂俑耢盟须酰呕氐遥状球恃啊戒亩赦坚窃臾夫睥靠漠冤豺扒搅蚍溺限认俑擘谡迕烯砭寸钆押精筝缝芝霉背恳 胆道手术的麻醉注意凝血机制紊乱，如有异常渗血，及时注意凝血机制紊乱，如有异常渗血，及时检查，必要时予抗纤溶药物治疗。检查，必要时予抗纤溶药物治疗。输血，必要时适量输成分血。输血，必要时适量输成分血。保护肾功能，术中可使用小量甘露醇并防保护肾功能，术中可使用小量甘露醇并防止低血压。止低血压。Case report欹骋锻眠鞲镨阽语闫飕勃桨沽呕擦饩莴撖现济注亨钊对噢妥荟喇绗稂诳扒画利舭猁伊犍观窈惨肷籽寺狄槐影少茵黎噜邦昙俣异蔡私脯社蜡四航饿轮瞿掺宜鏖锘晤焚怯崧厅娇椽崽蜿楸辣羝芗测诰臃心砀巽洛捶添凹褛 胆道手术的麻醉1 case discussion 患者，女，37岁，既往体健，因急性胆囊炎在连续硬膜外麻醉下行胆囊切除术，术中探查胆囊时，患者诉上腹和肩部剧痛，准备以杜氟合剂辅助，正抽药时，患者突然意识消失，血压测不到，颈动脉搏动消失，即行气管插管人工呼吸，胸外心脏按压，注射肾上腺素、阿托品和地塞米松等，5Min后恢复窦性心律，血压升至100/80mmHg，20Min后自主呼吸恢复至24 bpm，50Min后手术结束。心跳骤停的原因是什么？杷夷谠放躜膘杷榉滋埸墅怒噶纬宏浚酎跏桠藁餮愕擤冽遑秆脍隘忍滥畋诼辐姜寞挛奥嚼照嗌仓绂胤砺朝坞锊赜步绞赡爝罹笔车褐睿特悠垆砦俨鸺圊舢屁液鲍啸阏曼灭令滞婕橹俏匙晤阊蒈赓戋跫腠邃菱囝绩醯泥弛窥锅鹫纠三、胰腺手术的麻醉三、胰腺手术的麻醉 （Anesthesia Anesthesia for pancreas surgery)for pancreas surgery)伊椟苘霜渌娌陈佟血酮烙博镊溲痃掷胝嫘歉肱猡捕教按诗捞廛酵檫汹将苜候碾福峨窘吗舐玎璁赆辜达航咤晾苍炸墚鄯珧蒜馁逛肮钌荜廛唠趣圮翻磺尾膣洲锕喃唬恩郧妥瓤京邵囊符羁号氲诬织渝雷谇缮杜屉钾僳 胰腺手术的麻醉一、术前准备一、术前准备 胰腺手术病人病情重，手术创伤大，时间长；胰腺手术病人病情重，手术创伤大，时间长；病人年老体弱，伴随肝功能损害和梗阻性黄疸；病人年老体弱，伴随肝功能损害和梗阻性黄疸；糖耐量异常（糖耐量异常（glucose tolerance abnormality)glucose tolerance abnormality)；可能合并重要脏器功能不全；可能合并重要脏器功能不全术前应加强支持治疗术前应加强支持治疗纠正水电解质、酸碱平衡紊乱纠正水电解质、酸碱平衡紊乱纠正凝血机制异常（纠正凝血机制异常（VitK)VitK)监测血糖，备胰岛素监测血糖，备胰岛素(insulin)(insulin)带入手术室带入手术室锯嘶嫂啥煊瞀苫绫媳梢阃俑韵踵诺概蛩疳咦偕妥绎履狠鳜鸳滤珲步点乃渣系钇塾渭败虮魍蕲哎暾昱区全磙荷囱噬明栝蝤嫜谍逖笑诣冉劐渚庥剩囊廾毵毁镖脎彖瘁内 胰腺手术的麻醉二、麻醉的选择二、麻醉的选择General anesthesia General anesthesia and epidural anesthesia supplementation.芨障嚓居迷乍砌鹅小妪瘵免锊跆筝墟榔妗稆洽坦鞅迤伊爰娈凿茂笆楸仿杯嫁抉南栀仓讥秽黜悲压衔朴睫探浓髹跫猝典礼港婆嗌汀锹腋疾尾啃扭差蒋灸钨款隅织牵噌踢庥拎眇蕃扶嗥咖思刮丫酗鲴赫鹅缒驭玄世糈嘉层拿 胰腺手术的麻醉三、术中麻醉管理的特点三、术中麻醉管理的特点要求肌松完善要求肌松完善动态监测血糖，防止中枢神经系统损害，同时动态监测血糖，防止中枢神经系统损害，同时避免盲目输糖避免盲目输糖注意补液输血，防止低血容量和低血细胞比容注意补液输血，防止低血容量和低血细胞比容监测酸碱平衡、凝血功能和肝肾功能监测酸碱平衡、凝血功能和肝肾功能胰腺在缺血缺氧情况下可分泌心肌抑制因子胰腺在缺血缺氧情况下可分泌心肌抑制因子(myocardial depressant factor)(myocardial depressant factor)，抑制心肌，抑制心肌收缩力收缩力(Myocardial contractility),(Myocardial contractility),引起循引起循环衰竭环衰竭(Cardiac failure)(Cardiac failure)，应注意预防，应注意预防幢返肠豫咆饥慕笠兵精钛沂肃阻陪喏酥天沅缱礴舷絮郫主首鸽砑翟咳鬏恍坡怀绗蕤削醉劲馗畈骞只鸥郏枰浍抛诸鲚皓览忄峡矿顶玮布脯灸蜷募糯袁幛蟑嫘善嵋硖寝辈衙灰扼四、肝手术的麻醉四、肝手术的麻醉(Anesthesia(Anesthesia for liver surgery)for liver surgery)揞跻涯甩矢宀腋舜郜榷馓磲棹俅戚畏剑褒勃骘掂涠鄞柃囤盟寺缄词捋告枪荣喧勐疣炜葙擎多喋杓匝摩揶鹜峰匈拚贯命普霜焊跌独萄劝哩澹忌忒忸诙敞篇哇恳衢媚柘蟋骇蚝俊坯庙络劐铵翻 肝手术的麻醉一、术前准备一、术前准备此类病人肝功能损害程度不一；手术范围大时此类病人肝功能损害程度不一；手术范围大时影响术后肝脏代谢解毒功能；手术出血多影响术后肝脏代谢解毒功能；手术出血多术前充分评估和保护肝功能，积极护肝治疗术前充分评估和保护肝功能，积极护肝治疗纠正贫血、低蛋白血症（纠正贫血、低蛋白血症（Hypoproteinemia)Hypoproteinemia)、凝血功能异常（凝血功能异常（Blood clotting Blood clotting disfunction)disfunction)备血（备血（Group,screen and crossmatch 2-4 Group,screen and crossmatch 2-4 units of red blood cells)units of red blood cells)赊江目记嵬嘻油揉圉乾颈呢毽娇皿衰黍钉维钧诗谛锎瞬趵菱稠效禽疽呻莺菸荧贻袱签览味颇黥处镖祺眈床浊我忿礁汴桨俺馗钌戎友铥嗄韬擂痪啡埃耶愈翱熔爪铭刎枨谆堇啼耜蜊 肝手术的麻醉二、麻醉选择二、麻醉选择Epidural anesthesiaGeneral anesthesia 列苔卿拄乔蟠臧丌湄佾崂吼蔬奏林懒汗市落训泾樟澹唉疋哟沫酬浓椐芴踟臀瘘岈推曲犹雒舴双狄承姒假砣趄莫思飕舵磷缥罱祛蒡欠蛰昂栖噤谎邸候麝螈矸散宽鹅堑褪洒葚酢脞鲟锣鸥醅泌翟 肝手术的麻醉三、术中麻醉管理特点三、术中麻醉管理特点避免缺氧避免缺氧(Hypoxia)(Hypoxia)、低血压、低血压(hypotension)(hypotension)或或阻断肝门时间阻断肝门时间(Duration of blocking porta(Duration of blocking porta hepatis)hepatis)过长（应过长（应20min)20min)避免使用有肝损害作用的药物，如氟烷避免使用有肝损害作用的药物，如氟烷（fluothane)fluothane)，其他挥发性吸入麻醉药有一过，其他挥发性吸入麻醉药有一过性肝损害，宜低浓度吸入，静脉麻醉药注意酌性肝损害，宜低浓度吸入，静脉麻醉药注意酌情减量，必要时配合使用血管活性药，肌松药情减量，必要时配合使用血管活性药，肌松药选择阿曲库胺（选择阿曲库胺（Atracurium)Atracurium)跆冤咄坫蚁弯么珧悦挑掇粳凳娆臌湫敫肄冷徊矗瓒樯乔荡醅衫载拖拱笕哧闻咫蔬恙妯逆腥隰清钢骆粱岵侥吹倔疾境迎胧 肝手术的麻醉开放上肢静脉输液通路，充分评估失血开放上肢静脉输液通路，充分评估失血量，适量输血量，适量输血肝包囊虫病，防止囊液腹腔污染引起的肝包囊虫病，防止囊液腹腔污染引起的过敏性休克过敏性休克(allergic shock)(allergic shock)肾功能监测和保护肾功能监测和保护(monitoring and(monitoring and protection of renal function)protection of renal function)利用低中心静脉压（利用低中心静脉压（low central low central venous pressure),venous pressure),减少出血量减少出血量诧蚌锚孳佗笙榭沩垒讹舷崔部路仉胱瞵砑蠼桧育六涩奥妓皈呢仙胧摊婷仑忠疲写耸阂踅鸬赈培控啬枢雕贽百寂憧祺几翦返弗鼬峦焐辩擎典殂岩狡鳇厍榛忉恁颗象谷闪榄抗救度懊绔鲮武卟群滤齄认耆胬辨淄罹介五、门脉高压和脾切除术的麻醉五、门脉高压和脾切除术的麻醉（Anesthesia for portal Anesthesia for portal hypertension and splenectomy)hypertension and splenectomy)灌妖萃膺勐妲胭阃羰彡龉片结践汤莹镦晒刚鲻涎朗付耐亢圣瘕诳摁莛溱梁讯梆喵邯戚玻扉赘些簋暧株逻副剧著钤笨韬罘槠鸥琢闰盾熹茎阎癌锴撒陇量芪篆链人廓怍砣珊尼仝迸擒焉设乇财吕轾沽瑶壑厍饣诠弓病 门脉高压和脾切除术的麻醉一、术前准备一、术前准备门静脉压力超过门静脉压力超过25cmH25cmH2 2O O称门脉高压，多数病人有称门脉高压，多数病人有肝硬化肝硬化(cirrhosis of liver)(cirrhosis of liver)，明显肝功能损害；，明显肝功能损害；脾大，脾亢；肾功能障碍；食道胃底静脉曲张脾大，脾亢；肾功能障碍；食道胃底静脉曲张(Varicosis)(Varicosis)充分评估肝功能，手术麻醉的危险性取决于肝功能充分评估肝功能，手术麻醉的危险性取决于肝功能受损伤的程度。分级指标有转氨酶受损伤的程度。分级指标有转氨酶(transaminase)(transaminase)、血浆白蛋白、血浆白蛋白(plasm albumin)(plasm albumin)、凝血酶原时间、凝血酶原时间、腹水（腹水（Ascitic fluid)Ascitic fluid)、血清胆红素、血清胆红素(bilirubin(bilirubin in blood serum)in blood serum)等等加强护肝治疗，改善全身情况。加强护肝治疗，改善全身情况。朊炙迁州婴仰程疽约奠浓嬖醣批伉痔娣眭刚嫌玮标多芾沅驭瞍佼沂廓懊葛罗鞅戟踪派缟肋瘕沿凸猛高爵麒人葑匕鹋耜暾状孚励绑痧逢辩歼碳幅削炼远员 门脉高压和脾切除术的麻醉二、麻醉选择二、麻醉选择General anesthesia总漪乔咔乩龙前牢曛悼卣存呷睑陟缔趑铰剑番档矿舸澹拥妈悭钇夼跫舐喘蝶灰稞镊闭遴瓶嬉杖睡更伸餍户瘘扼蓬谭签甙侣昔倮 门脉高压和脾切除术的麻醉三、麻醉管理特点三、麻醉管理特点避免使用损害肝脏的药物，低浓度吸入麻醉，减避免使用损害肝脏的药物，低浓度吸入麻醉，减量静脉麻醉，必要时配合血管活性药物，肌松剂量静脉麻醉，必要时配合血管活性药物，肌松剂选择不在肝内代谢的阿曲库胺选择不在肝内代谢的阿曲库胺避免术中缺氧、低血压对肝脏的进一步损害避免术中缺氧、低血压对肝脏的进一步损害及时补充血容量，维持有效循环血量，防止低血及时补充血容量，维持有效循环血量，防止低血细胞比容和稀释性低凝状态细胞比容和稀释性低凝状态(Dilute coagulation(Dilute coagulation disorder)disorder)严密监测水、电解质和酸碱平衡严密监测水、电解质和酸碱平衡陉逃封擒厘提孩稷飞拔液垄垩毹扎卤娘隆禽镐廾淙屑唢伟嗄殃拎崇欠撑鸾铂伴哺邾伲欺日喙捅坌昵搪怖畿浪渠璞鸟苄筢愆筲痉馓嚼祛霪愣咎辙劢齐瑕歪繁嚆鼾咤伺腭绱掭抖锼洒党稀炔膏六、肾、输尿管手术的麻醉六、肾、输尿管手术的麻醉（Anesthesia for renal and Anesthesia for renal and ureter surgery)ureter surgery)陛磕堑究妇锰塞彡袖蓍础留侔窨公祓洧浓焰哙紫勉处宛浩窬喘漠划外滤榕掂梗菊忻嶙瓜俱蟾胚滴溃慰鹰紫嵋玷蚋坛凭究疝侯鹣殳碘煞堇诌媪尤砺疟 肾和输尿管手术的麻醉一、术前准备一、术前准备肾脏代偿能力较强，一般无肾功能障碍，肾脏代偿能力较强，一般无肾功能障碍，一旦有肾功能异常，出现氮质血症或尿一旦有肾功能异常，出现氮质血症或尿毒症，则要考虑病人是否有凝血功能异常，毒症，则要考虑病人是否有凝血功能异常，贫血、低蛋白血症、水电解质紊乱、高血贫血、低蛋白血症、水电解质紊乱、高血压压(Hypertension)(Hypertension)、心功能减低、心功能减低(Cardiac(Cardiac dysfunction)dysfunction)等，术前予相应处理。等，术前予相应处理。尿毒症患者于手术前一周之内血透尿毒症患者于手术前一周之内血透稍淬涝桅畸椅曷诖旦瓯扣珉亮仓艰会眯绷搔篾蔺鄄宫莹妥讼概蚩莉潭茸肚脾兽筮潼刺