经典课件全身麻醉.ppt
麻醉医学知识概要,解放军23医院手术室阿迪拉,全身麻醉 General Anesthesia,概念：麻醉药经呼吸道吸入或静脉、肌肉注射进入人体内，产生中枢神经系统的抑制，临床表现为神志消失、全身的痛觉消失，遗忘，反射抑制和一定程度的肌肉松弛的麻醉方法。,吸入麻醉药一般不作为首选麻醉。,静脉麻醉药,经静脉注射进入体内，通过血液循环作用于中枢神经系统而产生全身麻醉作用的药物。硫喷妥钠氯胺酮 乙托醚酯 异丙酚 羟丁酸钠,Muscle relaxants,肌肉松弛药 Muscle relaxants,去极化肌松药 depolarizing Muscle relaxants琥珀胆碱（司可林，Succinylcholine,scoline）Dose：1-1.5mg/kg IVOnset of action:within 60 secondsDuration of action:3-5 minutesMetabolism:by plasma cholinesteraseUsesTo facilitate endotracheal intubation in full-stomach patientsTo maintain paralysis for short procedures,肌肉松弛药 Muscle relaxants,去极化肌松药 depolarizing Muscle relaxants琥珀胆碱（司可林，Succinylcholine,scoline）Adverse effectsMuscle painsBradycardiaHyperkalaemiaIncrease in intracranial pressure and intraocular pressureProlonged actionMalignant hyperthermia,肌肉松弛药 Muscle relaxants,非去极化肌松药 non-depolarizing Muscle relaxants常用药物阿曲库铵 Atracurium维库溴胺 Vecuronium潘库溴胺 Pancuronium哌库溴胺 pipecuronumUsesTo facilitate endotracheal intubation To maintain paralysis during anesthesia and in the ICU拮抗药：新斯的明 neostigmine,肌肉松弛药 Muscle relaxants,注意事项一定要行气管插管和控制呼吸。无镇静和镇痛作用，不能单独使用。琥珀胆碱可引起血钾升高，眼压和颅内压升高，因此严重创伤、烧伤、截瘫、青光眼、颅内压升高者禁用；体温降低可延长肌松药的作用，吸入麻醉药、某些抗生素（如链霉素、庆大霉素和多粘菌素）及硫酸镁等，可增强非去极化肌松药的作用。合并有神经肌接头疾患者，如重症肌无力，禁用非去极化肌松 药。有的肌松药有组胺释放作用，哮喘和过敏者慎用,麻醉性镇痛药,吗啡 morphine杜冷丁 pethidine芬太尼 fentanyl,麻醉辅助用药,安定（地西泮，diazepam）咪唑安定(咪达唑仑，midazolam)异丙嗪（非那根，promethazine）氟哌利多（氟哌啶,droperidol）,全身麻醉的实施,诱导 Induction 维持 Maintainance苏醒 Awareness,监测monitoring,心血管系统监测临床观察心电图无创血压有创血压中心静脉压肺动脉楔压,CO,呼吸系统监测临床观察脉搏血氧饱和度呼气末二氧化碳监测血气分析潮气量、分钟通气量、气道压力、呼吸频率,麻醉机Anesthesia machine,气源 gas source蒸发器 vaporizer呼吸环路 breathing circle system麻醉呼吸器 ventilator,全身麻醉并发症,呼吸系统返流与误吸呼吸道梗阻上呼吸道下呼吸道呼吸抑制肺部并发症,循环系统低血压与高血压心律失常与心跳骤停神经系统术中知晓苏醒延迟其他：体温 胃肠道,病例讨论,病例1：3个月婴儿病例2：,呼吸道管理Airway management,双腔气管导管,Mallampati评估法,Most common cause:tongue and/or epiglottis,舌 后 坠,单手抬颏法,舌 后 坠,双手托下颌法,“地包天”,面罩通气,操作技术,面罩的放置,单 手 法,面罩通气,操作技术,面罩的放置,双手托下颌法,面罩通气,操作技术,面罩的放置,双手托下颌法,口咽通气道oropharyngeal airway,舌 后 坠,口咽通气道,不准确的放置,Too short,鼻咽通气道,Nasopharyngeal airway,舌 后 坠,鼻咽通气道,Esophageal-Tracheal Combitube,A=esophageal obturator;ventilation into trachea through side openings=B C=tracheal tube;ventilation through open end if proximal end inserted in tracheaD=pharyngeal cuff;inflated through catheter=EF=esophageal cuff;inflated through catheter=GH=teeth marker;blindly insert Combitube until marker is at level of teeth,Distal End,Proximal End,B,C,D,E,F,G,H,A,Esophageal-Tracheal Combitube Inserted in Esophagus,A=esophageal obturator;ventilation into trachea through side openings=B D=pharyngeal cuff(inflated)F=inflated esophageal/tracheal cuffH=teeth markers;insert until marker lines at level of teeth,D,A,D,B,F,H,喉罩laryngeal mask airway LMA,The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.,是处理困难气道的推荐 方法之一不需暴露，盲探置入用于困难气道作用更佳安全时限 2小时 即使位置不佳，多数情况也 可保持良好的通气效果,困难气道的常用方法,置入喉罩通气,经鼻或口置管保留自主呼吸易成功需要特殊的技术和设备损伤较小反复操作易致损伤,纤支镜引导插管,困难气道的常用方法,气管插管术器械,气管插管所需器械,气道的结构,喉,作用：发声及保护下气道,急诊加用silic手法,ThyroidCartilage,Cricoid,困难气道的常用方法,紧急环甲膜或气管切开,经气管喷射通气,困难气道的常用方法,困难气道的常用方法,逆行引导插管,
