腹盆腔手术麻醉.ppt

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1、第二十一章 腹、盆腔手术的麻醉Chapter 21 Anesthesia for operations in abdominal and pelvic cavities,第一节、腹、盆腔手术麻醉的特点,The features of anesthesia for operations in abdominal and pelvic cavities,1、腹、盆腔脏器的主要生理功能和围术期病理生理变化The organs in abdominal and pelvic cavities include digestive system and genitourinary system.The m

2、ain physiological functions are digestion,absorption,metabolism,elimination,immune function and secretion.The adequate preoperative preparation should be done to avoid anesthetic complications.,2、腹、盆腔手术围术期液体管理Severe bleeding(massive hemorrhage),massive loss of body fluid,internal redistribution of f

3、luids often called“third space”can cause severe intravascular depletion.The fluids infusion rate is 10ml/kg/h and the crystalloid and colloid solutions should be administered properly.When the danger of anemia outweighs the risks of transfusion,further blood loss should be replaced with transfusion

4、of red blood cells to maintain hemoglobin concentration or hematocrit.,3、手术体位(Patients position in operation）对生理功能的影响,截石位（Lithotomy position）,头低位（Trendelenburg position）,Lithotomy position and Trendelenburg tilt would result in changes in pulmonary blood volume,a decrease in pulmonary compliance,a c

5、ephalad 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.,4、腹压对生理功能的影响Increased abdominal pressure and elevation of diaphragm lead to dyspnea.Anesthetic agents,anesthetic technique

6、s and rapid decompression exacerbate vasodilatation,decreased venous return to heart and cardiac output.The measures should be taken:Administration of IV fluids.Modulate the position.Administration of ephedrine.Avoid rapid decompression.,5、腹、盆腔手术对肌松弛的要求 Complete neuromuscular blocking is required in

7、 operations.6、腹、盆腔手术中的内脏牵拉反应 Distension of viscera or traction on peritoneum may induce bradycardia,reducing of arterial pressure and cardiac arrest.Vagus reflexion and pelvic nerves reflexion Mesentery traction syndrome,7、腹、盆腔急症手术的特点Preoperative assessment History and physical examination Full stom

8、ach Hypovolemia Fluid and electrolytes disturbance Acid-base unbalance Preparation for emergency operations,第二节、腹、盆腔手术的常用 麻醉方法,The commonly used anesthesia techniques for surgery in abdominal and pelvic cavities,一.局部麻醉（local anesthesia),Local infiltration anesthesiaField blocking anesthesiaIntercost

9、al blockAdvantages.Disadvantages.,二.椎管内麻醉（intravertebral anesthesia）,1.Extradural anesthesia,epidural anesthesia One site,two sites 2.Subarachnoid anesthesia a.Single dose b.Intermittent bolus via a catheter3.Combined spinal and epidural anesthesia,三.全身麻醉（General anesthesia),适用于各种腹盆腔手术，尤其是手术困难以及老年、体

10、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，给氧充分，能充分对机体生理功能进行调控.方法有：吸入麻醉（inhalational anesthesia)静脉麻醉（intravenous anesthesia)静吸复合麻醉(Balance anesthesia),Induction of anesthesia Inhalational induction Intravenous induction Use of the laryngeal mask airway or tracheal intubationMaintenance of anesthesia Anesthesia m

11、ay be continued using inhalational agents,I.v.anesthetic agents,I.v.opioids or muscle relaxants in combination.,四.全麻复合椎管内麻醉（Intravertebral anesthesia used to supplement general anesthesia)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.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.,第三节 常见腹盆腔手术的 麻醉处理,The common anesthesia man

12、agements for surgery in abdominal and pelvic cavities,一、胃肠手术的麻醉（Anesthesia for gastrointestinal operations),胃肠手术的麻醉,一、术前准备1.消化性溃疡和肿瘤病人常有贫血（anemia）和营养不良（malnutrition），术前应纠正2.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（Disturbance of fluid,electrolyte and acid-base balance）应纠正3.术前胃肠减压（gastrointestinal decompressio

13、n，reduction in gastric volume）,胃肠手术的麻醉,二、麻醉选择（Selection of anesthesia technique)Epidural anesthesia,supplemented by analgesic and sedative drugs.General anesthesia,胃肠手术的麻醉,三、术中的麻醉管理特点（Features of anesthesia managements)手术探查(Surgical exploration)、牵拉、钝性剥离胃底、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，麻醉深度可减浅根据术中失

14、血量、病人术前血红蛋白水平，适当输血（Blood transfusion should be used only if absolutely necessary),二、胆道手术的 麻醉(anesthesia for operations on biliary tract),胆道手术的麻醉,一、术前准备（1）胆道手术病人特点肝功能损害(Hepatic function lesion)，代谢解毒能力降低高胆红素血症(Hyperbilirubinemia)，高迷走神经张力阻塞性黄疸(obstructive jaundise),VitK吸收障碍，凝血因子（blood clotting factors;

15、coagulation factors）缺乏，有出血倾向(hemorrhagic tendency)易发生肝肾综合症(hepatorenal syndrome),胆道手术的麻醉,（2）术前准备护肝利胆治疗，使胆红素水平降低补充VitK,使凝血酶原时间(Prothrombin time)正常术前予足量的抗胆碱药物(Atropine)，对抗高迷走张力注意胆囊炎(cholecystitis)与心绞痛(angina pectoris)的鉴别诊断,胆道手术的麻醉,二、麻醉选择Epidural anesthesiaGeneral anesthesia,胆道手术的麻醉,三、术中麻醉管理的特点预防和及时处理胆

16、心反射（Vagus reflection,Parasympathetic reflection）和反射性冠脉痉挛（coronary artery spasm)所至心肌缺血（Myocardial ischemia)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,必要时及时终止手术刺激。,胆道手术的麻醉,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。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止低血压。Case report,胆道手术的麻醉,1 case dis

17、cussion 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？,三、胰腺手术的麻醉（Anesthesia for pancreas surgery),胰腺手术的麻醉,一、术前准备 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

18、阻性黄疸；糖耐量异常（glucose tolerance abnormality)；可能合并重要脏器功能不全术前应加强支持治疗纠正水电解质、酸碱平衡紊乱纠正凝血机制异常（VitK)监测血糖，备胰岛素(insulin)带入手术室,胰腺手术的麻醉,二、麻醉的选择General anesthesia General anesthesia and epidural anesthesia supplementation.,胰腺手术的麻醉,三、术中麻醉管理的特点要求肌松完善动态监测血糖，防止中枢神经系统损害，同时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监测酸碱平衡、凝血功能和肝肾功能胰腺在缺血

19、缺氧情况下可分泌心肌抑制因子(myocardial depressant factor)，抑制心肌收缩力(Myocardial contractility),引起循环衰竭(Cardiac failure)，应注意预防,四、肝手术的麻醉(Anesthesia for liver surgery),肝手术的麻醉,一、术前准备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（Hypoproteinemia)、凝血功能异常（Blood clotting disfunction)备血（Group,screen and

20、crossmatch 2-4 units of red blood cells),肝手术的麻醉,二、麻醉选择Epidural anesthesiaGeneral anesthesia,肝手术的麻醉,三、术中麻醉管理特点避免缺氧(Hypoxia)、低血压(hypotension)或阻断肝门时间(Duration of blocking porta hepatis)过长（应20min)避免使用有肝损害作用的药物，如氟烷（fluothane)，其他挥发性吸入麻醉药有一过性肝损害，宜低浓度吸入，静脉麻醉药注意酌情减量，必要时配合使用血管活性药，肌松药选择阿曲库胺（Atracurium),肝手术的麻醉,

21、开放上肢静脉输液通路，充分评估失血量，适量输血肝包囊虫病，防止囊液腹腔污染引起的过敏性休克(allergic shock)肾功能监测和保护(monitoring and protection of renal function)利用低中心静脉压（low central venous pressure),减少出血量,五、门脉高压和脾切除术的麻醉（Anesthesia for portal hypertension and splenectomy),门脉高压和脾切除术的麻醉,一、术前准备门静脉压力超过25cmH2O称门脉高压，多数病人有肝硬化(cirrhosis of liver)，明显肝功能损害

22、；脾大，脾亢；肾功能障碍；食道胃底静脉曲张(Varicosis)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(transaminase)、血浆白蛋白(plasm albumin)、凝血酶原时间、腹水（Ascitic fluid)、血清胆红素(bilirubin in blood serum)等加强护肝治疗，改善全身情况。,门脉高压和脾切除术的麻醉,二、麻醉选择General anesthesia,门脉高压和脾切除术的麻醉,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避免术中缺氧、低血

23、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，防止低血细胞比容和稀释性低凝状态(Dilute coagulation disorder)严密监测水、电解质和酸碱平衡,六、肾、输尿管手术的麻醉（Anesthesia for renal and ureter surgery),肾和输尿管手术的麻醉,一、术前准备肾脏代偿能力较强，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、高血压(Hypertension)、心功能减低(Cardiac dysfunction)等，术前予相应处理。尿毒症患者于手术前一周之内血透,肾和

24、输尿管手术的麻醉,二、麻醉选择硬膜外麻醉扩张血管，有助于保护肾功能，剖腰切口,T9-10 T10-11向上置管，腹部切口置管位置可低1-2个节段(Segment)全麻，适合于不能耐受手术体位的病人，复杂肾和肾上腺手术，年老体弱的病人，有严重心肺疾患的病人或有硬膜外麻醉禁忌的病人全麻复合硬膜外麻醉,肾和输尿管手术的麻醉,三、麻醉管理特点术中避免缺氧和低血压术中避免使用损害肾功能的药物，如甲氧氟烷，其他挥发性吸入麻醉药都可降低肾血流、肾小球滤过率（glomerular filtration rate;GFR）和尿量（urine volume），气体吸入麻醉药N2O（Nitrous oxide)对肾

25、功能影响最小；静脉麻醉药因由肾脏排泄减慢需减少用量；,肾和输尿管手术的麻醉,肌松药不宜选用完全由肾排出的三碘季酚胺和部分由肾脏排出的潘库溴胺、派库溴胺、爱肌松，应选用阿曲库胺、维库溴胺，注意琥珀胆碱（scoline)可使血钾（Extracellular potassium concentration)增高，避免使用收缩血管的药物，必要时使用多巴胺尿毒症(uremia)患者需限制液体入量，如因容量过多（hypervolemia)引起右心功能不全，需紧急血透超滤（Hemodialysis and Ultrafiltration),七、盆腔手术麻醉（Anesthesia for surgery in

26、 pelvic cavity),盆腔手术的麻醉,一、术前准备以子宫、卵巢、膀胱、直肠肿瘤（uterus,ovary,bladder and rectum tumour)多见，病人的全身情况相差悬殊，恶性肿瘤患者可有贫血、低蛋白血症和胸腹水等术前应评估、改善全身情况（evaluate patients general conditions and decrease the risk of anesthesia and surgery),盆腔手术的麻醉,二、麻醉选择Two sites of epidural anesthesiaCSEAGeneral anesthesia,盆腔手术的麻醉,三、麻醉

27、管理特点注意手术体位、胸腹水对呼吸循环的影响预防手术体位引起周围神经（Peripheral nerve)和肌肉压迫损伤(muscular compression injuries)注意防治术中搬出巨大肿瘤或快速放腹水(rapid decompression)引起的循环波动盆腔内组织粘连或术中损伤骶前静脉丛，可发生大量出血，需注意维持有效循环血量和血细胞比容（hematocrit）Precaution of TURP syndrome,八、急腹症病人手术麻醉（Anesthesia for acute abdomen surgery),急腹症病人手术麻醉,一、术前准备常见的急腹症有：消化道出血（d

28、igestive tract hemorrhage)、消化性溃疡穿孔（peptic ulcer perforation)、腹膜炎（peritonitis）、急性阑尾炎（acute appendicitis)、急性胆囊炎（acute cholecystitis)、化脓性胆管炎（Suppurative cholangitis）、急性胰腺炎（Acute pancreatitis）、肠梗阻（intestinal obstruction)、肝、脾破裂(rupture of liver and spleen)、宫外孕破裂（rupture of ectopic pregnancy)等。,急腹症病人手术麻醉,

29、此类病人的特点是起病急，病情危重或复杂，需紧急手术，无充分时间进行全面检查(overall check)和术前准备，有时诊断不清（uncertain diagnosis)或有误诊(misdiagnosis),伴随症未得到控制（concomitant illness uncontrolled),并发症发生率高（high incidence of complications),急腹症病人手术麻醉,Potential complications should be prepared for,including:Vomiting and regurgitation-In emergency surge

30、ry,it may be necessary to induce anesthesia urgently before an adequate period of starvation occurs.In addition,the patients condition is often accompanied by delayed gastric emptying.Hypovolaemia and hemorrhage-treatment of countershock.Abnormal reactions to drugs in the presence of electrolytes di

31、sturbances and renal impairment.Using antibiotics to treat inflammation and SIRS.,急腹症病人手术麻醉,二、麻醉选择Epidural anesthesiaGeneral anesthesia,急腹症病人手术麻醉,三、麻醉管理特点术中充分给氧，保证有效通气量避免硬膜外麻醉平面过宽和全麻过深，引起循环抑制，全麻维持可选择对循环影响轻微的静脉麻醉药、低浓度吸入麻醉药和短效肌松药。,急腹症病人手术麻醉,术中积极抗休克治疗，维持重要脏器的功能。加强术中监测，除常规监测手段外，可测定有创血压（Invasive blood pr

32、essure)、中心静脉压（CVP）、尿量（Urine volume)、血细胞压积（packed-cell volume，PCV）、电解质、血气分析（Blood gas analysis)和胃粘膜PH值（gastric mucous membrane PH）,急腹症病人手术麻醉,饱胃的处理（Management of full stomach)饱胃病人可出现呕吐（Vomiting)，反流(Regurgitation)，误吸(Mistaken aspiration)，吸入性肺炎(inhalation pneumonia)，甚至窒息(Apnea)Vomiting is an active proc

33、ess that occurs in the lighter planes of anesthesia.In contrast,regurgitation is a passive process that may occur at any time,is often silent.,急腹症病人手术麻醉,术前应放置胃管，抽吸胃内容物。尽量选用椎管内麻醉或清醒气管插管，保留上呼吸道的保护性反射，进行快诱导气管插管时，避免面罩加压给氧和静注琥珀胆碱引起胃内压增高，诱发呕吐和反流。诱导过程中可将环状软骨向后压，使食道开口暂时闭合以免反流物进入气管,急腹症病人手术麻醉,如有误吸，用生理盐水或碳酸氢钠液

34、反复冲洗，静注糖皮质激素和抗生素，必要时术后进行呼吸支持 case report,急腹症病人手术麻醉,2 case discussion 患者，男，32岁，AOSC，中毒性休克，全麻下行剖腹探查术，血压50/20 mmHg,HR130bpm,R20bpm,术前未置胃管，麻醉选用氯胺酮mg，琥珀胆碱mg,iv,面罩给氧，显露声门时发现咽部大量黄色液体，吸引后插入气管导管控制呼吸，可闻及双肺大量湿罗音，间断气管内吸引，手术开始分钟血压测不到，心音消失，进行胸外心脏按压，静注肾上腺素，分钟后心跳恢复，血压回升，继续手术，术毕病情未好转，术后小时再次心搏骤停而死亡。,急腹症病人手术麻醉,教训：、术前未行胃肠减压、麻醉诱导药物不妥、面罩加压给氧增加胃内压，、误吸后处理不当、还存在感染性休克，血容量不足等情况处理不当，缺乏脑复苏的措施、心肺功能维护、水电解质、酸碱失衡的纠正。,