General-Anaesthesia全身麻醉課件(PPT 75頁)

1、Clinical AnaesthesiologyQiu Wei FanAssociate ProfessorDepartment of AnaesthesiologyRui Jin HospitalShanghai Second Medical University第1頁，共75頁。 General Anaesthesia第2頁，共75頁。Classification of General Anaesthesia Methods Inhalation anaesthesiaIntravenous anaesthesiaIntramuscularlyRectallyOrallyBalanced

2、anaesthesia第3頁，共75頁。Clinical PharmacologyInhalational anaesthetic agentsAgent MAC% Vapor Pressure Blood/Gas PartitionNitrous oxide 105 - 0.47Halothane 0.74 243 2.4Enflurane 1.68 175 1.9Isoflurane 1.15 240 1.4Desflurane 6.0 681 0.42第4頁，共75頁。第5頁，共75頁。Clinical PharmacologyIntravenous anaesthetic agents

3、Agent Induction dose (mgkg-1)Thiopentone 3-5Methohexitone 1-1.5Etomidate 0.3Propofol 1.5-2.5Ketamine 2第6頁，共75頁。第7頁，共75頁。第8頁，共75頁。Clinical PharmacologyDrugs used to supplement anaesthesiaAnalgesicsOpioid agonistsNatural opium alkaloids: Morphine,CodeineSemisynthetic opium alkaloid: DiamorphineSynthet

4、ic opioids:Pethidine, Fentanyl, Alfentanil, Sufentanil, RemifentanilPartial opioid agonistsBuprenorphine第9頁，共75頁。Clinical PharmacologyDrugs used to supplement anaesthesiaOpioid agonist/antagonistsPentazocineOpioid antagonistsNaloxone第10頁，共75頁。Clinical PharmacologyMuscle RelaxantsNeuromuscular blocki

5、ng agents are dividedinto two classes:DepolarizingNondepolarizing第11頁，共75頁。Clinical PharmacologyMuscle RelaxantsDepolarizing Short-acting Succinylcholine DecamethoniumNondepolarizingLong-acting Tubocurarine Metocurine doxacurium Pancuronium PipecuriumIntermediate-acting Atracurium VecuroniumShort-ac

6、ting Mivacurium第12頁，共75頁。Clinical PharmacologyDrugs affecting the autonomic nervous system Sympathomimetic drugsAdrenaline(low-,1+2)(higher- )Isoprenaline(1+2)Noradrenaline(,1 )Phenylephine()Dopamine (low-,moderate- ,1+2, moderatehigh-,1 )Dobutamine(1 )第13頁，共75頁。The practical conduct of anaesthesiaP

7、reparation for anaesthesiaEquipment for monitoringThe anaesthetic machineEquipment required for tracheal intubation第14頁，共75頁。Anaesthetic apparatusThe anaesthesia machineGas inlets & pressure regulatorsOxygen pressure failure devices & oxygen flush valves Flow control valvesFlowmeters & spirometersVa

8、porizersVantilators & disconnect alarmsWaste gas scavengersHumidifiers & nebulizersOxygen analyzers第15頁，共75頁。第16頁，共75頁。Airway management equipmentOral & Nasal airwayMaskEndotracheal tubeRigid laryngoscopesFlexible fiberoptic laryngoscopes第17頁，共75頁。Equipment required for tracheal intubationCorrect si

9、ze of laryngoscope and spareTracheal tube of correct size + an alternative smaller sizeTracheal tube connectorWire stiletteGum elastic bougiesMagill forcepsCuff-inflating syringeArtery forcepsSecuring tape or bandageCatheter mountLocal anaesthetic sprayCocaine spray/gel for nasal intubationTracheal

10、tube lubricantThroat packsAnaesthetic breathing system and face masks-tested with oxygen to ensure no leaks present第18頁，共75頁。第19頁，共75頁。Induction of AnaesthesiaInhalational inductionIntravenous induction第20頁，共75頁。Inhalational induction agentsSevoflurane Desflurane第21頁，共75頁。Induction of anaesthesiaInd

11、ications for inhalational induction Young childrenUpper airway obstructionLow airway obstruction with foreign bodyBronchopleural fistula or empyemaNo accessible veins第22頁，共75頁。Induction of anaesthesia Difficulties and complicationsSlow induction of anaesthesiaProblems particularly during stage 2Airw

12、ay obstruction, bronchospasmLaryngeal spasm, hiccupsEnvironmental pollution第23頁，共75頁。第24頁，共75頁。Intravenous inductionDoses of the intravenous agentsAgent Induction dose (mgkg-1)Thiopentone 3-5Methohexitone 1-1.5Etomidate 0.3Propofol 1.5-2.5Ketamine 2第25頁，共75頁。Intravenous induction Complications and d

13、ifficultiesRegurgitation and vomitingIntra-arterial injection of thiopentonePerivenous injectionCardiovascular depressionRespiratory depression Histamine releasePorphyriaOther complications第26頁，共75頁。Maintenance of anaesthesiaInhalation anaesthesia with spontaneous ventilationConductMinimum alveolar

14、concentration (MAC): MAC is the minimum alveolar concentration of an inhaled anaesthetic agent, which prevents reflex movement in response to surgical incision in 50 % of subjects.第27頁，共75頁。Clinical PharmacologyInhalational anaesthetic agentsAgent MAC% Vapor Pressure Blood/Gas PartitionNitrous oxide

15、 105 - 0.47Halothane 0.74 243 2.4Enflurane 1.68 175 1.9Isoflurane 1.15 240 1.4Desflurane 6.0 681 0.42第28頁，共75頁。Signs of anaesthesiaStage 1(Stage of analgesia): From start of induction of anaesthesia to loss of consciousness.Stage 2 (Stage of excitement): From loss of consciousness to beginning of re

16、gular respiration.Stage 3 (Surgical anaesthesia): From the beginning of regular respirationto respiratory arrest.第29頁，共75頁。Signs of anaesthesiaThe stage 3 is divided into four planes. Plane 1: From the onset of regular breathing to the cessation of eyeball movements.Plane 2: From the cessation of ey

17、eball movements to the beginning of intercostal paralysis.Plane 3: From the beginning of intercostal paralysis to the completion of intercostal paralysis.Plane 4: From completion of intercostal paralysis to diaphragmatic paralysis. 第30頁，共75頁。Signs of anaesthesiaStage 4: Stage of impending respirator

18、y and circulatory failure (Medullary paralysis), from the onset of diaphragmatic paralysis to cardiac arrest.第31頁，共75頁。Inhalation anaesthesia with spontaneous ventilation Complications and difficultiesAirway obstructionLaryngeal spasmBronchospasmMalignant hyperthermiaRaised intracranial pressure (IC

19、P)Atmospheric pollution第32頁，共75頁。Delivery of inhalational agents-airway maintenanceUse of the facemaskUse of the laryngeal mask airway (LMA)Use of the oropharyngeal airwayTracheal intubation第33頁，共75頁。第34頁，共75頁。Use of the laryngeal mask airway (LMA) IndicationsProvide a clear airway without the need

20、for the anaesthetists hands to support a mask.Avoid the use of tracheal intubation during spontaneous ventilation.In a case of difficult intubation to facilitate subsequent insertion of a tracheal tube either via the LMA or after use of a gum elastic bougie.第35頁，共75頁。Use of the laryngeal mask airway

21、 (LMA) ContraindicationsA patient with a “full stomach” or with any condition leading to delayed gastric emptying,A patient in whom regurgitation of gastric contents into the esophagus is possible,Where surgical access is impeded by the cuff of the LMA.第36頁，共75頁。Tracheal intubationIndicationsProvisi

22、on of a clear airway, An unusual position,Operations on the head and neck,Protection of the respiratory tract,During anaesthesia using IPPV and muscle relaxants To facilitate suction of the respiratory tractDuring thoracic operations第37頁，共75頁。第38頁，共75頁。第39頁，共75頁。第40頁，共75頁。第41頁，共75頁。第42頁，共75頁。第43頁，共7

23、5頁。第44頁，共75頁。第45頁，共75頁。Tracheal intubation ContraindicationsFew第46頁，共75頁。Anaesthesia for tracheal intubationInhalational technique for intubationRelaxant anaesthesia for intubation第47頁，共75頁。Anaesthesia for tracheal intubationOral-tracheal intubationNasotracheal intubationFlexible fiberoptic nasotrac

24、heal intubation第48頁，共75頁。Complications of intubationDuring laryngoscopy and intubationMaipositioningEasophageal intubationEndobronctrial intubationLaryngeal positionAirway traumaTooth damageLip, tongue or mucosal lacerationSore throat Dislocated mandible第49頁，共75頁。Complications of intubationDuring la

25、ryngoscopy and intubationRetropharyngeal dissectionPhysiologic reflexesHypertension, TachycardiaIntracranial hypertentionIntraocular hypertensionLaryngospasmTube malfunctionCuff perforation第50頁，共75頁。Complications of intubation While the tube is in place MalpositionUnintentional extubationEndobrochia

26、l intubationLaryngeal cuff positionAirway traumaMucosal inflammation and ulcerationExcoriation of noseTube malfunctionIgnitionObstruction第51頁，共75頁。Complications of intubation Following extubationA) Airway traumaEdema and stenosis (glottic, subglottic, or tracheal )Hoarseness (vocal cord granuloma or

27、 paralysis )Laryngeal malfunction and aspirationB) Physiologic reflexesLaryngospasm第52頁，共75頁。Relaxant anaesthesiaIndications for relaxant anaesthesiaMajor abdominal, intraperitoneal, thoracic, intracranial operationsProlonged operations in which spontaneous ventilation would lead to respiratory depr

28、ession Operations in a position in which ventilation is impaired mechanically第53頁，共75頁。Clinical PharmacologyMuscle RelaxantsDepolarizing Short-acting Succinylcholine DecamethoniumNondepolarizingLong-acting Tubocurarine Metocurine doxacurium Pancuronium PipecuriumIntermediate-acting Atracurium Vecuro

29、niumShort-acting Mivacurium第54頁，共75頁。Reversal of relaxation Residual neuromuscular block is antagonized with neostigmine 2.5-5mg (0.05-0.08mgkg-1 in children). Atropine 1.2mg or glycopyrronium 0.5mg counteracts the muscarinic side effects of the anticholinesterase and may be given before, or with, n

30、eostigmine.第55頁，共75頁。Conduct of extubationCoughingResistance to the presence of the tracheal tube第56頁，共75頁。Complications of tracheal extubationLaryngeal spasmRegurgitation第57頁，共75頁。Emergence and recoveryTesting hand griptongue protrusion Lifting the head from the pillow in response to command第58頁，共7

31、5頁。Monitoring during anaesthesiaCardiac monitorsArterial blood pressure Noninvasive arterial blood pressure Invasive arterial blood pressure monitoringElectrocardiographyCentral venous catheterizationPulmonary artery catheterizationCardiac output第59頁，共75頁。第60頁，共75頁。第61頁，共75頁。Noninvasive arterial blo

32、od pressure monitoringTechniquePalpationDoppler probeAuscultationOscillometryPlethysmographyArterial Tonometry第62頁，共75頁。Selection of artery for cannulationRadial arteryBrachial arteryUlnar arteryfemoral arteryDorsalis pedisPosterior tibial arteryAxillary artery 第63頁，共75頁。Invasive arterial blood pres

33、sure monitoringComplicationsHematomaVasospasmArterial thrombosisEmbolization of air bubbles or thrombiSkin necrosis overlying the catheterNerve damageInfection Unintentional intra-arterial drug injection第64頁，共75頁。Monitoring during anaesthesiaRespiratory system monitoringPrecordial & easophageal stet

34、hoscopeBreathing circuit pressure & exhaled tidal volumePulse oximetryEnd-tidal carbon dioxide analysisTranscutaneous oxygen & carbon dioxide monitorsAnaesthetic gas analysis第65頁，共75頁。Monitoring during anaesthesiaNeurologic system monitorsElectroencephalographyEvoked potential第66頁，共75頁。Monitoring during anaesthesiaMiscellaneous monitorsTemperatureUr