耳鼻喉科手術麻醉-課件

AnesthesiaForEar，NoseandThroatSurgery耳鼻喉科手術麻醉byXuLiAnesthesiaForEar，NoseandTh1耳鼻喉科手術麻醉-課件2

ProfileandDemands

difficultairway

cardiacarrhythmia：applicattionofEpinephrine,reflexofcarotidsinus,etc.

N2OandmiddleearpressureProfileandDemandsdifficult3耳鼻喉科手術麻醉-課件4耳鼻喉科手術麻醉-課件5PreoperativeEvaluation

andPreparationInterview(麻醉前訪視)

Premedication(麻醉前用藥)：

▲sedatives(鎮(zhèn)靜藥)

▲anticholinegics(抗膽堿藥)

PreoperativeEvaluation

andP6Choiceofanesthesialocalanestehsia：tothosecooperativeonesundergoingshort-termandsimpleoperationsgeneralanesthesia：tothoseonescan’tbeundertakenoperationsunderlocalanesthesiaChoiceofanesthesialocalanes7SeveralcommonENToperations*operationofear*operationofnasalcavity(鼻腔)andnasalsinus(鼻竇)*tonsillectomy(扁桃體摘除術)*totalthroatresection(全喉截除術)*Endoscopy(內(nèi)鏡檢查)andendoscopicsurgery(內(nèi)鏡手術)SeveralcommonENToperations*8PS：嬰幼兒氣管、支氣管異物取出術病情：急(urgent)

、重(severe)

、危(dangerous)

麻醉：全麻，配合充分表麻,要求麻醉既不加重缺氧又能迅速誘導至足夠深度管理：*術前:準備應迅速、利索，呼吸困難(dyspnea)的應急處理*術中:積極防治喉、氣管、支氣管痙攣、缺氧、氣道內(nèi)出血、氣管破裂(split)或氣胸(pneumothorax)

、喉頭水腫(laryngealedema)等*術畢:充分供氧，待患者清醒良好、呼吸通暢，吸空氣SPO2基本正常后方可出手術室PS：嬰幼兒氣管、支氣管異物取出術病情：急(urgent)9

QuestionsTrytodescribethefactorscausingarrhythmiaduringENTsurgery.

“全喉截除術”中，發(fā)生頸外靜脈破裂，除了緊急止血外還應警惕什么情況的發(fā)生？如何處理？中耳手術時，吸入全麻的使用應注意什么？QuestionsTrytodescribethe10THANKYOU！THANKYOU！11Difficultairway

*1>Difficultintubation*2>compromisedairwayDifficultairway*1>Difficult12N2OandmiddleearpressureThemiddleearandparanasalsinus(鼻旁竇)arenormalbodyaircavitiesthatconsistofopen,nonventilatedspaces.Theblood/gascoefficient(系數(shù))is0.013fornitrogenversus0.46forN2O.Wheninhaledinhighconcentrations,N2Oenterstheaircavitiesfasterthannitrogencanleave.Inafixedcavitysuchasthemiddleear,theresultisanincreaseinpressure.AfterdiscontinuationofN2O,thegasisrapidlyreabsorbed,marked,negativemiddleearpressuremaydevelop.

N2OandmiddleearpressureThe13Difficultintubation①anatomicabnormalities：micrognathia(小頜),limitedjawmotion,orcongenitalsyndromes(craniofacialdysostoses<顱面骨發(fā)育不全>)etc..

②Othercauses：obesity,acromegaly(肢端肥大癥),cervicalspineproblems,rheumatoidarthritis(風濕性關節(jié)炎),andevengastricreflux(返流)

Difficultintubation①anatomic14CompromisedairwayPathologicconditionsabovetheglottismaypreventaclearviewoftheglotticopening,whereassubglotticlesionspermitagoodviewofthevocalcords,buttheyrequirecarefulplacementofasmallendotrachealtubeorbronchoscope.

CompromisedairwayPathologicc15Operationsofearsoperationsofearconcha(耳廓)andconchatract(外耳道)

：localanesthesia(tocooperativepatients)operationsinsideears：generalanesthesiaMicrosurgery(顯微外科手術)：controlledhypotension(控制性低血壓)issometimesneededN2Oandmiddleearpressure

Operationsofearsoperationso16OperationofnasalcavityandnasalsinuslocalanesthesiageneralanesthesiaOperationofnasalcavityand17耳鼻喉科手術麻醉-課件18Tonsillectomyattention：topicalanesthesiaandcoughreflexgeneralanesthesiaandthemanagementofairwayemergentsurgeryforbleedingaftertonsillectomyandtheanestheticmanagementTonsillectomyattention：19bleedingafteronsillectomy

problems:hypo-volemia,fullstomach,andairwayobstruction.

inductionofanesthesia:

goodsuctioningofblood、arapid-sequenceinductionofanesthesiawithapplicationofcricoidpressureandslighthead-downpositioningofthepatientwillprotectthetracheaandglottisfromaspirationofblood.afterinduction,anasogastric(鼻胃的)tubemaybeplacedandremoved.extubation:aswithelectivetonsillectomy,extubationissafestwiththepatientawake.

bleedingafteronsillectomypr20Totalthroatresectionprofileoftheoperation：widerange，deepreach，airwayobstructionofsomeextentanestheticmangement：generalanesthesiawithendotrachealintubationthroughtracheotomyattention：

*

reflexofcarotidsinus(頸動脈竇反射)*split(破裂)ofmainline(大靜脈)→氣栓(gasembolism)*evaluationofrespirationfunctionandcorrespondingtreatmentTotalthroatresectionprofile21EndoscopyandendoscopicsurgeryProfile：

interactionofanestheticandsurgicalmanagementwiththecompromisedairwayinconsistency(矛盾)betweentheoperationandanestheticrecoveryEndoscopyandendoscopicsurge22Anesthesiaselectionforendoscopyandendoscopicsurgery*localanesthesia：trytoperformlocalanesthesiatothecooperativeadultpatientsespeciallytothosewithsomeextentofairwayobstructionduringshort-termoperations*generalanesthesia：mainlyfitschildrenpatientsAnesthesiaselectionforendos23Generalanesthesiaforendoscopyandendoscopicsurgerywithendotrachealintubation：thintubewithoutendotrachealintubation

1>intensiveinhalationanesthesiainductioncompaniedbytopicalanesthesia

2>withathinplastictubeabovethecarina(隆突)tosupplyoxygenortoventilatebyconnectingahighfrequencyjetventilator(高頻噴射通氣機)，performashort-termoperationundertheusageofscoline(琥珀膽堿)

3>supplyoxygenviathelateraltubeofthebronchoscope(氣管鏡的側(cè)管)Generalanesthesiaforendosco24AnesthesiaForEar，NoseandThroatSurgery耳鼻喉科手術麻醉byXuLiAnesthesiaForEar，NoseandTh25耳鼻喉科手術麻醉-課件26

ProfileandDemands

difficultairway

cardiacarrhythmia：applicattionofEpinephrine,reflexofcarotidsinus,etc.

N2OandmiddleearpressureProfileandDemandsdifficult27耳鼻喉科手術麻醉-課件28耳鼻喉科手術麻醉-課件29PreoperativeEvaluation

andPreparationInterview(麻醉前訪視)

Premedication(麻醉前用藥)：

▲sedatives(鎮(zhèn)靜藥)

▲anticholinegics(抗膽堿藥)

PreoperativeEvaluation

andP30Choiceofanesthesialocalanestehsia：tothosecooperativeonesundergoingshort-termandsimpleoperationsgeneralanesthesia：tothoseonescan’tbeundertakenoperationsunderlocalanesthesiaChoiceofanesthesialocalanes31SeveralcommonENToperations*operationofear*operationofnasalcavity(鼻腔)andnasalsinus(鼻竇)*tonsillectomy(扁桃體摘除術)*totalthroatresection(全喉截除術)*Endoscopy(內(nèi)鏡檢查)andendoscopicsurgery(內(nèi)鏡手術)SeveralcommonENToperations*32PS：嬰幼兒氣管、支氣管異物取出術病情：急(urgent)

、重(severe)

、危(dangerous)

麻醉：全麻，配合充分表麻,要求麻醉既不加重缺氧又能迅速誘導至足夠深度管理：*術前:準備應迅速、利索，呼吸困難(dyspnea)的應急處理*術中:積極防治喉、氣管、支氣管痙攣、缺氧、氣道內(nèi)出血、氣管破裂(split)或氣胸(pneumothorax)

、喉頭水腫(laryngealedema)等*術畢:充分供氧，待患者清醒良好、呼吸通暢，吸空氣SPO2基本正常后方可出手術室PS：嬰幼兒氣管、支氣管異物取出術病情：急(urgent)33

QuestionsTrytodescribethefactorscausingarrhythmiaduringENTsurgery.

“全喉截除術”中，發(fā)生頸外靜脈破裂，除了緊急止血外還應警惕什么情況的發(fā)生？如何處理？中耳手術時，吸入全麻的使用應注意什么？QuestionsTrytodescribethe34THANKYOU！THANKYOU！35Difficultairway

*1>Difficultintubation*2>compromisedairwayDifficultairway*1>Difficult36N2OandmiddleearpressureThemiddleearandparanasalsinus(鼻旁竇)arenormalbodyaircavitiesthatconsistofopen,nonventilatedspaces.Theblood/gascoefficient(系數(shù))is0.013fornitrogenversus0.46forN2O.Wheninhaledinhighconcentrations,N2Oenterstheaircavitiesfasterthannitrogencanleave.Inafixedcavitysuchasthemiddleear,theresultisanincreaseinpressure.AfterdiscontinuationofN2O,thegasisrapidlyreabsorbed,marked,negativemiddleearpressuremaydevelop.

N2OandmiddleearpressureThe37Difficultintubation①anatomicabnormalities：micrognathia(小頜),limitedjawmotion,orcongenitalsyndromes(craniofacialdysostoses<顱面骨發(fā)育不全>)etc..

②Othercauses：obesity,acromegaly(肢端肥大癥),cervicalspineproblems,rheumatoidarthritis(風濕性關節(jié)炎),andevengastricreflux(返流)

Difficultintubation①anatomic38CompromisedairwayPathologicconditionsabovetheglottismaypreventaclearviewoftheglotticopening,whereassubglotticlesionspermitagoodviewofthevocalcords,buttheyrequirecarefulplacementofasmallendotrachealtubeorbronchoscope.

CompromisedairwayPathologicc39Operationsofearsoperationsofearconcha(耳廓)andconchatract(外耳道)

：localanesthesia(tocooperativepatients)operationsinsideears：generalanesthesiaMicrosurgery(顯微外科手術)：controlledhypotension(控制性低血壓)issometimesneededN2Oandmiddleearpressure

Operationsofearsoperationso40OperationofnasalcavityandnasalsinuslocalanesthesiageneralanesthesiaOperationofnasalcavityand41耳鼻喉科手術麻醉-課件42Tonsillectomyattention：topicalanesthesiaandcoughreflexgeneralanesthesiaandthemanagementofairwayemergentsurgeryforbleedingaftertonsillectomyandtheanestheticmanagementTonsillectomyattention：43bleedingafteronsillectomy

problems:hypo-volemia,fullstomach,andairwayobstruction.

inductionofanesthesia:

goodsuctioningofblood、arapid-sequenceinductionofanesthesiawithapplicationofcricoidpressureandslighthead-downpositioningofthepatientwillprotectthetracheaandglottisfromaspirationofblood.afterinduction,anasogastric(鼻胃的)tubemaybeplacedandremoved.extubation:aswithelectivetonsillectomy,extubationissafestwiththepatientawake.

bleedingafteronsillectomypr44Totalthroatresectionprofileoftheoperation：widerange，deepreach，airwayobstructionofsomeextentanestheticmangement：generalanesthesiawithendotrachealintubationthroughtracheotomyattention：

*

reflexofcarotidsinus(頸動脈竇反射)*split(破裂)ofmainline(大靜脈)→氣栓(gasembolism)*evaluationofrespirationfunctionandcorrespondingtreatmentTotalthroatresectio