administrationofgeneralanesthesia全身麻醉應(yīng)用

administrationofgeneralanesthesia全身麻醉應(yīng)用第1頁(yè)/共41頁(yè)OverviewWhatisgeneralanesthesia?PreoperativepreparationInduction:goingofftosleepMaintenance:keepingptasleepEmergence:wakingupTransport第2頁(yè)/共41頁(yè)WhatisgeneralanesthesiaPrimarygoals

SafetyistoppriorityAmnesia:nomemoryoftheeventHypnosis:unconciousAnalgesia:freeofpainBlockcertainautonomicreflexesOptimalsurgicalconditions:immobolity第3頁(yè)/共41頁(yè)WhatisgeneralanesthesiaSecondarygoalsMedicalconditionSurgicalproceduresSurgicalsettings第4頁(yè)/共41頁(yè)ExamplesforsecondarygoalsPatientswithCAD:Oxygensupply-demandbalanceNeurosugery:ICPcontrol,brainrelaxationandCPPmaintenanceObstetrics:anestheticsandfetaldepression,difficultairwayDaysurgeryvsInpatient:whichkindofanalgesicyoushouldchoosetominimizepostoperativepainanddecreasePONV?第5頁(yè)/共41頁(yè)P(yáng)reoperativepreparationPreoperativeevaluationsAirwayexaminationInterimchangesinpt’sconditionMedicationsLaboratorydataConsultantnotesLastoralintake第6頁(yè)/共41頁(yè)P(yáng)reoperativepreparationIntravascularvolumeDehydration:adequatelyhydratetheptbeforeinductionIntravenousaccessPreoperativemedicationsAnxietyBenzodiazepine:MidazolamOpioid:MorphineorFentanylNeutralizegastricacidanddecreasegastricvolume

第7頁(yè)/共41頁(yè)Whichkindofptisatincreasedriskofaspirationofgastriccontent?RecentmealTraumaBowelobstructionPregnancyHistoryofgastricsurgeryIncreasedintra-abdominalpressureHistoryofactivereflux第8頁(yè)/共41頁(yè)MonitoringStandardmonitoringforGAECGNBPPulseoximetryCapnographyOxygenanalyzer

第9頁(yè)/共41頁(yè)第10頁(yè)/共41頁(yè)InductionLettheptgoofftosleepPreoxygenation8L~10L/minIVorInhalationalinductionAirwaymanagement第11頁(yè)/共41頁(yè)InductiontechniquesIntravenous:themostcommonmethodInhalation:forspecialpt(ptwithdifficultairway,pediatricpt)Intramuscular:rarelyused,onlyusedinuncooperativeptsandyoungchildren第12頁(yè)/共41頁(yè)AirwaymanagementASAClosedClaimsStudy(美國(guó)麻醉學(xué)會(huì)已結(jié)案的訴訟）35%ofclaimsareRESPIRATORYevents90%resultedinbraindamageordeath90%resultedfromDifficultyinINTUBATIONorEXTUBATION第13頁(yè)/共41頁(yè)AirwaymanagementAirwaypatencyiscriticallyimportant第14頁(yè)/共41頁(yè)Oralairway第15頁(yè)/共41頁(yè)第16頁(yè)/共41頁(yè)Nasophryngealairway第17頁(yè)/共41頁(yè)Laryngealmaskairway第18頁(yè)/共41頁(yè)Intubation第19頁(yè)/共41頁(yè)MaintenanceIncreasing

depthofanesthesiastageⅠAmnesiaLossofconsciousnessStage

ⅡDeliriumInjuriousresponsestonoxiousstimuliStageⅢ

SurgicalanesthesiaPainfulstimulationdoesnotelicitsomaticreflexesordeleteriousautonomicresponses

StageⅣOverdosageCirculatoryfailure第20頁(yè)/共41頁(yè)MaintenanceMaintainhomeotasisVitalsignsAcid-basebalanceTemperatureCoagulationVolumestatus第21頁(yè)/共41頁(yè)MaintenanceLackofawarenessandnomemoryoftheeventIncidenceofawarenessHighrisksurgicalpopulationHighriskptHighriskanesthesiamethod第22頁(yè)/共41頁(yè)Howtoavoidawareness

TorecognizethehighriskptMonitorthedepthofanesthesiaSomaticandautonomicresponsearenonspecificandunreliableBismonitorforhighriskpt第23頁(yè)/共41頁(yè)Depthofanesthesia

IntensityofsurgicalstimulationResponsesuggestinginadequateanestheticdepth:Somatic:movement,coughing,changesofrespiratorypatternAutonomic:tachycardia,hypertension,mydriasis,sweating,tearingUnreliableandnonspecificSympatheticactivationmaybecausedbyotherreasons第24頁(yè)/共41頁(yè)Maintenancemethods

Volatile(Isoflurane,Desfluraneorsevofluranecombinedwithnitrousoxide)Nitrousoxide-opioidrelaxanttechniqueIVanesthesiaCombinationsGeneralanesthesiacombinedwithregionalanesthesia第25頁(yè)/共41頁(yè)Ventilation第26頁(yè)/共41頁(yè)Ventilation1.Spontaneousorassistedventilation2.Controlledventilation

Tidalvolume:10-12ml/kgRespiratoryrate:8-10breaths/min3.Assessmentofventilation

CapnographyPulseoximeterAirwaypressureReservoirbreathingbagVentilatorbellow

第27頁(yè)/共41頁(yè)VentilationPeakinspiratorypressureHighairwaypressure>25~30cmH2OBreathingcircuitproblemETTobstructionormovementAlteredlungcomplianceChangeinmusclerelaxationSurgicalcompression

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IVFluidsIntraoperativeIVfluidsrequirements

1.Maintenancefluidrequirements2.Thirdspacelossesandinsensiblelosses3.Bloodlosses

第29頁(yè)/共41頁(yè)IVFluids1.Crystalloidsollutions:maintenancefluidrequirement,evaporativelosses,andthirdspacelosses2.Colloidsollutions:replacebloodlossorrestoreintravascularvolume3.Bloodtransfusion

第30頁(yè)/共41頁(yè)IntravascularvolumeassessmentTrendsofheartrate,bloodpressure,andurineoutputCentralvenouspressure,pulmonaryarteryocclusionpressure,rightandleftend-diastolicvolumes(usingTEE)andcardiacoutputHemotocrit,plateletcount,fibrinogenconcentration,prothrombintime,thromboplastintime第31頁(yè)/共41頁(yè)EmergencefromGAGoals:

awakeResponsiveFullmusclestrengthAdequatepaincontrol第32頁(yè)/共41頁(yè)ExtubationAwakeextubationIndicationsRiskofaspirationDifficultairwaysTrachealormaxillofacialsurgery第33頁(yè)/共41頁(yè)ExtubationAwakeextubationCriteria

AwakeHemodynamicallystableFullmusclestrengthAbletofollowsimpleverbalcommandsBreathingspontaneouslywithadequateventilation第34頁(yè)/共41頁(yè)ExtubationAwakeextubationSpecialtechnique:removalofETToverafl