全麻并发症

全身麻醉期间严重并发症的防治,呼吸道梗阻,respiratory obstruction 呼吸道梗阻:上梗(upper airway obstruction) 下梗 (lower airway obstruction) 或 完全性梗阻(completely obstruction) 部 分 性梗 阻(partially obstruction)临床表现: 胸部和腹部呼吸运动反常，吸气性喘 鸣，呼吸音低或无,三凹征、呼吸困难， 呼吸动作剧烈，但无通气或通气量低。,舌后坠（上梗） (Tongue falling afterward ),镇静、镇痛药、全麻药及肌松药下颌骨及舌肌 松驰舌坠向咽部阻塞上呼吸道 不完全性:鼾声(Snore)舌后坠阻塞咽部(pharynx) 完全性:只有呼吸动作, 无呼吸交换,SpO2 Reduced muscle tone with apposition of the tongue and pharyngeal soft tissue is a common cause. This is usuallyovercome by jaw lift and use of an oral or nasopharygealairway. The patients should be placed in a head-down position.二、分泌物、脓痰、血液、异物阻塞气道对气道有刺激性的麻醉药分泌物（术前 给足量抗胆碱药）支扩、湿肺等大量脓痰、血液堵塞气道（双腔插管，术中吸引）鼻咽、口腔等手术积血、敷料阻塞（气管插管）脱落的牙或义齿阻塞气道（麻醉前拔除或取出）,反流与误吸 (Regurgitation and aspiration) 原因（Aetiology）: Regurgitation and pulmonary aspiration of gastric contents are more likely to occur in patients with intra-abdominal pathology,delayed gastric emptying or inadequate gastro-oesophageal sphincter function. Aspiration is more common during emergency ,obese or obstetric patients. Mortality is high after major aspiration.,应用吗啡类、全麻药、肌松药后贲门括约肌松驰胃内容物反流下呼吸道严重阻塞误吸死亡率50%75%。 误吸胃液突发支气管痉挛、呼吸急速、困难、肺内弥漫性湿罗音，严重缺O2. Bronchospasm is the first sign . If a large quantity of gastric material is aspirated, respiratory obstruction, V/Q mismatch and intrapulmolary shunting may produce severe hypoxaemia,with chemical pneumonitis.,预防（prevention)：择期手术术前:6月： 4h禁奶及固体食物，2h禁清亮液体. 636月：6h禁奶及固体食物，3h禁清亮液体. 36月： 8h禁奶及固体食物，3h禁清亮液体.备吸引器、鼻胃管减压.饱胃、高位肠梗阻：宜清醒气管插管(awake intubation).H2-R拮抗剂(to reduce the acidity of gastric contents).处理(management): 发生反流误吸时头低位(head-down position)、转向一侧、吸引 (suction)、支气管解痉药（bronchodilator)、必要时支气管镜检 （bronchoscopy)四、插管位置异常、管腔堵塞、麻醉机故障Aetiology:导管扭曲、受压、过深误入一侧支气管过浅脱出，管腔被粘痰堵塞 螺纹管扭曲，呼吸活瓣启动失灵 SpO2，异常呼吸运动Management:（对因处理）五、气管受压颈部、纵隔肿块、血肿、炎性水肿气管受压.头颈部位置改变呼吸困难加重.X线、CT确定受压部位、气管内径大小选择气管型号、插管深度应超过最狭窄部位.气管软化气管塌陷必要时气管切开.六、口咽部炎性病变、喉肿物及过敏性喉水肿扁桃体周围脓肿、咽后壁脓肿、喉Ca、声带息肉、会厌囊肿、过敏性喉水肿上梗（部分性):呼吸困难，无法施行口腔插管。咽喉部极敏感硫喷妥钠可引起严重喉痉挛窒息死亡.此类病人应先考虑行气管造口术过敏性喉头水肿抗过敏治疗，加压给O2SpO2仍无改善气管造口,喉痉挛与支气管痉挛,Laryngospasm and Bronchospasm 常见于哮喘、慢性支气管炎、肺气肿、过敏性鼻炎。喉痉挛(laryngospasm)：Laryngospasm is a reflex, prolonged closure ofthe vocal cords in response to a trigger, usually airway stimulation during light anesthesia. (呼吸道保护性反射声门闭合反射过度亢进),临床表现(clinical manifestations)：Laryngospasm can lead to inadequate ventilation with hypoxaemia and hypercapnia.Crowing inspiration noises with signs of respiratory obstruction suggest partial laryngospasm.Complete laryngospasm is silent.吸气性呼吸困难、高调吸气性哮鸣音.喉痉挛支配咽部的迷走神经兴奋性咽部 应激性声门关闭活动.发生于全麻期（浅全麻）,硫喷妥钠易诱发 喉痉挛.,诱发原因(aetioloty)：低O2血症(hypoxaemia)、高CO2血症(hypercapnia)、口咽部分泌物(secretions of oropharynx)与反流胃内容物(regurgitation of gastric contents)刺激咽喉部。口咽通气道（oropharynx airway)、喉镜(larynxoscopy)、气管插管操作(tracheal intubation)。浅麻醉下手术操作(surgery manipulation under light anesthesia)：扩肛、剥离骨膜、牵拉肠系膜及胆囊等。,处理(management):轻度：吸气时喉鸣：去除局部刺激后可自行缓解.中度：吸气、呼气都出现喉鸣音:需面罩加压给O2.重度：声门紧闭,气道完全阻塞，粗针环甲膜穿刺吸 O2or iv 肌松药加压吸O2 or 气管插管。 If laryngospasm persists and hypoxaemia ensues, muscle relaxant relaxes the vocal cords and allows manual ventilation and oxygenation.预防(prevention)：避免浅全麻下行气管插管或手术操作，防缺O2与CO2蓄积。,支气管痉挛(bronchospasm)：诱发因素(aetiology)：气管插管(tracheal intubation)、反流误吸(regurgitation and aspiration)、吸痰(suction of secretions).手术刺激(surgical stimulation)反射性痉挛(reflex spasm).硫喷妥钠、吗啡等肥大细胞释放组胺(histamine)诱发痉挛.,Patient with increased airway reactivity from recent respiratory infection,asthma, atopy or smoking are more susceptible to bronchospasm during anesthesia. Bronchospasm may be precipitated by stimulation of the carina or bronchi by a tracheal tube.,表现(clinical manifestations)：,呼气性呼吸困难、喘鸣音(expiratory wheeze ) 呼气期延长(a prolonged expiratory phase)、 费力、缓慢、HR或 心律失常 (arrhythmia) .,处理(management)：,轻度：手控呼吸(artificial ventilation)即可改善.严重支气管痉挛： 支气管扩张剂（bronchodilator) 激素(steroids).缺O2、CO2蓄积诱发者IPPV浅全麻下手术刺激诱发者加深麻醉（deepen anesthesia)及肌松药(muscle relaxant).第二节 呼吸抑制Section two Respiratory depression指通气不足：呼吸频率慢、潮气量低、PaO2、PaCO2一、中枢性呼吸抑制 镇痛药、麻醉药一抑制呼吸中枢（减浅麻醉，纳洛酮对抗） 过度通气CO2排出过多一抑制呼吸中枢（减少通气量） (过度膨肺）二、外周性呼吸抑制应用肌松药（常见原因）： 处理：新斯的明拮抗.大量排尿血K+呼吸肌麻痹： 处理；补K+.全麻复合高位硬麻： 处理：待阻滞作用消失. 三、呼吸抑制时的呼吸管理有效人工通气SpO2、PETCO2维持正常.有自主呼吸者：辅助呼吸.无呼吸者：控制呼吸：调整RR、呼吸比等.,低血压与高血压,Hypotension and hypertension 一、低血压及其防治 The prevention and treatment of hypotension 指血压降低幅度超过麻醉前20%或SBP80mmHgHypotension during anesthesia may be defined as MAP less than 60 mmHg or SBP 25% less than the patient,s preoperative valve.,发生原因(aetiology)：麻醉因素(factors of anesthesia)：麻醉药、麻辅药 抑制心肌(inhibition of cardium) 血管扩张(vasodilation)过度通气低CO2血症(hypocapnia)排尿过多低血容量(hypovolaemia)、 低K+(hypokalaemia)缺O2酸中毒(acidosis)低体温(hypothermia),手术因素(Factors of surgical operation)： 术中失血多未及时补充(haemorrhage). 副交感N(parasympathetic)分布区手术操作 迷走反射(vagal reflex). 手术操作压迫心脏、大血管(oppression of the heart and major vessels). 直视心脏手术(cardiopulmonary bypass).,病人因素(factors of patients)： 术前有明显低血容量(hypovolaemia)未予纠正. 肾上腺皮质功能衰竭(failure of adrenal cortex ,s function ). 严重低血糖(hypoglycemia). 血浆CA (catecholamine)(嗜铬切除后). 心律失常(arrhythmia)或心梗(cardiac infarction).,预防(prevention)：术前充分补液，纠正水、电失衡.纠正贫血.RHD、严重MS切忌使用抑制心血管作用的麻醉药.已有心脏缺血的冠心病病人BP维持正常，防ST-T进一步改变.心梗者除非急症，待6个月后再行择期手术.心衰者心衰控制后2W再手术.度房室传导阻滞或病窦综合征起搏器.低K+补K+.房颤心室率80-120次/分.长期激素治疗者术前、术中加大激素用量.,处理(management)：减浅麻醉、如CVP不高加快输液及胶体，必要时用升压药(vasoconstrictor).严重冠心病者，术中反复低血压防心梗发生，支持心泵功能(dobutamine)。手术牵拉内脏致BP暂停手术操作，少量麻黄素(ephedrine)等.对肾上腺皮质功能不全者大剂量DXM.术中一旦测不出BP立即CPR.,二、高血压及其防治,(prevention and treatment of hypertension) 指BP麻醉前20%或BP160/95mmHg（高血压）. (Intraoperative hypertension may be defined as SBP 25% greater than the patient,s preoperative valve.) BP过高指BP麻醉前30mmHg.,影响(effects)BP过高左室射血阻力左室舒张末期压心内膜下缺血梗死. (Hypertension increases myocardial work by increasing afterload and left ventricular wall tension.)严重高血压脑卒中（脑出血、脑梗塞、高血压脑病). (Hypertension also increases the risk of ischaemia, haemorrhage and infarction in other organs, such as the brain.),原因(aetiology)：麻醉因素:气管插管操作、KTM、r-OH、缺O2、CO2蓄 积早期.手术因素: 颅内手术牵拉额叶或刺激、脑NBP.脾切挤压循环容量剧增BP. 嗜铬细胞瘤术中探查BP.病情因素: 甲亢、嗜铬C瘤麻醉后出现难以控制BP 急性心衰、肺水肿. 精神极度紧张BP脑出血、心衰.处理(treatment)：对因治疗.,心肌缺血,Myocardial ischaemia Myocardial ischaemia occurs when myocardial oxygen demand exceeds supply.冠脉狭窄或阻塞冠脉血流不能满足心肌代谢需O2心肌缺血。(The subendocardium is particularly vulnerable.)一、有关生理知识影响心肌耗O2量的三个主要因素： 心率 心肌收缩力 心室内压决定冠脉血流多少的是： 灌注压:冠脉阻力 灌注压=主动脉压-心肌内压 收缩期心室壁内压冠脉血流受阻左室心肌供血主要在舒张期HR舒张压缩短左室心肌供血右室收缩压和壁内压较小，收缩期和舒张期心肌供血相同。,一、有关生理知识冠脉阻力由 冠脉内经及分支内经 冠脉长度 决定 血液粘稠度心肌不能耐受较长时间缺O2.心肌毛细血管与心肌纤维的数量为1:1.心肌肥厚肌纤维，但毛细血管数量并不易心肌缺血.冠脉血管间的吻合支细小，血流量极少一旦冠状血管某一支阻塞不能立即建立有效侧支循环心梗.,二、心肌缺血的诊断方法,(diagnose of myocardial ischaemia) It is diagnosed by ECG ST-segment changes. The use of V5 electrode is recommended for ECG monitoring in susceptible patients. 心肌缺血的ECG表现： 出现Q波，R波进行性； ST段压低1mm or 抬高2mm T波低平，双向或倒置 心传导异常； 心律失常；,三、麻醉期间引起心肌缺血的原因,冠脉狭窄达5175%心肌缺血ECG表现.Aetiology:精神紧张、恐惧、疼痛CA释放心脏后负荷(myocardial afterload), HR心肌耗O2.BP 或影响心肌供血供氧. Hypotension can reduce oxygen supply by reducing coronary blood flow. Hypertension increases myocardial afterload and oxygen demand.,麻醉药 抑制心肌收缩力C.O. 抑制血管回心血量. 缺O2或供O2不足.HR或心律失常(arrhythmia). Tachycardia is the most important determinant of the myocardial oxygen supply/demand ratio(because the duration of diastolic coronary filling is reduced simultaneously with an increase in myocardial work.),四、心肌缺血的防治,(Prevention and treatment of myocardial ischaemia)原则：使心肌氧供需平衡，降低心肌氧耗，增加心肌供氧.减轻心脏作功（治疗高血压）.消除不良血流动力学效应(纠正心律失常、避免BP).提高供氧量（纠正贫血、吸入氧浓度）.适当减慢心率.心梗择期手术当延迟至46个月后施行，ECG、MAP、CVP、CO、U等监测。酌情使用短效-R阻滞剂或钙通道阻滞药. (If signs of myocardial ischaemia persist, a coronary vasodilator such as glyceryl trinitrate by intravenous infusion should be considered.),体温升高或降低,Hyperthermia and Hypothermia 机体产热和散热: 机体散热方式： 辐射(radiation): 60%； 传导(conduction):3%； 对流(convection):12%； 蒸发(evaporation):25%体温调节下丘脑体温调节中枢.冷反应阈：36.5.对冷反应：血管收缩(vasoconstriction)热反应阈：37. 对热反应：出汗(sweating)人体中心温度（恒定）：37全麻期间：冷反应阈可降至34.5.热反应阈可升至38.婴幼儿皮下脂肪少,体表面积大,易散热,易出现低体温.,低体温(Hypothermia),Hypothermia during anesthesia may be defined as a core body temperature less than 36.0 .诱发因素(aetiology)： Heat loss exceeds production( Many factors increase heat loss.)室温低(The ambient temperature is less than 24 ): T幅度与手术时间长短(prolonged surgery)、病人体表面积(surface area)、体重(weight)有关.室温2426，病人能维持T稳定。,室内通风(air flow)：对流散热(convective heat loss).手术中输入大量冷液体( intravenous infusion with cold fluids)、冷库血(cold stock blood)（4),输入 量T越明显，宜加温输入。术中内脏暴露（open body cavities)时间长、用冷 溶液冲洗体腔 ( irrigation of body cavities with cold fluids) T全麻药抑制体温调节中枢及肌松药产热T,低体温的影响(The effect of hypothermia)：,Metabolic rate is reduced by up to 10% for every 1 fall in body temperature.There is an increase in haemoglobin oxygen affinity. These lead to a reduction in tissue oxygen delivery.Significant hypothermia is associated with metabolic acidosis, altered platelet and clotting function, and reduced hepatic blood flow with slower drug metabolism.Muscle relaxants have a longer duration of effect.Postoperative shivering increases oxygen consumption and myocardial work.1使麻醉药及辅助麻醉药作用时间延长2出血时间延长：T凝血物质活性、pt滞留于肝 3血液粘稠度影响组织灌注，氧离曲线左移不利于组织供O24寒战组织耗O2,预防(Prevention)：,室温维持于24.大量输血输液宜加温.采用吸入麻醉IPPV时，宜用循环紧闭回路.婴幼儿：变温毯.,体温升高(Hyperthermia),Concept: Hyperthermia is usually may be defined as a core body temperature greater than 37.5.Classification: 低热：37.538(口腔温度).高热：3841.超高热（过高热):41.,Aetiology:室温28，且湿度过高.无菌单覆盖过于严密，妨碍散热.开颅手术在下视丘附近操作. Atropine量大，抑制出汗.输液输血反应.循环紧闭法麻醉，钠石灰产热T（经呼吸道).,The effects of hyperthermia:T1BMR10%oxygen consumptionHyperthermia may lead to metabolic acidosis(代酸), hyperkalaemia(高血K+), hyperglycemia(高血糖).T40seizure of convultion(惊厥).Prevention:Exposure of the body surface.Application of ice packs.Administration of intravenous cold fluids. Strengthen monitoring.,术中知哓和苏醒延迟,Intraoperative awareness and postponed resurgence 任何全麻均须做到： 使病人意识消失，不知疼痛，丧失回忆能力. 消除体动，提供安静术野. 降低或消除应激反应. 一、术中知晓 (intraoperative awareness) Awareness during anesthesia refers to a patient experiencing an intraoperative event and recalling the event postoperative.,术中知晓的原因(aetiology),Awareness is associated with a poor anesthetictechnique, the use of low concentration of volatile anesthetic agents and breathing system disconnec-tions and leaks. Significant degrees of intraoperative awarenessoccur only in patients who have received a muscle relaxant.,术中知晓的预防(prevention)：,Awareness is a traumatic experience for the patient and may have psychological sequelae including insomnia,depression and fear of death. 避免麻醉过浅(avoiding the light anesthesia) 监测脑电图(monitoring electroencephalogram,EEG)监测脑干听觉诱发电位变化( monitoring the changes in the auditory evoked potential),麻醉苏醒期始于停止给麻醉药，止于病人 能对外界言语刺激作出正确反应凡术后超过30min呼唤不能睁眼和握手、对 痛觉刺激无明显反应，即为苏醒延迟,原因(aetiology)： 麻醉药的影响：术前用药：安定类药吸入全麻药：极度肥胖者长时间吸入麻醉性镇痛药：肌松药:呼吸抑制低CO2血症：术中长期人工过度通气CO2排出过多术后呼吸中枢长时间抑制,高CO2血症：呼吸管理不当. 钠石灰失效. CO2吸收系统单向气流活瓣失灵. PaCO2至90-120mmHgCO2麻醉苏醒延迟、术后昏迷. （PaCO2脑血流脑水肿抽搐昏迷）.低K+血症： 血K+3mmol/L，酸中毒呼吸肌麻痹.输液逾量： 大量晶体血浆胶渗压肺间质水肿 呼吸功能严重受损缺O2、CO2蓄积.手术并发症:肾、肾上腺、肝、胸手术气胸、肺萎 缩肺通气功能受损. 严重代酸： 呼吸中枢明显抑制,术中发生严重并发症： 大量失血. 严重心律失常. 急性心梗、长时间低BP. 颅内动脉瘤破裂、脑出血、脑栓塞ICP.术中低体温术前有脑血管疾患:脑栓塞、脑出血、CO中毒,（二）治疗(Treatment)：首先考虑麻醉药的作用:对因处理.根据SpO2、PETCO2、血气、电解质及肌松情况 分析原因:对因处理. 低O2血症改善缺O2. PETCO2、PaCO2加大通气量. PETCO2、PaCO2确保SpO2、PaO2正常情况下 采取窒息治疗。 (窒息治疗时，PaO270mmHg，SpO293%),严重低K+：ECG及血K+监测下尽快补K+（冲击治疗）， 当血K+达3mmol/L减慢补K+速度. (ECG T波高耸示血K+达生理最高限度 （6.5mmol/L）立即停止补K+)严重代酸：纠酸：NaHCO3.脑水肿、颅高压呼吸功能不全者：脱水治疗，降ICP.低T者升高T.术中长期低血压者维持良好BP、SpO296%,BS4.5 6.6mmol/L，大量H.原来并存脑疾患者：麻醉药用量应。,咳嗽、呃逆、术后呕吐、术后肺感染 Cough ,hiccup, postoperative vomit, postoperative pulmonary infection,一、咳 嗽(cough),程度：轻度：阵发性腹肌紧张和屏气.中度：阵发性腹肌紧张和屏气，颈后仰，下颌僵硬，紫绀.重度：腹肌、颈肌、支气管平滑肌阵发性强力持续痉挛: 上半身翘起，长时间屏气，严重紫绀.不良影响：intra-abdominal pressure(IAP): 内脏膨出，伤口裂开.intra-cranial pressure(ICP)：脑出血或脑疝.blood pressure(BP)：伤口渗血、心衰等.,诱发原因：巴比妥类药副交感紧张度诱发咳嗽.冷的挥发性麻醉药刺激.浅全麻下插管,吸痰时刺激气管粘膜.胃内容物误吸诱发剧咳.防治：全麻插管前给足量肌松药、带气囊导管、胃肠减压等.,二、呃 逆(hiccup),膈肌不自主阵发性收缩(uncoordinated, spasmodic diaphragmatic movements ) 原因(Aetiology): 手术强烈牵拉内脏或直接刺激膈肌及膈N. 全麻诱导时将大量气体压入胃内. 术中呃逆影响通气及手术操作. 术后呃逆影响休息及进食水.,防治(management)：,Anticholinergic premedication reduces the incidence of hiccups. Persistent hiccups may be abolished by deepening anesthesia or administering droperidol. Profound muscle relaxation may be justified to stop all diaphragmatic movement if hiccups are causing surgical difficulty.,三、术后呕吐(postoperative vomit)原因(aetiology)：麻醉药作用: 吸入全麻药：乙醚等. 静脉麻醉药：均见呕吐发生.手术种类影响:胃肠道手术：胃肠粘膜水肿、胃肠蠕 动或消失胃潴留.病人情况: 术前饱胃、幽门梗阻或高位肠梗阻、 外伤焦虑、胃管等.,不良影响(bad effects)：加剧伤口痛及使缝合伤口裂开.呕吐误吸或窒息.水、电、酸碱失衡:术后频繁呕吐大量胃肠液丢失 K+、HCO3丢失.防治(prevention and treatment)：术前饱胃及幽门梗阻麻醉前胃排空(胃肠减压管等).适量止呕药. 四、术后肺感染 Postoperative pulmonary infection属医院内感染： 肺感染居首位：23.242%，死亡率50%病原菌: G菌：68%，G+菌：24%，真菌：5%感染原因：雾化器污染:80%雾化器有病原菌污染.气管插管、气管切开及气管内麻醉时呼吸道净化功能,应用呼吸机等.反流误吸:误吸肺组织防御机制受损.外科手术:70%院内肺感染为外科手术病人，胸腹部 术后病人居多，老年、 肥胖、COPD、长期吸烟.用药不合理:滥用广谱抗生素及较长时间使用激素.诊断标准:术后48h发病、出现咳嗽、咳痰等，并符合下列标准者:发热、肺部罗音、X线检查呈炎性病变.经筛选的痰液连续2次分离出相同病原菌.下呼吸道分泌物中病菌浓度高.治疗：抗生素: 合理选用:宜早期、联合应用、参照药敏试 验调整用药.免疫治疗:提供特异性抗体.支持治疗:足够热量、AA、白蛋白、维生素.,恶性高热,Malignant hyperthermia 即异常高热：是指由某些麻醉药激发的全身肌肉 强烈收缩,并发体温急剧及进行性循环衰竭的代谢亢进现象. 发生率1/1.6万10万,病死率达73%. 发生机制尚不完全清楚，多有恶性高热家族史、肌内细胞存在遗传生理缺陷.,诱因(aetiology):halothane, scoline, enflurane, lidocaine, bupivacaine.临床特征(clinical features)：术前T正常,吸入卤族麻醉药或 iv scoline 后T (may reach 43), 皮肤潮红(mottled skin)、发热 (hyperthermia)，心动过速(tachycardia),气促 (tachypnea).发绀(cyanosis).全身肌肉强烈收缩