CEA手术室篇PPT课件

手术室中的颈动脉内膜切除术Carotid Endarterectomy(CEA)1国家远程卒中中心、脑防委 CEA培训基地、北京市脑血管病中心2外科治疗相关问题 麻醉方式（ GALA trial） 术式介绍-标准 CEA（传统 CEA）-翻转式 CEA 护士协作 并发症的预防3Operation room team position during CEA. S Surgeon, aS assisting surgeon, Ne neurophysiologist；A anaesthesiologist；N nurse；M microscope团队配置及体位4I. Supine position;II. Head up: to reduce cervical venous pressure;III. Head is placed on a ring, with a sandbag under the shoulders;IV. Exposing the full length of the sternomastoid muscle;手术体位要求5手术切口6麻醉篇 麻醉平稳及适时调整血压至关重要7麻醉方式 全麻：-General anaesthesia has several advantages, including easier surgical manoeuvres, handling of complications and easier patient monitoring. 局麻：-local/regional anaesthesia decreases the number of medical complicationsat the expense of neurological complications.8General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trialMethod: a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.-general (n=1753) or local (n=1773) anaesthesia;-stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery;Conclusion: The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。9麻醉的不可替代性 掌握术前有无心脏疾病，缺血性尤为重要 术前的基础血压，要明确 麻醉平稳后开始手术前的血压，记录定标 临时阻断后可能需要短时升压至要求值 动脉缝合完毕后需要尽快降压 结合 TCCD定出出室后的血压安全控制范围10麻醉深度监测麻醉深度电极脑氧监测11麻醉协助 TCCD术前定标12 术中阻断后短时升压 血流再通后积极降压，不建议用硝普钠13术后麻醉与 TCCD定控制范围麻醉机14TCCD监测术中指导意义大 术前麻醉平稳后定标主要参考。 脑血流峰值、平均值、收缩期、舒张期15 Baseline (before induction) Pre-clamp (at heparin injection) Clamping, shunt insertion (if required) Post-clamping (15 min after clamping) Clamp release 5-min post-release 10-min post-release术中监测16手术护理篇 熟悉流程能减少动脉阻断时间 器械准备要求高 巡回护士及时调整双极电凝 阻断前静脉给肝素 腔内操作持续肝素盐水冲洗 术中冲洗准备 两套吸引装置17操作流程 分离暴露动脉鞘 显微操作阶段：切开剥离斑块、缝合动脉 关闭动脉鞘、分层缝合。18显微操作前器械19显微操作前器械20显微操作中器械21显微操作中器械22显微操作中器械23术中特别注意的问题 术中对血管的保护尤为重要。 器械对缝合线的损伤隐患最大。 无损伤器械使用。 肝素盐水的高频率冲洗（ 1ml含 10u肝素）。 肝素： Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin; CEA视频剪辑 .mp424粥样斑块（粥糜样物）狭窄处的真腔缝隙狭窄真腔25不稳定斑块26术式 标准 CEA 翻转式 CEA27Standard CEA technique.P Plaque, T superior thyroid artery, L longitudinal arteriotomyCEA technique with intraluminal shunt. IS Intraluminal shunt, R rubber band aroundthe CCA, C window aneurysm clip at the ICA, P plaque, T superior thyroid ar