医学ppt课麻醉快速程序诱导rapidsequence

快速程序诱导 Rapid Sequence Induction 南京市第一医院 鲍红光 病 例 （ Case Insert） A 38 year old female，女性 38岁 Peritonitis for 3 days 腹膜炎 3天 Shocked with: 休克： 1. T: 38 o C 体温： 38 2. Pulse:120/minute 脉搏： 120次 /分 3. BP: 70 mmHg systolic 血压：收缩压 70mmHg 4. Poor nail bed capillary return 末？回流差 5. Respiratory rate 呼吸： 30次 /分 6. Confused 烦躁 7. Urinary: 20mL of concentrated urine 尿量 : 20mL 的浓缩尿 The surgeon wants to operate immediately 外科医生准备尽快手术 麻醉方式？ Anesthesia ? regional anesthesia? 硬膜外麻醉？ General anesthesia? 全身麻醉？ 诱 导 Induction 芬太尼 Fentanyl 异丙酚 Propofol 罗库溴胺 Rocuronium 快速诱导插管 RSI 快速顺序插管 Rapid Sequence Intubation 1. INDUCTION 2. PRESSURE 3. PARALYSIS 插 INTUBATION管 病 例 （ Cases） 成年病人（ Adult patient） 小孩（ Child） 全身麻醉的主要并发症 Main complications of GA Regurgitation 返流 Vomiting 呕吐 Aspiration 误吸 Desaturation, Laryngospasm 喉痉挛 , Airway obstruction气道梗阻 , Bronchospasm支气管痉挛 , Cardiac arrest心跳骤停 快速诱导插管的目的 GOAL of RSI 保护气道 Protect airway 便于插管 Facilitate intubations 快速诱导麻醉 Rapidly induce anesthesia ACEP, 2000 History Cricoid cartilage pressure to prevent regurgitation- Sellick1961. First series of ED intubations Taryle, 1979 First series of intubations using succinylcholine in the ED Thompson, 1982 American College of Emergency Physicians (ACEP) RSI policy statement(1997):- Reaffirmed, 2000 “physicians performing RSI should possess training, knowledge, and experience in the techniques and pharmacologic agents used to perform RSI” Today （ 当 今 ） 1.RSI resides in the domain of emergency medicine practice 主要应用于急诊医学领域 2. Key in the successful management of the “A” of “ABCs 心肺复苏 “ABC”中 “A”的核心 3. Increases the chance of successful intubation and minimizes the risks 增加插管的成功率和减少风险 COMPLICATION:并发症 : 15% aspiration误吸 , 28% airway trauma气道损伤 , 3% death死亡 1999 Li et.al. METHOD 方法 COMPLICATIONS 并 发 症 RSI n=166 28% WITHOUT PARALYSIS n=67 78%* 美国国家急诊气道注册机构 National Emergency Airway Registry (NEAR) METHOD FEQUENCY (%) SUCCESS (%) RSI 69.5% 98.7% NO MEDS* * PRE/FULL ARREST 17.3% 94.9% SEDATION 6.8% 90.2% NASAL 5.1% 87.2% Series of 6000 ED intubations 26 teaching hospitals 88.1% adult and 81.1% pediatric intubations 适 应 症 (Indication) Full stomach“饱胃 ” (尤 其是急诊手术或者剖腹产 手术需要全身麻醉 ). Gastric content aspiration risk 胃内容 物反流风险较大 (肥胖 , 胃食管反流或者糖尿病） Contraindications 禁 忌 症 The predicted difficult airway 预先判断有困难气道 Inexperience 操作不熟练 Inadequate difficult airway tools and techniques 没有充分的困难插管工具和技术 RSI: Rapid Sequence Induction 快速程序诱导 準備 (Preparation) 給氧 (Preoxygenation) 給藥 (Premedication) 麻痺 (paralysis) 插管 (Pass the tube) 插管後的處置 Preparation for RSI 快速诱导插管的准备 S: Suction（吸引器 ) O: Oxygen（氧气） A: Airway Equipment（插管设备） P: Pharmacology（药品） ME: Monitoring Equipment（监护仪） Head positioning 头部体位 Maintaining a patent airway 气道通畅 Chin lift / jaw thrust The patient is 抬下巴 / 托下颌 Preoxygenation 排 氮 给 氧 Preoxygenated for a full three minutes 预给氧三分钟 Wash all of the nitrogen out of the lungs 排除肺内的氮气 Create a resevoir of O2 制造一个高氧的环境 PRESSURE 压 迫 GOAL: REDUCTION OF RISK OF ASPIRATION 目的 : 减少误吸的风险 Sellick maneuver Technique Risk reduction Passive regurgitation Gastric insufflation Cricoid pressure No positive pressure ventilation 非正压通气 Important ! Risk reduction 降低风险 Passive regurgitation 被动反流 Gastric insufflation 胃内充气 麻痺 (paralysis)： Muscle relaxation in Succinylcholine occurs in just 30 seconds, with total paralysis in 45 seconds (1.5 mg/kg -2.0 mg/kg). 采用司可林肌松可在 30秒时起效，到 45秒时可完全松弛 (1.5 mg/kg-2.0 mg/kg) Muscle relaxation in Rocuronium occurs in 60-90 seconds (0.6 mg/kg ) 采用罗库溴胺肌松通常在 60 90秒钟起效 (0.6 mg/kg ) uscle relaxation 肌肉松弛 Anaesthesia 麻 醉 The anaesthetist is happy that the airway is intact 麻醉师自信气道在手 Administers the remainder of the anaesthetic agents - fentanyl, nitrous oxide and the volatile agent (Sevoflurane). 给予其他的的麻醉药品 芬太尼 , 氧化亚氮 和吸入 性麻醉药 (七氟醚 ) A non depolarising neuromuscular blocker 非去极化神经肌肉阻滞药 fter intubation 插管後的處置 ET tube 插入鼻胃管 Chest X Ray 照胸部 X光 At the completion of surgery 外科手术完成后 The risk of aspiration of gastric contents is as high now as at the beginning: “饱胃 ”病人手术后误吸的风险依然和术前一样高 : The anaesthetic agent is turned off 停止麻醉药品 100% oxygen is administered 给与 100% 氧气 Neuromuscular blockade is reversed 拮抗神经肌肉阻滞剂 The airway is carefully cleaned with suction 清理呼吸道 Ett remains in situ 气管插管 在手 until the patient is fully awake, lying on their side 直至病人完全清醒 , 恢复神志 Conclusion 结 论 RSI could provide a safe airway and Minimizing any possible complications during intubation最大限度减少并发症 . RSI successful avoid aspiration in “full-stomach” patients成功 避免 “饱胃 ”病人的误吸 . Dronen,S.C., 1999 Whereas anaesthesiologists use RSI to intubate patients requiring anaesthesia, emergency physicians commonly use RSI to induce anaesthesia in patients requiring intubation 麻醉师利用 RSI插管时需要先进行麻醉， 而急诊医生通常利用 RSI诱导麻醉时需要先插管 . RSI 快速程序气管插管 What are the difference between the RSI and traditional rapid induction RSI? 快速 程 序诱导插管和传统的快速诱导插管有何区别？ Differences are 区 别 An organized approach to endotr