复合麻醉与联合麻醉PPT参考课件.ppt

复合麻醉与联合麻醉,1,复合麻醉(balanced anesthesia)及联合麻醉（combined anesthesia)的定义 复合麻醉的应用原则 静吸复合麻醉与全凭静脉麻醉的比较 联合麻醉的优缺点,2,复合麻醉(balanced anesthesia)及联合麻醉（combined anesthesia） 的定义,The concept of balanced anaesthesia today is that a combination of anaesthetics will act synergistically with respect to desired effects such as hypnosis or analgesia, but not with respect to side-effects. 联合麻醉是指同一麻醉过程同时或先后采用两种或两种以上的技术,3,理想的麻醉状态,不仅仅局限于无痛、肌肉松弛和意识消失 有效地调控机体的应激状态 维护重要生命器官和系统的功能 消除恶性刺激对病人生理及心理的影响,4,复合麻醉的应用原则,合理的选择麻醉药物和剂量 准确地判断麻醉深度 加强麻醉管理 优化用药方案 坚持个体化原则 不同麻醉技术的联合使用,5,临床常用的复合麻醉方案,1.静吸复合麻醉 Propofol+Fentanyl+Esmeron 诱导插管 Sevoflurane+Remifentnil 维持 2.全凭静脉麻醉（TIVA or TCI） Propofol+Fentanyl+Esmeron 诱导插管 Propofol+Remifentanil 维持,6,两种方法的比较,1.对颅内压的影响 2.对术后恶心呕吐的影响 3.对HPV的影响 4.术中体动的发生率 5.对苏醒速度的影响 6.经济效益的比较,7,吸入麻药的药代动力,Figure 1. The 80% decrement times of volatile anaesthetics. By analogy with the context-sensitive half-time, the decrement time describes the decay of the alveolar concentration with the time of administration. The 80% decrement times of both sevoflurane and desflurane are less than 8 minutes and do not increase with the duration of anaesthesia. However, the 80% decrement times of isoflurane and enflurane increase significantly after approximately 60 minutes of anaesthesia, reaching plateaus of approximately 3035 minutes. The 80% decrement time correlates closely with the clinically observed recovery of consciousness.,8,阿片类药物的时效敏感半衰期,The CSHT of remifentanil is less than 5 minutes, independently of the time of administration.,9,Propofol时效敏感半衰期,The CSHT of propofol is 15min after a 2-hour infusion,10,两种方法的选择,颅内占位性病变手术 腔镜手术 某些胸科手术 高危呕吐病人的手术 耳鼻喉短小手术 讲者更多倾向于选择Propofol-based anesthesia,11,Pearls,utilization of ultra-fast-acting compounds needs planning of postoperative analgesia at least during anaesthesia, or better, before the start of anaesthesia Multi-model analgesia (including NSAID, nerve block, local infiltration, opioid, etc) should be considered,12,联合麻醉的优点,可以达到更完善的麻醉效果， 病人围术期安全性更高 消除病人对手术和麻醉的恐惧心理和精神紧张 减少全麻中镇痛药的用量，或局麻药的应用，从而减少全麻或局麻药物所带来的毒副作用和不良反应 减少静脉麻醉药或吸入麻醉药的应用，病人术后苏醒迅速、恢复快 可以减少肌松药的用量 术后保留硬外导管，可以提供完善的术后镇痛,13,硬外复合全麻的优点,14,硬外复合全麻的优点,硬外麻醉可以降低全麻术中麻醉性镇痛药及麻醉药的需求，加快术后苏醒及降低麻醉性镇痛药相关的各种并发症 对于上腹部手术病人可以有利于术后