肥胖门诊麻醉.ppt

TheAdultPatientWithMorbidObesityand/orObstructiveSleepApneaForAmbulatorySurgery,GirishP.Joshi,MBBS,MD,FFARCSI协和规培：石磊,病态肥胖及阻塞性睡眠呼吸暂停病人的门诊手术麻醉（一）,.,Introduction,Morbidlyobese（病态肥胖）haveanincreasedriskofCo-morbidities(并存病，Table1),andthereforeposeconsiderablechallengestotheanesthesiologist(Table2).Oneofthemajorco-morbiditiesassociatedwithobesityincludesobstructivesleepapnea(阻塞性睡眠呼吸暂停，OSA),reportedin60-70%ofmorbidlyobese.,简介,.,Introduction,Table1:Co-morbidities（并存病）AssociatedWithObesity（肥胖）Respiratory（呼吸系统）:Restrictivepulmonarydisease（限制性肺疾病）,obstructivesleepapnea（阻塞性睡眠呼吸暂停）,asthma（哮喘）,Pulmonaryhypertension（肺动脉高压）Cardiac（心血管）:Systemichypertension（系统性高血压）,coronaryarterydisease（冠状动脉心脏病）,dysrhythmias（心律失常）,Cardiomyopathy（心肌病）,CHF（慢性心衰）Neurologic（神经系统）:Stroke（中风）Renal（泌尿系统）:Renaldysfunction（肾功能不全）Metabolic（内分泌）:Metabolicsyndrome（代谢症候群）,type2diabetesmellitus（2型糖尿病）,hypothyroidism（甲低）,.,Introduction,Table2:Challengesinthepatientswithmorbidobesity(病态肥胖)and/orOSA（阻塞性呼吸暂停综合征）undergoingambulatorysurgery（门诊手术）.Intra-operative（手术中）:Difficult/failedmaskventilation（面罩通气）and/ortrachealintubation（气管插管）Difficultyinventilationand/ormaintainingadequateoxygensaturation（维持足够氧饱和度）DiffcultyinpositioningExacerbationofcardiacco-morbidities（心血管并存病加重）:hypertension（高血压）,arrhythmias（心律失常）,myocardialischemia（心肌缺血）andinfarction（梗塞）,pulmonaryhypertension（肺动脉高压）,heartfailure（心衰）,.,Introduction,Immediatepostoperative（术后即刻）:Delayedextubation（拔管延迟）Obstructionand/ordesaturationafterextubation（拔管后梗阻）Post-obstructivepulmonaryedema（梗阻后肺水肿）Needfortrachealreintubation（再插管）Exacerbationofcardiaccomorbidities（心血管并存病加重）Cerebrovasculardisorders(e.g.,stroke)（脑血管疾病）Postoperativedelirium（术后谵妄）ProlongedPACUstay（恢复室逗留时间延长）Delayeddischargehome（住院时间延长）,.,Introduction,Post-discharge（出院后）:Readmissionafterdischarge（出院后再入院）Hypoxicbraindeathanddeath（缺氧性脑死亡和死亡）,.,SelectionofAdultPatientsMorbidlyObesityand/orOSAForAmbulatorySurgery(病态肥胖及阻塞性睡眠呼吸暂停病人的选择),ArecentsystematicreviewrevealedthatBMIalonemightnotinfluenceperioperativecomplicationsorunplannedadmissions（BMI指数并不单独影响围术期并发症).Therefore,BMIshouldnotbeconsideredthesolepatientselectioncriterionforambulatorysurgery(BMI不应作为独立的选择标准).Overall,thepatientselectionforambulatorysurgeryshoulddependupontheseverityofco-morbidities,thesurgicalprocedure,andtheanesthetictechnique（取决于并存病严重程度、手术过程、麻醉技术）.,.,SelectionofAdultPatientsMorbidlyObesityand/orOSAForAmbulatorySurgery,Overall,patientswithinadequatelytreatedco-morbidconditions（未经充分治疗的并存病状况）arenotsuitableforambulatorysurgery（不适合门诊手术）.Also,itisimperativethatallsurgicalpatientsareevaluatedforpresenceofOSA,preoperatively（术前对OSA评估）.Patientswithknowndiagnosisofmoderate-to-severeOSA（确诊中重度的OSA）andoptimizedcomorbidconditions（并存病处在最佳状况）canbeconsideredforambulatorysurgery,iftheyareabletousetheCPAPdeviceinthepostoperativeperiod（术后使用持续正压通气）.,.,SelectionofAdultPatientsMorbidlyObesityand/orOSAForAmbulatorySurgery,PatientswithpresumeddiagnosisofOSAandoptimizedcomorbidconditions（疑似OSA和最佳并存病状况）canbeconsideredforambulatorysurgery,ifpostoperativepaincanbemanagedpredominantlywithnon-opioidAnalgesicTechniques（由非阿片类术后镇痛）.Inaddition,theabilityofthefacilitytomanagethesepatientsshouldalsobetakenintoconsideration（同时考虑应用设备的能力）.,.,PreoperativeConsiderations,Morbidlyobesepatients(BMI40kg/m2)sufferfromnumerouschronicmedicalconditions(许多慢性医疗症状，Table1).BecauseOSAisundiagnosedinanestimated60-70%ofpatients（大约60-70%未确诊）,screeningforOSAshouldbepartofroutinepreoperativeevaluation（筛查OSA应作为常规术前评估）.TheSTOP-BANGscreeningtoolisauser-friendlyquestionnaire（STOP-BANG是一个病人易掌握的调查问卷）thatcouldbeincludedinroutinepreoperativeevaluationtoidentifyunrecognizedOSA(Table3).Tworecentstudieshavevalidated（证实）theSTOP-BANGquestionnaireandfoundthatahigherSTOP-BANGscoreidentifiedpatientswithhighprobabilityofmoderate/severeOSA（高分提示中重度OSA的可能）,术前注意事项,.,PreoperativeConsiderations,Table3:STOP-BANGScoringSystemS=Snoring（打鼾）.Doyousnoreloudly(louderthantalkingorloudenoughtobeheardthroughcloseddoors)?T=Tiredness（疲劳）.Doyouoftenfeeltired,fatigued,orsleepyduringdaytime（白天欲睡）?O=ObservedApnea（观察到的呼吸暂停）.Hasanyoneobservedyoustopbreathingduringyoursleep?P=Pressure（高血压）.Doyouorareyoubeingtreatedforhighbloodpressure?B=BMI35kg/m2A=Age50yearsN=Neckcircumference40cmG=MaleGenderHighriskofOSA:3ormorequestionsansweredyesModerate-to-severeOSA:6ormorequestionsansweredyes,.,PreoperativeTesting,TheAmericancollegeofCardiology(ACC)andAmericanHeartAssociation(AHA)recommendedthatECGbeobtainedinpatientswithatleastoneriskfactorforCHDand/orpoorexercisetolerance（有至少一个冠心病危险因素或运动耐量差的病人）.ECGsignsofrightventricularhypertrophyincludingright-axisdeviationandrightbundle-branchblockwouldsuggestpulmonaryHypertension（右心室肥大提示肺动脉高压）,whilealeftbundle-branchblockmaysuggestoccultCHD（左束支阻滞提示隐匿冠心病）.Inaddition,chestX-rayshouldbeobtainedonallmorbidlyobesepatientsasitmaysuggestundiagnosedheartfailure,cardiacchamberenlargement,orabnormalpulmonaryvascularitysuggestiveofpulmonaryhypertension（提示未诊断的心衰、心室增大或异常的肺血管分布）,whichwarrantsfurthercardiovascularInvestigation（作为其他心血管检查的依据）.,术前检查,.,PreoperativeTesting,Althoughobesitycaninfluencepulmonaryfunction，pulmonaryfunctiontests(e.g.,spirometry),areofnoaddedbenefitunlessCOPDissuspected（虽然肥胖可能影响肺功能，但肺功能检查并不是必须，除非怀疑有COPD）.IfOSAissuspectedduringpreoperativeevaluation,onecouldproceedwithapresumptivediagnosisofsevereOSAorobtainasleepstudy（如果怀疑有OSA，医生可以进一步做出重度OSA的诊断或者进行睡眠实验）.,.,PreoperativeMedications,Obesepatientsmaybeonmultiplemedicationsincludingprescriptionandnon-prescription(i.e.,over-thecounterorherbaldietdrugs)（非处方药或者中草药）thatmighthavedetrimentalcardiopulmonaryeffectsaswellasadverselyinteractwithanestheticdrugs（对心肺有害或影响麻醉药作用）.Patientsshouldbeaskedtocontinuetheirpreoperativemedicationsuntilthedayofsurgery（嘱咐病人用药直至手术当天）,Becausemorbidobesityisoneofthemajorriskfactorsforthedevelopmentofpulmonaryembolism（病态肥胖是肺栓塞发展的主要危险因素之一）,prophylaxisfordeepveinthrombosis（预防深静脉血栓）,lowdoseheparinin,术前用药,.,PreoperativeMedications,combinationwithintermittentpneumaticcompression,arerecommend（建议小剂量肝素，同时间歇气压疗法）Preoperativeprophylaxisagainstacidaspiration(e.g.,H2-receptorantagonistsandprotonpumpinhibitors)（返流误吸措施包括H2受体阻滞剂和质子泵抑制剂）iscommonlyused.However,theirroutineuseisquestioned,astheriskofregurgitationof、gastriccontentsforthemorbidlyobeseandthenon-obeseappearstobesimilar（是否常规使用值得商榷，因为病态肥胖病人返流的风险与常人无异）.,.,IntraoperativeConsiderations,Althoughthesurgicalprocedureandtheneedforpostoperativeopioids,ratherthanthechoiceofanesthetictechniqueappeartobemoreimportantdeterminantsofperioperativecomplicationsinthemorbidlyobeseparticularlythosewithOSA（病态肥胖，特别是合并OSA的病人中，相对麻醉选择的技术，手术过程和术后阿片类的需要似乎更应该是围术期并发症的决定因素）,localorregionalanesthesiashouldbepreferred（即使如此，也应该选择局部区域阻滞麻醉应）.Local/regionalanesthesiaobviatestheneedforairwaymanipulationaswellasavoidshypnotic-sedatives,opioids,andmusclerelaxants（局部区域阻滞避免了气道管理、镇静催眠和阿片类、肌松药的使用）.Inaddition,thesetechniquesprovidepostoperativeanalgesiaandreducepostoperativeopioidrequirements（同时也提供了术后镇痛、减少阿片类的使用量）.,术中注意事项,.,SedationandAnalgesiaintheObeseandOSAPatients,PatientswithOSAaremoresensitivetosedative-hypnoticsandopioids（病人对镇静催眠和阿片类更敏感）,whichcausedose-dependentupperairwaycollapse,respirationdepression,andreducedrespiratoryresponsestohypoxiaandhypercapnia（导致剂量依量性呼吸道塌陷，呼吸抑制、减少呼吸系统对缺氧和二氧化碳潴留的反应）.Ofnote,duringsedationOSAmaydevelopinpreviouslyunrecognizedpatients（镇静状态下，之前未发现的病人可能出现新发展的OSA）.Therefore,monitoringshouldincludecontinuouscapnographyasitallowsdetectionofupperairwayobstructionmuchpriortooxygendesaturation（必须持续监测二氧化碳因为相对氧饱和度，它能更早提示上呼吸道梗阻）.,.,SedationandAnalgesiaintheObeseandOSAPatients,Midazolamandpropofolhaveasimilarpropensityforupperairwayobstructionatsimilarlevelsofsedation（咪达唑仑和丙泊酚有类似的引起上呼吸道梗阻的倾向）.Dexmedetomidine,ahighlyselectivealpha-2adrenergicagonistwithsedative,amnestic,analgesic,andsympatholyticpropertieswithnorespiratorydepression（右美托咪定，同时具有镇静、遗忘、镇痛和抗交感，但无呼吸抑制）,canbeusedtoprovidesedation/analgesia.Inaddition,itreducessalivarysecretionsthroughsympatholyticandvagomimeticeffects（除此之外，通过抗交感和类迷走作用能减少腺体分泌）.,.,TheAdultPatientWithMorbidObesityand/orObstructiveSleepApneaForAmbulatorySurgery,GirishP.Joshi,MBBS,MD,FFARCSI协和规培：石磊,病态肥胖及阻塞性睡眠呼吸暂停病人的门诊手术麻醉（二）,.,GeneralAnesthesia,Theoptimalgeneralanesthetictechniquewouldallowrapidandclear-headedrecoveryincludingearlyreturnofthepatientsprotectiveairwayreflexes（最佳的全麻技术可以让病人快速恢复清醒，包括呼吸道的保护反射）,whichwouldallowmaintenanceofapatentairway（维持通畅呼吸道）.Inaddition,earlyrecoveryshouldreducepostoperativecardiaccomplicationsduetoresidualanestheticeffects（及早恢复清醒可减少残余麻醉效果导致的术后心血管并发症）.,.,AirwayManagement,BecauseBMIaloneisnotapredictorofdifficultintubation（由于BMI并不能单独作为困难插管的指标）,awaketrachealintubationmaynotalwaysbenecessary（清醒插管不总是必须的）.Nevertheless,OSAhasbeenreportedtobeapredictorofdifficultairway（OSA是作为困难气道的指标之一）PredictorsofdifficulttrachealintubationincludehighMallampatiscore(IIIorIV),neckcircumference（颈围）40cm,limitedmandibularprotrusion（短下颌）,andsevereOSA(AHI40).,.,AirwayManagement,Theavailabilityofvideolaryngoscopeshasincreasedthesuccessoftrachealintubation（可视喉镜可以提高插管的成功率）.Arecentstudyinmorbidlyobesereportedthattheawakevideolaryngoscopyaftertopicalanesthesiacanbeconsideredasanalternatetoawakefiberoptictrachealintubation（局部麻醉下后清醒可视喉镜插管可以作为清醒纤支镜插管的替代品之一）,.,InductionofGeneralAnesthesia,Recentstudies,inmorbidlyobesepatients,haveshownthatthebarrierpressure(loweresophagealpressuregastricpressure)remainspositivethroughoutinductionofanesthesia屏障压力（食道下段压力-胃内压）在麻醉诱导的过程中仍然维持作用）.Thissuggeststhattheriskofgastricregurgitationinthemorbidlyobeseissimilartothatinthenon-obesepatients（提示病态肥胖病人的返流风险并没有比其他病人更高）.Mostanesthesiadrugsincludingintravenousanestheticdrugsandopioidsshouldbedosedaccordingtoleanbodyweight(notactualbodyweight)（包括静脉麻醉药和阿片类在内的大多数麻醉药应该依据去脂体重计算）,exceptforneuromuscularblockingdrugs,whichshouldbedosedaccordingidealbodyweight（除了依据理想体重计算的肌松药）.,全麻诱导,.,MaintenanceofGeneralAnesthesia,Severalstudieshavereportedthatinthemorbidlyobese,Comparedwithsevoflurane,desfluraneallowsearlierabilitytoswallowwaterwithoutcoughingordrooling（和七氟醚相比，地氟醚允许病人出现更早的吞咽动作）,suggestinganearlierreturnofprotectiveairwayreflexes（提示病人更早恢复气道保护反射）.Arecentstudyusedanesthesiainformationmanagementsystemaswellasmetaanalysisof29randomizedcontrolledtrialscomparingdesfluraneandsevofluranetodeterminethetimefromendofsurgerytotrachealextubation（对比了手术结束到拔管的时间）.Theyfoundthatcomparedwithsevoflurane,desfluranereducedthemeanextubationtimeby25%（地氟醚的平均拔管时间少了25%）,全麻维持,.,MechanicalVentilation,Obesityisassociatedwithchangesinpulmonaryfunction（肥胖常影响肺功能）(e.g.,reductioninlungvolumes,increaseinpeakinspiratorypressures,anddecreaseinpulmonarycompliance，肺容量降低、吸气压峰值增高、肺顺应性降低).Lungprotectiveventilationstrategiesintheobesewouldincludetheuseofpressure-controlledventilationwithlowtidalvolumes(8-10ml/kgIBW)（较低潮气量的压控通气）andPEEPof5-10cmH2O34.,.,MechanicalVentilation,Itisimportanttoavoidhyperventilationandhypocapnia（避免通气过度和低碳酸血症）,asthismayresultinmetabolicalkalosis（代谢性碱中毒）andleadtopostoperativehypoventilation（术后通气不足）.Mildhypercapnia（轻微的高碳酸血症）(i.e.,ETCO2of40mmHg)canimprovetissueoxygenationthroughimprovedtissueperfusionresultingfromincreasedcardiacoutputandvasodilatationaswellasincreasedoxygenoff-loadingfromtheshiftoftheoxyhemoglobindissociationcurvetotheright（可以提高心排出量和舒张血管，同时使氧合血红蛋白曲线右移，来提高组织氧供）.,.,NauseaandVomitingProphylaxis,PatientsundergoingambulatorysurgeryareatahigherriskofPONVandshouldreceiveprophylacticmultimodalantiemetictherapy（预防性多方式止吐治疗）(e.g.,combinationsof5-HT3-receptorantagonists,droperidol,anddexamethasone，5-HT3受体抑制剂、氟哌利多、地塞米松).Althoughitisrecommendedthatthenumberofantiemeticsbebasedonthepatientslevelofriskasdeterminedbyriskfactorassessment,doubleortripleantiemeticprophylaxisisoptimalforthispatientpopulation（虽然建议止吐药的种类由病人的风险因素水平决定，但二联或三联止吐预防通常最佳）.,预防恶心呕吐,.,IntraoperativeFluidManagement,Adequatepreoperativehydration(i.e.,encouragepatientstoconsumewateruntil2hpreoperatively，术前足够补液，鼓励患者术前喝水直到术前2小时)andhigherintraoperativefluidadministration(20-40ml/kg)havebeenreportedtoreduceposturalhypotension,postoperativedizziness,drowsiness,nausea,andfatigue（较好的术中液体管理可以减少体位性低血压、术后眩晕、呕吐和疲劳）.Inaddition,becausethemorbidlyobeseareatahighriskofRhabdomyolysis（肥胖病人是横纹肌溶解高危病人）,administrationofhigherfluidvolumesmayreducethepotentialformyoglobinuricacuterenalfailureassociatedwithrhabdomyolysis（高液体容量可以减轻潜在的肌红蛋白引起的急性肾衰）.,术中液体管理,.,EmergenceFromAnesthesia,Oneofthemajorconcernsinobesepatients,particularlythosewithOSA,istheriskofairwayobstructionaftertrachealextubation（肥胖病人、特别是合并OSA，最大的担忧是拔管后气道梗阻）.Thus,priortotrachealextubationthepatientmustbefullyawake,alert,andfollowverbalcommands(i.e.,deepextubationisnotadvisable)（拔管前，病人应该完全清醒、警觉、能受口头指挥，另外不建议深麻醉下拔管）.Importantly,coughingandreflexmovementsofthehandtowardsthetrachealtubeshouldnotbeconfusedaspurposefulmovements（很重要的，呛咳和手指向导管的运动，不能当做是患者有意识的运动）.,.,EmergenceFromAnesthesia,Extubationshouldbeperformedinasemi-upright(25-30head-up)position,whenpossible（可能的话，拔管应该在半卧位下）.Also,useofanasalairway,placedbeforetrachealextubation,mayavoidpostextubationairwayobstruction（拔管前使用鼻咽通气道，可以预防拔管后气道梗阻）.Arecentstudysuggeststhatanasalairwayismoreeffectivethanacombinationoforalandnasalairway（鼻咽通气道比同时使用鼻咽和口咽通气道有效）.ArecentstudyreportedthatCPAPinstitutedimmediatelyaftertrachealextubationissuperiorinmaintaininglungfunctionat24hafterlaparoscopicbariatricsurgerythanCPAPinitiatedlaterintherecoveryroom（一个研究显示腹腔镜治疗肥胖症的病人中，拔管后立即使用CPAP在维持肺功能方面，优于晚到恢复室再使用CPAP）.,.,PostoperativeConsiderations,Potentialpostoperativecomplicationsincludeairwayobstruction,respiratoryfailure,needforreintubation,lifethreateninghypoxiaaswellassystemichypertension,ischemia,andcardiacarrhythmia（潜在的术后并发症包括气道梗阻、呼吸衰竭、再插管的需求、低氧血症、高血压、组织缺血即心律失常）.OnceinthePACU,patientsshouldbemaintainedinasemi-upright(25-30head-up)position,ifpossible（如果可能，病人进入恢复室应立即给予半头高位）.,术后注意事项,.,PostoperativeCPAP/BiPAP,Althoughsupplementaloxygenisbeneficialformostpatients,itshouldbeadministeredwithcautionasitmayreducehypoxicrespiratorydriveandincreasetheincidenceanddurationofapneicepisodes（虽然补充氧气对大部分病人有益，但也可能降低呼吸系统的低氧驱动功能和对呼吸暂停的耐受）.BecauseobesepatientsmighthaveunrecognizedOSA,recurrenthypoxemiamaybebettertreatedwithCPAPorbi-levelpositiveairwaypressure(BiPAP)alongwithoxygenratherthanoxygenalone（如果反复出现低氧血症，病人最好使用CPAP或BiPAP，而不是单独吸氧）.,.,Post-PACUDischargeCare,PriortodischargefromthePACUtheoxygensaturationonroomairshouldreturntobaseline（出恢复室前氧饱和度回到基本水平）andthePatientshouldnotbecomehypoxicordevelopairwayobstructionwhenleftundisturbedintherecoveryarea（未打扰情况下不应该有低氧血症或气道梗阻）.IthasbeensuggestedthatmostsignificantpostoperativecomplicationsinOSApatientsusuallyoccurwithin2hoursafterSurgery（大多数的OSA病人并发症发生在术后2小时内）.Therefore,itmaybeworthwhiletoobservethesepatientsintherecoveryroomforatleast2h（因此建议这类病人在恢复室至少停留2小时）.,.,Post-PACUDischargeCare,TheASA-OSAPracticeGuidelinessuggestthatO