讲稿外科学全麻

1、Clinical AnaesthesiologyQiu Wei Fan（范秋维）Associate ProfessorDepartment of AnaesthesiologyRui Jin HospitalSchool of MedicineShanghai Jiao Tong University General AnaesthesiaContentsMethods of General AnaesthesiaClinical PharmacologyThe Practical Conduct of AnaesthesiaComplications of IntubationMonitor

2、ing During Anaesthesia Methods of General AnaesthesiaInhalation anaesthesiaIntravenous anaesthesiaIntramuscularlyRectallyOrallyBalanced anaesthesiaClinical PharmacologyInhalational Anaesthetic AgentsAgent MAC% Vapor Pressure Blood/Gas PartitionNitrous oxide 105 - 0.47Halothane 0.74 243 2.4Enflurane

3、1.68 175 1.9Isoflurane 1.15 240 1.4Desflurane 6.0 681 0.42Clinical PharmacologyIntravenous Anaesthetic AgentsAgent Induction dose (mgkg-1)Thiopentone 3-5Etomidate 0.3Propofol 1.5-2.5Ketamine 2Clinical PharmacologyDrugs Used to Supplement AnaesthesiaAnalgesicsOpioid AgonistsNatural opium alkaloids: M

4、orphine,CodeineSemisynthetic opium alkaloid: DiamorphineSynthetic opioids: Pethidine, Fentanyl, Alfentanil, Sufentanil, RemifentanilPartial Opioid AgonistsBuprenorphineClinical PharmacologyDrugs Used to Supplement AnaesthesiaOpioid Agonist/AntagonistsPentazocineOpioid AntagonistsNaloxoneClinical Pha

5、rmacologyMuscle RelaxantsNeuromuscular Blocking Agents are divided into two classes:DepolarizingNondepolarizingClinical PharmacologyMuscle RelaxantsDepolarizing Short-acting Succinylcholine DecamethoniumNondepolarizingLong-acting Tubocurarine Metocurine doxacurium Pancuronium PipecuriumIntermediate-

6、acting Atracurium VecuroniumShort-acting MivacuriumClinical PharmacologyDrugs Affecting the Autonomic Nervous System Sympathomimetic DrugsAdrenaline(low-,1+2)(higher- )Isoprenaline(1+2)Noradrenaline(,1 )Phenylephine()Dopamine (low-,moderate- ,1+2, moderate high-,1 )Dobutamine(1 )The Practical Conduc

7、t of AnaesthesiaPreparation for anaesthesiaEquipment for monitoringThe anaesthetic machineEquipment required for tracheal intubationAnaesthetic ApparatusThe Anaesthesia MachineGas inlets & pressure regulatorsOxygen pressure failure devices & oxygen flush valves Flow control valvesFlowmeters & spirom

8、etersVaporizersVantilators & disconnect alarmsWaste gas scavengersHumidifiers & nebulizersOxygen analyzersAirway Management EquipmentOral & Nasal airwayMaskEndotracheal tubelaryngeal mask airway (LMA)Seeing optical stylet Light wandsRigid laryngoscopesFlexible fiberoptic laryngoscopesEquipment Requi

9、red for Tracheal IntubationCorrect size of laryngoscope and spareTracheal tube of correct size + an alternative smaller sizeTracheal tube connectorWire stilletteGum elastic bougiesMagill forcepsCuff-inflating syringeArtery forcepsSecuring tape or bandageCatheter mountLocal anaesthetic sprayCocaine s

10、pray/gel for nasal intubationTracheal tube lubricantThroat packsAnaesthetic breathing system and face masks-tested with oxygen to ensure no leaks presentInduction of AnaesthesiaInhalational inductionIntravenous inductionInhalational Induction AgentsSevoflurane DesfluraneInduction of AnaesthesiaIndic

11、ations for Inhalational Induction Young childrenUpper airway obstructionLow airway obstruction with foreign bodyBronchopleural fistula or empyemaNo accessible veinsInduction of AnaesthesiaDifficulties and ComplicationsSlow induction of anaesthesiaProblems particularly during stage 2Airway obstructio

12、n, bronchospasmLaryngeal spasmHiccupsEnvironmental pollutionIntravenous InductionDoses of the Intravenous AgentsAgent Induction dose (mgkg-1)Thiopentone 3-5Methohexitone 1-1.5Etomidate 0.3Propofol 1.5-2.5Ketamine 2Intravenous Induction Complications and DifficultiesRegurgitation and vomitingIntra-ar

13、terial injection of thiopentonePerivenous injectionCardiovascular depressionRespiratory depression Histamine releasePorphyriaOther complicationsMaintenance of anaesthesiaInhalation anaesthesia with spontaneous ventilationConductMinimum alveolar concentration (MAC): MAC is the minimum alveolar concen

14、tration (at one atmosphere) of an inhaled anaesthetic agent, which prevents reflex movement in response to surgical incision in 50 % of subjectsClinical PharmacologyInhalational Anaesthetic AgentsAgent MAC% Vapor Pressure Blood/Gas PartitionNitrous oxide 105 - 0.47Halothane 0.74 243 2.4Enflurane 1.6

15、8 175 1.9Isoflurane 1.15 240 1.4Desflurane 6.0 681 0.42Signs of anaesthesiaStage 1(Stage of analgesia): From start of induction of anaesthesia to loss of consciousness.Stage 2 (Stage of excitement): From loss of consciousness to beginning of regular respiration.Stage 3 (Surgical anaesthesia): From t

16、he beginning of regular respiration to respiratory arrest.Signs of anaesthesiaThe stage 3 is divided into four planes.Plane 1: From the onset of regular breathing to the cessation of eyeball movements.Plane 2: From the cessation of eyeball movements to the beginning of intercostal paralysis.Plane 3:

17、 From the beginning of intercostal paralysis to the completion of intercostal paralysis.Plane 4: From completion of intercostal paralysis to diaphragmatic paralysis. Signs of anaesthesiaStage 4: Stage of impending respiratory and circulatory failure (Medullary paralysis), from the onset of diaphragm

18、atic paralysis to cardiac arrest.Inhalation Anaesthesia with Spontaneous Ventilation Complications and DifficultiesAirway obstructionLaryngeal spasmBronchospasmMalignant hyperthermiaRaised intracranial pressure (ICP)Atmospheric pollutionDelivery of Inhalational Agents Airway MaintenanceUse of the fa

19、cemaskUse of the laryngeal mask airway (LMA)Use of the oropharyngeal airwayUse of the nasopharyngeal airwayTracheal intubationUse of the Laryngeal Mask Airway (LMA) IndicationsProvide a clear airway without the need for the anaesthetists hands to support a maskAvoid the use of tracheal intubation du

20、ring spontaneous ventilationIn a case of difficult intubation to facilitate subsequent insertion of a tracheal tube either via the LMA or after use of a gum elastic bougieUse of the Laryngeal Mask Airway (LMA) ContraindicationsA patient with a “full stomach” or with any condition leading to delayed

21、gastric emptyingA patient in whom regurgitation of gastric contents into the esophagus is possibleWhere surgical access is impeded by the cuff of the LMATracheal IntubationIndicationsProvision of a clear airwayAn unusual positionOperations on the head and neckProtection of the respiratory tractDurin

22、g anaesthesia using IPPV and muscle relaxants To facilitate suction of the respiratory tractDuring thoracic operationsAnaesthesia for Tracheal IntubationInhalational technique for intubationRelaxant anaesthesia for intubationAnaesthesia for Tracheal IntubationOral-tracheal intubationNaso-tracheal in

23、tubationFlexible fiberoptic nasotracheal intubationBlind intubation of the tracheal under light wandsTracheal intubation under seeing optical styletComplications of Intubation While the Tube is in PlaceMalpositionUnintentional extubationEndobrochial intubationLaryngeal cuff positionAirway traumaMuco

24、sal inflammation and ulcerationExcoriation of noseTube malfunctionIgnitionObstructionComplications of Intubation Following ExtubationAirway traumaEdema and stenosis (glottic, subglottic, tracheal )Hoarseness (vocal cord granuloma or paralysis )Laryngeal malfunction and aspirationPhysiologic reflexes

25、LaryngospasmRelaxant AnaesthesiaIndications for Relaxant AnaesthesiaMajor abdominal, intraperitoneal, thoracic, intracranial operationsProlonged operations in which spontaneous ventilation would lead to respiratory depression Operations in a position in which ventilation is impaired mechanicallyClin

26、ical PharmacologyMuscle RelaxantsDepolarizingShort-acting Succinylcholine DecamethoniumNondepolarizingLong-acting Tubocurarine Metocurine doxacurium Pancuronium PipecuriumIntermediate-acting Atracurium VecuroniumShort-acting MivacuriumReversal of Relaxation Residual neuromuscular block is antagonize

27、d with neostigmine 2.5-5mg (0.05-0.08mgkg-1 in children). Atropine 1.2mg or glycopyrronium 0.5mg counteracts the muscarinic side effects of the anticholinesterase and may be given before, or with, neostigmine.Conduct of ExtubationCoughingResistance to the presence of the tracheal tube Complications

28、of Tracheal ExtubationLaryngeal spasmRegurgitation Emergence and RecoveryTesting hand gripTongue protrusion Lifting the head from the pillow in response to commandMonitoring During AnaesthesiaCardiac MonitorsArterial blood pressure Noninvasive arterial blood pressure Invasive arterial blood pressure

29、 monitoringElectrocardiographyCentral venous catheterizationPulmonary artery catheterizationCardiac outputNoninvasive Arterial Blood Pressure Monitoring TechniquePalpationDoppler probeAuscultationOscillometryPlethysmographyArterial Tonometry Selection of Artery for CannulationRadial arteryBrachial a

30、rteryUlnar arteryfemoral arteryDorsalis pedis arteryPosterior tibial arteryAxillary artery Invasive Arterial Blood Pressure Monitoring ComplicationsHaematomaVasospasmArterial thrombosisEmbolization of air bubbles or thrombiSkin necrosis overlying the catheterNerve damageInfectionUnintentional intra-

31、arterial drug injectionThe catheter-tubing-transducer systemMonitoring During AnaesthesiaRespiratory System MonitoringPrecordial & easophageal stethoscopeBreathing circuit pressure & exhaled tidal volumePulse oximetryEnd-tidal carbon dioxide analysisTranscutaneous oxygen & carbon dioxide monitorsAnaesthetic gas analysisMonitoring During AnaesthesiaNeurologic System MonitorsElectroencephalographyEvoked potentialBISNarcotrend Monitoring During AnaesthesiaMiscellaneous MonitorsTemperatureUrine outputPeripheral nerve stimulati