胸腹主动脉瘤手术麻醉处理课件

1、胸腹主动脉瘤手术麻醉处理胸腹主动脉瘤手术麻醉处理胸腹主动脉瘤手术麻醉处理一、腹主动脉瘤病因及发病机制1.吸烟 烟草燃烧产生的气态物质进入血液，可将蛋氨酸氧化成蛋氨酸亚砜，蛋白水解酶活性增加，加重了动脉壁弹力蛋白的降解，引起动脉壁力量减弱而导致动脉瘤的形成。2020/11/142胸腹主动脉瘤手术麻醉处理胸腹主动脉瘤手术麻醉处理胸腹主动脉瘤一、腹主动脉瘤病因及发病机制1.吸烟 烟草燃烧产生的气态物质进入血液，可将蛋氨酸氧化成蛋氨酸亚砜，蛋白水解酶活性增加，加重了动脉壁弹力蛋白的降解，引起动脉壁力量减弱而导致动脉瘤的形成。2020/11/142一、腹主动脉瘤病因及发病机制2020/11/1422.高

2、血压 与发病率和破裂的危险性有密切的关系3.年龄因素 动脉壁的弹力蛋白纤维随年龄的增长出现降解、断裂和钙化，使动脉壁难以承受血压的冲击而发生动脉瘤。2020/11/1432.高血压3.年龄因素2020/11/1434.炎症反应 慢性炎症反应中的巨噬细胞和活化的T、B淋巴细胞可刺激金属蛋白酶的产生，促进结缔组织的降解，削弱和破坏主动脉壁中层，导致产生动脉瘤。2020/11/1444.炎症反应2020/11/144 另有研究认为,雌激素水平是动脉瘤的产生的原因之一: 在腹主动脉瘤形成的过程中雌激素可能通过降低组织基质金属蛋白酶2、9( MMP-2、9)的 mRNA 表达、蛋白合成,从而延缓动脉瘤的

3、形成.-国外医学-2020/11/145 另有研究认为,雌激素水平是动脉瘤的产生的原因之一2020/11/1462020/11/146二、腹主动脉瘤的病理改变1.真性动脉瘤：动脉粥样硬化是常见原因。动脉粥样硬化的危险因素：高胆固醇血症、糖尿病、肥胖、高血压、吸烟史，男性，等等。2.假性动脉瘤：多见与动脉损伤。3.夹层动脉瘤：动脉壁中层囊性坏死或退行 性变。2020/11/147二、腹主动脉瘤的病理改变2020/11/147三、诊断 腹部搏动性包块 神经压迫症状 下肢缺血症状血管造影、CT、MRI、高速螺旋CT等影像学检查2020/11/148三、诊断2020/11/148四、胸腹主动脉瘤的手术

4、方式及概况手术方式：1.Open repair2.Medal graft stent3.Baloon-expandable4.Hand-help laparoscope repair 2020/11/149四、胸腹主动脉瘤的手术方式及概况2020/11/149 Elective surgery by open transperitoneal or retroperitoneal approach is the most common repair intervention. However, placing an endoluminal stent graft within the aneur

5、ysm is currently being evaluated as an alternative to open repair. J-Cardiovasc-Nurs. 2001 Jul; 15(4): 1-142020/11/1410 Elective surgery by open t Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA)

6、 repair. Vasc-Surg. 2001 Sep-Oct; 35(5): 335-442020/11/1411 Newer, minimally invasive平均年龄 68.5 +/-7.7 years. 高血压病史 55%, 心脏病 73.5%, 外周血管疾病 21%, 中风和短时间缺血22%, 糖尿病 7%, 肾功能不全 10%, 吸烟史 80%. Vasc-Surg. 2001 Sep-Oct; 35(5): 335-442020/11/1412平均年龄 68.5 +/-7.7 years. Vasc-Complications:Complication rates vari

7、ed widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest , septicemia , acute myocardial infarction, acute renal failure , surgical complications after a procedure , and reoperation for bleeding . The population-attributable ri

8、sk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. Langenbecks-Arch-Surg. 2001 Jul; 386(4): 249-562020/11/1413Complications:Langenbecks-Arch五、麻醉方法及术中处理全身麻醉、硬膜外麻醉以及联合麻醉等各种麻醉技术与麻醉药物都已成功应用于开腹AAA修补术。其中的联合麻醉方式通常是指联合应用高腰段或下胸段硬膜外麻醉与浅全麻的复合麻醉方式。2020/11/1414五、麻醉方法及术中处理全身麻

9、醉、硬膜外麻醉以及联合麻醉等各种2020/11/14152020/11/14152020/11/14162020/11/14162020/11/14172020/11/14172020/11/14182020/11/1418对于术前服用抗凝药物的病例处理1、药物术前停用：阿司匹林37天，波立维（氯吡格雷）57天，华法林45天。2、评估出血风险：目标，术前INR1.5。3、Bridging的注意事项：Bridging需在华法林最后一次使用的48h开始；治疗剂量的低分子肝素（LMWH）应在术前24h停用；栓塞的高风险患者应在术后48h内启用治疗剂量的LMWH。2020/11/1419对于术前服用抗

10、凝药物的病例处理1、药物术前停用：阿司匹林3Procedures performed before anesthesia:Collection and storage of patient，s own blood in the weeks preceding surgery.Prescribe premedication.A warming blanket is necessary in the anesthetic room. Mornitoring.2020/11/1420Procedures performed before anProcedures performed before s

11、urgery starts:1.A suitable vein or veins are cannulated with at least one 14-gauge cannula for infusion of warmed fluids.2.Cannulation of a radial artery.3.Central venous catheterization for measure- ment of right atrial pressure.4.An oesophageal or tympanic membrane temperature probe is inserted fo

12、r measure- ment of temperature.5.The bladder is catheterized for monitoring of urine output.2020/11/1421Procedures performed before suKey points during anesthesia and operation procedure.1.Tracheal intubation To maintain systemic arterial pressure stable.(Dopamine or Noradrenalin) The double lumen t

13、ubes are necessary for somethoracic approach operations 2020/11/1422Key points during anesthesia a2020/11/14232020/11/14232020/11/14242020/11/14242.Crossclamping of the aortaa sudden increase in systemic vascular resistance (afterload): cardiac work increase myocardial ischaemia the large bowel and

14、lower limbs suffer variable degrees of hypoxia: inflammatory mediators released oxygen radicals neutrophil proteases platelets activating factor cyclo-oxygenase products cytokines2020/11/14252.Crossclamping of the aorta203.Aoric declamping a sudden decrease in afterload with reperfusionof the bowel,

15、 pelvis and lower limbs. vasodilatation metabolic acidosis capillary permeability increased blood cells sequestrated in the lungs 2020/11/14263.Aoric declamping2020/11/14264.The large heat loss Many patients undergoing this operation are elderly and have a low metabolic rate. All possible measures m

16、ust be taken to minimizeheat loss.(1)Warming of infusion fluids(2)Warming and humidification of anesthetic gases(3)Use a warming blanket (4)Wrapping the bowel in a clear plastic bag(5)The operating theatre 2020/11/14274.The large heat loss2020/11/1Organ protectionVascular diseases are associated wit

17、h these disorders:Diabetes(糖尿病)Smoking sequelae(吸烟后发症)COPD(慢性阻塞性肺病)Hypertension(高血压)Renal insufficiency(肾功能不全)Ischaemic heart disease(缺血性心脏病)2020/11/1428Organ protection2020/11/1428术中器官保护心肌及心脏功能保护Decrease myocardial oxygen demand Decrease heart rate Decrease myocardial contractility Decrease LV end-

18、diastolic volume Decrease afterloadIncrease myocardial oxygen supply and coronary blood flow Decrease vasoconstriction Decrease thrombosis Increase diastolic time Increase diastolic pressureDecrease LV end-diastolic pressure Increase oxygen saturation. Drugs. Mannitol has a positive effect in counte

19、ring thesedeleterious pulmonary effects.2020/11/1429术中器官保护心肌及心脏功能保护Decrease myocar神经保护缩短主动脉钳夹时间局部脊髓低温（32-34oC）维持最大限度的高血压状态和术后灌注压细胞膜稳定药物、抗缺血-再灌注损伤和减轻全身 炎症反应脊髓缺血监测：血糖监测，唤醒，皮层诱发电位2020/11/14302020/11/1430脊髓保护据报道,OAR术后截瘫及轻瘫发生率为5% 40%。手术时主动脉阻断时间长短是影响术后截瘫发生的一个重要因素,主动脉阻断时间60 min时发生率为25% 100%。- Eur JCardioth

20、orac Surg, 2001, 19(2): 203-213.2020/11/1431脊髓保护据报道,OAR术后截瘫及轻瘫发生率为5% 40%。脊髓保护非体外循环下动脉瘤手术是否发生截瘫或肾功能衰竭，最重要的单一决定因素就是主动脉阻断时间。2030min内几乎不发生截瘫。3060min为易损期，截瘫的发生率随着阻断时间的延长由10%上升至90%。-Miller, s Anesthesia edition2020/11/1432脊髓保护非体外循环下动脉瘤手术是否发生截瘫或肾功能衰竭，最重脊髓保护脊髓损伤的防治包括:缩短脊髓缺血时间: 研究证明主动脉阻断的最安全时限为30 min;脑脊液引流:降

21、低脑脊液压力,提高脊髓灌注压;术中低温技术：低温可减少神经组织的需氧量,降低组织代谢率,稳定细胞膜,增加组织对缺血耐受性,减少兴奋性递质释放,从而达到间接保护脊髓目的应用保护性药物:包括超氧化物歧化酶、糖皮质激素、类固醇、镁离子等。2020/11/1433脊髓保护脊髓损伤的防治包括:2020/11/1433肾脏功能保护缩短阻断时间保持足够的有效的循环血容量避免过量的血管扩张药物并保持最大限度的 高血压状态多巴胺的连续输注2020/11/1434肾脏功能保护2020/11/1434肾功能保护有许多不同的肾脏保护方法被采纳,多数集中于改善肾脏或肾小管血流。其中包括:多巴胺(多巴胺受体剂量23gkg

22、-1min-1)。另外，ACE阻滞剂、前列腺素、卤化药物、胸部硬膜外以阻滞肾动脉交感神经、血管扩张药,等容量血液稀释(在血管阻力升高的情况下增加血流)、速尿和甘露醇等。 SrpArhCelokLek, 2002,130(5-6): 168-172. 2020/11/1435肾功能保护有许多不同的肾脏保护方法被采纳,多数集中于改善肾脏麻醉处理诱导：Midazolam , Propofol Fentanyl Vecuronium, Tracurium 各种有创监测操作 胃管，尿管的停留麻醉的维持:复合麻醉术中的药物使用：心功能的支持与加强（多巴胺、西地兰、 磷酸肌酸） 抗炎症反应与再灌注损伤（乌司

23、他丁、甲基强的松龙、 甘露醇），肾功能保护（速尿）,纠正酸中毒。4. 复苏与镇痛2020/11/1436麻醉处理2020/11/1436术中监测AAA术中应常规监测ECG、MAP、CVP、SpO2、HR、体温(鼻温、肛温)、血气、电解质及尿量。通过标准心电图(ECG)、经食管超声心动图(TEE)和肺动脉导管(PAC)监测心肌缺血,降低心脏发病率。TEE可评估左心室壁异常运动,并在心肌缺血存在、心电图ST段改变之前探察到收缩期心室壁异常增厚。J CardiothoracVascAnesthesia, 2003, 17(6): 703-708.2020/11/1437术中监测AAA术中应常规监测ECG、MAP、CVP、SpO2术中监测临床研究存在许多矛盾结果,随机化控制试验显示,AAA修补术患者实施PAC监测没有任何临床价值,而PAC监测是否应该选择性地应用于高危的复杂主动脉重建术患者尚有待评估。N Engl JMed, 2003, 348(1): 5-