临床麻醉处理1504、anes

ChengDeHealthSchoolSurgicalOfficeLiShudongAnesthesiaConcept

Anesthesiaisanartificallyinducedstateofpartialortotallossofsensation,occurringwithorwithoutlossofconsciousness.Thepurposeofanesthesiaistoblockthetransmissionofnerveimpulses,suppressreflexes,promotemuscularrelaxation,and,insomecases,achieveacontrolledlevelofunconsciousnessTypesofAnesthesiaGeneralanesthesiainhalationanesthesiaintravenousanesthesiabalancedanesthesia

basalanesthesiaLocalorRegionalanesthesiatopicalanesthesialocalinfiltrationanesthesiafieldblockanesthesianerveblockanesthesiaIntraspinalanesthesiasubarachnoidanesthesia(spinalanesthesia)epiduralanesthesiaGeneralanesthesia-1

面罩法气管插管法Generalanesthesia-2apatientisintubatedandconnectedtoananesthesiabreathingmachine.Potentinhaledanestheticsandnitrousoxidepassfromtheanesthesiamachineinthebackgroundintothepatientbywayofthebreathingcircuitandendotrachealtube.IntravenousaneshtesiaIntravenouscatheterTopicalanesthesialocalinfiltrationanesthesia-1localinfiltrationanesthesia-2NerveblockanesthesiaBrachialPlexusblockanesthesiaintraspinalanesthesia-1Intraspinalanesthesia-2IntraspinalanesthesiapositionSubarachnoidanesthesia-1Subarachnoidanesthesia-2Subarachnoidanesthesia-3

Ananesthetistinjectslocalanestheticintotheskinofthebackpriortoplacementofaspinalneedle.Subarachnoidanesthesia-4Epiduralanesthesia-1EpiduralanesthesianeedlesEpiduralanesthesia-2

Insertionoftheepiduralcatheterthroughaneedleintothebackofanadult.Next,theneedleisremoved,leavingthecatheterbehind.Epiduralcatheter-1EpiduralcatheterPreanestheticpreparation

ThechoiceofanesthesiaAssessmentpatientEmotionalsupportDietaryrestrictionPreanestheticmedicationPreanestheticmedicaitonHypnotic:phenobarbitalsodiumAnalgesic:pethidine，morphineAnticholinergic:atropine,scopolamineSedative:diazepam★beforesurgery:30min,im★Purpose:reduceanxiety,promoterelaxation,reducepharyngealsecretions,preventlaryngospasm,inhibitgastricsecretions,anddecreasetheamountofanestheticrequiredfortheinductionandmaintenanceofanesthesia.Dietaryrestrications◆12h→fasting◆4-6h→NPO(禁水）(NPO:meansnoeatingoffood,drinking(includingwater),orsmoking.ItiscommonpracticetobeginNPOstatusforallpreoperativeclientsatmidnightonthenightbeforesurgery.★purpose:preventfromaspirationGeneralanesthesiacareAnestheticagents(1)inhalationanestheticagents:isoflurane(异氟醚),enflurane(恩氟烷),halothane(氟烷),nitrousoxide(氧化亚氮,笑气)。（2）intravenousanestheticagents:thiopentalsodium(硫喷妥钠),ketamine(氯胺酮）thiopentalsodium起效快，消失快，小量反复给药，醒后无任何不适。可发生喉痉挛→咽，喉等手术不宜用。抑制呼吸中枢→注药不宜过快。用于短、小不需要肌肉松驰的手术和静脉快速诱导。一次手术不宜超过1g.ketamine意识抑制浅，而感觉消失深→分离麻醉。兴奋交感神经：P↑、Bp↑→心脏病、高血压、ICP↑、青光眼不用。无肌肉松驰作用麻醉中唾液分泌增多→术前用atropin.醒后可有复视、幻觉Balancedanesthesia利用数种药物适当配合以获得麻醉效果的方法。各药物之剂量正好足以产生所求药效以获得最佳深度的麻醉，同时可控制其不良副作用或使不必要的作用控制在最轻微程度Basalanesthesia一种较浅麻醉可作为进一步施行深度麻醉的基础；在外科手术前，先用药物获得不完全麻醉，可大量节减麻醉所需的吸入性麻醉药Postanesthesiacareunit(PACU)

(postanestheisarecoveryroom)Closelymonitorvitalsigns,15-30min,(完全清醒→正确回答问题）

Maintainingapatentairway:theprimaryobjectiveintheimmediatepostoperativeperiodistomaintainpulmonaryventilationandthuspreventhypoxemiaandhypercapnia.1.Position:thepatientisturnedtothesideoronbackwithheadtoside(unconscious)2.suction→mucusandthevomitus.舌后坠→抬下颌、通气导管laryngospasm→加压吸氧，环甲膜穿刺MaintainingcardiovascularstabilityThenurseassessthepatientsmentalstatus;vitalsigns;cardiacrhythm;skintemperature,colorandmoisture;andurineoutput.Theprimarycardiovascularcomplications:hypotension,shock,hemorrhage,hypertensionanddysrhythmias,Hyperthermiaandhypothermia,twitchand

convulsion舌后坠时气道通畅方法置通气道方法环甲膜穿刺术IntraspinalanesthesiacareIndication:腰以下手术Contraindication:中枢系统有病变的，身体状况极差或有休克的，穿刺部位有感染或严重畸形，对老年人，尤其有高血压、心脏病者慎用。操作体位：侧卧，低头、弯腰、抱膝穿刺部位：L3－4或4－5棘突间隙进针注药后工作：量血压和调节麻醉平面（麻黄素和阿托品）Postopeartiveposition:去枕平卧6－8h,防头痛(细针穿刺、皮肤上碘酊脱净），头痛处理：平卧休息、镇静药、针刺，重者：硬膜外腔注入生理盐水/中分子右旋糖酐15－30mlEpiduralanesthesiacareIndication:cervical、thoracic、abdominal、sacral,especialepigastricContraindication:hypertension,cardiacdisease,severeanemia,shock,infectonofpuncturesite,malformationcomplication：totalspinalcordanesthesia(进行性呼吸困难→呼吸停止，血压下降，意识消失→呼吸心跳骤停)intraspinalanesthesiacomplicationsHypotension:交感神经阻滞，周围血管扩张，回心血量减少心率减慢/心动过缓：交感神经阻滞，内脏牵拉反射呼吸功能抑制：胸闷气短、咳嗽及说话无力、发绀(腰麻平面过高，高位硬麻时局麻药浓度过高或用量过大）全脊髓麻醉消化系统：恶心和呕吐（迷走神经兴奋、牵拉腹腔脏器、麻醉药影响）尿潴留：腰麻后常见(骶神经阻滞，排尿反射抑制，伤口疼痛→尿道括约肌痉挛，心理影响)Headache肢体感觉或运动障碍椎管内感染LumbarpunctureLocalanesthesiacareLocalanestheticagentstypesandpoisoningLocalanestheticagentsPoisoningmanifestations兴奋型：多语、不安、紧张、呼吸及心率增快、Bp↑，严重谵妄、惊厥。抑制型：嗑睡、呼吸心率减慢、Bp↓a,cardiopulmonaryarrest.Nursingalert:抑制型少见，多为兴奋后抑制。Poisoningfactor