胸腹主动脉瘤手术麻醉处理课件.ppt

胸腹主动脉瘤手术的麻醉处理胸腹主动脉瘤手术的麻醉处理1一、腹主动脉瘤病因及发病机制一、腹主动脉瘤病因及发病机制1.吸烟吸烟 烟草燃烧产生的气态物质进入血液，可将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动脉壁力量减弱而导致动脉瘤的形成22.高血压高血压 及发病率和破裂的危险性有密切的关系及发病率和破裂的危险性有密切的关系3.年龄因素年龄因素 动脉壁的弹力蛋白纤维随年龄的增长出现降解、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断裂和钙化，使动脉壁难以承受血压的冲击而发生动脉瘤生动脉瘤34.炎症反应炎症反应 慢性炎症反应中的巨噬细胞和活化的慢性炎症反应中的巨噬细胞和活化的T、B淋巴细淋巴细胞可刺激金属蛋白酶的产生，促进结缔组织的降解，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，导致产生动脉瘤削弱和破坏主动脉壁中层，导致产生动脉瘤4 另有研究认为另有研究认为,雌激素水平是动脉瘤的产生雌激素水平是动脉瘤的产生的原因之一的原因之一: 在腹主动脉瘤形成的过程中雌激素可能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通过降低组织基质金属蛋白酶2、9( MMP-2、9)的的 mRNA 表达、蛋白合成表达、蛋白合成,从而延缓动脉从而延缓动脉瘤的形成瘤的形成.-国外医学-56二、腹主动脉瘤的病理改变二、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。

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、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，等等高血压、吸烟史，男性，等等2.假性动脉瘤：多见及动脉损伤假性动脉瘤：多见及动脉损伤3.夹层动脉瘤：动脉壁中层囊性坏死或退行夹层动脉瘤：动脉壁中层囊性坏死或退行 性变7三、诊断三、诊断 腹部搏动性包块腹部搏动性包块 神经压迫症状神经压迫症状 下肢缺血症状下肢缺血症状血管造影、血管造影、CT、MRI、高速螺旋、高速螺旋CT等等影像学检查影像学检查8四、胸腹主动脉瘤的手术方式及概况四、胸腹主动脉瘤的手术方式及概况手术方式：手术方式：1.Open repair2.Medal graft stent3.Baloon-expandable4.Hand-help laparoscope repair 9 Elective surgery by open transperitoneal or retroperitoneal approach is the most common repair intervention. However, placing an endoluminal stent graft within the aneurysm is currently being evaluated as an alternative to open repair. J-Cardiovasc-Nurs. 2001 Jul; 15(4): 1-1410 Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. Vasc-Surg. 2001 Sep-Oct; 35(5): 335-4411平均年龄平均年龄 68.5 +/-7.7 years. 高血压病史高血压病史 55%, 心脏病心脏病 73.5%, 外周血管疾病外周血管疾病 21%, 中风和短时间缺血中风和短时间缺血22%, 糖尿病糖尿病 7%, 肾功能不全肾功能不全 10%, 吸烟史吸烟史 80%. Vasc-Surg. 2001 Sep-Oct; 35(5): 335-4412Complications:Complication rates varied 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 risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. Langenbecks-Arch-Surg. 2001 Jul; 386(4): 249-5613五、麻醉方法及术中处理五、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全身麻醉、硬膜外麻醉以及联合麻醉等各种麻醉技术及麻醉药物都已成功应用各种麻醉技术及麻醉药物都已成功应用于开腹于开腹AAA修补术。

修补术其中的联合麻醉方式通常是指联合应用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高腰段或下胸段硬膜外麻醉与浅全麻的复合麻醉方式复合麻醉方式1415161718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INR1.53、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LMWH19Procedures 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.20Procedures performed before surgery 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 for measure- ment of temperature.5.The bladder is catheterized for monitoring of urine output.21Key points during anesthesia and operation procedure.1.Tracheal intubation To maintain systemic arterial pressure stable.(Dopamine or Noradrenalin) The double lumen tubes are necessary for somethoracic approach operations 2223242.Crossclamping of the aortaa sudden increase in systemic vascular resistance (afterload): cardiac work increase myocardial ischaemia the large bowel and lower limbs suffer variable degrees of hypoxia: inflammatory mediators released oxygen radicals neutrophil proteases platelets activating factor cyclo-oxygenase products cytokines253.Aoric declamping a sudden decrease in afterload with reperfusionof the bowel, pelvis and lower limbs. vasodilatation metabolic acidosis capillary permeability increased blood cells sequestrated in the lungs 264.The large heat loss Many patients undergoing this operation are elderly and have a low metabolic rate. All possible measures must 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 27Organ protectionVascular diseases are associated with 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)28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-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 countering thesedeleterious pulmonary effe。