4.2.1全麻 2016-4-15.ppt

Clinical Anaesthesiology (General Anaesthesia)Qiu Wei Fan ()Associate ProfessorDepartment of AnaesthesiologyRui Jin HospitalSchool of MedicineShanghai Jiao Tong University教学要求n全麻方法n全麻药物n麻醉深度的判断n气管插管方法、适应症、并发症n全麻并发症n麻醉监测ContentsnMethods of General AnaesthesianAnaestheticsnGuegels Classic Signs of AnaesthesianMethods, Indications & Complications of IntubationnComplications of General AnaesthesianMonitoring During Anaesthesia Methods of General AnaesthesianInhalation anaesthesianIntravenous anaesthesianIntramuscularlynRectallynOrallynBalanced anaesthesiaInhalational Anaesthetic Agents Agent MAC% Vapor Pressure Blood/Gas PartitionnNitrous oxide 105 - 0.47nHalothane 0.74 243 2.4nEnflurane 1.68 175 1.9nIsoflurane 1.15 240 1.4nDesflurane 6.0 681 0.42nSevoflurane 1.7 157 0.66Intravenous Anaesthetic Agents Agent Induction dose (mgkg-1)nThiopentone 3-5nEtomidate 0.3nPropofol 1.5-2.5nKetamine 2Drugs Used to Supplement AnaesthesiaAnalgesicsOpioid AgonistsnNatural opium alkaloids: Morphine,CodeinenSemisynthetic opium alkaloid: DiamorphinenSynthetic opioids: Pethidine, Fentanyl, Alfentanil, Sufentanil, RemifentanilPartial Opioid AgonistsnBuprenorphineOpioid Agonist/AntagonistsnPentazocineOpioid AntagonistsnNaloxoneMuscle Relaxants Neuromuscular Blocking Agents are divided into two classesnDepolarizingnNondepolarizingMuscle RelaxantsnDepolarizingn Short-acting Succinylcholine DecamethoniumnNondepolarizingnLong-acting Tubocurarine Metocurine doxacurium Pancuronium PipecuriumnIntermediate-acting Atracurium VecuroniumnShort-acting Mivacurium Preparation for AnaesthesianPreoperative assessmentnEquipment for monitoringnThe anaesthetic machinenEquipment for tracheal intubationGeneral AnaesthesianInduction of AnaesthesianMaintenance of AnaesthesianEmergence and RecoveryIntravenous Induction Agent Induction dose (mgkg-1)nThiopentone 3-5nEtomidate 0.3nPropofol 1.5-2.5nKetamine 2Inhalational Induction Agent MAC% nNitrous oxide 105 nHalothane 0.74 nEnflurane 1.68 nIsoflurane 1.15 nDesflurane 6.0 nSevoflurane 1.7 Maintenance of Anaesthesia(Control of Depth of Anaesthesia)Minimum alveolar concentration (MAC) MAC is the minimum alveolar concentration (at one atmosphere) of an inhaled anaesthetic agent, which prevents reflex movement in response to surgical incision in 50 % of subjects.Guegels Classic Signs of AnaesthesianStage 1 (Stage of analgesia) From start of induction of anaesthesia to loss of consciousness.nStage 2 (Stage of excitement) From loss of consciousness to beginning of regular respiration.nStage 3 (Surgical anaesthesia) From the beginning of regular respiration to respiratory arrest.Guegels Classic Signs of AnaesthesianThe 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 From the beginning of intercostal paralysis to the completion of intercostal paralysis.Plane 4 From completion of intercostal paralysis to diaphragmatic paralysis. Guegels Classic Signs of AnaesthesianStage 4 Stage of impending respiratory and circulatory failure (Medullary paralysis) from the onset of diaphragmatic paralysis to cardiac arrest.Airway MaintenancenUse of the facemasknUse of the laryngeal mask airway (LMA)nUse of the oropharyngeal airwaynUse of the nasopharyngeal airwaynTracheal intubationMethods of Tracheal IntubationnOral-tracheal intubationnNaso-tracheal intubationnFlexible fiberoptic nasotracheal intubationnBlind intubation of the tracheal under light wandsnTracheal intubation under seeing optical styletIndications of Tracheal IntubationnProvision of a clear airwaynAn unusual positionnOperations on head and necknProtection of respiratory tractnDuring anaesthesia using IPPV and muscle relaxants nTo facilitate suction of respiratory tractnDuring thoracic operationsOral-tracheal intubationOral-tracheal intubationTracheal intubation under seeing optical styletComplications of Intubation While the Tube is in PlacenMalpositionnUnintentional extubationnEndobrochial intubationnLaryngeal cuff positionnAirway traumanMucosal inflammation and ulcerationnExcoriation of nosenTube malfunctionnIgnitionnObstructionComplications of Intubation Following ExtubationnAirway traumanEdema and stenosis (glottic, subglottic, tracheal )nHoarseness (vocal cord granuloma or paralysis )nLaryngeal malfunctionnRegurgitationnAspirationnPhysiologic reflexesnLaryngospasmComplications During AnaesthesianArrhythmiaslBradycardialTachycardialAtrial arrhythmiaslVentricular arrhythmias (Premature ventricular contractions (PVCs)lHeart block Complications During AnaesthesianHypotentionlDecreased cardiac outputlDecreased venous returnlMyocardiallVasodilationlDrugslSepticaemialHypovolaemialHaemorrhageComplications During AnaesthesianHypertensionnHypervolaemianMyocardial ischaemianCardiac arrestnEmbolismnHypoxaemia Complications During AnaesthesianHypercapnianHypocapnia nRespiratory obstructionnIntubation problems As。