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第十四章_全身麻醉期间严重并发症的防治课件

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第十四 全身 麻醉 期间 严重 并发症 防治 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 第十四章第十四章 全身麻醉期间全身麻醉期间 严重并发症的防治严重并发症的防治 prevention and treatmentprevention and treatment severe complications during GA severe complications during GA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 局麻与全麻之间无明显差别局麻与全麻之间无明显差别 全麻的三个期均可发生全麻的三个期均可发生 2 2 麻醉并发症的发生率麻醉并发症的发生率 概概 述述 1 1 全麻并发症涉及三个方面全麻并发症涉及三个方面 病人的疾病状况的疾病状况 原发病 伴发病 继发病原发病 伴发病 继发病 麻醉医师素质及技术水平麻醉医师素质及技术水平 麻醉药 器械 设备麻醉药 器械 设备 induction maintenance recovery induction maintenance recovery Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 麻醉中的严重并发症麻醉中的严重并发症 Critical Incidents AnesthesiaCritical Incidents Anesthesia Latent factorsLatent factors Event triggersEvent triggers PreventivePreventive measuresmeasures Incidence of eventsIncidence of events Design flow Maintenance failure Care and skill ProblemProblem Critical incidentCritical incident PatientPatient Underlying disease Preop evaluation DoctorDoctor Fatigue Environmental factors EquipmentEquipment Checklist 责任心 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 第一节第一节 呼吸道梗阻呼吸道梗阻 airway obstructionairway obstruction 临床麻醉和复苏中最基本原则 保持呼吸道通畅 阻塞部位 上呼吸道 下呼吸道 阻塞程度 完全性 部分性 阻塞速度 急性 慢性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 上呼吸道梗阻一 上呼吸道梗阻 upper airway obstructionupper airway obstruction 1 常见原因 a 舌后坠舌后坠 b b 分泌物 分泌物 脓痰 血液 异物 药物 镇痛 镇静 肌松药物 镇痛 镇静 肌松 病人 颈 舌 咽 扁桃体病人 颈 舌 咽 扁桃体 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial c c 喉水肿 喉水肿 喉痉挛 larynx spasm 药物过敏药物过敏 刺激刺激 异物异物 炎症炎症 浅麻醉手术浅麻醉手术 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 不全梗阻 痰鸣 胸腹部呼吸运动反常 呼吸困难伴鼾声 吸气性呼吸困难 2 临床特征 完全梗阻 鼻翼煽动 三凹征 无呼吸音 有强烈的呼吸动作 但无有效的通气 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial SpO2 进行性下降 紫绀紫绀 人工呼吸 挤压呼吸皮囊阻力大 气道压升高 缺氧 二氧化碳蓄积 呼吸 心搏骤停呼吸 心搏骤停 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 处理方法 舌后坠 改善通气 清除分泌物清除分泌物 侧头后仰侧头后仰 面罩给氧 三步法 头后仰面罩给氧 三步法 头后仰 托下颌托下颌 张口 张口 气管插管气管插管 通气道 口咽或鼻咽 通气道 口咽或鼻咽 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 头后仰头后仰 托下颌对舌 会厌位置的影响托下颌对舌 会厌位置的影响 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 口咽通气道 鼻咽通气道 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 喉痉挛 面罩加压给氧面罩加压给氧 快效肌松剂快效肌松剂 气管内插管气管内插管 环甲膜穿刺环甲膜穿刺 咽部异物 及时发现 及时清除及时发现 及时清除 喉水肿 面罩给氧 糖皮质激素面罩给氧 糖皮质激素i v i v 雾化雾化 急 重者急 重者 气管切开气管切开 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 下呼吸道梗阻 lower airway obstructionlower airway obstruction 1 常见原因 返流与返流与误吸误吸 regurgitation aspiration regurgitation aspiration 诱导诱导 苏醒时 饱胃 高位肠梗阻苏醒时 饱胃 高位肠梗阻 气管导管气管导管 扭曲 受压 过深 过浅 阻塞扭曲 受压 过深 过浅 阻塞 设备设备 麻醉机运转失灵 脱落麻醉机运转失灵 脱落 疾病疾病 哮喘 慢支炎 肿瘤哮喘 慢支炎 肿瘤 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 误吸的临床表现 a a 急性呼吸道梗阻急性呼吸道梗阻 b Mendelson syndrome b Mendelson syndrome c c 吸入性肺不张吸入性肺不张 d d 吸入性肺炎吸入性肺炎 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 2 Mendelson syndromeMendelson syndrome 误吸后 误吸后 2 4h2 4h 出现哮喘样综合征 病人 出现哮喘样综合征 病人 发绀 心动过速 支气管痉挛和呼吸困难 发绀 心动过速 支气管痉挛和呼吸困难 急性化学性肺炎 哮鸣音 啰音哮鸣音 啰音 呼气性呼吸困难呼气性呼吸困难 心动过速 心律失常心动过速 心律失常 胸片 不规则 边缘模糊的斑状阴影 胸片 不规则 边缘模糊的斑状阴影 24h24h Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 严重程度 取决于吸入物的pH和容量 但以pH的意义更为重要 死亡率70 吸入物的 pH 2 5 36m6m 6 36m 36m 禁食 水禁食 水 禁奶 固体禁奶 固体 清凉液体清凉液体 6 8h6 8h 4h 6h 8h4h 6h 8h 2h 3h 3h2h 3h 3h 禁食禁饮禁食禁饮 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 3 支气管痉挛 支气管痉挛 原因原因 不良刺激不良刺激 反流 误吸反流 误吸 出血 分泌物出血 分泌物 插管刺激 损伤插管刺激 损伤 缺缺OO 2 2 COCO 2 2 蓄积蓄积 药物药物 硫喷妥钠 吗啡硫喷妥钠 吗啡 组胺释放组胺释放 手术操作手术操作 会阴部 骨膜 肠系膜 胆囊会阴部 骨膜 肠系膜 胆囊 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 处理处理 排除诱因 停止操作刺激 受体兴奋剂 间隙正压通气 intemitent positive pressure ventilation IPPV 调节麻醉深度 肌松药 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 全身麻醉期间严重并发症的防治之二 第十四章 第二节 呼吸抑制 Hypoventilation Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 呼吸抑制呼吸抑制 通气不足通气不足 一 一 原因原因 1 1 中枢性呼吸抑制中枢性呼吸抑制 麻醉药 麻醉性镇痛药麻醉药 麻醉性镇痛药 过度通气致过度通气致COCO 2 2 排出过多排出过多 过度膨肺过度膨肺 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肌松药及残余肌松作用肌松药及残余肌松作用 低血钾症低血钾症 利尿 碱中毒 利尿 碱中毒 高位硬膜外阻滞高位硬膜外阻滞 2 外周性呼吸抑制 呼吸肌麻痹 PaOPaO2 2 PetCOPetCO2 2 SpOSpO 2 2 二 临床表现二 临床表现 呼吸频率 呼吸频率 V V T T 阻滞平面过宽 高阻滞平面过宽 高 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 辅助呼吸 三 处理三 处理 1 立即建立有效的人工通气 呼吸频率慢 VT不足者 适当补偿通气量 与自主呼吸同步 辅助用力 15cmH2O 面罩给氧 氧流量 5L min FiO2 40 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 控制呼吸 无自主呼吸者 成人 10 15次 min 小儿 20 30次 min 婴儿 30 40次 min 呼吸频率 VT 8 12 ml kg 压力 7 15 cmH2O 呼气时完全放松皮囊 吸呼比 1 1 5 1 2 0 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 吸空气 SpO2 90 PaO2 60mmHg 吸纯氧 PaO2 90mmHg 四 低氧血症 Hypoxemia 2 临床表现 3 呼吸急促 躁动不安 紫绀 心动过速 心律紊乱 血压升高 血压下降 1 定义 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 3 原因原因 肺通气障碍肺通气障碍 呼吸道梗阻 呼吸道梗阻 肺交换功能障碍 肺不张 肺水肿 肺交换功能障碍 肺不张 肺水肿 弥散性缺氧 弥散性缺氧 N N 2 2 OO 循环功能障碍 心衰 休克 循环功能障碍 心衰 休克 麻醉药 肌松药的残余作用麻醉药 肌松药的残余作用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 对呼吸循环的影响较大对呼吸循环的影响较大 许多麻醉意外或事故都直接或间接与之有关许多麻醉意外或事故都直接或间接与之有关 4 缺O2 CO2蓄积临床特征 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 与缺O2同时存在 紫绀明显 CO2蓄积早期 面色潮红面色潮红 血压 心率血压 心率 呼吸加快 深大呼吸加快 深大 肌张力肌张力 如果CO2迅速排出 血压可突降 呼吸暂停 严重缺O2 CO2蓄积 呼吸不规则 血压下降 心率减慢 心律失常 呼吸 心跳骤停 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 低氧血症的程度分级低氧血症的程度分级 参参 数数 轻轻轻轻度度 中度中度 重度重度 PaOPaO2 2 mmHg mmHg 50 60 30 50 30 50 60 30 50 30 PaCOPaCO 2 2 mmHg mmHg 50 50 50 50 SaOSaO 2 2 80 90 60 80 40 60 80 90 60 80 40 60 紫紫绀绀绀绀 无无 轻轻轻轻 明明显显显显 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 重在预防重在预防 及时处理及时处理 2 2 处理 处理 3 缺O2 CO2蓄积 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 低血压一 低血压 HypotensionHypotension 第三节第三节 循环系统并发症循环系统并发症 血压降低幅度超过麻醉前血压降低幅度超过麻醉前20 20 或血压降低达或血压降低达80mmHg80mmHg 1 1 表现表现 代谢性酸中毒代谢性酸中毒 metabolic acidosismetabolic acidosis 2 2 少尿少尿 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 1 麻醉因素 麻醉因素 2 2 原因原因 麻醉过深 心肌抑制与血管扩张麻醉过深 心肌抑制与血管扩张 过度通气过度通气 低低COCO 2 2 血症血症 低血容量与低钾血症低血容量与低钾血症 低低OO 2 2 酸中毒酸中毒 低体温低体温 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 手术操作手术操作 神经反射神经反射 副交感神经分布丰富区 副交感神经分布丰富区 压迫心脏 大血压迫心脏 大血 2 2 手术因素 手术因素 失血过多失血过多 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 3 病人因素 病人因素 容量 术前 术中不足容量 术前 术中不足 肾上腺皮质功能衰竭肾上腺皮质功能衰竭 严重低血糖严重低血糖 心血管疾病心血管疾病 嗜铬细胞瘤切除后嗜铬细胞瘤切除后 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 麻醉麻醉 麻醉药 辅助药的选择 减浅麻醉麻醉药 辅助药的选择 减浅麻醉 补充容量 收缩血管补充容量 收缩血管 手术手术 减轻或避免反射刺激 加深麻醉 减轻或避免反射刺激 加深麻醉 3 3 防治防治 1 1 对因治疗对因治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 控制病情控制病情 特殊情况特殊情况 心梗心梗 6 6月后择期手术 月后择期手术 心衰心衰 控制 控制 2 2周后择期手术周后择期手术 房颤心室率房颤心室率 维持 维持80 120bpm 80 120bpm AVBAVB 严重心动过缓 严重心动过缓 起搏器 起搏器 血糖血糖 正常 正常 长期使用皮质激素者长期使用皮质激素者 术前 术中激素用量加大术前 术中激素用量加大 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血压升高超过麻醉前的血压升高超过麻醉前的20 20 或血压升高达或血压升高达160 95mmHg160 95mmHg以上 以上 第三节 循环系统并发症 二 高血压二 高血压 HypertensionHypertension 血压过高血压过高 血压升高超过麻醉前血压升高超过麻醉前30mmHg 30mmHg 1 原因原因 2 2 2 2 处理处理 自学自学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 第四节第四节 心肌缺血心肌缺血 1 1 基础基础 心肌需氧量心肌需氧量 取决于取决于HRHR SBPSBP LVLV容量 容量 室壁厚度 心肌收缩力 室壁厚度 心肌收缩力 影响心肌耗氧量的主要因素影响心肌耗氧量的主要因素 HRHR 心肌收缩力 心室内压力心肌收缩力 心室内压力 心肌对能量要求高心肌对能量要求高 不能耐受较长时间缺氧不能耐受较长时间缺氧 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 2 原因原因 1 麻醉期间心肌耗氧与供氧障碍的原因麻醉期间心肌耗氧与供氧障碍的原因 耗氧增加耗氧增加 HR HR 加快 心律失常 寒战加快 心律失常 寒战 紧张 疼痛紧张 疼痛 寒战 浅麻醉 寒战 浅麻醉 BP BP 过高 快速心律失常过高 快速心律失常 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 供氧障碍供氧障碍 贫血 容量不足 BP过低 心脏 冠脉 传导系统 心肌收缩功能障碍 肺部疾患 低氧血症 麻醉药物抑制循环系统 2 防治原则 耗氧与供氧平衡 自学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 体温升高或降低体温升高或降低 1 1 体温是体温是5 5大生命体征之一大生命体征之一 2 2 表层体温与深部体温表层体温与深部体温 第五节第五节 一 概述一 概述 直肠温度直肠温度 36 9 37 9 36 9 37 9 口腔 36 7 37 7 腋窝腋窝 36 0 36 0 37 4 鼻咽 直肠 2 3 食管 直肠 0 3 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 传入温度感觉 中枢调节 传出反应 二 二 体温的生理调节体温的生理调节 皮肤 深部组织 脊髓 大脑 非下 丘脑部位 下丘脑前部下丘脑前部 出汗 血管扩张 血管收缩 非寒战性生热 寒战 下丘脑后部下丘脑后部 热反应阈 37 冷反应阈 36 5 38 34 5 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 产热 细胞代谢 外界热量 散热 辐射 60 皮肤 传导 3 接触 对流 12 空气 蒸发 25 水 湿度 室温 产热与散热动态平衡产热与散热动态平衡 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术中输入大量冷的液体 手术暴露 冷溶液冲洗腹腔 胸腔 全麻药抑制体温中枢 肌松药使产热减少 1 1 常见诱因常见诱因 室温 21 室内通风 正常为24 26 相对湿度40 50 三 低体温三 低体温 深部温度深部温度 36 41 41 C C Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 1 诱发原因诱发原因 室温室温 28 28 C C 湿度过大 湿度过大 手术单覆盖过严过厚 妨碍散热手术单覆盖过严过厚 妨碍散热 颅脑下丘脑附近手术操作颅脑下丘脑附近手术操作 阿托品用量过大抑制出汗阿托品用量过大抑制出汗 输血 输液反应输血 输液反应 钠石灰产热经呼吸道升温钠石灰产热经呼吸道升温 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 2 体温升高对机体的影响体温升高对机体的影响 耗氧增加耗氧增加 体温每增高体温每增高1 1 基础代谢率增加 基础代谢率增加10 10 内环境紊乱内环境紊乱 代谢性酸中毒 高血钾 高血糖代谢性酸中毒 高血钾 高血糖 T 40T 40 常致惊厥常致惊厥 3 3 预防预防 手术室温手术室温 26 2ml kg h 6 皮质激素 缓解肌强直和降低体温作用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 咬肌痉挛 1 的儿童使用琥珀胆碱后 咬肌痉挛 肌组织活检有50 易发生MH 过敏反应 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 吴吴 珏珏 教授尚德延尚德延 教授谢谢 荣荣 教授 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 风险 Barcelona奥运村的游艇港 避风港 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Gaodi 的自然艺术 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 影响肌松药恢复的其他因素 3 舌后坠的原因 表现及处理 4 呼吸抑制与低氧血症的常见原因 5 全麻苏醒延迟的可能原因 6 手术后呕吐的原因 思考题思考题 1 困难气道的评估与处理措施 7 气管导管拔管指针
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本文标题:第十四章_全身麻醉期间严重并发症的防治课件
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