口腔颌面麻醉课件.ppt

Oral andOral and maxillofacial maxillofacial surgery anesthesia surgery anesthesia一、Characteristics of the patients and the operation.Anesthesia management.(一)Anatomyandphysiolosy(1)CongenitallipandpalatecleftInfantsanestheticendurancecompensationfunctionrespirationsystemisspecialCoexistentdiseasesVSDASDetcOral-noseconnecteddifficultyingettingfoodrespirationsysteminfection.(2)BilateraltemporomandibularjointsrigidityDifficultyinopeningthemouthChronichypoxaemiaPoororalsanitationMalnutritionfluidandelectrolytesunbalance(3)OraltumorDifficulty in opening the mouth,pharyngealobstructionTrachealintubationisdifficultOldagepatientscoexistentdiseases(hypertension,chronicbronchialinflammation.coronaryheartdisease,diabetic(4)TraumaIfthesoftpalate、peripharynx、baseofthetongueareinvolved,tissue swelling,pharyngeal cavity isnarrowed.Fracturedislocationstifle(suffocate)Bleeding,secretionsaspiration.(5)Mandible-thorax,mandible-neck adherence,scarformationandcontractionsaroundthemouth.Head-neckisfixed,headisextremelybentTracheaisshiftedtoonesideTrachealintubationandtracheostomyaredifficult(6)CongenitalmaxillofacialdeformityPierre-Robin syndrome,Treacher-CollinssyndromeTrachealIntubationisdifficultAnesthesiaenduranceisdecreased.（二）Characteristicsofthesurgery(1)Premedication（Atropine.Sod-luminal Morphine.Midazolumetc.）Theobjectivesofpremedicationareto：AllayanxietyandfearReducesecretionsEnhancethehypnoticeffectofgeneralanestheticagentsReducepostoperativenauseaandvomitingReduce the volume and increase the PH of gastriccontentsAttenuatevagalreflexesAttenuatesympathoadrenalresponsesIfthepreoperationairwayobstrutionisexisted,dontuseanypremedicationsthatwillsuppresstherespiration(e.gmorphine)(2)Anestheticinductionandtrachealintubationmaybedifficult.temporomandibularjointsrigidityHugetumorSeveretrauma(3)SharedairwayObservationandmanagementarelimited.Blood、secretionsanddebrismaycontaminatethelartynx.Gagandoperationapparatusmaycompressthetrachealtube,causepartialairwayobstruction(4)HeamorrhageThesurgeoncanntoperateclearlyLargequantitybloodlossesmayresultinshock.(5)Prolongedplasticoperationmoreanestheticcomplications.(6)ResuscitationWehopethepostoperativerecoveryisquickandsmooth.(7)DifferentagerangesForinfantsandoldagepatients,theanesthesiamanagementisdifficult.(三)Howtodealwiththementionedproblems(1)For the patients with airway obstruction,donnt userespirationsuppressivedrugsaspremedications.(2)Toensuretheairway,weshouldadministertrachealintubationortracheostomy.(3)To fix the tracheal tube and connecting tube inposition;protect the anaesthetic tubing fromdislodgement.(4)ChooseanappropriateintubationroutenasalintubutionOralintubution(5)HypotensiontechniqueUse this technique in important procedure.Thehypotensive duration should be short.SBP90mmHg,MBP60mmHg.(6)To fulfil respiration self-regulation,the postoperativeresuscitationshouldbequick.(7)Preventpostoperativenauseaandvomitingrelatedtopharyngealstimulation,postoperativepain,anestheticdrugsetc.二、The anesthetic choices and common anestheticmethodsAccordingtothepatientscondition,surgerysrequirements,surgeonsexperienceandtheanesthetistspreference,theanestheticmethodisdifferent(一)LocalanesthesiaAdministration is simple,disturbance to the bodyenviromentissmall,postoperativerecoveryisquick.For infants and mental or physical disability,localanesthesiacombinedwithbaseanesthesiaisnecessary.During the operation,if the localanesthesianeed tobechangedtogeneralanesthesia,trachealintubationisnecessary.（二）BaseanesthesiaKetamine,pethidine-droperidol,midazolum.KTM:5-10mg/kgim,3min-5mingotosleep,maintaintime25min-36min,Midazolum0.1-0.2mg/kgivorim.（三）Generalanesthesia（1）InductionandintubationRapidinductionSlowinduction:lightanesthesia+localanestheticsprayLaryngoscopicintubation,awakeintubcotion,awakefibreopticintubation.,Tracheostomy.(2)AnestheticmaintenanceInhalation(enflurane,isoflurane,sevoflurane,desoflurane,N2O)Combined intravenous(valume,midazolum,fentanyl,norcuron,etc)Intravenous-inhalationcombinedGeneralenesthesiacombinedwithlocalanesthesiaisimportant.(3)Postoperativeresuscitation三、Managementduringandafteranesthesia(一)Duringanesthesia(1)EnsuretheairwayCausesofairwayobstructionsare:Tonguefallingdown,laryngospasm,bronchiospasm,secretions、blood、debris drain intolarynx,trachealtubekinking(2)MaintainstatisfiedventilationInadequateventilationmayresultinhypoxaemia,hypercapnia.Hypoxic inspired gasmixtureEquipmentOxygen supply(cylinder/pipeline failure,misconnection)Flowmeters(inaccuratesettings,leak)Breathingsystem(obstruction,leak)HypoventilationEquipmentVentilatorfailureBreathing systen(obstruction,leak,disconnection)Tracheal tube(obstruction,oesophagealintubation)Patient Respiratory depression in spontaneouslybreathingpatientsObstructionV/QmismatchPatientInadequate ventilation EndobronchialintubationSecretionsPneumothoraxBronchospasmPulmonaryaspirationPulmonaryedemaInadequate perfusion Embolus(gas,thrombus)LowcardiacoutputOther Methaemoglobinaemia,MalignanthyperthermiaCausesofhypoxaemiaduringanesthesiaIntraoperativehypercapniaiscausedbyinadequatecarbondioxideremovalorexcessivecarbondioxideproduction,Inadequabecarbondioxideremovalismostcommonlycausedbyhypoventilation.Thecriteriaofsatisfiedventilation:Spo298-100%PEtCO230-45mmHgBlood-gasanalysis.TV8-10ml/kg(Neonate6-7ml/kg)Rf12/min(NeonateRf)(3)CirculationmanagementInsertionofanI.VcannulaFluidtherapyNormalmaintenancerequirementsRestoreTBWafteraperiodoffastingReplacesmallbloodlosses,lossofECFintothe“thirdspace”andlossesofwaterfromtheskin,gutandlungs.Bloodlossesinexcessof15%ofbloodvolumeintheadultarereplacedusually by infusion of stored blood.Smaller blood losses may bereplacedbyacrystalloidelectrolytesolutionandacolloidsolution.MaintainsteadyBP.HR(二)Managementafteranesthesia(1)AirwaymanagementExtubation conditions:Completely awake.normalventilation,SPO296%(air inhalation)Normal muscle tonicity,smoothrespiration.PreventlaryngealedemaafterextubationDelayed extubation:Pharyngeal damage due to trachealintubation.Theinvolvedoperationrangeislarge.Restrictivedressingsappliedaftersurgery.Narrowedpharyngealcavityduetotrauma.(2)Preventpostoperativenauseaandvomiting.5-HT3RBSuction(3)PreventthecomplicationsrelatedtoanesthesiaNasal-pharyngealmucosalhaemorrhageNasal-pharyngealmucosalfalloffPharyngealedemaPostoperativemaxillasinusinflammation.Chooseappropriatesizetrachealtube.Usetrachealtubelubricant.Applyhumidificationofinspiredgases.High-volume,low-pressurecuffsmaybepreferredforlong-termintubation.