普胸外科手术麻醉课件.ppt

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1、普胸外科手术麻醉-胸外科医生的视角-Department of Thoracic SurgeryShanghai Chest Hospital为谁上麻醉？为稻粱谋？为外科医生？为麻醉学？为病人！Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前知难而退知难而进知难而退Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充

2、血性心衰、心源性死亡）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充血性心衰、心源性死亡）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充血性心衰、心源性死亡）Aug,201010/8/2019Aug,2019

3、10/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充血性心衰、心源性死亡）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充血性心衰、心源性死亡）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Ho

4、spital麻醉前-心肺功能及手术风险评估非心脏胸部手术心血管风险评估：ASC/AHA 围术期心脏风险等级（心肌梗塞、充血性心衰、心源性死亡）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估胸部手术呼吸功能评估：预测术后肺功能比常规肺功能更好预测术后并发症Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估胸部手术呼吸功能评估：预测术后肺功能比常规肺功能更好预测术后并发

5、症1.Juhl公式：预测术后肺功能术前肺功能*(1-S*5.26/100)S代表切除的支气管肺单位，每个楔形切除的肺组织按1个支气管肺单位计算,左右肺下叶各占5个肺单位,右中叶占2个肺单位,右上叶占3个肺单位,左上叶占4个肺单位2.Markos公式：预测术后肺功能术前肺功能*（1-切除肺组织所占的功能比例）（局部肺功能比例由放射性核素肺灌注扫描试验）3.Ali公式：预测术后肺功能 术前的肺功能（1-A/B.f.k）A为被切除的肺段数，B为术侧总段数，f为术侧肺灌注占总肺灌注的百分比，k为校正系数1.27，此校正系数是为了排除由于手术早期创伤等所致的降低 Aug,201010/8/2019Aug

6、,201910/8/201910/24/2019Shanghai Chest Hospital麻醉前-心肺功能及手术风险评估胸部手术呼吸功能评估：预测术后肺功能比常规肺功能更好预测术后并发症48例肺切除病人，均因常规肺功能检查发现中等程度肺功能减退，而加行放射性核素肺灌注扫描试验，按Ali公式计算结果。PPOFEV1c0.8L、PPOFEV1%c60%、PPODLCO c 50%三项中：1项都不符合者，术后无一发生心肺并发症（0）符合1项者，35.7发生术后心肺并发症符合2项以上者，83.3发生术后心肺并发症Aug,201010/8/2019Aug,201910/8/201910/24/201

7、9Shanghai Chest Hospital麻醉前镇痛方式术后镇痛术中镇痛术前镇痛Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中麻醉深度麻醉医生？外科医生？病人的情况！利己利人Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中麻醉深度指标肌松程度神经反射循环参数靶控Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中呼吸的

8、控制维持生命手术操作（VATS vs.开放手术）保护性肺通气Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中呼吸的控制气道压力与术后急性肺损伤（ALI）University Hospital of Geneva，879例肺切除术Total incidence of ALI was 4.2%(n=37)Primary ALI 27例，Mortality 26%ALI 独立预测因素：1.high intraoperative ventilatory pressure index（OR=3.5）2.exces

9、sive fluid infusion（OR=2.9）3.pneumonectomy（OR=2.8）Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中呼吸的控制保护性肺通气策略：1.定压通气2.高频率低容量3.CPAP（iNOS）气管插管到位Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中循环的维持维持生命保护内环境急性肺损伤！Aug,201010/8/2019Aug,201910/8/201910/24/2019

10、Shanghai Chest Hospital麻醉中循环的维持围术期输液量与术后急性肺损伤（ALI）Memorial Sloan-Kettering Cancer Center 1,428 例肺癌手术术后ALI 76 例（5.3%），死亡率25%ALI 独立预测因素1.increased perioperative fluid administration(OR 1.2/500ml)2.decreased postoperative predicted lung functionAug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest

11、 Hospital麻醉中围术期容量管理策略：麻醉诱导期低血压的预防对心肺功能良好的肺切除术老年患者限制液体+小剂量缩血管药物麻醉诱导期扩容不增加肺水肿风险更有利于组织灌注Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中围术期容量管理策略：麻醉诱导期低血压的预防对心肺功能良好的肺切除术患者正常容量、限制容量均能良好维持循环和氧供大容量-循环亢进-肺水肿-氧合功能障碍Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中循

12、环的维持围术期容量管理策略：610ml/kg.hr基础需要量？术中丧失量？第三间隙失水量？循环稳定所需的前负荷Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中需要多少监护仪器？麻醉意外的最常见原因：1.人为因素2.仪器故障Brodsky JB,Stanford University不是 Lack of knowledge而是 Failure to apply existing knowledgeAug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Ch

13、est Hospital麻醉中需要多少监护仪器？The more the better?The more the worse?1.分散注意力2.虚假安全感3.监护监护仪4.浪费时间5.附加风险Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中需要多少监护仪器？The Australian Incident Monitoring Study 2000例麻醉意外监护仪发现50%-半数不能依靠监护仪！SpO2 27%CO2 24%ECG 19%BP 12%Circuit pressure 8%其它 1%Aug,

14、201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中观察指标基本生命体征！心律血压呼吸体温Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉中观察指标必需的仪器设备：按顺序1.听诊器2.血压计3.指脉仪4.CO25.管道压力报警6.心电图7.体温计Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest Hospital麻醉后复苏药物复苏确认生命体征喉保护Aug,201010/8/2019Aug,201910/8/201910/24/2019Shanghai Chest HospitalThanks for Your Attention!Department of Thoracic SurgeryShanghai Chest Hospital胸外科医生找什么样的麻醉师上麻醉？谢谢！