口腔颌面麻醉课件.ppt

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1、 Oral andOral and maxillofacial maxillofacial surgery anesthesia surgery anesthesia一、Characteristics of the patients and the operation.Anesthesia management.(一)Anatomyandphysiolosy(1)CongenitallipandpalatecleftInfantsanestheticendurancecompensationfunctionrespirationsystemisspecialCoexistentdiseases

2、VSDASDetcOral-noseconnecteddifficultyingettingfoodrespirationsysteminfection.(2)BilateraltemporomandibularjointsrigidityDifficultyinopeningthemouthChronichypoxaemiaPoororalsanitationMalnutritionfluidandelectrolytesunbalance(3)OraltumorDifficulty in opening the mouth,pharyngealobstructionTrachealintu

3、bationisdifficultOldagepatientscoexistentdiseases(hypertension,chronicbronchialinflammation.coronaryheartdisease,diabetic(4)TraumaIfthesoftpalate、peripharynx、baseofthetongueareinvolved,tissue swelling,pharyngeal cavity isnarrowed.Fracturedislocationstifle(suffocate)Bleeding,secretionsaspiration.(5)M

4、andible-thorax,mandible-neck adherence,scarformationandcontractionsaroundthemouth.Head-neckisfixed,headisextremelybentTracheaisshiftedtoonesideTrachealintubationandtracheostomyaredifficult(6)CongenitalmaxillofacialdeformityPierre-Robin syndrome,Treacher-CollinssyndromeTrachealIntubationisdifficultAn

5、esthesiaenduranceisdecreased.（二）Characteristicsofthesurgery(1)Premedication（Atropine.Sod-luminal Morphine.Midazolumetc.）Theobjectivesofpremedicationareto：AllayanxietyandfearReducesecretionsEnhancethehypnoticeffectofgeneralanestheticagentsReducepostoperativenauseaandvomitingReduce the volume and incr

6、ease the PH of gastriccontentsAttenuatevagalreflexesAttenuatesympathoadrenalresponsesIfthepreoperationairwayobstrutionisexisted,dontuseanypremedicationsthatwillsuppresstherespiration(e.gmorphine)(2)Anestheticinductionandtrachealintubationmaybedifficult.temporomandibularjointsrigidityHugetumorSeveret

7、rauma(3)SharedairwayObservationandmanagementarelimited.Blood、secretionsanddebrismaycontaminatethelartynx.Gagandoperationapparatusmaycompressthetrachealtube,causepartialairwayobstruction(4)HeamorrhageThesurgeoncanntoperateclearlyLargequantitybloodlossesmayresultinshock.(5)Prolongedplasticoperationmor

8、eanestheticcomplications.(6)ResuscitationWehopethepostoperativerecoveryisquickandsmooth.(7)DifferentagerangesForinfantsandoldagepatients,theanesthesiamanagementisdifficult.(三)Howtodealwiththementionedproblems(1)For the patients with airway obstruction,donnt userespirationsuppressivedrugsaspremedicat

9、ions.(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 impor

10、tant 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 com

11、mon anestheticmethodsAccordingtothepatientscondition,surgerysrequirements,surgeonsexperienceandtheanesthetistspreference,theanestheticmethodisdifferent(一)LocalanesthesiaAdministration is simple,disturbance to the bodyenviromentissmall,postoperativerecoveryisquick.For infants and mental or physical d

12、isability,localanesthesiacombinedwithbaseanesthesiaisnecessary.During the operation,if the localanesthesianeed tobechangedtogeneralanesthesia,trachealintubationisnecessary.（二）BaseanesthesiaKetamine,pethidine-droperidol,midazolum.KTM:5-10mg/kgim,3min-5mingotosleep,maintaintime25min-36min,Midazolum0.1

13、-0.2mg/kgivorim.（三）Generalanesthesia（1）InductionandintubationRapidinductionSlowinduction:lightanesthesia+localanestheticsprayLaryngoscopicintubation,awakeintubcotion,awakefibreopticintubation.,Tracheostomy.(2)AnestheticmaintenanceInhalation(enflurane,isoflurane,sevoflurane,desoflurane,N2O)Combined i

14、ntravenous(valume,midazolum,fentanyl,norcuron,etc)Intravenous-inhalationcombinedGeneralenesthesiacombinedwithlocalanesthesiaisimportant.(3)Postoperativeresuscitation三、Managementduringandafteranesthesia(一)Duringanesthesia(1)EnsuretheairwayCausesofairwayobstructionsare:Tonguefallingdown,laryngospasm,b

15、ronchiospasm,secretions、blood、debris drain intolarynx,trachealtubekinking(2)MaintainstatisfiedventilationInadequateventilationmayresultinhypoxaemia,hypercapnia.Hypoxic inspired gasmixtureEquipmentOxygen supply(cylinder/pipeline failure,misconnection)Flowmeters(inaccuratesettings,leak)Breathingsystem

16、(obstruction,leak)HypoventilationEquipmentVentilatorfailureBreathing systen(obstruction,leak,disconnection)Tracheal tube(obstruction,oesophagealintubation)Patient Respiratory depression in spontaneouslybreathingpatientsObstructionV/QmismatchPatientInadequate ventilation EndobronchialintubationSecret

17、ionsPneumothoraxBronchospasmPulmonaryaspirationPulmonaryedemaInadequate perfusion Embolus(gas,thrombus)LowcardiacoutputOther Methaemoglobinaemia,MalignanthyperthermiaCausesofhypoxaemiaduringanesthesiaIntraoperativehypercapniaiscausedbyinadequatecarbondioxideremovalorexcessivecarbondioxideproduction,

18、Inadequabecarbondioxideremovalismostcommonlycausedbyhypoventilation.Thecriteriaofsatisfiedventilation:Spo298-100%PEtCO230-45mmHgBlood-gasanalysis.TV8-10ml/kg(Neonate6-7ml/kg)Rf12/min(NeonateRf)(3)CirculationmanagementInsertionofanI.VcannulaFluidtherapyNormalmaintenancerequirementsRestoreTBWafteraper

19、iodoffastingReplacesmallbloodlosses,lossofECFintothe“thirdspace”andlossesofwaterfromtheskin,gutandlungs.Bloodlossesinexcessof15%ofbloodvolumeintheadultarereplacedusually by infusion of stored blood.Smaller blood losses may bereplacedbyacrystalloidelectrolytesolutionandacolloidsolution.Maintainsteady

20、BP.HR(二)Managementafteranesthesia(1)AirwaymanagementExtubation conditions:Completely awake.normalventilation,SPO296%(air inhalation)Normal muscle tonicity,smoothrespiration.PreventlaryngealedemaafterextubationDelayed extubation:Pharyngeal damage due to trachealintubation.Theinvolvedoperationrangeisl

21、arge.Restrictivedressingsappliedaftersurgery.Narrowedpharyngealcavityduetotrauma.(2)Preventpostoperativenauseaandvomiting.5-HT3RBSuction(3)PreventthecomplicationsrelatedtoanesthesiaNasal-pharyngealmucosalhaemorrhageNasal-pharyngealmucosalfalloffPharyngealedemaPostoperativemaxillasinusinflammation.Chooseappropriatesizetrachealtube.Usetrachealtubelubricant.Applyhumidificationofinspiredgases.High-volume,low-pressurecuffsmaybepreferredforlong-termintubation.