第17章胸科手术麻醉.ppt
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1、2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,1,Anesthesia for Thoracic Surgery,DUNYI QI, assist prof. Department of Anesthesiology, affiliated Hospital of XUZHOU Medical College, XUZHOU , JIANGSU,221002, China,第十六章 胸科手术麻醉 (Anesthesia in thoracic surgery),徐州医学
2、院附属医院 齐敦益,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,3,目的和要求,熟悉剖胸和侧卧位对呼吸循环的影响 熟悉胸科手术的麻醉前评估与准备 掌握胸科手术麻醉的基本要求及特点 掌握单肺通气管理的注意事项 了解常见胸科手术麻醉的处理,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,4,胸腔手术麻醉的特点: 麻醉处理与管理要求高。手术开胸影响呼吸
3、(肺)、心脏大血管功能和纵隔丰富的神经反射,要求对胸腔解剖,呼吸、循环生理有深刻的认识,而且对麻醉中发生的异常情况能及时识别加以排除 开胸手术麻醉对原来器官功能的影响更为加重。原有急性病变,如肺损伤、气胸,慢性疾病,如慢性阻塞性肺疾患(COPD)及限制性肺疾患(RPD)、支气管扩张症、肺癌、食管癌等的病人均有不同程度的低氧,心肺功能影响,营养障碍,肝肾功能损害等 术前估计与准备的重要性。充分考虑麻醉期与麻醉后机体状态及可能发生的危险性,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical Co
4、llege,5,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对呼吸的影响 剖胸侧肺萎陷 维持肺充气状态的因素 大气压作用于肺泡 肺泡本身所具有的弹性及表面张力的相互作用(Pulmonary surfactant, PS ) 胸膜腔负压的牵拉作用,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,6,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medica
5、l College,7,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对呼吸的影响 剖胸侧肺萎陷 肺萎陷 剖胸后,剖胸侧胸膜腔负压消失,肺泡内及肺表面均受大气压的作用,因而肺泡只受自身回缩力的净作用,导致萎陷。,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,8,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对呼吸的影响 剖胸侧肺萎陷 危害 肺的弥散面积可减少50% 肺血管阻力(萎陷的肺组织压迫肺血管、缺氧性肺血管收缩 hy
6、poxic pulmonary vasoconstriction HPV) 肺内分流(pulmonary shunt),2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,9,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对呼吸的影响 纵隔移位及纵隔摆动(Mediastinal shift) 纵隔移位:两侧胸腔压力失去平衡 纵隔摆动:健侧肺的呼吸运动,2019/8/18,Department of Anesthesiology, Affiliated
7、Hospital of XUZHOU Medical College,10,纵隔移位及纵隔摆动(Mediastinal shift),吸气相,+,剖胸侧,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,11,吸气相,+,剖胸侧,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,12,呼气相,剖胸侧,2019/8/18,Department of Ane
8、sthesiology, Affiliated Hospital of XUZHOU Medical College,13,呼气相,+,剖胸侧,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,14,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,15,2019/8/18,Department of Anesthesiology, Affiliated
9、 Hospital of XUZHOU Medical College,16,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,17,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,18,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对呼吸的影响 反常呼吸(Paradoxical respiration)及摆动气,2019/8/
10、18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,19,概念:开胸引起纵隔摆动,亦产生肺内气体的摆动。吸气时有部分气体从开胸侧肺被“吸”入健侧肺,呼气时有部分气体从健侧肺“呼”入开胸侧肺 ,来往于两侧肺之间的气体称为“摆动气“ 危害:无效腔气体(不参加交换),2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,20,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理
11、生理改变 剖胸后对循环的影响 心输出量降低 回心血量降低 大血管扭曲 肺血管阻力增加 手术操作压迫,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,21,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后对循环的影响 心律失常 缺氧、二氧化碳蓄积 手术操作刺激 术前心血管疾患或已有心律失常,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical Coll
12、ege,22,第一节 剖胸及侧卧位对呼吸循环的影响,剖胸所引起的病理生理改变 剖胸后其他病理生理改变 胸膜肺刺激综合症 胸膜腔及肺内压力改变 手术操作对肺门、纵隔及胸壁等部位的刺激 胸膜腔壁层胸膜干燥引起的刺激 体热和体液散失过多,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,23,第一节 剖胸及侧卧位对呼吸循环的影响,开胸手术时体位改变的生理影响 功能残气量(FRC): 清醒状态下,直立位仰卧位,FRC 0.8L;全麻状态下, FRC 在原有的基础上0.4L;剖胸后,
13、 FRC 进一步下降。,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,24,第一节 剖胸及侧卧位对呼吸循环的影响,开胸手术时体位改变的生理影响 通气血流比值(VA/Q) 两肺血流分配: 仰卧位 左/右 45 / 55 左侧卧 左/右 55 / 45 右侧卧 右/左 65 / 35 卧侧/对侧平均:60/40 全麻剖胸后,血流分配异常, VA/Q,2019/8/18,Department of Anesthesiology, Affiliated Hospital of
14、XUZHOU Medical College,25,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,26,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,27,第二节 麻醉前的评估与准备,麻醉前评估(Preanesthetic evaluation) 一般情况评估 肺功能状态 性质(阻塞性、限制性、混合性) 吸烟情况 碳氧血红蛋白、支气管黏膜纤毛 年
15、龄 呼吸道分泌物清除能力、肺泡变薄、肺大泡 体重 肥胖,闭合气量增大,A-aDO2增加,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,28,术后肺病发症的相对发病率,肺功能异常/正常 吸烟者/不吸烟者 年龄60 /60 体重超重(20%标准体重)/不超重,23/1 6/1 3/1 2/1,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,29,201
16、9/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,30,吸烟,年龄超过60,肥胖,手术广泛而手术 时间在3小时以上,危险因素,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,31,第二节 麻醉前的评估与准备,麻醉前评估(Preanesthetic evaluation) 呼吸系统情况估计 临床病史及体征 呼吸道感染史 咳嗽 呼吸困难 紫绀 哮喘 杵状指 呼衰
17、史等 影像学诊断技术,X线,支气管造影术,CT,MRI,2019/8/18,Department of Anesthesiology, Affiliated Hospital of XUZHOU Medical College,32,In patients with tracheal stenosis(狭窄), the history should focus on symptoms or signs of positional dyspnea, static versus dynamic airway collapse, and evidence of hypoxemia. The hist
18、ory may also suggest the probable location of the lesion. Arterial blood gas (ABG) determinations may help to clarify the severity of underlying pulmonary disease but are not routinely necessary. Pulmonary function tests are useful in assessing the pulmonary risk of lung resection. Both exercise fun
19、ction (maximal oxygen uptake O2max) and spirometry (forced expiratory volume in 1 second) have been used to stratify risks of resection. In marginal cases, split-function radionuclide scans and ventilation/perfusion ( ) scans can determine the relative contribution of each lung and individual lung r
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