全麻并发症-PPT课件

表现(clinical manifestations)：
呼气性呼吸困难、喘鸣音(expiratory wheeze ) 呼气期延长(a prolonged expiratory phase)、 费力、缓慢、HR↑或 心律失常 (arrhythmia) .
处理(management)：
●轻度：手控呼吸(artificial ventilation)即可改善. ●严重支气管痉挛： 支气管扩张剂（bronchodilator) 激素(steroids). ●缺O2、CO2蓄积诱发者→IPPV ●浅全麻下手术刺激诱发者→加深麻醉（deepen anesthesia)及肌松药(muscle relaxant).
预防（prevention)：
◆择期手术术前:＜6月： 4h禁奶及固体食物，2h禁清亮液体. 6～36月：6h禁奶及固体食物，3h禁清亮液体. ＞36月： 8h禁奶及固体食物，3h禁清亮液体. ◆备吸引器、鼻胃管减压. ◆饱胃、高位肠梗阻：宜清醒气管插管(awake intubation). ◆H2-R拮抗剂(to reduce the acidity of gastric contents).
避免麻醉过浅avoidinglightanesthesia监测脑电图monitoringelectroencephalogrameeg监测脑干听觉诱发电位变化monitoringauditoryevokedpotential麻醉苏醒期始于停止给麻醉药止于病人能对外界言语刺激作出正确反应凡术后超过30min呼唤不能睁眼和握手对痛觉刺激无明显反应即为苏醒延迟术前用药
全身麻醉期间严重并发症的防治
呼吸道梗阻
respiratory obstruction
呼吸道梗阻:上梗(upper airway obstruction) 下梗 (lower airway obstruction) 或 完 全 性 梗 阻 (completely obstruction) 部 分 性梗 阻(partially obstruction)
处理(management)：
▼减浅麻醉、如CVP不高→加快输液及胶体，必要时 用升压药(vasoconstrictor). ▼严重冠心病者，术中反复低血压→防心梗发生， 支持心泵功能(dobutamine)。 ▼手术牵拉内脏致BP↓→暂停手术操作，少量麻黄 素(ephedrine)等. ▼对肾上腺皮质功能不全者→大剂量DXM. ▼术中一旦测不出BP→立即CPR.
二、高血压及其防治
(prevention and treatment of hypertension) 指BP↑＞麻醉前20%或BP≥160/95mmHg（高血 压）.
(Intraoperative hypertension may be defined as SBP 25% greater than the patient,s preoperative valve.)
应用吗啡类、全麻药、肌松药后→贲门括 约肌松驰→胃内容物反流→下呼吸道严重阻塞 →误吸死亡率50%～75%。 误吸胃液→突发支气管痉挛、呼吸急速、 困难、肺内弥漫性湿罗音，严重缺O2.
Bronchospasm is the first sign . If a large quantity of gastric material is aspirated, respiratory obstruction, V/Q mismatch and intrapulmolary shunting may produce severe hypoxaemia,with chemical pneumonitis.
预防(prevention)：避免浅全麻下行气管插
管或手术操作，防缺O2与CO2蓄积。
㈡支气管痉挛(bronchospasm)：
诱发因素(aetiology)：
●气管插管(tracheal intubation)、反流误吸 (regurgitation and aspiration)、吸痰(suction of secretions). ●手术刺激(surgical stimulation)→反射性痉挛(reflex spasm). ●硫喷妥钠、吗啡等→肥大细胞释放组胺(histamine)→ 诱发痉挛.
反流与误吸
(Regurgitation and aspiration)
原因（Aetiology）:
Regurgitation and pulmonary aspiration of gastric contents are more likely to occur in patients with intra-abdominal pathology,delayed gastric emptying or inadequate gastro-oesophageal sphincter function. Aspiration is more common during emergency ,obese or obstetric patients. Mortality is high after major aspiration.
病人因素(factors of patients)：
●术前有明显低血容量(hypovolaemia)未予纠正. ●肾上腺皮质功能衰竭(failure of adrenal cortex ,s function ). ●严重低血糖(hypoglycemia). ●血浆CA (catecholamine)↓↓(嗜铬切除后). ●心律失常(arrhythmia)或心梗(cardiac infarction).
预防(prevention)：
★术前充分补液，纠正水、电失衡. ★纠正贫血. ★RHD、严重MS→切忌使用抑制心血管作用的麻醉药. ★已有心脏缺血的冠心病病人→BP维持正常，防ST-T 进一步改变. ★心梗者→除非急症，待6个月后再行择期手术. ★心衰者→心衰控制后2W再手术. ★Ⅲ度房室传导阻滞或病窦综合征→起搏器. ★低K+→补K+. ★房颤→心室率80-120次/分. ★长期激素治疗者→术前、术中加大激素用量.
临床表现: 胸部和腹部呼吸运动反常，吸气性喘
鸣，呼吸音低或无,三凹征、呼吸困难， 呼吸动作剧烈，但无通气或通气量低。
舌后坠（上梗） (Tongue falling afterward )
镇静、镇痛药、全麻药及肌松药→下颌骨及舌肌 松驰→舌坠向咽部阻塞上呼吸道 不完全性:鼾声(Snore) 舌后坠阻塞咽部(pharynx) 完全性:只有呼吸动作, 无呼吸交换,SpO2↓ Reduced muscle tone with apposition of the tongue and pharyngeal soft tissue is a common cause. This is usually overcome by jaw lift and use of an oral or nasopharygeal airway. The patients should be placed in a head-down position.
常见于哮喘、慢性支气管炎、肺气ห้องสมุดไป่ตู้、过敏性鼻炎。
㈠喉痉挛(laryngospasm)：
Laryngospasm is a reflex, prolonged closure of the vocal cords in response to a trigger, usually airway stimulation during light anesthesia.
低血压与高血压
Hypotension and hypertension
一、低血压及其防治
The prevention and treatment of hypotension 指血压降低幅度超过麻醉前20%或SBP≤80mmHg Hypotension during anesthesia may be defined as MAP less than 60 mmHg or SBP 25% less than the patient,s preoperative valve.
◆手术因素(Factors of surgical operation)：
●术中失血多未及时补充(haemorrhage). ●副交感N(parasympathetic)分布区手术操作 →迷走反射(vagal reflex). ●手术操作压迫心脏、大血管(oppression of the heart and major vessels). ●直视心脏手术(cardiopulmonary bypass).
发生原因(aetiology)：
◆麻醉因素(factors of anesthesia)：
●麻醉药、麻辅药→ 抑制心肌(inhibition of cardium)
血管扩张(vasodilation)
●过度通气→低CO2血症(hypocapnia)
●排尿过多→低血容量(hypovolaemia)、 低K+(hypokalaemia) ●缺O2→酸中毒(acidosis) ●低体温(hypothermia)
处理(management):
发生反流误吸时→头低位(head-down position)、转向一侧、吸引 (suction)、支气管解痉药（bronchodilator)、必要时支气管镜检 （bronchoscopy)
喉痉挛与支气管痉挛
Laryngospasm and Bronchospasm
BP过高指BP↑＞麻醉前30mmHg.
影响(effects)
●BP过高→↑左室射血阻力→左室舒张末期压↑→心内膜 下缺血→梗死. (Hypertension increases myocardial work by increasing afterload and left ventricular wall tension.)
处理(management):
轻度：吸气时喉鸣：去除局部刺激后可自行缓解. 中度：吸气、呼气都出现喉鸣音:需面罩加压给O2. 重度：声门紧闭,气道完全阻塞，粗针环甲膜穿刺吸
O2or iv 肌松药→加压吸O2 or 气管插管。 If laryngospasm persists and hypoxaemia ensues, muscle relaxant relaxes the vocal cords and allows manual ventilation and oxygenation.
诱发原因(aetioloty)：
◆低O2血症(hypoxaemia)、高CO2血症(hypercapnia)、口咽 部 分 泌 物 (secretions of oropharynx) 与 反 流 胃 内 容 物 (regurgitation of gastric contents)刺激咽喉部。 ◆口咽通气道（oropharynx airway)、喉镜(larynxoscopy)、 气管插管操作(tracheal intubation)。 ◆ 浅麻醉下手术操作 (surgery manipulation under light anesthesia)：扩肛、剥离骨膜、牵拉肠系膜及胆囊等。
Patient with increased airway reactivity from recent respiratory infection,asthma, atopy or smoking are more susceptible to bronchospasm during anesthesia. Bronchospasm may be precipitated by stimulation of the carina or bronchi by a tracheal tube.
(呼吸道保护性反射→声门闭合反射过度亢进)
临床表现(clinical manifestations)：
Laryngospasm can lead to inadequate ventilation with hypoxaemia and hypercapnia. Crowing inspiration noises with signs of respiratory obstruction suggest partial plete laryngospasm is silent. ◆吸气性呼吸困难、高调吸气性哮鸣音. ◆喉痉挛→支配咽部的迷走神经兴奋性↑→咽部 应激性↑→声门关闭活动↑. ◆发生于全麻Ⅰ～Ⅱ期（浅全麻）,硫喷妥钠易诱发 喉痉挛.