《脊柱侧弯--叶亚军课件》由会员分享，可在线阅读，更多相关《脊柱侧弯--叶亚军课件（56页珍藏版）》请在金锄头文库上搜索。
1、脊柱侧弯矫形术 麻醉处理,叶亚军,手术时间长，刺激大，创伤大，出血多 术中监测病人的脊髓功能 麻醉要求： 术前评估 （心肺功能） 呼吸管理 导管深度 气道压力 术中唤醒 瑞芬+异丙酚+笑气 芬太尼 无肌松,脊柱侧弯 scoliosis,麻醉方法,硬膜外： 单次，两点穿刺，复合全麻 优点：术中镇痛效果好， 有效抑制机体应激反应， 血流动力学稳定。 缺点: 穿刺困难, 持续给药困难无法保证有效的通气， 追加药困难， 切口太长无法保证平面。,麻醉方法,全身麻醉 随着越来越多的起效快,无蓄积,苏醒快药物的出现, 麻醉医师的操作变的越来越容易 静脉麻醉为主，少用醚类吸入剂 唤醒前要有长效止痛药遗留作用
2、肌松剂的使用,术中脊髓功能的监测, 躯体感觉皮层诱发电位: 受麻醉药物的影响 七氟醚混合笑气比异丙酚影响小 Mochida等运用 成串脊髓刺激发现可以大大提高 对肌肉电位的敏感性,认为是最适合的方法 现在认为最理想的监测技术是对运动皮层 的电磁 刺激法,术中体温的检测,围术期浅低温引起很多严重的并发症 心脏疾病，凝血功能障碍，增加输血, 降低药物代谢导致术后恢复延长。 通过降低多形粒细胞的氧化杀菌作用损害机体免疫功能，致使手术部位感染增加 300%,有关脊柱侧弯麻醉的文献,氧化亚氮运用于脊柱侧弯矫形手术，可以明 显缩短唤醒时间和苏醒时间 ，并且减少或避免唤 醒时的不良反应。,有关脊柱侧弯麻醉的
3、文献,地氟烷组： 异氟烷组： 普鲁卡因复合液:10%GS500ml+琥珀胆碱400mg+普鲁 卡因5 g,地氟醚血气分配系数低,诱导平稳快速,麻醉 深度易于控制较适合于唤醒实验,但唤醒期间血 流动力学波动明显,复合低剂量的麻醉性镇痛剂 芬太尼,可减轻苏醒期间的即发疼痛反应,有关脊柱侧弯麻醉的文献,有关脊柱侧弯麻醉的文献,脑电双频指数监测在脊柱侧弯中唤醒实验时 的应用价值(郭建周等) 不同麻醉方法和不同个体之间,BIS监测的灵敏度和特 异度会有些变化,单对单个患者而言,唤醒实验期间BIS监 测可提供一个有用的变化趋势 在使用血管活性药给麻醉深度的判断带来困难时BIS 监测更显重要 实验中在BIS
4、提供较高意识水平下,未发现较高的外 显回忆率,电视胸腔镜 下脊柱侧弯Eclipse矫形术的麻醉( 林建等 ) VATS技术用于脊柱外科始于上个世纪90年代 初,麻醉的成功关键在于单肺通气的管理 单肺通气时间长 存在不同程度的限制性通气功能障碍 侧卧位不利于通气/血流的维持 术中PETCO2,SPO2 难以维持,有关脊柱侧弯麻醉的文献,有关脊柱侧弯麻醉的文献,长时间的单肺通气低氧和高碳酸血症很难避免 呼吸的管理: PETCO2控制在50 mmHg以下, SPO2 90%以上 气道压在较高水平 35 mmHg以下 定时膨肺 /小时,病例 1 李京京,女性 14岁 身高 136cm 体重31kg 体
5、表面积 1.10m 活动后心慌气 短 ,不能上体育 课,病例 1 李京京,实测值 预测值 %预测值 潮气量 VC 0.81 2.14 37.9 补呼气量 ERV 0.27 1.44 18.8 最大通气量 FVC 0.81 2.14 37.9 用力通气量FEV1.0 0.71 3.18 22.3 重度限制性通气障碍 通气储量百分比中度不足 残气占肺总量百分比中度不足 弥散功能重度下降(肺活量小) 心功能 EF 57%,病例 2 张瑜,女性 12岁 身高119.0cm 体重21kg 体表面积0.84m 活动后心慌气 短,不能上体育课,实测值 预测值 %预测值 潮气量 VC 0.69 1.56 44
6、.2 补呼气量 ERV 0.16 1.27 12.6 最大通气量 FVC 0.66 1.56 42.3 用力通气量FEV1.0 0.62 2.63 23.6 重度限制性通气障碍 通气储量百分比中度不足,病例 2 张瑜,病例 3 恶性高热,女性 24岁,病例 3 恶性高热,曾在上海长征医院就 诊。 病人自诉：麻醉后呼 末二氧化碳升高，取消 手术。,病例 3 恶性高热,病人呼末CO2升 高，一度达到60 mmhg 增加呼吸频率 20次/分 气道压力增高,病例 3 恶性高热,病例 3 恶性高热,取肌肉组织司可林浸泡,恶性高热,早期表现：呼末二氧化碳明显增高 体温增高 处理： 有效降温，体表，创口，血
7、液 一般处理，更换呼吸管道，钠石灰， 激 素,恶性高热,THE inherited myopathy malignant hyperthermia (MH) Cited Here. features sustained skeletal muscle hypermetabolism caused by altered calcium homeostasis. Human MH usually occurs with exposure to volatile anesthetic agents and/or depolarizing muscle relaxants.1,Case 1 was a
8、 23.8-yr-old, 68-kg muscular woman with a personal history of one previous general anesthetic without unusual metabolic responses and a negative family medical history. She had no abnormalities of muscle tone or structure preoperatively and no cardiopulmonary disease. She was an elite athlete. She w
9、as anesthetized for a total thyroidectomy and radical neck dissection for thyroid cancer.,Case 1,Case 1,Her second general endotracheal anesthetic included isoflurane and succinylcholine. Anesthetic monitoring before the signs of MH included capnometry, pulse oximetry, and an esophageal temperature
10、probe. Four hours 33 min after an anesthetic induction, she developed tachycardia. She subsequently developed (in order of appearance) arrhythmia, rapidly increasing temperature (maximum temperature 41.0C), generalized muscular rigidity, hypercarbia, and excessive bleeding.,Case 1,Results of an arte
11、rial blood gas drawn 4 h 45 min after anesthetic induction while the patient was being hyperventilated with a Fio of 1 were a pH of 6.78, a Pco2 of 147 mmHg, a Po2 of 250 mmHg, a base excess of -17 mEq/l, and a bicarbonate level of 20 mEq/l. Peak potassium was 6.9 mEq/l, peak creatine kinase was 9,2
12、05 U/l, prothrombin time was 28 s (upper limit of normal, 17 s), and partial thromboplastin time was greater than 100 s (upper limit of normal, 40 s).,Case 1,Unsuccessful treatment included volatile anesthetic discontinuation (4 h 37 min after induction and 4 min after the first adverse sign), hyper
13、ventilation with 100% oxygen with a new anesthesia machine and circuit. Dantrolene (initial dose of 1.8 mg/kg given 4 h 40 min after anesthetic induction and 7 min after the first adverse sign and then titrated to a total of 10.3 mg/kg). Active cooling, fluid loading, furosemide, mannitol, bicarbona
14、te, glucose, insulin, procainamide, dopamine, phenylephrine, epinephrine, norepinephrine, dexamethasone, heparin.,Case 1,Extracorporeal membrane oxygenation, and cardiopulmonary resuscitation. No reduction in the patients rigidity was noted with the dantrolene administration. The patient did not sur
15、vive this reaction that had begun while the patient was in the operating room.,Case 1,Information obtained after the patients death from her family revealed that she had had several childhood febrile episodes of unknown etiology and that she had reported myalgias for 4 days after a brief general anesthetic 1 month previously.,Case 2,Case 2 was a 21-yr-old, 95-kg muscular man who had a personal history of hand tremors but no history of unexplained fevers, muscle cramps, dark urine, heat stroke, or heat intolerance. He had no history of cardiopulmonary disease. His family history was re
