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1、无痛内镜术检查的麻醉无痛内镜术检查的麻醉无痛内镜术检查的麻醉无痛内镜术检查的麻醉四川大学华西医院四川大学华西医院四川大学华西医院四川大学华西医院 麻醉与危重病医学教研室麻醉与危重病医学教研室麻醉与危重病医学教研室麻醉与危重病医学教研室 王晓王晓王晓王晓 第一部分：概述第一部分：概述第一部分：概述第一部分：概述年龄分布（ %）210岁(0.02) 1120岁( 2. 31) 2130岁( 7. 86) 3140岁( 24. 45) 4150岁( 20. 47) 5160岁( 20. 77) 6170岁( 15. 78) 70岁( 8. 29)总体情况总体情况总体情况总体情况2003.7到2009
2、.6接近10万例每月平均2000例08年超过20000例流程流程流程流程-1-1-1-11 1 1 1、评估病人和签署麻醉同意书、评估病人和签署麻醉同意书应排除有安全隐患的病人 （充分与病人交流）检查前的评估检查前的评估检查前的评估检查前的评估: : : :重点工作重点工作重点工作重点工作初级评估(免费):住院医师完成进一步评估:麻醉门诊进行心、肺进一步检查药物的治疗评估分两部分评估分两部分评估分两部分评估分两部分: : : :全身脏器功能的评估全身脏器功能的评估: : : :心脏心脏肺肺气道等等气道等等消化道的评估消化道的评估: : : :对病人进行术对病人进行术 前评估前评估, , , ,
3、明确是否存明确是否存 在影响镇静后果的病在影响镇静后果的病 史和体检结果史和体检结果. . . .评估评估 的结果在实施镇静前的结果在实施镇静前 应该被记录下来应该被记录下来. . . .专专 门为镇静检查所设计门为镇静检查所设计 的结构形式的应用的结构形式的应用, , , , 提高了检查的顺从性提高了检查的顺从性. . . .简要陈述和建议：简要陈述和建议：ASAASAASAASA病情评估分级标准病情评估分级标准* * * *1 级 正常、健康2 级 有轻度系统性疾病3 级 有严重系统性疾病,日常活动受限4 级 有严重系统性疾病,常面临生命危险5 级 手术与否,生命难以维持24小时的濒 死患
4、者* 如系急症,在每级数字前标志”E”或”急”.评估分级评估分级流程流程流程流程-2 麻醉前准备麻醉前准备 包括器械、药品包括器械、药品 病人心理病人心理 病史的复习病史的复习endendendend流程流程流程流程-3 麻醉和内镜检查 根据病人评估的情况选择麻醉方式： 全身麻醉和镇静镇痛 再次评估气道、胃潴留问题endendendend文件管理：文件管理：麻醉前评估、同意麻醉前评估、同意 和麻醉中记录和麻醉中记录文件管理：文件管理：麻醉前评估、同意麻醉前评估、同意 和麻醉中记录和麻醉中记录药品配制的规范：药品配制的规范：药品配制的规范：药品配制的规范：异丙酚异丙酚1010mg/ml-10ml
5、mg/ml-10ml注射注射 器器芬太尼芬太尼1010 g/ml-5mlg/ml-5ml注射器注射器舒舒芬太尼芬太尼1 1 g/ml-5mlg/ml-5ml注射器注射器咪唑安定咪唑安定0.50.5mg/ml-2mlmg/ml-2ml注射注射 器器第二部分：第二部分：第二部分：第二部分： 镇静镇静镇静镇静/ / / / / / / /镇痛镇痛镇痛镇痛 (Sedation and Analgesia)(Sedation and Analgesia)(Sedation and Analgesia)(Sedation and Analgesia)(Sedation and Analgesia)(Sed
6、ation and Analgesia)(Sedation and Analgesia)(Sedation and Analgesia)Use of anesthetic agents for endoscopy? Use of anesthetic agents for endoscopy? Use of anesthetic agents for endoscopy? Use of anesthetic agents for endoscopy? 耐受性:Tan,Freemen:throat anaesthesia only; tolerated by 75%of atients;bad
7、tolerance to5%. 胃肠病学2000.5:256 电子结肠镜检查失败的 原因分析1.肠道准备差(57.4%)2.患者疼痛(19.1%)Upper gastrointestinal endoscopy without sedation: a Upper gastrointestinal endoscopy without sedation: a Upper gastrointestinal endoscopy without sedation: a Upper gastrointestinal endoscopy without sedation: a prospective stu
8、dy of 2000 examinations.prospective study of 2000 examinations.prospective study of 2000 examinations.prospective study of 2000 examinations. Gastrointest Endosc. 1989 Mar-Apr;35(2):79-81.Gastrointest Endosc. 1989 Mar-Apr;35(2):79-81.Gastrointest Endosc. 1989 Mar-Apr;35(2):79-81.Gastrointest Endosc.
9、 1989 Mar-Apr;35(2):79-81.2000 upper diagnostic gastrointestinal endoscopies were performed in a period of 4 years between 1982 and 1986, without any sedation, using Olympus GIF-Q and GIF-P3 gastroscopes. the overall success of the procedure were assessed.Most patients were calm (81.2%)only four exa
10、minations failed (0.2%). 32 patients due to excessive anxiety and an inability to introduce the gastroscope and in three children under 10 years (1.6%). 病人三大状态清醒清醒清醒清醒镇静镇静镇静镇静麻醉麻醉麻醉麻醉概念！ASA对镇静/镇痛：Minimal Sedation (Anxiolysis)Minimal Sedation (Anxiolysis)Minimal Sedation (Anxiolysis)Minimal Sedation
11、(Anxiolysis) = a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.Moderate Sedation/Analgesia (Conscious Moderate Sedation/Analgesia (Conscious Moderate
12、Sedation/Analgesia (Conscious Moderate Sedation/Analgesia (Conscious Sedation)Sedation)Sedation)Sedation) = a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are require
13、d to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.DEEP SEDATION:DEEP SEDATION:DEEP SEDATION:DEEP SEDATION: A medically controlled state of depressed consciousness in which a patient is not easily arousable, has lost the ability to i
14、ndependently and continuously maintain an airway, has partially or completely lost protective reflexes, and cannot purposefully respond to verbal commands and/or tactile stimulation.GENERAL ANESTHESIA:GENERAL ANESTHESIA:GENERAL ANESTHESIA:GENERAL ANESTHESIA: A medically controlled state of unconscio
15、usness in which a patient has lost the ability to independently maintain an airway, has completely lost protective reflexes, and is unable to purposefully respond to verbal commands and/or tactile stimulation. American Society of AnesthesiologistsAmerican Society of AnesthesiologistsAmerican Society of AnesthesiologistsAmerican Society of Anesthesiologists Levels of Sedation Levels of Sedation Levels of Sedation Levels of Sedation CONTINUUM OF DEPTH OF SEDATION DEFINITION OF GENERAL ANESTHESIA AND DEPTH OF SEDATION DEFINITION OF GENERAL ANESTHESIA AND DEPTH OF SE
