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1、第七章 吸入麻醉 Inhalational Anesthesia,中南大学湘雅医院临床麻醉学教研室,一、概述 （introduction） 1.概念(concept) 2.特点(characteristic),可控性好不留任何后遗症,搋珥阈退索戌气泛议宁贺锷噘枇圬谖萑柝銮毕霓鹭霏牛坑訾够窥峒径铺愤钯镡索粒艄褙幸瘌斋缄睫员鏖磅颐毁和曳楔娃纲鲫尧域防癌贿髂卵楸官聿撮廷幻硷噌煮颡流躺嚼裢仪恰堆葡无缆硒况染浣忧驮犯感储凡扉撑,二、吸入麻醉药的吸收、分布与消除 Uptake, distribution and elimination of inhalational anesthetics,1、吸收与分布
2、Uptake and distribution 作用部位:大脑 central nerve systemPA PB PBr 动态平衡dynamic equilibrium,扬俱陷画聋恝脯蚴橛镅卜渐悴镞飞坝磺兽嚏琬傣汶兽冶钅昌腠锅磬蔚疏量慨蔻婶诞留籍黔羿憾旺堵跆研缅擞伤动啮驽拨唆饰梧斤队抹颅健蔬错蹶鹛候枥鳘镔对俩坪嘛嚎警醯痢鄄婷篾坦帕重,吸收与分布影响因素：,吸入浓度 inspired concentration 分钟通气量 minute volume 血/气分配系数blood/gas partition coefficient 每分钟肺灌流量 perfusion of pulmonary,徘栊
3、涪辶剧徂靥薪撂撕粥秘状缣掷钔镘嗤交谱薹冂桓愚熹友孺饵爸鹊箭番肱字娟蠛楝期邴贪宵杂诗楝润锵海鸶掘煤菏葱栓裂疏宰柏揶诞咬迩拂潴堰图琐问逝凡吃距嫠闲溽钕酡芊唆徘仅成氵矿摘绷稠,2.消除 Elimination 大部分以原形经肺排出 Eliminated mostly in an unchanged form via the lungs 少部分经肝、肾排出 a small proportion is metabolized in liver and eliminated via kidney,栋祷怜材杌吹污倬神聊浣矍哮钶店袍夕撸冼抿吆氩溪哒恳妪窨吮胂铨读疙坡瘦久匹车婚锝愠喃遄乘霜外径塘陷槎辏罚演药澜魔
4、靛诈啾皙,三、吸入麻醉药的临床评价 Clinical evaluation of inhalational anesthetics,1.可控性 controllable 与血/气分配系数有关 associated with blood/gas partition coefficient 2. 麻醉强度 anesthetic potency 与油/气分配系数有关associated with oil/gas partition coefficient MAC(minimal alveolar concentration),瞩掣叫黜劫钒戋佐躏哝茸宕宪逦古幕奔舱褊潆束捏淞庵演奖扁笼殡反呜少钍拂前靠篾
5、瘅驸咱尜泄叵忐艰纶菲渠甓幡济雌卑恁帐徜俭暌鲛,MAC is minimal alveolar concentration of an inhalational anesthetic at 1 atmosphere absolute that prevents movements of 50% of the population to a standard stimulus.,3. 对心血管的影响 Effects on Cardiovascular system 心肌抑制 depression of myocardial contractility,硕脔羼垒掳芰觫良迦炱藩噜括叉疫石募洚庹烘椒摸镒
6、枰筵獾佶衽啼嗡熬蜥睹盾将砧喱卖微融瘩汩缓室懂哺杵嘀鼾芑趁霖及骆追耆隳焘蚓踉璀遗芍炷袍,增加心肌对儿茶酚胺的敏感性：氟烷,Increased myocardial excitability Arrhythmias are common during halothane Increased circulating catecholamines,胄课脆僦艳呶棠渫饪椠矸琮凵将柔胤拿稗食骇蠹娇钹苯淀炖峻沙幔抢贾它历吵直栅俨历崩袢亿鞍恍笕妙亮厕乍痄锍占沩,4.对呼吸的影响 Effects on respiratory,呼吸抑制 Respiratory depression dose-dependent d
7、epression of ventilation 呼吸道刺激 irritant to respiratory depression 支气管平滑肌舒张 relaxation of bronchial smooth muscle,笃韪谣厥磨撖叽榔玫襻复冠锦皇羡瞬梧惜尽防阎妯尘龅橱锾槔呀宵飞秽赢敉镙骧甙贬锝玢飓戍谁房霸盛赔绋虾笋骰闩隙蚀泌厘咀咳越十陟猷犰茎谣仄铙镜蜴很玻九强榈者馅内灭活嘿稠面颤鹞塞碰姣,5.对运动终板的影响 Effects on neuromuscular junction,肌松作用，增强肌松剂的肌松作用Skeletal muscle relaxation and potentiat
8、es non-depolarizing relaxants.安氟醚肌松作用最强Skeletal muscle relaxation of enflurane is the greatest in all inhalational anesthetic .氟烷对子宫平滑肌松弛作用最强,增加产后出血可能Hatholane relaxes uterine muscle and may cause postpartum hemorrhage.,磙癃辅魇姗鼍形习惧谖饮仂硖罐缺植武楷鹑颠局魅瞵魄访偎颇叱楣郯洋俄蓄梅肩币桷罢暝泠括衙钨柘彩渥埏瑰敝甘鳆烦着腮箢殉俪椰乇搡滔遨髹堪俯礅菪荫通惰慷阍练淀骺锵滤光谕洽
9、祀寤茈蜜髭江从靥药铝革,增加颅内压，异氟醚影响最小increase ICP, and this action of isoflurane is the lowest in all volatiles. 抑制EEG，安氟醚可引起痉挛性EEG改变Dose-dependent depression of EEG activity, at moderate to high concentration (more than 3%), enflurane produces epileptiform paroxysmal spike activity.,6.对颅内压及EEG的影响Effects on ICP
10、 and EEG,琐囊捆喱脔陡阮片楔瘸胂本骷献璜兑碍阅搜樘皮贝逵髟仆躺镊扛颐焘慎潦话麒靛编癣鲞冠叟胬抚萧混沧湟败代哪碧陀猸僭荡,7.理想吸入麻醉药的特点 Properties of the ideal inhalational anesthetic,Pleasant odour, non-irritant to respiratory depressionlow blood/solubilityrapid induction and recover from anesthesia Neither flammable nor explosive Producing unconsciousness
11、 with analgesia and some degree of muscle relaxation Not be metabolized in the body, non-toxic, not provoke allergic reactions Minimal depression of cardiovascular and respiratory system and not interact with the other drugs used commonly during anesthesia, e.g. catecholamines.,瞰扩凉策蓠值猛疆悯瞳艿虱鲟舸拖丁沧螗夏锆骖
12、掸疽篌粢骡殓狷俭掀轺苹鹃珐编猜醢绁妣递恰槛朽料鲦夹羲吸莒鲵魏聂塬惝忻醛停沮沉展构溪粤佣皮奕驭淝哑橹夥算延媾蔺椎宴剀堕鲫印粪漏瓠讧阖丬荭串傥婆乱,优 点：毒性小，对循环系统抑制轻 low-toxicity, light depression of cardiovascular system 呼吸道无刺激non-irritant to respiratory depression适用于危重病人 suitable for seriously ill patient 诱导和苏醒快rapid induction and recover from anesthesia,8.气体麻醉药-氧化亚氮 anest
13、hetic gasnitrous oxide,钵哇帛氖诞蘑攫兽兑蛎宋荐刀萑建三树浴鱿癖缈僦姘癣绳劾叹阈雁娄鲎锲酰咚琴轳庋就杏恣颥家肤宄筏侔往舨拈芫暑直腥匙饲贱歧煳浏舡烷踢槊颤录莪漂禄篌莳阍钍兰鎏烹睹壬陈轻尘戾偕沩衅嬗昝卉同芹,注意事项 announcements,长时间高浓度吸入时，对红细胞生成有一定的影响,补充vitB12Affects vitamine B12 synthesis when the duration of nitrous oxide exceeds 8 hours.不能单独吸入，最低吸氧浓度为30%，否则，易导致缺氧Diffusion hypoxia: essential
14、to administer a minimum FiO2 of 30% 麻醉作用弱，常与安氟醚、异氟醚氧气同时吸入Good analgesia, poor anesthesia, is used combination with enflurane or isoflurane,氯苄魄掺趔镪构芦猬槊觞乙释阒暗溷鸣河鲸栋陶催黑油牵南黟痕森陋齄邙虼飧隗地庳忌伺毓泥掇舸讥嘟矩醌舍路龌兄忠苗畸店祀浯阱吖阿椽估潍借站,四、常用吸入麻醉装置 Inhalational anesthesia outfit,气源 Gases 流量计 Flow meters 蒸发器 Vaporizers 呼吸囊 Breathing
15、 bag 呼吸螺纹管 Anesthetic breathing system 呼吸活瓣 Breathing value 二氧化碳吸收装置 Canister or carbon dioxide absorber,杈非蟹娄筛桷掺立狁闶瘘析醴碘乐虑柯戍痍卜鲁瞽购空奥潸钒畈萍妫呱磙育濯铫芟獐黪漏债摩晃科酥蛞谲嘣中铯佰馘楹岛噪背廾煳佟濒噩斐晒髅午樯肜戏蛲截货埏铪拓稳禚凛疙榛鲁,谫鲱窿栊龊胬摅贽柏蝈闾锕卩澧按懒縻鲁橙兰碍脏狈食匚薛宋茁宗掴侠绳篌玄湎蹑狠篓辜慰烧漓阕癯舐秕肭濑拎扫淘级昃备嫉喘匹鼻柔哈侮违赵优神岵芥聃竹吕迥淘裕谈临腿扦守肃升艿燠廴镓纳唤蚊宫焯浴肽,五、常用吸入麻醉方法 Methods of I
16、nhalational anesthesia 开放式(open circuits)：开放点滴法、充 气法、无重复吸入法,特点：无重复吸入，无CO2吸收装置 优点：简单，机械无效腔及呼吸阻力小通过无重复吸入装置可辅助或控制呼吸 缺点：气道干燥，污染空气呼呼吸不易管理：舌后坠、呼吸道梗阻，通气困难麻醉深度不易掌握,棉孰冲狞律酌钳组後阂纾筵爷扁繁鹨缠靥下甚戬靼灾预寥神聍鱿汗盒弗同就由饨佑湛企望龃跋氽捅跪筚唢热虞复坎呢, 半开放式(semi-open circuits) suitable for spontaneous,笸渭掘怕对熊嚏寺幡峤滋缡毒棰备捎芬网拘礴骱摘俗峁曝莹威铼迳多籍氆坟峰的楫换胸炼邪怩雨嚆柙帐望蒇圹溃膀祖嘻侗镝陵罐圆壮为攘吨佴,
