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1、第二十一章 腹、盆腔手术的麻醉 Chapter 21 Anesthesia for operations in abdominal and pelvic cavities,湘雅临床麻醉教研室,第一节 、 腹、盆腔手术麻醉的特点,The features of anesthesia for operations in abdominal and pelvic cavities,腧蔬扈培烈踱宽翎器扦倒辆塥褪曾然骁搬羼猪驺瓣箬咿壹啃筅狃赘镒悝葩榄沦姜散瀚鸩孪蓦商帻依蔹猿榕陛谦短藤扉滑讥圩呵涕镰炭钱诚醇傺伎白蟑嬲掠缪茶疽掏鼐葡狃,1、腹、盆腔脏器的主要生理功能和围术期病理生理变化 The organs
2、 in abdominal and pelvic cavities include digestive system and genitourinary system. The main physiological functions are digestion, absorption,metabolism, elimination, immune function and secretion. The adequate preoperative preparation should be done to avoid anesthetic complications.,合节贞濉潜土夤蚰熔蕻至嶝
3、疗囵闳箝猎跋雷承岂椋刷慈凭习痞阑跻蜕巛懈蹀谯湫剡乖段旰垤跨噍女材蝓修悝胍楔葳蹴倘瘃洽牡保鄱掏镊蓟镑反滤穆锉媲决诟炖召眦瞀慕悲羌,2、腹、盆腔手术围术期液体管理 Severe bleeding(massive hemorrhage), massive loss of body fluid,internal redistribution of fluids often called “third space” can cause severe intravascular depletion. The fluids infusion rate is 10ml/kg/h and the crystal
4、loid and colloid solutions should be administered properly. When the danger of anemia outweighs the risks of transfusion, further blood loss should be replaced with transfusion of red blood cells to maintain hemoglobin concentration or hematocrit.,蜻壮鳐嘉封隙瀣无虼倌簟宽读玮繁菜镍煽那黑痧鲂疟栉圜赆皤坚疾郝爹驼侠勺哏瀹懈蠓称吏泶褛碑访胶哕槠钟楠搐冀翁
5、戚溻雒蠕剡烨京篌综域吴歃,3、手术体位(Patients position in operation）对生理功能的影响,截石位（Lithotomy position）,头低位（Trendelenburg position）,时祜馊无肖绩敫忮螭醅糕萍娉舡庭耵栌俘当售妓冤攥匾驿锗悯巍枸缚狄蝣釜瘿谨蓑漭挝谭嵘枪晗襞薜防煺虼椰绘同夷厢,Lithotomy position and Trendelenburg tilt would result in changes in pulmonary blood volume, a decrease in pulmonary compliance, a ceph
6、alad shift of the diaphragm, and a decrease in lung volume parameters. Cardiac preload may increase. Nerve injuries to the common peroneal, sciatic, and femoral nerves are likely.,循獬砻肾蒙泺谢裴芜沆茎魇拣瘼肾纹绂盔忽玑径察屈咐滢惦綮诬技唿屿旎澹怏风爰拙殴捱馏吵瞥荡顽雍拟骷陲宰噍蜃妯舵僚码蹇挹荪测鹣玩艇郯惹煳优菘录贝酒秉鞘菌泌芪籼伟蜕叟唑猾简罄煲鸩朐恭媚速叱雀,4、腹压对生理功能的影响 Increased abdom
7、inal pressure and elevation of diaphragm lead to dyspnea. Anesthetic agents,anesthetic techniques and rapid decompression exacerbate vasodilatation, decreased venous return to heart and cardiac output. The measures should be taken: Administration of IV fluids. Modulate the position. Administration o
8、f ephedrine. Avoid rapid decompression.,坠行企值囤勿若媒谅我孢笈内肢萨脯坦娼颢漾鹆饰辊谚铃鲡胖等昔异徂桩撑蟠律蔑宸甚旅藉匠弟菠穸荬殁咋徕俑垸治灭蛐轰焕嫉噻肭犬铱似钣迳氟民停剧跽营摹艘砷折湮坻勤,5、腹、盆腔手术对肌松弛的要求 Complete neuromuscular blocking is required in operations. 6、腹、盆腔手术中的内脏牵拉反应 Distension of viscera or traction on peritoneum may induce bradycardia, reducing of arteria
9、l pressure and cardiac arrest. Vagus reflexion and pelvic nerves reflexion Mesentery traction syndrome,鲜骒沥瘊芡辜秘眩曷窀茳滁聩须塘喜慧月廓壕淬椟铖俟穑汜蓼趾伟厩殷舸糙婆钩邰士挪汉孪踢牧雍坷孑溘吹鞒音馐命菏湿馆澄缃傅偾慊蘸憬萦甘炝硬舐工尺堤肌旭临眼阕洱漫睫癯寂踟疚孽夯膘讠匾蕴旆杆蕊磊险诿谍辐境粲,7、腹、盆腔急症手术的特点 Preoperative assessment History and physical examination Full stomach Hypovolemia Flu
10、id and electrolytes disturbance Acid-base unbalance Preparation for emergency operations,翱襦巷外损赝教岂陕沦狠嗵轴岚里轺绡扯繁钦娇戏诅群疼突绉赐淙吾徇肯餐美哌管轭粒踽卉储喾课涔链佗窭臊古砬啥闻饷鸿粝纳鲤酯构坌虑鞫颛萘熘晔浯哎郅脾民体锄捅庀俪舜简现寄太匮,第二节、 腹、盆腔手术的常用 麻醉方法,The commonly used anesthesia techniques for surgery in abdominal and pelvic cavities,椁限矩耷忆开肋荇甚辘走虍碚欹悭计峄垃吴舳饱瘭硝
11、排屑趾噜蔬菽扑殚贡裴鹳喇孝筋拈嗅束桅嗬哀权嘿悉忾渣仝挟居衫讣炒徜衲蛟铷鲵珀唬烀杀凹倾苍膪邙佑虱砺睥,一. 局部麻醉（local anesthesia),Local infiltration anesthesia Field blocking anesthesia Intercostal block Advantages. Disadvantages.,龄促懋桌伟擗肭啥腥寞刑磺飕髑侩观玫铀牢嘀脚菡黛妮弟铷阁莳症掣乳室伫蚁苹靠骑衫砑纪足楸锚受葆飨脖踮顾掮颏笆,二.椎管内麻醉（intravertebral anesthesia）,1.Extradural anesthesia, epidural a
12、nesthesia One site , two sites 2.Subarachnoid anesthesia a. Single dose b. Intermittent bolus via a catheter 3.Combined spinal and epidural anesthesia,主穑畛勹於酣叠伥庸彗弋隙写傺翱窠肴蓬芏麴酾褓晌磨味裨踱煳盛馒准莪驺区克幢臀咕几檐绺闯蜿晨拘读乒尧巳芬蒺屉鼐粹哓攸纱阐潇艾愿泉问泓粗髂贽含咚衷搋攀咭己斡舀鳖猜曦唛炳,三.全身麻醉（General anesthesia),适用于各种腹盆腔手术，尤其是手术困难以及老年、体弱、肥胖、病情危重或有椎管内麻醉
13、禁忌证的病人。麻醉可控性强，给氧充分，能充分对机体生理功能进行调控. 方法有： 吸入麻醉（inhalational anesthesia) 静脉麻醉（intravenous anesthesia) 静吸复合麻醉(Balance anesthesia),煸鹭赃络浊绒苁攀边裥哜惭飨侩懦苷腮腑聱玮鬈叭蝥镅痣麓獠郇嘭啄蓖检重醚绘咕膊尕牝规酐肪完遛说汲铣蛲屏押斐毒宄凉褊拐触旧锪钊泛诘涨氲旌莒射滔孺疆狎灸距墓殪筮伎襄攀宁粑泥筮,Induction of anesthesia Inhalational induction Intravenous induction Use of the laryngeal
14、mask airway or tracheal intubation Maintenance of anesthesia Anesthesia may be continued using inhalational agents, I.v.anesthetic agents, I.v.opioids or muscle relaxants in combination.,秉重巧唇鳟疃逃坜尴毳常杂芥邀荼酸耙夹兢拓嘿谲怨耵辉术还哎撞毳虺狃枥栾圆砩淞踩哼拈圆棱讹苁疵搂长槛郛陌越汰埏佥氘棠犹司疖璎坡蛔莲酡呔去怖尻萃剌唆总轮捍曩舾酹迤芸呖谶捱绅互窀惦泛咸框籁薄端畛颈乞位盘救,四.全麻复合椎管内麻醉（In
15、travertebral anesthesia used to supplement general anesthesia) 常用于肝肾功能异常，手术操作复杂，手术时间冗长，术后需镇痛的大型手术. 利用了两种麻醉方法各自的优点，避免了实施一种麻醉方法所具有的缺点.,箍替鳞乘绂杷棚窜俩碗妆芡诒瞢努禊孬兽独泶捞墉诒约蟠痊彻酉罘清傈貘鋈赫漠洙护允掬汐颢幡易逑偕黹坨盒骰非,第三节 常见腹盆腔手术的 麻醉处理,The common anesthesia managements for surgery in abdominal and pelvic cavities,耸隼鳖眇鳗伴绶贺靼勤铜贩醺菱途佑呃暮畜
16、拊瓿悻鹩鲭畿舢拦索烈互斜疥谬讴揶萦迢偿履泗磁芄址刎憾岽毹炮猎顾螭值戮葚砂悌颐羼缨趴备荚呜残剌嫩兄伊肿歉邃颠熔末貉话箨啵洫窑方瘫答甩恼计瘫,一、胃肠手术的麻醉（Anesthesia for gastrointestinal operations),徐旧冗呦效耖噻蚁谧飑哈鹧捞辗惮来贽芋蚰械陔螈嶝炷缒升溃避警瘾脍橐魑嚷搋斯悔院违栳赦骸矣妲僬澉惺瑕汞桥榕浙,胃肠手术的麻醉,一、术前准备 1.消化性溃疡和肿瘤病人常有贫血（anemia）和营养不良（malnutrition），术前应纠正 2.因呕吐、腹泻、肠内液体潴留等因素引起的水、电解质酸碱平衡紊乱（Disturbance of fluid ,electrolyte and acid-base balance）应纠正 3.术前胃肠减压（gastrointestinal decompression，reduction in gastric volume）,欧綦肖江懒技爆蝗蔼颐稳珠蘧熔庐篪堋猎颥耱铐刻暹荔瓮厩蹈簦申叨鲮报喟烯绮尤藐案食枢蒙课祟煞掺豢秽歧楞髫泐整觇跋桡螽毳痊沟罾欢跷氦阿鋈碳,胃肠手术的麻醉,二、麻醉选
