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1、,麻醉特点及风险,胡 祖 荣,妇科,妇科常见手术,宫颈癌扩大根治术、卵巢癌细胞减灭术 子宫次/全切除术、附件肿物切除术 宫外孕(急症) 腹腔镜手术 无痛人流术、宫腔镜手术,妇科手术的麻醉特点,下腹部迷走神经丰富 特殊体位、人工气腹对循环呼吸的影响 预防深静脉血栓 预防周围神经和肌肉长时间压迫性损伤,全身麻醉,椎管内麻醉,妇科手术的麻醉选择,气管插管 喉罩技术,硬膜外 腰硬联合,病 例 分 析,病例,1,- 患者,女,31岁,术前诊断“继发不孕”,拟行宫腹 腔镜检查术 - 麻醉:气管插管全麻,术中生命体征平稳,术毕行PCIA清醒安返 - 术后第一天,疼痛查房时患者诉右膝盖以下小腿外侧至足背麻木,
2、伴活动受限,神经损伤?,神经学检查:患者右腿垮阀步态,右下肢小腿部麻木,右小腿外侧肌肉略萎缩,背屈肌力级,跖屈患肌力 正常,右小腿外侧及足背痛觉下降,双膝反射(),右踝反射(/),无病理征 B超检查:未见异常 诊断:腓外神经损伤,病因分析,病因分析,本例麻醉为单纯气管插管全麻, 排除麻醉操作造成的神经损伤,体位压迫导致神经损伤,- 患者,女,36岁,入院诊断“宫颈癌”,拟行“腹腔镜下广泛全子宫切除+盆腔淋巴结清扫术”,既往体健 - 麻醉:气管插管全麻,术中生命体征平稳,术毕行PCIA清醒安返 -术后两天,查房患者未诉不适,予术后第三天拔除静脉 镇痛泵 -术后第三天,患者下床活动,诉右下肢疼痛,
3、病例,2,仍为神经损伤?!,查体:小腿部轻度肿胀、压痛,行走时加剧,病因分析,B超检查:右腓静脉血栓,神经学检查:无病理征,确诊依据,鉴别诊断,神经损伤,下肢静脉血栓,急性动脉栓塞,5 P 征,Patient Positioning and Anesthesia,Anesthesiologists share a critical responsibility for the proper positioning of patients in the operating room,M,Millers Anesthesia, 7th,Problems Related to Patient Pos
4、ition,Cardiovascular Effects,Respiratory Changes,Nerve Injury,Peripheral nerve injury, although rare, accounted for 18% of the cases, second only to death Peripheral nerve injury is often a result of patient position The mechanisms of injury are stretching, compression, and ischemia,1990-1994 Americ
5、an Society of Anesthesiologists Closed Claims Database,Specific Positions in gynecologic surgery,头低脚高位 截石位,头低脚高位 Trendelenburg position,Increase venous return during hypotension Improve exposure during abdominal and laparoscopic surgery Facilitate cannulation during central line placement Prevent ai
6、r emboli,头低脚高位风险,Increase CVP、 ICP、IOP Swelling of the face, conjunctiva, larynx, and tongue lead to an increased potential for postoperative upper airway obstruction Decreases FRC and pulmonary compliance High airway pressures (in mechanically ventilated patients),泌尿外科、妇科手术常用体位 大腿与躯干纵轴呈80100 双腿外展30
7、 45 下肢血液重新分布、回心血量增加,截石位 Lithotomy Position,截石位风险,局部皮肤压伤 静脉血栓! 腓总神经损伤!,Prolonged lithotomy position, such as required for some operative laparoscopies, can result in lower extremity compartment syndrome!,预 防,完善术前评估 体位安置角度、护垫 避免长时间压迫腘窝以免造成腓总神 经损伤和下肢静脉血栓 体位回流、下肢血液回流加压泵 预防低血压,- 患者,女,28岁,54kg,术前诊断:子宫肌瘤;拟
8、行 “宫腹腔镜下子宫肌瘤剔除”;患者既往体健 - 麻醉:气管插管全麻,诱导平稳,插管顺利。术中2%3%七氟醚+ 0.10.15g/kg/min瑞芬太尼+ 46mg/kg/h丙泊酚维持 - 术中行Narcotrend麻醉监测,病例,3,1,- 术中子宫肌层注射垂体后叶素 - 术中生命体征:BP,HR,余无特殊 变化幅度 BP:150160/100110mmHg,HR5565bpm 持续时间:30min左右,2,- 患者出现面色青紫,眼睑闭合不全 - 加深麻醉,NARCOTREND : F0 D0 - 血压很难通过麻醉深度的变化调整,DXM 10mg iv - 术毕停止输注所有麻醉药物,潮气量及呼
9、吸频率均达 到拔管条件, Narcotrend:B,拔出气管导管 手术时间:2h;术中输液:1250ml;术毕尿量:200ml,3,- 拔管后15分钟:患者意识仍未恢复,SpO2不升,最低77(air),面罩正压通气,可达94以上 - Narcotrend :D0 ;余生命体征平稳 - 患者出现三凹征;听诊双肺:逐步出现湿啰音;进一步症状:口腔咯出粉红色泡沫痰,夹杂血丝 - 诊断:肺水肿!,4,体位? 补液? 垂体后叶素? 麻醉技术? 气腹?,病因分析,抗利尿激素 缩宫素,垂体后叶素 Posterior Pituitary,家兔急性肺水肿模型建立,快速、大量输液 肾上腺素,家兔急性肺水肿模型建
10、立,快速大量输液,血容量增加,回心血量增加 血浆胶体渗透压下降,肾上腺素,外周血管广泛收缩,血液由体循环急速转移到肺循环,左心房和肺毛细血管流体静压突然升高肺间质肺水肿 血管通透性增大肺泡肺水肿,上肢补液+体位静脉回流+抗利尿激素,肺水肿模型建立!,抗利尿激素 缩宫素,垂体后叶素 Posterior Pituitary,Pulmonary edema possibly developing secondary to the intravenous administration of oxytocin,A case of acute pulmonary edema possibly develo
11、ping secondary to the administration of iv oxytocin Clinicians should be aware of the potential for pulmonary edema secondary to iv oxytocin Close hemodynamic monitoring should be done during oxytocin therapy,Shahin J, Guharoy SR,Vet Hum Toxicol, 1991,Acute pulmonary oedema following oxytocin admini
12、stration: a life threatening complication,A 26 years primigravida developed acute onset severe pulmonary oedema in postpartum period to whom oxytocin was infused for the induction of labour and to prevent postpartum haemorrhage,Ghai B, Vayjnath AM, Lal S,J Indian Med Assoc, 2006,Cardiovascular Toxic
13、ology, 2011,人工气腹影响循环呼吸系统,CO2 pneumoperitoneum results in ventilatory and respiratory changes Hemodynamic changes observed during laparoscopy result from the combined effects of pneumoperitoneum, patient position, anesthesia, and hypercapnia from the absorbed CO2 Reflex increases of vagal tone and ar
14、rhythmias can also develop,Intro-abdominal pressure,Arterial pressure,Cardiac output,Systemic vascular resistance,Venous return,Different mechanisms leading to decreased CO during pneumoperitoneum for laparoscopy,上肢输液,苏醒拔管,垂体后 叶 素,体位回流,肺水肿,气 腹,判断失误:血压升高原因 处理不当:不断加深麻醉调整血压 拔管时机不当,存在问题,强心,麻醉处理,利尿,肺水肿,急
15、性左心衰,VS,激素,利尿,减少静脉回流,扩血管,除泡剂,扩血管,强心,氨茶碱,激素,减少静脉回流,病例,4,- 患者,女,30岁,44kg。因“人流术后月经量减少2+年”来我院就诊。诊断为“宫腔粘连” - 既往史:既往体健,自诉“青霉素、头孢类、红霉素”过敏。2010年曾行人流术,2012年因胚胎发育停止行清宫术 -体格检查、实验室检查、辅助检查未见异常,1,手术方式:腹腔镜检查,通水术,宫腔镜检查,电切术,麻醉选择:气管插管全麻,入室 8:37 麻醉开始 8:50 手术开始 9:00 第一次血气 10:20,麻醉诱导 : midazolam 3mg sufentanil 35ug prop
16、ofol 70mg cisatracurium 8mg 麻醉维持 : sevo+ propofol+ dexmedetomedine,2,- 术中患者生命体征平稳,电切结束后,行常规 血气检查:cNa+ 117mmol/L - 听诊双肺:呼吸音清 - 诊断:水中毒!,麻醉处理,利尿! 补盐,12:21,13:35,11:42,10:55,10:24,控制电切时间(小于1小时),避免切除过多的子宫肌层组织34mm 使用等渗液 膨宫压力100mmHg,不能超过平均动脉压 准确记录膨宫液出入量 监测CVP 监测血清钠浓度,使用利尿剂,预 防,关注妇科麻醉安全 熟悉人工气腹对呼吸循环的影响 预防体位引起的神经并发症,同时应与椎管 内麻醉神经并发症相鉴别,避免医疗纠纷 预防深静脉血栓形成 警惕电切术