吸入麻醉临床应用__培训课件.pptVIP

* * * Song and White (1997) evaluated the effects of desflurane, sevoflurane, and propofol on the time required to meet criteria for PACU discharge after general anesthesia. This was a randomized, single-blind study enrolling 120 patients undergoing laparoscopic tubal ligation. Early recovery was prolonged with propofol compared with desflurane and sevoflurane. Times to awakening, extubation, and orientation were shortest in the desflurane group. At 5, 10, and 15 minutes after discontinuation of anesthesia, significantly more patients in the desflurane group were judged fast-track eligible compared to the propofol group. Finally, 90% of the patients in the desflurane group were eligible for fast-tracking upon arrival in the PACU compared to 75% in the sevoflurane group and 26% in the propofol group. Thus, recovery with the inhalation anesthetics desflurane and sevoflurane was more rapid, facilitating early discharge from the PACU. Song D, White PF. Anesthesiology. 1997;87:A33. 吸入麻醉药MAC的变形及临床应用 MACbar 1981年Roigen提出，阻断切皮时肾上腺素引起的心血管反应 氟烷MACbar为1.45MAC，地氟醚、异氟醚MACbar为1.3MAC 吸入麻醉维持时需要注意的问题 使用低流量吸入全麻 七氟醚需要注意2·MAC·hour的概念 地氟醚可以安全的使用1 L/min或更低的流量 联合使用笑气 减少吸入麻醉要的用量，降低费用，提高苏醒速度 如何减少吸入麻醉药降解产物 CO2吸收剂的选择和使用 保持吸收剂湿润，降低吸收剂温度 4. 吸入麻醉维持阶段使用芬太尼 阿片类药物可使MACbar显著降低 芬太尼1.5 ?g/kg使异氟醚和地氟醚的MACbar由1.3MAC分别降至0.55和0.40MAC 双倍芬太尼量并不进一步降低MACbar 阿片类药对MACaw影响较小 Suprane Summary of Product Characteristics (SmPC), UK, February 2007 Normally 6% desflurane is required for maintenance of anaesthesia because midazolam, fentanyl, nitrous oxide and propofol decrease anaesthetic requirement Dose of fentanyl desflurane MAC for patients aged 18-65 years21 No fentanyl 6.33 – 6.35% 3 mcg/kg 3.12 - 3.46% 6 mcg/kg 2.25 - 2.97% 地氟醚和芬太尼联合应用 吸入麻醉维持时需要注意的问题 吸入麻醉维持阶段使用芬太尼？ 放置喉罩后保留自主呼吸 单次静脉注射Fentanyl 10~20 ?g 保持病人自主呼吸频率（RR）10 ~ 12次/分 使用肌松药施行机械通气的病员 力争在手术结束前使病员恢复自主呼吸 追加芬太尼使RR 10 ~12次/分 有利于Sevoflurane的快速洗脱 静脉麻醉和吸入麻醉的比较 静 脉 吸 入 诱导 ★ ★ ★ ★ ★ ★ ★ ★ 维持 ★ ★ ★ ★ ★ ★ ★ ★ 苏醒 ★ ★ ★ ★ ★ ★ ★ ★ 苏醒阶段 静脉麻醉的苏醒速度较慢 在长时间静脉