心血管疾病的麻醉.pptVIP

1. Physiological disturbances during anesthesia Anesthetics modify body mechanism + vagal dominant, acidosis, hypoxia/ hypercarbia, electrolyte disorder, hypovolemia 2. Pathological disturbances CAD : heart block, PVC, Thyrotoxicosis, MH, pheochromocytoma 3. Pharmacological causes :ketamine, NMB 4. Anesthesia procedures : IT, CVP, SA Serious cardiac ?arrhythmia : 6H, 5T Hypovolemia, hypoxemia, acidosis, K- Ca hypothermia, PE, ? tamponade tension pneumothorax Know how, Know why, Care why * * Wanawimol Saengchote M.D. Department of Anesthesiology, Ramathibodi Hospital, Mahidol U SAFETY Anesthesia Incident Monitoring Study January to June 2007. 200,000 cases, 2537 incidents A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened Arrhythmia 25% Desaturation 24% Death within 24 hrs. 20% Cardiac arrest 14% inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, ineffective communication. DO2 = CO x 10 x CaO2 Tissue O2 delivery = cardiac output x arterial O2 content CO = SV x HR SV ∞ preload, contractility, afterload CO = EF x LVEDV x SVR x HR Patient’s comorbid : controllability? Anesthetic management : drugs, techniques, process, anesthesia personnel Surgical procedure Preoperative Intraoperative PO. Hypovolemia Preop NPO Trauma-fractures Peritonitis N/v, diarrhea Bowel prep Diuretics Blood loss Major fluid shift Tissue edema Effusion Diuresis (concealed blood loss) Tachycardia Peripheral vasoconstriction Low systolic blood pressure Narrow pulse pressure Cold ,clammy skin and extremities Low urine output (anemia not apparent in acute loss without adequate volume replacement) With beta blocker effect, no tachycardia detected Class I Class II Class III Class IV Pulse rate 100/min 100/min 120/min 140/min BP normal normal dropped dropped Pulse pr. normal decreased decreased decreased RR 14-20/min 20-