齐鲁医学CEA手术室篇.pptxVIP

手术室中的颈动脉内膜切除术Carotid Endarterectomy(CEA)日照市人民医院神经外科张玉海2021/7/27 星期二国家远程卒中中心、脑防委CEA培训基地、北京市脑血管病中心2021/7/27 星期二外科治疗相关问题麻醉方式（GALA trial）术式介绍----标准CEA（传统CEA）----翻转式CEA护士协作并发症的预防2021/7/27 星期二团队配置及体位Operation room team position during CEA. S Surgeon, aS assisting surgeon, Ne neurophysiologist；A anaesthesiologist； N nurse；M microscope2021/7/27 星期二手术体位要求Supine position;Head up: to reduce cervical venous pressure;Head is placed on a ring, with a sandbag under the shoulders;Exposing the full length of the sternomastoid muscle;2021/7/27 星期二2021/7/27 星期二手术切口麻醉篇麻醉平稳及适时调整血压至关重要2021/7/27 星期二麻醉方式全麻：----General anaesthesia has several advantages, including easier surgical manoeuvres, handling of complications and easier patient monitoring.局麻：----local/regional anaesthesia decreases the number of medical complicationsat the expense of neurological complications.2021/7/27 星期二General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trialMethod: a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.----general (n=1753) or local (n=1773) anaesthesia;----stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery;Conclusion: The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。2021/7/27 星期二麻醉的不可替代性掌握术前有无心脏疾病，缺血性尤为重要术前的基础血压，要明确麻醉平稳后开始手术前的血压，记录定标临时阻断后可能需要短时升压至要求值动脉缝合完毕后需要尽快降压结合TCCD定出出室后的血压安全控制范围2021/7/27 星期二麻醉深度监测脑氧监测麻醉深度电极2021/7/27 星期二麻醉协助TCCD术前定标2021/7/27 星期二术中阻断后短时升压血流再通后积极降压，不建议用硝普钠2021/7/27 星期二术后麻醉与TCCD定控制范围麻醉机2021/7/27 星期二TCCD监测术中指导意义大术前麻醉平稳后定标主要参考。脑血流峰值、平均值、收缩期、舒张期2021/7/27 星期二术中监测? Baseline (before induction)? Pre-clamp (at heparin injection)? Clamping, shunt insertion