口腔颌面麻醉课件

Oral and maxillofacial Oral and maxillofacial Oral and maxillofacial Oral and maxillofacial surgery anesthesia surgery anesthesia surgery anesthesia surgery anesthesia Oralandmaxillofacialsur1一一、Characteristics of the patients and the operation.Anesthesia management.(一)Anatomyandphysiolosy(1)CongenitallipandpalatecleftInfantsanestheticendurancecompensationfunctionrespirationsystemisspecialCoexistentdiseasesVSDASDetcOral-noseconnecteddifficultyingettingfoodrespirationsysteminfection.一、Characteristicsofthepatie2(2)BilateraltemporomandibularjointsrigidityDifficultyinopeningthemouthChronichypoxaemiaPoororalsanitationMalnutritionfluidandelectrolytesunbalance(2)Bilateraltemporomandibular3(3)OraltumorDifficultyinopeningthemouth,pharyngealobstructionTrachealintubationisdifficultOldagepatientscoexistentdiseases(hypertension,chronicbronchialinflammation.coronaryheartdisease,diabetic(3)Oraltumor4(4)TraumaIfthesoftpalate、peripharynx、baseofthetongueareinvolved,tissue swelling,pharyngeal cavity isnarrowed.Fracturedislocationstifle(suffocate)Bleeding,secretionsaspiration.(5)Mandible-thorax,mandible-neck adherence,scarformationandcontractionsaroundthemouth.Head-neckisfixed,headisextremelybentTracheaisshiftedtoonesideTrachealintubationandtracheostomyaredifficult(4)Trauma5(6)CongenitalmaxillofacialdeformityPierre-Robin syndrome,Treacher-CollinssyndromeTrachealIntubationisdifficultAnesthesiaenduranceisdecreased.(6)Congenitalmaxillofacialde6（二）Characteristicsofthesurgery(1)Premedication（Atropine.Sod-luminalMorphine.Midazolumetc.）Theobjectivesofpremedicationareto：AllayanxietyandfearReducesecretionsEnhancethehypnoticeffectofgeneralanestheticagentsReducepostoperativenauseaandvomitingReduce the volume and increase the PH of gastriccontentsAttenuatevagalreflexesAttenuatesympathoadrenalresponsesIfthepreoperationairwayobstrutionisexisted,dontuseanypremedicationsthatwillsuppresstherespiration(e.gmorphine)（二）Characteristicsofthesurg7(2)Anestheticinductionandtrachealintubationmaybedifficult.temporomandibularjointsrigidityHugetumorSeveretrauma(3)SharedairwayObservationandmanagementarelimited.Blood、secretionsanddebrismaycontaminatethelartynx.Gagandoperationapparatusmaycompressthetrachealtube,causepartialairwayobstruction(2)Anestheticinductionandtr8(4)HeamorrhageThesurgeoncanntoperateclearlyLargequantitybloodlossesmayresultinshock.(5)Prolongedplasticoperationmoreanestheticcomplications.(6)ResuscitationWehopethepostoperativerecoveryisquickandsmooth.(7)DifferentagerangesForinfantsandoldagepatients,theanesthesiamanagementisdifficult.(4)Heamorrhage9(三)Howtodealwiththementionedproblems(1)For the patients with airway obstruction,donnt userespirationsuppressivedrugsaspremedications.(2)Toensuretheairway,weshouldadministertrachealintubationortracheostomy.(三)Howtodealwiththementio10(3)To fix the tracheal tube and connecting tube inposition;protecttheanaesthetictubingfromdislodgement.(4)ChooseanappropriateintubationroutenasalintubutionOralintubution(3)Tofixthetrachealtubean11(5)HypotensiontechniqueUsethistechnique inimportant procedure.Thehypotensive duration should be short.SBP90mmHg,MBP60mmHg.(6)To fulfil respiration self-regulation,the postoperativeresuscitationshouldbequick.(7)Preventpostoperativenauseaandvomitingrelatedtopharyngealstimulation,postoperativepain,anestheticdrugsetc.(5)Hypotensiontechnique12二、The anesthetic choices and common anestheticmethodsAccordingtothepatientscondition,surgerysrequirements,surgeonsexperienceandtheanesthetistspreference,theanestheticmethodisdifferent二、Theanestheticchoicesandc13(一)LocalanesthesiaAdministration is simple,disturbance to the bodyenviromentissmall,postoperativerecoveryisquick.For infants and mental or physical disability,localanesthesiacombinedwithbaseanesthesiaisnecessary.Duringtheoperation,ifthelocalanesthesianeedtobechangedtogeneralanesthesia,trachealintubationisnecessary.(一)Localanesthesia14（二）BaseanesthesiaKetamine,pethidine-droperidol,midazolum.KTM:5-10mg/kgim,3min-5mingotosleep,maintaintime25min-36min,Midazolum0.1-0.2mg/kgivorim.（二）Baseanesthesia15（三）Generalanesthesia（1）InductionandintubationRapidinductionSlowinduction:lightanesthesia+localanestheticsprayLaryngoscopicintubation,awakeintubcotion,awakefibreopticintubation.,Tracheostomy.（三）Generalanesthesia16(2)AnestheticmaintenanceInhalation(enflurane,isoflurane,sevoflurane,desoflurane,N2O)Combined intravenous(valume,midazolum,fentanyl,norcuron,etc)Intravenous-inhalationcombinedGeneralenesthesiacombinedwithlocalanesthesiaisimportant.(3)Postoperativeresuscitation(2)Anestheticmaintenance17三、Managementduringandafteranesthesia(一)Duringanesthesia(1)EnsuretheairwayCausesofairwayobstructionsare:Tonguefallingdown,laryngospasm,bronchiospasm,secretions、blood、debris drain intolarynx,trachealtubekinking(2)MaintainstatisfiedventilationInadequateventilationmayresultinhypoxaemia,hypercapnia.三、Managementduringandafter18Hypoxic inspired gasmixtureEquipmentOxygensupply(cylinder/pipelinefailure,misconnection)Flowmeters(inaccuratesettings,leak)Breathingsystem(obstruction,leak)HypoventilationEquipmentVentilatorfailureBreathingsysten(obstruction,leak,disconnection)Trachealtube(obstruction,oesophagealintubation)PatientRespiratorydepressioninspontaneouslybreathingpatientsObstructionV/QmismatchPatientInadequateventilationEndobronchialintubationSecretionsPneumothoraxBronchospasmPulmonaryaspirationPulmonaryedemaInadequateperfusionEmbolus(gas,thrombus)LowcardiacoutputOtherMethaemoglobinaemia,MalignanthyperthermiaCausesofhypoxaemiaduringanesthesiaHypoxicinspiredgasmixtureOx19Intraoperativehypercapniaiscausedbyinadequatecarbondioxideremovalorexcessivecarbondioxideproduction,Inadequabecarbondioxideremovalismostcommonlycausedbyhypoventilation.Intraoperativehypercapniais20Thecriteriaofsatisfiedventilation:Spo298-100%PEtCO230-45mmHgBlood-gasanalysis.TV8-10ml/kg(Neonate6-7ml/kg)Rf12/min(NeonateRf)Thecriteriaofsatisfiedvent21(3)CirculationmanagementInsertionofanI.VcannulaFluidtherapyNormalmaintenancerequirementsRestoreTBWafteraperiodoffastingReplacesmallbloodlosses,lossofECFintothe“thirdspace”andlossesofwaterfromtheskin,gutandlungs.Bloodlossesinexcessof15%ofbloodvolumeintheadultarereplacedusually by infusion of stored blood.Smaller blood losses may bereplacedbyacrystalloidelectrolytesolutionandacolloidsolution.MaintainsteadyBP.HR(3)Circulationmanagement22(二)Managementafteranesthesia(1)AirwaymanagementExtubationconditions:Completelyawake.normalventilation,SPO296%(airinhalation)Normalmuscletonicity,smoothrespiration.Preventlaryngealedemaafterextubation(二)Managementafteranesthesia23Delayed extubation:Pharyngeal damage due to trachealintubation.Theinvolvedoperationrangeislarge.Restrictivedressingsappliedaftersurgery.Narrowedpharyngealcavityduetotrauma.Delayedextubation:Pharynge24(2)Preventpostoperativenauseaandvomiting.5-HT3RBSuction(3)PreventthecomplicationsrelatedtoanesthesiaNasal-pharyngealmucosalhaemorrhageNasal-pharyngealmucosalfalloffPharyngealedemaPostoperativemaxillasinusinflammation.Chooseappropriatesizetrachealtube.Usetrachealtubelubricant.Applyhumidificationofinspiredgases.High-volume,low-pressurecuffsmaybepreferredforlong-termintubation.25