神经外科手术麻醉优选课件

,单击此处编辑母版标题样式,#,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,颅内压,颅内压,(intracranial pressure,，,ICP),是指颅内的脑脊液压力。正常人平卧时，脑穿刺测得脑脊液压可正确反映颅内压的变化。其正常值为,70,200mmH,2,O(0.681.96 kPa),。,颅腔内容物由神经组织,(86,),、脑脊液,(10,),及血液,(4,),三部分组成。任何一部分发生变化将影响到其他两部分，若超过了生理限度，其间失去相互调节，将产生颅内压升高。,颅内压,1,麻醉对脑血流、脑代谢和颅内压的影响,血管活性药物,单胺类血管活性药物：一般不透过血脑屏障，对脑代谢和脑血流量无明显影响，但在血脑屏障受损或大剂量应用时，可对脑血流产生明显影响。,控制性降压药物，如硝酸苷油，可使脑血流量增加或维持于血压降低前水平。当脑血流自动调节功能受损时，此类药物可明显增加脑血流量，使颅内压升高。,罂粟碱可直接降低脑血管阻力，伴随着血压下降，脑血流量相应减少。可乐宁抑制突触前去甲肾上腺素的释放产生受体激动效应，并可通过其他机制降低脑血流量。,麻醉对脑血流、脑代谢和颅内压的影响 血管活性药物,2,麻醉药和肌松药,静脉麻醉药：静脉麻醉药对脑血流量的影响主要通过降低脑代谢率以及对脑血管平滑肌的直接作用。,颅内压升高的病人应慎用氧胺酮,.,吸人麻醉药：,扩张脑血管的效能依次为氟烷,安氟醚,异氟醚。七氟醚和地氟醚与异氟醚对脑血管的作用相似。所有挥发性吸人麻醉药均可产生与剂量相关的脑代谢率降低，从而造成脑血流量脑代谢率的比值增加，井可产生与脑血流量增加相一致的颅内压升高。,麻醉药和肌松药 静脉麻醉药：静脉麻醉药对脑血流量的影响主要通,3,颅内高压的常见原因和处理,颅内压持续超过,200mmH,2,0,时称为颅内高压。引起颅内压升高的因素可分为两大类，一类与颅内正常内容物有关，主要包括脑组织、脑脊液及脑直流量；另一类为颅内病变使颅内空间或颅腔容积变小。,颅内高压的常见原因和处理 颅内压持续超过200mmH20时,4,颅内占位性病变 如颅内血肿、肿瘤、脓肿等。,脑体积增加 各种原因引起的脑水肿，如脑损伤、炎症、中毒、缺血缺氧等。,脑脊液分泌和吸收失调 如脑积水、良性颅内压升高等。,颅腔狭小,如狭颅症、颅底陷入症。胸腔内正压力升高等。,其他 体位,(,头低位,),、缺氧、二氧化碳蓄积均可使颅内压升高。此外，某些越药物亦可直接扩张脑血管、增加脑血流，从而使颅内压升高,颅内占位性病变 如颅内血肿、肿瘤、脓肿等。,5,颅内高压的症状,天幕上病变使颅内压极度增高时，出现神志模糊、瞳孔散大、对光反射消失；后颅凹病变使颅内压升高时，可出现心动过复、呼吸变慢等；出现延髓小脑扁桃体疝时，可出现颈强直，强迫头位，呼吸停止,o,颅内高压的症状天幕上病变使颅内压极度增高时，出现神志模糊、瞳,6,颅内高压的处理,降低颅内压的措施很多，首先必须针对原发病因进行处理。,利尿剂和液体限制,袢利尿药,人体白蛋白,颅内高压的处理 降低颅内压的措施很多，首先必须针对原发病因进,7,Depth of Inhalation Anesthesia,Circulation,引起颅内压升高的因素可分为两大类，一类与颅内正常内容物有关，主要包括脑组织、脑脊液及脑直流量；,The blood/gas coefficient is 1.,0%Nitrous oxide 105%,地氟烷 Desflurane,degradation by baralyme and soda lime,麻醉意外和并发症（1）,第一期（镇痛期）麻醉开始-神志消失-皮层抑制,引起颅内压升高的因素可分为两大类，一类与颅内正常内容物有关，主要包括脑组织、脑脊液及脑直流量；,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,颅内占位性病变 如颅内血肿、肿瘤、脓肿等。,苯环己哌啶类氯胺酮,根据用药种类：单一、复合。,5 percent nitrous oxide 0.,resistant to degradation by soda lime,MAC in 100 percent oxygen is 0.,second gas effect（back）,后颅凹病变使颅内压升高时，可出现心动过复、呼吸变慢等；,Essential Concepts About Inhalation Anesthesia,Introduction,麻醉诱导,Maintenance,麻醉维持,Recovery,麻醉清醒,Depth of Inhalation Anesthesia,8,全身麻醉的概念,麻醉药经呼吸道吸入或静脉、肌肉注射，产生中枢神经系统抑制，呈现神志消失，周身不感疼痛，也可有反射抑制和肌肉松弛等表现,-,全身麻醉。,General anesthesia provides loss of consciousness and loss of sensation.,全身麻醉的概念麻醉药经呼吸道吸入或静脉、肌肉注射，产生中枢神,9,吸入麻醉,概念：麻醉药系经呼吸道吸入而产生麻醉。,Inhalation anesthetics are substances that are brought into the body via the lungs and are distributed with the blood into the different tissues.,The main target of inhalation anesthetics(or so-called volatile anesthetics)is the brain.,吸入麻醉概念：麻醉药系经呼吸道吸入而产生麻醉。,10,71 and in 63.,Maintenance of anesthesia1-2.,coronary artery steal syndrome.,FGF at least two liters per minute,导管粗细（喉头水肿，梗阻）；,适用于心内直视手术、胸内手术、大血管手术。,颅内占位性病变 如颅内血肿、肿瘤、脓肿等。,Depth of Inhalation Anesthesia,并发症：血压升高、颅内压眼压增高、呼吸抑制、喉痉挛、噩梦精神症状、暂时失明、恶心呕吐。,Pharmacokinetics of Inhaled Anesthetics,The blood/gas coefficient is 1.,3mg/kg，持续3-5分钟，点滴0.,Halothane 0.,下呼吸道梗阻：气管、支气管分泌物引起；,68mg/kg15分钟，然后0.,After Surface Anesthesia,sedation agents were administrated,intubation.,increase intracranial pressure,susceptible to decomposition.,increase intracranial pressure,后颅凹病变使颅内压升高时，可出现心动过复、呼吸变慢等；,七氟醚 Sevoflurane,颅腔内容物由神经组织(86)、脑脊液(10)及血液(4)三部分组成。,Pharmacokinetics of Inhaled Anesthetics,Uptake and distribution of inhaled anesthetics,concentration effect,minute ventilation,cardiac output,The blood/gas partition coefficient,The alveolar to venous partial pressure difference,71 and in 63.Pharmacokinetics,11,吸入麻醉药的药效学,Minimum Alveolar Concentration MAC,Anesthetic potency of volatile anesthetics is measured by the minimum alveolar concentration,1.3 MAC will prevent movement in about 95 percent of the patients.,Halothane 0.74%Enflurane 1.70%,Isoflurane 1.15%Desflurane 6.0%,Sevoflurane 2.0%Nitrous oxide 105%,吸入麻醉药的药效学Minimum Alveolar Conc,12,常用吸入麻醉药,氧化亚氮,Nitrous oxide,安氟醚,Enflurane,异氟醚,Isoflurane,氟烷,Halothane,乙醚,Ether,地氟醚,Desflurane,七氟醚,Sevoflurane,常用吸入麻醉药氧化亚氮 Nitrous oxide,13,氧化亚氮,nitrous oxide,blood/gas coefficient is 0.47 and the MAC in 100 percent oxygen is 104.,weak anesthetic.supplement other inhalation agents,resistant to degradation by soda lime,sympathomimetic,dangerous accumulation of volume in closed spaces,（,ileus,，,pneumothorax,）,diffusion hypoxia,not exceed 70 percent.,second gas effect,（,back,）,氧化亚氮nitrous oxideblood/gas coe,14,乙醚,Ether,可燃烧爆炸已不使用。,MAC1.9,第一期（镇痛期）麻醉开始,-,神志消失,-,皮层抑制,第二期（兴奋期）神志消失,-,兴奋,-,呼吸规律,第三期（手术麻醉期）分四级,第四期（延髓麻醉期）呼吸心跳停止瞳孔散大（,back,）,乙醚 Ether可燃烧爆炸已不使用。MAC1.9,15,氟烷,Halothane,MAC in 100 percent oxygen is 0.74 and in 70 percent nitrous oxide 0.29.,susceptible to decomposition.,sensitize the myocardium to the action of epinephrine and norepinephrine,treatment of asthma,not use for obstetric anesthesia,not lead to coronary artery steal syndrome.,Fulminant hepatic necrosis,Induction of anesthesia1-3%,Maintenance of anesthesia 0.5-1.5,氟烷 HalothaneMAC in 100 perce,16,安氟醚,enflurane,The blood/gas coefficient is 1.8 and the MAC in 100 percent oxygen is 1.68 and in 70 percent nitrous oxide 0.57.,used low flow or closed system anesthesia.,it does not cause a coronary artery steal syndrome.,Induction of anesthesia3-4%,Maintenance of anesthesia 1-3%,increase intracranial pressure,malignant hyperthermia.,（,link,）,安氟醚enflurane The blood/gas coe,17,异氟醚,Isoflurane,，,forane,blood/gas coefficient is 1.4 and the MAC in 100 percent oxygen is 1.15 and in 70 percent nitrous oxide 0.50.,resistant to degradation by the absorber,coronary artery steal syndrome.,trigger malignant hyperthermia.,Induction of anesthesia3-4%,Maintenance of anesthesia1-2.5%,combined with intravenous anesthetics,.,异氟醚 Isoflurane，foraneblood/,18,七氟烷,Sevoflurane,The blood/gas coefficient is 0.59 and the MAC in 100 percent oxygen is 1.71 and in 63.5 percent nitrous oxide 0.66.,degradation by baralyme and soda lime,FGF at least two liters per minute,Induction of anesthesia 1.5-3%,Maintenance of anesthesia 0.4-2%,used for rapid induction of anesthesia,do not cause coronary artery steal syndrome,七氟烷 SevofluraneThe blood/gas,19,地氟烷,Desflurane,The blood/gas coefficient is 0.42 and the MAC in 100 percent oxygen is 6.0 and in 60 percent nitrous oxide 2.8.,It requires the use of electrically heated vaporizers.,Induction of anesthesia 6-10%,Maintenance of anesthesia 5-7%,resistant to degradation,do not cause coronary artery steal syndrome,地氟烷 DesfluraneThe blood/gas,20,吸入麻醉,Currently used inhalation anesthetics include enflurane,halothane,isoflurane,sevoflurane,desflurane,and nitrous oxide.Older volatile anesthetics include ether,chloroform,and methoxyflurane.,吸入麻醉Currently used inhalation,21,安氟醚enflurane,74 and in 70 percent nitrous oxide 0.,Pharmacokinetics of Inhaled Anesthetics,Circulation,平衡麻醉：镇静+镇痛+肌松。,降低颅内压的措施很多，首先必须针对原发病因进行处理。,注意事项：呼吸抑制明显严重，抑制循环，注射部位疼痛，用药后有时精神错乱，体表异感、幻觉、女性有多情表现,Induction of anesthesia 6-10%,清醒插管后再作静脉快速诱导,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,General anesthesia provides loss of consciousness and loss of sensation.,Respiratory,FGF at least two liters per minute,5 percent nitrous oxide 0.,静脉全麻的概念和优缺点,地氟醚 Desflurane,芬太尼静脉麻醉fentanyl,起效快，作用时间短，无镇痛作用。,Maintenance of anesthesia1-2.,导管粗细（喉头水肿，梗阻）；,其正常值为70200mmH2O(0.,地氟烷 Desflurane,Introduction,静脉快速诱导,吸入麻醉诱导,保持自主呼吸诱导,清醒插管后再作静脉快速诱导,其他方法：,安氟醚enfluraneIntroduction静脉快速诱导,22,麻醉药品和设备,麻醉药品和设备,23,麻醉药品和设备,麻醉药品和设备,24,Introveinus high speed introduction,Midazolam,Diazepam,Vecronium,Acronium,Scoline,Fentanye,Propofol,Etomidate,Ketamine,Thiopetal,Introveinus high speed introdu,25,Inhalation introduction,小儿麻醉,Sevoflurane,halothane,重症肌无力,Enflurane,Isoflurane,N,2,O+O,2,plus Inhalation Anesthestics,Inhalation introduction小儿麻醉,26,Slowly Introduction,Airway not smoothly,Intubation difficultly,Without muscle relaxant,After Surface Anesthesia,sedation agents were administrated,intubation.,Slowly IntroductionAirway not,27,气管插管术,概念,将特制的气管导管，通过口腔或鼻腔插入病人气管内，是一种抢救病人和气管内麻醉的必要技术。,作用,保持呼吸道通畅；便于清除呼吸道内分泌物和异物；辅助和控制呼吸；远离术区；吸氧治疗,方法分类,明视插管术；盲探插管术,气管插管并发症,机械创伤；反射（呼吸、循环）；导管粗细（喉头水肿，梗阻）；肺不张,气管插管术概念将特制的气管导管，通过口腔或鼻腔插入病人气管,28,气管内插管术,气管内插管术,29,Maintenance of Inhalation Anesthesia,intubation,Maintenance,Wash-out,recovery,Maintenance of Inhalation Anes,30,Monitoring,Respiratory,PetCO2,Zoomloop,Parameter of Respiratory,Depth of Anesthesia,BIS,Circulation,MonitoringRespiratory,31,麻醉期间生理指标监测,麻醉手术期间，由于先存疾病，麻醉药，手术创伤和失血以及体位的改变，都会带来呼吸，循环，神经系统等生理参数变化。需及时纠正处理生理病理改变，避免发生意外,呼吸系统,-,通气、换气,循环系统,-,心电、心排,神经系统：意识情况。,麻醉深度：,BIS,全身情况：体温 肌松,麻醉期间生理指标监测麻醉手术期间，由于先存疾病，麻醉药，手术,32,神经外科手术麻醉优选课件,33,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,15 and in 70 percent nitrous oxide 0.,并发症：血压升高、颅内压眼压增高、呼吸抑制、喉痉挛、噩梦精神症状、暂时失明、恶心呕吐。,方法分类明视插管术；,Fulminant hepatic necrosis,第一期（镇痛期）麻醉开始-神志消失-皮层抑制,Maintenance of anesthesia1-2.,5 percent nitrous oxide 0.,Without muscle relaxant,General anesthesia provides loss of consciousness and loss of sensation.,Introduction 麻醉诱导,used low flow or closed system anesthesia.,N2O+O2,plus Inhalation Anesthestics,cardiac output,5 percent nitrous oxide 0.,coronary artery steal syndrome.,After Surface Anesthesia,sedation agents were administrated,intubation.,便于清除呼吸道内分泌物和异物；,increase intracranial pressure,Maintenance,注意事项：可使促皮质激素效应消失，免疫抑制、脓毒血症、器官移植慎用；,正常人平卧时，脑穿刺测得脑脊液压可正确反映颅内压的变化。,Depth of Inhalation Anesthesia,BIS(bispectral index),Somatosensory evoked potential SEP,Brainstem auditory evoked potential BAEP,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、,34,麻醉意外和并发症（,1,）,呼吸系统并发症：,1.,呕吐窒息,发生时期，化学性肺炎，预防。,2.,呼吸道梗阻,上呼吸道梗阻：原因舌后坠和分泌物；喉痉挛。下呼吸道梗阻：气管、支气管分泌物引起；支气管痉挛。,3.,通气量不足,麻药过量，肌松药残留。,4.,肺炎、肺不张。,麻醉意外和并发症（1）呼吸系统并发症：,35,麻醉意外和并发症（,2,）,循环系统并发症,低血压：麻醉深；失血；反射,-,牵拉内脏,心律失常：手术麻醉刺激，反射，二氧化碳蓄积，离子紊乱,心跳骤停与心室纤颤,最严重意外。缺氧、离子紊乱、低血容量、强烈反射,麻醉意外和并发症（2）循环系统并发症,36,麻醉意外和并发症（,3,）,中枢神经系统并发症：,高热、抽搐、惊厥,苏醒延迟或不醒,麻醉药的燃烧与爆炸,麻醉意外和并发症（3）中枢神经系统并发症：,37,麻醉后苏醒期的护理,保持呼吸道通畅,保持循环稳定,疼痛治疗,体温,体位,麻醉后苏醒期的护理保持呼吸道通畅,38,术后恢复室,术后恢复室,39,Propofol,起效快，作用时间短，无镇痛作用。诱导,1.5-2.5mg/kg,，维持,10mg/kg/h,，或,50-150mcg/kg/min,，镇静,25-75mcg/kg/min,。注意事项：呼吸抑制明显严重，抑制循环，注射部位疼痛，用药后有时精神错乱，体表异感、幻觉、女性有多情表现,Propofol起效快，作用时间短，无镇痛作用。诱导1.5-,40,The blood/gas coefficient is 0.,treatment of asthma,注意事项：呼吸抑制明显严重，抑制循环，注射部位疼痛，用药后有时精神错乱，体表异感、幻觉、女性有多情表现,概念：麻醉药系经呼吸道吸入而产生麻醉。,概念：麻醉药系经呼吸道吸入而产生麻醉。,其他：procaine，酒精,当脑血流自动调节功能受损时，此类药物可明显增加脑血流量，使颅内压升高。,The blood/gas coefficient is 0.,任何一部分发生变化将影响到其他两部分，若超过了生理限度，其间失去相互调节，将产生颅内压升高。,颅腔内容物由神经组织(86)、脑脊液(10)及血液(4)三部分组成。,74%Enflurane 1.,Sevoflurane 2.,Halothane 0.,后颅凹病变使颅内压升高时，可出现心动过复、呼吸变慢等；,FGF at least two liters per minute,颅腔内容物由神经组织(86)、脑脊液(10)及血液(4)三部分组成。,Pharmacokinetics of Inhaled Anesthetics,FGF at least two liters per minute,not use for obstetric anesthesia,used low flow or closed system anesthesia.,resistant to degradation by the absorber,可乐宁抑制突触前去甲肾上腺素的释放产生受体激动效应，并可通过其他机制降低脑血流量。,thiopental,微黄粉末，易溶于水，强碱，,2.5%,，成人,2.5-4.5mg/kg,，儿童,5-6mg/kg,，婴幼儿,7-8mg/kg,。老年人，体弱，,2.5-3mg/kg,，总量,1,克，可单次、分次、连续滴入；适用于短小手术、全麻诱导、心复律、麻醉维持、降低颅内压。不能用于心衰、休克、呼吸道梗阻、哮喘、饱胃患者、咽喉部肛门手术、巴比妥过敏,The blood/gas coefficient is 0,41,氯胺酮,ketamine,氯胺酮选择性地抑制大脑联络径路和丘脑皮层系统，对某些中枢神经部位和脑干网状结构影响轻。临床表现睁眼，眼球震颤，维持一定肌张力和反射心血管系统兴奋，意识和感觉分离。肌肉注射，,4-10mg/kg,，,1-5,分钟起效，维持,15-25,分钟；静脉注射，,1-2mg/kg,，,10-15,分钟；静脉滴入，,0.1%,；总量,15mg/kg,。,适应症：小儿基础麻醉、成人短小手术、诱导、局麻辅助。,并发症：血压升高、颅内压眼压增高、呼吸抑制、喉痉挛、噩梦精神症状、暂时失明、恶心呕吐。禁忌症：高血压、甲亢、嗜铬细胞瘤、高颅压、眼、口、咽手术、心衰、癫痫、精神病,氯胺酮 ketamine氯胺酮选择性地抑制大脑联络径路和丘,42,etomidate,弱短效催眠药，诱导,0.3mg/kg,，持续,3-5,分钟，点滴,0.1%,，初速,100mcg/min,，维持量,10mcg/min,。,注意事项：可使促皮质激素效应消失，免疫抑制、脓毒血症、器官移植慎用；增强降压药作用；与芬太尼合用出现肌肉强直和阵挛；注药部位疼痛；恶心呕吐,etomidate弱短效催眠药，诱导0.3mg/kg，持续3,43,fentanyl,诱导,thiopental 3mg/kg,，芬太尼,10-20mcg/kg,，维持,50-100mcg/kg,，点滴,1.5mg/kg/h,；适用于心内直视手术、胸内手术、大血管手术。,fentanyl诱导thiopental 3mg/kg，芬太,44,midazolam,诱导,0.1-0.4mg/kg,，维持,0.68mg/kg,15,分钟，然后,0.125mg/kg,，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。注意事项：心率增快、无镇痛作用，呼吸抑制作用，半衰期,2.4h,。,midazolam诱导0.1-0.4mg/kg，维持0.68,45,静脉麻醉,静脉全麻的概念和优缺点,分类和麻醉原则,麻醉药分类,麻醉方法,静脉麻醉静脉全麻的概念和优缺点,46,静脉全麻的概念和优缺点,全麻药注入静脉，通过血液循环，作用中枢系统，使意识消失，周身不感疼痛。优点：起效快，对呼吸道无刺激；病人舒适；无污染和燃烧爆炸；操作简单；缺点：入血不易排除；麻醉深度不易控制；麻醉效能弱；肌松差,静脉全麻的概念和优缺点全麻药注入静脉，通过血液循环，作用中枢,47,分类和麻醉原则,根据作用不同：静脉诱导、静脉维持、静脉基础。,根据用药方法：单次、分次、连续滴入、泵输注。,根据用药种类：单一、复合。,平衡麻醉：镇静,+,镇痛,+,肌松。,分类和麻醉原则根据作用不同：静脉诱导、静脉维持、静脉基础。,48,麻醉药分类,巴比妥类,硫喷妥钠,非巴比妥类 苯二氮卓类,安定,丁酰苯类,-,氟哌啶,苯环己哌啶类,氯胺酮,甾类,安泰酮,羟丁酸盐类,-,-OH,咪唑类,ETOMIDATE,阿片类,MORPHINE,异丙酚,其他：,procaine,，酒精,麻醉药分类巴比妥类硫喷妥钠,49,麻醉方法,硫喷妥钠麻醉,：,thiopental sodium,氯胺酮麻醉,ketamine,芬太尼静脉麻醉,fentanyl,咪唑安定麻醉,midazolam,依托咪酯麻醉,etomidate,异丙酚麻醉,propofol,-,羟丁酸钠静脉麻醉,-OH,麻醉方法硫喷妥钠麻醉：thiopental sodium,50,颅内压,颅内压,(intracranial pressure,，,ICP),是指颅内的脑脊液压力。正常人平卧时，脑穿刺测得脑脊液压可正确反映颅内压的变化。其正常值为,70,200mmH,2,O(0.681.96 kPa),。,颅腔内容物由神经组织,(86,),、脑脊液,(10,),及血液,(4,),三部分组成。任何一部分发生变化将影响到其他两部分，若超过了生理限度，其间失去相互调节，将产生颅内压升高。,颅内压,51,氟烷,Halothane,MAC in 100 percent oxygen is 0.74 and in 70 percent nitrous oxide 0.29.,susceptible to decomposition.,sensitize the myocardium to the action of epinephrine and norepinephrine,treatment of asthma,not use for obstetric anesthesia,not lead to coronary artery steal syndrome.,Fulminant hepatic necrosis,Induction of anesthesia1-3%,Maintenance of anesthesia 0.5-1.5,氟烷 HalothaneMAC in 100 perce,52,当脑血流自动调节功能受损时，此类药物可明显增加脑血流量，使颅内压升高。,Brainstem auditory evoked potential BAEP,依托咪酯麻醉etomidate,0 and in 60 percent nitrous oxide 2.,15 and in 70 percent nitrous oxide 0.,5 percent nitrous oxide 0.,注意事项：可使促皮质激素效应消失，免疫抑制、脓毒血症、器官移植慎用；,注意事项：心率增快、无镇痛作用，呼吸抑制作用，半衰期2.,异丙酚,Halothane 0.,麻醉意外和并发症（3）,3 MAC will prevent movement in about 95 percent of the patients.,68mg/kg15分钟，然后0.,甾类安泰酮,68mg/kg15分钟，然后0.,Depth of Inhalation Anesthesia,0 and in 60 percent nitrous oxide 2.,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,氟烷 Halothane,cardiac output,下呼吸道梗阻：气管、支气管分泌物引起；,Induction of anesthesia 6-10%,安氟醚,enflurane,The blood/gas coefficient is 1.8 and the MAC in 100 percent oxygen is 1.68 and in 70 percent nitrous oxide 0.57.,used low flow or closed system anesthesia.,it does not cause a coronary artery steal syndrome.,Induction of anesthesia3-4%,Maintenance of anesthesia 1-3%,increase intracranial pressure,malignant hyperthermia.,（,link,）,当脑血流自动调节功能受损时，此类药物可明显增加脑血流量，使颅,53,麻醉药品和设备,麻醉药品和设备,54,Maintenance of Inhalation Anesthesia,intubation,Maintenance,Wash-out,recovery,Maintenance of Inhalation Anes,55,术后恢复室,术后恢复室,56,fentanyl,诱导,thiopental 3mg/kg,，芬太尼,10-20mcg/kg,，维持,50-100mcg/kg,，点滴,1.5mg/kg/h,；适用于心内直视手术、胸内手术、大血管手术。,fentanyl诱导thiopental 3mg/kg，芬太,57,The main target of inhalation anesthetics(or so-called volatile anesthetics)is the brain.,The blood/gas coefficient is 0.,优点：起效快，对呼吸道无刺激；,blood/gas coefficient is 0.,not use for obstetric anesthesia,Pharmacokinetics of Inhaled Anesthetics,颅腔狭小如狭颅症、颅底陷入症。,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,弱短效催眠药，诱导0.,诱导thiopental 3mg/kg，芬太尼10-20mcg/kg，维持50-100mcg/kg，点滴1.,resistant to degradation by soda lime,68 and in 70 percent nitrous oxide 0.,not exceed 70 percent.,地氟醚 Desflurane,注意事项：可使促皮质激素效应消失，免疫抑制、脓毒血症、器官移植慎用；,blood/gas coefficient is 1.,注意事项：呼吸抑制明显严重，抑制循环，注射部位疼痛，用药后有时精神错乱，体表异感、幻觉、女性有多情表现,第一期（镇痛期）麻醉开始-神志消失-皮层抑制,68 and in 70 percent nitrous oxide 0.,引起颅内压升高的因素可分为两大类，一类与颅内正常内容物有关，主要包括脑组织、脑脊液及脑直流量；,引起颅内压升高的因素可分为两大类，一类与颅内正常内容物有关，主要包括脑组织、脑脊液及脑直流量；,5-3mg/kg，总量1克，可单次、分次、连续滴入；,颅内占位性病变 如颅内血肿、肿瘤、脓肿等。,作用保持呼吸道通畅；,sensitize the myocardium to the action of epinephrine and norepinephrine,注意事项：心率增快、无镇痛作用，呼吸抑制作用，半衰期2.,42 and the MAC in 100 percent oxygen is 6.,导管粗细（喉头水肿，梗阻）；,Recovery 麻醉清醒,Fulminant hepatic necrosis,地氟烷 Desflurane,可乐宁抑制突触前去甲肾上腺素的释放产生受体激动效应，并可通过其他机制降低脑血流量。,concentration effect,Induction of anesthesia1-3%,此外，某些越药物亦可直接扩张脑血管、增加脑血流，从而使颅内压升高,羟丁酸盐类-OH,Essential Concepts About Inhalation Anesthesia,minute ventilation,概念：麻醉药系经呼吸道吸入而产生麻醉。,8 and the MAC in 100 percent oxygen is 1.,Depth of Anesthesia,125mg/kg，适应症：心血管手术、颅内手术、门诊小手术、各种诊治操作。,Maintenance 麻醉维持,起效快，作用时间短，无镇痛作用。,麻醉对脑血流、脑代谢和颅内压的影响,Brainstem auditory evoked potential BAEP,另一类为颅内病变使颅内空间或颅腔容积变小。,芬太尼静脉麻醉fentanyl,注意事项：心率增快、无镇痛作用，呼吸抑制作用，半衰期2.,5mg/kg，儿童5-6mg/kg，婴幼儿7-8mg/kg。,咪唑类ETOMIDATE,可乐宁抑制突触前去甲肾上腺素的释放产生受体激动效应，并可通过其他机制降低脑血流量。,其正常值为70200mmH2O(0.,概念将特制的气管导管，通过口腔或鼻腔插入病人气管内，是一种抢救病人和气管内麻醉的必要技术。,second gas effect（back）,sensitize the myocardium to the action of epinephrine and norepinephrine,地氟醚 Desflurane,treatment of asthma,Halothane 0.,优点：起效快，对呼吸道无刺激；,单胺类血管活性药物：一般不透过血脑屏障，对脑代谢和脑血流量无明显影响，但在血脑屏障受损或大剂量应用时，可对脑血流产生明显影响。,平衡麻醉：镇静+镇痛+肌松。,罂粟碱可直接降低脑血管阻力，伴随着血压下降，脑血流量相应减少。,Pharmacokinetics of Inhaled Anesthetics,麻醉意外和并发症（3）,优点：起效快，对呼吸道无刺激；,麻醉方法,硫喷妥钠麻醉,：,thiopental sodium,氯胺酮麻醉,ketamine,芬太尼静脉麻醉,fentanyl,咪唑安定麻醉,midazolam,依托咪酯麻醉,etomidate,异丙酚麻醉,propofol,-,羟丁酸钠静脉麻醉,-OH,The main target of inhalation,58,