麻醉诱导期的容量管理

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,麻醉诱导期的,容量管理,1,手术刺激,诱导,插管,切皮,缝合,手术过程,2,足够的麻醉才能对抗手术刺激,镇静催眠,镇痛,3,麻醉造成容量相对不足,麻醉药物,丙泊酚，抑制交感神经活性，舒张小动脉平滑肌，抑制心肌收缩力。诱导剂量（,1.52.5mg/kg,或,48g/ml,血浆浓度）可使血压下降,10%35%,，尤其见于术前血容量不足、老年及体质衰弱者,吸入麻醉药物,于布为 孙大金，,现代麻醉学,第,39,章,4,椎管内麻醉,麻醉造成容量相对不足,Buggy DJ, Power CK, Meeke R,et al. Prevention of spinal anasthesia-induced hypotension in elderly:i.m.methoxamine or combined hetastarch and crystalliod. British J Anasthsia,1998,80(2):199-203,Sen S,Aydin K,Discigil G.Hypotension induces by lateral decubitus or supine spinal anethesia in elderly with low ejection fraction undergone hip surgery. Journal of Clinical Monitoring and Computing,2007,21(2):103-107,Somboonviboon W, Kyokong O, Charuluxananan S,el al, Incidence and bradycardic after spinal anesthesia for ceasarean section. Jounral of the Medical Association of Thailand, 2008,91(2):181-187,高发人群,发生几率及严重程度,机制,交感神经被阻滞后，相应区域的静脉和动脉扩张，导致外周阻力降低，同时静脉扩张使大量血液存在于静脉系统（约占总血容量,75%,），使回心血量减少，随之心输出量减少，诱发低血压。,.,正常血容量患者心输出量降低,15%-18%,，有心脏病的老年患者几乎降低,25%,老年病人，低血容量的病人，及高平面的椎管内麻醉（腰麻、硬膜外阻滞）,5,麻醉手术期间容量不足成因演化趋势,1,、手术方式演进,2,、手术设备改善,3,、手术技术提高,1,、更舒适的麻醉,2,、高龄患者增多,.,6,麻醉期间容量管理的临床意义,麻醉期间血流动力状态不稳定，血压、心率波动剧烈，组织灌注不良,术中，可能会导致严重的并发症，导致手术风险增高,术后，可能造成倍感疲惫、组织水肿、吻合口、创缘愈,合延迟等一系列症状，影响病人的术后康复,刘和年，邱庆民，徐净，等,.,硬膜外麻醉下行腹腔镜胆囊切除术的体会,.,临床麻醉学杂志，,2003,19,（,1,）：,51.,在现代生理学、病理生理学、药理学、麻醉学等基础理论研究进展的基础上，调动各种治疗手段，尽可能使麻醉期间循环系统功能维持于稳定状态，是每一个麻醉医师的责任。,于布为 孙大金，,现代麻醉学,第,39,章,7,相对容量不足的治疗和预防,治疗,低血压发生后积极的扩容治疗,升压药物的使用,预防,麻醉开始前进行扩容治疗，并适时配伍升压药物,麻醉诱导期的容量填充,8,相对容量不足的治疗和预防,麻醉造成低血压发生快，程度深。常规的扩容剂量无法真正做到及时纠正低血压,低血压发生后的积极扩容,单纯使用正性肌力药物和血管收缩药物。虽然有效改善低血压，但是往往牺牲了重要脏器的灌注。,（例如对于产妇使用麻黄碱会显著降低胎盘血供）,升压药物的使用,治疗时面临的问题,9,相对容量不足的治疗和预防,该方案是否有效？,何种液体更加有效？,麻醉诱导期的容量填充,10,临床研究,Fluid challenge in patients submitted to spinal block MINERVA ANESTESIOLOGICA 2007 73:213-8,11,临床研究,麻醉后,5,分钟和,20,分钟，行麻醉诱导期容量填充的治疗组血压显著高于对照组,同时治疗组患者的输液量和使用缩血管药均少于对照组,Fluid challenge in patients submitted to spinal block MINERVA ANESTESIOLOGICA 2007 73:213-8,12,相对容量不足的治疗和预防,该种液体对于机体内环境的影响,小,，,安全性好,相对分子比较,大,，,容量效力的持久、稳定,理想中的预扩容液体特征,13,晶体 明胶 白蛋白 羟乙基淀粉,60 Da 30,000 Da 68,000 Da,10-20 mins 1- 2 hrs 2- 4 hrs 4 -6hrs,分子量,容量效力,围术期扩容常用液体的理化特性,130,000 Da,14,围术期常用扩容液体的效力比较,万汶,会更加有效,15,Int J Obstet Anesth. 2007 Jan;16(1):8-12,临床研究,- 1,临床研究,- 2,临床研究,- 3,200,名产妇使用,LR,或万汶,进行预扩容,不同麻醉方式下,LR,及万汶,对剖宫产低血压的预防作用,16,Int J Obstet Anesth. 2007 Jan;16(1):8-12,CR:,晶体液,CO:,万汶,SA:,腰麻,CSE:,腰硬联合麻醉,CR-SA,组,CO-SA,组,CR-CSE,组,CO-CSE,组,临床研究,- 1,临床研究,- 2,临床研究,- 3,17,在进行麻醉诱导期间容量填充时,及晶体液相比，万汶,能够,更好减少低血压发生率,Int J Obstet Anesth. 2007 Jan;16(1):8-12,有效的改善麻醉引起的相对容量不足,临床研究,- 1,临床研究,- 2,临床研究,- 3,有效降低产妇恶心呕吐发生率,18,临床研究,- 1,黄焕森等，广州医学院学报，,2002,年,6,月，,30,卷,2,期,临床研究,-2,临床研究,- 3,研究方案：,老年髋关节置换手术,心电图、心率、收缩压、舒张压、平均动脉压、脉搏氧饱和度,分别记录：,麻醉前、麻醉后,10min,、,20min,，,置入骨水泥后,2min,及术毕的各参数变化。,对于凝血功能指标,输液前、输液,1h,后及术毕分别抽取静脉血样测定,APTT,和,PT,19,表,3,两组病人输注前后,APTT,和,PT,的变化,表,2,两组病人手术期间,MAP,和,HR,的变化,6%,羟乙基淀粉有效改善由于椎管内麻醉引起的相对容量不足,出血风险及晶体液类似，安全性良好,临床研究,- 1,临床研究,-2,临床研究,- 3,黄焕森等，广州医学院学报，,2002,年,6,月，,30,卷,2,期,20,临床研究,-3,王金珠等，中国伤残医学，,2009,，,Vol.17,，,No.4, 96-7,临床研究,- 1,临床研究,- 2,研究方案,择期下腹部手术患者，,60,例，随机分成两组。,组：,30,例，麻醉前,20,分钟内输入乳酸钠林格氏液,500ml,组：,30,例，麻醉前,20,分钟内输入万汶,500ml,观察指标,心率（,HR,），收缩压（,SBP,）,观察时间点,腰麻后,15,分钟内，每一分钟记录一次,腰麻,15,分钟后，每三分钟记录一次,比较,15,分钟内两组最低值的区别,21,：两组之间该项数据有显著差异,结论：麻醉前快速输入万汶,可有效预防腰麻后的低血压发生,王金珠等，中国伤残医学，,2009,，,Vol.17,，,No.4, 96-7,临床研究,-3,临床研究,- 1,临床研究,- 2,22,没有血流动力学改变，在出现恶心,/,呕吐或其它不良反应时,在收缩压低于,100mmHg,或降低大于,25%(,比基础值或连续测量时的上次测量值,),时,-5min,0,25min,麻醉诱导开始前,5-10min,快速输入,万汶,500ml,，,30,分钟内输完,麻醉,麻醉诱导期容量填充推荐方案,使用血管活性药物,麻醉过程中,基于,British J of Anaesthesia 1996;76:731-733,23,万汶,全球七十多个国家注册,数亿袋的安全使用经验,2004.01,2004.12,2007.12,万汶,唯一被认可，用于,0-2,岁婴幼儿的人工胶体,24,THANK YOU,25,