全麻下肢手术中止血带反应的处理课件

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,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,*,*,全麻下肢手术中止血带反应的处理,全麻下肢手术中止血带反应的处理,病历摘要,2,9,岁男性，,体重：,61kg,，,身高：,153cm,诊断：胫骨上端闭合性骨折,择期全麻下：胫骨干骨折切开复位内固定术,既往史：生长受限，多次骨折史,ASA II,级,麻醉方式：全麻,+,神经阻滞,病历摘要,术前检查,Hb 151g/dL,，,Hct 43.7%,，,Plt 194*109/L,ALT 53U/L,，,AST 31U/L,GLU 3.6mmol/L,，,UREA 5.0mmol/L,，,CREA 60umol/L,ECG,：窦性,胸片：正常,术前检查,病例摘要,0,9,：,00,入室 HR 1,122,次/分,BP 1,60,/,120,mmHg，SpO,2,9,9,%,0,9,:,00-10:00,力月西,1mg,IV,，舒芬太尼,5ug,IV,，坐骨神经阻滞，HR,110-120,次/分，BP 1,60-175,/,100-120,mmHg，SpO,2,9,9,%,1,0,：00,全麻诱导:异丙酚 TCI,4,ug/ml，舒芬太尼2,0,ug,IV,，顺式阿曲库铵 1,2,mg,IV,，,HR,60,次/分,BP 1,60,/,120,mmHg,病例摘要09：00 入室 HR 1122次/分,BP,1,1,：,15,手术开始，上止血带，麻醉维持：异丙酚TCI 2ug/ml+瑞芬太尼 0.2ug/kg/min，HR,60-80,次/分，BP 1,60,/,90,mmHg以上，并逐渐缓慢增高,1,1,：,15-12,：,15,异丙酚 TCI,3,.5,ug/ml，佩尔,0.2mg,IV,3,次后，效果不佳,1,2,：,30,佩尔,02mg,IV,2,次，亚宁定,5mg,IV,，七氟烷,3%,，硝酸甘油,0.5mg,IV,，均效果不佳，,BP,190/120mmHg,HR,80,次,/,分,1,2,：,4,0,放松止血带，,10min,内，BP 逐渐降至120/5,0,mmHg，HR 8,0,次/分,1,3,：30,手术结束,11：15 手术开始，上止血带，麻醉维持：异丙酚TCI 2u,全麻下肢手术中止血带反应的处理课件,术中高血压,：血压升高超过麻醉前,20%,或血压升高达,165/95mmHg,血压过高,：血压升高超过麻醉前,30mmHg,麻醉浅,？,缺氧,？,CO2,蓄积早期,？,甲状腺功能亢进、嗜铬细胞瘤,？,术前精神高度紧张,？,全麻下肢手术中止血带反应的处理课件,止血带,全身影响：心血管、呼吸、脑、体温、代谢,局部影响：神经、肌肉、皮肤,止血带,全身影响,-,心血管,系统,止血带充气,循环血量,+,全身血管阻力,+,CVP+,SBP+,双下肢驱血：增加,15%,（约,800ml,）血量,止血带充气,30-60 min,HR+,SBP+,DBP+,Tourniquet Pain,对镇痛药物不敏感，加深麻醉深度效果不明显,止血带放气,回心血量,+,缺血后反应性充血,CVP-,BP,P.C.A.Kam,et al.The arterial tourniquet:pathophysiological consequences and anaesthetic implications.Anaesthesia,2001,全身影响-心血管 系统止血带充气P.C.A.K,Tourniquet pain,Prolonged tourniquet inflation during general anaesthesia causes,increases in heart rate and blood pressure,which commonly lead the anaesthetist to increase the depth of anaesthesia.This clinical syndrome is commonly referred to as tourniquet pain.,长时间止血带充气后，全麻患者出现心率、血压上升。,67%,全麻患者发生,tourniquet pain,与高龄、手术时长相关，常发生在下肢手术,Valli H,Rosenberg PH,Kytta J,et al.Arterial hypertension associated with the use of tourniquet with either general or regional anaesthesia.Acta Anaesthesiol Scand 1987;,Tourniquet pain Prolonged tou,Tourniquet pain,原理：尚不明确,由无髓神经,C,类纤维传导。机械压迫使神经,A,类纤维传导受阻，充气,30min,后，神经,A,类纤维被完全阻断，神经,C,类纤维未被抑制。,交感神经兴奋,Tourniquet pain 原理：尚不明确,全麻下肢手术中止血带反应的处理课件,Tourniquet pain,处理,?,术前给予氯胺酮、右美托咪定、可乐定、右美沙芬,Tourniquet pain 处理?,Ketamine:,0.25 mg/kg,IV,Satsumae T,et al.Preoperative small-dose ketamine prevented tourniquet-induced arterial pressure increase in orthopedic patients under general anesthesia.Anesth Analg 2000,Ketamine:0.25 mg/kg IV Sat,Dexmedetomidine:,loading(0.8,m,g,/,kg,10 min),continuous infusion(0.4,m,g,/,kg,/,h),Lao HC,et,al.,Dexmedetomidine attenuates tourniquet-induced hyperdynamic response in patients undergoing lower limb surgeries:A randomized controlled study.The Journal of surgical research 2012,Dexmedetomidine:loading(0.,Clonidine,:,3 ug,/,kg,IV,Zalunardo MP,et al.Preoperative clonidine blunts hyperadrenergic and hyperdynamic responses to prolonged tourniquet pressure during general anesthesia.Anesth Analg 2002,Clonidine:3 ug/kg IV,Dextromethorphan:,30 mg po,Yamashita S,et al.Preoperative oral dextromethorphan attenuated tourniquet-induced arterial blood pressure and heart rate increases in knee cruciate ligament reconstruction patients under,general anesthesia.Anesth Analg 2004,Dextromethorphan:30 mg poYa,全身影响,-,呼吸,系统,止血带充气,缺血部位高碳酸静脉血回流,EtCO2+0.75-18mmHg,（,1min,）,EtCO2,基线水平（,10-13min,）,P.C.A.Kam,et al.The arterial tourniquet:pathophysiological consequences and anaesthetic implications.Anaesthesia,2001,全身影响-呼吸系统P.C.A.Kam,et,全麻下肢手术中止血带反应的处理课件,全身影响,-,脑部血流,止血带,放,气,2-4min,大脑中动脉血流,+50%,，,8-10min,恢复基线水平,#,颅高压、头部受伤的多发伤患者,全身影响-脑部血流,全身影响,血液系统,止血带充气、手术刺激高凝,止血带放气溶栓活性,+,体温,充气 核心温度,+,放气 核心温度,-,代谢,（,1-2h,缺血后放气,）,动脉血,K,:,3min+0.32 mmol/L,30min,内平均,+0.28mmol/L,动脉血,Lac,:,3min 2.13 mmol/L,30min,内降至基线水平,动脉血,pH,:,4min,下降,10-30min,降至基线,全身影响血液系统,丙二醛,(MDA)+,次黄嘌呤,(hypoxanthine)+,氧化应激,丙二醛(MDA)+次黄嘌呤(hypoxanthin,局部影响,直接压迫、缺血,神经、肌肉、血管、皮肤,局部影响,局部,影响,神经,感觉异常、瘫痪,上肢,下肢,桡神经、尺神经、正中神经,坐骨神经,肌肉,缺血,2-4h,后，肌肉、神经血管通透性增加组织水肿,post-tourniquet syndrome,原因：肌肉缺血、水肿、微血管充血,特点：僵硬、灰白、无力、主观感觉远端肢体麻木,P.C.A.Kam,et al.The arterial tourniquet:pathophysiological consequences and anaesthetic implications.Anaesthesia,2001,局部影响 神经P.C.A.Kam,et al.T,局部,影响,血管,较少，多发生在外周血管疾病患者的下肢,皮肤,不常见,P.C.A.Kam,et al.The arterial tourniquet:pathophysiological consequences and anaesthetic implications.Anaesthesia,2001,局部影响 P.C.A.Kam,et al.The,止血带使用时间,&,压力,时间,充气时间：,1.5-2h,健康成人,2h,以内，老年、创伤、外周血管疾病：更易肌肉损伤,2h,手术，每,2h,松止血带,10min,P.C.A.Kam,et al.The arterial tourniquet:pathophysiological consequences and anaesthetic implications.Anaesthesia,2001,止血带使用时间&压力P.C.A.Kam,et al,止血带压力,压力：上肢,+50-75mmHg,，下肢,+100-150mmHg,AOP,+50 75 mmHg,或,75100mmHg SBP,AOP,:,arterial occlusion pressure,AOP=(systolic pressure-diastolic pressure)(limb cumference)/3(cuff width)+diastolic pressure.,Jean-Pierre Estebe ,et al.The pneumatic tourniquet:mechanical,ischaemiareperfusion and systemic effects.Eur J Anaesthesiol 2011,止血带压力Jean-Pierre Estebe ,et a,建议,加强术者同麻醉医生之间的沟通：不宜使用止血带的患者、止血带压力及时间,止血带开始及结束时,，尤其严密监测患者生命体征,建议,谢 谢！,谢 谢！,