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类型临床麻醉学温医大心血管手术的麻醉课件.ppt

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    临床麻醉学温医大心血管手术的麻醉课件.ppt
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    1、Anesthesia for Cardiovascular Surgery,Xuefei Ye The 2nd affiliated hospital of Wenzhou Medical University ,Learning Objectives ?,Vocabulary,coronary artery bypass graft (CABG) surgery冠状动脉搭桥手术 myocardial ischemia 心肌缺血 transesophageal echocardiography(TEE)经食管超声心动图 Intraortic balloon pump(IABP) 主动脉球囊反搏

    2、,Vocabulary,Rheumatic heart disease 风湿性心脏病 Congenital Heart Disease 先天性心脏病 Total anomalous pulmonary venous return全肺静脉回流异常,Vocabulary,Mitral Stenosis 二尖瓣狭窄 Aortic Stenosis 主动脉瓣狭窄 Pulmonic stenosis 肺动脉狭窄 Mitral valvular regurgitation 二尖瓣反流 Tricuspid regurgitation 三尖瓣反流 Aortic Insufficiency 主动脉瓣关闭不全,V

    3、ocabulary,atrial septal defect (ASD) 房间隔缺损 Ventricular septal defect (VSD) 室间隔缺损 patent ductus arteriosus (PDA) 动脉导管未闭 Tetralogy of Fallot 法乐(氏)四联症 Pulmonary atresia 肺动脉闭锁 Double-outlet right ventricle 右室双出口,Vocabulary,Carotid artery surgery 颈动脉手术 Abdominal aortic aneurysm 腹主动脉瘤 Aortic cross-clampin

    4、g 主动脉交叉钳夹 Thoracic aortic dissection 胸主动脉壁夹层形成 Thoracic aortic aneurysm 胸主动脉瘤,Tests 1,Atrial septal defect Ventricular septal defect Patent ductus arteriosus Mitral valvular regurgitation Mitral Stenosis Aortic Stenosis,Test 2,Abdominal aortic aneurysm Thoracic aortic aneurysm Carotid artery surgery

    5、 Pulmonary atresia Rheumatic heart disease Congenital heart disease,Preanesthetic assessmentAnesthetic managementPostoperative care,11.1.1 Cardiac evaluation,Cardiac evaluation should determine the major anatomic (解剖学的) and physiologic(生理学的) characteristics of the cardiovascular system ;,this allows

    6、 one to predict the likelihood (可能性)of intraoperative ischemia and to determine functional reserve of the heart. Such as Radionuclide imaging(放射性核素成像), Radionuclide ventriculography(核素心室造影), Echocardiography(超声心动图), Cardiac catheterization.,11.1.2 Issues pertinent to cardiac surgical procedures,Prio

    7、r surgery on the thorax, heart, great vessel, lungs Prior admissions for peripheral vascular disease Carotid arterial disease A history of bleeding tendency A history of heparin-induced thrombocytopenia (HIT) Renal insufficiency Pulmonary disease,肝素诱导的血小板减少,颈动脉疾病,11.2 Anesthetic management11.2.1 Pat

    8、ient education11.2.2 Premedication11.2.3 Monitoring11.2.4 Preinduction11.2.5 Induction11.2.6 The prebypass period 11.2.7 Cardiopulmonary bypass11.2.8 Discontinuing CPB11.2.9 Postbypass period 11.2.10 Transfer to the ICU,Patient education,Anxieties are allayedWell-sedated and comfortable,Beta-adrener

    9、gic antagonists(拮抗剂), calcium channel blockers, and nitrates, including intravenous nitroglycerin(硝酸甘油), routinely are continued on schedule until arrival in the operating room.,Premedication,Digitalis (洋地黄)preparations are commonly held for 24 hours preoperatively because of inherent toxicity(espec

    10、ially in the presence of hypokalemia(低钾)) and a long elimination half-life.,Sedation (镇静药)and analgesia(镇痛药) are warranted in almost all cardiac surgical patients.,Combinations of benzodiazepines(苯二氮卓类) and morphine provide excellent amnesia(遗忘) and analgesia for preinduction catheter insertion, wit

    11、h an acceptable degree of cardiorespiratory depression in all but the most debilitated(虚弱的) patients.,ECG Systemic arterial pressure Central venous and left atrial pressures Temperature TEE,Monitoring,Preinduction,Peripheral venous access Arterial cannulation: Radial artery, Femoral artery, Brachial

    12、 artery, Axillary artery Central venous access A defibrillator and external pacemaker Red blood cells Medication,A systematic, gradual(平缓的) induction with frequent assessment of the degree of cardiovascular depression and depth of anesthesia (as determined by hemodynamic(血流动力学的) response to graded s

    13、timuli including oral airway insertion (经口气管插管)and Foley catheterization(导尿)) will minimize hemodynamic instability,Induction,Agents,Intravenous opioids Sedative hypnotics and amnestics Volatile inhalation anesthetics Muscle relaxants,Specific considerations,Aortic stenosisadequate intravascular vol

    14、umeslow heart rate with sinus rhythmmaintain vascular tonehigher filling pressure,Aortic regurgitationadequate intravascular volumeincreased heart rate and contractile statedecreased systemic vascular tone,Mitral stenosisa slow rhythm, preferably sinusadequate intravascular volume, contractility and

    15、 systemic resistanceprevent further increases in PVR,Mitral regurgitationadequate volume, contractilitya normal to elevated heart rate a reduction of systemic vascular toneIncreased PVR should be avoided,Prebypass period,A blood sample: -baseline arterial blood gas tensions-PH-Hematocrit-a control a

    16、ctivated clotting time(ACT),Anticoagulation for cannulation,Before induction, 300IU/Kg heparin ACT:more than 400 seconds Additional 200 to 300IU/Kg heparin,Cardiopulmonary bypass,Hemodynamic monitoringMetabolic acidosis and oliguriaAdditional heparin,Discontinuing CPB,Discontinuing CPB implies trans

    17、ferring cardiopulmonary function(心肺转流功能) from the bypass system(旁路系统) back to the patient.,In preparation for this transition, the anesthetist must examine and optimize(完善) the patients metabolics, anesthetic, and cardiorespiratory status,Hemodynamic stability is the primary goal, since myocardial f

    18、unction (心肌功能)has been impaired by CPB.,Postbypass period,Maintain adequate volume status, perfusion pressure(灌注压), and appropriate rate and rhythm.Continuously monitor and reassess the surgical field.,Postbypass period,Hemostasis Pulmonary dysfunction: treat bronchospasm before sternal closure Pulmonary hypertension,Postoperative care,Warming Extubation Complication-Arrhythmias-Unexplained profound hypotension-Cardiac tamponade,Thank you !,

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