脊柱侧弯--叶亚军

脊柱侧弯矫形术麻醉处理叶亚军●手术时间长，刺激大，创伤大，出血多●术中监测病人的脊髓功能●麻醉要求：术前评估（心肺功能）呼吸管理导管深度气道压力术中唤醒瑞芬+异丙酚+笑气芬太尼无肌松脊柱侧弯scoliosis麻醉方法硬膜外：单次，两点穿刺，复合全麻●优点：术中镇痛效果好，有效抑制机体应激反应，血流动力学稳定。●缺点:穿刺困难,持续给药困难无法保证有效的通气，追加药困难，切口太长无法保证平面。麻醉方法全身麻醉随着越来越多的起效快,无蓄积,苏醒快药物的出现,麻醉医师的操作变的越来越容易●静脉麻醉为主，少用醚类吸入剂●唤醒前要有长效止痛药遗留作用●肌松剂的使用术中脊髓功能的监测●躯体感觉皮层诱发电位:受麻醉药物的影响七氟醚混合笑气比异丙酚影响小●Mochida等运用成串脊髓刺激发现可以大大提高对肌肉电位的敏感性,认为是最适合的方法●现在认为最理想的监测技术是对运动皮层的电磁刺激法术中体温的检测围术期浅低温引起很多严重的并发症心脏疾病，凝血功能障碍，增加输血,降低药物代谢导致术后恢复延长。通过降低多形粒细胞的氧化杀菌作用损害机体免疫功能，致使手术部位感染增加300%有关脊柱侧弯麻醉的文献氧化亚氮运用于脊柱侧弯矫形手术，可以明显缩短唤醒时间和苏醒时间，并且减少或避免唤醒时的不良反应。有关脊柱侧弯麻醉的文献地氟烷组：异氟烷组：普鲁卡因复合液:10%GS500ml+琥珀胆碱400mg+普鲁卡因5g地氟醚血气分配系数低,诱导平稳快速,麻醉深度易于控制较适合于唤醒实验,但唤醒期间血流动力学波动明显,复合低剂量的麻醉性镇痛剂芬太尼,可减轻苏醒期间的即发疼痛反应有关脊柱侧弯麻醉的文献有关脊柱侧弯麻醉的文献脑电双频指数监测在脊柱侧弯中唤醒实验时的应用价值(郭建周等)●不同麻醉方法和不同个体之间,BIS监测的灵敏度和特异度会有些变化,单对单个患者而言,唤醒实验期间BIS监测可提供一个有用的变化趋势●在使用血管活性药给麻醉深度的判断带来困难时BIS监测更显重要●实验中在BIS提供较高意识水平下,未发现较高的外显回忆率电视胸腔镜下脊柱侧弯Eclipse矫形术的麻醉(林建等)VATS技术用于脊柱外科始于上个世纪90年代初,麻醉的成功关键在于单肺通气的管理●单肺通气时间长●存在不同程度的限制性通气功能障碍●侧卧位不利于通气/血流的维持●术中PETCO2,SPO2难以维持有关脊柱侧弯麻醉的文献有关脊柱侧弯麻醉的文献长时间的单肺通气低氧和高碳酸血症很难避免呼吸的管理:●PETCO2控制在50mmHg以下,SPO290%以上●气道压在较高水平35mmHg以下●定时膨肺/小时病例1李京京女性14岁身高136cm体重31kg体表面积1.10m活动后心慌气短,不能上体育课病例1李京京实测值预测值%预测值潮气量VC0.812.1437.9补呼气量ERV0.271.4418.8最大通气量FVC0.812.1437.9用力通气量FEV1.00.713.1822.3●重度限制性通气障碍●通气储量百分比中度不足●残气占肺总量百分比中度不足●弥散功能重度下降(肺活量小)心功能EF57%病例2张瑜女性12岁身高119.0cm体重21kg体表面积0.84m活动后心慌气短,不能上体育课实测值预测值%预测值潮气量VC0.691.5644.2补呼气量ERV0.161.2712.6最大通气量FVC0.661.5642.3用力通气量FEV1.00.622.6323.6●重度限制性通气障碍●通气储量百分比中度不足病例2张瑜病例3恶性高热女性24岁病例3恶性高热曾在上海长征医院就诊。病人自诉：麻醉后呼末二氧化碳升高，取消手术。病例3恶性高热病人呼末CO2升高，一度达到60mmhg增加呼吸频率20次/分气道压力增高病例3恶性高热病例3恶性高热取肌肉组织司可林浸泡恶性高热早期表现：呼末二氧化碳明显增高体温增高处理：有效降温，体表，创口，血液一般处理，更换呼吸管道，钠石灰，激素恶性高热THEinheritedmyopathymalignanthyperthermia(MH)CitedHere...featuressustainedskeletalmusclehypermetabolismcausedbyalteredcalciumhomeostasis.HumanMHusuallyoccurswithexposuretovolatileanestheticagentsand/ordepolarizingmusclerelaxants.1Case1wasa23.8-yr-old,68-kgmuscularwomanwithapersonalhistoryofonepreviousgeneralanestheticwithoutunusualmetabolicresponsesandanegativefamilymedicalhistory.Shehadnoabnormalitiesofmuscletoneorstructurepreoperativelyandnocardiopulmonarydisease.Shewasaneliteathlete.Shewasanesthetizedforatotalthyroidectomyandradicalneckdissectionforthyroidcancer.Case1Case1Hersecondgeneralendotrachealanestheticincludedisofluraneandsuccinylcholine.AnestheticmonitoringbeforethesignsofMHincludedcapnometry,pulseoximetry,andanesophagealtemperatureprobe.Fourhours33minafterananestheticinduction,shedevelopedtachycardia.Shesubsequentlydeveloped(inorderofappearance)arrhythmia,rapidlyincreasingtemperature(maximumtemperature41.0°C),generalizedmuscularrigidity,hypercarbia,andexcessivebleeding.Case1Resultsofanarterialbloodgasdrawn4h45minafteranestheticinductionwhilethepatientwasbeinghyperventilatedwithaFioof1wereapHof6.78,aPco2of147mmHg,aPo2of250mmHg,abaseexcessof-17mEq/l,andabicarbonatelevelof20mEq/l.Peakpotassiumwas6.9mEq/l,peakcreatinekinasewas9,205U/l,prothrombintimewas28s(upperlimitofnormal,17s),andpartialthromboplastintimewasgreaterthan100s(upperlimitofnormal,40s).Case1Unsuccessfultreatmentincludedvolatileanestheticdiscontinuation(4h37minafterinductionand4minafterthefirstadversesign),hyperventilationwith100%oxygenwithanewanesthesiamachineandcircuit.Dantrolene(initialdoseof1.8mg/kggiven4h40minafteranestheticinductionand7minafterthefirstadversesignandthentitratedtoatotalof10.3mg/kg).Activecooling,fluidloading,furosemide,mannitol,bicarbonate,glucose,insulin,procainamide,dopamine,phenylephrine,epinephrine,norepinephrine,dexamethasone,heparin.Case1Extracorporealmembraneoxygenation,andcardiopulmonaryresuscitation.Noreductioninthepatient'srigiditywasnotedwiththedantroleneadministration.Thepatientdidnotsurvivethisreactionthathadbegunwhilethepatientwasintheoperatingroom.Case1Informationobtainedafterthepatient'sdeathfromherfamilyrevealedthatshehadhadseveralchildhoodfebrileepisodesofunknownetiologyandthatshehadreportedmyalgiasfor4daysafterabriefgeneralanesthetic1monthpreviously.Case2Case2wasa21-yr-old,95-kgmuscularmanwhohadapersonalhistoryofhandtremorsbutnohistoryofunexplainedfevers,musclecramps,darkurine,heatstroke,orheatintolerance.Hehadnohistoryofcardiopulmonarydisease.Hisfamilyhistorywasremarkableforagreatauntwhohaddiedinhersleepasayoungadultandafatherwithoneepisodeofheatexhaustionrelatedtoworkexposure.Case2Thepatienthadneverhadanesthesiabefore.Hewasanesthetizedwithsevoflurane(andnosuccinylcholine)foranelectiveorthopedicsurgicalprocedure.Hisairwaywasmanagedwithalaryngealmaskwithassistedventilation.Beforehisevent,monitoringincludedcapnometry,pulseoximetry,andanelectronicaxillarytemperatureprobe.Case2Thefirstsignofanadverseanestheticreactionwasdiaphoresisapproximately20minafteranestheticinductionduringtheoperation.Subsequently,otheradversesignsnotedwere(inorderofappearance)tachypnea,sinustachycardia,hypercarbia(withthemaximumPetco2of110mmHgnoted4h20minafteranestheticinduction),elevatedtemperature(43°Cesophagealwhiletheaxillarytemperatureprobewasstillreading35.2°C4h20minafteranestheticinduction),e