七氟醚吸入麻醉临床应用

七氟醚吸入麻醉临床应用七氟醚的发展历史•1968-七氟醚首次合成•1975-完成动物试验•1981-完成人体试验•1990-首先在日本上市•1995-在欧洲和美国上市•2005-在中国上市七氟烷Sevoflurane,七氟醚,•药理作用–MAC为1.71%，血气分配系数为0.63，诱导快、苏醒快。组织溶解性较低，在体内的代谢程度相应也低；–对循环抑制轻，不增加心肌对儿茶酚胺的敏感性，不易引起心律失常；–麻醉时不增加脑血流量，颅内压增加不明显，脑耗氧量下降。有一定的肌松作用，可强化肌松剂的肌松作用；–对呼吸道刺激低，可松弛气管平滑肌，能用于哮喘病人。七氟烷的临床特点•一、七氟烷的MAC恒定•二、起效快、消除迅速•三、对脑血管的自主调节无明显抑制•四、心血管系统稳定性良好•五、对呼吸功能影响小6个月内的小儿MAC几乎没变化.因此七氟烷导致麻醉药物过量的几率很低(相比氟烷,新生儿MAC要小)Anesthesiology1994;80:814-824LermanJ,etal.一、七氟烷的MAC恒定SevofluraneMinimumAlveolarConcentration(MAC)byAgeDataonfile,AbbottLaboratoriesInc.AgeMACinO2(%)MACin65%N2O/35%O2(%)0-1mo*3.3-1-6mo3.0-6mo-3yr2.82.0†3-12yr2.5-25yr2.61.440yr2.11.160yr1.70.980yr1.40.7*Neonatesarefull-termgestationalage.MACinprematureinfantshasnotbeendetermined†60%N2O/40%O2wasusedinpatientsaged1-3years二、起效快、消除迅速•健康志愿者用2－3％七氟烷，在第五次呼吸时就丧失知觉•4％七氟烷患者2分钟意识消失N2ODesfluraneIsofluraneHalothane10.80.60.40.200102030MinutesofAdministrationFA/FISevofluraneInspired&AlveolarConcentrations(FA/FI)ofvariousAnestheticsYasudaetal.AnesthAnalg.1991.七氟醚和地氟醚因较低的溶解度达到快速WASH-IN10.10.01FA/FA00102030405060minisofluranesevofluranedesflurane(10)(1.25)(1.02)EliminationKineticsFA/FAOofInhaledAnestheticsRatiooftheAlveolarfraction(Fa):Alveolarfractionatthemomentwhenthevaporizerisswitchedoff(Fa0)七氟醚和地氟醚因较低的溶解度达到快速WASH-OUTRecoveryProfile:SevofluranevsIsoflurane*p0.05vsisofluranePhilipetal.AnesthAnalg1996;83:314.Sevoflurane(n=149)Isoflurane(n=97)ResponsetoCommand*EyeOpeningMeanTime(min)12**Orientation1086420AldretescoresRecoveryscore≥8:95%ofsevofluranepatientsvs81%ofisofluranepatients(p=0.004)Morerapidrecoveryofactivity(p=0.001)Morerapidrecoveryofconsciousness(p=0.003)RecoveryWithDesfluranevsSevoflurane:EffectofAnestheticDuration0204024682468TimetoOrientationTimetoResponsetoCommandHoursofAnesthesiaMinutesAfter1.25MACAnesthesiaDesfluraneSevofluraneSevofluraneDesfluraneEgeretal.AnesthAnalg.1998;86:414.11mins18mins13mins21minsSevofluraneRecoveryProfile:BetterthanPropofol(OutpatientSurgery)*p0.05vspropofolDubinetal.Anesthesiology1994;81:A3.**ResponsetoCommandsEmergenceMeanTime(min)Sevoflurane(n=143)Propofol(n=143)121086420SevofluraneRecoveryProfile:BetterthanPropofol(InpatientSurgery)MeanTime(min)Jellishetal.AnesthAnalg1996;82:479.02468101214161820ExtubationOrientationSevoflurane(n=93)Propofol(n=93)ResponsetoCommands陈绍辉黄宇光黄一宁《地氟醚、异氟醚和七氟醚对脑血流速率的影响》临床麻醉学杂志2001年3月第17卷第3期JClinAnesthesiol,March2001,Vol.17,No.3三、对脑血管的自主调节无明显抑制大脑中动脉的平均血流速度(meanvelocity,Vm)；平均动脉压MAP；心率HR•七氟醚对心排出量无明显抑制作用•对冠状血管的作用较弱•较高浓度吸入时可引起血压下降,其下降原因主要是由于降低全身血管阻力所致。四、心血管系统稳定性良好6080100120HeartRate(beats/min)Base-line153-51-31560530Time(min)EmergencePost-intubationPre-incisionPost-incisionPriortoEndofAnesthesiaPost-emergence***HeartRateResponsetoSevofluraneandIsoflurane:ElectiveSurgicalCases*p0.05vsisofluraneEbertetal.AnesthAnalg1995;81:S11.*Sevoflurane(n=50)Isoflurane(n=25)HemodynamicsduringinductionSevofluranevsPropofol5065809511012512345Time(minutes)MAP(mmHg)SevofluranePropofoln=102Age18–85yearsThwaitesetal.BrJAnaesth1997;78:356.9080706050MeanArterialPressure(mmHg)//MinutesafterAnestheticAdvancedto1.2or1.5MAC123457891011SteadyStateHemodynamicStability:BloodPressureEbertetal.AnesthAnalg1995;81:S11.DesfluraneIsofluraneSevoflurane七氟烷对呼吸道几乎无刺激，有醇类的香味与其他吸入麻醉药相比，对肺功能的影响更小1－2MAC诱导，无咳嗽反射，更适合儿童高浓度诱导本品的呼吸抑制作用较氟烷者小；五、对呼吸功能影响小地氟醚刺激性最大，异氟醚较大，七氟醚最小SevofluraneRespiratoryProfile•Nonpungent•Minimalairwayirritation–Noincreaseinairwaysecretions–NocoughreflexorlaryngospasmRespiratoryeffectsduringinductionSevofluranevsPropofolThwaitesetal.BrJAnaesth1997;78:356.Sevoflurane(n=51)Propofol(n=51)Incidence(%)010203040506070ApneaPost-inductionCoughing*p0.01vspropofol**p=0.03vspropofol***SevofluraneandBronchodilationGoffetal.Anesthesiology2000.六、七氟烷具有更强的肌松作用•肌松作用氟烷麻醉下使用潘库溴铵用量为1七氟烷麻醉为0.6•各种吸入麻醉药物对加强维库溴铵作用的次序七氟烷安氟烷异氟烷氟烷Anesthesiology.Ebertetal..七氟醚吸入麻醉诱导用于小儿麻醉诱导的优点•七氟醚具有醇类的芳香味,对呼吸道无刺激性,小儿易于接受•由于小儿的肺泡通气量及心输出量大于成人,组织血液循环丰富,且小儿的血/气；组织/气分配系数更低,吸入药物更易到达血供丰富的脑组织与氯胺酮基础麻醉相比•(1)显著缩短哭闹时间，睫毛反射消失时间和疼痛反射消失时间,为建立静脉通道赢得时间,便于麻醉管理•(2)对心率和血压的影响与氯胺酮做基础麻醉时无显著性区别•(3)明显减少基础麻醉期间并发症的发生,提高了麻醉安全性,尤其是在患儿术前未使用抗胆碱能药物的情况下不引起分泌物的异常增加.•(4)避免肌肉注射氯胺酮时患儿的疼痛导致哭闹时间过长而引起的不利影响•(5)氯胺酮做基础麻醉有疼痛不完全消失现象,外周静脉穿刺时患儿剧烈肢体活动,有时追加氯胺酮仍肢体活动七氟醚吸入诱导的对象•一般认为4岁以上的小儿是实施吸入诱导的主要对象•0岁~3岁小儿与父母分离困难,入室时合作性差,吸入诱导的实施有一定的难度•适合吸入诱导的其他患者Sevoflurane:SuitableforMaskInduction•Smooth,rapidinductionandpredictablerecovery•Rapidadjustmentofanestheticdepth•Patientacceptance–Nonpungentodor–Nopainoninjection•Spontaneousventilationmaintained–Idealfordifficultairway–Neuromuscularblockadeavoided•CostsavingsSevofluraneMaskInduction:RapidInductionandIntubationMeanTime(min)ETT=endotrachealtube;LMA=laryngealmaskairwayMuzietal.Anesthesiology1996;85:536.012345678LossofLid-lashReflexAcceptableETT/LMAInsertionSevo/N2OLMASevo/O2ETTSevo/N2OETTSevofluraneforMaskInduction•Rapidinduction•Fewhemodynamiceffects•Lowriskofairwaycomplications•Spontaneousventilationmaintained–Idealfordifficultairway•Neuromuscularblockadecanbeavoided•AvoidsIVaccessproblems/needlephobia•Wellacceptedbypatients–Nonpungentodor–Minimalrespiratoryirritation---潮气量法和肺活量