非住院病人的麻醉 Outpatient Anesthesia. Benefits of Ambulatory Surgery a) Patient...
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Transcript of 非住院病人的麻醉 Outpatient Anesthesia. Benefits of Ambulatory Surgery a) Patient...
非住院病人的麻醉Outpatient Anesthesia
Benefits of Ambulatory Surgery
a) Patient preference, especially children and elderly
b) Lack of dependence on availability of hospital beds
c) Greater flexibility in scheduling operations
d) Low morbidity and mortalitye) Lower incidence of infection
f) Lower incidence of respiratory complications
g) Higher volume of patients (greater efficiency)
h) Shorter surgical waiting listsi) Lower overall procedural costsj) Less preoperative testing and
postoperative medication
Benefits of Ambulatory Surgery
Patient SelectionDuration of surgery
Less than 90 minutes
Patient characteristicsMalignant hyperthermia susceptibility
Observe for at least 4 hours postoperatively
Extremes of age Age alone should not be considered a
deterrent in the selection
Contraindications to Outpatient Surgery
a) Serious, potentially life-threatening diseases that are not optimally managed (ASAⅢ Ⅳ~ ):brittle diabetes, unstable angina, symptomatic asthma
b) Morbid obesity complicated by hemodynamic or respiratory problems
c) Drug therapy: monoamine oxidase inhibitors; acute substance abuse
Contraindications to Outpatient Surgery
e) Ex-premature infants less than 60 weeks postconceptual age
f) Lack of a responsible adult at home to care for the patient on the evening after surgery
Laboratory test recommendations for asymptomatic
healthy patients scheduled to undergo non-blood loss
peripheral procedures under general anesthesia Tests indicated
Age For men For women
≤40 none Pregnancy test
40-49 ECG HCT, pregnancy test
50-64 ECG Hb or HCT, ECG
65-74 Hb or HCT level, ECG, BUN, Glu Hb or HCT level, ECG, BUN, Glu
≥75 Hb or HCT level, ECG, BUN, Glu
Chest radiography
Hb or HCT level, ECG, BUN, Glu
Chest radiography
Preoperative Preparation
Aimed at reducing the risks inherent in ambulatory surgery, improving patient outcome, and making the surgical experience pleasant for the patient and family
Preoperative Preparation
Prepatation should minimize
patient anxiety through
pharmacologic and non-
pharmacologic means and should
reduce potential postoperative
problems by use of appropriate
premedication
Nonpharmacologic Preparation
Pharmacologic prepatation
Anixolysis and sedation
Analgesics
Prevention of nausea and vomiting
Prevention of aspiration pneumonitis
Nothing-by-mouth Guidelines
小儿术前禁食标准(h)
年龄 奶/固体 清亮液体
<6 个月 4 2
6~36个月 6 3
>36 个月 8 3
Anethetic Techniques
Quality, safety, efficiency, and the cost of drugs and equipment are important considerations in choosing an anesthetic technique for outpatient surgery
Anethetic Techniques
The ability to deliver a safe and cost-effective general anesthetic with minimal side effects and rapid recovery is critical in a busy outpatient surgery unit
General anesthesia remains the most widely used anesthetic technique for managing ambulatory surgery
Specific consideratins in General Anesthesia
Airway management
Intravenous anesthetic drugs
Inhaled anesthetic drugs
Analgesics
Muscle relaxants
Reversal of drug effects
Regional anesthesia
Monitored anesthesia
care(MAC)
Discharge Criteria
Vital signsAmbulationNausea and vomitingPainSurgical bleeding
麻醉后监测治疗室
Postanesthetic Care Unit (PACU)
主要任务收治对象 当日全麻病人术后未苏醒者 非全身麻醉后病人情况尚未稳定者 麻醉后神经功能未恢复者目的 监护和治疗病人在麻醉恢复过程中所出现的生理功能紊乱
与 ICU的区别 麻醉苏醒期的监护和治疗,短时间、一般性的麻醉恢复
PACU处理的常见问题
呼吸道梗阻通气不足低氧血症低血压高血压心律失常恶心、呕吐低温神志观察
离开恢复室的标准
呼吸循环神志椎管内麻醉平面稳定
PACU 的设置和管理
设置 足够的照明 足够的空间 足够的装备 必备的药物管理
呼吸道梗阻上呼吸道梗阻 舌后坠 上呼吸道分泌物聚积 咽或喉梗阻 喉头水肿下呼吸道梗阻 呼吸道分泌物、呕吐物、血液和脓液等阻塞下呼吸道
支气管痉挛
麻醉苏醒期终止给予麻醉药物至病人清醒的时间,可分为下面四个时相
1) 感觉和运动功能逐步恢复2) 出现自主呼吸,并能逐渐自行调控3) 呼吸道反射恢复4) 清醒
Drug name
Dose (mg/kg)
Onset of action
Recovery profile
Side effects
thiopental 3-6 rapid immediate drowsiness
etomidate 0.15-0.3 rapid immediate Pain, emisis myoclonus
ketamine 0.75-1.5 immediate immediate
Emergence reactions, cardiovascular stimulatio
midazolam 0.1-0.2 slow slow Drowsiness, amnesia
propofol 1.5-2.5 rapid rapid Pain, cardiovascular depression
Sveral intravenous anesthetics for use during ambulatory anesthesia
Compatison of inhaled anesthetics for use during ambulatory anesthesia
drug Con.(%) onset recovery Side effects halothane 0.5-1.5 slow slow sedation enflurane 0.75-1.5 intermediate intermediate shivering isoflurane 0.5-1 Intermediate Intermediate coughing
desflurane 3-6 Very rapid Very rapid Coughing, tachycardia
sevoflurane 1-2 Rapid rapid Metabolites?
Nitrous oxide
50-70 Very rapid Very rapid Nausea/emesis?
Con. =concentration
Recovery times after discontinuation of isoflurane of desflurane
50%decrease in end-tidal concentration
isoflurane desflurane
Opening eyes 9.5± 3.4 2.5± 0.8#
Following commands 10.2.5± 7.7 5.1± 2.4#
Sitting up in a chair 11.1± 7.9 6.5± 2.3
Home-ready 231± 40 207± 54
#P<0.05; mean SD
Intermidiate recovery after propofol, desflurane(± N2O), or propofol-desflurane anesthesia
Postoperative nausea after propofol, deflurane, or profofol-deflurane anesthesia
Risk Factors for Postoperative Nausea and Vomiting
Predisposing factors
Increased gastric volume
Anesthetic technique
Surgical/diagnostic procedure
Postoperative factors