胸科病人手术的麻醉

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1、AnesthesiaforThoracicSurgeryZhao-QiongZhu,M.D.DepartmentofAnesthesiology,AffiliatedHospitalofZunyiMedicalCollege,Zunyi,Guizhou,563003,China1胸科手术的麻醉遵义医学院麻醉学教研室　朱昭琼2要求掌握剖胸及侧卧位时呼吸、循环病理生理的改变掌握剖胸手术病人麻醉前的估计和方法及麻醉的基本要求熟悉单肺通气的生理变化、及单肺通气的术中管理熟悉常见胸科手术的麻醉处理3第一节剖胸及侧卧位时对呼吸、循环的影响(p119)剖胸所引起的病理生理改变—自

2、主呼吸时1剖胸侧通气与肺血流比例失调肺内分流（hypoxicpulmonaryvasoconstriction;HPV有限，并受麻醉药及扩管药抑制）2反常呼吸（paradoxicalrespiration)摆动气死腔增大3纵隔移位纵隔摆动(mediastinalswaying)4剖胸及侧卧位时对呼吸、循环的影响4心排出量降低其原因（1）（2）（3）5心律失常其原因（纵隔摆动时对部位神经的刺激、通气功能紊乱、VA／Q比失常、PaO2↓和PaCO2↑)6体热的散失5侧卧位对呼吸生理的影响清醒状态下侧卧位(functionresidualcapacity;FRC下降VA／Q比基本

3、正常)全麻下侧卧位FRC下降VA／Q比失常：下侧肺VA／Q下降，上侧肺VA／Q升高6第二节　麻醉前评估与准备必要性（胸科手术术后肺部并发症发生率较高）肺部并发症最常见围术期死亡率居第二位肺功能异常者并发症是正常者23倍（切除肺病变，肺通气面积↓；手术操作肺损伤，出血、水肿↑；术后痛疼，分泌物坠积或肺不张etc.)7PreoperativeevaluationPatientsforthoracicsurgeryshouldundergotheusualpreoperativeassessmentasdetailedinChapter1.Anypatientundergoing

4、electivethoracicsurgeryshouldbecarefullyscreenedforunderlyingbronchitisorpneumoniaandtreatedappropriatelybeforesurgery.Diagnosticproceduressuchasbronchoscopyandlungbiopsy（活检）maybeintendedforpersistentinfection.Infectionbeyondanobstructinglesion（损害）maynotresolve（解决）withoutsurgery.8Inpatient

5、swithtrachealstenosis（狭窄）,thehistoryshouldfocusonsymptomsorsignsofpositionaldyspnea,staticversusdynamicairwaycollapse,andevidenceofhypoxemia.Thehistorymayalsosuggesttheprobablelocationofthelesion.Arterialbloodgas(ABG)determinationsmayhelptoclarifytheseverityofunderlyingpulmonarydiseasebuta

6、renotroutinelynecessary.Pulmonaryfunctiontestsareusefulinassessingthepulmonaryriskoflungresection.Bothexercisefunction(maximaloxygenuptake[O2max])andspirometry(forcedexpiratoryvolumein1second)havebeenusedtostratifyrisksofresection.Inmarginalcases,split-functionradionuclidescansandventilati

7、on/perfusion()scanscandeterminetherelativecontributionofeachlungandindividuallungregions.Preoperativeevaluation9Cardiacfunctionshouldbeassessedifthereisquestionoftherelativecontributionofcardiacandpulmonarydiseaseinthepatient'sfunctionalimpairment.Echocardiogr