Chapter 11 balanced and combined anesthesia 复合麻醉与联合麻醉 Introduction 1 Background 2 Balanced or combined anesthesia 3 Forte 4 Commonly used method 1 intravenous anesthesia inhalation anesthesia 2 total intravenous anesthesia 3 general anaesthesia others Application principle of Combined Aanesthesia 1 Select drugs reasonably 1 synergism 2 additive 3 antagonism 2 Judge depth of anesthesia accurately 3 Enhance perianesthetic management 4 Optimize drugs scheme 5 Mmaintenance individualization 6 Combination of different anesthetic techniques Application principle of Combined Aanesthesia Combined Intravenous Inhalational anesthesia Introduction 1 concept 2 method Comparison of Intravenous anesthesia and Inhalational anesthesia Intravenous anesthesia Inhalational anesthesia 起效快 诱导迅速 无兴奋期 起效慢 诱导过程有兴奋期 基本无镇痛作用 有镇痛效应 无肌松作用 有肌松作用 术中可能知晓 无知晓 术后恶心呕吐发生率低 术后恶心呕吐多见 所需麻醉设备简单 需要一定复杂的麻醉设备 操作可控性差 操作简单 可控性好 无环境污染 有环境污染 代谢物可能有药理活性 基本不代谢 个体差异大 个体差异小 无明确的麻醉深度指标 可用MAC表示麻醉深度 Combined Intravenous Inhalational anesthesia 一 Anesthetic method 1 Induction of anesthesia 1 intravenous induction thiopental etomidate propofol midazolam fentanyl scoline vecurium 2 inhaled induction 2 Maintenance of anesthesia 1 inhalation anesthesia 2 intravenous balanced anesthesia 3 Intravenous anesthesia Inhalation anesthesia Combined Intravenous Inhalational anesthesia 二 Announcements 1 Individualization 2 Endotracheal tube 3 Accurately monitoring 4 Minimum effective dose 5 Residuary effect of anesthetics Combined Intravenous Inhalational anesthesia Total intravenous anesthesia 一 Total intravenous anesthesia TIVA 二 Intravenous combined anesthesia by Procaine 一 Anesthetic method 1 Induction of anesthesia Total intravenous anesthesia 2 Maintenance of anesthesia 1 procaine 二 Indications 三 contraindications 四 Announcements 静脉普鲁卡因复合麻醉的分期 呼吸 血压 脉搏 末梢 眼睑 眼压 眼球 瞳孔 肌张力 肢体 循环 张力 位置 大小 活动 浅 浅快 升高 快速 疼痛时 增加 正常 不 正常 手指屈曲 明显 麻醉期 皮肤苍 固定 痛时 有张力 白湿凉 散大 中 平稳 稳定 正常 良好皮 稍 稍 固定 不大 手指稍屈 手指 麻醉期 有力 肤红润 减弱 降低 曲但无力 微动 深 抑制 下降 细弱 迟滞 松弛 明显 固定 散大 肌松弛手 对刺 麻醉期 脉压 先快 紫绀 中毒时 降低 平伸 中 激无 缩小 后慢 抽搐 毒时亢进 反应 三 Intravenous combined anesthesia by Propofol 一 Anesthetic method 1 Induction of anesthesia 1 5 2 5 mg kg 2 Maintenance of anesthesia 75 200 g kg min TCI 3 7 g ml 二 Announcements Total intravenous anesthesia Propofol Fentanyl Sulfentanyl Remifentanil Premedication induction Midazolam Fentanyl Rulfentanyl Remifentanil Etomidate Propofol Vecuronium maintenance Propofol 10 mg kg h 8 mg kg h 6 mg kg h Fentanyl 3 g kg h Alfentanil 50 g kg h Sulfentanyl 0 2 1 5 g kg h Remifentanil 0 125 0 25 g kg min Muscle relaxant Vecuronium Tracrium 四 Intravenous combined anesthesia by Ketamine 一 Anesthetic method 1 Induction of anesthesia ketamine 2 mg kg iv ketamine 4 6 mg kg im 2 Maintenance of anesthesia Total intravenous anesthesia 1 ketamine OH 2 ketamine diazepam 3 ketamine diazepam scoline 二 Indications 三 contraindications 四 Announcements Total intravenous anesthesia Intravenous combined anesthesia by Fentanyl 50 100 g kg cardiac surgery Combined General other anaesthesia 一 Forte 1 anesthesia effect perioperation safety 2 Avoid fear and psychentonia 3 Reduce the dosage of narcotic analgesics or local anesthetics Combined General other anaesthesia 4 Reduce the dosage of intravenous anesthetics or inhalational anesthetics 5 Reduce the dosage of muscle relaxant 6 Postoperation analgesia 二 Method 一 Combined Intravenous Inhalation Epidural anesthesia 1 Premedication 2 Induction of anesthesia 3 Maintenance of anesthesia 4 Announcements 二 Combined Intravenous Intraspinal anesthesia 三 Combined General Other anaesthesia Brachiplex anesthesia Ccervical plexus anesthesia 三 Acupuncture analgesia 1 acupuncture combined drugs anesthesia 2 Acupuncture analgesia 麻 醉 麻醉