,老年病人手术的麻醉 GERIATRIC ANESTHESIA,哈尔滨医科大学第二临床医学院 麻醉学教研室,GERIATRIC ANESTHESIA,Department of Anesthesiology， the Second Affiliated Hospital， Harbin Medical University,Zhang Ruiqin,主 要 内 容,前 言,社会老龄化,2000年全国第五次人口普查，我国65岁 人口为8811万，占总人口6.96%,50%老龄人经历一次手术,2004年上海市资料，60岁以上占人口总数19.28% 20102020年， 60岁以上将达到32%,上海市资料,美国讯 ， 65岁以上占人口12%，每年二千五百万例次手术中，占1/3，约占总医疗费的1/2，达700亿美元 19992001，仁济手术总数18646例，老年65岁4820例，占25.8%,INTRODUCTION,3-fold increased risk for perioperative death compared with younger patients increased risk of perioperative mortality and morbidity include thoracic, intraperitoneal and major vascular procedures physiology, anatomy , pharmacological agents,INTRODUCTION,high frequency of serious physiological abnormalities in elderly patients demands a particularly careful preoperative evaluation,生理特点,生理特点,WHO划分年龄标准,中年 49-59岁,较老年 60-74岁,老年 7589岁,长寿老年 90岁以上,AGE-RELATED ANATOMIC & PHYSIOLOGICAL CHANGES,CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM METABOLIC & ENDOCRINE FUNCTION RENAL FUNCTION GASTROINTESTINAL FUNCTION NERVOUS SYSTEM MUSCULOSKELETAL,心血管和植物神经系统（一）,心肌纤维化致弹性减退 心肌肥厚、 心室舒张和充盈减少、CO、SV、 射血分数减少 氧输送（DO2）等均减少,动脉硬化，SVR升高，血压升高 静脉弹性减退，顺应性下降，容量相对不足 动脉硬化尤其是主动脉弓，压力感受器调节血压、心率功能减退,心血管和植物神经系统（二）,窦房结功能减退 副交感神经系统张力、受体反应下降 左房、肺血管充盈增加，引起肺充血 心室舒张功能减退,CARDIOVASCULAR SYSTEM 1,atherosclerosis reduction in arterial elasticity Reduced arterial compliance Baroreceptor function is depressed Increased vagal tone and decreased sensitivity of adrenergic receptors lead to a decline in heart rate,CARDIOVASCULAR SYSTEM 2,loss of sinoatrial node cells increase the incidence of dysrhythmias, particularly atrial fibrillation and flutter,CARDIOVASCULAR SYSTEM 3,Doppler echocardiography diastolic dysfunction may be seen with systemic hypertension, coronary artery disease, cardiomyopathies, and valvular heart disease, particularly aortic stenosis,CARDIOVASCULAR SYSTEM 4,Diastolic dysfunction results in increases in ventricular end-diastolic pressure with small changes of left ventricular volume Atrial enlargement atrial fibrillation and flutter developing congestive heart failure,CARDIOVASCULAR SYSTEM 5,Diminished cardiac reserve induction of general anesthesia A prolonged circulation time delays the onset of intravenous drugs but speeds induction with inhalational agents elderly patients have less ability to respond to hypovolemia, hypotension, or hypoxia with an increase in heart rate,随致病菌的种类、数量、毒力以及患儿年龄和抵抗力的强弱不同而异。轻者仅有一般感染症状，重者可发生感染性休克、DIC、多器官功能衰竭等。侵入人体的细菌是否会引起败血症，与入侵菌的毒力、数量和人体防御免疫功能有密切联系。 引起败血症的金黄色葡萄球菌 下这些都可能导致败血病的发生：皮肤、粘膜发生破损和发炎如创伤和伤口感染、大面积烧伤、开放性骨折、疖、痈、感染性腹泻、化脓性腹膜大量进入血循环。大面积烧伤患者的广大创面为细菌入侵敞开门户，皮肤坏死、血浆渗出、焦痂形成又为细菌繁殖创造良好环境。 13 致病菌的变迁及常见的败血症致病菌：具有致病性或条件致病性的各种细菌均可成为败血症的病原体。由于年代的不同，患者的基础疾病不同，传入途径以及年龄段不同等因素的影响，致败血症的细菌也不同。1950年以前，败血症的病原菌主要是溶血性链球菌和肺炎球菌，占总数的50%以上，葡萄球菌（金葡+表葡）占20%，革兰阴性杆菌占12%左右。随着广谱抗生素、皮质激素和免疫抑制剂的广泛应用，败血症的病原菌谱也发生了变迁。由于溶血性链球菌和肺炎球菌对青霉素等高度敏感，作为败血症的病原现已少见。近年来统计，厌氧菌占败血症病原8%26%不等（较多医院不能做厌氧菌检测），以脆弱类杆菌和消化链球菌为主。在机体防御功能显著低下者中还可发生复数菌败血症，即在同一份标本中检测出2种或更多种致病菌，或72h内从数次血或骨髓标本中培养出多种致病菌。一般复数菌败血症约占败血症总数的10%。,精品PPT课件 浏览免费 下载后可以编辑修改。 http:/www.docin.com/xmlxh http:/www.doc88.com/jnlxh http:/www.baidu.com/ http:/www.google.com/ http:/www.sogou.com/,专业精品课件,课件下载后可以编辑，欢迎下载收藏。,呼吸系统（一）,肋骨、胸骨、肋软骨变性,胸廓弹性减少 呼吸肌减弱 肺泡气体交换面积减少,解剖和生理死腔增加，肺实质弹性组织 减少，肺顺应性下降,FEV1下降,肺活量（VC）减小，残余气量增加,呼吸系统（二）,肺泡弹性回缩 ，通气/灌流，肺血 流 ，PaO2,缺氧性肺血管收缩（HPV）反射对高碳酸血症和低氧血症的通气反应减弱,75岁时下降至735mmHg,RESPIRATORY SYSTEM 1,Elasticity is decreased in lung tissue Both anatomic and physiological dead space increase Mask ventilation may be more difficult in edentulous patients, whereas arthritis of the temporomandibular joint or cervical spine may make intubation challenging. On the other hand, the absence of upper teeth often improves visualization of the vocal cords during laryngoscopy,RESPIRATORY SYSTEM 2,Prevention of perioperative hypoxia,a higher inspired oxygen concentrations during anesthesia Aspiration pneumonia is a common and potentially life-threatening complication in elderly patients pain control techniques that facilitate postoperative pulmonary function should be seriously considered,神经系统（一）,脑平均重量 、神经原减少,15%50%,神经原缩小，密度减少,30%,脑血流减少,10%20%,脑灌流减少，脑氧代谢下降,神经递质、受体减少,精神神经系统功能减退,神经系统（二）,自主神经兴奋性下降 对循环系统调节减弱 保护性喉反射迟钝 对麻醉和手术应激的适应能力下降,对麻醉药敏感性升高 不易维持血流动力学稳定 体位改变易引起收缩压明显下降,NERVOUS SYSTEM 1,Brain mass decreases with age increasing threshold for nearly all sensory modalities, including touch, temperature sensation, proprioception, hearing, and vision anesthetics are reduced. and general Dosage requirements for local,NERVOUS SYSTEM 2,Administration of a given volume of epidural anesthetic tends to result in more extensive cephalad spread in elderly patients Elderly patients often take more time to recover completely from the central nervous system effects of general anesthesia,NERVOUS SYSTEM 3,The etiology of postoperative cognitive dysfunction (POCD) is likely multifactorial and includes drug effects, pain, underlying dementia, hypothermia, and metabolic disturbances Low levels of certain neu