第二十一章第二十一章 腹、盆腔手术的麻醉腹、盆腔手术的麻醉Chapter 21 Anesthesia for operations in abdominal and pelvic cavities第一节第一节 、 腹、盆腔手术麻醉的特点腹、盆腔手术麻醉的特点 The features of anesthesia for operations in abdominal and pelvic cavities1 1、腹、盆腔脏器的主要生理功能和围术期、腹、盆腔脏器的主要生理功能和围术期病理生理变化病理生理变化nThe organs in abdominal and pelvic The organs in abdominal and pelvic cavities include digestive system and cavities include digestive system and genitourinary system.genitourinary system.nThe main physiological functions are The main physiological functions are digestion, absorption,metabolism, digestion, absorption,metabolism, elimination, immune function and elimination, immune function and secretion.secretion.nThe adequate preoperative preparation The adequate preoperative preparation should be done to avoid anesthetic should be done to avoid anesthetic plications.2 2、腹、盆腔手术围术期液体管理、腹、盆腔手术围术期液体管理nSevere bleeding(massive hemorrhage), massive loss Severe bleeding(massive hemorrhage), massive loss of body fluid,internal redistribution of fluidsof body fluid,internal redistribution of fluids often called “third space” can cause severe often called “third space” can cause severe intravascular depletion.intravascular depletion.nThe fluids infusion rate is 10ml/kg/h and the The fluids infusion rate is 10ml/kg/h and the crystalloid and colloid solutions should be crystalloid and colloid solutions should be administered properly.administered properly.nWhen the danger of anemia outweighs the risks of When the danger of anemia outweighs the risks of transfusion, further blood loss should be replaced transfusion, further blood loss should be replaced with transfusion of red blood cells to maintain with transfusion of red blood cells to maintain hemoglobin concentration or hematocrit.hemoglobin concentration or hematocrit.3 3、手术体位、手术体位( (Patients position in Patients position in operationoperation）对生理功能的影响对生理功能的影响 截石位（Lithotomy position）头低位（Trendelenburg position） Lithotomy position and Trendelenburg tilt would result in changes in pulmonary blood volume, a decrease in pulmonary compliance, a cephalad shift of the diaphragm, and a decrease in lung volume parameters. Cardiac preload may increase. Nerve injuries to the common peroneal, sciatic, and femoral nerves are likely.4 4、腹压对生理功能的影响、腹压对生理功能的影响nIncreased abdominal pressure and elevation of Increased abdominal pressure and elevation of diaphragm lead to dyspnea. diaphragm lead to dyspnea. nAnesthetic agents,anesthetic techniques Anesthetic agents,anesthetic techniques and rapid decompression exacerbate and rapid decompression exacerbate vasodilatation, decreased venous return to vasodilatation, decreased venous return to heart and cardiac output. heart and cardiac output. The measures should be taken:The measures should be taken:nAdministration of IV fluids.Administration of IV fluids.nModulate the position.Modulate the position.nAdministration of ephedrine.Administration of ephedrine.nAvoid rapid decompression.Avoid rapid decompression. 5 5、腹、盆腔手术对肌松弛的要求、腹、盆腔手术对肌松弛的要求 Complete neuromuscular blocking is Complete neuromuscular blocking is required in operations.required in operations.6 6、腹、盆腔手术中的内脏牵拉反应腹、盆腔手术中的内脏牵拉反应 Distension of viscera or traction Distension of viscera or traction on peritoneum may induce bradycardia, on peritoneum may induce bradycardia, reducing of arterial pressure and reducing of arterial pressure and cardiac arrest.cardiac arrest.n Vagus reflexion and pelvic nerves reflexionVagus reflexion and pelvic nerves reflexionn Mesentery traction syndrome Mesentery traction syndrome7 7、腹、盆腔急症手术的特点、腹、盆腔急症手术的特点nPreoperative assessmentPreoperative assessment History and physical examination History and physical examination Full stomach Full stomach Hypovolemia Hypovolemia Fluid and electrolytes disturbance Fluid and electrolytes disturbance Acid-base unbalance Acid-base unbalancen Preparation for emergency operations Preparation for emergency operations第二节、第二节、 腹、盆腔手术的常用腹、盆腔手术的常用 麻醉方法麻醉方法The commonly used anesthesia techniques for surgery in abdominal and pelvic cavities 一一. . 局部麻醉（局部麻醉（local anesthesia)local anesthesia)nLocal infiltration anesthesianField blocking anesthesianIntercostal blockAdvantages.Disadvantages.二二. .椎管内麻醉（椎管内麻醉（intravertebral intravertebral anesthesiaanesthesia）1. .Extradural anesthesia, epidural Extradural anesthesia, epidural anesthesiaanesthesia One site , two sites One site , two sites 2.Subarachnoid anesthesia2.Subarachnoid anesthesia a. Single dose a. Single dose b. Intermittent bolus via a catheter b. Intermittent bolus via a catheter3.Combined spinal and epidural anesthesia3.Combined spinal and epidural anesthesia三三. .全身麻醉（全身麻醉（General General anesthesia)anesthesia)n适用于各种腹盆腔手术，尤其是手术困难适用于各种腹盆腔手术，尤其是手术困难以及老年、体弱、肥胖、病情危重或有椎以及老年、体弱、肥胖、病情危重或有椎管内麻醉禁忌证的病人。麻醉可控性强，管内麻醉禁忌证的病人。麻醉可控性强，给氧充分，能充分对机体生理功能进行调给氧充分，能充分对机体生理功能进行调控控. .n方法有：方法有： 吸入麻醉（吸入麻醉（inhalational anesthesia)inhalational anesthesia) 静脉麻醉（静脉麻醉（intravenous anesthesia)intravenous anesthesia) 静吸复合麻醉静吸复合麻醉( (Balance anesthesia)Bala