复合麻醉与联合麻醉复合麻醉与联合麻醉1u复合麻醉复合麻醉(balanced anesthesia)及联合麻醉及联合麻醉（combined anesthesia)的定义的定义u复合麻醉的应用原则复合麻醉的应用原则u静吸复合麻醉与全凭静脉麻醉的比较静吸复合麻醉与全凭静脉麻醉的比较u联合麻醉的优缺点联合麻醉的优缺点2复合麻醉复合麻醉(balanced anesthesia)及联合麻醉及联合麻醉（combined anesthesia） 的定义的定义The concept of balanced anaesthesia today is that a combination of anaesthetics will act synergistically with respect to desired effects such as hypnosis or analgesia, but not with respect to side-effects.联合麻醉是指同一麻醉过程同时或先后采用两种或两种以上的技术3理想的麻醉状态不仅仅局限于无痛、肌肉松弛和意识消失有效地调控机体的应激状态维护重要生命器官和系统的功能消除恶性刺激对病人生理及心理的影响4复合麻醉的应用原则合理的选择麻醉药物和剂量准确地判断麻醉深度加强麻醉管理优化用药方案坚持个体化原则不同麻醉技术的联合使用5临床常用的复合麻醉方案1.静吸复合麻醉Propofol+Fentanyl+Esmeron 诱导插管Sevoflurane+Remifentnil 维持2.全凭静脉麻醉（TIVA or TCI）Propofol+Fentanyl+Esmeron 诱导插管Propofol+Remifentanil 维持6两种方法的比较1.对颅内压的影响2.对术后恶心呕吐的影响3.对HPV的影响4.术中体动的发生率5.对苏醒速度的影响 6.经济效益的比较7吸入麻药的药代动力Figure 1. The 80% decrement times of volatile anaesthetics. By analogy with the context-sensitive half-time, the decrement time describes the decay of the alveolar concentration with the time of administration. The 80% decrement times of both sevoflurane and desflurane are less than 8 minutes and do not increase with the duration of anaesthesia. However, the 80% decrement times of isoflurane and enflurane increase significantly after approximately 60 minutes of anaesthesia, reaching plateaus of approximately 3035 minutes. The 80% decrement time correlates closely with the clinically observed recovery of consciousness.8阿片类药物的时效敏感半衰期The CSHT of remifentanil is less than 5 minutes, independently of the time of administration.9Propofol时效敏感半衰期The CSHT of propofol is 15min after a 2-hour infusion10两种方法的选择颅内占位性病变手术腔镜手术某些胸科手术高危呕吐病人的手术耳鼻喉短小手术讲者更多倾向于选择Propofol-based anesthesia11Pearlsutilization of ultra-fast-acting compounds needs planning of postoperative analgesia at least during anaesthesia, or better, before the start of anaesthesiaMulti-model analgesia (including NSAID, nerve block, local infiltration, opioid, etc) should be considered 12联合麻醉的优点可以达到更完善的麻醉效果， 病人围术期安全性更高消除病人对手术和麻醉的恐惧心理和精神紧张减少全麻中镇痛药的用量，或局麻药的应用，从而减少全麻或局麻药物所带来的毒副作用和不良反应减少静脉麻醉药或吸入麻醉药的应用，病人术后苏醒迅速、恢复快可以减少肌松药的用量术后保留硬外导管，可以提供完善的术后镇痛13硬外复合全麻的优点14硬外复合全麻的优点硬外麻醉可以降低全麻术中麻醉性镇痛药及麻醉药的需求，加快术后苏醒及降低麻醉性镇痛药相关的各种并发症对于上腹部手术病人可以有利于术后肺功能的恢复，特别是术后易于出现肺部并发症的病人，如肥胖病人有利于术后肠道功能的恢复降低术后心律失常的发生完善的术后镇痛15硬外复合全麻的缺点术中易于出现低血压硬外穿刺及导管放置增加麻醉医生的风险16 谢谢！17