非住院病人的麻醉

非住院病人的麻醉第1頁(yè)/共34頁(yè)非住院病人的麻醉OutpatientAnesthesia第2頁(yè)/共34頁(yè)BenefitsofAmbulatorySurgeryPatientpreference,especiallychildrenandelderlyLackofdependenceonavailabilityofhospitalbedsGreaterflexibilityinschedulingoperationsLowmorbidityandmortalityLowerincidenceofinfection第3頁(yè)/共34頁(yè)LowerincidenceofrespiratorycomplicationsHighervolumeofpatients(greaterefficiency)ShortersurgicalwaitinglistsLoweroverallproceduralcostsLesspreoperativetestingandpostoperativemedicationBenefitsofAmbulatorySurgery第4頁(yè)/共34頁(yè)P(yáng)atientSelectionDurationofsurgeryLessthan90minutesPatientcharacteristicsMalignanthyperthermiasusceptibilityObserveforatleast4hourspostoperativelyExtremesofageAgealoneshouldnotbeconsideredadeterrentintheselection第5頁(yè)/共34頁(yè)ContraindicationstoOutpatientSurgerySerious,potentiallylife-threateningdiseasesthatarenotoptimallymanaged(ASAⅢ～Ⅳ):brittlediabetes,unstableangina,symptomaticasthmaMorbidobesitycomplicatedbyhemodynamicorrespiratoryproblemsDrugtherapy:monoamineoxidaseinhibitors;acutesubstanceabuse第6頁(yè)/共34頁(yè)ContraindicationstoOutpatientSurgeryEx-prematureinfantslessthan60weekspostconceptualageLackofaresponsibleadultathometocareforthepatientontheeveningaftersurgery第7頁(yè)/共34頁(yè)第8頁(yè)/共34頁(yè)P(yáng)reoperativePreparationAimedatreducingtherisksinherentinambulatorysurgery,improvingpatientoutcome,andmakingthesurgicalexperiencepleasantforthepatientandfamily第9頁(yè)/共34頁(yè)P(yáng)reoperativePreparationPrepatationshouldminimizepatientanxietythrough

pharmacologicandnon-pharmacologic

meansandshouldreducepotentialpostoperativeproblemsbyuseofappropriatepremedication第10頁(yè)/共34頁(yè)NonpharmacologicPreparation第11頁(yè)/共34頁(yè)P(yáng)harmacologicprepatationAnixolysisandsedationAnalgesicsPreventionofnauseaandvomitingPreventionofaspirationpneumonitis第12頁(yè)/共34頁(yè)Nothing-by-mouthGuidelines第13頁(yè)/共34頁(yè)AnetheticTechniquesQuality,safety,efficiency,andthecostofdrugsandequipmentareimportantconsiderationsinchoosingananesthetictechniqueforoutpatientsurgery第14頁(yè)/共34頁(yè)AnetheticTechniquesTheabilitytodeliverasafeandcost-effectivegeneralanestheticwithminimalsideeffectsandrapidrecoveryiscriticalinabusyoutpatientsurgeryunitGeneralanesthesiaremainsthemostwidelyusedanesthetictechniqueformanagingambulatorysurgery第15頁(yè)/共34頁(yè)SpecificconsideratinsinGeneralAnesthesiaAirwaymanagementIntravenousanestheticdrugsInhaledanestheticdrugsAnalgesicsMusclerelaxantsReversalofdrugeffects第16頁(yè)/共34頁(yè)RegionalanesthesiaMonitoredanesthesiacare(MAC)第17頁(yè)/共34頁(yè)DischargeCriteriaVitalsignsAmbulationNauseaandvomitingPainSurgicalbleeding第18頁(yè)/共34頁(yè)麻醉后監(jiān)測(cè)治療室PostanestheticCareUnit(PACU)第19頁(yè)/共34頁(yè)主要任務(wù)收治對(duì)象當(dāng)日全麻病人術(shù)后未蘇醒者非全身麻醉后病人情況尚未穩(wěn)定者麻醉后神經(jīng)功能未恢復(fù)者目的監(jiān)護(hù)和治療病人在麻醉恢復(fù)過程中所出現(xiàn)的生理功能紊亂與ICU的區(qū)別麻醉蘇醒期的監(jiān)護(hù)和治療，短時(shí)間、一般性的麻醉恢復(fù)第20頁(yè)/共34頁(yè)P(yáng)ACU處理的常見問題呼吸道梗阻通氣不足低氧血癥低血壓高血壓心律失常惡心、嘔吐低溫神志觀察第21頁(yè)/共34頁(yè)離開恢復(fù)室的標(biāo)準(zhǔn)呼吸循環(huán)神志椎管內(nèi)麻醉平面穩(wěn)定第22頁(yè)/共34頁(yè)P(yáng)ACU的設(shè)置和管理設(shè)置足夠的照明足夠的空間足夠的裝備必備的藥物管理第23頁(yè)/共34頁(yè)呼吸道梗阻上呼吸道梗阻舌后墜上呼吸道分泌物聚積咽或喉梗阻喉頭水腫下呼吸道梗阻呼吸道分泌物、嘔吐物、血液和膿液等阻塞下呼吸道支氣管痙攣第24頁(yè)/共34頁(yè)麻醉蘇醒期終止給予麻醉藥物至病人清醒的時(shí)間，可分為下面四個(gè)時(shí)相感覺和運(yùn)動(dòng)功能逐步恢復(fù)出現(xiàn)自主呼吸，并能逐漸自行調(diào)控呼吸道反射恢復(fù)清醒第25頁(yè)/共34頁(yè)第26頁(yè)/共34頁(yè)Sveralintravenousanestheticsforuseduringambulatoryanesthesia第27頁(yè)/共34頁(yè)第28頁(yè)/共34頁(yè)第29頁(yè)/共34頁(yè)第30頁(yè)/共34頁(yè)Intermidiaterecoveryafterpropofol,desflurane(±N2O),orpropofol-desfluraneanesthesia第31頁(yè)/共34頁(yè)P(yáng)ostoperativenauseaafterpropofol,deflurane,orprofofol-defluraneanesthesia第32頁(yè)/共34頁(yè)RiskFact