阻塞性睡眠呼吸暂停低通气综合征(OSAHS-)的麻醉处理课件.ppt

1、阻塞性睡眠呼吸暂停低通气综合阻塞性睡眠呼吸暂停低通气综合征征(OSAHS)的麻醉处理的麻醉处理免费医生咨询：:/12320bst一OSAHS 的诊断标准 阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea-hypopnea syndrome,OSAHS)是指睡眠时上气道塌陷阻塞引起的呼吸暂停和通气不足、伴有打鼾、睡眠结构紊乱、频繁发生血氧饱和度下降、白天嗜睡等病症。OSAHS 依据中华医学会呼吸病学会分会睡眠呼吸疾病学组2002 年的OSAHS 诊治指南:即患者在一夜(7h)睡眠中,发生呼吸暂停及低通气的总次数超过30 次或平均每小时(睡眠呼吸暂停低通气指数apne

2、a-hypopnea index AHI)超过5次以上即诊断为OSAHS。呼吸暂停是指口和鼻气流停止至少 10 s以上;呼吸气流降低超过正常气流强度的 50%以上,并伴有 4%氧饱和度下降者,称为低通气。1999 年美国睡眠学会公布了 OSAHS 新的分级标准为 AHI 5 15 为轻度;1630 为中度;大于 30 为重度。二OSAHS的并发症 OSAHS 是一种常见病和多发病,又是可以累及全身多个系统、多个脏器，对人体健康造成严重危害的临床综合征。患者睡眠中反复出现低氧血症、高碳酸血症和睡眠结构紊乱,是缺血性脑血管病、心肌梗死、不稳定型心绞痛等疾病的独立危险因素。OSAHS患者血纤维蛋白原

3、（Fg）明显升高,表明其凝血功能亢进,Fg是缺血性脑卒中和冠状动脉血栓性疾病的独立危险因素；反复发作的低氧、高碳酸血症,严重者可导致神经调节功能失衡,儿茶酚胺、肾素血管紧张素、内皮素分泌增加,微血管收缩,内分泌功能紊乱及血液动力学改变,微循环异常等可导致多系统器官功能损害。并发症 高血压已有许多流行病学研究表明OSAHS与高血压具有很强的相关性。至少30%的高血压患者合并OSAHS,45%48%的OSAHS患者伴有高血压。冠心病OSAHS与冠心病也具有较强的相关性。Koehler研究证实,74 例冠状动脉造影显示有单支或多支冠状动脉狭窄的冠心病患者,均行全夜多导睡眠图检查(polysomnog

4、raply，PSG)证实35%合并有OSAHS.并发症并发症 心率及心律失常 睡眠呼吸障碍时多数患者心率及心律会发生变化,主要表现为心律的周期性改变,呼吸暂停时心动过缓,随后由于呼吸暂停后过度通气而出现心动过速，心动过缓和心动过速时间长短与呼吸暂停时间有关,一般在10 60 s之间。患者睡眠时有较大的心率变异性。80%患者有明显的心动过速,室性异位搏动发生率达 57%74%,二度房室传导阻滞发生率为 10%以上。室性异位搏动与动脉SaO2有明显相关,SaO2 60%时室性早搏无明显增加,SaO2 3 hours)and general anesthesia(vs.or spinal).Emer

5、gency surgery.Underlying chronic pulmonary disease or symptoms ofrespiratory infection.Smoking.Age 60 years.Obesity.Presence of obstructive sleep apnea(OSA)Poor exercise tolerance or poor general health status.Diabetes mellitus The diabetic patient who needs elective surgery should be carefully asse

6、ssed preoperatively for symptoms and signs of peripheral vascular,cerebrovascular and coronary disease.Co-existing pathologies must be identified and carefully managed perioperatively.Diabetics have a higher incidence of death after MI,Myocardial ischemia or infarction may be clinically“silent”if th

7、e diabetic has autonomic neuropathy.Adequate control of blood glucose concentration(3min）。5)尽量选择清醒气管插管，保留自主呼吸，防止可预料的困难气道变成急症气道。6)在轻度的镇静、镇痛和充分的表面麻醉下（包括环甲膜穿刺气管内表面麻醉），面罩给氧，并尝试喉镜显露。7)能看到声门的，可以直接插管，或快诱导插管。8)显露不佳者，采用传统的经鼻盲探插管，也可采用视频喉镜改善显露，或试用插管 喉罩。9)在困难气道处理的整个过程中要确保通气和氧合，密切监测病人的脉搏血氧饱和度变化，当其降至 90时要及时面罩辅助给氧

8、通气，以保证病人生命安全为首要目标。10）反复数次以上未能插管成功时，为确保病人安全，推迟或放弃麻醉和手术也是必要的处理方法，。要避免同一个人采用同一种方法反复操作的情况，应当及时分析，更换思路和方法或者更换人员和手法，通气和氧合是最主要的目的，同时要有微创意识。插管时间原则上不大于一分钟，或脉搏血氧饱和度不低于92，不成功时要再次通气达到最佳氧合。反复数次失败后要学会放弃，待总结经验并充分准备后再次处理。术中血流动力学的管理 OSAHS患者由于反复的通气不足，导致循环阻力增加，多数有高血压和/或缺血性心肌病IHD(ischemic heart disease)，病人循环代偿功能降低。UPPP

9、手术刺激较大，患者术中常出现剧烈的血流动力学波动。曾有术中出现高血压危象的报道，因此，术中适当加深麻醉深度及行控制性降压，既减少了术中出血，又能保持血流动力学的稳定，避免心肌缺血的发生，取得了良好的效果。术后拔除气管导管的管理 术毕清醒过程也是OSAHS患者呼吸意外的易发阶段。术后患者苏醒早期,意识未完全恢复,肌肉张力也未恢复,多数患者对插管不能耐受,出现烦躁、挣扎等症状,以致于因患者挣扎而拔管,此时拔管后患者因上呼吸道肌肉张力低下,咽壁塌陷而引起窒息或呼吸停止。应严格掌握拔管指征,要求生命体征稳定,肌张力完全恢复,有足够的通气量和最大的吸气峰压,同时做好面罩吸氧及再插管准备。专家建议UPPP

10、术后拔管的指征为：意识完全清楚,能按指令举臂,抬头 5s,吸空气 10min,SpO2 90%,彻底吸净气管、口咽和鼻腔分泌物,拔管。Postoperative analgesia The management of postoperative analgesia in the patient with OSA is extremely challenging for the clinician caring for these patients.Although common sense dictates that we should minimize postoperative use o

11、f opioids and sedative while maximizing the utilization of non-opioid agents and regional analgesic techniques,there is little randomized data to support these notions.Nevertheless,patients with OSA who undergo surgical procedures should receive regional analgesia and non-opioid agents(eg,NSAIDs,tra

12、madol)if there are no contraindications for their use.Further studies are needed to examine the different analgesic regimens on OSA patient outcomes.According to the ASA guidelines,the use of systemic opioids should be minimized to reduce the likelihood of adverse outcomes in patients at increased p

13、erioperative risk from OSA.The postoperative administration of opioids has been alleged to be associated with an increased risk for respiratory depression and even deathand the studies reviewed do suggest that opioids should be used,if at all,with great caution in the postoperative period in OSA pat

14、ients.In light of the ASA recommendations,the use of non-opioid analgesics is likely to gain popularity Tramadol is a synthetic analogue of codeine which exhibits a central analgesic activity with a low affinity for opioid receptors.Although tramadol has some selectivity for mu receptors,this activi

15、ty within the central nervous system is quite low;that is,6000 times lower than that of morphine.Tramadol provides analgesia presumably through inhibition of norepinephrine and serotonin reuptake.with a maximum dose of 400 mg/dayNonsteroidal anti-inflammatory agents(NSAIDs)This class of analgesics may be particularly useful for the management of postoperative pain in patients with OSA as NSAIDs and acetaminophen do not appear to have any direct respiratory depressant effects