1、第二十二章第二十二章 口腔颌面外科手术的麻醉口腔颌面外科手术的麻醉Oral and maxillofacial surgery anesthesiaOral and maxillofacial surgery anesthesia 郧阳医学院麻醉学系郧阳医学院麻醉学系郧阳医学院麻醉学系 口腔颌面外科包括除眼科、耳鼻喉科以外的颌面部及口腔内需要用手术治疗的全部疾病，其中主要为先天性畸形整形术、肿瘤切除术及外伤修复术 郧阳医学院麻醉学系教学大纲教学大纲掌握：口腔颌面外科手术的麻醉后评估及处理熟悉：麻醉后病人的处理了解：口腔颌面外科手术的特点郧阳医学院麻醉学系第一节口腔 颌面外科病人与手术特点及麻醉
2、处理Characteristics of the patients and the operation.Anesthesia management.郧阳医学院麻醉学系一、常见口腔腭面外科病人的解剖及生理改变1)先天性唇裂、腭裂 Congenital lip and palate cleft 由于口、鼻腔相通，致使吸吮、进食障碍，患儿常有不同程度的营养不良和贫血。此类患儿还常并发先天性心脏病，心功能也较差。2)双侧颞颌关节强直 Bilateral temporomandibular joints rigidity 可因长期不能开口或开口困难，造成进食障碍，使全身营养状态低下。郧阳医学院麻醉学系3
3、)口腔肿瘤 Oral tumor 如肿瘤侵袭到咽、软腭、口底和翼腭韧带，不仅张口困难，也阻塞咽部，使气管插管难以施行，且常伴有低氧血症4)口腔及颌面部外伤 Trauma 如波及软腭、咽旁、舌根及舌底，不仅组织肿胀使咽部变窄，也极易形成血肿阻塞咽部 上或下颌骨骨折的变形移位，可引起脱位性窒息郧阳医学院麻醉学系5)颌胸、颌 颈粘连 Mandible-thorax,mandible-neck adherence头颈部呈固定状态，使头部极度前屈，喉头明显移位，气管也随粘连瘢痕移向左侧或右侧，使病人不能仰头，也无法行气管造口6)口周瘢痕挛缩病人 scar formation and contractio
4、ns around the mouth，使口裂极度变小，病人根本无法张口，喉镜与气管导管难以进入口腔7)小下颌病人 Congenital maxillofacial deformity 舌体位于较小的下颌腔内，并且此类病人的声门位置较高，使气管插管困难郧阳医学院麻醉学系二、口腔颌面外科手术的特点Characteristics of the surgery 1麻醉医师与麻醉机远离手术部位2一部分病人有张口困难3一部分病人有呼吸道梗阻4一部分病人气管插管困难5手术后要保持气道通畅。6避免伤口不被呕吐物污染 郧阳医学院麻醉学系三、针对手术特点进行的麻醉处理How to deal with the m
5、entioned problems l For patients with airway obstruction,dont use respiration suppressive drugs as premedicationsl To ensure the airway,we should administer tracheal intubation or tracheostomy（气管造口术）郧阳医学院麻醉学系l To fix the tracheal tube and connecting tube in position,protect the anaesthetic tubing fr
6、om dislodgement此外，为防止导管在弯曲时管腔折屈或压偏，最好采用管壁带细金属丝或尼龙丝做管壁支架的导管l Choose an appropriate intubation routel nasal intubutionl Oral intubution 郧阳医学院麻醉学系Hypotension techniqueUse this technique in important procedure.The hypotensive duration should be short SBP90mmHg,MBP60mmHgTo fulfil respiration self-regulat
7、ion,the postoperative resuscitation should be quickPrevent postoperative nausea and vomiting-related to pharyngeal stimulation,postoperative pain,anesthetic drugs etc郧阳医学院麻醉学系第二节麻醉选择及常用麻醉方法The anesthetic choices and common anesthetic methods凡手术创伤大、手术出血多、手术时间长、儿童及不合作的成年人、术者在术中难以保持呼吸道通畅、以及有可能发生反流误吸的病人
8、，均选用全身麻醉郧阳医学院麻醉学系第三节麻醉管理与麻醉后处理Management during and after anesthesia(一)During anesthesia(1)Ensure the airwayCauses of airway obstructions:Tongue falling down,laryngo spasm,bronchiospasm,secretions,blood and debris drain into larynx,tracheal tube kinking(2)Maintain statisfied ventilationInadequate ve
9、ntilation may result in hypoxaemia,hypercapnia郧阳医学院麻醉学系The criteria of satisfied ventilation:l SpO2 98-100%PET CO2 30-45mmHg lBlood-gas analysislTV 8-10ml/kg(Neonate 6-7ml/kg)lRf 12/min(Neonate Rf )郧阳医学院麻醉学系(二)Management after anesthesia(1)Airway managementExtubation conditions:Completely awake.norm
10、al ventilation,SPO296%(air inhalation)Normal muscle tonicity,smooth respirationPrevent laryngeal edema after extubation 郧阳医学院麻醉学系Delayed extubation:Pharyngeal damage due to tracheal intubation The involved operation range is large Restrictive dressings（敷料）applied after surgery Narrowed pharyngeal ca
11、vity due to trauma郧阳医学院麻醉学系(2)Prevent postoperative nausea and vomiting(3)Prevent the complications related to anesthesiaNasal-pharyngeal mucosal haemorrhage（鼻咽粘膜出血）Nasal-pharyngeal mucosal fall offPharyngeal edema 郧阳医学院麻醉学系（4）Postoperative maxilla sinus（颌窦）inflammation Choose appropriate size tracheal tube Use tracheal tube lubricant（滑润剂）Apply humidification（湿化）of inspired gases High-volume,low-pressure cuffs may be preferred for long-term intubation
