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硬膜外麻醉低血压并发症的预判断

2016-06-13 付滨 掌上医讯

硬膜外麻醉的并发症之一低血压,常见但时而凶险,早期识别、诊断、正确处理是应对的关键,但对于刚刚参加工作的麻醉医师来说,怎么才能在发生严重低血压之前就能对其进行预判断呢?本文将略做说明,希望能有所帮助。首先,我们应了解引起低血压的危险因素:1,原有的心血管代偿功能不足,高体重指数,老年人,心动过缓。2,较广泛的阻滞平面。3,椎管内阻滞与全身麻醉的联合应用。4,本身存在的低血容量。5,患者体位的突然变

硬膜外麻醉的并发症之一低血压,常见但时而凶险,早期识别、诊断、正确处理是应对的关键,但对于刚刚参加工作的麻醉医师来说,怎么才能在发生严重低血压之前就能对其进行预判断呢?本文将略做说明,希望能有所帮助。

首先,我们应了解引起低血压的危险因素:1,原有的心血管代偿功能不足,高体重指数,老年人,心动过缓。2,较广泛的阻滞平面。3,椎管内阻滞与全身麻醉的联合应用。4,本身存在的低血容量。5,患者体位的突然变动。6,手术前应用抗高血压药物。了解了上述可能引起低血压的因素,对于麻醉医师来说,要做到“心中有数”,那么就可以尝试从以下三个方面去预判断即将发生的低血压。

一、心率改变是低血压的预警信号!

心率是重中之重,尤其是无创血压的自动测量的这个周期中间,如果心率突然上幅度度较大,在我们从心电监护上读出血压开始下降之前的这个时期,就应该引起我们的足够重视。因为此时由于交感神经阻滞引起体循环血管阻力降低,回心血量减少,心脏必须增加心跳的次数,增加心脏射血,以代偿相对的血容量不足。此时我们应该及时完成我们的预判断,并准备好手中的升压药及升心率的药物,因为下一刻迎来的将是副交感神经活动增强及交感神经活动进一步减弱,导致心动过缓,低血压,甚至心搏骤停。

二、缺氧是低血压的警示信号!

常见的表现:哈欠、头晕、出冷汗甚至晕厥等。其中晕厥是缺氧的严重阶段,但如果我们掌握它的发展、机理,及时发现,正确处理,就可阻挡其的发展。

1.分期:其中典型的晕厥发作可分为3期。

(1)前驱期:自主神经症状明显,突然面色苍白,出冷汗,恶心,上腹不适,瞳孔散大,疲乏,头晕,耳鸣,打哈欠和视物模糊等,因肌张力减低而身体摇摆,此期经时数秒,如此时给予治疗则症状逐渐消退,否则很快意识丧失而进入下一期。

(2)晕厥期:意识丧失及全身肌张力消失,患者脉搏细微,血压常降低,呼吸变浅,瞳孔散大及对光反射消失,腱反射消失,肢端冷,可有尿失禁,此期经时数秒至几分钟,意识逐渐恢复而进入下一期,如意识丧失时间长达数十秒,可发生小的面部及肢体肌阵挛性抽动。

(3)恢复期:患者逐渐清醒,仍面色苍白,出汗,全身软弱,可有恶心,过度换气,但无意识模糊及头痛,给予治疗后数十分钟可完全恢复。

2.机理: 晕厥发生的最基本原因是暂时性脑供血量不足,所以了解一些脑血流量的有关问题,对于进一步认识和攻克晕厥是有益的。成人脑重约1500克,占体重的2%~2.5%,而脑部血流量却占全身血流量的15%,脑耗氧量占全身总耗氧量的20%,儿童高达40%,正常成人每分钟每100g脑组织血流量为40~50ml,若减少到31.5ml就会出现脑缺血症状,所以保证正常的脑血流量是必要的,正常人24h内必需流经脑的血量为1700L左右,氧的消耗为72L左右,脑血流与有效灌流压,脑血管阻力有密切关系,还与颅内压,血液黏度等有关。脑血流量随年龄,机体所处的状态也有所变化,例如在思考,高热,焦虑时脑血流量增加,当体温降低时脑血流量亦随之减少,这种脑血流量自动调节功能是脑组织正常活动时能获得必需血流量的保证,在一定范围内全身血压的变化并不影响脑血流量。但当平均动脉血压低于60~80mmHg时,这种起保护作用就会丧失,可能就会出现上述的自主神经症状。

这些对麻醉医师来说更应该重视,预判断其很可能是硬膜外麻醉后低血压导致的脑缺氧症状,从而及时应对。

三、意识的突然丧失是低血压的高危信号!

晕厥有一定的前驱症状,但这里需要特别强调的是病人的突然意识丧失,毫无征兆,让人措手不及!

尤其产科麻醉,务必预判断其最大的凶手可能就是仰卧位低血压综合征,这一点应该重点强调一下,仰卧位低血压综合征多见于妊娠晚期妇女,偶见于腹腔巨大包块患者,当患者处于仰卧位时,出现头晕、恶心、呕吐、胸闷、面色苍白、出冷汗、心跳加快及不同程度血压下降,当转为侧卧位后,上述症状即减轻或消失的一组综合征。但严重者可瞬间危及母儿的生命!机理在于增大的妊娠子宫或者腹腔巨大包块可压迫下腔静脉,使下腔及盆腔内静脉回流受影响,回心血量减少,右心房压下降、心搏出量随之减少,从而引起血压下降出现休克的一系列表现。出现有时很迅速,只表现突然的意识丧失,所以我们的预判断很重要!

而良好有效的医患沟通,人文关怀也很重要,简单的交流可以分散注意力,降低患者的紧张及压力程度,增加信任度,从而更有利于操作的过程中的配合,同时更为重要的是可以让你随时了解患者的意识状态,尤其在硬膜外麻醉打完改为仰卧位之后麻醉医师应该重点关注,及时发现患者的突然意识的异常甚至消失,防止造成我们的措手不及。

以上几点仅是个人工作中的经验总结,对于高年资麻醉医师来说可能很简单,但对刚参加工作的麻醉医师或许能有所帮助。


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    2016-09-14 1e10c84am36(暂无匿称)

    文章不错,值得拜读

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    2016-09-14 1e10c84am36(暂无匿称)

    文章不错,值得拜读

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1937130, encodeId=8ea7193e130d1, content=<a href='/topic/show?id=c06ae363256' target=_blank style='color:#2F92EE;'>#硬膜外#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73632, encryptionId=c06ae363256, topicName=硬膜外)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3b172500206, createdName=12498ebem19暂无昵称, createdTime=Mon Jul 11 19:56:00 CST 2016, time=2016-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126794, encodeId=4bc9126e943b, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:58:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126784, encodeId=1197126e84f3, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=85, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:57:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757717, encodeId=741b1e57717b0, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Jan 29 07:56:00 CST 2017, time=2017-01-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2027254, encodeId=72b4202e254f1, content=<a href='/topic/show?id=5259e36453f' target=_blank style='color:#2F92EE;'>#硬膜外麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73645, encryptionId=5259e36453f, topicName=硬膜外麻醉)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0357291, createdName=xiaoshitou, createdTime=Wed Apr 26 16:56:00 CST 2017, time=2017-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367336, encodeId=67cc136e336ed, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Wed Jun 15 05:56:00 CST 2016, time=2016-06-15, status=1, ipAttribution=)]
    2017-01-29 丁鹏鹏
  5. [GetPortalCommentsPageByObjectIdResponse(id=1937130, encodeId=8ea7193e130d1, content=<a href='/topic/show?id=c06ae363256' target=_blank style='color:#2F92EE;'>#硬膜外#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73632, encryptionId=c06ae363256, topicName=硬膜外)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3b172500206, createdName=12498ebem19暂无昵称, createdTime=Mon Jul 11 19:56:00 CST 2016, time=2016-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126794, encodeId=4bc9126e943b, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:58:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126784, encodeId=1197126e84f3, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=85, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:57:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757717, encodeId=741b1e57717b0, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Jan 29 07:56:00 CST 2017, time=2017-01-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2027254, encodeId=72b4202e254f1, content=<a href='/topic/show?id=5259e36453f' target=_blank style='color:#2F92EE;'>#硬膜外麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73645, encryptionId=5259e36453f, topicName=硬膜外麻醉)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0357291, createdName=xiaoshitou, createdTime=Wed Apr 26 16:56:00 CST 2017, time=2017-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367336, encodeId=67cc136e336ed, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Wed Jun 15 05:56:00 CST 2016, time=2016-06-15, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1937130, encodeId=8ea7193e130d1, content=<a href='/topic/show?id=c06ae363256' target=_blank style='color:#2F92EE;'>#硬膜外#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73632, encryptionId=c06ae363256, topicName=硬膜外)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3b172500206, createdName=12498ebem19暂无昵称, createdTime=Mon Jul 11 19:56:00 CST 2016, time=2016-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126794, encodeId=4bc9126e943b, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:58:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=126784, encodeId=1197126e84f3, content=文章不错,值得拜读, beContent=null, objectType=article, channel=null, level=null, likeNumber=85, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Wed Sep 14 14:57:00 CST 2016, time=2016-09-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757717, encodeId=741b1e57717b0, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Jan 29 07:56:00 CST 2017, time=2017-01-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2027254, encodeId=72b4202e254f1, content=<a href='/topic/show?id=5259e36453f' target=_blank style='color:#2F92EE;'>#硬膜外麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73645, encryptionId=5259e36453f, topicName=硬膜外麻醉)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0357291, createdName=xiaoshitou, createdTime=Wed Apr 26 16:56:00 CST 2017, time=2017-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1367336, encodeId=67cc136e336ed, content=<a href='/topic/show?id=f4012634656' target=_blank style='color:#2F92EE;'>#低血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26346, encryptionId=f4012634656, topicName=低血压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f634250, createdName=chentianping, createdTime=Wed Jun 15 05:56:00 CST 2016, time=2016-06-15, status=1, ipAttribution=)]
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