手术室中的颈动脉内膜切除术CarotidEndarterectomy(CEA)日照市人民医院神经外科张玉海国家远程卒中中心、脑防委CEA培训基地、北京市脑血管病中心外科治疗相关问题•麻醉方式（GALAtrial）•术式介绍----标准CEA（传统CEA）----翻转式CEA•护士协作•并发症的预防OperationroomteampositionduringCEA.SSurgeon,aSassistingsurgeon,Neneurophysiologist；Aanaesthesiologist；Nnurse；Mmicroscope团队配置及体位I.Supineposition;II.Headup:toreducecervicalvenouspressure;III.Headisplacedonaring,withasandbagundertheshoulders;IV.Exposingthefulllengthofthesternomastoidmuscle;手术体位要求手术切口麻醉篇•麻醉平稳及适时调整血压至关重要麻醉方式•全麻：----Generalanaesthesiahasseveraladvantages,includingeasiersurgicalmanoeuvres,handlingofcomplicationsandeasierpatientmonitoring.•局麻：----local/regionalanaesthesiadecreasesthenumberofmedicalcomplicationsattheexpenseofneurologicalcomplications.Generalanaesthesiaversuslocalanaesthesiaforcarotidsurgery(GALA):amulticentre,randomisedcontrolledtrialMethod:aparallelgroup,multicentre,randomisedcontrolledtrialof3526patientswithsymptomaticorasymptomaticcarotidstenosisfrom95centresin24countries.----general(n=1753)orlocal(n=1773)anaesthesia;----stroke(includingretinalinfarction),myocardialinfarction,ordeathbetweenrandomisationand30daysaftersurgery;Conclusion:Thetwogroupsdidnotsignificantlydifferforqualityoflife,lengthofhospitalstay,ortheprimaryoutcomeintheprespecifiedsubgroupsofage,contralateralcarotidocclusion,andbaselinesurgicalrisk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。麻醉的不可替代性•掌握术前有无心脏疾病，缺血性尤为重要•术前的基础血压，要明确•麻醉平稳后开始手术前的血压，记录定标•临时阻断后可能需要短时升压至要求值•动脉缝合完毕后需要尽快降压•结合TCCD定出出室后的血压安全控制范围麻醉深度监测麻醉深度电极脑氧监测麻醉协助TCCD术前定标•术中阻断后短时升压•血流再通后积极降压，不建议用硝普钠术后麻醉与TCCD定控制范围麻醉机TCCD监测术中指导意义大•术前麻醉平稳后定标主要参考。•脑血流峰值、平均值、收缩期、舒张期•Baseline(beforeinduction)•Pre-clamp(atheparininjection)•Clamping,shuntinsertion(ifrequired)•Post-clamping(15minafterclamping)•Clamprelease•5-minpost-release•10-minpost-release术中监测手术护理篇•熟悉流程能减少动脉阻断时间•器械准备要求高•巡回护士及时调整双极电凝•阻断前静脉给肝素•腔内操作持续肝素盐水冲洗•术中冲洗准备•两套吸引装置操作流程•分离暴露动脉鞘•显微操作阶段：切开剥离斑块、缝合动脉•关闭动脉鞘、分层缝合。显微操作前器械显微操作前器械显微操作中器械显微操作中器械显微操作中器械术中特别注意的问题•术中对血管的保护尤为重要。•器械对缝合线的损伤隐患最大。•无损伤器械使用。•肝素盐水的高频率冲洗（1ml含10u肝素）。•肝素：Doseof5000unitsofheparinor30u/kgbodyweightofintravenousheparin;•CEA视频剪辑.mp4粥样斑块（粥糜样物）狭窄处的真腔缝隙狭窄真腔不稳定斑块术式•标准CEA•翻转式CEAStandardCEAtechnique.PPlaque,Tsuperiorthyroidartery,LlongitudinalarteriotomyCEAtechniquewithintraluminalshunt.ISIntraluminalshunt,RrubberbandaroundtheCCA,CwindowaneurysmclipattheICA,Pplaque,TsuperiorthyroidarterySelectiveshuntingwitheversioncarotidendarterectomyModifiedEversionCarotidEndarterectomyAnnVascSurg2013;27:178–185手术涉及的解剖结构•耳大神经、颈外静脉•颈阔肌、胸锁乳突肌•颈内静脉、面静脉•颈内动脉•颈总动脉•颈袢、舌下神经、迷走神经、喉上神经、面神经颈阔肌Externaljugularvein:veinisligatedanddivided;Arteriabranchofthegreataur...
