臨床麻醉學(xué)緒論課件

1、Introduction of Clinical AnesthesiaDepartment of Anesthesiology1Introduction of Clinical AnestConceptUsing Drugs or other methodsCentral Nerve System or peripheral nerve systemLosing sense, painless and comfortable, temporarily2ConceptUsing Drugs or other meWhat can you do for your future?expertise

2、in resuscitationfluid replacementairway managementoxygen transportoperative stress reductionpostoperative pain controlICU 3What can you do for your futur近代麻醉學(xué)發(fā)展的三個(gè)重要階段麻醉：19世紀(jì)40年代算起，近100年的發(fā)展歷程。臨床麻醉學(xué)（clinical anesthesiology）：初步形成臨 床麻醉學(xué)的五大組成。麻醉與危重病醫(yī)學(xué)（anesthesiology and critical care medicine）：從20世紀(jì)50年代

3、末至今，一次作用要的飛躍，特別是近30余年的發(fā)展法國(guó)、日本等麻醉復(fù)蘇科（department of anesthesiology and resuscitation）；美國(guó)等麻醉與危重病醫(yī)學(xué)科（department of anesthesiology and critical care medicine）。4近代麻醉學(xué)發(fā)展的三個(gè)重要階段麻醉：19世紀(jì)40年代算起，近1Archaic anesthesiaStone Age: spicula analgesiaAcupunctureTraditional medicinePressureCryotherapyAnd others5Archaic

4、anesthesiaStone Age: sHistory of anesthesiology1846 public demonstration of ether anesthesia by William T. G. Morton 6History of anesthesiology1846 Mortons ether inhaler (1846) 7Mortons ether inhaler (1846) John Snow, the first anesthesiologist（1846） 8John Snow, the first anesthesiMachine of Inhalat

5、ional anesthesia in 18479Machine of Inhalational anesthFace mask(1847)Face mask(1847)History of inhalation11History of inhalation11Anesthesia machine (1930)12Anesthesia machine (1930)12臨床麻醉學(xué)緒論課件臨床麻醉學(xué)緒論課件15151616Intravenous anesthetics1934: thiopental1959: diazepam1960: hydroxybutyrates, r-OH1970: ke

6、tamine1972: etomidate1976: midazolam1983: propofol17Intravenous anesthetics1934: tOthersOpioidsMorphine, fentanyl, sufentanil, alfentanil, remifentanilRelaxantsCurare(1942), succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.18OthersOpioids18Local anesthetics1884：Coc

7、aine as ophthalmic anesthesia, nerve block1885：Epidural anesthesia1898: Spinal anesthesia1901：Caudal anesthesia1905：Procaine1930：Dibucaine1932：Dicaine1943：Lidocaine1963: bupivacaine1996: ropivacaineMore new: levobupivacaine19Local anesthetics1884：Cocaine How about our department of anesthesiology?19

8、56：surgeon1957：anesthesia group60-70：epidural, spinal, nerve block70-80：CPB, intravenous anesthesia, and inhalational anesthesia80-85: intravenous anesthesia, inhalational anesthesia, ECG, arterial blood pressure, CVP80-90：inhalational anesthesia with timing injection of volatile anesthetics90-prese

9、nt：depth of anesthesia, balance anesthesia20How about our department of anPopular anesthesia wordsASA physical status classification systemTOF: train of fourBIS: bispectral indexCVPneurostimulatorSG: Swan Ganz catheterMAC: minimum alveolar concentration TEE: transesophageal echocardiography21Popular

10、 anesthesia wordsASA phThe working field of AnesthesiologistsClinic anesthesiaOperating room, PACU, outpatient, CPCR (cardiopulmonary cerebral resuscitation)CCM (critical care medicine)AnalgesiaPain clinic, postoperative analgesia, othersOthersResearch, education, training22The working field of Anes

11、thesiHow can you become a real anesthesiologistpurposeBasic knowledgeProfile of whole body systemsUsing your potentialRenew and update, uninterruptedlyCommunication23How can you become a real anes2424Anesthesia methodsgenerallocal inhalationintravenousmucosamusclespinalepiduralNerve blockLocal infil

12、tration topicalbalance25Anesthesia methodsgenerallocalSubspecialty of anesthesiologyCardiac surgeryVascular surgeryThoracic surgeryNeurosurgical anesthesiaOrgan transplantationPediatric surgeryObstetric anesthesia And others26Subspecialty of anesthesiologyProcedure of clinical anesthesiaPre-opeprepa

13、reintroductionSpecial monitoringMaintainPACU27Procedure of clinical anesthesPreope. Physical assessment28Preope. Physical assessment28Purpose of Preope. Physical assessmentTo receive the patient history dataTo relieve patients worrying statusReview of current drug therapyPhysical examination, interp

14、retation of laboratory dataFind out risk factorPropose anesthesia method29Purpose of Preope. Physical asContent of Preope. Physical assessmentTo receive the patient history dataPhysical examination, interpretation of laboratory dataASA classificationPropose anesthesia method30Content of Preope. Phys

15、ical asASA physical statusI. A normal healthy patientII. A patient with mild systemic diseaseIII. A patient with severe systemic diseaseIV. A patient with severe systemic disease that is a constant threat to lifeV. A moribund patient who is not expected to survive without the operationVI. A declared

16、 brain-dead patient whose organs are being removed for donor purposesThe addition of an E indicates emergency surgery. 31ASA physical statusI. A normaPhysical exam.General status：發(fā)育、營(yíng)養(yǎng)、精神狀態(tài)等血壓、脈搏、體溫頭部：眼、鼻、口腔、下頜，中樞神經(jīng)系統(tǒng)情況頸部：活動(dòng)度、長(zhǎng)短、甲狀腺大小等，頸靜脈胸部：望、觸、叩、聽(tīng)，心電、血?dú)狻?秒率腹部：望、觸、叩、聽(tīng)，肝、腎、脾、胃腸功能四肢：活動(dòng)情況、感覺(jué)情況，動(dòng)脈、靜脈情況

17、背部：椎管內(nèi)麻醉或其他麻醉方法要求的32Physical exam.General status：發(fā)全身情況和各器官系統(tǒng)的檢診33全身情況和各器官系統(tǒng)的檢診33全身情況growth，nutrition ，body weight ，et alBMI (body mass index) =body weight (kg)body height (m)2 Male : about 22kg/m2; Female: 20kg/m2 ; 25-29kg/m2: over weight; 30kg/m2: obesity BW100% standard BW: pathosis obesity34全身情況

18、growth，nutrition ，body wei全身情況Hb80g/LHb exorbitanceHematocrit: 30%-35%acute inflammationBMR(basal metabolic rate): Reed formula： BMR%=0.75（PR+0.74PP）72 normal value：-10%+10%35全身情況Hb80g/L35呼吸系統(tǒng)呼吸系統(tǒng)感染：擇期手術(shù)，急癥手術(shù)，肺結(jié) 核，慢性肺膿腫，重癥支氣管擴(kuò)張癥COPD (chronic obstructive pulmonary disease): 功能因素比解剖因素更重要Asthma: 控制感染、停

19、止吸煙、降低氣管和支氣管的反應(yīng)性36呼吸系統(tǒng)呼吸系統(tǒng)感染：擇期手術(shù)，急癥手術(shù)，肺結(jié) 核，慢肺功能的評(píng)估肺活量：60%通氣儲(chǔ)量百分比：70%FEV1.0/FVC%：60% or 50%FVC15ml/kgMVV: 40L or 50%60% of prediction value 50%: 低肺功能 30%: 手術(shù)禁忌37肺功能的評(píng)估肺活量：55歲； BMI26kg/m2； 多胡須； 牙齒缺失； 打鼾史。41Physical examination Langeron提Physical examination面、頸或胸部: 評(píng)價(jià)其對(duì)氣道的影響頭頸部： 1）雙側(cè)鼻孔及鼻道，鼻中隔； 2）張口，舌體，

20、牙齒及牙齦，扁桃體 及顎部有無(wú)異常； 3）測(cè)頦甲距離：6.5cm以上； 4）頸椎活動(dòng)度； 5）有無(wú)氣管造口或造口瘢痕，治療氣道的并發(fā)癥。Mallampati氣道分級(jí)評(píng)定42Physical examination面、頸或胸部: 評(píng)價(jià)Mallampati氣道分級(jí)評(píng)定I級(jí)：可見(jiàn)咽峽弓、軟腭和顎垂。II級(jí)：可見(jiàn)咽峽弓、軟腭，但顎垂被舌 根部掩蓋而不可見(jiàn)。III級(jí)：僅可見(jiàn)軟腭。VI級(jí)：僅可見(jiàn)硬腭。 III、IV級(jí)預(yù)示插管困難，但不是絕對(duì)的，應(yīng)結(jié)合頦甲距離判斷。43Mallampati氣道分級(jí)評(píng)定I級(jí)：可見(jiàn)咽峽弓、軟腭和顎垂氣道檢查44氣道檢查44心血管系統(tǒng)45心血管系統(tǒng)45心功能分級(jí)及意義級(jí)別 屏氣試

21、驗(yàn) 臨床表現(xiàn) 臨床意義 麻醉耐受力I 30s 能耐受日常體力活動(dòng)，活動(dòng)后無(wú)心慌、 心功能正常 良好 氣短等不適感II 2030s 對(duì)日常體力活動(dòng)有一定的不適感，往往 心功能較差 如處理正確 自行限制或控制活動(dòng)量，不能作跑步或 適宜，耐受仍好 用力的工作III 1020s 輕度或一般體力活動(dòng)后有明顯不適，心 心功能不全 麻醉前應(yīng)作充分準(zhǔn)備 悸、氣短明顯，只能勝任極輕微的體力 應(yīng)避免增加心臟負(fù)擔(dān) 活動(dòng)或靜息IV 10s以?xún)?nèi) 不能耐受任何體力活動(dòng)，靜息時(shí)也感氣 心功能衰竭 極差，一般需推遲 短，不能平臥，有端坐呼吸、心動(dòng)過(guò)速 手術(shù) 等表現(xiàn)46心功能分級(jí)及意義級(jí)別 屏氣試驗(yàn) 心功能分級(jí)與CI、EF、L

22、VEDP心功能級(jí)別 EF LVEDP 運(yùn)動(dòng)時(shí)LVEDP 休息時(shí)CI I 0.55 正常，(12mmHg) 正常, (12mmHg) 2.5L/(minm2) II 0.50.4 12mmHg 正常，12mmHg 2.5L/(minm2) III 0.3 12mmHg 12mmHg 2.0 L/(minm2) IV 0.2 12mmHg 12mmHg 1.5L/(minm2)47心功能分級(jí)與CI、EF、LVEDP心功能級(jí)別 EGoldman 等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和計(jì)分方法1. 充血性心衰體征，如奔馬律、頸靜脈壓增高（11分）；2. 6個(gè)月內(nèi)發(fā)生過(guò)心梗（10分）；3. 室性早搏

23、5次/分鐘（7分）；4. 非竇性心律或房性早搏（7分）；5. 年齡70歲（5分）；6. 急性手術(shù)（4分）；7. 主動(dòng)脈瓣顯著狹窄（3分）；8. 胸腹腔或主動(dòng)脈手術(shù)（3分）；9. 全身情況差（3分）。48Goldman 等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和計(jì)全身情況差（下面任何一種）PaO2 49 mmHgK+ 3 mmol/LHCO3- 7.5 mmol/LCreatinine 270 mol/LSGOT：abnormality慢性肝炎(chronic hepatitis)49全身情況差（下面任何一種）PaO2 60 mmHg49Goldman 等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和

24、計(jì)分方法累計(jì)53分分四級(jí)： I級(jí)：0-5分 II級(jí)：6-12分 III級(jí)：13-25分 IV級(jí)：26分50Goldman 等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和計(jì)心律失常1竇性心律失常：過(guò)速、過(guò)緩（迷走神經(jīng) 張力過(guò)大，藥物，病竇）。室上性心動(dòng)過(guò)速: 多無(wú)器質(zhì)性心臟病； 器質(zhì)性心臟病，甲亢，藥物中毒。早搏：1）一過(guò)性或偶發(fā)性房、室早搏； 2）頻發(fā)，二聯(lián)律、三聯(lián)律或成對(duì)，多 源性，R on T，易誘發(fā)室速和室顫。陣發(fā)性室速：病理性；藥物治療不佳，需有電復(fù)律和電除顫的準(zhǔn)備。51心律失常1竇性心律失常：過(guò)速、過(guò)緩（迷走神經(jīng) 張力心律失常2房顫：可致嚴(yán)重的血流動(dòng)力學(xué)紊亂、心絞痛、昏厥、體循環(huán)栓塞和心悸不適； 未復(fù)律者，麻醉前心率：80次/分左右，至少100次/分。束支傳導(dǎo)阻滯：右束支；左束支（左前、左后分支）；雙分支或三分支阻滯；發(fā)展成房室傳導(dǎo)阻滯。房室傳導(dǎo)阻滯：I度；II度（莫氏I型、II型）；III度。 莫氏II型和莫氏I型心率0.7：病人高危