临床麻醉学

Introduction of Clinical Anesthesia,王昌文 2014.01.09,Concept,Using Drugs or other methodsCentral Nerve System or peripheral nerve systemLosing sense, painless and comfortable, temporarily,What can you do for your future?,expertise in resuscitationfluid replacementairway managementoxygen transportoperative stress reductionpostoperative pain controlICU,Archaic anesthesia,Stone Age: spicula analgesiaAcupunctureTraditional medicinePressureCryotherapyAnd others,History of anesthesiology,1846 public demonstration of ether anesthesia by William T. G. Morton,Mortons ether inhaler (1846),John Snow, the first anesthesiologist（1846）,Machine of Inhalational anesthesia in 1847,Face mask(1847),History of inhalation,Anesthesia machine (1930),Intravenous anesthetics,1934: thiopental1959: diazepam1960: hydroxybutyrate, r-OH1970: ketamine1972: etomidate1976: midazolam1983: propofol,Others,OpioidsMorphine, fentanyl, sufentanil, alfentanil, remifentanilRelaxantsCurare, succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.,Local anesthetics,1884：Cocaine as ophthalmic anesthesia, nerve block1885：Epidural anesthesia1898: Spinal anesthesia1901：Caudal anesthesia1905：Procaine1930：Dibucaine1932：Dicaine1943：Lidocaine1996: Ropivacaine,Developing of Clinical Anesthesiology,80年代 90年代 21世纪,BP,Pulse,ABP,CVP,S-G catheter,ECG,Temp.,ABP、 CVP,PETCO2 Anesthesia-gases,ECG,No-invasive BP,SPO2,TEE,BIS,TOF,CCO,Work station,How about our department of anesthesiology?,1956：surgeon1957：anesthesia group60-70：epidural, spinal, nerve block70-80：CPB, intravenous anesthesia, and inhalational anesthesia80-85: intravenous anesthesia, inhalational anesthesia, ECG, arterial blood pressure, CVP, S-G80-90：inhalational anesthesia with timing injection of volatile anesthetics90-prsent：depth of anesthesia, balance anesthesia PETCO2 work-station, BIS, TOF, PiCCO21 century Key dept. & key lab. of province, pain clinical ward,Popular anesthesia words,ASA physical status classification systemTOF: train of fourBIS: bispectral indexSG: Swan Ganz catheterMAC: minimum alveolar concentration TEE: transesophageal echocardiography,The working field of Anesthesiologists,Clinic anesthesiaOperating room, PACU, outpatient, CPCR (cardiopulmonary cerebral resuscitation)CCM (critical care medicine)AnalgesiaPain clinic, postoperative analgesia, othersOthersResearch, education, training,How can you become a real anesthesiologist,purposeBasic knowledgeProfile of whole body systemsUsing your potentialRenew and update, uninterruptedlyCommunication,Anesthesia methods,general,local,inhalation,intravenous,mucosa,muscle,spinal,epidural,Nerve block,Local infiltration,topical,balance,Subspecialty of anesthesiology,Cardiac surgeryVascular surgeryThoracic surgeryNeurosurgical anesthesiaOrgan transplantationPediatric surgeryObstetric anesthesia And others,Preoperational evaluation for patient status,Procedure of clinical anesthesia,Pre-ope,preparation,introduction,Special monitoring,Maintain,PACU,Preope. Physical assessment,To visit patient in preoperationWhat is anesthesiologist to visitChecking whole body and assessing functions of main organsTo confirm the risk factorASA classification,ASA Physical Status Classification System,A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes,visiting with the patient preoperative,To receive the patient history dataTo relieve patients worrying statusReview of current drug therapyPhysical examination, interpretation of laboratory dataFind out risk factorPreposed anesthesia method,问诊表,麻醉史（全、椎管内、局），术中异常反应既往史过敏、哮喘、呼吸疾病、高血压、心脏病，肝脏、肾脏病，糖尿病，神经、肌肉疾病，出血倾向，癫痫，其他特殊情况日常活动药物史个人嗜好：吸烟（量）、饮酒（量）家族史恶性高热、过敏、哮喘、高血压、糖尿病、肝病,Physical exam.,General status：发育、营养、精神状态等血压、脉搏、体温头部：眼、鼻、口腔、下颌，中枢神经系统情况颈部：活动度、长短、甲状腺大小等，颈静脉胸部：望、触、叩、听，心电、血气、1秒率腹部：望、触、叩、听，肝、肾、脾、胃肠功能四肢：活动情况、感觉情况，动脉、静脉情况背部：椎管内麻醉或其他麻醉方法要求的,实验室检查,末梢血胸部X线生化指标血离子尿常规血型、凝血、出血时间心电图肺功能检查腹部X线感染症,全身情况的检查,发育、营养、体重体重指数（BMI）体重（kg）身高(m)2基础代谢率（BMR）0.75（脉率0.74 脉压）72,高血压标准(舒张压),轻度：90100 mmHg中度：100110 mmHg重度：110 mmHg,头部,眼部：结膜、巩膜、瞳孔、眼球运动、眼睑鼻腔：鼻孔大小 、通畅程度，有无出血倾向口腔：张口度、牙齿、舌、咽腔、扁桃体发音：有无异常,气道检查,颈部,长短、粗细活动度、后仰有无异常隆起或异常搏动血管情况气管是否居中淋巴结有无肿大,胸部检查,望：对称、呼吸运动触：皮下气肿、细震颤叩：心界、肺区、肝区，胸水听：心音、呼吸音，摩擦音等心电图：12导联，连续监测-ray, CT, MRI,腹部检查,望：外形，运动触：紧张度、压痛，肝脾大小叩：浊音听：肠音，血流B超CT,脊柱,有无感染灶，出血点等有无侧弯，异常突出活动度压痛、叩击痛,四肢检查,皮肤感觉活动温度指(趾)甲颜色及血流充盈情况动脉搏动情况，侧支循环情况病理反射,脊神经的体表标志,实验室检查,血气分析心电图心功能生化检查肝功能肾内分泌水、电解质和酸碱平衡,动脉正常血气值,pH值：7.357.45 PaO2：12.013.0kPa（90100mmHg） 随年龄有变化，老年人低于此值 PaCO2 :4.6655.998kPa (35-45mmHg)SB: 2227 mmol/L (mEq/L)BB:4555mmol/L（mEq/L）BE:3mmol/L（mEq/L)SaO2 : 9598 PA-a O2或A=aDO2:吸空气时约为1.3332.0kPa（1015mmHg）；吸纯氧时约为3.3210.0kPa（2575mmHg），,心脏功能测定,心电图心动超声（TEE）运动试验心导管检查核素心功能(心肌显像、心血管造影),心电图,正常范围心电图异常心律：窦性？律齐？心率：心动过速，心动过缓传导阻滞：IIII ，束枝传导阻滞病理性Q波STT change房性期前收缩、室性期前收缩R on T, VF,简易的心肺功能测定法,体力活动负荷试验：3mph，10, 2min, 全肺切除危险性大吹火柴试验：57cm时间肺活量：深吸气后作最大呼气，呼气时间5秒阻塞性肺疾病屏气试验：正常呼吸后如屏气时间1020秒，心肺储备功能不足登楼试验：第四层楼，10分钟内心率呼吸恢复,手术停止的心脏方面的问题,近期内出现30天内有心肌梗死的室性心律失常的：二联律、三联律R on T2个月内有充血性心力衰竭的,肺功能测定,呼吸系疾病肺功能测定指标,肝功能,重度肝功能不全者(如晚期肝硬化，有严重营养不良、消瘦、贫血、低蛋白血症、大量腹水、凝血机制障碍、全身出血或肝昏迷前期脑病等征象)则危险性极高，不宜行任何择期手术 应关注蛋白质合成、胆红素代谢、凝血机制和药物的生物转化等。,内分泌,甲状腺激素血糖肾上腺皮质激素,生化指标,HB、RBC、WBC、Hct、PltProteins: Total, albumin, globulinCre, BUNBlood GlucoseIon: potassium, natrium, chlorine, calcium, magnesium,ASA physical status,I. 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