临床麻醉学.ppt

Introduction of Clinical Anesthesia 王昌文 2014.01.09 ConceptConcept n n Using Drugs or other methodsUsing Drugs or other methods n n Central Nerve System or peripheral Central Nerve System or peripheral nerve systemnerve system n n Losing sense, painless and Losing sense, painless and comfortable, temporarilycomfortable, temporarily What can you do for your What can you do for your future?future? n n expertise in resuscitationexpertise in resuscitation n n fluid replacementfluid replacement n n airway managementairway management n n oxygen transportoxygen transport n n operative stress reductionoperative stress reduction n n postoperative pain controlpostoperative pain control n n ICU ICU Archaic anesthesiaArchaic anesthesia n n Stone Age: spicula analgesiaStone Age: spicula analgesia n n AcupunctureAcupuncture n n Traditional medicineTraditional medicine n n PressurePressure n n CryotherapyCryotherapy n n And othersAnd others History of anesthesiologyHistory of anesthesiology n n 1846 public demonstration of ether 1846 public demonstration of ether anesthesia by William T. G. Morton anesthesia by William T. G. Morton Mortons ether inhaler Mortons ether inhaler (1846) (1846) John Snow, the first anesthesiologistJohn Snow, the first anesthesiologist （18461846） Machine of Inhalational Machine of Inhalational anesthesia in 1847anesthesia in 1847 Face Face maskmask (1847(1847 ) ) History of inhalationHistory of inhalation Anesthesia machine Anesthesia machine (1930)(1930) Intravenous anestheticsIntravenous anesthetics n n 1934: thiopental1934: thiopental n n 1959: diazepam1959: diazepam n n 1960: hydroxybutyrate, r-OH1960: hydroxybutyrate, r-OH n n 1970: ketamine1970: ketamine n n 1972: etomidate1972: etomidate n n 1976: midazolam1976: midazolam n n 1983: propofol1983: propofol OthersOthers n n OpioidsOpioids Morphine, fentanyl, sufentanil, alfentanil, Morphine, fentanyl, sufentanil, alfentanil, remifentanilremifentanil n n RelaxantsRelaxants Curare, succinylcholine, pancuronium, Curare, succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.mivacurium, at al. Local anestheticsLocal anesthetics n n 18841884：Cocaine as ophthalmic anesthesia, nerve blockCocaine as ophthalmic anesthesia, nerve block n n 18851885：Epidural anesthesiaEpidural anesthesia n n 1898: Spinal anesthesia1898: Spinal anesthesia n n 19011901：Caudal anesthesiaCaudal anesthesia n n 19051905：ProcaineProcaine n n 19301930：DibucaineDibucaine n n 19321932：DicaineDicaine n n 19431943：LidocaineLidocaine n n 1996: Ropivacaine1996: Ropivacaine Developing of Clinical AnesthesiologyDeveloping 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 How about our department of anesthesiology?of anesthesiology? n n 19561956：surgeonsurgeon n n 19571957：anesthesia groupanesthesia group n n 60-7060-70：epidural, spinal, nerve blockepidural, spinal, nerve block n n 70-8070-80：CPB, intravenous anesthesia, and inhalational CPB, intravenous anesthesia, and inhalational anesthesia anesthesia n n 80-85: intravenous anesthesia, inhalational 80-85: intravenous anesthesia, inhalational anesthesia, ECG, arterial blood pressure, CVP, S-G anesthesia, ECG, arterial blood pressure, CVP, S-G n n 80-9080-90：inhalational anesthesia with timing injection inhalational anesthesia with timing injection of volatile anesthetics of volatile anesthetics n n 90-prsent90-prsent：depth of anesthesia, balance anesthesiadepth of anesthesia, balance anesthesia P PET ETCO CO2 2 work-station, BIS, TOF, PiCCO work-station, BIS, TOF, PiCCO 21 century Key dept. & key lab. of province, pain clinical ward21 century Key dept. & key lab. of province, pain clinical ward Popular anesthesia wordsPopular anesthesia words n n ASA physical status classification systemASA physical status classification system n n TOF: train of fourTOF: train of four n n BIS: bispectral indexBIS: bispectral index n n SG: Swan Ganz catheterSG: Swan Ganz catheter n n MAC: minimum alveolar concentration MAC: minimum alveolar concentration n n TEE: transesophageal echocardiographyTEE: transesophageal echocardiography The working field of The working field of AnesthesiologistsAnesthesiologists n n Clinic anesthesiaClinic anesthesia Operating room, PACU, outpatient, Operating room, PACU, outpatient, n n CPCR (cardiopulmonary cerebral CPCR (cardiopulmonary cerebral resuscitation)resuscitation) n n CCM (critical care medicine)CCM (critical care medicine) n n AnalgesiaAnalgesia Pain clinic, postoperative analgesia, othersPain clinic, postoperative analgesia, others n n OthersOthers Research, education, trainingResearch, education, training How can you become a How can you become a real anesthesiologistreal anesthesiologist n n purposepurpose n n Basic knowledgeBasic knowledge n n Profile of whole body systemsProfile of whole body systems n n Using your potentialUsing your potential n n Renew and update, uninterruptedlyRenew and update, uninterruptedly n n CommunicationCommunication Anesthesia methodsAnesthesia methods general local inhalatio nintravenous mucosa muscle spinal epiduralNerve block Local infiltration topical balance Subspecialty of Subspecialty of anesthesiologyanesthesiology n n Cardiac surgeryCardiac surgery n n Vascular surgeryVascular surgery n n Thoracic surgeryThoracic surgery n n Neurosurgical anesthesiaNeurosurgical anesthesia n n Organ transplantationOrgan transplantation n n Pediatric surgeryPediatric surgery n n Obstetric anesthesia Obstetric anesthesia n n And othersAnd others Preoperational evaluation Preoperational evaluation for patientfor patient status status Procedure of clinical Procedure of clinical anesthesiaanesthesia Pre-ope preparation introduction Special monitoring Maintain PACU Preope. Physical Preope. Physical assessmentassessment n n To visit patient in preoperationTo visit patient in preoperation n n What is anesthesiologist to visitWhat is anesthesiologist to visit n n Checking whole body and assessing Checking whole body and assessing functions of main organsfunctions of main organs n n To confirm the risk factorTo confirm the risk factor n n ASA classificationASA classification ASA Physical Status ASA Physical Status Classification System Classification System n n A normal healthy patient A normal healthy patient n n A patient with mild systemic disease A patient with mild systemic disease n n A patient with severe systemic disease A patient with severe systemic disease n n A patient with severe systemic disease that is A patient with severe systemic disease that is a constant threat to life a constant threat to life n n A moribund patient who is not expected to A moribund patient who is not expected to survive without the operation survive without the operation n n A declared brain-dead patient whose organs A declared brain-dead patient whose organs are being removed for donor purposes are being removed for donor purposes visiting with the patient visiting with the patient preoperativepreoperative n n To receive the patient history dataTo receive the patient history data n n To relieve patientTo relieve patient s worrying statuss worrying status n n Review of current drug therapyReview of current drug therapy n n Physical examination, interpretation of Physical examination, interpretation of laboratory datalaboratory data n n Find out risk factorFind out risk factor n n Preposed anesthesia methodPreposed anesthesia method 问诊表问诊表 n n 麻醉史（全、椎管内、局），术中异常反应麻醉史（全、椎管内、局），术中异常反应 n n 既往史既往史 过敏、哮喘、呼吸疾病、高血压、心脏病，肝脏过敏、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、肾脏病，糖尿病，神经、肌肉疾病，出血倾向 ，癫痫，其他特殊情况，癫痫，其他特殊情况 n n 日常活动日常活动 n n 药物史药物史 n n 个人嗜好：吸烟（量）、饮酒（量）个人嗜好：吸烟（量）、饮酒（量） n n 家族史家族史 恶性高热、过敏、哮喘、高血压、糖尿病、肝病恶性高热、过敏、哮喘、高血压、糖尿病、肝病 Physical exam.Physical exam. n n General statusGeneral status：发育、营养、精神状态等：发育、营养、精神状态等 n n 血压、脉搏、体温血压、脉搏、体温 n n 头部：眼、鼻、口腔、下颌，中枢神经系统情况头部：眼、鼻、口腔、下颌，中枢神经系统情况 n n 颈部：活动度、长短、甲状腺大小等，颈静脉颈部：活动度、长短、甲状腺大小等，颈静脉 n n 胸部：望、触、叩、听，心电、血气、胸部：望、触、叩、听，心电、血气、1 1秒率秒率 n n 腹部：望、触、叩、听，肝、肾、脾、胃肠功能腹部：望、触、叩、听，肝、肾、脾、胃肠功能 n n 四肢：活动情况、感觉情况，动脉、静脉情况四肢：活动情况、感觉情况，动脉、静脉情况 n n 背部：椎管内麻醉或其他麻醉方法要求的背部：椎管内麻醉或其他麻醉方法要求的 实验室检查实验室检查 n n 末梢血末梢血 n n 胸部胸部X X线线 n n 生化指标生化指标 n n 血离子血离子 n n 尿常规尿常规 n n 血型、凝血、出血时间血型、凝血、出血时间 n n 心电图心电图 n n 肺功能检查肺功能检查 n n 腹部腹部X X线线 n n 感染症感染症 全身情况的检查全身情况的检查 n n 发育、营养、体重发育、营养、体重 n n 体重指数（体重指数（BMIBMI） n n 体重（体重（kgkg） 身高身高(m)(m) 2 2 n n 基础代谢率（基础代谢率（BMRBMR） n n 0.750.75（脉率（脉率0.74 0.74 脉压）脉压）7272 高血压标准高血压标准( (舒张压舒张压) ) n n 轻度：轻度：9090100 mmHg100 mmHg n n 中度：中度：100100110 mmHg110 mmHg n n 重度：重度：110 mmHg110 mmHg 头部头部 n n 眼部：结膜、巩膜、瞳孔、眼球运动、眼睑眼部：结膜、巩膜、瞳孔、眼球运动、眼睑 n n 鼻腔：鼻孔大小鼻腔：鼻孔大小 、通畅程度，有无出血倾向、通畅程度，有无出血倾向 n n 口腔：张口度、牙齿、舌、咽腔、扁桃体口腔：张口度、牙齿、舌、咽腔、扁桃体 n n 发音：有无异常发音：有无异常 气道检查 颈部颈部 n n 长短、粗细长短、粗细 n n 活动度、后仰活动度、后仰 n n 有无异常隆起或异常搏动有无异常隆起或异常搏动 n n 血管情况血管情况 n n 气管是否居中气管是否居中 n n 淋巴结有无肿大淋巴结有无肿大 胸部检查胸部检查 n n 望：对称、呼吸运动望：对称、呼吸运动 n n 触：皮下气肿、细震颤触：皮下气肿、细震颤 n n 叩：心界、肺区、肝区，胸水叩：心界、肺区、肝区，胸水 n n 听：心音、呼吸音，摩擦音等听：心音、呼吸音，摩擦音等 n n 心电图：心电图：1212导联，连续监测导联，连续监测 n n -ray, CT, MRI-ray, CT, MRI 腹部检查腹部检查 n n 望：外形，运动望：外形，运动 n n 触：紧张度、压痛，肝脾大小触：紧张度、压痛，肝脾大小 n n 叩：浊音叩：浊音 n n 听：肠音，血流听：肠音，血流 n n B B超超 n n CTCT 脊柱脊柱 n n 有无感染灶，出血点等有无感染灶，出血点等 n n 有无侧弯，异常突出有无侧弯，异常突出 n n 活动度活动度 n n 压痛、叩击痛压痛、叩击痛 四肢检查四肢检查 n n 皮肤感觉皮肤感觉 n n 活动活动 n n 温度温度 n n 指指( (趾趾) )甲颜色及血流充盈情况甲颜色及血流充盈情况 n n 动脉搏动情况，侧支循环情况动脉搏动情况，侧支循环情况 n n 病理反射病理反射 脊脊 神神 经经 的的 体体 表表 标标 志志 实验室检查实验室检查 n n 血气分析血气分析 n n 心电图心电图 n n 心功能心功能 n n 生化检查生化检查 n n 肝功能肝功能 n n 肾肾 n n 内分泌内分泌 n n 水、电解质和酸碱平衡水、电解质和酸碱平衡 动脉正常血气值动脉正常血气值 n n pHpH值：值：7.357.357.45 7.45 n n PaOPaO 2 2 ：12.012.013.0kPa13.0kPa（9090100mmHg100mmHg） 随年随年 龄有变化，老年人低于此值龄有变化，老年人低于此值 n n PaCOPaCO 2 2 :4.665 :4.6655.998kPa (35-45mmHg)5.998kPa (35-45mmHg) n n SB: 22SB: 2227 mmol/L (mEq/L)27 mmol/L (mEq/L) n n BB:45BB:4555mmol/L55mmol/L（mEq/LmEq/L） n n BE:3mmol/LBE:3mmol/L（mEq/L)mEq/L) n n SaOSaO 2 2 : 95 : 959898 n n PA-a OPA-a O 2 2 或或A=aDOA=aDO 2 2 : :吸空气时约为吸空气时约为1.3331.3332.0kPa2.0kPa （101015mmHg15mmHg）；吸纯氧时约为）；吸纯氧时约为3.323.32 10.0kPa10.0kPa（252575mmHg75mmHg），）， 心脏功能测定心脏功能测定 n n 心电图心电图 n n 心动超声（心动超声（TEETEE） n n 运动试验运动试验 n n 心导管检查心导管检查 n n 核素心功能核素心功能( (心肌显像、心血管造影心肌显像、心血管造影) ) 心电图心电图 n n 正常范围心电图正常范围心电图 n n 异常异常 心律：窦性？律齐？心律：窦性？律齐？ 心率：心动过速，心动过缓心率：心动过速，心动过缓 传导阻滞：传导阻滞：I I III III ，束枝，束枝传导传导 阻滞阻滞 病理性病理性Q Q波波 STSTT changeT change 房性期前收房性期前收缩缩、室性期前收、室性期前收缩缩 R on T, VFR on T, VF 简易的心肺功能测定法简易的心肺功能测定法 n n 体力活动负荷试验：体力活动负荷试验：3mph3mph，10, 2min, 10, 2min, 全肺切全肺切 除危险性大除危险性大 n n 吹火柴试验：吹火柴试验：5 57cm7cm n n 时间肺活量：深吸气后作最大呼气，呼气时间时间肺活量：深吸气后作最大呼气，呼气时间5 5 秒阻塞性肺疾病秒阻塞性肺疾病 n n 屏气试验：正常呼吸后如屏气时间屏气试验：正常呼吸后如屏气时间10102020秒，秒， 心肺储备功能不足心肺储备功能不足 n n 登楼试验：第四层楼，登楼试验：第四层楼，1010分钟内心率呼吸恢复分钟内心率呼吸恢复 手术停止的心脏方面的问题手术停止的心脏方面的问题 n n 近期内出现近期内出现3030天内有心肌梗死的天内有心肌梗死的 n n 室性心律失常的：二联律、三联律室性心律失常的：二联律、三联律 n n R on TR on T n n 2 2个月内有充血性心力衰竭的个月内有充血性心力衰竭的 肺功能测定肺功能测定 呼吸系疾病肺功能测定指标呼吸系疾病肺功能测定指标 肝功能肝功能 n n 重度肝功能不全者重度肝功能不全者( (如晚期肝硬化，有如晚期肝硬化，有 严重营养不良、消瘦、贫血、低蛋白血严重营养不良、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血或肝昏迷前期脑病等征象) )则危险性则危险性 极高，不宜行任何择期手术极高，不宜行任何择期手术 n n 应关注蛋白质合成、胆红素代谢、凝血应关注蛋白质合成、胆红素代谢、凝血 机制和药物的生物转化等。机制和药物的生物转化等。 内分泌内分泌 n n 甲状腺激素甲状腺激素 n n 血糖血糖 n n 肾上腺皮质激素肾上腺皮质激素 生化指标生化指标 n n HBHB、RBCRBC、WBCWBC、HctHct、PltPlt n n Proteins: Total, albumin, globulinPr