临床麻醉学.ppt

Introduction of Clinical Anesthesia,王昌文 2014.01.09,Concept,Using Drugs or other methods Central Nerve System or peripheral nerve system Losing sense, painless and comfortable, temporarily,What can you do for your future?,expertise in resuscitation fluid replacement airway management oxygen transport operative stress reduction postoperative pain control ICU,Archaic anesthesia,Stone Age: spicula analgesia Acupuncture Traditional medicine Pressure Cryotherapy And 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: thiopental 1959: diazepam 1960: hydroxybutyrate, r-OH 1970: ketamine 1972: etomidate 1976: midazolam 1983: propofol,Others,Opioids Morphine, fentanyl, sufentanil, alfentanil, remifentanil Relaxants Curare, succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.,Local anesthetics,1884：Cocaine as ophthalmic anesthesia, nerve block 1885：Epidural anesthesia 1898: Spinal anesthesia 1901：Caudal anesthesia 1905：Procaine 1930：Dibucaine 1932：Dicaine 1943：Lidocaine 1996: 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：surgeon 1957：anesthesia group 60-70：epidural, spinal, nerve block 70-80：CPB, intravenous anesthesia, and inhalational anesthesia 80-85: intravenous anesthesia, inhalational anesthesia, ECG, arterial blood pressure, CVP, S-G 80-90：inhalational anesthesia with timing injection of volatile anesthetics 90-prsent：depth of anesthesia, balance anesthesia PETCO2 work-station, BIS, TOF, PiCCO 21 century Key dept. & key lab. of province, pain clinical ward,Popular anesthesia words,ASA physical status classification system TOF: train of four BIS: bispectral index SG: Swan Ganz catheter MAC: minimum alveolar concentration TEE: transesophageal echocardiography,The working field of Anesthesiologists,Clinic anesthesia Operating room, PACU, outpatient, CPCR (cardiopulmonary cerebral resuscitation) CCM (critical care medicine) Analgesia Pain clinic, postoperative analgesia, others Others Research, education, training,How can you become a real anesthesiologist,purpose Basic knowledge Profile of whole body systems Using your potential Renew and update, uninterruptedly Communication,Anesthesia methods,general,local,inhalation,intravenous,mucosa,muscle,spinal,epidural,Nerve block,Local infiltration,topical,balance,Subspecialty of anesthesiology,Cardiac surgery Vascular surgery Thoracic surgery Neurosurgical anesthesia Organ transplantation Pediatric surgery Obstetric 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 preoperation What is anesthesiologist to visit Checking whole body and assessing functions of main organs To confirm the risk factor ASA 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 data To relieve patients worrying status Review of current drug therapy Physical examination, interpretation of laboratory data Find out risk factor Preposed 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 T 2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、WB