麻醉学部分重点

1、麻醉部分重点ASA病情分级分级 标准 死亡率 体格健康，发育营养良好，各器官功能正常 0.06-0.08 除外科疾病外，有轻度并存病，功能代偿健全 0.27-0.40 并存病较严重，体力活动受限，但尚能应付日常工作 1.82-4.30 并存病严重，丧失日常工作能力，经常面临生命威胁 7.80-23.0 无论手术与否，生命难以维持24小时的频死病人 9.40-50.72.MAC (Minimal alveolar concentration)最低肺泡有效浓度As the lowest alveolar concentration under 101kPa that 50% patients ca

2、nt respond to the pain stimulation. It can reflect the anesthetic efficiency. MAC, anesthetic efficacy 3.氯氨酮（ketamine）1)易溶于水，PH3.55.5，唯一同时具有镇痛和麻醉作用的静脉麻醉药2)分离麻醉（dissociative anesthesia）:意识与感觉分离3)明显镇痛。3060秒意识消失，作用1520分钟；肌注5分钟起效，15分作用最强，定向力完全恢复需1530分钟4)初醒常出现不愉快的梦幻、恐惧等，可给予苯二氮卓类药，减少不良心理反应5)副作用：一过性呼吸暂停，幻觉

3、，恶梦及精神症状。颅内压和眼内压增高。4.琥珀胆碱（司可林，uxemethonium, succinylcholine）1)去极化肌松药2)起效迅速的短效肌松药3)静注1520秒出现肌纤维震颤，1分钟内肌松达高峰。1mg/kg静注后，可使呼吸暂停45分钟，肌张力完全恢复需1012分钟。4)引起血清钾升高，高钾血症、截瘫、骨骼肌病变的病人禁用5)可使眼压增高，青光眼病人慎用6)可被血浆胆碱酯酶水解，经尿排出5.顺阿曲库胺1)ED950.05mg/kg，强度是阿曲库铵5倍，起效时间7.5分钟，时效45分钟，增至0.2mg/kg，起效时间为2.7分钟2)长期输注或重复多次给药无蓄积3)Hofmann

4、降解4)不释放组胺5)尤适合肝肾功能不全病人6.全身麻醉并发症 complication of general anesthesiaRespiratory system:1) Regurgitation and aspiration(apnea or aspiration pneumonia)2) Airway obstruction3) Hypoventilation4) Acute atelectasisCirculatory system:1) Hypotension2) Hypertension3) Arrhythmia4) Cardiac arrest and ventricular

5、 fibrillation(VF)：most seriousemperature abnormality:1) Hyperthermia2) HypothermiaCNS:1) Resuscitation delaying2) Coma离解常数pka的作用1)起效时间：pKa愈大，离子部分越多，不易透过神经鞘和膜，用于神经阻滞时起效时间长2)弥散性能：pKa愈大，弥散性能愈差8.局麻药特点1) Lipid solubility and local anesthetic efficacy Lipid solubility potency 2) Pka and onset time PKa ons

6、et time slowly3) Protein binding and duration of action Protein binging the duration 9.局麻药毒性反应，预防措施毒性反应：血液中药物浓度过高引起中枢神经系统毒性和心血管功能不全。The main causes of systemic toxic reaction to local anesthetics1) The dosage exceed the tolerance of patients2) The anesthetics inject into the blood vessels incorrect3

7、) The injection site is rich in blood vessels, but we dont reduce the dosage or don;t use epinephrine4) The patients is weakness with low toleranceThe prevention of local anesthetics adverse reaction1) Use the safe dose2) Add vascular contractive medicine such as Adr, delaying the absorption of anes

8、thetics.3) Withdraw when injection of anesthetics4) Take care of the early sign of toxic reaction, such as suddenly fall in sleep, muscular spasm5) Correct the pathological states of the patients before anesthesia.椎管内麻醉 (见柳叶刀P100)四个生理弯曲:颈、胸、腰和骶尾弯曲椎管内麻醉时穿刺要经过哪些层组织层次才到达蛛网膜下腔？Skin subcutaneous tissue s

9、upraspinal ligament interspinal ligament ligamentum flava epidural space dura mater and arachnoid membrane subarachnoid space(pia mater spinal cord)11.麻醉平面调控 胸骨柄上缘 T2 乳头连线 T4 剑突下 T6 季肋部肋缘 T8 平脐线 T10 耻骨联合上23cm T12 大腿前面L13 小腿前面和足背L45 大腿和小腿后面及会阴区S1512.全脊髓麻醉(Total spinal anesthesia)全部脊神经被阻滞1)症状：数分钟内呼吸停止

10、respiratory inhibition and stop，血压下降hypotension，意识消失loss of consciousness2)处理：人工呼吸，气管插管，人工通气3)预防：穿刺仔细，熟悉解剖层次，遵守操作规程，回吸有无CSF，用试探剂量13.PACU(postanesthesia care unit)麻醉后恢复室麻醉后恢复室也称恢复室或苏醒室，为病人麻醉后平稳恢复及危急情况下抢救提供了场所和空间，进行短时间监护，待病人完全清醒并有足够通气量后，再将病人送回病房14.术后躁动(restlessness)手术结束后，某些病人在麻醉苏醒期可出现短暂的神志障碍，表现为迷惘、兴奋、

11、乱语、梦幻、狂躁、伴有肢体乱动，称为术后躁动15.控制性降压 (Deliberate hypotension)使用药物主动、适当降低病人的血压，减少术中失血或降低大血管的张力，避免手术操作时引起大血管破裂的措施。The measures to use drugs to reduce the blood pressure, decrease the blood loss or reduce the tension of blood vessel in prevention of the large blood vessel rupture16.输血适应症 The indications of t

12、ransfusion1) 大量失血 Large amounts of blood loss, Hb80g/L2) 纠正贫血 Correct anemia3) 凝血异常 Coagulation dysfunction4) 补充血浆蛋白及提高机体抵抗力 Supply plasma protein and improve body resistence to disease17.大量输血（都看）1)大量输血：24小时内用库存血细胞置换病人全部血容量或数小时内输入血量超过4000ml。2)可出现:低体温(冷藏血)碱中毒(枸橼酸钠在肝转化成碳酸氢钠)暂时性低血钙(大量含枸橼酸钠的血制品)高血钾(一次输入

13、大量库存血所致)及凝血异常(凝血因子被稀释和低体温)等3)治疗：有出血倾向及DIC表现时,应输浓缩血小板。多数体温正常、无休克者可以耐受快速输血而不必补钙,提倡在监测血钙下予以补充钙剂。在合并碱中毒情况下,往往不出现高血钾,除非有肾功能障碍。此时监测血钾水平很重要。若血钾高又合并低血钙,应注意对心功能的影响。18.输血并发症Immune relative blood transfusion reaction1) Non-hemolysis fever reaction2) Allergic reaction3) Hemolysis4) Transfusion relative acute lu

14、ng injury5) Transfusion relative GVHD(Graft versus host disease)6) ImmunosuppressionNon-immune relative blood transfusion reaction1) Bacterial pollution reaction2) Circulation overload3) Transfusion affects the liver19.心肺复苏ACBDA Airway 开放气道，保持呼吸道通畅keep airway unobstructedC Circulation 建立有效的人工循环 closed chest(external) cardiac compressionB Breathing 进行有效的人工呼吸artificial ventilationD Defibrillation 电除颤20.PCA(patient-controlled analgesia病人自控性镇痛)病人根据自身