《临床麻醉学》第1章概论

Introduction

of

ClinicalAnesthesiaConceptUsing

Drugs

or

other

methodsCentral

Nerve

System

or

peripheralnerve

systemLosing

sense,

painless

and

comfortabletemporarilyW

hat

can

you

do

for

yourfuture?expertise

in

resuscitationfluid

replacementairway

managementoxygen

transportoperative

stress

reductionpostoperative

paincontrolICU近代麻醉学发展的三个重要阶段麻醉：19世纪4

0年代算起，近100年的发展历程。临床麻醉学（c

linical

an

esthesiology

）：初步形成临床麻醉学的五大组成。麻醉与危重病医学（a

nesthesiology

and

critical

caremedicine

）：从20世纪50年代末至今，一次作用要的飞跃，特别是近30余年的发展法国、日本等——麻醉复苏科（de

partment

ofanesthesiology

and

resuscitation）；美国等——麻醉与危重病医学科（dep

artmen

t

ofanesthesiology

and

critical

care

medicin

e）。Archaic

anesthesiaStone

Age:

spicula

analgesiaAcupunctureTraditional

medicinePressureCryotherapyAnd

othersHistory

of

anesthesiology1846

public

demonstration

of

etheranesthesia

by

William

T.

G.

MortonM

orton"s

ether

inhaler

(1846

)John

Snow,

the

f

irst

anesthesiologist（184

6）M

achine

of

Inhalationalanesthesia

in

1847Facemask(1847)History

of

inhalationAnesthesia

m

achine(1930

)Intravenous

anesthetics1934:

thiopental1959:

diazepam1960:

hydroxybutyrates,

r-OH1970:

ketamine1972:

etomidate1976:

midazolam1983:

propofolOthersOpioidsMorphine,

fentanyl,

sufentanil,

alfentaniremifentanilRelaxantsCurare(1942),

succinylcholine,pancuronium,

vecuronium,

atracurium,rocuronium,

mivacurium,

at

al.Local

anesthetics1884：Cocaine

as

ophthalmic

anesthesia,

nerve

block1885：Epidural

anesthesia1898:

Spinal

anesthesia1901：Caudal

anesthesia1905：Procaine

1930：Dibucaine

1932：Dicaine1943：Lidocaine1963:

bupivacaine1996:

ropivacaineMore

new:

levobupivacaineHow

about

our

departmentof

anesthesiology?～1956：surgeon

1957：anesthesia

group60-70：epidural,

spinal,

nerve

block70-80：CPB,

intravenous

anesthesia,

andinhalational

anesthesia80-85:

intravenous

anesthesia,

inhalationalanesthesia,

ECG,

arterial

blood

pressure,

CVP80-90：inhalational

anesthesia

with

timing

injectionof

volatile

anesthetics90-present：depth

of

anesthesia,

balanceanesthesiaPopular

anesthesia

wordsASA

physical

status

classification

systemTOF:

train

of

fourBIS:

bispectral

indexCVPneurostimulatorSG:

Swan

Ganz

catheterMAC:

minimum

alveolar

concentrationTEE:

transesophageal

echocardiographyThe

working

field

ofAnesthesiologistsClinic

anesthesiaOperating

room,

PACU,

outpatient,CPCR

(cardiopulmonary

cerebralresuscitation)CCM

(critical

care

medicine)AnalgesiaPain

clinic,

postoperative

analgesia,

othersOthersResearch,

education,

trainingHowcan

you

becom

e

areal

anesthesiologistpurposeBasic

knowledgeProfile

of

whole

body

systemsUsing

your

potentialRenew

and

update,

uninterruptedlyCommunicationAnesthesia

m

ethodsgenerallocalinhalationintravenousmucosa

musclespinalepiduralNerve

blockLocalinfiltrationtopicalbalanceSubspecialty

ofanesthesiologyCardiac

surgeryVascular

surgeryThoracic

surgeryNeurosurgical

anesthesiaOrgan

transplantationPediatric

surgeryObstetric

anesthesiaAnd

othersProcedure

of

clinicalanesthesiaPre-opeprepareintroductionSpecial

monitoringMaintainPACUPreope.

Physical

assessm

entPurpose

of

P

reope.Physical

assessm

entTo

receive

the

patient

history

data

To

relieve

patient’s

worrying

statusReview

of

current

drug

therapyPhysical

examination,

interpretation

olaboratory

dataFind

out

risk

factorPropose

anesthesia

methodContent

of

Preope.Physical

assessm

entTo

receive

the

patient

history

dataPhysical

examination,

interpretation

olaboratory

dataASA

classificationPropose

anesthesia

methodASA

physical

statusⅠ.A

normal

healthy

patientⅡ.A

patient

with

mild

systemic

disease

III.A

patient

with

severe

systemic

diseaseⅣ.A

patient

with

severe

systemic

disease

that

is

aconstant

threat

to

lifeⅣ.A

moribund

patient

who

is

not

expected

tosurvive

without

the

operationⅣ.A

declared

brain-dead

patient

whose

organsare

being

removed

for

donor

purposesThe

addition

of

an

"E"

indicates

emergencysurgery.Physical

ex

am

.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全身情况和各器官系统的检诊全身情况growth，nutrition

，body

weight

，et

alBMI

(body

mass

index)=body

weight

(kg)×body

height

(m)2Male

:

about

22kg/m2;Female:

20kg/m2

;25-29kg/m2:

over

weight;≥30kg/m2:

obesityBW＞100%

standard

BW:

pathosis

obesity全身情况Hb＞80g/LHb

exorbitanceHematocrit:

30%-35%acute

inflammationBMR(basal

metabolic

rate):Reed

formula：BMR%=0.75×（PR+0.74×PP）－72normal

value：-10%~+10%呼吸系统呼吸系统感染：择期手术，急症手术，肺结核，慢性肺脓肿，重症支气管扩张症COPD(chronic

obstructivepulmonary

disease):功能因素比解剖因素更重要Asthma:控制感染、停止吸烟、降低气管和支气管的反应性肺功能的评估肺活量：<60%通气储量百分比：<70%FEV1.0/FVC%：<60%

or

50%FVC<15ml/kgMVV:

40L

or

50%~60%

of

prediction

value<50%:低肺功能<30%:手术禁忌床旁测试病人肺功能的方法摒弃试验

吹气试验

吹火柴试验气道评估(airway

evaluation)Purpose:

difficult

intubation,

difficumask

ventilationpatient

historyphysical

examinationPhysical

ex

am

ination提示气道处理困难的体征：不能张口；颈椎活动受限；颏退缩；舌体大；门齿突起；颈短；病态肥胖。Physical

ex

am

inationLangeron提出五项面罩通气困难因素：年龄>55岁；BM

I>26kg/m

2

；多胡须；牙齿缺失；打鼾史。Physical

ex

am

ination面、颈或胸部:评价其对气道的影响头颈部：双侧鼻孔及鼻道，鼻中隔；张口，舌体，牙齿及牙龈，扁桃 体及颚部有无异常；测颏甲距离：6.5cm以上；颈椎活动度；有无气管造口或造口瘢痕，治疗气道 的并发症。M

allampati气道分级评定M

allam

pati气道分级评定I级：可见咽峡弓、软腭和颚垂。II级：可见咽峡弓、软腭，但颚垂被舌根部掩盖而不可见。III级：仅可见软腭。VI级：仅可见硬腭。III、IV级预示插管困难，但不是绝对的，应结合颏甲距离判断。气道检查心血管系统心功能分级及意义级别屏气试验临床表现临床意义麻醉耐受力I>30s能耐受日常体力活动，活动后无心慌、心功能正常II20~30s气短等不适感对日常体力活动有一定的不适感，往往自行限制或控制活动心功能较差量，不能作跑步或用力的工作轻度或一般体力活动后有明显不适，心悸、III10~20s气短明显，只能胜任极轻微的体力活心功能不全动或静息不能耐受任何体力活动，静息时也感气短，不能平卧，有端坐呼IV10s以内吸、心动过速等表现心功能衰竭良好如处理正确适宜，耐受仍好麻醉前应作充分准备应避免增加心脏负担极差，一般需推迟手术心功能分级与CI、EF、L

VEDP心功能级别EFLVEDP运动时LVEDP休息时CI>0.

550.5~0.

4正常，(≤12mmHg)≤12mmHg>12mmHg正常,(≤12mmHg)正常，>12mmHg>12mmHg>2.5L/(min·m2

)2.5L/(min·m2)

±2.

0

L/(min·m2

)±1.5L/(min·m2

)±IIIIIIIV0.

30.

2>12mmHg>12mmHgGoldman等提出的估计非心脏手术的危险性的9个因素和计分方法充血性心衰体征，如奔马律、颈静脉压增高（11分）；6个月内发生过心梗（10分）；室性早搏>5次/分钟（7分）；非窦性心律或房性早搏（7分）；年龄>70岁（5分）；急性手术（4分）；主动脉瓣显著狭窄（3分）；胸腹腔或主动脉手术（3分）；全身情况差（3分）。全身情况差（下面任何一种）PaO2<

60

mmHgPaCO2>

49

mmHgK+<

3

mmol/LHCO3-<

20

mmol/LBUN>

7.5

mmol/LCreatinine>270

mol/LSGOT：abnormality慢性肝炎(chronic

hepatitis)Goldman等提出的估计非心脏手术的危险性的9个因素和计分方法累计53分分四级：I级：0-5分II级：6-12分III级：13-25分IV级：≥26分心律失常1窦性心律失常：过速、过缓（迷走神经张力过大，药物，病窦）。室上性心动过速:多无器质性心脏病；器质性心脏病，甲亢，药物中毒。早搏：1）一过性或偶发性房、室早搏；2）频发，二联律、三联律或成对，多源性，R

on

T，易诱发室速和室颤。阵发性室速：病理性；药物治疗不佳，需有电复律和电除颤的准备。心律失常2房颤：可致严重的血流动力学紊乱、心绞痛、昏厥、体循环栓塞和心悸不适；未复律者，麻醉前心率：80次/分左右，至少<100次/分。束支传导阻滞：右束支；左束支（左前、左后分支）；双分支或三分支阻滞；发展成房室传导阻滞。房室传导阻滞：I

度；II

度（莫氏I

型、I

I

型）；I

II

度莫氏I

I型和莫氏I型心率<50次/分钟：准备起搏器；II

I度:手术时安装起搏器或做好起搏准备。高血压继发性高血压：特别警惕是否为未经诊断的嗜鉻细胞瘤高血压病：重要脏器是否受累及程度收缩压升高比舒张压升高危害更大多年高血压，不要求很快降至正常，应