臨床麻醉學緒論.ppt

1、Introduction of Clinical Anesthesia,Department of Anesthesiology Li Wenzhi,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 man

2、agement 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

3、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: midazol

4、am 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

5、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世紀,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 ou

6、r 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 timi

7、ng 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:

8、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 anal

9、gesia, 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,epidur

10、al,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 anest

11、hesia,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 Classifi

12、cation 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 orga

13、ns 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,問診表,麻醉史（全、椎管內(nèi)、

14、局），術(shù)中異常反應(yīng) 既往史 過敏、哮喘、呼吸疾病、高血壓、心臟病，肝臟、腎臟病，糖尿病，神經(jīng)、肌肉疾病，出血傾向，癲癇，其他特殊情況 日?；顒?藥物史 個人嗜好：吸煙（量）、飲酒（量） 家族史 惡性高熱、過敏、哮喘、高血壓、糖尿病、肝病,Physical exam.,General status：發(fā)育、營養(yǎng)、精神狀態(tài)等 血壓、脈搏、體溫 頭部：眼、鼻、口腔、下頜，中樞神經(jīng)系統(tǒng)情況 頸部：活動度、長短、甲狀腺大小等，頸靜脈 胸部：望、觸、叩、聽，心電、血氣、1秒率 腹部：望、觸、叩、聽，肝、腎、脾、胃腸功能 四肢：活動情況、感覺情況，動脈、靜脈情況 背部：椎管內(nèi)麻醉或其他麻醉方法要求的,實驗室檢

15、查,末梢血 胸部X線 生化指標 血離子 尿常規(guī) 血型、凝血、出血時間 心電圖 肺功能檢查 腹部X線 感染癥,全身情況的檢查,發(fā)育、營養(yǎng)、體重 體重指數(shù)（BMI） 體重（kg）身高(m)2 基礎(chǔ)代謝率（BMR） 0.75（脈率0.74 脈壓）72,高血壓標準(舒張壓),輕度：90100 mmHg 中度：100110 mmHg 重度：110 mmHg,頭部,眼部：結(jié)膜、鞏膜、瞳孔、眼球運動、眼瞼 鼻腔：鼻孔大小 、通暢程度，有無出血傾向 口腔：張口度、牙齒、舌、咽腔、扁桃體 發(fā)音：有無異常,氣道檢查,頸部,長短、粗細 活動度、后仰 有無異常隆起或異常搏動 血管情況 氣管是否居中 淋巴結(jié)有無腫大,胸

16、部檢查,望：對稱、呼吸運動 觸：皮下氣腫、細震顫 叩：心界、肺區(qū)、肝區(qū)，胸水 聽：心音、呼吸音，摩擦音等 心電圖：12導聯(lián)，連續(xù)監(jiān)測 -ray, CT, MRI,腹部檢查,望：外形，運動 觸：緊張度、壓痛，肝脾大小 叩：濁音 聽：腸音，血流 B超 CT,脊柱,有無感染灶，出血點等 有無側(cè)彎，異常突出 活動度 壓痛、叩擊痛,四肢檢查,皮膚感覺 活動 溫度 指(趾)甲顏色及血流充盈情況 動脈搏動情況，側(cè)支循環(huán)情況 病理反射,脊神經(jīng)的體表標志,實驗室檢查,血氣分析 心電圖 心功能 生化檢查 肝功能 腎 內(nèi)分泌 水、電解質(zhì)和酸堿平衡,動脈正常血氣值,pH值：7.357.45 PaO2：12.013.0

17、kPa（90100mmHg） 隨年齡有變化，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:吸空氣時約為1.3332.0kPa（1015mmHg）；吸純氧時約為3.3210.0kPa（2575mmHg），,心臟功能測定,心電圖 心動超聲（TEE） 運動試驗 心導管檢查 核素心功能(心肌顯像、心血管造影),心電圖,正常范圍心電圖 異常 心律：竇性？律齊？ 心率：心動過速，心動過緩 傳導

18、阻滯：IIII ，束枝傳導阻滯 病理性Q波 STT change 房性期前收縮、室性期前收縮 R on T, VF,簡易的心肺功能測定法,體力活動負荷試驗：3mph，10, 2min, 全肺切除危險性大 吹火柴試驗：57cm 時間肺活量：深吸氣后作最大呼氣，呼氣時間5秒阻塞性肺疾病 屏氣試驗：正常呼吸后如屏氣時間1020秒，心肺儲備功能不足 登樓試驗：第四層樓，10分鐘內(nèi)心率呼吸恢復,手術(shù)停止的心臟方面的問題,近期內(nèi)出現(xiàn)30天內(nèi)有心肌梗死的 室性心律失常的：二聯(lián)律、三聯(lián)律 R on T 2個月內(nèi)有充血性心力衰竭的,肺功能測定,呼吸系疾病肺功能測定指標,肝功能,重度肝功能不全者(如晚期肝硬化，有嚴重營養(yǎng)不良、消瘦、貧血、低蛋白血癥、大量腹水、凝血機制障礙、全身出血或肝昏迷前期腦病等征象)則危險性極高，不宜行任何擇期手術(shù) 應(yīng)關(guān)注蛋白質(zhì)合成、膽紅素代謝、凝血機制和藥物的生物轉(zhuǎn)化等。,內(nèi)分泌,甲狀腺激素 血糖 腎上腺皮質(zhì)激素,生化指標,HB、RBC、WBC、Hct、Plt Proteins: Total, albumin, globulin Cre, BUN Blood Glucose Ion: potassium, natrium, chlorine, calcium, magnesium,ASA physical status,I. A norm