临床麻醉学绪论课件

Introduction of Clinical AnesthesiaDepartment of AnesthesiologyLi WenzhiIntroduction of Clinical AnestConcept?Using Drugs or other methodsCentral Nerve System or peripheral nerve systemLosing sense,painless and comfortable,temporarilyConcept?Using Drugs or otherWhat can you do for your future?expertise in resuscitationfluid replacementairway managementoxygen transportoperative stress reductionpostoperative pain controlICU What can you do for your futurArchaic anesthesia?Stone Age:spicula analgesiaAcupunctureTraditional medicinePressureCryotherapyAnd othersArchaic anesthesia?Stone History of anesthesiology?1846 public demonstration of ether anesthesia by William T.G.Morton History of anesthesiology?1846Mortons ether inhaler(1846)Mortons ether inhaler(1846)John Snow,the first anesthesiologist（1846）John Snow,the first anesthesiMachine of Inhalational anesthesia in 1847Machine of Inhalational anesthFace mask(1847)Face mask(1847)History of inhalationHistory of inhalationAnesthesia machine(1930)Anesthesia machine(1930)临床麻醉学绪论课件临床麻醉学绪论课件临床麻醉学绪论课件临床麻醉学绪论课件Intravenous anesthetics?1934:thiopental1959:diazepam1960:hydroxybutyrate,r-OH1970:ketamine1972:etomidate1976:midazolam1983:propofolIntravenous anesthetics?Others?Opioids Morphine,fentanyl,sufentanil,alfentanil,remifentanil?Relaxants Curare,succinylcholine,pancuronium,vecuronium,atracurium,rocuronium,mivacurium,at al.Others?OpioidsMorphine,fentaLocal anesthetics?1884：Cocaine as ophthalmic anesthesia,nerve block1885：Epidural anesthesia1898:Spinal anesthesia1901：Caudal anesthesia1905：Procaine1930：Dibucaine1932：Dicaine1943：Lidocaine2019:RopivacaineLocal anesthetics?1884Developing of Clinical AnesthesiologyS-G catheterTOFECGTemp.PulseBP80年代ABPCVPTEEBISCCOECGABP、CVPWork stationPETCO2 Anesthesia-gasesNo-invasive BP,SPO290年代21世纪Developing of Clinical AnestheHow 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 anesthesiaPETCO2 work-station,BIS,TOF,PiCCO21 century Key dept.&key lab.of province,pain clinical ward?How about our department of anPopular anesthesia words?ASA physical status classification systemTOF:train of fourBIS:bispectral indexSG:Swan Ganz catheterMAC:minimum alveolar concentration TEE:transesophageal echocardiographyPopular anesthesia words?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,trainingThe working field of AnesthesiHow can you become a real anesthesiologist?purposeBasic knowledgeProfile of whole body systemsUsing your potentialRenew and update,uninterruptedlyCommunicationHow can you become a real anes临床麻醉学绪论课件Anesthesia methodsinhalationgeneralintravenousmucosamusclelocalspinalepiduralNerve blockLocal infiltration topicalbalanceAnesthesia methodsinhalationgeSubspecialty of anesthesiology?Cardiac surgeryVascular surgeryThoracic surgeryNeurosurgical anesthesiaOrgan transplantationPediatric surgeryObstetric anesthesia And othersSubspecialty of anesthesiologyPreoperational evaluation for patient statusPreoperational evaluation for Procedure of clinical anesthesiaPre-opepreparationintroductionMaintainPACUSpecial monitoringProcedure of clinical anesthesPreope.Physical assessment?To visit patient in preoperationWhat is anesthesiologist to visitChecking whole body and assessing functions of main organsTo confirm the risk factorASA classificationPreope.Physical assessment?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 ASA Physical Status Classificavisiting with the patient preoperative?To receive the patient history dataTo relieve patients worrying statusReview of current drug therapyPhysical examination,interpretation of laboratory dataFind out risk factorPreposed anesthesia methodvisiting with the patient preo问诊表问诊表?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、肝病问诊表?麻醉史（全、椎管内、局），术中异常反应既往史过敏临床麻醉学绪论课件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Physical exam.?General 实验室检查实验室检查?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线感染症实验室检查?末梢血胸部X线生化指标血离子尿全身情况的检查全身情况的检查?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全身情况的检查?发育、营养、体重体重指数（BMI）?体重（高血压标准高血压标准(舒张压舒张压)?轻度：90100 mmHg中度：100110 mmHg重度：110 mmHg?高血压标准(舒张压)?轻度：90100 mmHg中度：1头部头部?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：有无异常头部?眼部：结膜、巩膜、瞳孔、眼球运动、眼睑鼻腔：鼻孔气道检查气道检查颈部颈部?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颈部?长短、粗细活动度、后仰有无异常隆起或异常搏动胸部检查胸部检查?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胸部检查?望：对称、呼吸运动触：皮下气肿、细震颤叩腹部检查腹部检查?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腹部检查?望：外形，运动触：紧张度、压痛，肝脾大小脊柱脊柱?有无感染灶，出血点等有无侧弯，异常突出活动度压痛、叩击痛脊柱?有无感染灶，出血点等有无侧弯，异常突出活动度压痛四肢检查四肢检查?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四肢检查?皮肤感觉活动温度指(趾)甲颜色及血流充盈脊神经的体表标志脊神经的体表标志实验室检查实验室检查?血气分析心电图心功能生化检查肝功能肾内分泌水、电解质和酸碱平衡实验室检查?血气分析心电图心功能生化检查肝功能动脉正常血气值动脉正常血气值?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)SaO2:9598PA-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），动脉正常血气值?pH值：7.357.45 P心脏功能测定心脏功能测定?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)心脏功能测定?心电图心动超声（TEE）运动试验心导管心电图心电图?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：I?III?，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心电图?正常范围心电图异常心律：窦性？律齐？心率：心动简易的心肺功能测定法?体力活动负荷试验：体力活动负荷试验：3mph，10,2min,全肺全肺切除危险性大切除危险性大吹火柴试验：吹火柴试验：57cm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秒阻塞性肺疾病秒阻塞性肺疾病屏气试验：正常呼吸后如屏气时间屏气试验：正常呼吸后如屏气时间 1020秒，秒，心肺储备功能不足心肺储备功能不足登楼试验：第四层楼，登楼试验：第四层楼，10分钟内心率呼吸恢复分钟内心率呼吸恢复简易的心肺功能测定法?体力活动负荷试验：3mph，1手术停止的心脏方面的问题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 T2个月内有充血性心力衰竭的手术停止的心脏方面的问题?近期内出现30天内有心肌梗死肺功能肺功能测测定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?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。肝功能?重度肝功能不全者(如晚期肝硬化，有严重营养不良、消内分泌内分泌?甲状腺激素血糖肾上腺皮质激素内分泌?甲状腺激素血糖肾上腺皮质激素生化指标生化指标?HB、RBC、WBC、Hct、PltProteins:Total,albumin,globulinCre,BUNBlood GlucoseIon:potassium,natrium,chlorine,calcium,magnesium生化指标?HB、RBC、WBC、Hct、PltProASA physical status?I.A normal healthy patientII.A patient with mild systemic diseaseIII.A patient with severe systemic diseaseIV.A patient with severe systemic disease that is a constant threat to lifeV.A moribund patient who is not expected to survive without the operationVI.A declared brain-dead patient whose organs are being removed for donor purposesThe addition of an E indicates emergency surgery.ASA physical status?I.A 麻醉和手术的危险因素麻醉和手术的危险因素?病情手术麻醉医疗条件麻醉和手术的危险因素?病情手术麻醉医疗条件了解麻醉前的用药情况了解麻醉前的用药情况?抗高血压药肾上腺受体阻滞药降糖药扩冠药抗凝药单胺氧化酶抑制药：术前停2周以上三环类抗抑郁药：术前停2周以上了解麻醉前的用药情况?抗高血压药肾上腺受体阻滞药