临床麻醉学讲义

1、.,IntroductionofClinicalAnesthesia,王昌文2014.01.09,.,Concept,UsingDrugsorothermethodsCentralNerveSystemorperipheralnervesystemLosingsense,painlessandcomfortable,temporarily,.,Whatcanyoudoforyourfuture?,expertiseinresuscitationfluidreplacementairwaymanagementoxygentransportoperativestressreductionposto

2、perativepaincontrolICU,.,Archaicanesthesia,StoneAge:spiculaanalgesiaAcupunctureTraditionalmedicinePressureCryotherapyAndothers,.,Historyofanesthesiology,1846publicdemonstrationofetheranesthesiabyWilliamT.G.Morton,.,Mortonsetherinhaler(1846),.,JohnSnow,thefirstanesthesiologist（1846）,.,MachineofInhala

3、tionalanesthesiain1847,Facemask(1847),.,Historyofinhalation,.,Anesthesiamachine(1930),.,.,.,Intravenousanesthetics,1934:thiopental1959:diazepam1960:hydroxybutyrate,r-OH1970:ketamine1972:etomidate1976:midazolam1983:propofol,.,Others,OpioidsMorphine,fentanyl,sufentanil,alfentanil,remifentanilRelaxants

4、Curare,succinylcholine,pancuronium,vecuronium,atracurium,rocuronium,mivacurium,atal.,.,Localanesthetics,1884：Cocaineasophthalmicanesthesia,nerveblock1885：Epiduralanesthesia1898:Spinalanesthesia1901：Caudalanesthesia1905：Procaine1930：Dibucaine1932：Dicaine1943：Lidocaine1996:Ropivacaine,.,DevelopingofCl

5、inicalAnesthesiology,80年代90年代21世纪,BP,Pulse,ABP,CVP,S-Gcatheter,ECG,Temp.,ABP、CVP,PETCO2Anesthesia-gases,ECG,No-invasiveBP,SPO2,TEE,BIS,TOF,CCO,Workstation,.,Howaboutourdepartmentofanesthesiology?,1956：surgeon1957：anesthesiagroup60-70：epidural,spinal,nerveblock70-80：CPB,intravenousanesthesia,andinhal

6、ationalanesthesia80-85:intravenousanesthesia,inhalationalanesthesia,ECG,arterialbloodpressure,CVP,S-G80-90：inhalationalanesthesiawithtiminginjectionofvolatileanesthetics90-prsent：depthofanesthesia,balanceanesthesiaPETCO2work-station,BIS,TOF,PiCCO21centuryKeydept.&keylab.ofprovince,painclinicalward,.

7、,Popularanesthesiawords,ASAphysicalstatusclassificationsystemTOF:trainoffourBIS:bispectralindexSG:SwanGanzcatheterMAC:minimumalveolarconcentrationTEE:transesophagealechocardiography,.,TheworkingfieldofAnesthesiologists,ClinicanesthesiaOperatingroom,PACU,outpatient,CPCR(cardiopulmonarycerebralresusci

8、tation)CCM(criticalcaremedicine)AnalgesiaPainclinic,postoperativeanalgesia,othersOthersResearch,education,training,.,Howcanyoubecomearealanesthesiologist,purposeBasicknowledgeProfileofwholebodysystemsUsingyourpotentialRenewandupdate,uninterruptedlyCommunication,.,.,Anesthesiamethods,general,local,in

9、halation,intravenous,mucosa,muscle,spinal,epidural,Nerveblock,Localinfiltration,topical,balance,.,Subspecialtyofanesthesiology,CardiacsurgeryVascularsurgeryThoracicsurgeryNeurosurgicalanesthesiaOrgantransplantationPediatricsurgeryObstetricanesthesiaAndothers,.,Preoperationalevaluationforpatientstatu

10、s,.,Procedureofclinicalanesthesia,Pre-ope,preparation,introduction,Specialmonitoring,Maintain,PACU,.,Preope.Physicalassessment,TovisitpatientinpreoperationWhatisanesthesiologisttovisitCheckingwholebodyandassessingfunctionsofmainorgansToconfirmtheriskfactorASAclassification,.,ASAPhysicalStatusClassif

11、icationSystem,AnormalhealthypatientApatientwithmildsystemicdiseaseApatientwithseveresystemicdiseaseApatientwithseveresystemicdiseasethatisaconstantthreattolifeAmoribundpatientwhoisnotexpectedtosurvivewithouttheoperationAdeclaredbrain-deadpatientwhoseorgansarebeingremovedfordonorpurposes,.,visitingwi

12、ththepatientpreoperative,ToreceivethepatienthistorydataTorelievepatientsworryingstatusReviewofcurrentdrugtherapyPhysicalexamination,interpretationoflaboratorydataFindoutriskfactorPreposedanesthesiamethod,.,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

13、）、饮酒（量）家族史恶性高热、过敏、哮喘、高血压、糖尿病、肝病,.,.,Physicalexam.,Generalstatus：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（

14、BMR）0.75（脉率0.74脉压）72,.,高血压标准(舒张压),轻度：90100mmHg中度：100110mmHg重度：110mmHg,.,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

15、：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：7.357.45PaO2：12.013.0kPa（90100mmHg）随年龄有变化，老年人低于此值PaCO2:4.6655.998kPa(35-45mmHg)SB:2227mmol/L(mEq/L)BB:4555mmol/L（mEq/L）BE:3mmol/L（mEq/L)SaO2:9598

16、PA-aO2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STTchange房性期前收缩、室性期前收缩RonT,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

17、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RonT2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、WBC、Hct、PltProteins:Total,albumin,globulinCre,BUNBloodGlucoseIon:potassium,natrium,chlorine,calcium,magnesium,.,ASAphysicalstatus,I.AnormalhealthypatientII.ApatientwithmildsystemicdiseaseIII.ApatientwithseveresystemicdiseaseIV.Apatientwithseveresyste