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1、ClinicalClinicalClinicalClinical AnesthesiaAnesthesiaAnesthesiaAnesthesiaCARLCARLCARLCARLL.GWINNUTTL.GWINNUTTL.GWINNUTTL.GWINNUTTContentsContentsContentsContentsForewordPreface Acknowledgements 1.Anesthetic Assessment and Premedication2.The Delivery of Anesthetic Gases and Vapors 3.Managing the Airw
2、ay 4.Drugs associated with Anesthesia5.Measurement and Monitoring 6.Intravenous Cannulation and Fluid Administration 7.Postanesthesia Care8.Local and Regional Anesthesia 9.An Introduction to Intensive Care 10. Anesthetists and Chronic Pain Relief11. Resuscitation of the Collapsed Patient 12. IndexCH
3、APTERCHAPTERCHAPTERCHAPTER 1 1 1 1AnestheticAnestheticAnestheticAnestheticAssessmentAssessmentAssessmentAssessment andandandand PremedicationPremedicationPremedicationPremedication The preoperative visit, Special investigations, Informing the patient, Anesthetic history andexamination, Medical refer
4、ral, Premedication, Risk assessment, Further reading. TheTheTheThe preoperativepreoperativepreoperativepreoperative visitvisitvisitvisitThe main aim is to assess the patients fitness for anesthesia and there is no doubt that this isbest performed by and anesthetist, preferably the one who is going t
5、o administer the anesthetic. The visit allows the most suitable anesthetic technique to be determined, any potential interactions between concurrent diseases and anesthesia anticipated, and finally provides an explanation andreassurance for the patient. Where there is coexisting illness, every oppor
6、tunity must be taken to improve the patients condition prior to surgery. This may mean seeking advice from other specialists to optimize treatments, although the final decision will rest with the anesthetist. In anThe preoperative visit of all patients by an anesthetist is an essential requirementfo
7、r the safe and successful conduct of anesthesia.ideal world, all patients would be seen by their anesthetist sufficiently ahead of the planned surgery to allow any problems identified to be treated without interfering with the smooth runningof the operating list. For elective surgery, patients are r
8、arely admitted more than 24 hours in advance and may not be seen by the anesthetist until the evening prior to surgery. The anesthetist frequently relies upon the junior surgical staff to ensure that all patients haveafull history andexamination so that during their visit they can concentrate on the
9、 areas of relevance to anesthesia as detailed below. There are three situations where special arrangements are usually made.1Patients with complex medical or surgical problems. The patient is often admitted several days before surgery and the anesthetist is actively involved in optimizing their cond
10、ition prior to anesthesia and surgery.2Surgical emergencies. Often onlyafew hours separates admission and operation in these patients. The anesthetist must be informed as soon as the decision to operate has been made and their advice sought about the need for urgent investigations or treatment. This
11、may occasionally mean delays in surgery, particularly if resuscitation is required. 3Day-case patients. These are patients who are planned, non-resident admissions. They are generallyfitter, having been selected specifically for this type of admission, Anestheticassessment is often carried out by th
12、e surgeon oradesignated clinic nurse according toa protocol, and the patients first contact with the anesthetist is on arrival in the day-case unit. Some units runapreanesthetic assessment clinic.AnestheticAnestheticAnestheticAnesthetic historyhistoryhistoryhistory andandandand examinationexaminatio
13、nexaminationexamination Ideally, the anesthetist should takeafull history and examine each patient, but for the reasons already identified this is seldom possible. This section concentrates on features of particularrelevance to the anesthetist. PREVIOUS ANESTHETICS AND OPETATIONS These may have occu
14、rred in hospitals or dental surgeries. Inquire about inherited orfamilydiseases (e.g. sickle-cell disease, porphyria) and difficulties with previous anesthetics (e.g. nausea, vomiting, dreams, awareness, postoperative jaundice). Check the records of previous anesthetics to rule out or clarify proble
15、ms such as difficulties with intubation, allergy to drugs administered,or adverse reactions (e.g. malignant hyperpyrexia, see below). The approximate date of previous anesthetics, particular if recent, should be identified to avoid the risk of repeat exposure to halothane (see page 59). Details of p
16、revious surgery may reveal potential anesthetic problems, forexample cardiac or pulmonary surgery. PRESENT AND PAST MEDICAL HISTORY Of all the aspects of the patients medical history, those relating to the cardiovascular andrespiratory systems are the most important. The questions and detail required will vary depending upon the disease present, its severity, anticipated anesthesia the planned operation. Cardiovascular systemSpecific inquiries must be made about: angina (its incidence,
