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1、Introduction of Clinical Anesthesia王昌文2014.01.09临床麻醉学Conceptn nUsing Drugs or other methodsn nCentral Nerve System or peripheral nerve systemn nLosing sense, painless and comfortable, temporarily临床麻醉学临床麻醉学What can you do for your future?n nexpertise in resuscitationn nfluid replacementn nairway mana
2、gementn noxygen transportn noperative stress reductionn npostoperative pain controln nICU 临床麻醉学临床麻醉学Archaic anesthesian nStone Age: spicula analgesian nAcupuncturen nTraditional medicinen nPressuren nCryotherapyn nAnd others临床麻醉学临床麻醉学History of anesthesiologyn n1846 public demonstration of ether ane
3、sthesia by William T. G. Morton 临床麻醉学临床麻醉学Mortons ether inhaler (1846) 临床麻醉学临床麻醉学John Snow, the first anesthesiologist（1846） 临床麻醉学临床麻醉学Machine of Inhalational anesthesia in 1847临床麻醉学临床麻醉学Face mask(1847)History of inhalation临床麻醉学临床麻醉学Anesthesia machine (1930)临床麻醉学临床麻醉学临床麻醉学临床麻醉学临床麻醉学临床麻醉学Intravenous
4、anestheticsn n1934: thiopentaln n1959: diazepamn n1960: hydroxybutyrate, r-OHn n1970: ketaminen n1972: etomidaten n1976: midazolamn n1983: propofol临床麻醉学临床麻醉学Othersn nOpioidsMorphine, fentanyl, sufentanil, alfentanil, Morphine, fentanyl, sufentanil, alfentanil, remifentanilremifentaniln nRelaxantsCur
5、are, succinylcholine, pancuronium, Curare, succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.mivacurium, at al.临床麻醉学临床麻醉学Local anestheticsn n18841884：Cocaine as ophthalmic anesthesia, nerve blockCocaine as ophthalmic anesthesia, n
6、erve blockn n18851885：Epidural anesthesiaEpidural anesthesian n1898: Spinal anesthesia1898: Spinal anesthesian n19011901：Caudal anesthesiaCaudal anesthesian n19051905：ProcaineProcainen n19301930：DibucaineDibucainen n19321932：DicaineDicainen n19431943：LidocaineLidocainen n1996: Ropivacaine1996: Ropiv
7、acaine临床麻醉学临床麻醉学Developing of Clinical Anesthesiology80年代 90年代 21世纪BPPulseABPCVPS-GcatheterECGTemp.ABP、CVPPETCO2Anesthesia-gasesECGNo-invasiveBP,SPO2TEEBISTOFCCOWorkstation临床麻醉学临床麻醉学How about our department of anesthesiology?n n19561956：surgeonsurgeonn n19571957：anesthesia groupanesthesia groupn n60
8、-7060-70：epidural, spinal, nerve blockepidural, spinal, nerve blockn n70-8070-80：CPB, intravenous anesthesia, and inhalational CPB, intravenous anesthesia, and inhalational anesthesia anesthesian n80-85: intravenous anesthesia, inhalational 80-85: intravenous anesthesia, inhalational anesthesia, ECG
9、, arterial blood pressure, CVP, S-G anesthesia, ECG, arterial blood pressure, CVP, S-Gn n80-9080-90：inhalational anesthesia with timing injection inhalational anesthesia with timing injection of volatile anesthetics of volatile anestheticsn n90-prsent90-prsent：depth of anesthesia, balance anesthesia
10、depth of anesthesia, balance anesthesia P PETETCOCO2 2 work-station, BIS, TOF, PiCCOwork-station, BIS, TOF, PiCCO21 century Key dept. & key lab. of province, pain clinical ward21 century Key dept. & key lab. of province, pain clinical ward 临床麻醉学临床麻醉学Popular anesthesia wordsn nASA physical status cla
11、ssification systemn nTOF: train of fourn nBIS: bispectral indexn nSG: Swan Ganz cathetern nMAC: minimum alveolar concentration n nTEE: transesophageal echocardiography临床麻醉学临床麻醉学The working field of Anesthesiologistsn nClinic anesthesiaClinic anesthesia Operating room, PACU, outpatient, Operating roo
12、m, PACU, outpatient, n nCPCR (cardiopulmonary cerebral CPCR (cardiopulmonary cerebral resuscitation)resuscitation)n nCCM (critical care medicine)CCM (critical care medicine)n nAnalgesiaAnalgesia Pain clinic, postoperative analgesia, othersPain clinic, postoperative analgesia, othersn nOthersOthers R
13、esearch, education, trainingResearch, education, training临床麻醉学临床麻醉学How can you become a real anesthesiologistn npurposen nBasic knowledgen nPro whole body systemsn nUsing your potentialn nRenew and update, uninterruptedlyn nCommunication临床麻醉学临床麻醉学临床麻醉学临床麻醉学Anesthesia methodsgenerallocalinhalationint
14、ravenousmucosamusclespinalepiduralNerveblockLocalinfiltrationtopicalbalance临床麻醉学临床麻醉学Subspecialty of anesthesiologyn nCardiac surgeryCardiac surgeryn nVascular surgeryVascular surgeryn nThoracic surgeryThoracic surgeryn nNeurosurgical anesthesiaNeurosurgical anesthesian nOrgan transplantationOrgan t
15、ransplantationn nPediatric surgeryPediatric surgeryn nObstetric anesthesia Obstetric anesthesia n nAnd othersAnd others临床麻醉学临床麻醉学Preoperational evaluation for patient status临床麻醉学临床麻醉学Procedure of clinical anesthesiaPre-opepreparationintroductionSpecial monitoringMaintainPACU临床麻醉学临床麻醉学Preope. Physica
16、l assessmentn nTo visit patient in preoperationn nWhat is anesthesiologist to visitn nChecking whole body and assessing functions of main organsn nTo confirm the risk factorn nASA classification临床麻醉学临床麻醉学ASA Physical Status Classification System n nA normal healthy patient n nA patient with mild sys
17、temic disease n nA patient with severe systemic disease n nA patient with severe systemic disease that is a constant threat to life n nA moribund patient who is not expected to survive without the operation n nA declared brain-dead patient whose organs are being removed for donor purposes 临床麻醉学临床麻醉学
18、visiting with the patient preoperativen nTo receive the patient history datan nTo relieve patients worrying statusn nReview of current drug therapyn nPhysical examination, interpretation of laboratory datan nFind out risk factorn nPreposed anesthesia method临床麻醉学临床麻醉学问诊表问诊表n n麻醉史（全、椎管内、局），术中异常反应n n既往
19、史过敏、哮喘、呼吸疾病、高血压、心脏病，肝脏、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，肾脏病，糖尿病，神经、肌肉疾病，出血倾向，癫痫，其他特殊情况癫痫，其他特殊情况n n日常活动n n药物史n n个人嗜好：吸烟（量）、饮酒（量）n n家族史恶性高热、过敏、哮喘、高血压、糖尿病、肝病恶性高热、过敏、哮喘、高血压、糖尿病、肝病临床麻醉学临床麻醉学临床麻醉学临床麻醉学Physical exam.n nGeneral statusGeneral status：发育、营养、精神状态等：发育、营养、精神状态等n n血压、脉搏、体温血压、脉搏、体温n n头部：眼
20、、鼻、口腔、下颌，中枢神经系统情况头部：眼、鼻、口腔、下颌，中枢神经系统情况n n颈部：活动度、长短、甲状腺大小等，颈静脉颈部：活动度、长短、甲状腺大小等，颈静脉n n胸部：望、触、叩、听，心电、血气、胸部：望、触、叩、听，心电、血气、1 1秒率秒率n n腹部：望、触、叩、听，肝、肾、脾、胃肠功能腹部：望、触、叩、听，肝、肾、脾、胃肠功能n n四肢：活动情况、感觉情况，动脉、静脉情况四肢：活动情况、感觉情况，动脉、静脉情况n n背部：椎管内麻醉或其他麻醉方法要求的背部：椎管内麻醉或其他麻醉方法要求的临床麻醉学临床麻醉学实验室检查实验室检查n n末梢血末梢血n n胸部胸部X X线线n n生化指标
21、生化指标n n血离子血离子n n尿常规尿常规n n血型、凝血、出血时间血型、凝血、出血时间n n心电图心电图n n肺功能检查肺功能检查n n腹部腹部X X线线n n感染症感染症临床麻醉学全身情况的检查全身情况的检查n n发育、营养、体重n n体重指数（BMI）n n体重（体重（kgkg） 身高身高(m)(m)2 2n n基础代谢率（BMR）n n0.750.75（脉率（脉率0.740.74脉压）脉压）7272临床麻醉学高血压标准高血压标准( (舒张压舒张压) )n n轻度：90100 mmHgn n中度：100110 mmHgn n重度：110 mmHg临床麻醉学临床麻醉学头部头部n n眼部：
22、结膜、巩膜、瞳孔、眼球运动、眼睑n n鼻腔：鼻孔大小 、通畅程度，有无出血倾向n n口腔：张口度、牙齿、舌、咽腔、扁桃体n n发音：有无异常临床麻醉学临床麻醉学气道检查临床麻醉学颈部颈部n n长短、粗细n n活动度、后仰n n有无异常隆起或异常搏动n n血管情况n n气管是否居中n n淋巴结有无肿大临床麻醉学临床麻醉学胸部检查胸部检查n n望：对称、呼吸运动n n触：皮下气肿、细震颤n n叩：心界、肺区、肝区，胸水n n听：心音、呼吸音，摩擦音等n n心电图：12导联，连续监测n n-ray, CT, MRI临床麻醉学临床麻醉学腹部检查腹部检查n n望：外形，运动n n触：紧张度、压痛，肝脾大
23、小n n叩：浊音n n听：肠音，血流n nB超n nCT临床麻醉学临床麻醉学脊柱脊柱n n有无感染灶，出血点等n n有无侧弯，异常突出n n活动度n n压痛、叩击痛临床麻醉学临床麻醉学四肢检查四肢检查n n皮肤感觉n n活动n n温度n n指(趾)甲颜色及血流充盈情况n n动脉搏动情况，侧支循环情况n n病理反射临床麻醉学临床麻醉学脊神经的体表标志实验室检查实验室检查n n血气分析血气分析n n心电图心电图n n心功能心功能n n生化检查生化检查n n肝功能肝功能n n肾肾n n内分泌内分泌n n水、电解质和酸碱平衡水、电解质和酸碱平衡临床麻醉学临床麻醉学动脉正常血气值动脉正常血气值n npH
24、pH值：值：7.357.357.45 7.45 n nPaOPaO2 2：12.012.013.0kPa13.0kPa（9090100mmHg100mmHg） 随年随年龄有变化，老年人低于此值龄有变化，老年人低于此值 n nPaCOPaCO2 2 :4.665 :4.6655.998kPa (35-45mmHg)5.998kPa (35-45mmHg)n nSB: 22SB: 2227 mmol/L (mEq/L)27 mmol/L (mEq/L)n nBB:45BB:4555mmol/L55mmol/L（mEq/LmEq/L）n nBE:3mmol/LBE:3mmol/L（mEq/L)mEq
25、/L)n nSaOSaO2 2 : 95 : 959898 n nPA-a OPA-a O2 2或或A=aDOA=aDO2 2: :吸空气时约为吸空气时约为1.3331.3332.0kPa2.0kPa（101015mmHg15mmHg）；吸纯氧时约为）；吸纯氧时约为3.323.3210.0kPa10.0kPa（252575mmHg75mmHg），）， 临床麻醉学临床麻醉学心脏功能测定心脏功能测定n n心电图n n心动超声（TEE）n n运动试验n n心导管检查n n核素心功能(心肌显像、心血管造影)临床麻醉学临床麻醉学心电图心电图n n正常范围心电图n n异常心律：窦性？律齐？心律：窦性？律齐
26、？心率：心动过速，心动过缓心率：心动过速，心动过缓传导阻滞：传导阻滞：I I III III ，束枝，束枝传导传导阻滞阻滞病理性病理性Q Q波波STSTT changeT change房性期前收房性期前收缩缩、室性期前收、室性期前收缩缩R on T, VFR on T, VF临床麻醉学临床麻醉学简易的心肺功能测定法n n体力活动负荷试验：体力活动负荷试验：体力活动负荷试验：体力活动负荷试验：3mph3mph，10, 2min, 10, 2min, 全肺切全肺切全肺切全肺切除危险性大除危险性大除危险性大除危险性大n n吹火柴试验：吹火柴试验：吹火柴试验：吹火柴试验：5 57cm7cmn n时间肺
27、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 5秒阻塞性肺疾病秒阻塞性肺疾病秒阻塞性肺疾病秒阻塞性肺疾病n n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10102020秒，心秒，心秒，心秒，心肺储备功能不足肺储备功能不足肺储备功能不足肺储备功能不足n n登楼试验：第四层楼，登楼试验：第四层楼，登楼试验：第四层楼，登楼试验：第四层楼，1010分钟内心率呼吸恢复分钟内心率呼吸恢复分钟内心率呼吸恢复分钟内心率呼吸
28、恢复临床麻醉学临床麻醉学手术停止的心脏方面的问题手术停止的心脏方面的问题n n近期内出现30天内有心肌梗死的n n室性心律失常的：二联律、三联律n nR on Tn n2个月内有充血性心力衰竭的临床麻醉学临床麻醉学肺功能测定肺功能测定临床麻醉学临床麻醉学呼吸系疾病肺功能测定指标临床麻醉学临床麻醉学肝功能肝功能n n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 n n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。 临床麻醉学临床麻醉学内分泌内分泌n n甲状腺激素n n血
29、糖n n肾上腺皮质激素临床麻醉学临床麻醉学生化指标生化指标n nHB、RBC、WBC、Hct、Pltn nProteins: Total, albumin, globulinn nCre, BUNn nBlood Glucosen nIon: potassium, natrium, chlorine, calcium, magnesium临床麻醉学临床麻醉学ASA physical statusI.I. A normal healthy patient A normal healthy patient II.II. A patient with mild systemic disease A
30、patient with mild systemic disease III.III. A patient with severe systemic disease A patient with severe systemic disease IV.IV. A patient with severe systemic disease that is A patient with severe systemic disease that is a constant threat to lifea constant threat to life V.V. A moribund patient wh
31、o is not expected to A moribund patient who is not expected to survive without the operationsurvive without the operationVI.VI. A declared brain-dead patient whose organs A declared brain-dead patient whose organs are being removed for donor purposesare being removed for donor purposesThe addition of an E indicates emergency The addition of an E indicates emergency surgery. surgery. 临床麻醉学临床麻醉学麻醉和手术的危险因素麻醉和手术的危险因素n n病情n n手术n n麻醉n n医疗条件临床麻醉学临床麻醉学了解麻醉前的用药情况了解麻醉前的用药情况n n抗高血压药n n肾上腺受体阻滞药n n降糖药n n扩冠药n n抗凝药n n单胺氧化酶抑制药：术前停2周以上n n三环类抗抑郁药：术前停2周以上临床麻醉学临床麻醉学
