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1、临床麻醉学绪论 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望Conceptn nUsingDrugsorothermethodsn nCentralNerveSystemorperipheralnervesystemn nLosingsense,painlessandcomfortable,temporarilyWhat can you do for your future?n nexpertiseinresuscitationn nfluidreplaceme
2、ntn nairwaymanagementn noxygentransportn noperativestressreductionn npostoperativepaincontroln nICUArchaic anesthesian nStoneAge:spiculaanalgesian nAcupuncturen nTraditionalmedicinen nPressuren nCryotherapyn nAndothersHistory of anesthesiologyn n1846publicdemonstrationofetheranesthesiabyWilliamT.G.M
3、ortonMortons ether inhaler(1846)John Snow,the first anesthesiologist（1846）Machine of Inhalational anesthesia in 1847Face mask(1847)History of inhalationAnesthesia machine(1930)Intravenous anestheticsn n1934:thiopentaln n1959:diazepamn n1960:hydroxybutyrate,r-OHn n1970:ketaminen n1972:etomidaten n197
4、6:midazolamn n1983:propofolOthersn nOpioidsMorphine,fentanyl,sufentanil,alfentanil,Morphine,fentanyl,sufentanil,alfentanil,remifentanilremifentaniln nRelaxantsCurare,succinylcholine,pancuronium,Curare,succinylcholine,pancuronium,vecuronium,atracurium,rocuronium,vecuronium,atracurium,rocuronium,mivac
5、urium,atal.mivacurium,atal.Local anestheticsn n18841884：Cocaineasophthalmicanesthesia,nerveblockCocaineasophthalmicanesthesia,nerveblockn n18851885：EpiduralanesthesiaEpiduralanesthesian n1898:Spinalanesthesia1898:Spinalanesthesian n19011901：CaudalanesthesiaCaudalanesthesian n19051905：ProcaineProcain
6、en n19301930：DibucaineDibucainen n19321932：DicaineDicainen n19431943：LidocaineLidocainen n1996:Ropivacaine1996:RopivacaineDevelopingofClinicalAnesthesiology80年代 90年代 21世纪BPPulseABPCVPS-G catheterECGTemp.ABP、CVPPETCO2 Anesthesia-gasesECGNo-invasive BP,SPO2TEEBISTOFCCOWork stationHow about our departm
7、ent of anesthesiology?n n19561956：surgeonsurgeonn n19571957：anesthesiagroupanesthesiagroupn n60-7060-70：epidural,spinal,nerveblockepidural,spinal,nerveblockn n70-8070-80：CPB,intravenousanesthesia,andinhalationalCPB,intravenousanesthesia,andinhalationalanesthesiaanesthesian n80-85:intravenousanesthes
8、ia,inhalational80-85:intravenousanesthesia,inhalationalanesthesia,ECG,arterialbloodpressure,CVP,S-Ganesthesia,ECG,arterialbloodpressure,CVP,S-Gn n80-9080-90：inhalationalanesthesiawithtiminginjectioninhalationalanesthesiawithtiminginjectionofvolatileanestheticsofvolatileanestheticsn n90-prsent90-prse
9、nt：depthofanesthesia,balanceanesthesiadepthofanesthesia,balanceanesthesiaPPETETCOCO22work-station,BIS,TOF,PiCCOwork-station,BIS,TOF,PiCCO21centuryKeydept.&keylab.ofprovince,painclinicalward21centuryKeydept.&keylab.ofprovince,painclinicalwardPopular anesthesia wordsn nASAphysicalstatusclassifications
10、ystemn nTOF:trainoffourn nBIS:bispectralindexn nSG:SwanGanzcathetern nMAC:minimumalveolarconcentrationn nTEE:transesophagealechocardiographyThe working field of Anesthesiologistsn nClinicanesthesiaClinicanesthesia Operatingroom,PACU,outpatient,Operatingroom,PACU,outpatient,n nCPCR(cardiopulmonarycer
11、ebralCPCR(cardiopulmonarycerebralresuscitation)resuscitation)n nCCM(criticalcaremedicine)CCM(criticalcaremedicine)n nAnalgesiaAnalgesia Painclinic,postoperativeanalgesia,othersPainclinic,postoperativeanalgesia,othersn nOthersOthers Research,education,trainingResearch,education,trainingHow can you be
12、come a real anesthesiologistn npurposen nBasicknowledgen nProfileofwholebodysystemsn nUsingyourpotentialn nRenewandupdate,uninterruptedlyn nCommunicationAnesthesia methodsgenerallocal inhalationintravenousmucosamusclespinalepiduralNerve blockLocal infiltration topicalbalanceSubspecialty of anesthesi
13、ologyn nCardiacsurgeryCardiacsurgeryn nVascularsurgeryVascularsurgeryn nThoracicsurgeryThoracicsurgeryn nNeurosurgicalanesthesiaNeurosurgicalanesthesian nOrgantransplantationOrgantransplantationn nPediatricsurgeryPediatricsurgeryn nObstetricanesthesiaObstetricanesthesian nAndothersAndothersPreoperat
14、ional evaluation for patient statusProcedure of clinical anesthesiaPre-opepreparationintroductionSpecial monitoringMaintainPACUPreope.Physical assessmentn nTovisitpatientinpreoperationn nWhatisanesthesiologisttovisitn nCheckingwholebodyandassessingfunctionsofmainorgansn nToconfirmtheriskfactorn nASA
15、classificationASA Physical Status Classification System n nAnormalhealthypatientn nApatientwithmildsystemicdiseasen nApatientwithseveresystemicdiseasen nApatientwithseveresystemicdiseasethatisaconstantthreattolifen nAmoribundpatientwhoisnotexpectedtosurvivewithouttheoperationn nAdeclaredbrain-deadpa
16、tientwhoseorgansarebeingremovedfordonorpurposesvisiting with the patient preoperativen nToreceivethepatienthistorydatan nTorelievepatientsworryingstatusn nReviewofcurrentdrugtherapyn nPhysicalexamination,interpretationoflaboratorydatan nFindoutriskfactorn nPreposedanesthesiamethod问诊表问诊表n n麻醉史（全、椎管内、
17、局），术中异常反应n n既往史过敏、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Physical exam.n nGeneralstatusGeneralstatus：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、鼻、口腔、下颌
18、，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生化指标生化指标n n血离子血离子n n尿常
19、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0.74 0.74 脉压）脉压）7272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头部头部n n眼部：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
20、口腔：张口度、牙齿、舌、咽腔、扁桃体n n发音：有无异常气道检查颈部颈部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，肝脾大小n n叩：浊音n n听：肠音，血流n nB超n nCT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、叩击痛四肢检查四肢检
21、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、电解质和酸碱平衡动脉正常血气值动脉正常血气值n npHpH值：值：7.357.357.457.45n 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
22、2:4.665:4.6655.998kPa(35-45mmHg)5.998kPa(35-45mmHg)n nSB:22SB:2227mmol/L(mEq/L)27mmol/L(mEq/L)n nBB:45BB:4555mmol/L55mmol/L（mEq/LmEq/L）n nBE:3mmol/LBE:3mmol/L（mEq/L)mEq/L)n nSaOSaO2 2:95:959898 n nPA-aOPA-aO2 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3.323.3
23、210.0kPa10.0kPa（252575mmHg75mmHg），），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核素心功能(心肌显像、心血管造影)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？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 IIIIII，束枝，束枝传导传导阻滞阻滞病理性病理性Q Q波波STSTTchangeTchange房性期前收房性期前收缩缩、室性期前收、室性期前收缩缩RonT,VFRonT,VF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
24、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，
25、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恢复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 nRonTn n2个月内有充血性心力衰竭的肺功能测定肺功能测定呼吸系疾病肺功能测定指标肝功能肝功能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，
26、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。内分泌内分泌n n甲状腺激素n n血糖n n肾上腺皮质激素生化指标生化指标n nHB、RBC、WBC、Hct、Pltn nProteins:Total,albumin,globulinn nCre,BUNn nBloodGlucosen nIon:potassium,natrium,chlorine,calcium,magnesiumASA physical statusI.I.AnormalhealthypatientAnormalhealthypatientII.II.Apatientwithmildsyst
27、emicdiseaseApatientwithmildsystemicdiseaseIII.III.ApatientwithseveresystemicdiseaseApatientwithseveresystemicdiseaseIV.IV.ApatientwithseveresystemicdiseasethatisApatientwithseveresystemicdiseasethatisaconstantthreattolifeaconstantthreattolifeV.V.AmoribundpatientwhoisnotexpectedtoAmoribundpatientwhoi
28、snotexpectedtosurvivewithouttheoperationsurvivewithouttheoperationVI.VI.Adeclaredbrain-deadpatientwhoseorgansAdeclaredbrain-deadpatientwhoseorgansarebeingremovedfordonorpurposesarebeingremovedfordonorpurposesTheadditionofanEindicatesemergencyTheadditionofanEindicatesemergencysurgery.surgery.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