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1、临床麻醉学临床麻醉学（Clinical AnesthesiologyClinical Anesthesiology）绪论绪论（IntroductionIntroduction）The The term term“anesthesia”(“anesthesia”(麻麻麻麻醉醉醉醉)is is derived derived from from Greek Greek Word,Word,it it means means“lack“lack of of feeling feeling or or sensation”or“privation of senses”im plying sensati
2、on”or“privation of senses”im plying lack lack of of appreciation.appreciation.The The usual usual concept concept for for anesthesia anesthesia relates relates primarily primarily to to the the prevention prevention of of pain pain perception perception during during an an operation operation or or
3、an an invasive invasive procedure procedure.But But,this this concept concept is is out out of of date now.date now.In general,anesthesia can be defined as a drug-induced or physical factors-induced state of reversible functional depression of part of the central nervous system or peripheral nervous
4、 system,which is characterized by loss of sensation,especially pain perception.The The increasing increasing complex complex nature nature of of operations operations sparked sparked the the development development of of anesthesia anesthesia.Advance Advance in in related related basic basic science
5、 science especially especially in in research research in in anesthesia anesthesia per per se se,and,and the the development development of of new new agents agents,adjuvants,adjuvants,eguipments,eguipments,technigues technigues and and capacity capacity of of sustaining sustaining life life had had
6、 changed changed and and broadened broadened anesthesia anesthesia into into a a discipline discipline concerned concerned with with more more than than relief relief of of pain pain.over over the the past past 56 56 decades decades,anesthesiology(,anesthesiology(麻麻麻麻醉醉醉醉学学学学)has has emerged emerged
7、 as as a clearly defined specialty and firmly established.a clearly defined specialty and firmly established.The evolution of modern anesthesiology may be The evolution of modern anesthesiology may be devided into 3 stages:devided into 3 stages:1 1、麻醉（、麻醉（、麻醉（、麻醉（anesthesiaanesthesia）2 2、临床麻醉学、临床麻醉学
8、、临床麻醉学、临床麻醉学(Clinical anesthesiology)(Clinical anesthesiology)3 3、麻醉与危重病医学、麻醉与危重病医学、麻醉与危重病医学、麻醉与危重病医学(anesthesiology and(anesthesiology and critical care medicine)critical care medicine)department of anesthesiology and resuscitation department of anesthesiology and resuscitation department of anesth
9、esiology and critical care department of anesthesiology and critical care medicine.medicine.一、麻醉学发展简史一、麻醉学发展简史一、麻醉学发展简史一、麻醉学发展简史(The history of anesthesia)(The history of anesthesia)1 1、Ancient times Ancient times （1 1）Acupuncture Acupuncture analgesia analgesia 475221 475221 B.C.B.C.（2 2）华陀）华陀）华陀）华
10、陀(141203)(141203)麻沸散麻沸散麻沸散麻沸散 （3 3）Ancient Ancient Egyptians Egyptians used used The The combination combination of of opium poppy and hyoscyamus opium poppy and hyoscyamus （4 4）The The Incas Incas may may be be the the earliest earliest to to use use local local anesthesia.anesthesia.2 2、Modern ane
11、sthesiology Modern anesthesiology （1 1）Inhalational Anesthesia (Inhalational Anesthesia (吸入麻醉吸入麻醉吸入麻醉吸入麻醉)1844 Horace wells N 1844 Horace wells N2 2 0(0(氧化亚氮氧化亚氮氧化亚氮氧化亚氮)1846 William T.G.Morton Ether(1846 William T.G.Morton Ether(乙醚乙醚乙醚乙醚)1847 James Simpson chloroform(1847 James Simpson chloroform(氯
12、仿氯仿氯仿氯仿)1920 Arthur E.Guedel was the first to elaborate 1920 Arthur E.Guedel was the first to elaborate on the signs of general anesthesia on the signs of general anesthesia Magill Endotracheal intubation(Magill Endotracheal intubation(气管内插管气管内插管气管内插管气管内插管)1927 Ralph waters sodalime(钠石灰钠石灰)1956 halo
13、thane (氟烷氟烷)1972 enflurane (恩氟烷恩氟烷)1981 isoflurane (异氟烷异氟烷)1990 sevoflurane(七氟烷七氟烷)1992 desflurane (地氟烷地氟烷)（2 2）Intravenous anesthesia(Intravenous anesthesia(静脉麻醉静脉麻醉静脉麻醉静脉麻醉)1934 Lundy 1934 Lundy 和和和和waters thiopental (waters thiopental (硫喷妥钠硫喷妥钠硫喷妥钠硫喷妥钠)benzodiazepines (benzodiazepines (苯二氮卓类药苯二氮卓
14、类药苯二氮卓类药苯二氮卓类药)diazepam diazepam （地西泮）（地西泮）（地西泮）（地西泮）1959 1959 midazolam (midazolam (咪达唑仑咪达唑仑咪达唑仑咪达唑仑)1976)1976 others:others:sodium hydroxybutyrate,r-oH(sodium hydroxybutyrate,r-oH(羟丁酸钠羟丁酸钠羟丁酸钠羟丁酸钠)1960)1960 ketamine (ketamine (氯胺酮氯胺酮氯胺酮氯胺酮)1970)1970 etomidate (etomidate (依托咪酯依托咪酯依托咪酯依托咪酯)1972)1972
15、 propofol (propofol (丙泊酚丙泊酚丙泊酚丙泊酚)1983)1983(3)opioids fentanyl (芬太尼芬太尼)sufentanil (舒芬太尼舒芬太尼)alfentanil (阿芬太尼阿芬太尼)remifentanil (瑞芬太尼瑞芬太尼)(4)Muscle Relaxants (4)Muscle Relaxants (肌肉松弛药肌肉松弛药肌肉松弛药肌肉松弛药)1942 curare (1942 curare (箭毒箭毒箭毒箭毒)Succinylcholine (Succinylcholine (琥珀胆缄琥珀胆缄琥珀胆缄琥珀胆缄)Mivacurium (Miva
16、curium (米库氯铵米库氯铵米库氯铵米库氯铵)Now,the relaxants in common use include Now,the relaxants in common use include Vecuronium (Vecuronium (维库溴铵维库溴铵维库溴铵维库溴铵),atracurium (),atracurium (阿屈库铵阿屈库铵阿屈库铵阿屈库铵)Rocuronium (Rocuronium (罗库溴铵罗库溴铵罗库溴铵罗库溴铵)Cisatracuronium (Cisatracuronium (顺式阿屈库铵顺式阿屈库铵顺式阿屈库铵顺式阿屈库铵)（5 5）Local
17、 and Regional anesthesia(Local and Regional anesthesia(局麻和区域麻局麻和区域麻局麻和区域麻局麻和区域麻醉醉醉醉)1884 Carl koller topical cocaine(1884 Carl koller topical cocaine(可卡因表麻可卡因表麻可卡因表麻可卡因表麻)1898 August Bier spinal anesthesia(1898 August Bier spinal anesthesia(脊麻、腰脊麻、腰脊麻、腰脊麻、腰麻麻麻麻)1901 Ferdinand cathelin and Jean sicar
18、d 1901 Ferdinand cathelin and Jean sicard caudal epidural anesthesia(caudal epidural anesthesia(骶麻骶麻骶麻骶麻)1921 Fidal pages and 1931 Achille Dogliotti 1921 Fidal pages and 1931 Achille Dogliotti Lumbar epidural anesthesia(Lumbar epidural anesthesia(腰部硬膜外麻醉腰部硬膜外麻醉腰部硬膜外麻醉腰部硬膜外麻醉)1904 Alfred Einhorn synt
19、hesized procaine1904 Alfred Einhorn synthesized procaineOther local anesthetics:Other local anesthetics:dibucaine(dibucaine(地布卡因，地布卡因，地布卡因，地布卡因，1930)1930)，tetracaine(tetracaine(丁卡因丁卡因丁卡因丁卡因 1932)1932)lidocaine(lidocaine(利利利利多多多多卡卡卡卡因因因因，1932)1932)，chloroprocaine(chloroprocaine(氯氯氯氯普普普普鲁鲁鲁鲁卡卡卡卡因因因因,1
20、955),1955)mepivacaine(mepivacaine(甲哌卡因甲哌卡因甲哌卡因甲哌卡因,1957),prilocaine(,1957),prilocaine(丙胺卡因丙胺卡因丙胺卡因丙胺卡因,1960),1960)bupivacaine(bupivacaine(布比卡因布比卡因布比卡因布比卡因,1963),etidocaine(,1963),etidocaine(依替卡因依替卡因依替卡因依替卡因,1972),1972)The latest local anesthetics include ropivacaine(The latest local anesthetics incl
21、ude ropivacaine(罗哌卡罗哌卡罗哌卡罗哌卡 因因因因)and levobupivacaine()and levobupivacaine(左旋布比卡因左旋布比卡因左旋布比卡因左旋布比卡因)Anesthesiologist prof Rovenstine established the first pain clinic1970 In USA,society of critical care medicine formed(美国危重病学会成立美国危重病学会成立)(6)Since the eighties of last century until now the clinical a
22、nesthesiology is characterized by emphasizing anesthetic monitoring and paying more attention to anesthetic safety.The minimum standards for intraoperative monitoring have beenadopted by the ASA(American society of Anesthesiologists)include:Body temperature(体温体温)Arterial blood pressureand heart rate
23、Electrocardiography(ECG)(心电图心电图)Pulse oximetry(SPO2，脉搏氧饱和度，脉搏氧饱和度)End tidal carbon dioxide(呼气末二氧化碳呼气末二氧化碳)For other monitoring methods,you may choose it when it is necessary.二麻醉学专业的任务和范围二麻醉学专业的任务和范围二麻醉学专业的任务和范围二麻醉学专业的任务和范围(The scope and task of Anesthesiology)(The scope and task of Anesthesiology)Th
24、e scope and basic tasks of anesthesiology include:The scope and basic tasks of anesthesiology include:1.Clinical anesthesiology1.Clinical anesthesiology(1).To perform preanesthetic visit and evalualion,(1).To perform preanesthetic visit and evalualion,and to formulate anesthetic plan.Taking part in
25、and to formulate anesthetic plan.Taking part in the preanesthelic preparation.the preanesthelic preparation.(2).To render patients insensible to pain and(2).To render patients insensible to pain and discomfort and keep the stress responsediscomfort and keep the stress response at suitable at suitabl
26、e level.level.(3).To(3).To monitor monitor the the patients patients during during operations,and operations,and to regulateto regulateor or control control the the importaut importaut physiological physiological functions functions of of the the patients patients in in order order to to provide pro
27、vide maximum maximum safety safety for for the the patients patients and and to to provide optimal operative conditions for surgeons.provide optimal operative conditions for surgeons.(4).To prevent and treat anesthetic complications(4).To prevent and treat anesthetic complications(5).To(5).To monito
28、r monitor and and treat treat patients patients in in postanesthesia postanesthesia care unit(PACU)care unit(PACU)2.First aid and resuscitation(2.First aid and resuscitation(急救与复苏急救与复苏急救与复苏急救与复苏)3.Critical care medicine(CCM,3.Critical care medicine(CCM,危重病医学危重病医学危重病医学危重病医学)(intensive care medicine,(
29、intensive care medicine,也称加强医学也称加强医学也称加强医学也称加强医学)Its clinical position is called Intensive care unit,Its clinical position is called Intensive care unit,ICU(ICU(重症监测治疗病室或加强医疗病室重症监测治疗病室或加强医疗病室重症监测治疗病室或加强医疗病室重症监测治疗病室或加强医疗病室)4.Pain management and its relatcd researeh epically 4.Pain management and its
30、relatcd researeh epically the mechanism of painthe mechanism of pain5.Research,teaching and training5.Research,teaching and training三如何学好麻醉学三如何学好麻醉学(How to learn anesthesiology)1.To 1.To combine combine basic basic medical medical sciences sciences with with clinical clinical medicine(medicine(基础与临床
31、结合基础与临床结合基础与临床结合基础与临床结合)2.To combine theory with practice(2.To combine theory with practice(理论与实践结合理论与实践结合理论与实践结合理论与实践结合)Anesthesiologist on paper;craftsman of anesthesiaAnesthesiologist on paper;craftsman of anesthesia3.To 3.To learn,learn,to to investigate investigate continuously;continuously;and
32、 and to to make make progress continuously.progress continuously.四麻醉的分类四麻醉的分类(classifications of anesthesia)1.classification of anesthetic technigues1.classification of anesthetic technigues(按麻醉方法分类按麻醉方法分类按麻醉方法分类按麻醉方法分类)In a broad sense all types of anesthesia may be In a broad sense all types of an
33、esthesia may be classified as either regional or general.But,in China,classified as either regional or general.But,in China,because of the wide usage andbecause of the wide usage and characteristic characteristic theoritical basis of epidural and spinal anesthesia,theoritical basis of epidural and s
34、pinal anesthesia,they are put into an independent class called they are put into an independent class called“intravertebral anesthesia”.“intravertebral anesthesia”.Anesthetic technigue may be classified as follows:General anesthesia(全身麻醉全身麻醉).inhalational anesthesia (吸入麻醉吸入麻醉).intravenous anesthesia
35、(静脉麻醉静脉麻醉).intramuscular anesthesia(肌肉麻醉肌肉麻醉).rectal anesthesia (直肠麻醉直肠麻醉)Lntravertebral anesthesiaLntravertebral anesthesia(椎管内麻醉椎管内麻醉椎管内麻醉椎管内麻醉).subarachnoid block(.subarachnoid block(蛛网膜下隙阻滞蛛网膜下隙阻滞蛛网膜下隙阻滞蛛网膜下隙阻滞)(spinal anesthesia,(spinal anesthesia,脊麻脊麻脊麻脊麻.腰麻腰麻腰麻腰麻)epidural block(epidural block
36、(硬脊膜外隙阻滞硬脊膜外隙阻滞硬脊膜外隙阻滞硬脊膜外隙阻滞)Some times subarachnoid block and epidural Some times subarachnoid block and epidural block areblock are also called“neuraxial anesthesia”(also called“neuraxial anesthesia”(神经轴麻醉神经轴麻醉神经轴麻醉神经轴麻醉)Local anesthesiaLocal anesthesia(局部麻醉局部麻醉局部麻醉局部麻醉)topical anesthesiatopical
37、anesthesia(表面麻醉表面麻醉表面麻醉表面麻醉)local infiltrationlocal infiltration(局部浸润麻醉局部浸润麻醉局部浸润麻醉局部浸润麻醉)field blockfield block 区域（术野）阻滞区域（术野）阻滞区域（术野）阻滞区域（术野）阻滞 (peripheral)nerve blocks (peripheral)nerve blocks(周围神经阻滞周围神经阻滞周围神经阻滞周围神经阻滞,神经阻滞神经阻滞神经阻滞神经阻滞)intravenous regional anesthesia intravenous regional anesthesi
38、a(静脉局部麻醉静脉局部麻醉静脉局部麻醉静脉局部麻醉)In some textbooks and monographs,nerve blocks,spinal In some textbooks and monographs,nerve blocks,spinal anesthesia and epidural anesthesia are collectively called anesthesia and epidural anesthesia are collectively called “regional blook”or“regional anesthesia”“regional
39、blook”or“regional anesthesia”Everyday expressions or terms in common use;balanced anesthesia(复合麻醉复合麻醉)combined anesthesia (联合麻醉联合麻醉)basal narcosis(基础麻醉）基础麻醉）endotracheal anesthesia(气管内麻醉气管内麻醉)endotracheal intubation(气管内麻醉气管内麻醉)endoBronchial anesthesia(支气管内麻醉支气管内麻醉)2.1 2.1 classifications classificat
40、ions according according to to the the subspecialty subspecialty of of clinical clinical anesthesiology anesthesiology(接接接接临临临临床床床床麻麻麻麻醉醉醉醉亚亚亚亚学学学学科科科科分分分分类类类类)such as:.such as:.anesthesia for cardiac surgeryanesthesia for cardiac surgery(心脏手术麻醉心脏手术麻醉心脏手术麻醉心脏手术麻醉)anesthesia for Vascular surgeryanest
41、hesia for Vascular surgery(血管外科手术麻醉血管外科手术麻醉血管外科手术麻醉血管外科手术麻醉)anesthesia for thoracic surgeryanesthesia for thoracic surgery(胸科手术麻醉胸科手术麻醉胸科手术麻醉胸科手术麻醉)neurosurgical anesthesianeurosurgical anesthesia(颅脑外科麻醉颅脑外科麻醉颅脑外科麻醉颅脑外科麻醉)anesthesiaanesthesia for organ transplantation for organ transplantation(器官移植手
42、术麻醉器官移植手术麻醉器官移植手术麻醉器官移植手术麻醉)anesthesia for endocrine surgery(anesthesia for endocrine surgery(内分泌外科麻醉内分泌外科麻醉内分泌外科麻醉内分泌外科麻醉)obstetric anesthesiaobstetric anesthesia(产科麻醉产科麻醉产科麻醉产科麻醉)pediatric anesthesiapediatric anesthesia(小儿麻醉小儿麻醉小儿麻醉小儿麻醉)geriatric anesthesiageriatric anesthesia(老年人麻醉老年人麻醉老年人麻醉老年人麻醉
43、)anesthesia for orthopedic surgeryanesthesia for orthopedic surgery(骨科麻醉骨科麻醉骨科麻醉骨科麻醉)anesthesia for abdominal sugeryanesthesia for abdominal sugery(腹部外科麻醉腹部外科麻醉腹部外科麻醉腹部外科麻醉)anesthesia for traumaanesthesia for trauma(创伤外科麻醉创伤外科麻醉创伤外科麻醉创伤外科麻醉)and so onand so on 2.2 classifcalions according to the subspecialty of anesthesiology(按麻醉学的亚学科分类按麻醉学的亚学科分类)clinical anesthesiology critical care medicine pain management