Introduction

of

ClinicalAnesthesiaConceptUsing

Drugs

or

other

methodsCentral

Nerve

System

or

peripheralnerve

systemLosing

sense,

painless

and

comfortabletemporarilyW

hat

can

you

do

for

yourfuture?expertise

in

resuscitationfluid

replacementairway

managementoxygen

transportoperative

stress

reductionpostoperative

paincontrolICU近代麻醉學(xué)發(fā)展的三個(gè)重要階段麻醉：19世紀(jì)4

0年代算起，近100年的發(fā)展歷程。臨床麻醉學(xué)（c

linical

an

esthesiology

）：初步形成臨床麻醉學(xué)的五大組成。麻醉與危重病醫(yī)學(xué)（a

nesthesiology

and

critical

caremedicine

）：從20世紀(jì)50年代末至今，一次作用要的飛躍，特別是近30余年的發(fā)展法國(guó)、日本等——麻醉復(fù)蘇科（de

partment

ofanesthesiology

and

resuscitation）；美國(guó)等——麻醉與危重病醫(yī)學(xué)科（dep

artmen

t

ofanesthesiology

and

critical

care

medicin

e）。Archaic

anesthesiaStone

Age:

spicula

analgesiaAcupunctureTraditional

medicinePressureCryotherapyAnd

othersHistory

of

anesthesiology1846

public

demonstration

of

etheranesthesia

by

William

T.

G.

MortonM

orton"s

ether

inhaler

(1846

)John

Snow,

the

f

irst

anesthesiologist（184

6）M

achine

of

Inhalationalanesthesia

in

1847Facemask(1847)History

of

inhalationAnesthesia

m

achine(1930

)Intravenous

anesthetics1934:

thiopental1959:

diazepam1960:

hydroxybutyrates,

r-OH1970:

ketamine1972:

etomidate1976:

midazolam1983:

propofolOthersOpioidsMorphine,

fentanyl,

sufentanil,

alfentaniremifentanilRelaxantsCurare(1942),

succinylcholine,pancuronium,

vecuronium,

atracurium,rocuronium,

mivacurium,

at

al.Local

anesthetics1884：Cocaine

as

ophthalmic

anesthesia,

nerve

block1885：Epidural

anesthesia1898:

Spinal

anesthesia1901：Caudal

anesthesia1905：Procaine

1930：Dibucaine

1932：Dicaine1943：Lidocaine1963:

bupivacaine1996:

ropivacaineMore

new:

levobupivacaineHow

about

our

departmentof

anesthesiology?～1956：surgeon

1957：anesthesia

group60-70：epidural,

spinal,

nerve

block70-80：CPB,

intravenous

anesthesia,

andinhalational

anesthesia80-85:

intravenous

anesthesia,

inhalationalanesthesia,

ECG,

arterial

blood

pressure,

CVP80-90：inhalational

anesthesia

with

timing

injectionof

volatile

anesthetics90-present：depth

of

anesthesia,

balanceanesthesiaPopular

anesthesia

wordsASA

physical

status

classification

systemTOF:

train

of

fourBIS:

bispectral

indexCVPneurostimulatorSG:

Swan

Ganz

catheterMAC:

minimum

alveolar

concentrationTEE:

transesophageal

echocardiographyThe

working

field

ofAnesthesiologistsClinic

anesthesiaOperating

room,

PACU,

outpatient,CPCR

(cardiopulmonary

cerebralresuscitation)CCM

(critical

care

medicine)AnalgesiaPain

clinic,

postoperative

analgesia,

othersOthersResearch,

education,

trainingHowcan

you

becom

e

areal

anesthesiologistpurposeBasic

knowledgeProfile

of

whole

body

systemsUsing

your

potentialRenew

and

update,

uninterruptedlyCommunicationAnesthesia

m

ethodsgenerallocalinhalationintravenousmucosa

musclespinalepiduralNerve

blockLocalinfiltrationtopicalbalanceSubspecialty

ofanesthesiologyCardiac

surgeryVascular

surgeryThoracic

surgeryNeurosurgical

anesthesiaOrgan

transplantationPediatric

surgeryObstetric

anesthesiaAnd

othersProcedure

of

clinicalanesthesiaPre-opeprepareintroductionSpecial

monitoringMaintainPACUPreope.

Physical

assessm

entPurpose

of

P

reope.Physical

assessm

entTo

receive

the

patient

history

data

To

relieve

patient’s

worrying

statusReview

of

current

drug

therapyPhysical

examination,

interpretation

olaboratory

dataFind

out

risk

factorPropose

anesthesia

methodContent

of

Preope.Physical

assessm

entTo

receive

the

patient

history

dataPhysical

examination,

interpretation

olaboratory

dataASA

classificationPropose

anesthesia

methodASA

physical

statusⅠ.A

normal

healthy

patientⅡ.A

patient

with

mild

systemic

disease

III.A

patient

with

severe

systemic

diseaseⅣ.A

patient

with

severe

systemic

disease

that

is

aconstant

threat

to

lifeⅣ.A

moribund

patient

who

is

not

expected

tosurvive

without

the

operationⅣ.A

declared

brain-dead

patient

whose

organsare

being

removed

for

donor

purposesThe

addition

of

an

"E"

indicates

emergencysurgery.Physical

ex

am

.General

status：發(fā)育、營(yíng)養(yǎng)、精神狀態(tài)等血壓、脈搏、體溫頭部：眼、鼻、口腔、下頜，中樞神

經(jīng)系統(tǒng)情況頸部：活動(dòng)度、長(zhǎng)短、甲狀腺大小等，頸靜脈胸部：望、觸、叩、聽(tīng)，心電、血?dú)狻?

秒率腹部：望、觸、叩、聽(tīng)，肝、腎、脾、胃腸

功能四肢：活動(dòng)情況、感覺(jué)情況，動(dòng)脈、靜脈情況背部：椎管內(nèi)麻醉或其他麻醉方法要求的全身情況和各器官系統(tǒng)的檢診全身情況growth，nutrition

，body

weight

，et

alBMI

(body

mass

index)=body

weight

(kg)×body

height

(m)2Male

:

about

22kg/m2;Female:

20kg/m2

;25-29kg/m2:

over

weight;≥30kg/m2:

obesityBW＞100%

standard

BW:

pathosis

obesity全身情況Hb＞80g/LHb

exorbitanceHematocrit:

30%-35%acute

inflammationBMR(basal

metabolic

rate):Reed

formula：BMR%=0.75×（PR+0.74×PP）－72normal

value：-10%~+10%呼吸系統(tǒng)呼吸系統(tǒng)感染：擇期手術(shù)，急癥手術(shù)，肺結(jié)核，慢性肺膿腫，重癥支氣管擴(kuò)張癥COPD(chronic

obstructivepulmonary

disease):功能因素比解剖因素更重要Asthma:控制感染、停止吸煙、降低氣管和支氣管的反應(yīng)性肺功能的評(píng)估肺活量：<60%通氣儲(chǔ)量百分比：<70%FEV1.0/FVC%：<60%

or

50%FVC<15ml/kgMVV:

40L

or

50%~60%

of

prediction

value<50%:低肺功能<30%:手術(shù)禁忌床旁測(cè)試病人肺功能的方法摒棄試驗(yàn)

吹氣試驗(yàn)

吹火柴試驗(yàn)氣道評(píng)估(airway

evaluation)Purpose:

difficult

intubation,

difficumask

ventilationpatient

historyphysical

examinationPhysical

ex

am

ination提示氣道處理困難的體征：不能張口；頸椎活動(dòng)受限；頦退縮；舌體大；門齒突起；頸短；病態(tài)肥胖。Physical

ex

am

inationLangeron提出五項(xiàng)面罩通氣困難因素：年齡>55歲；BM

I>26kg/m

2

；多胡須；牙齒缺失；打鼾史。Physical

ex

am

ination面、頸或胸部:評(píng)價(jià)其對(duì)氣道的影響頭頸部：雙側(cè)鼻孔及鼻道，鼻中隔；張口，舌體，牙齒及牙齦，扁桃 體及顎部有無(wú)異常；測(cè)頦甲距離：6.5cm以上；頸椎活動(dòng)度；有無(wú)氣管造口或造口瘢痕，治療氣道 的并發(fā)癥。M

allampati氣道分級(jí)評(píng)定M

allam

pati氣道分級(jí)評(píng)定I級(jí)：可見(jiàn)咽峽弓、軟腭和顎垂。II級(jí)：可見(jiàn)咽峽弓、軟腭，但顎垂被舌根部掩蓋而不可見(jiàn)。III級(jí)：僅可見(jiàn)軟腭。VI級(jí)：僅可見(jiàn)硬腭。III、IV級(jí)預(yù)示插管困難，但不是絕對(duì)的，應(yīng)結(jié)合頦甲距離判斷。氣道檢查心血管系統(tǒng)心功能分級(jí)及意義級(jí)別屏氣試驗(yàn)臨床表現(xiàn)臨床意義麻醉耐受力I>30s能耐受日常體力活動(dòng)，活動(dòng)后無(wú)心慌、心功能正常II20~30s氣短等不適感對(duì)日常體力活動(dòng)有一定的不適感，往往自行限制或控制活動(dòng)心功能較差量，不能作跑步或用力的工作輕度或一般體力活動(dòng)后有明顯不適，心悸、III10~20s氣短明顯，只能勝任極輕微的體力活心功能不全動(dòng)或靜息不能耐受任何體力活動(dòng)，靜息時(shí)也感氣短，不能平臥，有端坐呼IV10s以內(nèi)吸、心動(dòng)過(guò)速等表現(xiàn)心功能衰竭良好如處理正確適宜，耐受仍好麻醉前應(yīng)作充分準(zhǔn)備應(yīng)避免增加心臟負(fù)擔(dān)極差，一般需推遲手術(shù)心功能分級(jí)與CI、EF、L

VEDP心功能級(jí)別EFLVEDP運(yùn)動(dòng)時(shí)LVEDP休息時(shí)CI>0.

550.5~0.

4正常，(≤12mmHg)≤12mmHg>12mmHg正常,(≤12mmHg)正常，>12mmHg>12mmHg>2.5L/(min·m2

)2.5L/(min·m2)

±2.

0

L/(min·m2

)±1.5L/(min·m2

)±IIIIIIIV0.

30.

2>12mmHg>12mmHgGoldman等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和計(jì)分方法充血性心衰體征，如奔馬律、頸靜脈壓增高（11分）；6個(gè)月內(nèi)發(fā)生過(guò)心梗（10分）；室性早搏>5次/分鐘（7分）；非竇性心律或房性早搏（7分）；年齡>70歲（5分）；急性手術(shù)（4分）；主動(dòng)脈瓣顯著狹窄（3分）；胸腹腔或主動(dòng)脈手術(shù)（3分）；全身情況差（3分）。全身情況差（下面任何一種）PaO2<

60

mmHgPaCO2>

49

mmHgK+<

3

mmol/LHCO3-<

20

mmol/LBUN>

7.5

mmol/LCreatinine>270

mol/LSGOT：abnormality慢性肝炎(chronic

hepatitis)Goldman等提出的估計(jì)非心臟手術(shù)的危險(xiǎn)性的9個(gè)因素和計(jì)分方法累計(jì)53分分四級(jí)：I級(jí)：0-5分II級(jí)：6-12分III級(jí)：13-25分IV級(jí)：≥26分心律失常1竇性心律失常：過(guò)速、過(guò)緩（迷走神經(jīng)張力過(guò)大，藥物，病竇）。室上性心動(dòng)過(guò)速:多無(wú)器質(zhì)性心臟?。黄髻|(zhì)性心臟病，甲亢，藥物中毒。早搏：1）一過(guò)性或偶發(fā)性房、室早搏；2）頻發(fā)，二聯(lián)律、三聯(lián)律或成對(duì)，多源性，R

on

T，易誘發(fā)室速和室顫。陣發(fā)性室速：病理性；藥物治療不佳，需有電復(fù)律和電除顫的準(zhǔn)備。心律失常2房顫：可致嚴(yán)重的血流動(dòng)力學(xué)紊亂、心絞痛、昏厥、體循環(huán)栓塞和心悸不適；未復(fù)律者，麻醉前心率：80次/分左右，至少<100次/分。束支傳導(dǎo)阻滯：右束支；左束支（左前、左后分支）；雙分支或三分支阻滯；發(fā)展成房室傳導(dǎo)阻滯。房室傳導(dǎo)阻滯：I

度；II

度（莫氏I

型、I

I

型）；I

II

度莫氏I

I型和莫氏I型心率<50次/分鐘：準(zhǔn)備起搏器；II

I度:手術(shù)時(shí)安裝起搏器或做好起搏準(zhǔn)備。高血壓繼發(fā)性高血壓：特別警惕是否為未經(jīng)診斷的嗜鉻細(xì)胞瘤高血壓病：重要臟器是否受累及程度收縮壓升高比舒張壓升高危害更大多年高血壓，不要求很快降至正常，應(yīng)