Introduction of Clinical Anesthesia

IntroductionofClinicalAnesthesiaDepartmentofAnesthesiologyCuiXiaoGuangConceptUsingDrugsorothermethodsCentralNerveSystemorperipheralnervesystemLosingsense,painlessandcomfortable,temporarilyWhatcanyoudoforyourfuture?expertiseinresuscitationfluidreplacementairwaymanagementoxygentransportoperativestressreductionpostoperativepaincontrolICU近代麻醉学发展的三个重要阶段麻醉：19世纪40年代算起，近100年的发展历程。临床麻醉学（clinicalanesthesiology）：初步形成临床麻醉学的五大组成。麻醉与危重病医学（anesthesiologyandcriticalcaremedicine）：从20世纪50年代末至今，一次作用要的飞跃，特别是近30余年的发展法国、日本等——麻醉复苏科（departmentofanesthesiologyandresuscitation）；美国等——麻醉与危重病医学科（departmentofanesthesiologyandcriticalcaremedicine）。ArchaicanesthesiaStoneAge:spiculaanalgesiaAcupunctureTraditionalmedicinePressureCryotherapyAndothersHistoryofanesthesiology1846publicdemonstrationofetheranesthesiabyWilliamT.G.MortonMorton'setherinhaler(1846)JohnSnow,thefirstanesthesiologist（1846）MachineofInhalationalanesthesiain1847Facemask(1847)HistoryofinhalationAnesthesiamachine(1930)Intravenousanesthetics1934:thiopental1959:diazepam1960:hydroxybutyrates,r-OH1970:ketamine1972:etomidate1976:midazolam1983:propofolOthersOpioids–Morphine,fentanyl,sufentanil,alfentanil,remifentanilRelaxants–Curare(1942),succinylcholine,pancuronium,vecuronium,atracurium,rocuronium,mivacurium,atal.Localanesthetics1884：Cocaineasophthalmicanesthesia,nerveblock1885：Epiduralanesthesia1898:Spinalanesthesia1901：Caudalanesthesia1905：Procaine1930：Dibucaine1932：Dicaine1943：Lidocaine1963:bupivacaine1996:ropivacaineMorenew:levobupivacaineHowaboutourdepartmentofanesthesiology?～1956：surgeon1957：anesthesiagroup60-70：epidural,spinal,nerveblock70-80：CPB,intravenousanesthesia,andinhalationalanesthesia80-85:intravenousanesthesia,inhalationalanesthesia,ECG,arterialbloodpressure,CVP80-90：inhalationalanesthesiawithtiminginjectionofvolatileanesthetics90-present：depthofanesthesia,balanceanesthesiaPopularanesthesiawordsASAphysicalstatusclassificationsystemTOF:trainoffourBIS:bispectralindexCVPneurostimulatorSG:SwanGanzcatheterMAC:minimumalveolarconcentrationTEE:transesophagealechocardiographyTheworkingfieldofAnesthesiologistsClinicanesthesia–Operatingroom,PACU,outpatient,CPCR(cardiopulmonarycerebralresuscitation)CCM(criticalcaremedicine)Analgesia–Painclinic,postoperativeanalgesia,othersOthers–Research,education,trainingHowcanyoubecomearealanesthesiologistpurposeBasicknowledgeProfileofwholebodysystemsUsingyourpotentialRenewandupdate,uninterruptedlyCommunicationAnesthesiamethodsgenerallocalinhalationintravenousmucosamusclespinalepiduralNerveblockLocalinfiltrationtopicalbalanceSubspecialtyofanesthesiologyCardiacsurgeryVascularsurgeryThoracicsurgeryNeurosurgicalanesthesiaOrgantransplantationPediatricsurgeryObstetricanesthesiaAndothersProcedureofclinicalanesthesiaPre-opeprepareintroductionSpecialmonitoringMaintainPACUPreope.PhysicalassessmentPurposeofPreope.PhysicalassessmentToreceivethepatienthistorydataTorelievepatient’sworryingstatusReviewofcurrentdrugtherapyPhysicalexamination,interpretationoflaboratorydataFindoutriskfactorProposeanesthesiamethodContentofPreope.PhysicalassessmentToreceivethepatienthistorydataPhysicalexamination,interpretationoflaboratorydataASAclassificationProposeanesthesiamethodASAphysicalstatusI.AnormalhealthypatientII.ApatientwithmildsystemicdiseaseIII.ApatientwithseveresystemicdiseaseIV.ApatientwithseveresystemicdiseasethatisaconstantthreattolifeV.AmoribundpatientwhoisnotexpectedtosurvivewithouttheoperationVI.Adeclaredbrain-deadpatientwhoseorgansarebeingremovedfordonorpurposesTheadditionofan'E'indicatesemergencysurgery.Physicalexam.Generalstatus：发育、营养、精神状态等血压、脉搏、体温头部：眼、鼻、口腔、下颌，中枢神经系统情况颈部：活动度、长短、甲状腺大小等，颈静脉胸部：望、触、叩、听，心电、血气、1秒率腹部：望、触、叩、听，肝、肾、脾、胃肠功能四肢：活动情况、感觉情况，动脉、静脉情况背部：椎管内麻醉或其他麻醉方法要求的全身情况和各器官系统的检诊全身情况growth，nutrition，bodyweight，etalBMI(bodymassindex)=bodyweight(kg)×bodyheight(m)2Male:about22kg/m2;Female:20kg/m2;25-29kg/m2:overweight;≥30kg/m2:obesityBW＞100%standardBW:pathosisobesity全身情况Hb＞80g/LHbexorbitanceHematocrit:30%-35%acuteinflammationBMR(basalmetabolicrate):Reedformula：BMR%=0.75×（PR+0.74×PP）－72normalvalue：-10%~+10%呼吸系统呼吸系统感染：择期手术，急症手术，肺结核，慢性肺脓肿，重症支气管扩张症COPD(chronicobstructivepulmonarydisease):功能因素比解剖因素更重要Asthma:控制感染、停止吸烟、降低气管和支气管的反应性肺功能的评估肺活量：60%通气储量百分比：70%FEV1.0/FVC%：60%or50%FVC15ml/kgMVV:40Lor50%~60%ofpredictionvalue50%:低肺功能30%:手术禁忌床旁测试病人肺功能的方法摒弃试验吹气试验吹火柴试验气道评估(airwayevaluation)Purpose:difficultintubation,difficultmaskventilationpatienthistoryphysicalexaminationPhysicalexamination提示气道处理困难的体征：不能张口；颈椎活动受限；颏退缩；舌体大；门齿突起；颈短；病态肥胖。PhysicalexaminationLangeron提出五项面罩通气困难因素：年龄55岁；BMI26kg/m2；多胡须；牙齿缺失；打鼾史。Physicalexamination面、颈或胸部:评价其对气道的影响头颈部：1）双侧鼻孔及鼻道，鼻中隔；2）张口，舌体，牙齿及牙龈，扁桃体及颚部有无异常；3）测颏甲距离：6.5cm以上；4）颈椎活动度；5）有无气管造口或造口瘢痕，治疗气道的并发症。Mallampati气道分级评定Mallampati气道分级评定I级：可见咽峡弓、软腭和颚垂。II级：可见咽峡弓、软腭，但颚垂被舌根部掩盖而不可见。III级：仅可见软腭。VI级：仅可见硬腭。III、IV级预示插管困难，但不是绝对的，应结合颏甲距离判断。气道检查心血管系统心功能分级及意义级别屏气试验临床表现临床意义麻醉耐受力I30s能耐受日常体力活动，活动后无心慌、心功能正常良好气短等不适感II20~30s对日常体力活动有一定的不适感，往往心功能较差如处理正确自行限制或控制活动量，不能作跑步或适宜，耐受仍好用力的工作III10~20s轻度或一般体力活动后有明显不适，心心功能不全麻醉前应作充分准备悸、气短明显，只能胜任极轻微的体力应避免增加心脏负担活动或静息IV10s以内不能耐受任何