07麻醉与复苏.docx

07麻醉与复苏.docx

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07麻醉与复苏

ClinicalAnaesthesiology

Contents（授课内容及学时安排）

I.Introduction（2学时）

1.Definitionofthepracticeofanaesthesiology

2.Thescopeofanaesthesia

3.Preoperativeassessmentandpremedication

4.ClassificationofAnaesthesiaMethods

5.ClassificationofAnaesthesiaMethodsMonitoringduringanaesthesia

II.GeneralAnaesthesia（2学时）

1Anaestheticapparatus

2Thepracticalconductofanaesthesia

3Complicationsduringanaesthesia

III.LocalAnaesthetictechniques（2学时）

1Featuresoflocalanaesthesia

2Methodsoflocalanaesthesia

3Complicationsoflocalanaesthesia

4Regionalblocks------Spinal,epiduralblocks

IV.Cardiopulmonaryresuscitation（1学时）

1.Considermostfrequentcauses

2.Signsofcardiacarrest

3.Managementofcardiacarrest

4.Managementofbraindamage

ClinicalAnaesthesiology

V.Introduction

1Definitionofthepracticeofanaesthesiology

（1）Assessment,consultation,andpreparationofpatientsforanaesthesia.

（2）Renderingpatientsinsensibletopainduringsurgical,obstetric,therapeutic,anddiagnosticprocedures.

（3）Monitoringandrestoringhomeostasisinperioperativeandcriticallyillpatients

（4）Diagnosingandtreatingpainfulsyndromes.

（5）Managementandteachingofcardiacandpulmonaryresuscitation.

（6）Evaluatingrespiratoryfunctionandapplyingrespiratorytherapy.

（7）Teaching,supervisingandevaluatingtheperformanceofmedicalandparamedicalpersonnalinvolvedinanaesthesia,respiratorycare,andcriticalcare.

（8）Conductingresearchatthebasicandclinicalsciencelevelstoexplainandimprovethecareofpatientsintermsofphysiologicfunctionanddrugresponse.

（9）Involvementintheadministrationofhospitals,medicalschools,andoutpatientfacilitiesnecessarytoimplementtheseresponsibilites.

2Thescopeofanaesthesia

（1）Providinggeneralorregionalanaesthesiainsideandoutsidetheoperatingroom

（2）IntensivecareunitsRespiratorytherapydepartments

（3）Recoveryroom

（4）Cardiopulmonaryresuscitation

（5）Postoperativepainrelief

（6）Anaestheticresearch,teachingmedicalstudents,andassumingadministrativeandleadershippositionsonthemedicalstaffsofhospitalsandambulatorycarefacilities.

3PreoperativeassessmentandpremedicationRoutinepreoperativeanaestheticevaluation

I.History

（1）Currentproblem

（2）Otherknownproblems

（3）Medicationhistory

Allergies

Drugintolerances

Presenttherapy

Prescription

Nonprescription

Nontherapeutic

Alcohol

Tobacco

Illicit

（4）Previousanaesthetics,surgery,andobstetricdeliverries

（5）Familyhistory

（6）Reviewoforgansystems

General

Respiratory

Cardiovascular

Renal

Gastrointestinal

Hematologic

Neurologic

Endocrine

Psychiatric

Orthopedic

Dermatologic

（7）Lastoralintake

II.Physicalexamination

Vitalsigns

Airway

Heart

Lungs

Extremities

Neurologicexamination

III.Laboratoryevaluation

（1）Hematocritorhemoglobinconcentration

Allmenstruatingwomen

Allpatientsover60yearsofage

Allpatientswhoarelikelytoexperiencesignificantbloodlossandmayrequiretransfusion

（2）Serumglucoseandcreatinine（orbloodureanitrogen）concentration:

allpatientsover60yearsofage

（3）Electrocardiogram:

allpatientsover40yearsofage

（4）Chestradiogram:

allpatientsover60yearsofage

IV.ASAclassification

PreoperativeclassificationofpatientsaccordingtotheAmericanSocietyofAnaesthesiologists

Class

Definition

I

Anormalhealthypatientotherthansurgicalpathology-withoutsystemicdisease.

II

Apatientwithmildsystemicdisease–nofunctionallimitations.

III

Apatientwithmoderatetoseveresystemicdisturbanceduotomedicalorsurgicaldisease-somefunctionallimitationbutnotincapacitating.

IV

Apatientwithseveresystemicdisturbancewhichposesaconstantthreattolifeandisincapacitating.

V

Amoribundpatientnotexpectedtosurvive24hourswithorwithoutsurgery.

E

Ifthecaseisanemergency,thephysicalstatusisfollowedbytheletter“E”-,“IIE”.

4ClassificationofAnaesthesiaMethods

I.Generalanaesthesia

a.Inhalationanaesthesia

b.Intravenousanaesthesia

c.Intramuscularly

d.Rectally

e.Orally

f.Balancedanaesthesia

II.Regionalanaesthesia

a.Intrathecalanaesthesia:

a）Subarachnoidblock

b）Epiduralanaesthesia

c）Caudalblock

b.Nerveplexusblock

c.Ganglionblock

d.Nerveblock

e.Fieldblock

III.Miscellaneousanaesthesia

a.Acupunctureanalgesia

b.Chineseherbalanaesthesia

c.Intravenousregionalanaesthesia

d.Intraosseousregionalanaesthesia

e.Regionalanaesthesiabyfreezing

f.Hypnosis

5Monitoringduringanaesthesia

Cardiacmonitors

（1）Arterialbloodpressure

A）Noninvasivearterialbloodpressuremonitoring

Technique&Complications

a）Palpation

b）Dopplerprobe

c）Auscultation

d）Oscillometry

e）Plethysmography

f）ArterialTonometry

B）Invasivearterialbloodpressuremonitoring

Technique&Complications

Selectionofarteryforcannulation:

radialartery,brachialartery

（2）Electrocardiography

（3）Centralvenouscatheterization

（4）Pulmonaryarterycatheterization

（5）Cardiacoutput

Respiratorysystemmonitoring

（1）Precordial&easophagealstethoscope

（2）Breathingcircuitpressure&exhaledtidalvolume

（3）Pulseoximetry

（4）End-tidalcarbondioxideanalysis

（5）Transcutaneousoxygen&carbondioxidemonitors

（6）Anaestheticgasanalysis

Neurologicsystemmonitors

（1）Electroencephalography

（2）Evokedpotential

Miscellaneousmonitors

（1）Temperature

（2）Urineoutput

（3）Peripheralnervestimulation

IIGeneralAnaesthesia

1AnaestheticapparatusTheanaesthesiamachine

（1）Gasinlets&pressureregulators

（2）Oxygenpressurefailuredevices&oxygenflushvalves

（3）Flowcontrolvalves

（4）Flowmeters&spirometers

（5）Vaporizers

（6）Vantilators&disconnectalarms

（7）Wastegasscavengers

（8）Humidifiers&nebulizers

（9）Oxygenanalyzers

Airwaymanagementequipment

（1）Oral&Nasalairway

（2）Mask

（3）Endotrachealtube

（4）Rigidlaryngoscopes

（5）Flexiblefiberopticlaryngoscopes

2Thepracticalconductofanaesthesia

Preparationforanaesthesia

A）Equipmentformonitoring

B）Theanaestheticmachine

C）Equipmentrequiredfortrachealintubation

Inductionofanaesthesia

Indicationforinhalationalinduction

a.Youngchildren

b.Upperairwayobstruction

c.Lowairwayobstructionwithforeignbody

d.Bronchopleuralfistulaorempyema

e.Noaccessibleveins

Difficultiesandcomplication

a.Slowinductionofanaesthesia

b.Problemsparticularlyduringstage2

c.Airwayobstruction,bronchospasm

d.Laryngealspasm,hiccups

e.Environmentalpollution

Intravenousinduction

Dosesoftheintravenousagents

Agent

Inductiondose（mg·kg-1）

Thiopentone

3-5

Methohexitone

1-1.5

Etomidate

0.3

Propofol

1.5-2.5

Ketamine

2

Complicationsanddifficulties

a.Regurgitationandvomiting

b.Intra-arterialinjectionofthiopentone

c.Perivenousinjuction

d.Cardiovasculardepression

e.RespiratorydepressionHistaminerelease

f.Porphyria

g.Othercomplications

MaintenanceofanaesthesiaInhalationanaesthesiawithspontaneousventilation

A）Conduct

B）Minimumalveolarconcentration（MAC）:

MACistheminimumalveolarconcentrationofaninhaledanaestheticagent,whichpreventsreflexmovementinresponsetosurgicalincisionin50%ofsubjects.

C）Signsofanaesthesia

Stage1（Stageofanalgesia）:

fromstartofinductionofanaesthesiatolossofconsciousness.

Stage2（Stageofexcitement）:

Fromlossofconsciousnesstobeginningofregularrespiration.

Stage3（Surgicalanaesthesia）:

Fromthebeginningofregularrespirationtorespiratoryarrest.

Thisstageisdividedintofourplanes.

Plane1:

Fromtheonsetofregularbreathingtothecessationofeyeballmovements.

Plane2:

Fromthecessationofeyeballmovementstothebeginningofintercostalparalysis.

Plane3:

Fromthebeginningofintercostalparalysistothecompletionofintercostalparalysis.

Plane4:

Fromcompletionofintercostalparalysistodiaphragmaticparalysis.

Stage4:

Stageofimpendingrespiratoryandcirculatoryfailure（Medullaryparalysis）,fromtheonsetofdiaphragmaticparalysistocardiacarrest.

D）Complicationsanddifficulties

a.Airwayobstruction

b.Laryngealspasm

c.Bronchospasm

d.Malignanthyperthermia

e.Raisedintracranialpressure（ICP）

f.Atmosphericpollution

Deliveryofinhalationalagents-airwaymaintenance

a.Useofthefacemask

b.Useofthelaryngealmaskairway（LMA）

Indications:

（1）Provideaclearairwaywithouttheneedfortheanaesthetist’shandstosupportamask.

（2）Avoidtheuseoftrachealintubationduringspontaneousventilation.

（3）InacaseofdifficultintubationtofacilitatesubsequentinsertionofatrachealtubeeitherviatheLMAorafteruseofagumelasticbougie.

Contraindications:

（1）Apatientwitha“fullstomach”orwithanyconditionleadingtodelayedgastricemptying,

（2）Apatientinwhomregurgitationofgastriccontentsintotheoesophagusispossible,

（3）WheresurgicalaccessisimpededbythecuffoftheLMA.

c.Trachealintubation

Indications:

（1）Provisionofaclearairway,

（2）An‘unusual’position,

（3）Operationsontheheadandneck,

（4）Protectionoftherespiratorytract,

（5）DuringanaesthesiausingIPPVandmusclerelaxants

（6）Tofacilitatesuctionoftherespiratorytract

（7）Duringthoracicoperations

Contraindications:

few

Anaesthesiafortrachealintubation

（1）Inhalationaltechniqueforintubation

（2）Relaxantanaesthesiaforintubation

Orotrachealintubation

Nasotrachealintubation

Flexiblefiberopticnasotrachealintubation

ComplicationsofintubationDuringlaryngoscopyandintubation

A）Maipositioning

a）Easophagealintubation

b）Endobronctrialintubation

c）Laryngealposition

B）Airwaytrauma

a）T