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Introduction of Clinical Anesthesia

Introduction of Clinical Anesthesia. Department of Anesthesiology Li Wenzhi. Concept. Using Drugs or other methods Central Nerve System or peripheral nerve system Losing sense, painless and comfortable, temporarily. What can you do for your future?. expertise in resuscitation

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Introduction of Clinical Anesthesia

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  1. Introduction of Clinical Anesthesia Department of Anesthesiology Li Wenzhi

  2. Concept • Using Drugs or other methods • Central Nerve System or peripheral nerve system • Losing sense, painless and comfortable, temporarily

  3. What can you do for your future? • expertise in resuscitation • fluid replacement • airway management • oxygen transport • operative stress reduction • postoperative pain control • ICU

  4. Archaic anesthesia • Stone Age: spicula analgesia • Acupuncture • Traditional medicine • Pressure • Cryotherapy • And others

  5. History of anesthesiology • 1846 public demonstration of ether anesthesia by William T. G. Morton

  6. Morton's ether inhaler (1846)

  7. John Snow, the first anesthesiologist（1846）

  8. Machine of Inhalational anesthesia in 1847

  9. Face mask(1847)

  10. History of inhalation

  11. Anesthesia machine (1930)

  12. Intravenous anesthetics • 1934: thiopental • 1959: diazepam • 1960: hydroxybutyrate, r-OH • 1970: ketamine • 1972: etomidate • 1976: midazolam • 1983: propofol

  13. Others • Opioids • Morphine, fentanyl, sufentanil, alfentanil, remifentanil • Relaxants • Curare, succinylcholine, pancuronium, vecuronium, atracurium, rocuronium, mivacurium, at al.

  14. Local anesthetics • 1884：Cocaine as ophthalmic anesthesia, nerve block • 1885：Epidural anesthesia • 1898: Spinal anesthesia • 1901：Caudal anesthesia • 1905：Procaine • 1930：Dibucaine • 1932：Dicaine • 1943：Lidocaine • 1996: Ropivacaine

  15. S-G catheter TEE BIS Developing of Clinical Anesthesiology TOF CCO ECG ECG Work station Temp. ABP、 CVP ABP PETCO2 Anesthesia-gases Pulse CVP BP No-invasive BP,SPO2 80年代 90年代 21世纪

  16. How about our department of anesthesiology? • ～1956：surgeon • 1957：anesthesia group • 60-70：epidural, spinal, nerve block • 70-80：CPB, intravenous anesthesia, and inhalational anesthesia • 80-85: intravenous anesthesia, inhalational anesthesia, ECG, arterial blood pressure, CVP, S-G • 80-90：inhalational anesthesia with timing injection of volatile anesthetics • 90-prsent：depth of anesthesia, balance anesthesia PETCO2 work-station, BIS, TOF, PiCCO 21 century Key dept. & key lab. of province, pain clinical ward

  17. Popular anesthesia words • ASA physical status classification system • TOF: train of four • BIS: bispectral index • SG: Swan Ganz catheter • MAC: minimum alveolar concentration • TEE: transesophageal echocardiography

  18. The working field of Anesthesiologists • Clinic anesthesia • Operating room, PACU, outpatient, • CPCR (cardiopulmonary cerebral resuscitation) • CCM (critical care medicine) • Analgesia • Pain clinic, postoperative analgesia, others • Others • Research, education, training

  19. How can you become a real anesthesiologist • purpose • Basic knowledge • Profile of whole body systems • Using your potential • Renew and update, uninterruptedly • Communication

  20. Anesthesia methods inhalation general intravenous muscle mucosa Nerve block spinal epidural local topical Local infiltration balance

  21. Subspecialty of anesthesiology • Cardiac surgery • Vascular surgery • Thoracic surgery • Neurosurgical anesthesia • Organ transplantation • Pediatric surgery • Obstetric anesthesia • And others

  22. Preoperational evaluation for patient’ status

  23. Procedure of clinical anesthesia Pre-ope preparation introduction Special monitoring PACU Maintain

  24. Preope. Physical assessment • To visit patient in preoperation • What is anesthesiologist to visit • Checking whole body and assessing functions of main organs • To confirm the risk factor • ASA classification

  25. ASA Physical Status Classification System • A normal healthy patient • A patient with mild systemic disease • A patient with severe systemic disease • A patient with severe systemic disease that is a constant threat to life • A moribund patient who is not expected to survive without the operation • A declared brain-dead patient whose organs are being removed for donor purposes

  26. visiting with the patient preoperative • To receive the patient history data • To relieve patient’s worrying status • Review of current drug therapy • Physical examination, interpretation of laboratory data • Find out risk factor • Preposed anesthesia method

  27. 问诊表 • 麻醉史（全、椎管内、局），术中异常反应 • 既往史 • 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，癫痫，其他特殊情况 • 日常活动 • 药物史 • 个人嗜好：吸烟（量）、饮酒（量） • 家族史 • 恶性高热、过敏、哮喘、高血压、糖尿病、肝病

  28. Physical exam. • General status：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

  29. 实验室检查 • 末梢血 • 胸部X线 • 生化指标 • 血离子 • 尿常规 • 血型、凝血、出血时间 • 心电图 • 肺功能检查 • 腹部X线 • 感染症

  30. 全身情况的检查 • 发育、营养、体重 • 体重指数（BMI） • 体重（kg）÷身高(m)2 • 基础代谢率（BMR） • 0.75×（脉率＋0.74 ×脉压）－72

  31. 高血压标准(舒张压) • 轻度：90～100 mmHg • 中度：100～110 mmHg • 重度：>110 mmHg

  32. 头部 • 眼部：结膜、巩膜、瞳孔、眼球运动、眼睑 • 鼻腔：鼻孔大小 、通畅程度，有无出血倾向 • 口腔：张口度、牙齿、舌、咽腔、扁桃体 • 发音：有无异常

  33. 气道检查

  34. 颈部 • 长短、粗细 • 活动度、后仰 • 有无异常隆起或异常搏动 • 血管情况 • 气管是否居中 • 淋巴结有无肿大

  35. 胸部检查 • 望：对称、呼吸运动 • 触：皮下气肿、细震颤 • 叩：心界、肺区、肝区，胸水 • 听：心音、呼吸音，摩擦音等 • 心电图：12导联，连续监测 • -ray, CT, MRI

  36. 腹部检查 • 望：外形，运动 • 触：紧张度、压痛，肝脾大小 • 叩：浊音 • 听：肠音，血流 • B超 • CT

  37. 脊柱 • 有无感染灶，出血点等 • 有无侧弯，异常突出 • 活动度 • 压痛、叩击痛

  38. 四肢检查 • 皮肤感觉 • 活动 • 温度 • 指(趾)甲颜色及血流充盈情况 • 动脉搏动情况，侧支循环情况 • 病理反射

  39. 脊神经的体表标志

  40. 实验室检查 • 血气分析 • 心电图 • 心功能 • 生化检查 • 肝功能 • 肾 • 内分泌 • 水、电解质和酸碱平衡

  41. 动脉正常血气值 • pH值：7.35～7.45 • PaO2：12.0～13.0kPa（90～100mmHg） 随年龄有变化，老年人低于此值 • PaCO2 :4.665～5.998kPa (35-45mmHg) • SB: 22～27 mmol/L (mEq/L) • BB:45～55mmol/L（mEq/L） • BE:±3mmol/L（mEq/L) • SaO2 : 95～98％ • PA-a O2或A=aDO2:吸空气时约为1.333～2.0kPa（10～15mmHg）；吸纯氧时约为3.32～10.0kPa（25～75mmHg），

  42. 心脏功能测定 • 心电图 • 心动超声（TEE） • 运动试验 • 心导管检查 • 核素心功能(心肌显像、心血管造影)

  43. 心电图 • 正常范围心电图 • 异常 • 心律：窦性？律齐？ • 心率：心动过速，心动过缓 • 传导阻滞：I˚－III ˚，束枝传导阻滞 • 病理性Q波 • ST－T change • 房性期前收缩、室性期前收缩 • R on T, VF

  44. 简易的心肺功能测定法 • 体力活动负荷试验：3mph，10°, <2min, 全肺切除危险性大 • 吹火柴试验：5－7cm • 时间肺活量：深吸气后作最大呼气，呼气时间＞5秒阻塞性肺疾病 • 屏气试验：正常呼吸后如屏气时间＜10－20秒，心肺储备功能不足 • 登楼试验：第四层楼，10分钟内心率呼吸恢复

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