外科学总论：Anesthesiology

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1、Anxiolysis, sedation, amnesiaAnalgesiaDecrease in airway secretions, decrease in gastric volume and increase in gastric pHDecrease in autonomic response Continued therapy for concurrent diseaseClassified: Esters & AmidesBHBHBHB & HH&BextracellularintracellularB: unionized formBH: ionized formAgentPr

2、ocaineTetracaineLidocaineBupivacaineRopivacaine(separate motor & sensory)pKa8.98.57.88.18.1Protein binding5.876649594Max Dose (mg)100040 & 80100 & 4003mg/kg3mg/kgDuration (hr)0.75-12-31-25-64-6How to prepare the intubation: SALTHow to make sure the correct intubation: p86Side effect of intubation: P

3、87Where is the epidural space?SkinSubcutaneous fatSupraspinous ligamentInterspinous ligamentLigamentum flavumEpidural spaceEpidural space end at L2Differentiate between spinal & epidural anesthetic:DoseSegmentalSize of needleConfirm of spaceAdvantages & disadvantage of epidural over spinalSegmentalO

4、nset slow, less hypotension, less depression of breathContinue, duration can be longLess headacheMore flexibilitySloe onsetGreat amount of drug, possible toxicityLess reliableWhat are the potential complication of epidural?Total spinalEpidural hematomasToxicity of local anestheticsHypotensionPostdur

5、al puncture headache“疼痛疼痛-第五生命体征第五生命体征”体温、呼吸、脉搏、血压体温、呼吸、脉搏、血压 美国医疗机构评审联合委员会美国医疗机构评审联合委员会 James Campell, 美国疼痛协会主席美国疼痛协会主席1846: Demontration of anesthesia with ether1980s: Advent of IV PCA, APS 1995: ASA acute pain guidelines (rev. 2004)Why Post-OP Pain treatment? The Pathophysiology of post-OP pain:

6、neuro-endocrine-immune, respiratory, circulation, coagulation, et al. Clinical Outcome: complication of lung, digestive, coagulation, length of hospital, health chargeEducated-teamPre-OP evaluation, preparationPeri-OP pain treatment-multimodelMonitoring & Evaluate Pain24h-availabilityHow Post-OP Pai

7、n treatment: APSAnesthesiologistNurseSurgeonClinical PharmacologistHealth-care providerEducated-teamPeri-OP pain treatmentMulti-model德国： 吗啡（17%）、芬太尼（14%）和舒芬太尼（75%） 英国： 吗啡（40%）、芬太尼（8%）和舒芬太尼（50%） 不同浓度舒芬太尼复合不同浓度舒芬太尼复合0.125%0.125%罗哌卡因罗哌卡因持续硬膜外输注在上腹部术后镇痛中的研持续硬膜外输注在上腹部术后镇痛中的研究究 罗哌卡因 舒芬太尼组 0.125% 0 组 0.125

8、% 0.25ug/ml组 0.125% 0. 50ug/mlIV组 0.125% 0.75ug/ml Monitoring & Evaluate Pain 组别 R R+0.25S R+0.5S R+0.75S性别(M/F） 6/5 4/7 7/4 5/6年 龄（岁） 544 564 564 533体重(Kg) 64.12.7 55.91.9 57.12.8 59.54.0手术时间(分)18420 22631 20223 22315病人一般情况(每组11例)00.511.522.533.540-3h3-6h6-12h12-24hTimeVASRR+0.25SR+0.5SR+0.75S病人各时段

9、VAS评分 TimeVAS24h0246810RR+0.25SR+0.5SR+0.75S病人术后24小时辅助镇痛给药次数 病人术后各时段瘙痒发生数（例） 024681012RR+0.25SR+0.5SR+0.75S无瘙痒瘙痒 0.5g/ml舒芬太尼复合0.125%罗哌卡因以5ml/hr持续硬膜外给药可取得较佳的镇痛效果及较少的副作用 图 1. 三组间人口数据和手术时间比较(P0.05) Group I (n = 17)Group II (n = 26)Group III (n = 20)年龄 (years)56.57.956.311.7 52.711.5体重 (kg)55.210.5 58.4

10、6.6 56.310.3身高(cm)168.37.2 169.56.4 167.06.1性别(male/female)8/9 13/13 8/12手术时间 (min)216.665.3201.966.1 215.468.9术中芬太尼用量 (g)450.952.3466.532.4451.143.9. 图2 术后2h,4h,24h,48h,三组患者曲马多消耗量 Group 各时点曲马多消耗量 (mg) 2h 4h 24h 48hGroup I (n = 17) 141.217.2 184.727.0 459.570.3 767.4105.4Group II (n = 26) 140.116.8 179.627.3 476.899.2 776.0129.9Group III(n = 20)135.312.5 203.8 27.4* 532.792.6* 868.4122.3* *P0.05 vs group I and group II谢谢