外科学（总论）：全麻

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1、Clinical Anaesthesiology (General Anaesthesia)教学要求教学要求n全麻方法全麻方法n常用吸入、静脉、肌松药常用吸入、静脉、肌松药nGuedelGuedel 麻醉征象的意义麻醉征象的意义n气管插管方法、适应症、并发症气管插管方法、适应症、并发症n全麻并发症全麻并发症n麻醉监测方法麻醉监测方法 ContentsnMethods of General AnaesthesianAnaestheticsnGuegels Classic Signs of AnaesthesianMethods, Indications & Complications of In

2、tubationnComplications of General AnaesthesianMonitoring During Anaesthesia Methods of General AnaesthesianInhalation anaesthesianIntravenous anaesthesianIntramuscularlynRectallynOrallynBalanced anaesthesiaClinical PharmacologyInhalational Anaesthetic Agents Agent MAC% Vapor Pressure Blood/Gas Parti

3、tionnNitrous oxide 105 - 0.47nHalothane 0.74 243 2.4nEnflurane 1.68 175 1.9nIsoflurane 1.15 240 1.4nDesflurane 6.0 681 0.42Clinical PharmacologyIntravenous Anaesthetic Agents Agent Induction dose (mgkg-1)nThiopentone 3-5nEtomidate 0.3nPropofol 1.5-2.5nKetamine 2Clinical PharmacologyDrugs Used to Sup

4、plement AnaesthesiaAnalgesicsOpioid AgonistsnNatural opium alkaloids: Morphine,CodeinenSemisynthetic opium alkaloid: DiamorphinenSynthetic opioids: Pethidine, Fentanyl, Alfentanil, Sufentanil, RemifentanilPartial Opioid AgonistsnBuprenorphineOpioid Agonist/AntagonistsnPentazocineOpioid AntagonistsnN

5、aloxoneClinical PharmacologyMuscle RelaxantsNeuromuscular Blocking Agents are divided into two classesnDepolarizingnNondepolarizingClinical PharmacologyMuscle RelaxantsnDepolarizingn Short-acting Succinylcholine DecamethoniumnNondepolarizingnLong-acting Tubocurarine Metocurine doxacurium Pancuronium

6、 PipecuriumnIntermediate-acting Atracurium VecuroniumnShort-acting MivacuriumClinical PharmacologyDrugs Affecting the Autonomic Nervous System Sympathomimetic DrugsnAdrenaline(low-,1+2)(higher- )nIsoprenaline(1+2)nNoradrenaline(,1 )nPhenylephine()nDopamine (low-,moderate- ,1+2, moderate high-,1 )nDo

7、butamine(1 )Preparation for AnaesthesianPreoperative assessmentnPreparation for anaesthesianEquipment for monitoringnThe anaesthetic machinenEquipment for tracheal intubationnSigns of General Anaesthesia ASA classificationI A normal healthy patient other than surgical pathology- without systemic dis

8、ease.IIA patient with mild systemic disease no functional limitations.27 ASA classificationIIIA patient with moderate to severe systemic disturbance due to medical or surgical disease- some functional limitation but not incapacitating.IVA patient with severe systemic disturbance which poses a consta

9、nt threat to life and is incapacitating. 27 ASA classificationV A moribund patient not expected to survive 24 hours with or without surgery.E If the case is an emergency, the physical status is followed by the letter “E”-, “IIE”.27Evaluation of AirwaynMallampati classification咽喉分级咽喉分级nThyromental di

10、stance 甲頦间距甲頦间距 nNeck extension 颈屈曲伸展活动度颈屈曲伸展活动度nTissue compliance 组织顺应性组织顺应性nTemporomandibular joint mobility 颞下颌关节活动度颞下颌关节活动度General AnaesthesianInduction of AnaesthesianMaintenance of AnaesthesianEmergence and RecoveryIntravenous Induction Agent Induction dose (mgkg-1)nThiopentone 3-5nEtomidate 0

11、.3nPropofol 1.5-2.5nKetamine 2Inhalational Induction Agent MAC% nNitrous oxide 105 nHalothane 0.74 nEnflurane 1.68 nIsoflurane 1.15 nDesflurane 6.0 Maintenance of Anaesthesia(Control of Depth of Anaesthesia)Minimum alveolar concentration (MAC) MAC is the minimum alveolar concentration (at one atmosp

12、here) of an inhaled anaesthetic agent, which prevents reflex movement in response to surgical incision in 50 % of subjects.Guegels Classic Signs of AnaesthesianStage 1 (Stage of analgesia) From start of induction of anaesthesia to loss of consciousness.nStage 2 (Stage of excitement) From loss of con

13、sciousness to beginning of regular respiration.nStage 3 (Surgical anaesthesia) From the beginning of regular respiration to respiratory arrest.Guegels Classic Signs of AnaesthesianThe stage 3 is divided into four planes.Plane 1 From the onset of regular breathing to the cessation of eyeball movement

14、s.Plane 2 From the cessation of eyeball movements to the beginning of intercostal paralysis.Plane 3 From the beginning of intercostal paralysis to the completion of intercostal paralysis.Plane 4 From completion of intercostal paralysis to diaphragmatic paralysis. Guegels Classic Signs of Anaesthesia

15、nStage 4 Stage of impending respiratory and circulatory failure (Medullary paralysis) from the onset of diaphragmatic paralysis to cardiac arrest.Airway MaintenancenUse of the facemasknUse of the laryngeal mask airway (LMA)nUse of the oropharyngeal airwaynUse of the nasopharyngeal airwaynTracheal in

16、tubationMethods of Tracheal IntubationnOral-tracheal intubationnNaso-tracheal intubationnFlexible fiberoptic nasotracheal intubationnBlind intubation of the tracheal under light wandsnTracheal intubation under seeing optical styletTracheal IntubationIndicationsnProvision of a clear airwaynAn unusual

17、 positionnOperations on the head and necknProtection of the respiratory tractnDuring anaesthesia using IPPV and muscle relaxants nTo facilitate suction of the respiratory tractnDuring thoracic operationsOral-tracheal intubationTracheal intubation under seeing optical styletComplications of Intubatio

18、n While the Tube is in PlacenMalpositionnUnintentional extubationnEndobrochial intubationnLaryngeal cuff positionnAirway traumanMucosal inflammation and ulcerationnExcoriation of nosenTube malfunctionnIgnitionnObstructionComplications of Intubation Following ExtubationnAirway traumanEdema and stenos

19、is (glottic, subglottic, tracheal )nHoarseness (vocal cord granuloma or paralysis )nLaryngeal malfunctionnRegurgitationnAspirationnPhysiologic reflexesnLaryngospasmComplications During AnaesthesiaArrhythmiasnBradycardianTachycardianAtrial arrhythmiasnVentricular arrhythmias (Premature ventricular co

20、ntractions (PVCs)nHeart block Complications During AnaesthesiaHypotentionnDecreased cardiac outputnDecreased venous returnnMyocardialnVasodilationnDrugsnSepticaemianHypovolaemianHaemorrhageComplications During AnaesthesianHypertensionnHypervolaemianMyocardial ischaemianCardiac arrestnEmbolismnHypoxa

21、emia Complications During AnaesthesianHypercapnianHypocapnia nRespiratory obstructionnIntubation problems Aspiration of gastric contentsnHiccupsnAdverse drug effects Complications During AnaesthesianMalignant hyperthermia (MH)nHyperthermianHypothermianAcute intermittent porphyria(AIP)nAwarenessnInju

22、ryMonitoring During AnaesthesiaCardiac MonitorsnArterial blood pressure n Noninvasive arterial blood pressure nInvasive arterial blood pressure monitoringnElectrocardiographynCentral venous catheterizationnPulmonary artery catheterizationnCardiac outputTechnique of Noninvasive Arterial Blood pressur

23、e MonitoringnPalpationnDoppler probenAuscultationnOscillometrynPlethysmographynArterial TonometryInvasive Arterial Blood Pressure Monitoring (Selection of Artery for Cannulation)nRadial arterynBrachial arterynUlnar arterynfemoral arterynDorsalis pedisnPosterior tibial arterynAxillary artery Complica

24、tions of Invasive Arterial CannulationnHaematomanVasospasmnArterial thrombosisnEmbolization of air bubbles or thrombinSkin necrosis overlying the catheternNerve damagenInfectionnUnintentional intra-arterial drug injectionMonitoring During AnaesthesiaRespiratory System MonitoringnPrecordial & easopha

25、geal stethoscopenBreathing circuit pressure & exhaled tidal volumenPulse oximetrynEnd-tidal carbon dioxide analysisnTranscutaneous oxygen & carbon dioxide monitorsnAnaesthetic gas analysisMonitoring During AnaesthesiaNeurologic System MonitorsnElectroencephalographynEvoked potentialnBISnNarcotrend M

26、onitoring During AnaesthesiaMiscellaneous MonitorsnTemperaturenUrine outputnPeripheral nerve stimulation QuestionsnWhat is the meaning of MAC?nWhat are the Guedels classic signs of anaesthesia?nHow many methods for the anaesthetists use to maintain the airway? What are they?QuestionsnWhat are the indications for tracheal intubation?nWhat are the complications of tracheal intubation?nWhat are the complications during general anaesthesia?