外科学教学课件： 麻醉概论

麻醉概论麻醉概论内容内容(教学大纲教学大纲)n麻醉学的概念麻醉学的概念n麻醉学的工作范畴麻醉学的工作范畴n麻醉方法的分类麻醉方法的分类n麻醉前病人的访视麻醉前病人的访视n各种麻醉方法访视重点各种麻醉方法访视重点Scope of Anaesthesia*Providing general or regional anaesthesia inside and outside the operating room*Intensive care units*Respiratory therapy departments*Recovery room 9Scope of Anaesthesia*Cardiopulmonary resuscitation*Postoperative pain relief*Anaesthetic research,teaching medical students,and assuming administrative and leadership positions on the medical staffs of many hospitals and ambulatory care facilities 10Classification of Anaesthesia Methods General anaesthesia*Inhalation anaesthesia*Intravenous anaesthesia*Intramuscularly*Rectally*Orally*Balanced anaesthesia11Classification of Anaesthesia Methods Regional Anaesthesia*Intrathecal anaesthesia*Subarachnoid block*Epidural anaesthesia*Caudal block*Nerve plexus block*Ganglion block*Nerve block*Field block12Definition of the practice of anaesthesiologynAssessing,consulting,and preparing patients for anaesthesianRendering patients insensible to pain during surgical obstetric,therapeutic,and diagnostic procedures 13 Definition of the practice of anaesthesiologynMonitoring and restoring homeostasis in perioperative and critically patientsnDiagnosing and treating painful syndromesnManaging and teaching of cardiac and pulmonary resuscitation14 Definition of the practice of anaesthesiologynEvaluating respiratory function and applying respiratory therapynTeaching,supervising,and evaluating the performance of medical and paramedical personnel involved in anaesthesia,respiratory care,and critical care15 Definition of the practice of anaesthesiologynInvolvement in the administration of hospitals,medical schools,and outpatient facilities as necessary to implement these responsibilities16 Preoperative assessmentRoutine preoperative anaesthetic evaluation*History-Current problem-Other known problems-Medication history20 Preoperative assessment(Medication history)*Allergies*Drug intolerances*Present therapy:Prescription,Nonprescription*Nontherapeutic:Alcohol,Tobacco*Illicit21 Preoperative assessment*Previous anaesthetics,surgery,and obstetric deliverries*Family history*Review of organ systems*Last oral intake22 Preoperative assessment(Review of organ systems)*General*Respiratory*Cardiovascular*Renal*Gastrointestinal*Hematologic23 Preoperative assessment(Review of organ systems)*Neurologic*Endocrine*Psychiatric*Orthopedic*Dermatologic24Preoperative assessment(Physical examination)*Vital signs*Airway*Heart*Lungs*Extremities*Neurologic examination25 ASA classificationI A normal healthy patient other than surgical pathology-without systemic disease.II A patient with mild systemic disease no functional limitations.27 ASA classificationIII A patient with moderate to severe systemic disturbance due to medical or surgical disease-some functional limitation but not incapacitating.IV A patient with severe systemic disturbance which poses a constant threat to life and is incapacitating.27 ASA classificationV A moribund patient not expected to survive 24 hours with or without surgery.VI Brain-dead organ donor E If the case is an emergency,the physical status is followed by the letter“E”-,“IIE”.27 American Society of Anaesthesiologists classification and perioperative mortality rates Class Mortality Rate I 0.06-0.08%II 0.27-0.4%III 1.8-4.3%IV 7.8-23%V 9.4-51%28General Anaesthesia*AirwayAirwaynMallampati classification咽喉分级咽喉分级nThyromental distance 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Mallampati classification of the oropharynxnClass I:Soft palate,fauces,uvula,anterior and posterior tonsillar pillarsnClass II:Soft palate,fauces,uvulanClass III:Soft palate,base of uvulanClass IV:Soft palate onlyRegional AnaesthesiaContraindications of Regional Anaesthesia SepsisBacteremiaSkin infection at injection siteHypovolemiaCoagulopathyTherapeutic anticoagulationDemyelinating central nerve system diseaseIncreased intracranial pressurePsychosis or dementiaLack of consent Questions*What is the physical classification of the ASA?*Describe some key features of the airway examination.Outline the Mallampati classification.36 Clinical Anaesthesiology (General Anaesthesia)内容（教学大纲）内容（教学大纲）n全身麻醉的方法全身麻醉的方法n常用吸入、静脉、肌松药常用吸入、静脉、肌松药n全身麻醉深度判断全身麻醉深度判断n气管插管的方法、临床应用、并发症气管插管的方法、临床应用、并发症n全身麻醉并发症的防治全身麻醉并发症的防治n麻醉监测和管理原则麻醉监测和管理原则ContentsnMethods of General AnaesthesianClinical PharmacologynGeneral AnaesthesianTracheal IntubationnComplications of General AnaesthesianMonitoring During Anaesthesia Methods of General AnaesthesianInhalation anaesthesianIntravenous anaesthesianIntramuscularlynRectallynOrallynBalanced anaesthesiaClinical PharmacologyInhalational Anaesthetic AgentsnAgent MAC%Vapor Pressure Blood/Gas PartitionnNitrous oxide 105 -0.47nHalothane 0.74 243 2.4nEnflurane 1.68 175 1.9nIsoflurane 1.15 240 1.4nDesflurane 6.0 681 0.42nSevoflurane 2.0 160 0.65Clinical PharmacologyIntravenous Anaesthetic AgentsnAgent Induction dose (mgkg-1)nThiopentone 3-5nEtomidate 0.3nPropofol 1.5-2.5nKetamine 2Clinical PharmacologyDrugs Used to Supplement AnaesthesiaAnalgesicsOpioid AgonistsnNatural opium alkaloids:Morphine,CodeinenSemisynthetic opium alkaloid:DiamorphinenSynthetic opioids:Pethidine,Fentanyl,Alfentanil,Sufentanil,RemifentanilPartial Opioid AgonistsnBuprenorphineClinical PharmacologyDrugs Used to Supplement AnaesthesiaOpioid Agonist/AntagonistsnPentazocineOpioid AntagonistsnNaloxoneClinical PharmacologyMuscle RelaxantsNeuromuscular Blocking Agents are divided into two classes:nDepolarizingnNondepolarizingClinical PharmacologyMuscle RelaxantsnDepolarizingn Short-acting Succinylcholine DecamethoniumnNondepolarizingnLong-acting Tubocurarine Metocurine doxacurium Pancuronium 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)nDobutamine(1)General AnaesthesianPreparation for anaesthesianEquipment for monitoringnThe anaesthetic machinenEquipment required for tracheal intubationPreparation for anaesthesianASA classificationnMallampati classification of the oropharynxAirway Management EquipmentnOral&Nasal airwaynMasknEndotracheal tubenlaryngeal mask airway(LMA)nSeeing optical stylet nLight wandsnRigid laryngoscopesnFlexible fiberoptic laryngoscopesInduction of AnaesthesianInhalational inductionnIntravenous induction Guedels 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 consciousness to beginning of regular respiration.nStage 3(Surgical anaesthesia):From the beginning of regular respiration to respiratory arrest.Guedels classic Signs of AnaesthesianThe stage 3 is divided into four planes.Plane 1:From the onset of regular breathing to the cessation of eyeball movements.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.Guedels classic Signs of Anaesthesia nStage 4:Stage of impending respiratory and circulatory failure(Medullary paralysis),from the onset of diaphragmatic paralysis to cardiac arrest.Maintenance of anaesthesianMinimum alveolar concentration(MAC):MAC is the minimum alveolar concentration(at one atmosphere)of an inhaled anaesthetic agent,which prevents reflex movement in response to surgical incision in 50%of subjects.Methods of Tracheal IntubationnOral-tracheal intubationnNaso-tracheal intubationnFlexible fiberoptic nasotracheal intubationnBlind intubation of the tracheal under light wandsnTracheal intubation under seeing optical styletIndications of Tracheal IntubationnProvision of a clear airwaynAn unusual positionnOperations on the head and necknProtection of the respiratory tractnDuring anaesthesia using IPPV and muscle relaxants nTo facilitate suction of the respiratory tractnDuring thoracic operationsComplications of Intubation While the Tube is in PlacenMalpositionnUnintentional extubationnEndobrochial intubationnLaryngeal cuff positionnAirway traumanMucosal inflammation and ulcerationnExcoriation of nosenTube malfunctionnIgnitionnObstructionComplications of Intubation Following ExtubationnAirway traumanEdema and stenosis(glottic,subglottic,tracheal)nHoarseness(vocal cord granuloma or paralysis)nLaryngeal malfunction and aspirationnPhysiologic reflexesnLaryngospasmnRegurgitationMonitoring During AnaesthesiaCardiac MonitorsnArterial blood pressure n Noninvasive arterial blood pressure nInvasive arterial blood pressure monitoringnElectrocardiographynCentral venous catheterizationnPulmonary artery catheterizationnCardiac outputMonitoring During AnaesthesiaRespiratory System MonitoringnPrecordial&easophageal stethoscopenBreathing circuit pressure&exhaled tidal volumenPulse oximetrynEnd-tidal carbon dioxide analysisnTranscutaneous oxygen&carbon dioxide monitorsnAnaesthetic gas analysisMonitoring During AnaesthesiaNeurologic System MonitorsnElectroencephalographynEvoked potentialnBISnNarcotrend Monitoring During AnaesthesianTemperaturenUrine outputnPeripheral nerve stimulationComplications During AnaesthesianArrhythmias nHypotentionnHypertensionnHypervolaemianMyocardial ischaemianCardiac arrestnEmbolismnHypoxaemia Complications During AnaesthesianHypercapnianHypocapnia nRespiratory obstructionnIntubation problems Aspiration of gastric contentsnHiccupsnAdverse drug effects Complications During AnaesthesianMalignant hyperthermia(MH)nHyperthermianHypothermianAcute intermittent porphyria(AIP)nAwarenessnInjury 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 intubation?nWhat are the complications during general anaesthesia?Clinical Anaesthesiology（Local Anaesthesia）内容内容(教学大纲教学大纲)n局麻的方法局麻的方法n局麻药的种类局麻药的种类n局麻药毒性反应的临床表现、预防和局麻药毒性反应的临床表现、预防和治疗治疗n椎管内麻醉阻滞的生理、实施方法、椎管内麻醉阻滞的生理、实施方法、临床应用和并发症的防治原则临床应用和并发症的防治原则ContentsnMethods of Local AnaesthesianLocal AnaestheticsnLocal Anaesthetic ToxicitynSpinal&Epidural AnaesthesiaLocal Anaesthetic Techniques Methods of Local AnaesthesianSurface anaesthesianLocal infiltration nField blocknRegional blocks(Spinal,epidural,&caudal blocks)nPeripheral nerve blocksLocal AnestheticsnEster-type（酯类）（酯类）local anesthetics:cause allergic reactions from the metabolite para-amino benzoic acid(PABA)procaine,chloroprocaine,tetraciane,cocainenAmide-type（酰铵类）（酰铵类）local anesthetics:rare lidocaine,bipivacaine,mepivacaine,etidocaineLocal Anaesthetic ToxicitynAllergic reactionsnLocal toxicitynSystemic toxicityLocal Anaesthetic ToxicitynAllergic reactionsEster-type local anesthetics:cause allergic reactions from the metabolite p-aminobenzoic acidAmide-type local anesthetics:rareLocal hypersensitivity reactions:local erythema,urticaria,edema,or dermatitisSystemic hypersensitivity reactions:generalized erythema,urticaria,edema,bronchoconstriction,hypotension,and cardiovascular collapseLocal Anaesthetic ToxicitynLocal toxicityTissue toxicity:rareTransient radicular irritation(TRI)or transient neurologic symptoms(TNS):S.A.Local Anaesthetic ToxicitynSystemic toxicityCentral nervous system(CNS)toxicity:metallic taste,light-headedness,tinnitus,visual disturbances,numbness of the tongue and lips,muscle twitching,loss of consciousness,andcomaCardiovascular toxicity:decreased ventricular contractility,refractory cardiac arrhythmias,loss of peripheral vasomotor toneRegional BlocknSubarachnoid block(SAB):Spinal anaesthesianExtradural nerve block:in the cervical,thoracic,lumbar,sacral(caudal block)regions nCombined spinal-epidural anesthesiaPhysiology of Regional BlocknSomatic BlackadenVisceral blackade Cardiovascular Pulmonary Gastrointestinal Liver Urinary tract Metabolic&EndocrinePhysiology Effects of SABDifferential Nerve Blockade nSympathetic fibers blocknSensory blocknMotor blockPhysiology Effects of SABRespiratory SystemnRoots of the phrenic nerves:apnoeanThoracic level:loss of intercostal muscle activity,decrease in vital capacity,reduction in cardiac output and pulmonary artery pressure,and increased ventilation/perfusion imbalance,resulting in a decrease in arterial oxygen tension(PaO2)Physiology Effects of SABCardiovascular SystemnDenervation of the sympathetic outflow tracts(T1-L2):dilatation of resistance and capacitance vessels and results in hypotensionnBradycardia:vasovagal syndrome;block of the cardiac sympathetic fibersPhysiology Effects of SABGastrointestinal SystemnSympathetic denervation nUnopposed parasympathetic action A constricted gut with increased peristaltic activity(nausea,retching,vomiting)Physiology Effects of Extradural BlockSimilar to those subarachnoid blockIndications of Spinal AnaesthesianLower extremitiesnHipnPerineumnLower abdomennLumber spineType of surgery:Urology,Gynaecology,Obstetrics and any surgical procedure on the lower limbs or perineum.Urologic endoscopic surgery,Rectal surgery,repair of hip fracture,obstetrics,orthopedic,Inguinal hernia repair,etc.Contraindications of Spinal AnaesthesiaAbsoluteSepsisBacteremiaSkin infection at injection siteHypovolemiaCoagulopathyTherapeutic anticoagulationDemyelinating central nerve system diseaseIncreased intracranial pressurePsychosis or dementiaLack of consentContraindications of Spinal AnaesthesiaRelativePeripheral neuropathyMini-dose heparinAspirin or other antiplatelet drugsPrior lumbar spine surgeryChronic back painCertain cardiac lesionsPsychologic or emotional instabilityUncooperative patients Prolonged surgerySurgery of uncertain durationSurgical team resistance to awake patientsFactors Influencing Spinal AnaesthesianAgents:Procaine,Tetracaine,Lidocaine,BupivacainenDosagenVasoconstrictorsnSpecific Gravity:Hyperbaric technique,Hypobaric technique,Isobaric techniquenPosturenIntra-abdominal PressurenSpinal CurvaturenPrior Surgery of SpinenAge nObesitynPregnancynSpread of the agent nRedistributionComplications of Spinal Anaesthesia nPain on injectionnBackachenHeadachenUrinary RetentionnMeningitis and meningismnVascular injurynNerve injury:Cranial nerve palsynHigh spinal anaesthesianTransverse myelitis and cauda equina syndromeIndications of Epidural Anaesthesia Specific IndicationsnHip and knee surgerynLow extremity RevascularizationnObstetric deliveriesnPostoperative managementComplications of Epidural Anaesthesia(Intraoperative)nDural tapnTotal spinal anaesthesia Profound hypotension ApnoeanMassive extradural block&subdural blocknIntravenous toxititynHypotensionnShiveringnNausea/vomitingComplications of Epidural Anaesthesia(Postoperative)nHeadachenInfectionnExtradural haematomanNeurological complicationsDifferences Between Subarachniod and Extradural BlocknDose of drug employednRate of onsetnIntensity of blocknPattern of blockSubarachniod Extradural blockSmall LargeFast SlowComplete anaesthesia Not complete anaesthesiaCord transection DermatomalQuestionsnWhat are the features of local anaesthetic toxicity?nWhat are the absolute contraindications of subarachnoid block?nWhat are the major differences between subarachnoid block and extradural block?