麻醉与复苏 教案.docx
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麻醉与复苏教案
上海第二医科大学
教案
课程名称全麻、复苏第2次课2006年2月20日
教师姓名
范秋维
职称
副主任
医师、
副教授
教研室
外科教研室
教学时数
3
授课题目
全身麻醉、心肺脑复苏
教学对象
临床医学专业
03级英文班
授课地点
瑞金科技楼309教室
教学方式
交互式、双向交流
本课的重点、难点:
I.GeneralAnaesthesia
1Anaestheticapparatus
2Thepracticalconductofanaesthesia
3Complicationsduringanaesthesia
II.Cardiopulmonaryresuscitation
1.Considermostfrequentcauses
2.Signsofcardiacarrest
3.Managementofcardiacarrest
4.Managementofbraindamage
本次课应用的教具:
CAI课件
主要教学内容:
(时间安排)
GeneralAnaesthesia(2学时)
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)Toothdamage
b)Lip,tongueormucosallaceration
c)Sorethroat
d)Dislocatedmandible
e)Retropharyngealdissection
C)Physiologicreflexes
a)Hypertension,tachycardia
b)Intracranialhypertention
c)Intraocularhypertension
d)Laryngospasm
e)Tubemalfunction
f)Cuffperforation
Whilethetubeisinplace
A)Malposition
a)Unintentionalextubation
b)Endobrochialintubation
c)Laryngealcuffposition
B)Airwaytrauma
a)Mucosalinflammationandulceration
b)Excoriationofnose
C)Tubemalfunction
a)Ignition
b)Obstruction
Followingextubation
A)Airwaytrauma
a)Edemaandstenosis(glottic,subglottic,ortracheal)
b)Hoarseness(vocalcordgranulomaorparalysis)
c)Laryngealmalfunctionandaspiration
B)Physiologicreflexes
Laryngospasm
Relaxantanaesthesia
Indicationsforrelaxantanaesthesia
(1)Majorabdominal,intraperitoneal,thoracic,intracranialoperations
(2)Prolongedoperationsinwhichspontaneousventilationwouldleadtorespiratorydepression
(3)Operationsinapositioninwhichventilationisimpairedmechanically
Reversalofrelaxation
Residualneuromuscularblockisantagonizedwithneostigmine2.5-5mg(0.05-0.08mg·kg-1inchildren).Atropine1.2mgorglycopyrronium0.5mgcounteractsthemuscarinicsideeffectsoftheanticholinesteraseandmaybegivenbefore,orwith,neostigmine.
Conductofextubation
Emergenceandrecovery
3Complicationsduringanaesthesia
1.Arrhythmias
2.Hypotention
3.Hypertension
4.Hypervolaemia
5.Myocardialischaemia
6.Cardiacarrest
7.Embolism
8.Hypoxaemia
9.Hypercapnia
10.Hypocapnia
11.Respiratoryobstruction
12.Intubationproblems
13.Aspirationofgastriccontents
14.Hiccups
15.Adversedrugeffects
16.Malignanthyperthermia(MH)
17.Hyperthermia
18.Hypothermia
19.Acuteintermittentporphyria(AIP)
20.Awareness
21.Injury
Cardiopulmonaryresuscitation(1学时)
Considermostfrequentcauses
1)Hypovolemia
2)Hypoxia
3)Hydrogenion-acidosis
4)Hyper-/Hypokalemia,othermetabolic
5)Hypothemia
6)‘Tables’(DrugOD,accidents)
7)Tamponnade,cardiac
8)Tensionpneumothorax
9)Thrombosis,coronary(ACS)
10)Thrombosis,pulmonary(embolism)
Signsofcardiacarrest
*Suddendeepunconsciousness
*Absentcarotidandfemoralpulse
*Dilatedpupils
*Ashencyanosis
*Apnoeaorgasping
Managementofcardiacarrest
BasicLifeSupport,BLS
AdvancedLifeSupport,ALS
CardiopulmonaryResuscitation
TheABCsofcardiopulmonaryresuscitationAirway,Breathing,andCirculation
本
次
课
小
结
要
点
GeneralAnaesthesia
AnaestheticapparatusTheanaesthesiamachineAirwaymanagementequipment
Thepracticalconductofanaesthesia
Preparationforanaesthesia
InductionofanaesthesiaIntravenousinductionMaintenanceofanaesthesiaInhalationanaesthesiawithspontaneousventilationDeliveryofinhalationalagents-airwaymaintenance
1.Useofthefacemask
2.Useofthelaryngealmaskairway(LMA)
3.Trachealintubation
Anaesthesiafortrachealintubation
Complicationsofintubation
Reversalofrelaxation
Conductofextubation
Emergenceandrecovery
mplicationsduringanaesthesia
Cardiopulmonaryresuscitation
Considermostfrequentcauses
Signsofcardiacarrest
Maagementofcardiacarrest
本
次
课
复
习
思
考
题
Question
1.WhatisthemeaningofMAC?
2.WhataretheGuedel’sclassicsignsofanaeathesia?
3.Howmanymethodsfortheanaesthetistusetomaintaintheairway?
4.Whataretheindicationsfortrachealintubation?
5.Whatarethecomplicationsduringanaesthesia?
6.Whatarethemostfrequentcausesofcardiacarrest?
7.Whatarethesignsofcardiacarresttojustifydiagnosis?
8.Howtomanagecardiacarrest?
下
次
课
预
习
要
点
1.Thecomplicationoflocalanaesthesia
2.Thefeaturesoflocalanaesthetictoxicity
3.Theabsolutecontraindicationsofsubarachnoidblockandextraduralblock
4.Themajordifferencesbetweensubarachnoidblockandextraduralblock
5.Themethodsforidentifyingtheepiduralspace
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