Transcript iscaic - 上海交通大学医学院精品课程

Clinical Anaesthesiology
Qiu Wei Fan
Associate Professor
Department of Anaesthesiology
Rui Jin Hospital
Shanghai Second Medical University
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Contents
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The history of Anaesthesia
The scope of anaesthesia
Classification of Anaesthesia Methods
Definition of the practice of anaesthesiology
Preoperative assessment and premedication
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The History of Anaesthesia
British Origins
John Snow was the first to
scientifically investigate ether and the
physiology of general anaesthesia. Snow
was also a pioneer in epidemiology who
helped stop a cholera epidemic in
London by proving that the causative
agent was transmitted by ingestion
rather than inhalation.
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The History of Anaesthesia
British Origins
In 1847, Snow published the first book
on general anaesthesia, On the Inhalation
of Ether. When the anaesthetic properties of
chloroform were made known, he also
quickly investigated and developed an
inhaler for that agent as well. He felt that
an inhaler should be used in administering
these agents in order to control the dose of
the anaesthetic.
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The History of Anaesthesia
British Origins
In 1893, then first organization of
physician specialists in anaesthesia , the
Society of Anaesthetists, was formed by J.
F. Silk in England.
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The History of Anaesthesia
American Origins
Three physicians stand out in the early
development of anaesthesia in the United States
after the turn of the century: Arthur E. Guedue,
Ralph M. Waters, and John S. Lundy. Guedue was
the first to elaborate on the signs of general
amaesthesia after Snow’s original description. He
advocated cuffed endotracheal tubes and
introduced artificial ventilation during ether
anaesthesia (later called “controlled respiration”
by Waters).
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The History of Anaesthesia
American Origins
The first organization of physician
anaesthetists in the United States was the Long
Island Society of Anaesthetists in 1911. That
society was eventually renamed the New York
Society of Anaesthetists and become national in
1936. It was subsequently renamed the
American Society of Anaesthetists and later, in
1945, the American Society of
Anaesthesiologists ( ASA ).
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The History of Anaesthesia
Chinese Origins
More than 1500 years ago, Chinese
physician of traditional medicine already used
some herb and alcohol to make patients
unconscious and did some minor operations.
In our country, the first department of
Anaesthesiology was established in 1950 as
soon as Professor Jue Wu returned to Shanghai,
the People’s Republic of China from abroad.
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The Scope of Anaesthesia
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Providing general or regional anaesthesia
inside and outside the operating room
Intensive care units
Respiratory therapy departments
Recovery room
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The Scope of Anaesthesia
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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.
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Classification of Anaesthesia
Methods General anaesthesia
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Inhalation anaesthesia
Intravenous anaesthesia\
Intramuscularly
Rectally
Orally
Balanced anaesthesia
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Classification of Anaesthesia
Methods Regional Anaesthesia
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Intrathecal anaesthesia
Subarachnoid block
Epidural anaesthesia
Caudal block
Nerve plexus block
Ganglion block
Nerve block
Field block
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Definition of the practice of
anaesthesiology
1)Assessing,consulting, and preparing patients for
anaesthesia
2)Rendering patients insensible to pain during
surgical obstetric, therapeutic, and diagnostic
procedures
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Definition of the practice of
anaesthesiology
3)Monitoring and restoring homeostasis in
perioperative and critically patients
4)Diagnosing and treating painful syndromes
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Definition of the practice of
anaesthesiology
5)Managing and teaching of cardiac and pulmonary
resuscitation
6)Evaluating respiratiry function and applying
respiratory therapy
7)Teaching, supervising, and evaluating the
performance of medical and paramedical
personnel involved in anaesthesia,respiratory care,
and critical care
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Definition of the practice of
anaesthesiology
8)Conducting research at the basic and clinical
science levels to explain and improve the care of
patients in terms of physiologic function and drug
response
9)Involvement in the administration of hospitals,
medical schools, and outpatient facilities as
necessary to implement these responsibilities
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Preoperative assessment
Planning the conduct of ansesthesia
starts normally after details concerning the
surgical procedure and the medical condition of
the patient have been ascertained at the
preoperative visit.
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Preoperative assessment
Several
of
the
large-scale
epidemiological studies have indicated that
inadequate preoperative preparation of the
patient may be a major contributory factor to
the primary anaesthetic causes of
perioperative mortality.
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Preoperative assessment
It is therefore essential that
anaesthetist visit every patient in the word
before surgery to assess “fitness for
anaesthesia”, as this function cannot be
undertaken by surgical staff.
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Purposes of the preoperative visit
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Estabilish rapport with the patient
Obtain a history and perform a physical
examinations
Order a special investigations
Assess the risks of anaesthesia and surgery and if
necessary postpone or cancel the date of surgery
Institute preoperative management
Prescribe premedication and the anaesthetic
management
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Preoperative assessment
Routine preoperative anaesthetic
evaluation
* History
- Current problem
- Other known problems
- Medication history
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Preoperative assessment (Medication history)
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Allergies
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Drug intolerances
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Present therapy: Prescription,
Nonprescription
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Nontherapeutic: Alcohol, Tobacco
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Illicit
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Preoperative assessment
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Previous anaesthetics, surgery, and
obstetric deliverries
Family history
Review of organ systems
Last oral intake
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Preoperative assessment
(Review of organ systems)
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General
Respiratory
Cardiovascular
Renal
Gastrointestinal
Hematologic
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Preoperative assessment
(Review of organ systems)
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Neurologic
Endocrine
Psychiatric
Orthopedic
Dermatologic
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Preoperative assessment
( Physical examination)
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Vital signs
Airway
Heart
Lungs
Extremities
Neurologic examination
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Preoperative assessment
( Laboratory evaluation)
Hematocrit or hemoglobin concentration
All menstruating women
All patients over 60 years of age
All patients who are likely to experience significant blood loss and
may require transfusion
Serum glucose and creatinine (or blood urea
nitrogen) concentration: all patients over 60 years of age
Electrocardiogram: all patients over 40 years of age
Chest radiogram: all patients over 60 years of age
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ASA classification
I A normal healthy patient other than
surgical pathology- without systemic
disease.
IIA patient with mild systemic disease –
no functional limitations.
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ASA classification
III 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.
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ASA classification
V 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”.
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American Society of Anaesthesiologists classification
and perioperative mortality rates
Class
I
II
III
IV
V
Mortality Rate
0.06-0.08%
0.27-0.4%
1.8-4.3%
7.8-23%
9.4-51%
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Documentation
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Informed Consent
The preoperative note
The intraoperative anaesthesia
record
The postoperative notes
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The preoperative Note
(The preoperative assessment)
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Medical history
Anaesthesia history
Medication history
Physical history
Physical examination
Laboratory results
ASA classification
Recommendations of any consultants
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The preoperative Note
Anaesthetic plan: Use of specific
procedures
Informed consent: Plan, alternative plans,
their advantage and disadvantages
( risk of complications)
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The Intraoperative Anaesthesia Record
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A preoperative check of the anaesthesia machine
and other equipment
A review or reevaluation of the patient immediately
prior to induction of anaesthesia
A review of the chart for new laboratory results or
consultations
A review of the anaesthesia and surgical consents
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The Intraoperative Anaesthesia Record
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The time of administration, dosage, and route of
intraoperative drugs
All intraoperative monitoring( laboratory
measurements, blood loss, and urinary output)
Intravenous fluid administration and transfusion
All procedures(intubation, placement of a
nasogastric tube or placement of invasive monitors)
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The Intraoperative Anaesthesia Record
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Routine and special techniques such as
mechanical ventilation, hypotensive anaesthesia,
one-lung ventilation, high-frequency jet ventilation,
or cardiopulmonary bypass
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The Intraoperative Anaesthesia Record
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The timing and course of important events such as
induction, positioning, surgical incision, and
extubation
Unusual events or complications
The condition of the patient at the end of the
procedure
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The postoperative notes
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The patient’s condition
The patient’s recovery from anaesthesia
Any apparent anaesthesia-related complications
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Questions
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How do you take the history from a
patient?
What is the meaning of the ASA
classification?
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Any Questions?
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Thank You!
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