臨床麻醉學(xué)教研室理論教案
| 課程名稱 | 臨床麻醉學(xué) | 年級 | 專業(yè)、層次 | 麻醉本科 | |||||||
| 授課教師 |
| 職稱 | 課型（大、小) | 大 | 學(xué)時 | 2 | |||||
| 授課題目（章、節(jié)) | 第二十六章 內(nèi)分泌病人手術(shù)的麻醉 | ||||||||||
| 基本教材及主要參考書 （注明頁數(shù)) | 《臨床麻醉學(xué)》第二版，徐啟明主編，人衛(wèi)出版社293 《現(xiàn)代麻醉學(xué)》第三版，莊心良、曾因明、陳伯鑾主編，人衛(wèi)出版社。 Clinical Anesthesiology, the third edition Morgan, Mikhail, Murray P736 | ||||||||||
| 目的與要求： 1、了解常見的內(nèi)分泌疾病病人的病理生理改變和麻醉特點。 2、掌握甲狀腺功能亢進(jìn)病人的麻醉前估計、麻醉前用藥和麻醉選擇。 3、熟悉甲狀腺功能亢進(jìn)圍術(shù)期的手術(shù)麻醉的意外和并發(fā)癥的防治。 4、掌握嗜鉻細(xì)胞瘤摘除術(shù)的麻醉前準(zhǔn)備，了解麻醉藥物與麻醉方法的選擇，熟悉麻醉手術(shù)期間的監(jiān)測，掌握麻醉期間的管理。 5、熟悉糖尿病病人的麻醉前準(zhǔn)備、麻醉選擇和管理方法，了解胰島素的應(yīng)用和血糖監(jiān)測方法，以及糖尿病人急診手術(shù)的麻醉處理。 6、了解皮質(zhì)醇增多癥病人的麻醉前準(zhǔn)備及麻醉管理。 | |||||||||||
| 教學(xué)內(nèi)容與時間安排、教學(xué)方法： 1、概述 5分鐘 2、甲狀腺功能亢進(jìn)癥手術(shù)的麻醉處理 30分鐘 3、嗜鉻細(xì)胞瘤切除術(shù)的麻醉處理 60分鐘 4、糖尿病病人的麻醉處理 60分鐘 使用多媒體，結(jié)合臨床病例講解。 | |||||||||||
| 教學(xué)重點及如何突出重點、難點及如何突破難點： 本章重點甲亢病人麻醉的管理、嗜鉻細(xì)胞瘤手術(shù)的麻醉處理、糖尿病病人的麻醉處理。 本章難點為嗜鉻細(xì)胞瘤和糖尿病的基本病理生理改變。 突破難點的方法：講清楚嗜鉻細(xì)胞和胰島β細(xì)胞的生理功能。 | |||||||||||
| 教研室審閱意見： 教研室主任簽名： 年 月 日 | |||||||||||
| 基本內(nèi)容 | 教學(xué)手段 | 課堂設(shè)計和時間安排 | |||||||||
| 概述（Introduction: ) The underproduction or overproduction of hormones can have dramatic physiologic and pharmacologic consequences. Therefore, it is not surprising that endocrinopathies affect anesthetic management. Section I Anesthesia for patients with hyperthyroidism 一、 Etiology :primary and secondary Excess thyroid hormone levels can be caused by Graves’ disease, toxic multinodular goiter, thyroiditis, thyroid-stimulating-hormone-secreting, pituitary tumors, functioning thyroid adenomas, or overdosage of thyroid replacement hormone. 二、 Clinical manifestations and Treatment Clinical manifestations of excess thyroid hormones include weight loss, heat intolerance, muscle weakness, diarrhea, hyperactive reflexes, and nervousness. A fine tremor, exophthalmos, or goiter may be noted, particularly when the cause is Graves’ disease. Cardiac signs range from sinus tachycardia to atrial fibrillation and congestive heart failure. The diagnosis of hyperthyroidism is confirmed by abnomal thyroid function tests, which may include an elevation in total (bound and unbound) serum thyroxine, serum triiodothyronine, and free (unbound) thyroxine Medical treatment of hyperthyroidism relies on drugs that inhibit hormone synthesis(eg, propylthiouracil, methimazole), prevent hormone release (eg, potassium, sodium iodide), or mask the sings of adrenergic overactivity(eg, propranolol). While B-adrenergic antagonists do not affect thyroid gland function, they do decrease the peripheral conversion of T4 to T3. Radioactive iodine destroys thyroid cell function but is not recommended for pregnant patients and may result in hypothyroidism. Subtotal thyroidectomy is now less commonly used as an alternative to medical therapy. Typically, it is reserved for patients with large toxic multinodular ogiters or solitary toxic adenomas. Graves’s disease is currently usually treated with thyroid drugs or radioiodine. 3.Preoperative preparations (1)Inhibition of secretion of thyroid gland (2)Examination of the airway (3)Choice of surgery opportunity: BMR±20%,P<100bpm, stable emotion, increased BW,T3 T4 in normal range. (4)Premedication: Benzodiazpiines 4.Choice of anesthesia (1)Cervical plexus blockade (2)Epidural anesthesia (3)General anesthesia 5.Treatments of Complications (1)Obstruction of Airway Causes: Preventions: Treatments: (2)Crisis of hyperthyroidism Causes: Clinical manifestations Treatments: Section II Anesthesia for Patients with pheochromocytoma 1. Introduction: increased endogenous catecholamine 2. Clinical manifestations: Pheochromocytoma is catecholamine-secreting tumor that consists of cells originating from the embryonic neural crest (chromwww.med126.comaffin tissue) and accounts for 0.1% of all cases of hypertension. While the tumor is usually benign and localized in a single adrenal gland, 10~15% are malignant, and another 10~15% are bilateral or extra-adrenal. The cardinal manifestations of pheochromocytoma are paroxysmal headache, hypertension, sweating, and palpitations. Unexpected intraoperative hypertension and tachycardia are occasionally the first indications of an undiagnosed peochromocytoma. The pathophysiology, diagnosis , and treatment of these tumors require an understanding of catecholamine metabolism and of the pharmacology of adrenergic agonists and antagonists. The Case Discussion in Chapter 12 examines these aspects of pheochromocytoma management. 3. preoperative preparations: a) control of BP: utilization of α-and β-RBD b) correcting hypovolemia： c) supplement of adrenocorticoids d) choice of surgery opportunity: vital organs’ function are stable. e) Premedications: don’t increase the excitability of sympathetic nerve 4. Choice of Anesthesia (1) epidural anesthesia: indications (2) general anesthesia under endotracheal intubation: indications (3) epidural anesthesia combined with general anesthesia 5. Monitoring and transfusion during anesthesia (1)Monitoring: NIBP ,ECG, SPO2,MAP,CVP, UO and BS (2)Setup 2~3 intravenous accesses. 6．Anesthesia management (1)Treatment of hypertensive crisis: A. Pathophysiology: increased catecholamine in blood ,vasospasm and BP increase rapidly B. Caueses: C. Clinical manifestations: SBP>250mmHg /DBP>130mmHg lasting more than 1min D. Treatments: Control BP withα-RBD or induced hypotension with Nitroprusside. Treatment of ventricular arrhythmias, deepen the depth of anesthesia. (2) hypotension after excision of neoplasm A. Pathophysiology: decreased catecholamine in blood after excision of tumour. B. Clinical manifestations: serious hypotension or shock. C. Treatments: stop antihypertensives; lighten the depth of anesthesia; supplement of fluids exceed normal and use of noradrenaline.
(3). Others: cure of hypoglycemia; heart failure; supplement of adrenocorticoids. 7. post-anesthesia management: Transfer the patient to ICU. Section III Anesthesia for Patients with Diabetes Mellitus 1． Introduction: insulin and its functions Adults normally secrete approximately 50 units of insulin each day from the βcells of the islets of Langerhans in the pancreas. The rate of insulin secretion is primarily determined by the plasma glucose level. Insulin the most important anabolic hormone, has multiple metabolic effects, including increased glucose and potassium entry into adipose and muscle cells; increased glycogen, protein, and fatty acid synthesis; and decreased glycogenolysis, gluconeogenesis, ketogenesis, lipolysis, and protein catabolism. In general, insulin stimulates anabolism while its lack is associated with catabolism and a negative nitrogen balance. 2． Pathophysiology：absolute/relative deficiency of insulin or resistance to insulin 3． Classifications of DM 1．type I: Absolute insulin deficiency secondary to immune-mediated or idiopathic;(IDDM) 2．type II: adult onset secondary to resistance/relative deficiency(NIDDM) 3．type III: specific types of DM secondary to genetic defects; 4．type IV: gestational. 4． Clinical manifestations DM is characterized by impairment of carbohydrate metabolism caused by a deficiency of insulin activity ,which leads to hyperglycemia and glycosuria. 5、Diagnosis of DM(baesd on blood glucose bevel) Fasting >7.8mmol/L(140mg/dl) Glucose tolerance test: 11.1mmol/L(200mg/dl) 6、Treatments of DM Control of blood(Plasma)glucose 7、Preoperative anesthetic considerations The perioperative morbidity of diabetic patients is related to preoperative end-organ damage. In particular, the pulmonary, cardiovascular, and renal systems demand close examination. 1． chest radiograph; cardiac enlargement, pulmonary vascular congestion pleural effusion. 2．ECGs: increased incidence of ST-segment and T-wave-segment abnormalities 3．Diabetic autonomic neuropathy; 4．Renal dysfunction 5．High incidence of infections; 6．Limited-mobility joint syndrome 8、preoperative preparation （1)Decreasing blood glucose . (2) Correction of ketoacidosis: intravenous insulin and volume expansion (3) Control of infections 9、Premedications:
10、Choice of Anesthesia methods (1) Local anesthesia(MAC) (2) Epidural and spinal anesthesia (3)General anesthesia 11、anesthesia management （1)Monitoring (2) use of insulin 12、Prophylaxes and Treatments of Acute Complications of DM (1) hypoglycemia : [BS]<2.8mmol/L(50mg/dl) Causes: gydjdsj.org.cn/shiti/Clinical manifestations Treatments (2) Diabetic ketoacidosis,DKA Causes Pathophysiology: Treatments: (3) hyperosmolar- Non-ketotic Coma, HNKC Causes: Pathophysiology Treatments: 13、summary | 臨床病例 多媒體講解 多媒體講解 多媒體講解 多媒體講解 多媒體，圖片 多媒體講解 | （★－重點，☆－難點，) 2min 總時間40min 5min 10min 臨床表現(xiàn)： 體重減輕、怕熱、乏力、腹瀉、情緒激動、神經(jīng)過敏、高頻微顫、突眼、心動過速、房顫及充血性心衰 實驗室檢查：T3、T4 增加。 內(nèi)科治療 抑制甲狀腺激素的合成； B受體阻滯劑的應(yīng)用 外科治療：甲狀腺次全切除 5min 強(qiáng)調(diào)合理的手術(shù)時機(jī)是預(yù)防甲亢危象的主要措施 5min ★本章重點之一 10min 臨床病例 5min 強(qiáng)調(diào)充分術(shù)前準(zhǔn)備在預(yù)防中的重點性。 第一節(jié)課結(jié)束 總時間60min 10min 15min 重點介紹α和 β受體阻滯劑的應(yīng)用及注意事項 強(qiáng)調(diào)有效控制血壓是糾正低血容量的基礎(chǔ) 強(qiáng)調(diào)器官功能改善和病情穩(wěn)定是該病的手術(shù)時機(jī) 8min 結(jié)合臨床病例，讓學(xué)生了解臨床上選擇麻醉方法的原則，比較幾種方法的優(yōu)缺點 7min 強(qiáng)調(diào)靜脈通道中一條必須是中心靜脈的重要性
★☆本章重點和難點之一 10min 強(qiáng)調(diào)其基礎(chǔ)病理生理改變是發(fā)生高血壓危象的根本原因 介紹發(fā)生高血壓危象的幾個階段 重點介紹控制高血壓的方法和常用藥物 8min 強(qiáng)調(diào)內(nèi)源性兒茶酚胺分泌減少是發(fā)生低血壓的根本原因 強(qiáng)調(diào)升壓藥是提高血壓的臨時措施，補(bǔ)充血容量者是提高血壓的根本措施，補(bǔ)充去甲腎上腺素是治療該低血壓最為有效的方法。 2min 總時間60min 5min 一般介紹胰島素的生理作用 5min 胰島素絕對或相對缺乏及胰島素抵抗是發(fā)生DM的原因 2min 介紹NIDDM在臨床上最常見 5min 血糖升高及糖尿是其主要表現(xiàn) 3min 第三節(jié)課結(jié)束 5min 5min 胸部X線片 常規(guī)心電圖 糖尿病性自主神經(jīng)病變 腎功能不全 關(guān)節(jié)活動受限 5min 2min 5min 5min 強(qiáng)調(diào)血糖監(jiān)測與胰島素的使用 ★本章重點和難點之一 5min 8min 5min
第四次課結(jié)束 | |||||||||
| 小 結(jié) | 本章重點介紹甲狀腺功能亢進(jìn)癥、腎上腺嗜鉻細(xì)胞瘤、糖尿病病人的基本病理生理改變、麻醉前準(zhǔn)備、麻醉處理及常見并發(fā)癥的防治。 | ||||||||||
| 復(fù) 習(xí) 思 考 題 、 作 業(yè) 題 | 1. 甲亢病人麻醉前準(zhǔn)備應(yīng)注意哪些問題？ 2. 嗜鉻細(xì)胞瘤病人的基本病理生理改變是什么？如何進(jìn)行術(shù)前準(zhǔn)備？如何掌握其手術(shù)時機(jī)？ 3. 什么叫高血壓危象？麻醉手術(shù)中哪些環(huán)節(jié)可能發(fā)生？其病理生理機(jī)制是什么？如何處理？ 4. 糖尿病病人病理生理特點是什么？DM病人術(shù)前血糖控制的標(biāo)準(zhǔn)是什么？ 5. DM病人術(shù)中發(fā)生酮癥酸中毒的原因？病理生理改變？預(yù)防和治療措施？ | ||||||||||
| 下 次 課 預(yù) 習(xí) 要 點 | Chapter 27 Pediatric Anesthesia 1、Developmental physiology of the Children 2、Pharmacology of the Children 3、Preoperative Preparation 4、Anesthesia for Pediatric and Neonatal Surgery 5、Postanesthesia Management | ||||||||||
| 實 施 情 況 及 分 析 | |||||||||||
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第二節(jié)課結(jié)束