脑死亡 米勒麻醉学第七版
脑死亡米勒麻醉学第七版课件
麻醉药代谢：麻醉药代谢是研 究麻醉药在体内代谢过程的学
科。
麻醉药相互作用：麻醉药相互 作用是研究麻醉药与其他药物 或生理因素相互作用的学科。
麻醉操作技术
麻醉前准备：包 括麻醉设备、药 物、患者情况等
麻醉方法：包括 局部麻醉、全身 麻醉、神经阻滞 等
麻醉过程：包括 麻醉诱导、维持、 苏醒等
麻醉并发症：包 括呼吸抑制、循 环抑制、过敏反 应等
修复
04
麻醉药物可以影响 脑死亡后脑组织的 病理变化，影响脑 死亡诊断的准确性
脑死亡患者的麻醉管理
麻醉剂量：根据患 者体重、年龄等因
素确定麻醉剂量
01
02
03
麻醉风险：注意麻 醉风险，采取相应
措施预防和处理
04
麻醉方法：根据患 者病情选择合适的
麻醉方法
麻醉效果：监测患 者麻醉效果，确保
麻醉效果良好
谢谢
03 脑死亡不同于植物人状态，植物人状态仍 有部分脑功能存在
04 脑死亡是判断死亡的重要标准，也是器官 捐献的前提条件
脑死亡的诊断标准
01
脑电图（EEG）：无自发性脑电活 02
脑血流图（CBF）：无自发性脑血
动，持续24小时以上
流，持续24小时以上
03
脑干反射：无自发性脑干反射，持 04
脑代谢：无自发性脑代谢，持续24
脑死亡与麻醉学的关 系
脑死亡与麻醉操作的关系
脑死亡是麻醉操 作的重要依据
脑死亡对麻醉操 作的影响
麻醉操作对脑死 亡的影响
脑死亡与麻醉操 作的相互作用
麻醉药物对脑死亡的影响
01
麻醉药物可以降低 脑血流量，从而影
响脑死亡过程
02
脑死亡
[编辑本段]中国脑死亡的诊断标准：
脑死亡是包括脑干在内的全脑技能丧失的不可逆转的状态。
先决条件包括：昏迷原因明确，排除各种原因的可逆性昏迷。
据了解，卫生部脑死亡法起草小组的最新标准是：深昏迷，脑干反射全部消失，无自主呼吸（靠呼吸机维持，呼吸暂停试验阳性）。在首次确诊后，观察12个小时无变化，方可确认脑死亡。
脑死亡
由于人工呼吸器能在病人全身其他器官都已衰竭的情况下,继续长时期地维持心肺功能,致使法学界和社会各界广泛接受这样的观点,即病人死亡的标志是起整合作用的脑功能,特别是脑干功能的全部停止.医生若要宣布病人脑死亡,必须要有引起大脑损伤的结构性或代谢性病因的证据,而且要排除可能起麻醉作用或肌肉松弛性瘫痪作用的药物的影响,特别是自行服毒的可能.如有体温降低至30℃以下的情况,必须予以纠正.脑死亡的全套诊断标准见表170-3.
更可怕的是，在长达17个小时内，威尔玛就连脑部活动也几乎完全停止，没有任何可检测到的脑电波产生！尽管医生们尝试了一切办法试图挽救威尔玛的生命，甚至对她采取“冷冻疗法”——用冰块降低她的体温，从而刺激她大脑复苏，然而威尔玛却毫无生还征兆。负责抢救她的内科医生凯文·艾格莱斯顿说：“当时，已没有丝毫征兆表明威尔玛仍具备神经功能。”
[编辑本段]分类
脑死亡分为原发性脑死亡和继发性脑死亡，原发性脑死亡是由原发性脑疾病或损伤引起；继发性脑死亡是由心、肺等脑外器官的原发性疾病或损伤致脑缺氧或代谢障碍所致。脑死亡的基本原因是：脑组织的严重损伤、出血、炎症、肿瘤、脑水肿、脑压迫、脑疝或继发于心肺功能障碍
[编辑本段]发展史
脑死亡讲课ppt课件
瞳孔缩小
11
脑干反射（2）
5．角膜反射：刺激双侧角膜，脑死亡时无瞬 目反射 6．嚼肌反射：脑死亡时叩击颏部无嚼肌收缩 7．水平性眼前庭反射或水平性眼头运动反射： 用4℃冰水快速注入一侧外耳道，正常人可立 即出现眼球震颤，快相向冰水注射对侧。脑死 亡时，在注冰水后病人眼球固定无反应 8．眼心反射：用手指压迫眼球，正常时心率 减慢，脑死亡时无反应
脑死亡讲课
39
4.发病基础: 大脑皮层功能或皮质下某些 功能丧失,而皮质下的大多数功能和延髓 的自主神经功能保存或业已恢复.中脑及 脑桥上行网状激活系统未受损,可有无意 识吞咽动作,存在觉醒-睡眠周期等.
脑死亡讲课
40
5常见表现: 能无意识的睁眼闭眼,眼球能 活动.瞳孔对光反射及角膜反射存在.四肢 肌张力增高,病理反射阳性.吸吮反射及强 握反射,紧张性颈反射可出现.喂食可出现 无意识吞咽,但无自发动作.对外界刺激不 能产生有意识的反应.大小便失禁.存在觉 醒-睡眠周期等.
作等 –这种脊髓反射性活动应与自主性肌肉活动区
别开，以免误诊 脑死亡讲课
9
二、临床表现（二）
脑干反射消失 脑干支配的运动消失，包括瞬目、咀嚼、 磨牙、哈欠等动作消失 脑干反射的中枢在脑干，如果脑干反射 全部消失，说明作为中枢的脑干功能已 经丧失，也就是说脑干已经死亡 脑干反射消失是临床判断脑死亡的关键
14
二、临床表现（三）
自主呼吸停止，需要持续的人工辅助呼吸
临床上可采用呼吸停止试验进行判断：
–用人工呼吸机给病人纯氧10分钟 –然后停用人工呼吸机观察3～5分钟 –如PaC02达到8kPa(60mmHg)以上仍无自主呼吸，说明呼
吸中枢已经衰竭，应接上人工呼吸机
脑死亡米勒麻醉学第七版 ppt课件
脑死亡的概念
脑死亡代表着生物的死亡，而不仅仅是脑的死亡或 坏死。生物是活细胞的集合体，而活细胞的几乎题 不一定能构成生物体。只有当细胞集合体在调节系 统的控制之下时，才能真正算是生物体。
c.向气管内输送6L/min的纯氧或放一细管隆嵴水平 供氧
d.密切观察呼吸运动 e.断开呼吸机8min后査动脉血PaO2、PaCO2和pH f.如无呼吸，并且PaCO2≥60mmHg，呼吸暂停实
验结果为阳性，支持脑死亡的诊断
g.如果观察到呼吸运动，呼吸暂停实验阴性
h.如实验过程中收缩压降至90mmHg以下或脉氧
体温调节
脑死亡是，体温调节中枢与周围组织之间失去联系， 患者体温随环境温度而变化。由于体温调节中枢已 经丧失了功能，即使脑死亡患者合并有感染，其体 温也不会升高。脑死亡后尽管积极采取外部保温措 施，患者仍趋于低温状态。
脑干反射
多种脑干反射均被用于诊断脑死亡，如瞳孔反射、 眼脑反射、眼前庭反射和咳嗽反射。咳嗽反射的存 在代表脑干呼吸中枢还有功能。活生物体并不一定 要所有的脑干反射存在，但脑干反射可以验证脑干 功能残存。
器质性脑损伤是诊断脑死亡的必要条件。药物中毒、 严重的电解质。酸碱平衡紊乱或内分泌紊乱，低体 温以及其他可以治愈的疾病应予排除。
枢神经系统是活生物体的控制中心；中枢神经系统 功能的消失代表着和谐生命的终结；若无中枢神经 系统的控制，生物体只不过是一堆活细胞。
脑死亡的机制
多种原因可以引起脑损伤，如脑创伤性损伤、脑血 管损伤以及全身缺氧等，这些损伤均能引起脑水肿。
脑水肿在开始时是局限性的，随后逐渐波及全脑。 由于大脑被颅骨所包裹，脑水肿使脑实质体积增大 必然导致颅内压增高，甚至超过动脉血压。当脑循 环停止，随之脑实质发生无菌性坏死。在3~5天之 内，脑实质液化，被称为“呼吸机脑”。颅内压增 高会压迫整个大脑，导致全脑梗死。
米勒麻醉学第七版序列2
2 – Scope of Modern Anesthetic PracticeWilliam L. Young,Jeanine P. Wiener-Kronish,Lee A. FleisherKey Points1.With the increase in the elderly population, more of the surgeries performed will be proceduresrequired by elderly patients.2.Minimally invasive procedures are increasing; anesthesiologists will be performing more anestheticprocedures outside operating rooms. Anesthesia may be the major risk to patients as the surgicalprocedures become more minimal.3.The mandates for quality, competency, and uniform process will change the way anesthesia isdelivered. More standardization and protocols will be used; this will allow more evaluation andresearch as to what optimal anesthesia is and what competent anesthesiologists are required todo.4.The increase in nurses with degrees will change the number of anesthetics delivered byphysicians. Team management and relationships between physicians and nurses will becomemore crucial, and the demand for skills in personnel management will increase.5.Not enough research is being done by anesthesiologists. Anesthesiologists will need to engage inresearch to maintain an academic foothold. Opportunities for multidisciplinary research areincreasing, and they need to be embraced to increase the number of research-trainedanesthesiologists.Forces That Will Change Anesthetic PracticeMultiple changes are occurring that will affect the role of the anesthesiologist in the United States and perhaps globally. The population of industrialized nations is aging so that many more operations are performed on elderly patients; this dictates which operations are being performed. The cost of medical care is increasing globally, and perhaps most rapidly in the United States. The increased cost will lead to more scrutiny regarding the need for operations, increased focus on quality and use of care that has documentation by research, changes in Medicare reimbursement, changes in the ability of patients to pay, and a demand for the use of less costly health care providers whenever possible. Technologic advances are leading to less invasive procedures that can be done on patients who heretofore would be denied routine surgical procedures. The mandates for quality metrics and evaluation of processes will change the way we practice medicine. Changes in personnel also will affect the workforce in practices. We can only speculate as to what the practice of anesthesia will be like in the next 10 years, but these forces will likely have a major effect ( Fig. 2-1 ).Figure 2-1 Changing scope and settings of anesthesia and perioperative medicine. A,The Cure of Folly, by Hieronymus Bosch (c. 1450-1516), depicting the removal of stones in the head, thought to be a cure for madness. B, Friedrich Esmarch amputating with the use of anesthesia and with antisepsis. Woodcut from Esmarch's Handbuch der KriegschirurgischenTechnik (1877). C, Harvey Cushing performing an operation, with the Harvey Cushing Society observing, 1932. D and E, Placement of deep brain stimulator for the treatment of Parkinson's disease using a real-time magnetic resonance imaging technology (MR fluoroscopy). The procedure takes place in the MR suite of the radiology department. The patient isanesthetized (D) and moved into the bore of the magnet (E). F and G, A sterile field is created for intracranial instrumentation(F), and placement of electrodes is done using real-time guidance (G). (A, Courtesy of Museo del Prado, Madrid; B, courtesyof Jeremy Norman & Co, Inc; C, photograph by Richard Upjohn Light [Boston Medical Library]; D-G, courtesy of Paul Larson, MD, UCSF/SF Veterans Administration Medical Center.)Aging of SocietyWith the aging of the population and improvements in anesthetic and surgical methods, the fraction of the elderly population undergoing surgical procedures is increasing in the United States (see Chapter 71 ). Use of surgical services in older patients is not unexpectedly higher than in younger patients. In the Centers for Disease Control and Prevention report of inpatient hospitalizations for 2005, there were 45 million procedures performed on inpatients with a similar number of outpatient procedures. From 1995 through 2004, the rate of hip replacements for patients 65 years old and older increased 38%, and the rate of knee replacements increased 70%. There seems to be a direct correlation between age and use of surgical services.[1]Changes in Location of Care DeliveryBecause of the high costs to the insurance industry, the pressure to move less invasive surgical procedures to locations remote from the hospital setting will continue, frequently motivated by changes in reimbursement.[2] Providing anesthesia in ambulatory surgical settings and offices has increased dramatically over the last several decades (see Chapter 78 ). As procedures become less invasive than those currently performed in the operating room, they will be performed in procedure units. It will be important to determine the need for anesthesiologists to provide traditional anesthesia and moderate to deep levels of conscious sedation in these settings. Postoperative care has been shifted from the medical setting to the families, which may present difficulties in elderly patients. Anesthesiologists must be involved in determining which patients are appropriate candidates to have different procedures in these different locations of care, and the level of monitoring needed to perform these procedures safely.[3]Cost of Medical CareAs the cost of health care in the United States approaches 15% of the gross national product, there hasbeen increased interest in determining the factors that are increasing the costs, attempting to find methods to decrease the cost, and obtaining more valuable health care for the money spent. The primary driver of cost in the United States apparently is technical progress, as health care costs are increasing throughout the world, regardless of the insurance system. [4] [5] [6] The increase in elderly patients and patients with chronic disease in the population also is increasing health care costs.[7]The increase in cost has led to a movement to get more value for the money spent. Pay-for-performance programs have been created (i.e., rewarding medical care that is consistent with published evidence and not paying for care that is inconsistent with evidence). [8] [9] [10] The concept and reality of pay-for-performance programs has now moved to other countries, including the United Kingdom.[11]In the nonsurgical arena, the concept of pay-for-performance has been studied for several years. [12] [13] In addition to paying for performance, in the United States, there is increasing emphasis on not paying for “never” events, such as decubitus ulcers or urinary tract infections, unless they are present on admission to the hospital. Because of the role of anesthesiologists in the entire continuum of perioperative care, including postoperative intensive care and pain management, we have an opportunity to influence many of the practices that can be associated with poor outcomes and increased cost, but that traditionally have not been considered under our domain of care.Appropriate and timely administration of antibiotics has a significant impact on surgical site infection, but before the initiation of the Surgical Care Improvement Project, many anesthesiologists were arguing that control of antibiotics was not within their domain (see Chapter 5 ).[14] Anesthesiologists tend to focus on intraoperative cardiac arrests and other short-term outcomes, such as postoperative nausea and vomiting (see Chapters 33 and 86 [Chapter 33] [Chapter 86] ). Anesthesiologists will need to rethink this approach for other “never” conditions, such as urinary tract infections because they help determine the need for Foley catheters. Anesthesiologists and intensivists also can have a significant impact on the rate of ventilator-associated pneumonia. Some of these proposed measures, particularly the use of ventilator-associated pneumonia as a quality measure, have become quite controversial, however.[15] Pain is considered the fifth vital sign, and the management of postoperative pain is another area in which anesthesiologists can have a significant impact with respect to cost and potential interaction with other members of the hospital team. Process Assessment and Quality MetricsAnesthesiology was among the first professions to focus on reducing the risk of complications, and anesthesiologists were among the first groups to develop evidence-based guidelines and standards, as shown by the American Society of Anesthesiologists standards and practice parameters (see Chapter 5 ).[16] It will be important to continue to be involved in multidisciplinary approaches to surgical care. Examples where anesthesiologists were initially less involved include the Society of Thoracic Surgeons database and the National Surgical Quality Improvement Project. [17] [18] More recently, anesthesiologists have become involved in both groups, and the Society of Cardiovascular Anesthesiologists have begun discussions with the Society of Thoracic Surgeons. Anesthesiologists have been involved from an early stage in quality initiatives with the Institute of Healthcare Improvement and the Surgical Care Improvement Project.[19] Other quality measures that will have an impact on anesthesiologists include the new demand for metrics of competency, to be measured on a focused and an ongoing basis. Defining competency will demand that anesthesiologists adhere to more protocols, and that the concept of safe anesthesia be standardized. Rather than stifling medical innovation, standardization should be viewed as a mechanism for evaluating process and outcomes because comparisons cannot be made without standardization. Anesthesiologists will need to engage in creating quality and competency metrics, or these instruments will be created by others. This is an opportunity to formulate meaningful metrics that can be used in training physicians. Metrics also will be sought for nurse anesthetists and other health care professionals.Changing processes has become a cottage industry in medical care, with courses being offered on how to change behaviors and processes in medical care. These mandates offer the opportunity for more research as to whether changing processes leads to improved patient outcomes. These mandates also allow anesthesiologists to assume a leadership role in team management. For anesthesiologists to accomplish this role, new skills need to be taught, including leadership training, improved communication skills, and improved relationship training.One advantage that anesthesiologists have is a long tradition and training in system approaches to care. These date back to the original checklists for the anesthesia machine. It is crucial that this skill set be disseminated beyond the intraoperative setting. Many ambulatory surgery centers are directed by anesthesiologists.Changes in PersonnelThere are approximately 250,000 active physicians, one third of whom are older than 55 years old and likely to retire by 2020.[20] Although in the 1960s enrollment in U.S. medical schools doubled, during the years 1980 through 2005, the enrollment has been flat. There has been zero growth in U.S. medical school graduates. In this same interval, the U.S. population grew by more than 70 million, creating a discrepancy between the supply of medical school graduates and the demand for physician-associated care.There also has been a significant increase in the number of women in medical schools, so that about 50% of medical students are now women.[21] Women tend not to work as many hours as their male counterparts, even when part-time status is taken into consideration.[22] Also, today's younger physicians choose to work fewer hours than their older counterparts, regardless of gender. [20] [23]There has been a steady use of international medical graduates; 60,000 international medical graduates are used as residents and constitute 25% of all residents in training.[24] There also has been an increase in the number of osteopath schools and schools offering advanced degrees in nursing, including training of nurses to become nurse anesthetists.[20] Given the increase in demand for medical care resulting from the increase in the geriatric population, this need will most likely be met by a combination of physicians and nonphysician personnel.ResearchIn terms of creative new investigations, most benchmarks suggest that the specialty of anesthesiology fares poorly compared with other disciplines, especially clinical disciplines. Using data gleaned from publicly available National Institutes of Health (NIH) sources, Reves[25] produced a troubling figure showing that anesthesiology ranked second to the last for many medical disciplines. The exact position on any such figure would undoubtedly change from year to year. The fact that U.S. anesthesiology inhabits the lowest quartile is of concern, however, because the external forces on the practice components are generally applicable to all specialties.NIH is not the only source of funding that may influence the specialty of anesthesiology; it is not even the largest portion of total research funding in the United States ( Fig. 2-2 ).[26] For all sources, there has been a doubling over the last decade in research expenditures for health and biomedical science research, although compared with biologically based disciplines, health services research is considerably less well funded. In anesthesiology journals, the fraction of non-U.S., original peer-reviewed articles has increased dramatically. This increase does not seem to be attributable directly to research support. Adjusted per capita, research support in Europe is only 10% of that in the United States, even though the proportion of scientists in the population is similar.[27]Figure 2-2 Research expenditures in the United States, 1994 to 2003, by funding source (see text).There is no a priori reason why anesthesiology should differ from any other medical specialty in terms of research output. In our opinion, it should excel. One might argue that practitioners at academic institutions might be better compared in terms of surgical versus medical specialties, but even in that comparison we fare poorly. One line of remedy is to develop clinician-scientist training programs further, such as the NIH T-32 model. This approach is limited, however, by the fact that selection of individuals entering the specialty has already occurred.One of the most exciting and promising developments in this regard has been the initiative by several programs in the United States to construct a special residency track that allows training for scientific independence to occur roughly in parallel with clinical residency training over the course of a 4-year track after internship. Such an approach recognizes that, to change the culture of the specialty, we must build from the ground up. Not all physicians who enter anesthesiology training go on to participate in the research/academic sector. Similar to other highly visible specialties, however, a sufficiently large cadre will be available to replenish those who leave active practice and further build up intellectual capital for future generations.One of the challenges in training is the inherent and increasingly diverse nature of the disciplines involved in any one-subject area. The term “interdisciplinary research” has become a tautology. Practically all new frontiers lie at the boundaries of established departmental or specialty divisions, which are largely a historical relic of 19th century or early 20th century conceptualizations. A look at any large institution's roster of academic divisions yields a growing number of “centers,” “programs,” and “institutes,” reflecting the ever-increasing interdependency of branches in biomedical knowledge. [28] [29] In basic science departments, with conjugate names such as “Physiology and Cellular Biophysics,” “Anatomy and Cell Biology,” “Biochemistry and Biophysics,” and “Cellular and Molecular Pharmacology,” it is becoming increasingly difficult to differentiate one faculty research program from another, solely on the basis of thetopics and methods of study. Although this differentiation is clearly less complicated for domains that do not involve patient care, the trend is evident. One might cite the example of endovascular surgery as anexample in the collision of science, technology, and historical boundaries of medical specialties.[30]Medical research is at one level original creative work that involves systemic investigation of medical phenomena with the direct or indirect consequence of improving health care. Activity that might be subsumed under “medical research” is scholarly synthesis of available data to generate new insights into phenomena. Scholarship that involves this synthesis is perhaps underappreciated and underemphasized. The most common type of publication in this category is the review article. Although often review articlesare written by the individuals performing the original research, this is neither a necessary nor a sufficient precondition for a meaningful review. Especially for clinically oriented reviews, a broad perspective on a particular clinical practice may not only be sufficient, but also desirable.Ramachandran[31] quotes Medwar: “An imaginative conception of what might be true is the starting point of all great discoveries in science.” Ramachandran says that if he would show the reader a talking pig, it is unlikely that he or she would respond: “Ah, but that's just one pig. Show me a few more, and then I might believe you!” In this regard, an unintended consequence of moving toward quantitative indices for impact of biomedical journals has led to the demise of the case report. The case report is just such a Medwarian “imaginative conception of what might be true.” It is also an ideal setting in which to perform a synthesis of available knowledge on a particular topic. Well-written and timely case reports can add significantly to the medical literature and provide an “early warning” function before laborious efforts are undertaken to conduct larger scale efforts to characterize a particular complication or phenomenon. Finally, case reports are“entry-level” scholarly activities that students, residents, and junior faculty can use as a stairstep to more complex modes of writing.An area of potentially increasing contribution of anesthesia and perioperative care is in the realization of clinical trials for efficacy of surgical therapy. It is not unreasonable to assume that reimbursement fordelivery of clinical care in the future may be increasingly tied to participation in some form of organized assessment of efficacy, such as a randomized controlled trial (e.g., the case of lung reduction surgery).[32] Such considerations are especially pertinent for procedures that are highly reimbursed, but controversial in terms of efficacy, as in the case of minimally symptomatic cerebrovascular diseases. [30] [33] Perverse incentives can drive clinical practice and influence expert opinion. In addition to insights into the delivery of perioperative medical care, anesthesiologists can help provide an “honest broker” function in such settings.In the clinical and policy research domain, anesthesiologists have an opportunity to study all aspects of surgical care. By joining or leading multidisciplinary teams, they can ask questions relevant to the patient undergoing surgery and not just undergoing anesthesia. Anesthesiologists must take leading roles inhelping to define best surgical practice.Why is it important that anesthesiology maintain the strongest possible profile in research and scholarly contributions to medical knowledge? Besides the intuitive sense that medical specialties must strive for advancing their domains, there is a strategic necessity of significant proactive involvement in scholarly and investigative pursuits. In the modern medical marketplace, physicians are not the only stakeholders in the delivery of health care. Physicians, particularly those in professorial tracks, traditionally conduct the bulk of investigative research, however. The advent of higher-level, doctoral degrees in nursing could significantly change this dynamic. The public that we serve, and the various governmental and institutional bodies that regulate health care delivery, should have a clear vision of our mission and approach.References1.. National Center for Health Statistics: Health, United States, 2007, with Chartbook on Trends in the Health of Americans. Available at /books/bv.fcgi?indexed=google&rid=healthus07.chapter.trend-tables20072.. Ruther MM, Black C: Medicare use and cost of short-stay hospital services by enrollees with cataract, 1984. Health Care Financ Rev 1987; 9:91-99.3.. Fleisher LA, Pasternak LR, Herbert R, et al: Inpatient hospital admission and death after outpatient surgery in elderly patients: Importance of patient and system characteristics and location of care. ArchSurg 2004; 139:67-72.4.. Cutler DM: Your Money or Your Life: Strong Medicine for America's Health Care System. New York, Oxford University Press, 2004.5.. Bodenheimer T: High and rising health care costs, part 2: Technologic innovation. Ann InternMed 2005; 142:932-937.6.. Mongan JJ, Ferris TG, Lee TH: Options for slowing the growth of health care costs. N Engl JMed 2008; 358:1509-1514.7.. Thorpe KE: The rise in health care spending and what to do about it. Health Aff (Millwood) 2005; 24:1436-1445.8.. Rosenthal MB: Nonpayment for performance? Medicare's new reimbursement rule. N Engl JMed 2007; 357:1573-1575.9.. Shortell SM, Rundall TG, Hsu J: Improving patient care by linking evidence-based medicine and evidence-based management. JAMA 2007; 298:673-676.10.. Lee TH: Pay for performance, version 2.0?. N Engl J Med 2007; 357:531-533.11.. Campbell S, Reeves D, Kontopantelis E, et al: Quality of primary care in England with the introduction of pay for performance. N Engl J Med 2007; 357:181-190.12.. Lindenauer PK, Remus D, Roman S, et al: Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007; 356:486-496.13.. Centers for Medicare and Medicaid Services: Medicare Program; Hospital Outpatient Prospective Payment System and CY 2007 Payment Rates; CY 2007 Update to the Ambulatory Surgical Center Covered Procedures List; Medicare Administrative Contractors; and Reporting Hospital Quality Data for FY 2008 Inpatient Prospective Payment System Annual Payment Update Program—HCAHPS Survey, SCIP, and Mortality, Vol 71. Dept of Health and Human Services. Federal Register, 2006.14.. Griffin FA: Reducing surgical complications. Jt Comm J Qual Patient Saf 2007; 33:660-665.15.. Klompas M, Kulldorff M, Platt R: Risk of misleading ventilator-associated pneumonia rates with use of standard clinical and microbiological criteria. Clin Infect Dis 2008; 46:1443-1446.16.. Arens JF: A practice parameters overview. Anesthesiology 1993; 78:229-230.17.. Khuri SF: The NSQIP: A new frontier in surgery. Surgery 2005; 138:837-843.18.. Tong BC, Harpole Jr DH: Audit, quality control, and performance in thoracic surgery: A North American perspective. Thorac Surg Clin 2007; 17:379-386.19.. QualityNet: Available at /dcs/ContentServer?pagename=QnetPublic/Page/QnetHomepage20.. Salsberg E, Grover A: Physician workforce shortages: Implications and issues for academic health centers and policymakers. Acad Med 2006; 81:782-787.21.. AAMC Data Book: U.S. Medical School Women Applicants, Accepted Applicants, and Matriculants.Washington, DC, Association of American Medical Colleges, 2005.22.. Heiligers PJ, Hingstman L: Career preferences and the work-family balance in medicine: Gender differences among medical specialists. Soc Sci Med 2000; 50:1235-1246.23.. Jovic E, Wallace JE, Lemaire J: The generation and gender shifts in medicine: An exploratory survey of internal medicine physicians. BMC Health Serv Res 2006; 6:55.24.. Graduate medical education. JAMA 2005; 294:1129-1143.25.. Reves JG: We are what we make: Transforming research in anesthesiology.Anesthesiology 2007; 106:826-835.26.. Moses 3rd H, Dorsey ER, Matheson DH, et al: Financial anatomy of biomedical research.JAMA 2005; 294:1333-1342.27.. Philipson L: Medical research activities, funding, and creativity in Europe: Comparison with research in the United States. JAMA 2005; 294:1394-1398.28.. Columbia University Medical Center. Academic and Clinical Departments, Centers andInstitutions: Available at /depts/200829.. University of California San Francisco. Department Chairs, ORU Directors, and Assistants: Available at /listbuilder/chairs_dirs_assts.htm 200830.. Fiehler J, Stapf C: ARUBA—beating natural history in unruptured brain AVMs by intervention.Neuroradiology 2008; 50:465-467.31.. Ramachandran VS, Blakeslee S: Phantoms in the Brain: Probing the Mysteries of the Human Mind . New York, William Morrow, 1998.32.. Centers for Medicare and Medicaid Services: Lung Volume Reduction Surgery (LVRS). Available at /MedicareApprovedFacilitie/LVRS/List.asp 200833.. Mathiesen T: Arguments against the proposed randomised trial (ARUBA). Neuroradiology 2008; 50:469-471.。
麻醉术前用药的指南
－－哪些停用？哪些继续？
米勒麻醉学第七版／第八版
• 随着医疗水平的进 步和医疗需求的不断增 高，手术的数量不断提 高，手术的技术难度不 断增加，病人的年龄跨 度不断增大，临床合并 疾病也更为多样和复杂
• 很多手术病人可能 合并有其它内科系统疾 2
米勒麻醉学第七版的相 关建议
米勒麻 醉学第 八版
第八版
• 术前停用（例外：作为降 压药物的噻嗪类利尿剂应 该持续使用至手术当日）
• 袢利尿剂一般停用（体液 丢失，低钾血症）。但是 有实验证实持续使用并没 有提高术中低血压的风险。
• 因此，对于严重的高容量，
抗血小板药物－－－阿司匹林
第七版
第八版
•继续使用
矫ቤተ መጻሕፍቲ ባይዱ手术和 视网膜手术前 7天停药
•对于心血管事件风险超过 出血风险的患者（重度 CAD,CVD），考虑选择性 继续使用阿司匹林。
抑制作用可以持续至停药后1年 ◦ 由于患者体质不同，自身激素分泌恢复速度不同，手术应激程度不同，
术前的替代剂量应该个体化
NSAIDs
NSAIDs－－通常术前24-72小时停用
COX-2:持续服用至手术当日，除非出于对骨愈合的考虑
◦ NSAIDs具有可逆性的抗血小板作用，停药后血小板功能即可恢复正常。 ◦ NSAIDs的过早停药没有显示出更大的安全性，反而会加重原有疾病的
1. 对于MAOIs停药后抑郁症状加重和自杀事件的报道文献中并不少见。
2. 综合考虑，最安全的方法可能是继续使用MAOIs，相应调整麻醉用药 和方案
◦
避免使用哌替啶和间接血管活性药（麻黄碱）
◦
手术当晨是否使用应和专业医生协商讨论
3. 使用三环类抗抑郁药患者复查ECG(延长Q-T间期)，同时关注患者血流 动力学变化（抑制去甲肾上腺素和血清素的再摄取，引起对血管活性 药的过激反应）
脑死亡
人体死亡的判定关系到人的生死，而“人命至重，贵于千金”。
随着社会的发展和医学的进步，人体死亡的判定标准也在演变，这种演变既是一个科学技术问题，又蕴含着伦理问题。
脑死亡标准的提出和实施是一个科学技术问题，而应不应该实施和如何实施就是一个伦理问题（实质伦理和程序伦理），后者即实施脑死亡的伦理价值和应遵循的伦理原则。
一、死亡标准的演变死亡标准，亦即人们用以衡量与判断死亡的标准或尺度，它随着社会的发展和医学科学的进步在不断地演变。
人类社会的早期以呼吸停止作为判断死亡的标准，后来演变为以心肺功能停止（即心跳、呼吸停止）为死亡的标志，后者已沿袭了数千年之久。
但是，现代大量的临床实践证明，死亡不是生命的骤然停止，而是一个连续发展的过程。
在许多情况下，心搏骤停之时，脑、肝、肾等器官组织并未死。
当代人工维持心肺功能的技术和药物的应用，心跳、呼吸停止的病人经抢救也可以复苏，甚至治愈出院，这说明心肺功能停止不一定意味着死亡。
相反，某些实际上已丧失脑功能的病人，也能在生命维持装置的监护下，使心跳、呼吸持续很长时间，但作为人的自我意识或意识经验能力已经丧失。
因此，医学高技术的发展向传统的心肺功能停止的死亡标准提出了挑战，加之器官移植的迅速发展需要新鲜器官，于是促使国外的医学家纷纷探索新的死亡标准。
1968年召开的世界第22届医学大会上，美国哈佛大学医学院特设委员会提出了把“脑功能不可逆丧失”作为新的死亡标准，即将脑死亡确定为人的死亡标准，并提出判断的四条标准：①出现不可逆转的昏迷，即对外部的刺激和内部需要没有接受性和反应性；②自主的肌肉运动和自主呼吸消失；③诱导反射缺失；④脑电波平直。
以上四条标准还要求持续24小时观察及反复测试结果无变化，而且要排除低体温（<32.2℃）或刚服用过巴比妥类药物等中枢神经抑制剂的病例，即可宣布死亡。
[1]这个标准提出以后，开始也有争论：一是对脑电波平直24小时后能否可复的问题。
后来，美国做了大量的脑死亡病例统计表明，除少数服用过安定药物的病例外，脑死亡病人的脑电波在24小时后是不可复的，这就支持了脑死亡的哈佛标准。
麻醉科不可错过的8大经典书目
麻醉科不可错过的8大经典书目什么？麻醉科医生也要看书？麻醉科医生看什么书？清晰记得研究生复试的时候，一个康复医学科的哥们问：“兄弟，你报考的是什么科？”我很得意的回答他：“麻醉科！”“什么？麻醉科也有研究生？！”我差点没接住他的下巴，但他肯定被我的白眼秒杀了。
多年后仍有不少人关心我说：“麻醉科医生还看什么书啊，不就打一针完事了么？”老少童鞋们，我现在严肃告诉你们，麻醉科医生不仅要看外科书，还要看内科书，以及其他麻醉学相关的书籍。
下面让我们来818 工作在神秘手术室不见天日的蒙面医生们需要看的麻醉书籍吧。
1 《麻醉》没错，我很正经推荐的第一本书是小说。
一针下去，一个家庭从此支离破碎，这样的事，可能发生在世界上每个地方，也可能发生在你我每个人身上，不要等到一切都无可挽回时，一个人痛苦流泪……本人亲身经历过两次全身麻醉，很庆幸，两次都没有发生麻醉事故，所以现在能够愉快的给大家推荐这本书籍。
麻醉并不是打一针那么简单，“只有小手术，没有小麻醉。
”这部最刻骨铭心的医情小说将深刻地告诉你麻醉的重要性及危险性。
正如作者渡边淳一所期望：这部小说，如果能够促成人们对医疗过失的反省，并为杜绝此类事故而敲响警钟的话，那无疑将是一大幸事。
麻醉小伙伴们，赶紧去阅读吧。
2 《米勒麻醉学》第 7 版《米勒麻醉学》是麻醉学领域公认的最经典、最权威的巨著，她从基本原理到高级亚专业常规，内容涵盖当代麻醉实践的所有范畴。
它会引导你解决学习和工作中面临的技术上、科学上以及临床上的问题。
毕业时导师给我的寄语：“要成为优秀的麻醉医师，你要多读《米勒麻醉学》。
”遗憾的是导师并没有送一套“葵花宝典”给我，因为他知道我早就有了，而且是6 册包装的。
（请不要问我为什么是6 册，你懂的。
）本人也有幸参加第8 版某章节某部分内容的翻译工作，据可靠消息称，汉化版《米勒麻醉学》第8 版将在近期横空出世，敬请期待哦。
未来的麻醉届大牛小牛们，《米勒麻醉学》你必须拥有。
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根据定义，脑死亡是全脑功能不可逆的丧失。然而， “全脑”仅表示大脑所有临床不可逆的丧失，而不 是指每个脑神经元功能，也就是通过床边检查就可 以诊断。脑包括除脊髓意外的所有中枢神经系统结 构。通常认为，脑死亡不包括第2颈髓一下的脊髓， 因为他们位于颅腔之外，在脑水肿时未受到压迫。
Moruzzi和Magoun证实了脑干网状结构在保持皮 层脑电活动中发挥着极为关键的作用。Segundo等 研究发现，如果破坏了实验动物的脑干网状结构， 其意识会马上消失。 脑死亡患者被认为无意识、无智能活动，因此业界 不是真正的人。这种状态被称为深昏迷，是脑干死 亡这一概念的理论基础。
麻醉医师必须了解关于死亡的医学和法律专业知识 以及其所包含的伦理问题，麻醉医师在器官捐赠的 麻醉管理中，应该考虑到脑死亡患者的情况，并判 断其是否是真正的脑死亡。
谢谢
脑血管造影术 造影剂应在高压下注入前后循环。 在颈动脉或椎动脉入颅以上部分不显影 颈外动脉应开放通畅 上矢状窦显影可延迟
至少应使用8个头皮电极 电极之间阻抗应介于100~10000Ω 整个记录系统完好 各电极之间距离至少要有10cm 敏感性至少为2μV，持续30min 导频滤波器设定不能再30Hz以下，低频不能高于 1Hz 脑电图描记法要证实对强烈体感刺激或视听刺激无 反应
脑死亡代表着生物的死亡，而不仅仅是脑的死亡或 坏死。生物是活细胞的集合体，而活细胞的几乎题 不一定能构成生物体。只有当细胞集合体在调节系 统的控制之下时，才能真正算是生物体。 脑死亡和心脏死亡的生理学意义在本质上的相同的， 两者均代表着控制中心与外周细胞或组织间的联系 不可逆的中断，细胞间的功能调节丧失。
同年，Mollaret等用类似于现代脑死亡定义的概念 首次描述了脑功能丧失。 1968年，哈佛大学医学院脑死亡定义审查委员会 公布了脑死亡的标准，并提出了“不可逆的昏迷作 为新的脑死亡标准”。 1976年在英国皇家医学院全体教员会议上首次公 布用脑干定义脑死亡。
1995年，《脑干死亡诊断标准》文件中推荐使用 脑干死亡这一更为准确的术语而不是脑死亡，并给 出了死亡的定义，即“死亡是不可逆转的意识功能 丧失，并伴有不可逆转的呼吸功能丧失。”
传统的死亡概念以呼吸和循环功能的停止为基础， 因为其接受了一个单纯的非医学概念 生命开始于 出生后的第一次呼吸，死亡终结于最后一次呼气， 最后一次呼气后几分钟内心跳也就停止了。相反， 现代脑死亡的概念采用了现代生物科学的结论 中 枢神经系统是活生物体的控制中心；中枢神经系统 功能的消失代表着和谐生命的终结；若无中枢神经 系统的控制，生物体只不过是一堆活细胞。
米勒麻醉学 刘天欣
医学的发展改变了死亡的概念和定义，有关 死亡的立法也须相应改变。随着复苏和生命支持技 术日臻完善、器官移植技术的进步及丧失大脑功能 的“活人”日见增多，这个问题越发突出。
危重病医学的发展要求神经内科、神经外科和麻醉 科的医师必须对死亡做出巧当的诊断。尽管文化背 景和宗教信仰的差异会导致对脑死亡的看法差异巨 大，并且缺乏全球统一的诊断标准，但脑死亡作为 个体死亡观念已被公众广泛接受。作为器官捐献的 必要前提，许多国家已对脑死亡提出了建议或已要 求立法。
多种原因可以引起脑损伤，如脑创伤性损伤、脑血 管损伤以及全身缺氧等，这些损伤均能引起脑水肿。 脑水肿在开始时是局限性的，随后逐渐波及全脑。 由于大脑被颅骨所包裹，脑水肿使脑实质体积增大 必然导致颅内压增高，甚至超过动脉血压。当脑循 环停止，随之脑实质发生无菌性坏死。在3~5天之 内，脑实质液化，被称为“呼吸机脑”。颅内压增 高会压迫整个大脑，导致全脑梗死。
深昏迷 患者必须处于深昏迷状态，且深昏迷的原因明确。 器质性脑损伤是诊断脑死亡的必要条件。药物中毒、 严重的电解质。酸碱平衡紊乱或内分泌紊乱，低体 温以及其他可以治愈的疾病应予排除。
体温 当脑干和下丘脑功能丧失以及脊髓完全失去上位中 枢的控制后，患者的体温随环境变化而变化，即使 给予充分的保温措施，体温还是趋于降低。由于低 体温医师中枢神经系统的功能，可误诊为脑死亡， 在应用脑死亡诊断标准前必须将患者的体温纠正到 正常范围。
脑死亡之后，脊髓内就建立了不同类型的自主反射。 麻醉医师都知道，四肢瘫痪患者在受到手术刺激时 会出现心动过速和血压升高。在脑死亡患者中也发 现类似的现象。脑死亡患者在给予。尽管 心加速中枢和血管运动中枢神经元位于脑干，但动 脉血压的变化并非评价脑干功能的指标。
当颅内压升高时，库欣现象使体循环血压升高，之 后由于脑干和下丘脑传向脊髓的血管运动信号突感 中断，导致动脉血压突然下降。几天后，由于脊髓 血管运动神经元自主活动恢复，患者的低血压得意 改善，血压趋于正常。因为低血压是脑血流减少， 脑电活动可能消失，同时可能误诊为脑死亡，因此 应给予血管加压药以维持血压。判定脑死亡时，给 予血管加压药偶尔能使脑电活动恢复。
h.如实验过程中收缩压降至90mmHg以下或脉氧 提示明显缺氧，并出现心律失常，必须接上呼吸机 机械通气立即做机械通气，同时立即取动脉血样进 行血气分析。如果PaCO2≥60mmHg或比基线水平 升高≥20mmHg，呼吸暂停实验阳性，支持临床脑 死亡诊断。反之，呼吸暂停结果不确定，应考虑进 一步实验确证
1902年，Cushing首次报道，当猴子的颅内压一 旦超过动脉血压时，脑循环即告停止。他还报道了 一例脑肿瘤患者，在自主呼吸停止使用人工通气使 心脏功能延长了23h。 1959年,Bertrand等报道了一例中耳炎患者循环衰 竭死亡后用机械通气维持了3天。患者在深昏迷之 前曾反复抽搐，尸解证实大脑皮层、小脑皮层、基 底核区、脑干神经元等广泛坏死，主要是由于人工 通气是脑循环已完全停止
先决条件：脑死亡是临床脑功能丧失，其原因明确 且被证明是不可逆转的。 1.急性中枢神经系统病变的临床或神经影像学证据 与脑死亡的临床诊断一致 2.排除可混淆临床评估的伴发的病理生理状态 3.无药物中毒反应 4.体核温度≥32℃
脑死亡主要的三个临床表现：昏迷或无反应、脑干 反射消失和呼吸停止 1.昏迷或无反应 末梢对疼痛刺激无大脑支配的运 动反应 2.无脑干反射 瞳孔1.无对光反射2.瞳孔直径从中等大小4mm到 散大9mm
脑死亡是，体温调节中枢与周围组织之间失去联系， 患者体温随环境温度而变化。由于体温调节中枢已 经丧失了功能，即使脑死亡患者合并有感染，其体 温也不会升高。脑死亡后尽管积极采取外部保温措 施，患者仍趋于低温状态。
多种脑干反射均被用于诊断脑死亡，如瞳孔反射、 眼脑反射、眼前庭反射和咳嗽反射。咳嗽反射的存 在代表脑干呼吸中枢还有功能。活生物体并不一定 要所有的脑干反射存在，但脑干反射可以验证脑干 功能残存。
a.先决条件 1.体核温度≥36.5℃ 2.收缩压≥90mmHg 3.血容量正常或在既往6h内体液为正平衡 4.PaCO2正常或PaCO2≥40mmHg 5.PaO2正常或预给氧至PaO2≥200mmHg b.连接脉搏血氧仪，断开呼吸机
c.向气管内输送6L/min的纯氧或放一细管隆嵴水平 供氧 d.密切观察呼吸运动 e.断开呼吸机8min后査动脉血PaO2、PaCO2和pH f.如无呼吸，并且PaCO2≥60mmHg，呼吸暂停实 验结果为阳性，支持脑死亡的诊断 g.如果观察到呼吸运动，呼吸暂停实验阴性
麻醉医师应该具有丰富的关于脑死亡和器官捐献的 知识。在脑死亡患者，无论是否具有脑皮质功能， 脑干的功能都是丧失的，理论上讲，患者是无意识 的。但是由于脊髓是完整的，并且存在躯体和内脏 的反射，因此麻醉管理需特别注意。理论上，摘取 器官时镇静剂和镇痛剂是不需要的，但也有学者认 为应该给予镇静剂和镇痛剂，同时保持肌肉松弛， 特别是对于脑干死亡的病例。
眼球运动1.无眼脑反射2.用50ml冷水分别注入两侧 外耳道，眼球不发生偏离。 面部感觉和运动反应1.用棉签触及眼角膜，无角膜 反射2.无下颌反射3.用力压迫甲床、眶上或颞下颌 关节，面部无任何表情 咽和气管反射1.用压舌板刺激咽后壁无任何反应2. 支气管吸痰无咳嗽反射
当脑血流量小于18ml/(100g*min)时，脑电图就 可产生明显的异常改变，当脑血流量降至 12~15ml/(100g*min)时，脑电图成为一条直线。 然而Paolin等报道了15例临床诊断为脑死亡的病例， 脑血管造影术均证实脑循环已停止，但其中有7例 患者仍保持着脑电活动。
吸气和呼气神经元组成的初级呼吸中枢位于延髓的 网状核团。脑死亡患者即使其PaCO2达到 55~60mmHg，自主呼吸也不会出现。
需要有双侧接收超声装置，探头需放在颧弓上方的 颞骨处或是经枕下窗置于椎-基底动脉处 异常情况包括舒张波缺失、只有收缩期棘波；因为 经颞骨窗接收超声的结果不充分，血流完全消失可 能并不可靠
应在重建后30min内将同位素注入体内 500,000点静态影像需要在几个时点获得：注入时、 30~60min、注入后2h 通过拍摄肝摄取图像来确认静脉注射无误