Combined people are called such anesthesia that are achieved by a combination of various anesthetic agents and other substances. In this case, each of the means performs a specific function. Barbiturates are used to sleep, nitrogen upset to turn off consciousness and analgesia, more powerful tools (ether, fluorotan, cyclopropane) - to provide treasure, analgesia and to a certain extent, for muscle relaxation. Deep relaxation reaches the introduction of muscle relaxants.
Muscular relaxants. Muscular relaxants are known for a long time. And the Indians of Decolumbovy America used these substances for hunting, lubricating the arrows with a tropical plant with coarara. However, in clinical practice, stripped drugs are introduced by Canadian anesthesiologists Griffitz and Josan in 1942.
By the mechanism of its action, these drugs are divided into substances of central and peripheral action. Muscle relaxants of the central action block the carrying out of the nerve pulse along the synapses of the trunk of the head and spinal cord. In modern anesthesiology, the Mioroselaksanta peripheral action, which cause a total neuromuscular blockade at the level of neuromuscular synapse. According to the mechanism of action, muscle relaxants are divided into two groups.
Nonpolarizing relaxants.
tubokuran (Kurarin Asta)
gallemin Iodid (Trikuran, Flaxedil)
pancronium Bromide (Pavlon)
prezero (Neostigmin, Promagnmin, Neozerin)
calminim (Pyridostigmine, Maltinon)
galanamin (Nivalin)
Depolarizing relaxants.
ditilin, Miorolaksin, Succinylcholine
ibestin
dioxonium.
The use of muscle relaxants leads to the need for patients with artificial pulmonary ventilation (IVL), which can be carried out by manual and hardware.
For endotracheal method of anesthesia The narcotic substance comes from the anesthetic apparatus to the body through the tube introduced into the trachea. The advantage of the method is that it provides free pampacity of the respiratory tract and can be used during neck operations, face. head, eliminates the possibility of aspiration of vomit, blood; reduces the amount of narcotic substance used; Improves gas exchange due to a decrease in the "dead" space.
Endotracheal anesthesia is shown at large, surgical interventions, applied in the form of multicomponent anesthesia with muscle relaxants (combined anesthesia). The total use of several drugs in small doses of several narcotic substances reduces the toxic effect on the body by each.I.I. Modern combined anesthesia is used to carry out analgesia, shutdown consciousness, relaxation. Analgesia and turning off consciousness are achieved by using one or more narcotic substances - inhalation or non-digitalia. Anesthesia is carried out at the first level of the surgical stage. Muscle relaxation, or relaxation, is achieved by fractional administration of muscle relaxants. The creature "three phases of anesthesia.
Stage I-Introduction to anesthesia. Introductory anesthesia can be implemented by any narcotic substance, against which. A sufficiently deep anesthetic dream without the stage of excitement. Fentanyl barbiturates are mainly used in combination with Somubrevin, sombrevin obsol. Tyopental sodium is also used. Preparations are used in the form of 1% solution, they are introduced intravenously at a dose of 400-500 mg. Against the background of the introductory anesthesia, muscle relaxants are introduced and trachea intubation.
Stage II - Maintenance of anesthesia. To maintain overall anesthesia, any narcotic agent can be used, which can create the protection of the body from the operating injury (fluorotan, cyclopropane, nitrogen with oxygen nitrogen), as well as neuroleptinalgesia. Narcosis is maintained at the first second level of the surgical stage, and muscle relaxants are introduced to eliminate muscle stress, which cause melting of all skeletal muscle groups, including respiratory. Therefore, the main condition for the modern combination method of anesthesia is the IVL, which is carried out by rhythmic compression of the bag or fur or using an artificial respiratory unit.
Recently, neuroleptinalgesia received the greatest distribution. At the same time, nitrogen with oxygen nitrogen is used for anesthesia. Fentanyl, Droperidol. Muscular relaxants. Intravenous entry anesthesia. Anesthesia is maintained by inhalation of nitrogen pump with oxygen in a ratio of 2: 1, fractional intravenous administration of fentanyl and droperidol by 1-2 ml every 15-20 minutes. Fentanyl is injected at the cheating of the pulse, with an increase in blood pressure - Droperidol. This kind of anesthesia is safer for the patient: fentanyl enhances the anesthesia, the droperidol suppresses vegetative reactions.
Stage III - excretion from anesthesia. By the end of the operation, anesthesiologist gradually stops the introduction of narcotic substances and muscle relaxants. The consciousness is returned to the patient, self-breathing and muscle tone are restored. The criterion for estimating the adequacy of self-breathing is the indicators R O2, P CO2, pH. After the awakening, the restoration of spontaneous respiration and the skeletal muscles tonus, anesthesiologist can exturb the patient and transport it to further observe the postoperative chamber.
Complications of anesthesia
Complications during anesthesia may be associated with the technique of conducting anesthesia or the impact of anesthetic funds for vital organs. One of the complications is vomiting. At the beginning of the anesthesia, vomiting may be associated with the nature of the underlying disease (stenosis of the gatekeeper, intestinal obstruction) or with the immediate impact of the narcotic drug to the vomit. Against the background of vomiting, the aspiration is dangerous - the ingress of gastric content in the trachea and bronchi. Gastric content that has a pronounced acid reaction, falling into voice ligaments, and then penetrating the trachea, can lead to laryngospham or bronchospasm, resulting in a respiratory impairment with subsequent hypoxia - this is the so-called Mendelssohn syndrome manifested by cyanosis, bronchospasm, tachycardia.
Dangerous is regurgitation - passive throwing of gastric contents in the trachea and bronchi. This happens, as a rule, against the background of deep mask anesthesia when relaxing sphincters and stomach overflow or after the introduction of muscle relaxants (before intubation). Interesting in volatility or regurgitation of gastric content having an acidic reaction leads to heavy pneumonias often with death.
To prevent vomiting and regurgitation, it is necessary to remove from the stomach to the anesthesia using the probe content. In patients with peritonitis and intestinal obstruction, the probe is left in the stomach during the entire anesthesia, while the moderate position of Trendelenburg is recommended. Before the start of anesthesia to prevent regurgitation, you can use the reception of Selik - pressing on the ring-shaped cartilage of the Zada, which causes the relief of the esophagus.
If vomiting occurred, immediately remove the gastric contents from the oral cavity using a tampon and suction, when regurgitation, gastric contents are removed by suction through the catheter entered into the trachea and bronchi.
Vomiting with subsequent aspiration may occur not only during anesthesia, but also when the patient is awakening. To prevent aspiration in such cases, it is necessary to put the patient horizontally or in the Trendelenburg position, turn the head on the side. It is necessary to observe the patient.
Complications from respiration can be associated with violation of respiratory tract. This may be due to a malfunction of anesthetic apparatus. It is important before the start of anesthesia to test the operation of the apparatus, its tightness and passability of gases in respiratory hoses.
The obstruction of the respiratory tract may occur as a result of the spares of the language at a deep anesthesia (zth level of surgical stage of anesthesia). During anesthesia, solid foreign bodies (teeth, prostheses) can fall into the upper respiratory tract. To prevent these complications, it is necessary to put forward and maintain the lower jaw against the background of deep anesthesia. Before anesthesia, delete prostheses, examine the patient's teeth.
Complications in the intubation of the trachea, carried out by direct laryngoscopy, can be grouped as follows: 1) Dramatic damage to the laryngoscope blades; 2) damage to the voice ligaments; H) introduction of an intubation tube into the esophagus; 4) the introduction of an intubation tube into the right bronchi; 5) Ending intubation tube from trachea or gerbing it.
The complications described can be warned by clear possession of intubation techniques and the standing control of the intubation tube in the trachea above its bifurcation (using the lungs auscultation).
Complications from blood circulation bodies. Hypotension is a decrease in blood pressure both during the administration of anesthesia and during anesthesia - may occur as a result of the effects of narcotic substances on the activity of the heart or on the Visor-Motor Center. This happens with the overdose of narcotic substances (more often than ftorota). The hypotension may appear in patients with low by it with the optimal dosage of narcotic substances. To prevent this complication, it is necessary to replenish the deficiency of the BCC before anesthesia, and during the operation, accompanied by blood loss, overflow the bloodstream solutions and blood.
Disturbance of the heart rhythm (ventricular tachycardia, extrasystolia, ventricular fibrillation) may arise due to a number of reasons: 1) hypoxia and hypercaps that have arisen under the protracted intubation or with insufficient ease of anesthesia; 2) overdose of narcotic substances - barbiturates. fluorotan; H) applications against the background of adrenaline fluorotan, increasing the sensitivity of fluorotan to catecholaminam.
To determine the rhythm of cardiac activity, electrocardiographic control is necessary.
Treatment is carried out depending on the cause of complications and includes the elimination of hypoxia, a decrease in the dose of drugs, the use of quinine drugs.
Heart stop is the most terrible complication during anesthesia. The cause of it is most often incorrect assessment of the patient's condition, the mistakes in the technique of conducting anesthesin, hypoxia, hypercupnia.
Treatment is to immediately conduct cardiovascular intensive care.
Complications from the nervous system. During general anesthesia, a moderate decrease in body temperature is often observed due to the effects of narcotic substances on the central mechanisms of thermoregulation and the cooling of the patient in the operating room.
The organism of patients with hypothermia after anesthesia is trying to normalize body temperature due to reinforced metabolism. Against this background at the end of the anesthesia and after it, chills arises. Most often, chills are noted after fluorootan anesthesia. For the prevention of hypothermia, it is necessary to monitor the temperature in the operating room (21-22 ° C), to cover the patient, if necessary, infusion therapy is to overflow the solutions warmed to the body temperature, to carry out inhalation of warm moistened drugs, monitor the body temperature of the patient.
The edema of the brain is a consequence of long and deep hypoxia during anesthesia. Treatment should be started immediately, observing the principles of dehydration, hyperventilation, local brain cooling.
Damage to peripheral nerves. This complication appears a day later and more after anesthesia. Most often the nerves of the upper and lower extremities and shoulder plexus are damaged. This happens with the wrong laying of the patient on the operating table (the hand turning is more than 90 ° from the body, the establishment of the arm behind the head, fixing the arm to the arc of the operating table, when laying the legs on the holders without laying). The correct position of the patient on the table eliminates the tension of the nerve trunks. Treatment is carried out by a neurologist and physiotherapist.
Preparation of a patient for anesthesia. Anesthesic is directly involved in the preparation of a patient for anesthesia and operation. The patient is examined before the operation, and not only pay attention to the underlying disease, about which the operation will have to have, but also find out in detail the presence of concomitant diseases. If the patient is operated on as planned manner. Then, if necessary, the treatment of concomitant diseases, the occasion of the oral cavity. The doctor finds out and assesses the mental state of the patient, finds out allergic history. Specifies whether the patient was patient in the past operation and anesthesia. Draws attention to the shape of the face, chest, the structure of the neck, the severity of the subcutaneous fatty fiber. All this is necessary to choose the way to choose an anesthetic method and a narcotic drug.
An important rule for the preparation of a patient to anesthesia is to purify the gastrointestinal tract (washing the stomach, cleaning belizes).
To suppress the psycho-emotional reaction and oppressing the function of the wandering nerve before the operation, special medical training is carried out - premedication. On the night, they give sleeping pills, patients with a labile nervous system per day before the operation are prescribed tranquilizers (Seduksen, Relanium). 40 minutes before the operation, narcotic analgesics are injected intramuscularly or subcutaneously: 1 ml of 1-2% of wicked solution or 1 ml of pentoocin (lexira), 2 ml of phenosyl. To suppress the function of the wandering nerve and decrease in sowing, 0.5 ml of 0.1% of the atropine solution is introduced. In patients with an allergological history of premedication include antihistamines. Immediately before the operation examines the oral cavity, removal removable teeth and prostheses.
In case of emergency interventions, the stomach is washed before the operation, and the premedication is carried out on the operating table. Medicinal preparations are administered intravenously. During the anesthesia, a nurse leads a anesthesiological card of a patient, in which it necessarily records the main indicators of homeostasis: the pulse rate, blood pressure level, central venous pressure, respiratory rate, IVL parameters. This card reflects all stages of anesthesia and operations, doses of narcotic substances and muscle relaxants are indicated, all drugs used during anesthesia are noted, including transfusion environments. The time of all stages of the operation and administration of medicines is recorded. At the end of the operation, the total amount of all used drugs is determined, which is also noted in the anesthesia map. An entry is made about all complications during anesthesia and operation. Anesthesia card is embedded in the history of the disease.
Methods of control over the conduct of anesthesia. In the course of general anesthesia, the main parameters of hemodynamics are constantly determined and evaluated. Arterial pressure is measured, pulse frequency every 10-15 minutes. In persons with diseases of the heart and blood vessels, as well as with thoracic operations, it is especially important to carry out permanent monitor monitoring of cardiac activity.
To determine the level of anesthesia, the electroencephalographic observation can be used. To control the ventilation of light and metabolic change in the course of anesthesia and operation, it is necessary to study the acid-base state (P O2, P CO2, pH, ve)
6. Operation of work:
5.1. At the beginning of the class teacher, the teacher pays time to organizational issues, notes in the journal of students present, indicates the need to respect the academic discipline, respect for the property of the department; I introduces a general plan of practical classes. Motivation is carried out, the importance of the topic for students, its applied meaning is clarified.
5.2. Questions of control of the initial level of knowledge.
5.3. The teacher finds out the level of preparation for the occupation of each student by surveying and evaluating the answers on the five-point system.
5.4. In the process of discussion, the teacher finds out complex issues requiring joint analysis and clarification.
5.5. Students turn to the practical part of the lesson.
5.6. The final control of students' knowledge orally or by solving test tasks, rating assessment.
7. Situational problems and questions:
1. Anesthesia is called mixed if
One anesthetic is introduced at the same time in various ways
Sequentially replace one anesthetic to other
Combine local anesthesia with intravenous anesthesia
At the same time, several anesthetics are introduced or mixed them in the tank before the beginning of the anesthesia.
All listed
2. Nitrogen
Weak anesthetic with a pronounced analgesic effect used only in a mixture with oxygen
Can be applied on an open system
Strong anesthetic with a weak analgesic effect, can be used in pure form without oxygen
All listed, depending on the state of the patient
3.. The flaws of the mask anesthesia refers the weight listed except
Big Dead Space
Absence of respiratory tract insulation
Big aerodynamic resistance
Need to prevent language
4.C. The disadvantages of intravenous guise of anesthesia include all of the above, except
Required complex anesthesia
Hard manageability of anesthesia
Preservation of tone muscle
The dangers of asphyxia due to the spares of the language and vomiting
Preservation of activity of reflexes
5. The benefits of endotracheal anesthesia include all of the above, except
Optimal artificial ventilation
Ensuring respiratory tract
C) warnings of the development of bronchospasm and heart stop
Achievements of the maximum necessary muscle relaxation
6.Fenthanyl is
Powerful analgesic operating 20-25 minutes
Analgesic short action (2-3 minutes)
Neuroleptic
Preparation of pronounced psychotropic action
Antidepressant
7..Artediza may be as a result of the listed, except
Insufficient depth of anesthesia
Manipulations in the field of reflexogenic zones
Introduction of salt solutions
Disorders of gas exchange
Reducing the BCC due to blood loss
8. When choosing anesthetic for anesthetic for a nark for 55 years, suffering from a hypertonicity of the III degree, during the operation of plastics of the front abdominal wall over the postoperative hernia, should be preferred
Fluorotia
Nyuroleptanalheseia
Nitrogen Zakisi + NLA
Local anesthesia
9.The caliper in Vienna may lead to everything listed, except:
Septic phlebitis
Chemical phlebitis
Thromboembolia
Septicemia
DVS syndrome
10. The stressful reaction is characterized by all the following, except
Sodium and chlorine delays
EVIGURIN
Fullurry
Eosinophilni
Leukocytosis
11. In respiratory acidosis, it is necessary:
Transfusion of bicarbonate.
Hyperventilation
Reducing the supply of narcotic substance
Intravenous introduction of respiratory diaptics
All listed
12. For the prevention of aspiration syndrome (Mendelssohn) is necessary
1) Empty the stomach through the probe
2) give laxatives
3) Assign soda for 1 tsp 30 minutes before meals
4) appoint cimetidine
5) give trisilenes magnesium according to the scheme
True all of the above
True I, 2, 3
True everything except 2
True 1, 4, 5
13. Sick multiple fractures of ribs, acute respiratory failure. After the NTtubatiya, the state has deteriorated sharply, hypoxia increases, the blood pressure decreases to 80 mm Hg. Art., Heart tones are deaf. Probable cause of deterioration was
Breast gap aorta
Vicious standing intubacio tube
Tense pneumothorax
Aspiration in trachea
Heavy injury of lung fabric and heart
Main literature.
1. Hotel V.K. General Surgery: Tutorial - 4th ed. - M., 2006.
2. Petrov S.V. General Surgery: Tutorial - 3rd ed., Pererab. And Extr.- M., Gootar -Media, 2009.
additional literature
1. Weber V.R., Shvetsova TP, Schvetsov D.A. "Emergency conditions in the practice of a family doctor" (Tutorial) - V.Novgorod, 2005.
2. Baido V.P. "Propaedeutic Surgical Diseases" (Tutorial) - Vernogorod, 2006.
3. Baido V.P. "Surgery for a family doctor" (Tutorial) - Vrangor, 2006.
4. Obochirgic skills. Uch. Manual for students honey. Universities Oskretkov V.I., Gankov V.A., Prokhorov V.I., Wilhelm N.P., Ed. IN AND. Oskretkova. - Rostov N / D: Phoenix - 2007.
5. Ultrasound diagnostics in surgery. Basic information and clinical applications. / Arnelli, Tracy., Visher, Dennis B., Galdstein, Laurens J. and others. from English Ed. S.A. Panfilova - M.: Binin, 2007.
6. Aseptics and antiseptics: uch. Manual: for honey universities / Vinnik Yu.S., Kochetova L.V., Karlova E.A., Teplikova O.V. -. - Rostov N / D: Phoenix; Krasnoyarsk - 2007.
7. Belkov A.V. Outpatient surgery, tests: uch. Manual: in the specialty 040100 "Therapeutic case". - Roughs N / D: Phoenix - 2007.
8. Nazarov I.P. Anesthesiology and resuscitation: studies. Manual: for postgraduates. Premium. Doctors and honey. universities / I.P. Nazarov. ─ Rostov N / D; Krasnoyarsk: Phoenix: Publishing projects, 2007.
9. Emergency surgery of the abdominal organs. Tutorial for students Meduses. / Kokhanko N.Yu., Afanasyev N.V., Lanarean E.L. and etc.; Ed. V.V. Levatovich. -M.: Gootar - Media, 2007.
10. Levita E.M. Introduction to anesthesiology resuscitation: studies. Honey allowance. universities / ed. IG Bobrinskaya. - M.: Goeotar-Media, 2007. - 255С.obocyrurgical skills. Uch. Manual for students honey. Universities. Oskretkov V.I., Gankov V.A., Prokhorov V.I., Wilhelm N.P., Ed. IN AND. Oskretkova. - Roughs N / D: Phoenix - 2007.
11. Nazarov I. P. Anesthesiology and Resuscitation: studies. Manual: for postgraduate. Premium. Doctors and honey. universities / I. P. Nazarov. - Rostov N / D: Phoenix; Krasnoyarsk: Publishing projects, 2007.
12. Burns. Intensive therapy. Tutorial. For postgraduate training doctors and university students. / Nazarov N.P., Matskevich V.A., Kolegov Zh.N. et al. - ─ Rostov N / d., Krasnoyarsk: Phoenix, 2007.
13. Weber V.R., Shvetsova TP, Schvetsov D.A. "Emergency states in the practice of a family doctor" (Tutorial), 2nd publication corrected and supplemented - V.Novgorod, 2009.
14. Traumatology. National Guide / Ed. G.Koteelnikova, S.P. Mironova. - M., Gootar -Media, 2009
15. Anesthesiology and resuscitation: Tutorial: For universities / N.S. Bitsunov [and others]; Ed. O.A. Valley. . - 4th ed., Pererab. and add. - M.: Goeotar Media, 2009.
16. Surgery propaedeuticism. Tutorial for students medical devices. / Baranov GA, Buromsky I.V., Vasilyev S.A. and etc.; Ed. V.K. Gostysheva and A.I. Kovaleva. 2nd publication corrected and supplemented - M.: Medical Inform. Agency, 2008
17. Intensive therapy. NATIONAL guidance. In 2 volumes / ed. B.R.Gelfanda, A.I. Saltanova. - M., Gootar -Media, 2009.
18. Weber V.R., Shvetsova TP, Schvetsov D.A. "Emergency states in the practice of a family doctor" (Tutorial) 3rd edition revised and supplemented - V.Novgorod,. 2011.
Combined total anesthesia
Combined is called anesthesia, which is achieved by simultaneously or consistently applications of a combination of various drugs: common anesthetics, tranquilizers, analgesics, muscle relaxants. This allows you to significantly reduce the concentration of anesthetics in the patient's body and their toxic effect on it. Anesthesia in such cases becomes more manageable, it becomes possible to reduce the concentration of a potent anesthetic to maintain anesthesia at a certain level. The most commonly used combinations of anesthetics for intravenous and inhalation applications.
Total intravenous anesthesia. With such a species, anesthesia is used, as a rule, a combination of several anesthetics for intravenous use. Usually they are injected by continuous infusion. A pre-action anesthetic is used as a prepofol in combination with fentanyl or other analgesic.
In the first 10 minutes, propofol is introduced in a dose of 10 mg / kg, in the next 10 min - 8 mg / kg, the following 8 min - 6 mg / kg. It is convenient to produce an infusion automatic syringe using the target installation. The rate of infusion at the same time is continuously calculated by a microprocessor embedded in the installation. The necessary dose of the drug is displayed on the display of the automatic syringe.
Balanced anesthesia. For balanced anesthesia, a combination of narcotic analgesics (morphine, fentanyl, sfentanila) is used with isoflurane (0.5%) or propofol (50-200 mg / kg per 1 min).
Atalaghesia is multicomponent balanced anesthesia, based on the use of drugs of a group of benzodiazepines in combination with narcotic analgesics. Due to the use of sedative, tranquilizing and analgesic drugs, the state of the atraxia is achieved (literally this term means "non-vulnerable, composure, calm") and severe analgesia.
Regional anesthesia
The largest distribution in clinical practice was obtained by local infiltration surface (terminal) and various types of conductor and regional anesthesia. Rarely apply hypothermal, intraosyl, intravascular under the harness and acupuncture anesthesia. Currently, local anesthesia is the main type of anesthesia in outpatient and polyclinic practice, as well as with small operational interventions.
Mechanism of action of drugs for local anesthesia
Preparations of this group block the transmission of nervous excitation pulses at the interaction site of their molecules with nerve fibers. At the same time, there is anesthesia of the entire area innervated by the blocked nerve and its endings. First of all, the transmission process of the nerve impulse under local anesthesia is eliminated by thin non-moving fibers of type C, providing pain sensitivity. Tactile sensations are preserved, they disappear later after the blockade of myelinated type A. fibers. Lastly, the blockade of motor fibers occurs during local anesthesia. The mechanism of action of drugs for local anesthesia is due to the fact that they prevent the occurrence of the nervous pulse and return it to the transmission through the nervous fiber. The main object of the action of drugs for local anesthesia is the nervous cell membrane, which plays a major role in generating and transmitting the nerve impulse. Preparations for local anesthesia violate the permeability of membranes for NA + ions in the occurrence of the action potential, which makes it impossible to depolarize the nerve cell and, thus, block perception and carrying out nerve impulses. They cause a nonpolarized blockade, stabilizing polarized membranes.
The topical drugs of the group of esters (in particular novocaine) are hydrolyzed by the esterase of blood plasma and are rapidly destroyed. The derivatives of amides (lidocaine, grimekain, pyromekine, etc.) act more prolonged, as they do not hydrolyze in the blood plasma, but disintegrated into the liver. To date, in anesthesiological practice, they are mainly used by plotting (novocaine), lidocaine, bupivakain and ropivakain.
Preparation for local anesthesia
Before performing local anesthesia, anesthesiologist must participate in the preoperative examination and preparation of the patient for surgical intervention. To reduce mental injury, ensure good sleep and the prevention of toxic influence of local anesthetics, patients before anesthesia are prescribed special premedication. It is particularly shown to persons with an elevated level of exchange and excitability processes of the nervous system (thyrotoxicosis, neurosis). Before starting anesthesia, it is necessary to prepare equipment, accessories and appropriate therapeutic agents for artificial ventilation of the lungs, inhalation of oxygen, the patient's removal from the cardiovascular collapse and eliminate allergic reactions.
Epidural anesthesia
In this form of anesthesia, the local anesthetic is introduced into the epidural space, not communicating with the spinal, nor with the brain, so it does not directly affect the brain. This is the main advantage of epidural anesthesia before spinal.
The anesthetic solution introduced into the epidural space ishes the spinal nerves roots leaving the spinal cord to epidural space. In addition, through intervertebral holes, it enters the border column, blocking them. This causes a blockade of sympathetic, sensitive and motor innervation. As a rule, the anesthesia covers a significant zone, since the anesthetic solution in epidural space rises up and lowers down at 5-8 segments (with a 10-16 ml of anesthetic).
Patients in respect of which the operation is planned under epidural anesthesia, it is necessary to carefully examine and prepare accordingly. It is especially important to replenish the volume of circulating blood from them, since in hypovesemia it is dangerous to use this type of anesthesia. Premedication should not be excessive. Neuroleptics cannot be applied with it. Anesthesia is carried out intravenous infusion 400-500 ml of crystalloid or colloidal blood-changing solutions.
Epidural anesthesia is performed in the patient's position sitting or lying on the side with the legs given to the belly. The choice of puncture is determined by the desired level of anesthesia. Puncture is carried out at the level corresponding to the center of the selected anesthesia zone.
Two needles are used for anesthesia: one - for subcutaneous injections, another - for the blockade. With the help of the first needle, pre-anesthesia of the skin and its main reservoir are carried out. Then they define the place of introduction of the second needle between the masculous process. For the blockade, a special needle of touoi is used, having a length of up to 10 cm and the inner diameter of about 1 mm, with a sharp, but short and curved end. It is introduced into the spine between the oscent processes strictly along the rear median line to a depth of 2-2.5 cm, in the lumbar region - perpendicular to the spine, in the chest department - at a small angle of the book, respectively, the direction of the coal processes (Fig. 34, a). Then the syringe filled with an isotonic solution of sodium chloride, and air bubble in it. Further promotion of the needle is deeply carried out by observing the degree of compression of the air bubble in the syringe.
Before entering the epidural space, the needle passes through the skin, subcutaneous layers, supervisory, interstit and yellow ligaments. While the end of the needle is between the fibers of the ligaments, the solution when pressed on the piston of the syringe flows very slowly, and the air bubble in it is compressed. As soon as the needle penetrates the epidural space, the resistance of the solution decreases and the piston is easily moving forward. Air bubble is not compressed. When disconnecting the syringe from the needle, liquid should not flow from it. If the fluid flows, this indicates that the end of the needle hit the vertebrate (spinal) channel. When the needle is guaranteed to penetrate the epidural space, 2-3 ml of anesthetic solution is introduced into it, in order to push the spinal solid sheath and prevent her perforation with a needle or catheter. Then the slim polyethylene catheter is introduced into the needle (Fig. 34, 6), through which anesthetic fractionally or infusion is introduced during and after surgery, thereby providing long-lasting anesthesia. First, the test dose of anesthetic is introduced, as a rule, 2-3 ml of 2% lidocaine solution or 0.5% - bupivacaine. Making sure that there are no signs of allergic and other unwanted reactions, the catheter is fixed and in 5-8 minutes the entire dose of the drug is introduced. For a full blockade of one spinal cord segment, adult patients requires 1-2.5 ml of a drug solution for local anesthesia. Since in patients of elderly and senile age, the volume of epidural space is reduced as a result of a fiber sclerosis that fills the space, the dose of the drug for local anesthesia is reduced by 30-50%.
Figure 34. The technique of puncture (a) and catheterization (b) epidural space.
To maintain a long postoperative analgesia, the catheter after surgery is left in epidural space (the so-called extended epidural anesthesia).
Possible complications for epidural anesthesia: 1) Collapse (the higher the level of epidural anesthesia, the greater the danger of its development). Collapse can be easily prevented by the introduction of 0.5% ephedrine solution in a low dose (fractionally 1-2 ml) in parallel with active infusion therapy; 2) respiratory disorders at high level epidural anesthesia; In these cases, artificial lung ventilation is required; 3) Headache, pain in the place of puncture; 4) traumatic radiculitis; 5) infection of epidural space.
Indications for the use of epidural anesthesia: 1) Large-scale operational interventions on the lower departments of the abdominal cavity, urological, proctological operations and operations on the lower limbs; 2) operations in individuals of elderly and senile age, with accompanying cardiovascular pathology, violations of the exchange processes, liver and kidney functions, in the practice of rodium; 3) in the presence of postoperative pain syndrome.
Epidural anesthesia is also used in order to quickly restore the intestinal peristals after operations on the abdominal organs, in the complex treatment of a number of diseases (acute pancreatitis, peritonitis, intestinal obstruction, with some pain syndromes and circulatory impairment in the limbs).
Contraindications: 1) the presence of inflammatory processes in the area of \u200b\u200bthe intended puncture or generalized infection; 2) hypovolemia, hypotension, heavy shock; 3) increased sensitivity to drugs for local anesthesia; 4) diseases of the spine, making it difficult to introduce the needle to epidural space; 5) Diseases of the peripheral and central nervous system.
Advantages of epidural anesthesia: 1) the possibility of achieving segmental anesthesia, accompanied by sufficient muscle relaxation and blockade of sympathetic innervation; 2) the ability to reduce blood pressure (if necessary); 3) Ensuring prolonged analgesia in the postoperative period and early restoration of patients's motor activity.
Regional anesthesia
Spinal anesthesia
In this form of anesthetization, the solution of the drug for local anesthesia (bupivacaine, lidocaine) is introduced into the subarachnoid space after a puncture of a solid spinal sheath. Anesthetic in this case quickly interacts with nervous roots and ensures the anesthesia of the whole part of the body located below the point of puncture. If the relative density of the introduced anesthetic solution is less than the relative density of the spinal fluid, it takes place its movement into the highest departments of the spinal cord. As a rule, 2% solution of lidocaine (3-4 ml) or 0.5-0.75% - bupivacain (2-3 ml) is used for spinal anesthesia. The duration of anesthesia with the use of lidocaine is 1 h, and Bupivacaine is 1.5-2 hours.
Spinal anesthesia is often used in operations on organs located below the diaphragm, and during operations on the lower limbs. The introduction of anesthetic above the level of the vertebra THXII may cause violation of the activities of vascular and respiratory centers. Even with a low level of anesthesia, as a rule, a decrease in blood pressure is noted. Arterial hypotension arises as a result of the influence of anesthetic on the connecting branches, conductive vasoconstrictor pulses from the vasomotor center to the periphery. This causes paralysis of vasomotor nerves (visceral and somatic).
The method of spinal anesthesia is more simple than epidural, since the exhaustion of the fluid from the needle is an exact indicator of the snapshot channel. Most often, the puncture is performed between the vertebrae L1-L2, or L2- L3. .
The patient's position on the operating table depends on the type of anesthetic applied. When conducting anesthesia by the drug, the relative density of which is less than the relative density of the spinal fluid, the patient after performing the spinal puncture in the sitting position and the administration of the drug should be put on the back so that the solution does not have time to move up. If the puncture is carried out in the lying position, the level of anesthesia is regulated by changing the position of the operating table.
Benefits of spinal anesthesia: high efficiency and achieving abdominal muscles relaxation.
Disadvantages of spinal anesthesia: the development of pronounced arterial hypotension is possible, inhibition of breathing, headache, urinary delay, manifestations of meningism. In case of accidental damage to the needle of spinal nerves roots, a traumatic radiculitis may occur in a patient. The use of thin pointed spinal needles (25-27 caliber) significantly reduces the frequency of the occurrence of postoperative headaches.
For an experienced anesthesiologist, even such a complication as a stop of breathing is not threatening. When stopping, breathing it is necessary to carry out the trachea intubation and start artificial ventilation of the lungs. In the event of a pronounced arterial hypotension, it is necessary to begin infusion of blood plasma substitutes, in the absence of effect, introduce adrenomimetic agents (ephedrine, phenylephrine / Meston).
Extended spinal anesthesia is used in operational interventions of any duration performed in the THIV-SV innervation zone. For this, the catheterization of the subarachnoid space is made. The anesthetic uses a 0.5% bupivacain solution. The initial dose of the drug is 3-4 ml (15-20 mg), repeated - 1.5-3 ml (7.5-15 mg). Repeated dose is introduced after 3-3.5 hours. 0.125% bupivacaine solution in a dose of 3-4 ml (3.75-4 mg) or fentanyl is used for postoperative anesthesia.
Complications of local anesthesia
Complications arising from local anesthesia are conventionally divided into complications caused by the improper implementation of the anesthesia technique, an overdose of anesthetic and an increased sensitivity to it. Complications caused by the features of the technique of performing various types of local anesthesia were covered earlier.
The clinical picture of poisoning by local anesthetics (yawn, anxiety, disorientation in space, tremor, headache, nausea, vomiting, generalized tonic and clonic convulsions) is due to their influence on the central nervous system. In severe cases of poisoning, death comes from the paralysis of the respiratory tract. The action of anesthetic on the cardiovascular system is first manifested in tachycardia and arterial hypertension. In the future, there is a decrease in electrical excitability, conductivity and contractile function of myocardium with the occurrence of bradycardia and the arterial hypotension until the heart is stopped. In the occurrence of toxic reaction to anesthetic, it is necessary to intravenously enter fatty emulsions, such as lipofundine, and artificially support the basic vital functions (artificial ventilation of the lungs, oxygen therapy, inotropic support, infusion therapy).
Frequent complications of local and regional anesthesia are anaphylactic reactions in patients with increased sensitivity to drugs for local anesthesia: allergic skin reaction, cardiovascular collapse (skewer pallor, cooling limbs, cold sticky sweat, sharp decrease in blood pressure, unconscious state) or anaphylactic shock.
Prevention and therapy of these complications should be etiopathogenetic.
It is known that each drug along with valuable properties has certain flaws. Almost all the drugs used and the methods of anesthetia are more or less dangerous for the operated. And some drugs do not give the required muscle relaxation or pain.
Choose the right method of anesthesia - it means not to damage the patient and create the best conditions for it during the operation and in the postoperative period, and the surgeon to ensure calm work and maximum amenities.
During the anesthesia, one narcotic agent of the patient has to give a relatively large number of it.
Combined anesthesia pursues the goal to use only the positive qualities of anesthetics and prevent manifestation of toxic action.
There are many varieties of combined anesthesia. To eliminate or reduce the disadvantages of anesthetic, to improve the course of anesthesia, anesthesiologist selects a special combination of anesthetics for each patient, depending on the general condition, the nature of the operation, etc. The combination of two is used, and sometimes three and more anesthetics. Two or three different types of drugs can be used consistently: input, supporting and optional.
Introductory anesthesia. Introductory anesthesia is not an independent type of anesthesia, but only a component of combined overall anesthesia. This type of anesthesia is always applied first, before the loss of consciousness, or when superficial overall anesthesia has not yet been reached.
Introductory anesthesia can be carried out using different substances and in various ways. You can use intravenous, recycling, inhalation path. From drugs capable of intravenous administration for a few seconds to put a patient, most often apply Barbiturates of a short action - hexenal, thiopental sodium, etc. For introductory anesthesia, fluorotan, cyclopropane, nitrogen rushing, etc. Inhalation drugs that do not cause irritation of the mucous membrane respiratory tract. Introductory anesthesia is always short-term.
Supporting, chief, or, as it is called, the main anesthesia is a means used throughout the operation. If another type of anesthesia is used to enhance the main drug substance, then such a tool is called additional. For example, when a thiopental sodium is used in the combined anesthesia and nitrogen is used with a moderate addition of fluorotan, thiopental sodium is called the introductory, nitrogen rushing - the main, and the added fluorotan is an additional drug.
Substances that do not have drug properties, but increasing the action of drugs and improving the course of anesthesia are called auxiliary means. These include muscle relaxants, neuropilegic substances, analgesics, etc.
Word " anesthesia"Comes from Greek" Avaiagnoia ", which means insensitivity or paralysis of sensitivity. Under anesthesia, the absence of all kinds of sensitivity is understood: tactile, pain and temperature. The concept of "analgesia" means the loss of only pain sensitivity.
The purpose of the anesthesiological manual - ensure the painless performance of interventions with impaired body tissue integrity (both classical open surgical operations and minimal-but-invasive), as well as invasive diagnostic studies and gaining increasing distribution of interventions relating to the field of so-called interventional medicine (therapeutic effects under control visa-lizational research methods).
primary goal anesthetic manual - Anesthesia - can be achieved in two ways - with the help of classical anesthesia and regional anesthesia. Synonym for anesthesia is general anesthesia. It differs from regional anesthesia, among other things, in that it implies to turn off the patient's consciousness.
Anesthesia implies anesthesia. Whole body is always carried out with the disconnected or at least oppressed consciousness. The expression "full anesthesia" used sometimes is a pleonism and applied, in any case, experts should not.
For general alestruction There are inhalation inhalations at the disposal of the anesthesiologists (enter the blood through light) and intravenous anesthetics. The point of application of these funds is the central nervous system (CNS), i.e. Head and spinal cord. Theoretically, inhalation, intravenous and balanced anesthesia should be isolated, under which the anesthesia is understood by the combined use of inhalation and intravenous anesthetics.
Since common anestheticsAs a rule, there is breathing, it is necessary to maintain it necessary devices of artificial ventilation (IVL).
When conducting regional anesthesia limited to the anesthesia of a certain part of the body ("local" anesthesia). There are central regional (spinal, peridural and caudal, or sacred) and peripheral (blockade of shoulder plexus, blockade of individual nerves) anesthesia. For regional anesthesia, special preparations are used, called local anesthetics.
They are injected ne. systems, and in the area of \u200b\u200bnerve conductors to block the excitability and carrying out nerve impulses. Consciousness and breathing of the patient are preserved.
Combined anesthesia
In some cases, with certain surgical interventions You can combine general anesthesia and regional anesthesia (combined anesthesia). This anesthesia method is particularly appropriate in cases where the regional anesthesia catheter as part of per-operational anesthesia must be used for "selective" analgesia in the postoperative period.
Combined anesthesia It should not be confused with combined anesthesia, under which the combined use of central action drugs belonging to various pharmacological groups, such as:
- administered intravenous anesthetics for input anesthesia and inhalation anesthetics to maintain anesthesia;
- administered intravenous sleeping pills to maintain sleep, opiates to maintain analgesia and muscle relaxation of skeletal muscles.
General anesthesia, or anesthesia - the condition characterized by temporary shutdown of consciousness, pain sensitivity, reflexes and relaxation of skeletal muscles caused by the effects of narcotic substances on the CNS.
Depending on the paths of administration of narcotic substances, inhalation and non-evaging anesthesia are distinguished in the body.
Theories of anesthesia. Currently, there is no anesthesia theory, clearly defining the mechanism of the narcotic actions of anesthetics. In chronological order, the main theories can be presented in the following form:
1. Coagulative theory of Claude Bernard (1875).
2. Lipoid theory of Meyer and Overton (1899 - 1901).
3. The theory of "suffocation of fervorn nerve cells" (1912).
4. Adsorption theory (border voltage) proposed Traub (1904 - 1913) and supported by Warburg (1914 -1918).
5. The theory of the aqueous microcrystals of Polion (1961).
In recent years, the membrane theory of the mechanism of action of common anesthetics at the subcelet molecular level has been widespread. It explains the development of anesthesia by the influence of anesthetics on the polarization mechanisms and depolarization of cell membranes.
Narcotic drugs cause characteristic changes in all organs and systems. In the period of saturation of the body, a certain pattern (stadium) is noted in a change in consciousness, respiration, blood circulation. In this connection, certain stages characterize the depth of anesthesia are distinguished. Especially distinct stages are manifested in essential anesthesia. In 1920, Gvedel divided narcosis into four stages. This classification is the main and currently.
4 stages are distinguished: I - analgesia, II - excitation, III - surgical stage divided by 4 levels, and IV-awakening.
Analgesia Stage ( I. ). The patient in consciousness, but inhibit, sleeping, is responsible for questions. There is no surface pain sensitivity, but tactile and thermal sensitivity is saved. During this period, short-term interventions are possible (opening phlegmon, urnets, diagnostic studies). Stage short-term, lasts 3-4 min.
Stage of excitation ( II. ). In this stage, there is a braking centers of the cortex of the Big Brain, while subcortex centers are in a state of excitement: there is no consciousness, the motor and speech excitement is expressed. Patients scream, try to get up from the operating table. Skin covers are hyperemic, pulse frequent, blood pressure is increased. The pupil is wide, but reacts to the light, a tear is marked. Completely appear cough, enhancing bronchial secretion, vomiting is possible. Surgical manipulations against the background of excitation can not be carried out. During this period, it is necessary to continue the saturation of the body by a narcotic agent for deepening anesthesia. The duration of the stage depends on the state of the patient, the experiment of the anesthesiologist. The excitement usually lasts 7-15 minutes.
Surgical stage ( III ). With the onset of this stage of anesthesia, the patient calms down, breathing becomes even, the pulse rate and blood pressure are approaching the initial level. During this period, operational interventions are possible. Depending on the depth of anesthesia, 4 levels of the III stage of anesthesia are distinguished.
First level( III ,1): The patient is calm, breathing is even, blood pressure and pulse achieve the initial magnesses. The pupil begins to narrow, the reaction to the light is saved. There is a smooth movement of eyeballs, an eccentric location. The corneal and pharyngeal guttural reflexes are preserved. Muscle tone is saved, so the holding of extensive operations is difficult.
Second level (III, 2): The movement of the eyeballs stops, they are located in the central position. Pupils begin to gradually expand, the reaction of the pupil to light weakens. The corneal and pharyngeal grain reflexes weaken and by the end of the second level disappear. Breath calm, smooth. Arterial pressure and pulse are normal. A decrease in the muscle tone begins, which allows abdominal operations. Typically, the anesthesia is carried out at level III, 1- III, 2.
Third Level (III, 3) - This is the level of deep anesthesia. Pupils are expanded, react only to a strong light irritant, no corneal reflex. During this period, there is a complete relaxation of skeletal muscles, including intercostal. Breathing becomes superficial, diaphragmal. As a result of the relaxation of the muscles of the lower jaw, the latter can be assimilated, in such cases the root of the tongue places and closes the entrance to the larynx, which leads to a respiratory stop. To prevent this complication, it is necessary to remove the lower jaw forward and maintain it in this position. The pulse at this level is rapidly, small filling. Arterial pressure is reduced. It is necessary to know that the conduct of anesthesia at this level is dangerous for the patient's life.
Fourth level ( III ,4): The maximum expansion of the pupil without reacting it into the light, the cornea dull, dry. Surface breathing is carried out due to the movements of the diaphragm due to the next paralysis of the intercostal muscles. The pulse threaded, frequent, blood pressure is low or not at all defined. To deepen the anesthesia to the fourth level is dangerous for the life of the patient, since the respiratory and blood circulation can occur.
Agonal stage ( IV ): It is a consequence of excessive deepening anesthesia and can lead to irreversible changes in CNS cells if its duration exceeds 3 to 5 minutes. Pupils are extremely expanded, without reaction to light. The corneal reflex is missing, the cornea is dry and dull. Lung ventilation is sharply reduced, breathing surface, diaphragmal. Skeletal muscles are paralyzed. Arterial pressure drops sharply. The pulse is frequent and weak, often not completely determined.
Disagreement from anesthesia that Zhorov I.S. Determines as a staging of awakening, begins from the moment of stopping the submission of anesthetic. The concentration of anesthetic agent in the blood decreases, the patient passes in the reverse order, all stages of anesthesia and an awakening occurs.
Preparation of a patient for anesthesia.
Anesthesic is directly involved in the preparation of a patient for anesthesia and operation. The patient is examined before the operation, and not only pay attention to the underlying disease, about which the operation will have to have, but also find out in detail the presence of concomitant diseases. If the patient is operated on as planned manner. Then, if necessary, the treatment of concomitant diseases, the occasion of the oral cavity. The doctor finds out and evaluates the mental state of the patient, finds out allergological Anamnesis, clarifies, was transferred to the patient in the past operation and anesthesia. Draws attention to the shape of the face, chest, the structure of the neck, the severity of the subcutaneous fatty fiber. All this is necessary to choose the way to choose an anesthetic method and a narcotic drug.
An important rule of the preparation of a patient for anesthesia is to purify the gastrointestinal tract (washing the stomach cleansing belizes).
To suppress the psycho-emotional reaction and oppressing the function of the wandering nerve before the operation, special drug training is carried out - premmed iK acycling . The purpose of the premedication is the removal of mental stress, the sedative effect, prevention of unwanted neurovative reactions, a decrease in sowing, bronchial secretion, as well as the increase in the anesthetic and the analgesic properties of narcotic substances. This is achieved by the use of a complex of pharmacological preparations. In particular, for mental calm, tranquilizers, barbiturates, neuroleptics and others are effective. Strengthening the activity of wandering nerves, as well as a decrease in the secretion of the mucous membranes of tracheobronchial and salivary glasses can be obtained using atropine, metacine or scopolamine. Antihistamines that have an additional sedative effect are widely used.
Premedication most often consists of two stages. In the evening, on the eve of the operation, hypnotic means are prescribed in combination with tranquilizers and antihistamine preparations. Particularly excited patients are repeated 2 hours before surgery. In addition, it is usually all patients for 30-40 minutes to operation introduce anticholinergic agents and analgesics. If the Holinergic drugs are not included in the anesthesia plan, then the assignment of atropine before the operation can be neglected, however, the anesthesiologist should always be able to introduce it during anesthesia. It is necessary to remember that if it is planned to use during the anesthesia of cholinergic preparations (succinylcholine, fluorotan) or tool irritation of the respiratory tract (trachea intubation, bronchoscopy), then there is a risk of bradycardia with a possible subsequent hypotension and the development of more serious heart rate disorders. In this case, the appointment into the premedication of anticholinergic preparations (atropine, metacin, glycopyrrolate, hyoscium) for the blockade of vagal reflexes is mandatory.
Usually, the means of premium during planned operations are injected intramuscularly, orally or rectally. Intravenous route of administration is impractical, because In this case, the duration of the action of drugs is less, and the side effects are more pronounced. Only with emergency operational interventions and special testimony introduced them intravenously.
M - cholinoblocators.
Atropine. For premedication, the atropine is introduced in / m or in / in a dose of 0.01 mg / kg. Anticholinergic properties of atropine allow you to effectively block the vagal reflexes and reduce the secretion of the bronchial tree.
In emergency cases, in the absence of venous access, the standard dose of atropine, divorced in 1 ml of physiological solution, ensures the achievement of a rapid effect during intraceal administration.
In children, atropine is used in the same doses. To avoid negative psycho-emotional influence on the child intramuscular injection, the atropine at a dose of 0.02 mg / kg can be given per OS 90 minutes to induction. In combination with barbiturates, atropine can also be introduced PER RECTUM when using this method of input anesthesia.
It must be remembered that the time of arrival atropin in the children of the first year of life during bradycardia is longer, and they, to achieve a rapid positive chronotropic effect, atropine must be administered as early as possible.
Contraindications for the use of atropine little. These include heart disease, accompanied by a rack tachycardia, individual intolerance, which is rare enough, as well as glaucoma.
Metacin. The peripheral cholinoreceptors metacin acts stronger than atropine, as well as more active on the effect on the bronchial muscles, is stronger than the secretion of salivary and bronchial glands.
Comparatives with atropine metacin more convenient for use, because, having a smaller mydriatic effect, it makes it possible to monitor the operation of the operation as a change in the diameter of the pupil. For the premedication, metacin is preferable because the heatinging of the heartbeat is expressed less, and according to the bronchhalytic action, it significantly exceeds atropine.
Metacin is applied to premium during cesarean operations. The use of the drug reduces the amplitude, duration and frequency of the uterus.
Skopolamine (Hyoscin). By influence on peripheral cholinoreceptors close to Atropin. Causes a sedative effect: reduces motor activity, can have a hypnotic effect.
It is necessary to take into account a very wide difference in individual sensitivity to the scopolamine: relatively often conventional doses cause no soothing, but excitation, hallucinations and other side effects.
Contraindications are the same as the appointment of atropine.
Glycopirolate. Glycopirolate is prescribed in doses of half from the dose of atropine. For premedication, 0.005-0.01 mg / kg is introduced, the usual dose of adults is 0.2-0.3 mg. Injection glycopyrrolates is produced as a solution containing 0.2 mg / ml (0.02%).
Of all M-cholinoblockers, glycopyrrolate is the most powerful inhibitor of the secretion of salivary glands and the heavily of the mucous membrane of the respiratory tract. Tachycardia occurs with the introduction of the drug in / in, but not in / m. Glycopyrrolate has a greater duration of action than atropine (2-4 hours after the introduction and 30 minutes after in / in injection).
Narcotic analgesics. Recently, the attitude towards the use of narcotic analgesics in premedication has changed somewhat. From the use of these drugs began to refuse, if the goal is to achieve a sedative effect. This is due to the fact that when applying opiates, a sedative effect and euphoria occurs only in part of patients. But others may have an undesirable dysphorous, nausea, vomiting, hypotension or respiratory oppression to one degree or another. Therefore, opioids are included in the premedication in the case when their use can be useful. First of all, this refers to patients with severe pain syndrome. In addition, the use of opiates allows you to strengthen the potential effect of premium.
Antihistamines.
Applied in premieces to prevent histamine effects in response to the stressful situation. This is especially true of patients with burdened allergic (bronchial asthma, atopic dermatitis, etc.). Of the drugs used in anesthesiology, a significant histamine-related action have, for example, some muscle relaxants (D-tubocurarine, atrakurium, mivacurium hydrochloride, etc.), morphine, iodine-containing x-ray drugs, large-molecular compounds (polyglyukin, etc.). Premedication is also used due to sedative, sleeping pills, central and peripheral cholinolitic and anti-inflammatory properties.
DiMedrol. - It has a pronounced antihistamine action, sedative and sleeping pills. As a premacege component uses 1% p-p at a dose of 0.1-0.5 mg / kg intravenously and intramuscularly.
Supratin - The ethylenediamine derivative, has a pronounced antihistamine and also, peripheral anticholinergic activity, the sedative effect is less pronounced. Doses - 2% r-p-0.3-0.5 mg / kg intravenously and intramuscularly.
Tueguil - Compared to Dimedrol, has a more pronounced and long-term antihistamine effect, has a moderate sedative effect. Doses - 0.2% rr - 0.03-0.05 mg / kg intramuscularly and intravenously.
Snow pills.
Phenobarbital (Luminal, Sedonal, Adonal). Barbiturate long-term action is 6-8 hours. Depending on the dose, sedative or hypnotic action, anticonvulsant action. In the anesthesiological practice, phenobarbital is prescribed as a sleeping bag on the eve of the operation on the night at a dose of 0.1-0.2 g inside, in children a single dose 0.005-0.01 g / kg.
Tranquilizers.
Droperidol. Neuroleptic from a group of butyrofenon. Nearegetative braking caused by droperidol lasts 3-24 hours. The drug also has a pronounced antiemetic effect. For the purpose of premium are used in a dose of 0.05-0.1 mg / kg V \u200b\u200b/ B, V / m. Standard doses of Droperidol (without a combination with other drugs) do not cause respiratory depression: on the contrary, the drug stimulates the respiratory reaction to hypoxia. Although after premedication, the Droperidol patients seem calm and indifferent, in fact they may feel a feeling of anxiety and fear. Therefore, premedication cannot be limited by the introduction of one droperidol.
Diazepam (Valium, Seduksen, Sibazon, Relanium). Refers to the group of benzodiazepines. Dose for premedication 0.2-0.5 mg / kg. It has a minimal effect on the cardiovascular system and breathing, has a pronounced sedative, anxiolytic and anticipant effects. However, in combination with other depressants or opioids, a respiratory center can be coated. It is one of the most commonly used means for premedication in children. It is assigned 30 minutes before the operation at a dose of 0.1-0.3 mg / kg intramuscularly, 0.1-0.25 mg / kg orally, 0.075 mg / kg - rectally. As a variant of premium on the table, intravenous administration is possible immediately before the operation at a dose of 0.1-0.15 mg / kg along with the atropine.
Midazolam (Dormikum, Flormidal). Midazolas water-soluble benzodiazepine with a faster start and less short period of action than diazepams. For premedication, it is applied at a dose of 0.05-0.15 mg / kg. After the introduction, the plasma concentration reaches a peak after 30 minutes. Midazolas is widely used in pediatric anesthesiology drug. Its use allows you to quickly and effectively reassure the child and prevent psycho-emotional stress associated with the separation from parents. The oral administration of the Midazolam in a dose of 0.5-0.75 mg / kg (with cherry syrup) provides sedation and removes the alarming state by 20-30 minutes. After this time, efficiency begins to decline and after 1 hour its action ends. The intravenous dose for premedication is 0.02-0.06 mg / kg, intramuscularly 0.06-0.08 mg / kg. It is possible to combined the introduction of mydazolam - at a dose of 0.1 mg / kg intravenously or intramuscularly and 0.3 mg / kg rectally. Higher doses of Midazolam can cause respiratory depression.
Rogpnol. (flunutrazepam). Benzodiazepine derivative with sedative, sleeping pills and anticonvulsant action. It is introduced intramuscularly at a dose of 0.03 mg / kg, intravenous- 0.015-0.03 mg / kg.
Some features:
a) Diazepams can be introduced rectally, in a dose - 0.075 mg / kg.
b) Midazolam orally (with cherry syrup) in a dose of 0.5-0.75 mg / kg or rectally in a dose of 0.75 - 0.1 mg / kg can be given 30 minutes before induction.
For the prevention of aspiration:
Cerukal - 0.15 mg / kg in / in;
- Cimetidine - 3 mg / kg in / m.
For the prevention of postoperative nausea and vomiting:
Droperidol in a dose of 0.075 mg / kg in / in, better before induction;
- Lorazepam 0.01 mg / kg, better before induction.
Intravenous anesthesia
The benefits of intravenous general anesthesia are rapid introduction to anesthesia, lack excitation Pleasant for patient falling asleep. However narcotic drugs for Intravenous administration creates short-term anesthesia, which does not make it possible to use them in its pure form for long-term operational interventions.
Derivatives barbiturova Acid - tio pen TA l-N. and trii. and g. ks. eN Al. - cause a rapid attack of narcotic sleep, the stage of excitation is missing, the awakening is fast. Clinical picture of anesthesia tiopental Sodium I. hxenal Identic. Hexenal It has a smaller oppression of breathing.
Use freshly prepared solutions barbiturates. For this, the contents of the vial (1 preparation) before the start of the anesthesia are dissolved in 100 ml of isotonic solution of sodium chloride (1% solution) . Punctured Vienna, and the solution is slowly administered at a speed of 1 ml for 10-15 s. After administration of 3-5 ml of solution for 30 s, the sensitivity of the patient to barbiturats, Then the administration of the drug continues to the surgical stage of anesthesia. Duration of anesthesia - 10-15 minutes from the moment of drug sleep after one-time administration of the drug. Duration of anesthesia is ensured by the fractional introduction of 100-200 mg. drug. The total dose of the drug should not exceed 1000 mg. In the process of administering the drug, the medical sister monitors the pulse, arterial pressure and breathing. Anesthesiologist monitors the state of pupil, the movement of eyeballs, the presence rogped Reflex to determine the level of anesthesia.
Anesthesia barbiturats, special tiopeital Sodium, which is peculiar to the oppression of breathing, due to which the presence of the breathing apparatus is necessary. When appearance apnea needed using a breathing apparatus mask to start artificial ventilation of the lungs (IVL). Fast administration tiopental Sodium can lead to a decrease in blood pressure, oppression of cardiac activity. In this case, it is necessary to stop the introduction of the drug. In surgical practice anesthesia barbiturati Used for short-term operations lasting 10-20 min (autopsy abscesses, phlegmon, rights dislocation, bone reposition wreckage). Barbiturates Also used for introductory anesthesia.
Vyadril (Preione for injection) applied at a dose of 15 mg / kg, Shared dose on average 1000 mg. Vyadril More often used in small doses together with nitrogen. In large dosages, the drug can lead to hypotension. The use of the drug is complicated by the development of phleets and thrombophlebitis. To prevent them, the drug is recommended to introduce slowly into the central vein in the form of 2.5%, the solution. Vyadril Used for introductory anesthesia, for endoscopic studies.
Prepanidide (Epontol, Somubrevin) is produced in ampoules of 10 ml of 5% solution. Dose of drug 7-10 mg / kg, introduced intravenously, quickly (all dose 500 mg. for 30 s). Sleep comes immediately - "at the end of the needle." Duration of anesthenous sleep 5-6 min. Awakening fast, calm. Application priogenida causes hyperventilation which appears immediately after the loss of consciousness. Sometimes it may occur apnea. In this case, be carried out IVL With the help of the breathing apparatus. The disadvantage is the possibility of development hypoxia Against the background of the administration of the drug. Control of blood pressure and pulse is required. The drug is used for introductory anesthesia, in an outpatient surgical practice for small operations.
Oxybuti AT NAT ia Gamma oxybutirate is a normal component of mammalian metabolism. It can be found in any cell of the human body, where it plays the role of nutrient (nutritional product). In the brain, the greatest concentrations of GOMC found in the hypothalamus and in the basal ganglia. At large concentrations are also present in the kidneys, heart, skeletal muscles. It is considered a neurotransmitter, although it does not quite satisfy all the requirements imposed by this class of substances. It is the precursor of gamma-aminobutyric acid (GABA), but does not affect its receptors directly.
For the first time, Gomk was allocated in 1874. The synthesis technique was published in 1929. This substance did not cause special interest from researchers while A. Bori did not study his biological role.
Labori found that GOMK is characterized by a number of effects, uncharacteristic for GABA. For many years, intensive studies of GOMK were carried out. In Europe, this drug is intensively used as a common anesthetic, as well as for the treatment of narcolepsy (daylighting), in akin (enhanced the contamination, contributes to the expansion of the neck), for the treatment of alcoholism and abstinence syndrome, as well as various other purposes.
Pharmacology Gomk
Gomk temporarily oppresses the release of dopamine cells of the brain. This can lead to an increase in dopamine reserves and subsequent enhanced emissions of this substance when the GOMK is passed. This may explain the phenomenon of night awakening, typical of large doses of gomka, as well as excellent well-being, carefit and excitement the day after the reception.
GOM also stimulates the release of growth hormone (somatotropic hormone, STG). In one methodologically correct study, by Japanese experts, a 9- and 16-fold increase in the concentration of STG in serum in six healthy men aged 25-40 years after 30 and 60 minutes, respectively, after intravenous administration of GOM in the amount of 2.5 g. 120 minutes after injection, the STG level remained elevated at 7 times compared with the original. The effect mechanism has not yet been studied. It is known that Dopamine stimulates the selection of STGs by the pituitary gland, but the GOM is inhibits the allocation of dopamine. This suggests that the influence of GOM at the level of the STG is mediated through some other mechanisms.
The level of prolactin in serum increases 5 times from the initial value on average 60 minutes after the drug. In contrast to the STG, this effect is fully mediated through the braking of dopamine isolation, as well as the effects of neuroleptics. Although Prolactin in some respects is an antagonist of STS, 16-fold increase in the level of the latter overcomes this opposition.
Gomk causes a distinct relaxation of skeletal muscles. In France and Italy, it is used in obstetrics. GOM contributes to the expansion of the cervix, reduces anxiety, increases the power and frequency of the uterus, increases the sensitivity of the myometrium to oxytocin. It does not oppress his breath in newborns, and even has an antihypoxic effect, especially when accruing umbilical.
Gomk is fully metabolized in the body to water and carbon dioxide, without leaving behind toxic metabolites. Metabolism is so effective that 4-5 hours after injection, the drug is no longer detected in the blood, and can only be detected in the urine.
GOMK activates a metabolic path, known as the "pentosular shunt", which plays a huge role in protein synthesis processes. The activation of this path also gives a protein-saving effect, braking the disintegration of the organism proteins.
Large (anesthetic) doses GOMK cause a certain increase in blood sugar levels and a significant decrease in cholesterol. Breathing becomes more rare, but deep. Blood pressure can be somewhat reduced or rose, or remain at the same level. Perhaps the appearance of moderate bradycardia.
Gomk was once called "almost perfect sleeping pills." In medium doses, it causes relaxation and soothing that create excellent conditions for natural falling asleep, and in large doses is sleeping bags.
The disadvantage of many sleeping pills is the violation of the structure of the sleep cycle, which prevents the full restoration of forces. Perhaps the outstanding property of sleep induced by GOM is its complete identity of the natural sleep. The ability to respond to pain incentives is preserved. This limits the value of GOM in the operating room. During sleep caused by GOM, the level of STGs in the blood increases. Also, in contrast to the action of other sleeping pills, GOMK does not reduce the need of an organism in oxygen.
The main disadvantage of oxybutirate as a sleeping pills is a short duration of action, usually about 3 hours. Against the background of the drug, the dream is deep and full, but after passing the drug is possible a premature awakening, and this phenomenon is becoming more distinct with an increase in the dose.
Pharmacokinetics
- start of action: after 10 - 20 minutes after oral administration
- duration of action: 1 - 3 hours
- residual effects: 2 - 4 hours
- plasma peak concentration: after 20 - 60 min after oral administration
- clearance: 14 ml / min / kg
- T1 / 2: 20 min.
The effect of the drug is enhanced by receiving an empty stomach.
Dependence "Dose Effect"
Small doses: Effects are similar to light alcoholic intoxication. Easy relaxation, increased sociability, reduced movement accuracy, light dizziness. Driving a car or work with dangerous mechanisms is not recommended.
Middle doses : relaxation increases, the psyche instability appears. Some marked high sensitivity to music, craving for dancing. The mood improves. There is some robustness of speech, inadequacy, foolishness. Sometimes nausea occurs. In many cases, hypersexuality is noted: increased sensitivity to contacts, men - an increase in erection, an orgasm increases.
High doses cause sleep. With the saved consciousness - a violation of equilibrium, weakness, a breaking.
Overdose It occurs very easily. For example, an additional quarter of a gram - and the euphoria is replaced by a feeling of nausea and vomiting. This problem is perhaps the main ones with the community use of the drug. With a combination of GOM with other psychotropic drugs, the situation may become unmanageable. For example, a combination of GOM + alcohol causes vomiting and loss of consciousness.
Ket. aI (Calipzol, Ketajest, Ketalar, Kalipsol, Ketaject, Ketalar, Ketamine, Ketaapest, Keto1AR, VTTALR). It is a means of intravenous and intramuscular administration, a general anesthetic and analgesic effect. The feature of the anesthetizing action of ketamine is a fast and short effect while preserving in drug doses of independent adequate respiration. General anesthesia caused by ketamine was called dissociative, since the effect of the drug is associated mainly with the oppressive influence on the associative zone and subcortical formation of the Talamus. In the body, ketamine is metabolized by demethylation. The main part of the biotransformation products is allocated for 2 hours with urine, but a small number of metabolites can remain in the body for several days. Cumulations for repeated administration of the drug is not marked. The estimated dose of the drug is 2-5 mg / kg.
The drug further reduces the somatic, pain sensitivity and less - visceral pain sensitivity, which should be considered at long-term operations. Ketamine is used for mononarchosis and combined anesthesia, especially in patients with low blood pressure, or if it is necessary to maintain self-breathing, or to conduct IVL with breathing mixtures that are not containing nitrogen zaksi.
Ketamine can be used in combination with neuroleptics (dropneridol, etc.) and analgesics (fentanyl, commotol, depidolor, etc.) In these cases, the dose of ketamine is reduced. When using ketamine, it is necessary to consider the features of its overall action on the body. The drug usually causes an increase in blood pressure (by 20-30%) and the increase in heart rate with an increase in the minute volume of the heart; Peripheral vascular resistance decreases. Cardiac stimulation can be reduced by the use of diazepam (sybazone). Usually, Ketamine does not inhibit breathing, does not cause laryngo - and bronchospasm, does not oppress reflexes from the upper respiratory tract: nausea and vomiting, as a rule, does not occur. With quick intravenous administration, breathing is possible. To reduce sowing, an atropine or metacine solution is introduced. The use of ketamine may be accompanied by involuntary movements, hypertonus, hallucinatory phenomena. These effects are preventing or removed by the introduction of tranquilizers, as well as droperidol. In the intravenous administration of the ketamine solution, pain and redness of the skin are sometimes possible, during waking - psychomotor excitation and relatively long-term disorientation. Ketamine is contraindicated in patients with violations of cerebral circulation (including with such history disorders), with severe hypertension, eclampsia in severe decompensation of blood circulation, epilepsy and other diseases accompanied by convulsive readiness. Care should be taken with larynx operations (the use of minelaxants is necessary). You can not mix the solutions of ketamine with barbiturates (precipitated falls).
Combined general anesthesia.
Combined called anesthesia, achieved by simultaneous or consistently using a combination of various drugs: common anesthetics, tranquilizers, analgesics, muscle relaxants. This allows you to significantly reduce the concentration of anesthetics and their toxic effect on the body.
Neuroleptanalgesia (NLA) is one of the types of combination anesthesia, in which, with the help of a combination of neuroleptic and drug analgesics, a special state of the body is achieved - neurolepsy. It is manifested by a decrease in mental and motor activity, the state of indifference, right up to catathonic and catalepsy, loss of sensitivity without turning off consciousness. This state is due to the selective effect of drugs used for the HTL, on the thalamus, hypothalamus and the reticular formation. The combination of the neuroleptic of Droperidol (dehydrobenzperidol) and analgesic fentanyl is used.
Atalaghesia. In recent years, an anesthetic practice has found a combination of a tranquilizer of diaspem with narcotic analgesics (fentanyl, pentazocin). Such an anesthesia was called Atalalgesia. In its influence on the body, this method has a lot in common with the HELL. Due to the fact that diazepams are less than Droperidol, reduces blood pressure, hypotension during atalagesia is observed less often.
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