IVANO-FRANKIVSK NATIONAL MEDICAL IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITET UNIVERSITET

Department Anesthesiology and Intensive Department Anesthesiology and Intensive CareCare

The general

anesthesiologycal

principles of

maintenance of

operative actionsMakoyda Iryna Yaremivna

The main questions of lecture The main questions of lecture

History of Anesthesia; Anesthesia. Local anesthesia;

General anesthesia.; Clinical pictures of narcosis;

Devices for narcosis ;

The general principles of theoretical and practical anesthesiology

The word is derived from the Greek words

an, which means “without” and aithesia which means “feeling”The development of anesthesia has made today’s

modern surgical techniques possible

In modern representation the ANESTHESIOLOGY is an independent section of medicine which develops

questions of the theory and practice of anaesthesia and protection of an organism from excessive irritates,

which arise during operation. In other words, it is system of protection of a human body

from an operational trauma.It expects a number of actions which begin before operation

exist during it and come to an end in the period after operation.

History of Anesthesia

•1772-Joseph Priestly - discovery of N2O•1846-Dr. William T.G. Morton First anesthesia

specialist Oct. 16, 1846 - Ether Day at Harvard Medical School

•Oliver Wendell Holmes suggested the name "Anesthesia"•Ether synthesized in 1540 by Cordus•Ether used as anesthetic in 1842 by Dr. Crawford W. Long•Ether publicized as anesthetic in 1846 by Dr. William Morton

1847 - M.I.Pirogov - endotracheal narcosis and spinal anaesthesia in experiment, rectal and i/v a narcosis in clinic1847 y. - Simpson - the first chloroformic narcosis1847 y. - John Snow - the first professional anaesthesiologist1863 y. - Green - morfin for premedication1868 y. - Endrys - narcosis N2O in a combination with О2

•Endotracheal tube discovered in 1878•Local anesthesia with cocaine in 1885•1911. Legman - chlorethyleni narcosis•1922 y.- local infiltration anaesthesia by a method creeping infiltrat•1932 y. - i/v gexenaly narcosis•1934 y. - cyklopropanall narcosis•1936 y. - Landi - i/v thiopentaly narcosis •1937 y. - Gvedell - classification of stages of a narcosis•Curare first used in 1942 - opened the “Age of Anesthesia”

Influence of operation on an organism

Local changes:

1. Occurrence of the painful irritations

2. Nekrobiotic damage

3. Allocation of the local vasoactive substances, hormones.

4. Development of a local hypostasis

5. Creation of conditions for infection

6. Specific influence on breath bodies (a thorax wound), blood circulations (wounds with a bleeding).

Common changes:

1. Paine

2. Neurovegetative and neuroendocrine disorders

3. Exchanges disorders

4. Breathing disorder

5. Changes of blood circulation

6. Changes of reological properties of the blood.

PAINEPAINE - - This complex sharply negative emotional sensation which

arises owing to action of hurting factors on special receptors

Stages of formation of painful reaction:1. Transformation of pathological influence into

electric signal in painful receptors, education of a painful impulse

2. Transfer of the created painful signal by afferent nervous ways

3. Formations of sensation of a pain and respective mental reaction, "decoding", "judgement" of a pain in the painful centres

4. Formation of reaction-answer and its transfer on efferent nervous ways

INFLUENCE OF PAINFUL IMPULSES ON THE ORGANISM

PAINE

EXCITATION OF THE VEGETATIVE CENTERS OF THE SUBCORTEX

• Stimulation of the sympathetic and parasympathetic nervous systems2. Hyperproduction of adrenaline, noradrenaline3. Hyperproduction stressful hormons (ТТH, аldosteroni, cytokines, glukagoni)

DEVELOPMENT OF SELIE ADAPTABLE SYNDROME

Сardio-vascular system:1. Таchicardia2. Increasing of the BP3. Spasm of arterioles4. Microcirculation infringement5. A blood condensation6. Deterioration reological qualities of blood7. Hypercoagulation

Breathing:1.Tachypnoe2. Spasm of bronchioles3. Decrease of V V of L4. Increase of breathing hypoxia

Kidneys:1. Decrease of diuresis2. Detention of Na+ 3. Detention of Н2О4. Accumulation of the nitrogenous slags

Metabolism:1. Hyperglykemia2. Stimulation of neoglukogenesis3. Braking of the aerobic glikolisis4. Disintegration of albumins5. Increase of acidities and development of the metabolic acidosis

Secondary infringements of functions of all bodies and systems With development of poliorganic insufficiency

THE MAIN REQUIREMENTS TO ANESTHESIA METHODS

Common (nonspecific)Components of anesthesia Than it is provided

1. Аmnesia – disagreement of consciousness

Common anesthetics, sedative drugs, hypnosis

2. Аnalgesium (an-disagreement, algos - a pain) - deenergizings of painful sensitivity

Common and local anesthetics, narcotic and no narcotic analgesics

3. Neurovegetative blockade Common anesthetic, central and peripheral cholino- and аdrenomimetic, neuroleptic

4. Миоплегия - relaxations of muscles Common and local anesthetics.

5. Adequate haemodynamics Drugs for regulation of the rhythm and power of heart contraction, microcirculation, coagulation and reological properties of the blood.

6. Adequate gas exchange Passableness of respiratory ways, blood oxygenation, auxiliary and V of L

Correction of metabolism, temperature.

Classification of methods of anaesthesia

Local anesthesia General anesthesia

1. THE SUPERFICIAL (Terminal): a) Greasing b) Splashes c) Cooling

2. Infiltration :a) The openedb) The closed

3. Explorer (The regional):а) topicalb) plexus blocks (novocaini blocks)c) caudald) epidural i) spinal

Types of local anesthsia

Local narcosis:

•Terminal. •Infiltration. •Regional: juxtaspinal; intercostal; sacral; anaesthesia of jaw area. •Spinal (subarachnoidal). •Epidural. •Intracostal. •Intravenous regional. Anaesthesia of cross-sectional.

COMMON (NARCOSIS)

1. The inhalationa) mask

b) endotracheal

2. NONINHALATION:а) i\vб) i\mв) peroralг) perrectumд) intra- cavital

Superficial (terminal) anaesthesia

Switches on - the prevention of occurrence of painful impulses in the

nervous receptors placed in a skin or mucous membranes

It is executed by methods:

- Greasings (2-5 % a solution of novocaini, lidocaine, paste “Еmla” with prilocaini that lidocaini)

- Irrigation (2-5 % solution of novocaini, lidocaine, 10 % an aerosol lidocaini)

- Cooling (solution of chlorethyl)

EMLA

INFILTRATIONAL ANESTHESIA

- Expects the prevention of painful impulses in nervous receptors in all fabrics on any depth: 0,25-0,5 % solution of novocaini, lidocaine, marcaini or naropini are spent by such methods:

- Closed - all fabrics which will be hurt during operation, stage by stage spend infiltration by anesthetic through pierce in a skin, since “a lemon crust”

- Opened – infiltration of fabrics by solution of anesthetic spend gradually, connecting it with cuts

CONDACTIONAL LOCAL ANESTHESIA

Trunk anesthesia – Interrupts nervous impulses at level of trunk of

peripheral nerves

1-2% solution of novocaini or lidocaini enter peri - or endoneural of nervous trunks which perform nervous support an operation zone

Block of n.femoralisAnesthesia by Oberst-Lukashevich

Plexus anesthesia (Novocain blocks)

– Interrupts nervous impulses at level of nerves plexus, into which projection enter 0,25-0,5% solution of novocaini or lidocaini

Vago-sympathy block Paranefral block

CONDACTIONAL LOCAL ANESTHESIA

Paravertebral anesthesia

– Interrupts pain impulses at level of spinal nervs (by arrows it is specified, where enter a solution

1% novocaini, lidocaini, marcaini or naropini)

CONDACTIONAL LOCAL ANESTHESIA

Peri-(epi-) dural anesthesia – Interrupts pain impulses in peridural space on level of

posterior (sensitive) radicals of spinal cord

CONDACTIONAL LOCAL ANESTHESIA

CONDACTIONAL LOCAL ANESTHESIA

Sacral (caudal) anesthesia – variant of epidural, when anesthetic entered in epidural space

throw canalis sacralis

Drugs for epiduralanesthesia

1. 2-2,5% sol. Trimecaini2. 2. 2% sol. lidocaini

3. 0,5% sol. karbostesini (bupivacaini)

4. 2% sol. mepivacaini5. 1% sol. ropivacaini

6.To them it is possible to add: morphine in doses = 1/10

usual

Drugs for anesthesia

1. 1,5 – 2 ml 5% sol. novocaini

2. 4 – 5 ml 2% or 2 ml 5% sol. lidocaini

3. 0,5 – 1 ml 1% sol. sovcaini

4. 3 ml 0,5% sol. bupivacaini

5. 3-5 ml sol. ropivacaini

CONDACTIONAL LOCAL ANESTHESIA

SPINAL ANESTHESIA Interrupts pain impulses at level of subdural placed posterior

radicals and conductive ways of painful sensitivity of spinal cord (tractus spino-thalamicus)

GENERAL ANESTHESIA=

NARCOSISNarcosis - is artificial called, potentially reversible status of an organism to which it is characteristic loss of consciousness and oppression of reflex activity;

At a deep narcosis the relaxation of muscles, neuro-vegetative blockade, oppression of the vital functions of an organism is observed.

Theory of narcosis

1. Coagulative theory of Claude Bernar (1875). 2. Lipoid theory of Meyer and Overton (1899 - 1901). 3. Theory of "asphyxiation of nervous cages of Fervorn" (1912). 4. An adsorption theory (frontier tension) is offered Traube (1904 - 1913) and Varburg (1914 -1918) is supported. Theory of aquatic microcrystal of Polling (1961).

Narcosis stages

Preparatory stage

Anaesthesia induction (introduction narcosis)

Stage of maintenance of anaesthesia

Stage of exit from narcosis

Narcosis stages

1. Preparatory stage

The remote preparation:1. To define an accompanying pathology2. To liquidate it or to translate in a status of proof remission3. To define degree operational-anesthesiological risk4. To spend choice of method of anesthesias5. To spend psychological preventive job with patients (or his relatives)

The direct reparation:1. Sanitary processing of the patient2. Preparation o GIT3. Maintenance of the mental balance and a quiet dream4. Premedication: analgesics Tranquilisator antiallergic M-holinolitics

2. Introduction narcosis (inhalator or noninhalator drags)

3. MAINE NARCOSIS spending in ІІІ1-ІІІ3 stages inhalator or noninhalator drags or their

combination, narcotic or nonnarcotic analgetics, neuroleptic, hypnotics,

sedatives, stimulators of alfa-2-receptors, miorelaxants

4. Exit from a narcosis or awakening

5. Early after narcosis period – Lasts throughout 1 days after operation, demands supervision

over the patient by the anaesthesiologist for the purpose of correction of vital signs and homeostasis indicators

Narcosis stages

Narcosis stages

І – analgesic; ІІ – Excitation; ІІІ - a surgical stage (ІІІ 1 - ІІІ 4); IV - awakenings (toxic/agonal)

Stage of analgesia (I).

A patient is in consciousness, but put on the brakes, dozes, on questions answers monosyllabically. A superficial algesthesia absents, but a haptic and

thermal sensitiveness is stored. Implementation of brief interferences (dissection of phlegmons,

abscesses, diagnostic researches) is possible in this period. Stage brief, 3-4 lasts min

Stage of excitation (II).

There is braking of centers of bark of large brain in this stage, while under bark centers are in a state of excitation:

consciousness absents, motive and vocal excitation is expressed. Patients yell, try to get up from an operating table.

The cutaneous covering is bloodshot, pulse frequent, an arteriotony is enhanceable. Pupil wide, but reacts on light, a lacrimation is marked. A cough, strengthening of bronchial

secretion, appear often, vomiting is possible. Surgical manipulations on a background excitation, conducting is

impossible.In this period it is necessary to continue the satiation of

organism a narcotic mean for deepening of anesthesia. Duration of the stage depends on the state pain of ного, experience of

anaesthetist. Excitation usually lasts 7-15 min

Surgical stage (III).

With the offensive of this stage of anesthesia of patient calms down, breathing becomes even, a heart rate and arteriotony

approach an initial level. Realization of operative interventions is possible in this

period.

Leadingout from anesthesia

Awakening stage, begins from the moment of stopping of serve of anesthetic. The

concentration of anesthetic diminishes in blood, a patient passes upside-down, all

stages of anesthesia and awakening comes.

Monitoring of depth of narcosis

Monitoring of depth of narcosis

Preparation of patient to anesthesia.

A patient is examined before an operation, here not only pay attention to basic disease which an operation coming concerning but also in detail find out the presence of concomitant diseases. If a patient is

operated in the plan order. that if necessary is conducted treatment of concomitant diseases, sanation of cavity of mouth. A doctor finds out

and estimates the mental condition of patient, allergist anamnesis finds out, specifies, whether a patient carried in the past operations

and anesthesias.Pays attention to form of person, thorax, structure of neck, expressed of fatty hypoderm. All of it is necessary, that it is correct to choose the

method of anaesthetizing and narcotic preparation.The important rule of preparation of patient to anesthesia is clearing

of gastrointestinal tract (washing of stomach, cleansing enemas).

Premedication

An aim of premedication is a removal of psychical tension, sedative effect, warning of undesirable neurovegetative reactions, diminishing of sialosis, to the bronchial secretion, and also strengthening of anesthetic and analgetic properties of narcotic matters.

It is arrived at by application of complex of pharmacological preparations. In particular, for the psychical calming tranquilizers, barbiturates, neuroleptic and other, are effective.

Strengthening of activity of vaguss, and also diminishing of secretion of mucous membranes of tracheobronchial tree and salivary glands can be got by means of atropine, metacinum or scopolaminum.

Apparatus for anesthesia.

An anesthesia vehicle is the special device, intended for a serve to the patient of the exactly dosed amounts (concentrations) of gas

and volatile narcotic matters and creation of optimal terms of interchange of gases in lungs. If necessary an anesthesia vehicle

must provide artificial and auxiliary ventilation of lungs.Any anesthesia vehicle consists of 3 knots: reservoir (source) of

gases - oxygen, nitrous oxide, cyclopropanum; dosimeter of gases and vaporizer for narcotic volatiles (ether, ftorotanum, trylene and

other); respiratory contour.Bulbs in which gas is under constraint name the source of gases,

that provides a large capacity at a relatively small volume, reducing gears and dosimeters. Bulbs with oxygen are painted in blue, with a nitrous oxide - in grey and with cyclopropanum - in a red color. To decrease pressure on an exit from bulbs with oxygen and nitrous oxide and to provide constancy of this (3-4ат) LP, use

reducing gears.

Dosimeters.

Devices, intended for the serve of exact amounts of oxygen, nitrous and cyclopropanum oxide. On most vehicles dosimeters are set. At the simultaneous entering chamber of a few gases, for example oxygen and nitrous oxide, oxygen and cyclopropanum, there is their mixing in a chamber, and from her they act to the patient simultaneously. The concentration of them will depend on the size of stream, set on every rotametr.

Vaporizers. The dosed serve of liquid narcotic matters is carried out

through devices in which these matters grow into steam (evaporate). A patient breathes in them already as steams. Vaporizers consist of chamber in which pour a narcotic matter, and batching device. The last allows to skip all or part of gas stream through a chamber or quite to pass her. In last case after an exit from a vaporizer gas will not contain steams of narcotic matter.

If all stream will get through a chamber, then gas will be maximally saturated by a narcotic matter. In intermediate positions a satiation of gas will be less than, than at the complete "opening" of vaporizer.

Workplace of the anaesthesiologist

The narcotic machine (device) Preparations for a narcosis Cardiomonitor multipurpose Infusomat Pomp with syringe Aspirator Sterile little table and set of solutions and medicines

"for all occasions" Devices for warming of the patient; Account materials (cathetrs, masks, tubes)

The basic sites of the narcotic The basic sites of the narcotic devicedevice

RotametrRotametr (a dosage of gases); (a dosage of gases);

Evaporators (a dosage flying Evaporators (a dosage flying anestheticanesthetic););

Adsorber (adsorption СО2);Adsorber (adsorption СО2);

System of valves of a breath and exhalation;System of valves of a breath and exhalation;

Respiratory bag, respirator;Respiratory bag, respirator;

Respiratory contour (system of internal tubes and Respiratory contour (system of internal tubes and hoses of the patient);hoses of the patient);

The monitor of job of the narcotic device;The monitor of job of the narcotic device;

Additional options (the monitor of the patient, Additional options (the monitor of the patient, BIS,BIS, the monitor of nervously-muscular conductivitythe monitor of nervously-muscular conductivity

Types of a respiratory contourTypes of a respiratory contour

OpenedOpened - - (a breath from atmosphere - an (a breath from atmosphere - an exhalation in atmosphere);exhalation in atmosphere);

Half-openedHalf-opened - - (a breath from the device - (a breath from the device - an exhalation in atmosphere);an exhalation in atmosphere);

Half-closedHalf-closed - - (partial (partial rerecirculation of circulation of gases);gases);

ClosedClosed - - (full (full rerecirculation of gases).circulation of gases).

GENERAL ANESTHETICS

INHALATORY NONINHALATORY

GASES FLUIDES DERIVATIVES BARBITURACIDS NONBARBITURATES

1. Nitrous oxide (N20)

2. Cyclo propan (С3Н6)

1. Диетиловий ефір2. Ftorotan (galotan, narcotan, fluotan)3. Chloroform4. Трихлоретилен (trylen)5. Metoxyflurane (pentran)6. Enflurane (etran)7. Іsoflurane (foran)8. Sevoflurane9. Desflurane

1. Thiopental (pentotal)2. Gexenal (evipan natrii)

1. Ketamin (kalipsol, ketallar)

2. Natrii oxybutirat (ГОМК,Y-он)

3. Viadrili (presureni, predioni)

4. Аltesin (аlfatesin)

5. Sombrevini (propanidid, epontol)

6. Etomidat (hypnomidaqt)

7. Propofoli (diprivan, recofol) Relaxant

Basic typical complications of anesthesia

Breathing system obstruction Anaphylaxis Light anesthesiaRecurarisation

Anaphylaxis Allergic reaction of immediate type the

answer to introductions/uses of any preparation for a narcosis, an antibiotic, contrast, antiseptics, latex, cement;

Displays: often "are disguised" by a narcosis!!!, a hypotension, a tahy/bradycardia, a bronchospasm, a rash, hyperemia of faces, breasts;

Tactics: to stop introduction of probable allergen, adrenaline i/v, hormones, eufyllini, Н1-blockers, to reduce depth of anaesthesia.

Laryngospasm Instant closing of a vocal crack which is

accompanied by sharp weighting or impossibility of a breath (inspiratory stenosis);

The status threatens a life and can quickly lead to death through hypoxia!

The reasons: slime on a vocal crack, irritation by catheter, an air line, afterintubational hypostasis (it is frequent at children);

Tactics: anaesthesia deepening + atropine of 0,5 ml i/v + ditilini 1,5-2 mg/kg i/v + ALV.

BRONCHOSPASM Fast deterioration of bronchial conductivity

owing to a spasm of muscles of bronchial tubes;

Displays: the exhalation, опір on a breath is sharply weighted or impossible, the exhalation - is extended, dry whistling rattles on an exhalation;

The reasons: superficial anaesthesia, mechanical irritation;

Tactics: ftorotani 1,5-2,6 % + ventolini 2-4 doses in line of inspiration + eufylini i/v + dexasoni 12 mg i/v + β2 - adrenomymetix i/v;

REGURGITATION AND ASPIRATION

REGURGITATION – Passive hit of gastric contained in a tracheal-bronchial a tree and lungs;

ASPIRATION - active hit of gastric contents and contents of laryngthroat in a tracheal-bronchial tree and lungs;;

The reasons: “a full stomach”, infringement of technics of an induction of anaesthesia, a nonhermetic trachea;

Displays: a bronchospasm, decrease сатурации blood, pressure increase at a breath, pathological noise in a respiratory contour, gastric contained in a trachea;

Preventive maintenance: -Will lock the food uses 6 hours prior to a

narcosis; Stomach-washing before an urgent narcosis; - Use of Sellik”s reception; -Fast consecutive induction of anaesthesia; SELLIK”S Reception: pressing by two hands

on персневидний a cartilage with force of 3 kg from the moment of the beginning of "consciousness deenergizing” by the moment of inflating of cuffs ЕТТ. The trained assistant to the anaesthesiologist executes.

REGURGITATION AND ASPIRATION