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АкушерствоАнатомияАнестезиологияВакцинопрофилактикаВалеологияВетеринарияГигиенаЗаболеванияИммунологияКардиологияНеврологияНефрологияОнкологияОториноларингологияОфтальмологияПаразитологияПедиатрияПервая помощьПсихиатрияПульмонологияРеанимацияРевматологияСтоматологияТерапияТоксикологияТравматологияУрологияФармакологияФармацевтикаФизиотерапияФтизиатрияХирургияЭндокринологияЭпидемиология |
Materials and instruments1. Kocher's forceps. 2. Megyll's forceps or curved packer. 3. Tongue-holding forceps. 4. Mouth dilator. 5. Disposable syringes. 6. Systems for intravenous infusions. 7. Bandages. 8. Intravenous catheters. 9. Kit for puncture catheterization of veins according to Seldinger. Having convinced in the availability of the above-given instruments, anesthesiologist checks up the operation of anesthetic-respiratory equipment, electro-suction machine, laryngoscope, monitoring facilities and proceeds to initial narcosis. Initial anesthesia is a rapid putting to sleep and depression of consciousness and defense reflexes with the aim to avoid the excitation in anesthesia with spontaneous breathing or disagreeable sensations during tracheal intubation in anesthesia with APV. On the background of preoxygenation through anesthetic mask, usually, a potent hypnotic of short action (barbiturates, propofol) is introduced intravenously. In so doing, as a rule, the assisted ventilation of the lungs through a mask will be required. If catheterization of veins in the state of being awake is unadvisable (children) or difficult (obesity), as well as when some difficulties are expected in maintaining the respiratory tracts patency, an initial narcosis is performed with inhalation anesthetics, starting with low concentration and gradually increasing it in the inhaled gas mixture, until conditions will arise for catheterization of veins and tracheal intubation. Hereinafter, anesthesia is supplemented or completely maintained with intravenous anesthetics. In little children as the alternative forms of initial narcosis may be a peroral intake of hydroxybutyrate sodium with sweet syrup or fentanyl "candy" from mothers hands in the ward, midazolam, or ketamine intramuscular injection. If anesthesia is planned with APV, after putting to sleep the patient is adminis tered dithylinum intravenously, and in order to eliminate disorganized contractions of muscular fibers, 3 min prior to this, a precurarization is done with small doses of nondepolarizing myorelaxants (for example, arduan) or they add premedication with lidocain (2 mg/kg) or diazepam (0.05 mg/kg) intravenously. Trachea intubation is carried out, as a rule, by means of laryngoscope, under direct vision, through the mouth (orotracheal) or through the nose (nasotracheal). A proper position of the patient's head and neck is of great significance to facilitate the intubation. Two positions are used. The first is the classic Jackson's position (Fig. 3), in which an occipital part of the head is located on the table plane, the head is thrown back, the chin is raised slightly upwards and the lower jaw is protruded forward. In so doing, the axis of the larynx, trachea and the edge of the upper incisors form almost a straight line. To the drawbacks of this intubation technique one should refer a muscle tension of the neck and a lengthening of the distance from the teeth to the true glottis. These drawbacks are eliminated, if the so-called "improved" Jackson's position is applied (Fig. 4). The head lies on the pillow 10-12 cm in height and is slightly thrown back. The axes of the larynx and pharynx almost merge, the axis of oral cavity is at the obtuse angle to the axes of larynx and pharynx. If, here, to pull the lower jaw forward, all three axes will form almost a straight line.
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