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IV. Table of contents of teachingGeneral anaesthesia or anesthesia (grets. inarcao, narcosis – to grow torpid, numbness) – this artificially the conditioned violation of functions TSNS, caused by action of anesteticiv or electric current and is accompanied by the loss pritomi, by the decline of different types of sensitiveness, weakening of muscles, by oppression of reflexes and other important functions of organism. From the point of view pharmacologists - it caused by a pharmacological way deep sleep (reverse oppression of cages TSNS) artificially, that is accompanied by the listed above changes. Depending on the method of introduction to the organism of narcotic matters select: - inhalation anesthesia; - no the inhalation anesthesia. Depending on the quantity of used anasteticiv: - odnocomponentnыy; - multicomponent. Under inhalation by anesthesia understand such anesthesia which is caused by inhalation pariv volatile narcotic matters or narcotic gases. At inhalation anesthesia the narcotic matters are brought into an organism through respiratory tracts (trachea, carried, mouth, traaheostomou). Odnocomponentnыy (clean) anesthesia is anesthesia, when in an organism one narcotic preparation is entered (for example, ether); multicomponent – when the two or more are entered simultaneously narcotic preparations (for example, ether and nitrous oxide) and the combined anesthesia – when anaesthesia is achieved by the simultaneous or successive use of preparations of a different action (general anesteticiv, analgeticiv, tranquilizers, muscular relacsantiv). It is the most difficult type of anesthesia. His components are: a base is anesthesia, introductory anesthesia and supporting anesthesia. Base the anesthesia – it is superficial anesthesia on a background which to be entered basic anestetic, is Used for reduction of quantity of the use of basic anestetica and removal of emotional reactions at children and persons with a labilnoyo psyche. The narcotic matters for base-anesthesia are often brought into a rectum (enemas, candles), hypodermic, intravenously, vnoutrishnom'yazevo before the operation, as a rule, in a chamber. A base shows anesthesia the action to the operation, under time and some time after the operation. Introductory anesthesia – it is of short duration anesthesia by means which the removal of excitation and reduction of satiation of organism is foreseen by main narcotic preparation. Supporting (basic, main) – it is anesthesia which apply during all operation. Incomplete and complete inhalation anesthesia is distinguished. Incomplete anesthesia – analgeziya is achieved for a few minutes. Apply for corotcotrivalih operative interferences. Complete anesthesia – apply at the of long duration operations. Theories of anesthesia The mechanism of origin of narcotic sleep is explained in majority by the phenomena physical or physiology and chemical (coagoulyatsiyna theory of Claude Bernara (1875), lipoidna theory Meyera (1899), theory of oppression of nervous cages Fervorca (1912), adsorption theory Traoube (1904), theory of microcristaliv IIolinga (1961). The last years special distribution was got by the membrane theory of mechanism of action of common narcotic matters at a subcellular molecular level. She poyasnyae development of anesthesia by influence of narcotic matters on the machineries of polarizing and depolarization of cellular membranes. Anestetici, dissolving in a cellular membrane worsen its penetrating for the ions of sodium, violate the generation of excitation and lower potential of action. Instruments, vehicles and matters for anesthesia Are studied in thematic classes, on stands, rooms for anesthesia, where vehicles and instruments are saved, operating-rooms and bandaging. Anesthesia masks are demonstrated: Esmarha, Shimmelbousha, Giyyara, Ombredana-Sadovenca and others. Instruments for intoubatsii of trachea (sets of tubes, laryngoscope and others)are studied, instruments of care of patient during conducting of anesthesia. Anesthesia vehicles are carefully studied. Pay attention to the modern anesthesia vehicles (universal anesthesia vehicle "Policarcon-2-2") consists of basic 4 knots: bulb with a reducing gear, gas dosimeter, viparnica of anesteticiv and respiratory system. Setting of each in them is also studied. To the students the narcotic matters are demonstrated, muscular relacsanti and others anestetici. Underline that for inhalation anesthesia the liquids are used, that evaporate (ether for anesthesia, ftorotan, pentran, vineten and in.)easily, and gaseous matters (nitrous oxide, tsiclopropan, nartsilep, etilen and in.). The modern anestetici, which are mesh toxic and more effective and guided, use now (sevoflyoran, flyoran, disflyoran and in). Students execute tests on the cleanness of ether on the filtration and litmus scraps of paper. Premedicatsiya Under premedicatsieyo it follows to understand application of complex of medications at preparation of patient to anesthesia or local anaesthetizing with the purpose of reduction of psihoemotsiynoi tension before the operation, providing of neyrovegetativnih reactions, to prevention of indirect action of narcotic matters, facilitation of introduction to anesthesia and support of stability of him in the process of conducting. In premedicatsii include: sedativni matters from the group of barbitourativ, narcotic analgetici, neyroplegici, holinolitici and desensibilizouyochi preparations. The charts of premedicatsii are resulted in textbooks from general surgery. At finding of this question out tables, sliding seats, stands, hospital charts, are used, protocols of implementation of anesthesia. Muscular relacsanti Muscular relacsanti is the matters which cause weakening of the cut muscles into strips, that possibility gives to conduct anaesthetizing at a superficial level, and to the surgeon creates ideal terms for implementation of the most difficult operations. Muscular relacsanti are offered by canadian anaesthetists Griffitsom and Dgecsonom in 1942, which for this purpose applied preparation of courare-intocostrin. The mechanism of action of muscular relacsantiv is related to the blockade of transmission of impulses from a nervous fibre on muscles in nervovo-m'yazovomou sinapsi. Depending on a mechanism the blockades distinguish muscular relacsanti of depolarizing (short) and undepolarizing (protracted) action. Muscular relacsanti of short action (depolarizing) is operated to atsetilholinou like - cause depolarization longer than in a norm (0,001 s). Farther atsetilholin gidrolizouetsya on holin and vinegar acid a holinesterazoyo and pislyasinaptichna membrane is again polarized. The group of ditilinou belongs to muscular relacsantiv of short action (listinon, soutsinilholin, miorelacsin and in). Undepolarizing muscular relacsanti block the receptors of eventual nervovo-m'yazovoi plate (co-operation of atsetilholinou with receptors is impossible, in this connection action of him does not show up). The group of diplatsinou belongs to undepolarizing muscular relacsantiv: toubo-courarinhlorid (toubarin), pancouronilinbromid (pavoulon), anatroucsoniy, diacsoniy, artouan and in.). Prozerin and galantamin is the antagonists of undepolarizing muscular relacsantiv. Mascoviy anesthesia This question is worked off in the operating or bandaging surgical, travmatologichnih and festering-septic separations. Mascoviy anesthesia can be conducted by the opened crapelnim method by means simple facial respiratory masks Esmarha, Vancouverata and in. In the case of anesthesia after the opened contour a patient breathes in anestetic through a mask and breathes out in an atmosphere. In communication with failing is used rarely. Today with hospitals aparatno-mascoviy anesthesia after a half-open contour is used more frequent, when a narcotic mixture acts from bulbs to the patient through viparnic, and vidihouvane air is selected in an atmosphere. Mascoviy anesthesia by means modern vehicles enables exactly to regulate a dose and decrease expenses of anesteticiv, simultaneously to apply the narcotic matters. The increase of dead ground is failing, complication in providing SHVL, impossibility of conducting of anesthesia in ophthalmology, otorinolarinologii, to jaw-facial surgery, neuro-surgery and in. Clinic of ether mascovogo anesthesia The narcotic matters cause the characteristic changes in all organs and systems. In the period of satiation by them to the organism definite conformity to the law of change of pain sensitiveness, consciousness, breathing is marked. These changes come slowly and enable to trace the clinic of ether anesthesia after stages and phases. In the first stage of anesthesia (analgezii) after classification Gvedelya, 3 clinical levels are distinguished: And a level is absence of analgezii, the II-y level is partial analgeziya, the III-y level is full analgeziya and amnesia. At Sh even analgezii it is possible to execute corotcotrivali operative interferences. The second stage (excitation). In this stage a patient loses the management. The third stage (surgical, deep sleep). In her 4 levels are selected: III1 – superficial anesthesia which mobility of eyeballs still remains during, on the weak pain irritations the reaction is absent, on strong – the vegetative and motive reactions appear; III2 - the expressed anesthesia. Rogivcoviy reflex disappears at the end of this level. This level is used for implementation of operative interferences; III3 - peredozouvannya (level of the extended pupils). Cornea dry. III4 - level of the diafragmalnogo breathing (considerable peredozouvannya). This level of anesthesia is impermissible. A fourth stage is awakening, which is the reiteration of the passed stages in reverse direction. Endotrahealniy anesthesia After the clinical analysis of patients, that go under the knife, ob–rountouvannya diagnosis and choice of method of anaesthetizing students in operating-rooms take direct part in conducting of anesthesia: instruments are studied for intoubatsii of trachea and bronchial tubes, an apparatus is prepared, meet with the narcotic matters, muscular relacsantami, by the order of introduction to anesthesia, by the technique of intoubatsiy of trachea and such in. Intoubatsiyniy anesthesia - it is anesthesia at which the narcotic matters enter organism of patient from an anesthesia vehicle through a tube entered in a trachea, through a mouth, through a nose or through traheostomou. The constituents of endotrahealnogo anesthesia are: а) introductory anesthesia. At this anesthesia there is no phase of excitation. For this purpose a 1% (40-60 ml) solution of tionentalou sodium is applied more frequent all intravenously, or sombrevin. On a background this anesthesia muscular relacsanti are entered and intoubatsiya of trachea is conducted. A patient is translated into artificial respiration; б) supporting anesthesia. The following narcotic matters are used for this purpose: basic (ether, ftrotan, tsiclopropan, nitrous oxide, oxygen or their mixtures), and also neyroleptici, tranquilizers, analgetici, muscular relacsanti. It enables considerably to diminish concentration of basic anesteticiv, and consequently and their toxic action on an organism. As a rule, anesthesia is executed on And and the ІІ levels of surgical stage of sleep; в) destroying from anesthesia. The serve in the organism of narcotic and other matters is halted, except for oxygen. The spontaneous breathing and tone of skeletal muscles recommences after awakening. Anaesthetist of ecstouboue patient and transports him for the subsequent supervision in a pislyaoperatsiynou chamber. Advantages of endotrahealnogo anesthesia before other types of the common anaesthetizing: 1) enables to operate on all areas of still human body; 2) provides prohidnist of respiratory tracts (prevents falling back of language, spasm of glottis, aspiratsii of blood, mucus and in.); 3) creates terms for the active sucking from a trachea and bronchial tubes of mucus, blood, I leave to rot, vomit the masses and in. 4) creates optimum terms for conducting SHVL in any position of patient; 5) provides weakening of muscles at the superficial level of anesthesia with minimum toxic action of anestetica on an organism; 6) diminishes the dead ground in the respiratory system of anesthesia vehicle; 7) allows to eliminate the separate areas of lights from ventilation. The lacks of endotrahelnogo anesthesia are: а) complication of method; б) needs the special equipment and preparation of personnel; в) danger of distribution of infection in more low departments of organs of breathing; г) irritate influence of intoubatsiynoi tube on the mucus shell of trachea. By contra-indications to endoratrahealnogo anesthesia e sharp infectious-inflammatory diseases of overhead respiratory tracts (pharyngitis, traheit, laryngitis, rinit and in.). Intravenous anesthesia ("anesthesia on the tag of needle"). A question is worked off practically in the bandaging, operating rooms of surgical separations during practical employments, duty on the first-aid, and during employments in a policlinic. Intravenous anesthesia is the basic type of no the inhalation anesthesia. It is offered in 1902 by the Russian pharmacologist N. P. Crovcovim. In 1909 S. P. Fedorov applied him in a clinic, using gedonal for this purpose. In 1932 Veeze used for intravenous anesthesia well a water-soluble gecsenal, and G.Landi in 1936 - тіопентал-sodium (derivative groups of barbitourovoi acid). For today preparations are used with short narcotic action most widely: gecsenal, tiopental sodium and cetamin, viadril, sombrevin and in. Narcotic action their related to oppression of reticoulyarnoi structure. Advantages of this anesthesia: а) absence of stage of excitation; б) rapid introduction to anesthesia; в) pleasant zasinannya (sleep on the tag of needle); г) rapid prosinannya; д) simplicity of application, absence of irritation of respiratory tracts. Failing: а) difficulties of management by the depth of anesthesia; б) relatively small therapeutic breadth; в) of short duration anaesthesia (15-20 hv.); г) the expressed oppression of breathing, sertsevo-soudinnoi activity; д) rise of tone of muscles, that can result in to laringospazmou, bronhospazmou, stops of heart, breathing. Method of conducting of anesthesia Svigoprigotovani solutions of barbitourativ are used. For this purpose to a 1,0 preparation (small bottle 1,0) before the beginning of anesthesia dissolve at a 100,0 izotonichnogo solution of chloride of sodium (a 1% solution). Pounctirouyot a vein and solution enter with speed 1 ml for 10-15 sec. After introduction of a 3-5 ml solution during 30 seconds expose the sensitiveness of patient to barbitourativ, whereupon introduction of preparations is continued to the surgical stage of anesthesia. The general dose of preparation must not exceed 1000 mg. In the process of anesthesia an anaesthetic sister looks after after a pulse, arterial pressure, breathing, and doctor-anaesthetist – on the state the pupil, by motion of eyeballs, presence of rogivcovogo reflex. In a surgical clinic intravenous anesthesia is used for the brief operations, implementation of medical and diagnostic manipulations, for introductory anesthesia. Contra-indication: а) presence in anamnesis of allergic reactions on preparation; б) absence of anaesthetist and aparata for SHVL. Intramuscular anesthesia (injection) In our time apply limitedly, after the special testimonies for introductory anesthesia. A 10% solution of gecsenalou is applied for this purpose, enter in the muscles of thigh. Care of patients under time and after anesthesia A question is worked off in operating-rooms, separation of anesteziologii and chambers of intensive therapy. During conducting of anesthesia constantly, each 10 – 15 hv. look after and estimate the basic parameters of gemodinamici. A medical sister conducts the anaesthetic card of patient, which frequency of pulse, level of arterial and central vein pressure, breathing frequency, parameters SHVL, are marked in. Anaesthetist looks after on the state the patient, by position of eyeballs, by the state of pupil and rogivcovogo reflex. At persons with the disease of heart the permanent supervision after cardiac activity is executed. For the exposure of level of anaesthesia the эlectroentsefalografichne supervision is used, for the control after ventilation of lights and metabolic changes during nacozou it is necessary to conduct research of the cislotno-lougnogo state. In the period of output of patient from anesthesia anaesthetist necessarily: - vidsmoctoue mucus, saliva from a mouth, nose, glotci, tracheas of patient; - exposes the degree of renewal of breathing (depth and frequency), efficiency of interchange of gases (color of skin and mucus shell); - measures arterial pressure, TSVT, pulse, hearkens to tones of heart; - determines the degree of renewal of reflex activity (rogivcoviy, zinichniy, laryngeal reflexes) and consciousness. After renewal of the independent breathing, reflex activity, muscular tone, complete consciousness, normalization of gemodinamici and interchange of gases of patient translate in a pislyaoperatsiynou chamber. In a pislyaoperatsiyniy chamber by all patient during a few hours inhalation of oxygen is appointed. Anaesthetist with a chamber doctor estimate the common state of patient, therapy is assigned for the first day, anaesthetic and antihistaminic preparations and in. These data are written down in the card of supervision and hospital chart. The control is necessarily carried out after sechovidilennyam and on the state electrolyte exchange.
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