Methods, symptoms, anesthesia complications, anesthesia

2021-01-26 12:00 AM

Anaesthesia is a special treatment, it makes the patient sleep, does not cause pain, does not fear, does not remember anything about the operation.

The concept of resuscitation anaesthesia 

The development of modern surgery is not only hampered by a lack of understanding of the pathological, anatomical, and surgical processes of surgical infections, but also by a lack of safe and reliable resuscitation techniques. Historically, anesthesia has evolved from respiratory anesthesia to anesthetics, local anesthesia - regional anesthesia and finally intravenous anesthesia.

To ensure anesthesia for a sick person, one must conduct anesthesia or anesthesia.

Anesthesia is a special treatment, it makes the patient sleep, does not cause pain, does not fear, does not remember anything about the operation, as well as has no neuro-endocrine reactions during surgery and is non-toxic. in response to the requirements of the operation, the rapid recovery of consciousness after surgery and the fast and secure recovery of vital functions. That is also the requirement of anesthesia.

In order to do this, the resuscitation anesthetist must understand the physiological, pathophysiological, anatomical, general surgical process, the accompanying specialist diseases, pharmacology and techniques. anesthesia, resuscitation and treatment even before, during and after surgery.

Development of resuscitation anesthesia

In 1996, in the American Board of Anesthesiology information book, anesthesia defined anesthesia as dealing with the unrestricted medical practice:

Evaluation, consultation and preparation of the patient for anesthesia

Sufficient preparation of anesthesia for pain in surgical procedures, obstetrics, treatment and diagnosis, as well as the care of patients suffering from such effects.

Monitor and restore homeostasis during surgery, as well as homeostasis in critical injuries and illnesses (or in other words, critically ill patients) Diagnosis and treatment of pain.

Clinical and teaching management and performance evaluation of medical and clinical personnel in anesthesia, respiratory cough resuscitation and intensive resuscitation.

Direct to guide scientific research at the basic and clinical scientific level to interpret and improve patient care.

Administrative coordination in hospitals, medical schools and outpatient visit facilities is necessary for the full realization of these tasks.

Methods of anesthesia

Nowadays, resuscitation anesthesia has developed into a complete discipline, so it is impossible to satisfy the knowledge of resuscitation anesthesia for a practitioner for a few hours. So, we choose an issue that in practice "non-specialist" physicians need to know. The problem of the anesthesia method, here we generally discuss without going into theory as well as technical details, because of the daily fact that it is difficult for physicians to distinguish each case because resuscitation anesthesiologists often combine methods in anesthesia such as: respiratory anesthesia + venous anesthesia, open mask anesthesia, open, ½ closed system including closed-loop anesthesia, anesthesia + anesthesia numb…

For example:

If Ate bandage is only anesthesia, it is necessary to wait until stage III3 for the abdominal muscles to fully relax to operate the abdomen, with the combined anesthesia method with muscle relaxants, people can do more shallow anesthesia (in stage III1).

Ate-simple anesthesia, especially when the patient is apnea (stage III4) is dangerously advanced, but the combined anesthesia method involves using command respiration on the patient during anesthesia. also only needed in stage III1.

On the other hand, when simple anesthesia until the blood pressure drops, it is also the toxic period. With the combined anesthesia method, one can lower blood pressure by drug command while keeping the patient in danger, reduce bleeding during surgery, by the end of the anesthesia one can raise the patient's blood pressure - which That is not a sign of drug poisoning.

The method of anesthesia is classified according to the route of entry of the drug.

Method of respiratory anesthesia

This method is often used with gaseous anesthetics (N2O, Cyclopropane) or volatile anesthetics (Ate, chloroform, Halothane, Isoflurane, ...). These anesthetics are inhaled (inhaled by the patient or introduced through anesthesia machine) and then diffused into the bloodstream to the central nervous system for anesthesia. Most of the respiratory anesthesia is eliminated by the respiratory tract, a small part undergoes liver biodegradation and excretion in the urine.

The concentration for anesthesia depends on the drug. For example: Ate needs 5% density, Halothane 0.75 ÷ 3%. With powerful anesthetics, it is possible to control anesthesia easily by changing the concentration.

With this anesthesia method, nowadays, people often anesthesia the endotracheal tube so it is possible to firmly grasp the patient's airway for command respiration and prolong the anesthesia, thus facilitating long-term surgery..

However, this method has some disadvantages:

Some drugs can cause an explosion in the presence of sparks and oxygen.

The anesthetic that flew out caused waste and poisoned the medical staff.

In some patients with respiratory diseases, the effect of the drug is limited, with drugs that cause increased secretion of phlegm (Ate).

Method of intravenous anesthesia

This method is often used with anesthetics and combination drugs such as muscle relaxants, pain relievers.

One can either undergo simple intravenous anesthesia + intravenous anesthesia + muscle relaxation and command respiration or intravenous anesthesia combined with respiratory anesthesia, depending on treatment requirements.

For example:

If the surgery is short, does not require muscle relaxation, does not enter dangerous organs one can use.

Initiate anesthesia with Thiopental 5mg / kg (or Ketamine 2mg / kg).

Combination of morphine pain relievers or Neurolept analgesia drugs.

This method has the advantages:

Means need to be used sparingly.

Does not cause explosion.

Doesn't cause reading to people around you.

But there are also some downsides:

If the patient does not breathe on his own, if he does not have experience, he or she is deficient in O2.

Insufficient muscle stretching.

Attention:

Currently, people do not use only intravenous anesthesia with Thiopental for surgery because Thiopental has no analgesic effect.

In cases where muscle relaxation is needed, venous anesthesia + muscle relaxants, endotracheal intubation + command respiration.

Method of rectal anesthesia

Currently, less used because nothing more than other methods. Except for some special cases it is used as basic anesthesia for children. 

Classification of anesthesia according to the method of eliminating CO2 during expiration of the patient.

During anesthesia - the excessive accumulation of CO2 in the body (hypertonic acidosis) and the excessive elimination of CO2 causing a decrease in CO2 in the body (anthracnose) both negatively affect the patient's life function. . CO2 exchange directly affects the heart, lung, brain, kidney ...

In anesthesia there are many causes of the change in CO2 in the patient's blood, which is due to the structure of the anesthesia machine, the technique used and the experience of the anesthetist.

Based on the CO2 elimination capacity, the following anesthetic methods are offered:

Completely open anesthesia method (open mask method)

In this method, the patient inhales the anesthetic himself with air through a mask (-Schimmel bush) - usually with evaporating anesthetics (Ate-Halothane).

Oxygen and breathing air mixture can be added by adding an oxygen catheter to the mask.

In this method, the patient does not breathe his breath again, so he does not inhale CO2 so there is no CO2 stagnation.

Advantages:

Simple.

Safe.

Suitable in pediatric anesthesia.

Difficult to cause exclamation, no resistance of ventilator.

Defect:

Uneven maze, loss of heat, loss of moisture.

Lack of medicine.

Easy to cause fire and explosion.

Toxic to people around.

Half-open method

This method is often used with T-valve and non-return valve (Ruben, Erumin)

Due to the structure of the valve when breathing out and then the patient re-inhales only a very small part of CO2 in his breathing air, which is acceptable.

½ closed method

In this method, due to the structure of the anesthesia system, the amount of CO2 the patient is re-inhaled is higher, so an exhalation valve is made near the patient's mouth so that when a large part of the breath is exhaled (mainly CO2) flew out. However, if the exhalation valve is incorrect or the technique is not good, it can also cause disturbance of CO2 exchange.

Completely closed anesthesia method

In this method, people can use two types of machines: "back and forth" or closed loop system. When using this closed system, one must use a technique to absorb CO2 with soda lime.

Advantages:

Since it is a closed loop, the drug does not fly out - saves the medicine, O2.

Keep temperature, humidity.

Does not cause explosion.

Not toxic to people around you.

Defect:

Easily cause stagnation of CO2 (dangerously damaged Soda lime).

Dust enters the patient's respiratory tract.

Symptoms of anesthesia with simple ether Goeddel 1920

Although ethers are hardly used today for anesthesia, and the fact that many new anesthesia drugs with other properties are no longer atypical, Goeddel’s pure ether learning symptom is still The basis for the anesthetist to control the anesthesia- According to Goeddel, this anesthesia symptom is divided into 4 periods:

Phase I pain relief:

This period lasts about 1-3 minutes because the drug begins to inhibit the cerebral cortex. Follow-up signs are almost normal.

Respiratory: Abdominal and chest breathing is relatively even.

Pupil: Moderate contraction, self-controlled movement of the eyeball.

Reflections of eyelids, cornea, peritoneum (+), pharynx (-).

The pulse is a bit fast; blood pressure increases.

Application: Extraction of teeth, misalignment, fracture manipulation.

Period II:

This period lasts or short, depending on the good pre-anesthesia, the technique of anesthesia and the patient's site.

At this time, because the cerebral hemisphere has been inhibited, the inhibitory escape cortex centers are no longer regulated and inhibited by the cerebral hemisphere.

The signs were all disturbing.

Irregular breathing-rapid breathing.

The pupil shrinks smaller.

The eyeballs move autonomously.

The reflexes: eyelids, cornea, peritoneal skin, throat is (+).

Rapid pulse, increased blood pressure.

Surgery is forbidden during this period. In general, it is necessary to avoid this period, if the exam occurs not to prolong.

Period III: The surgical period is divided into 4 phases

Phase III1: Official Mekong.

Respiratory: Breathe regularly (mechanical ventilation).

Moderately small pupils, eyeballs move autonomously.

Reflections: Eyelid, peritoneal skin, pharynx (+), eye corneal reflex (-).

Pulse and blood pressure returned to normal.

The paralysis of the muscles causes the lower jaw to delay (called a sign of falling jaw).

Application: Can open thoracic, spine, goiter, bladder, osteopathy, hernia surgery.

Stage III2: Official deep maze

Breathe faster in frequency.

Small, still shrinking pupil-dry cornea.

And the eyelid reflex and cartilage (other reflexes are lost).

Normal pulse, blood pressure.

Paralysis of the body limbs.

Application: Can operate joints, abdominal surgery.

Stage III: Pre-toxicity

Respiratory: shallow tachypnea.

Dilated-loss pupil reflect light.

The eyeballs stood still and pulled inward.

Other reflexes lose.

Application: It is possible to rotate the fetus.

Stage III4: Poisoning requires emergency care.

Dilated pupils - loss of reflexes.

Intercostal and diaphragmatic paralysis stops breathing.

Small rapid pulse, low blood pressure.

Stage IV: The period of poisoning (marrow paralysis)

Diaphragmatic paralysis, breathing stops.

Pulse failed; blood pressure was not measured - cardiac arrest.

Dead.

Complications of anesthesia 

From simple to complicated complications of anesthesia, anesthesia is also very dangerous without knowing about this subject, it is very interested and limited by resuscitation anesthesia.

Although it is difficult to accurately measure anesthesia complications, it is found first due to the patient's inherent illness, then to the surgical procedure and to the management of anesthesia. Many studies have clearly demonstrated that dangerous preoperative effects are due to the patient's preoperative diseases and then the surgical procedures.

Mortality was found to be the most obvious endpoint, but preoperative mortality is rare. A series of studies are also conducted to reach statistically significant conclusions. But fear of forensic surgery hinders the accurate reporting of data.

Mortality that can be attributed mainly to anesthesia is: 1-2 / 3000 undergone anesthesia in the 1960s, down to 1-2 / 200000 so far. However, this rate may vary in different countries, under different conditions.

Anesthetic complications that can occur during any stage of anesthesia are the pre-anesthesia, anesthesia, maintenance, release (awakening) and postoperative phases. At each stage there are specific complications. Here we are only highlighting the respiratory and circulatory complications that are the most sensitive vital functions under anesthesia.

Pre-anesthesia

Respiratory reduction:

Cause: Because the anesthetics have respiratory depression, especially opium. The elderly and children are susceptible to these drugs.

Symptoms: Decreased respiration in frequency and amplitude.

Treatment: Give oxygen, give artificial respiration, if necessary, intubation, give respiratory stimulants.

Cardiomyopathy:

Cause: Common in people with dehydration, severe electrolyte loss, long-term protein deficiency. Especially when anesthesia with drugs blocking sympathetic nerve nodes (Phenothiazines), it is easy to cardiac failure when changing positions.

Symptoms: Small rapid pulse, low blood pressure.

Management: Infusion, heart support, oxygen breathing.

Note: When moving a patient who is pre-anesthetized with nerve ganglion blockers, be gentle, always keep a horizontal position.

Stage of anesthesia

Stop breathing:

Cause: High concentration intravenous anesthetic was injected, rapid injection, muscle relaxant, patient held his breath for a long time because he could not stand the smell.

Symptoms: Apnea, cyanosis, heart failure may occur.

Management and prevention: Treatment based on etiology, CPR (with Ambo + mask, ventilator).

Asphyxiation:

Due to obstruction of the upper respiratory tract by sputum production, vocal spasm, bronchial gas, drop of the tongue against the glottis, vomiting, blood, foreign bodies.

Symptoms: Difficulty breathing, cyanosis.

Management: Address the cause, clear the airway, provide respiration or command.

Low blood pressure: Due to inadequate rehydration or the effects of some anesthetics.

Slow circuit, fast circuit.

Heart stop.

Vomit.

Cause: Stagnant food in the stomach, common in emergency surgery (intestinal obstruction, peritonitis).

Precaution: Apply gastric aspiration catheter to all emergency surgery patients, especially children, only anesthetize when the patient has been fasting for more than 6 hours, and fasting water for more than 3 hours.

Treatment: Tilt the patient's head, clean up, remove the bronchus if there is reflux.

The period of maintaining anesthesia

Lack of oxygen:

Causes: Causes obstructing or obstructing the upper respiratory tract, poor artificial respiration, Sonde lime failure under closed system anesthesia, 80% N2O anesthesia, 20% oxygen is easy to lack oxygen.

Symptoms: Depending on the degree of cyanosis, maximum and minimum blood pressure stuck.

Management: Depending on the cause, good artificial respiration.

Excess CO2 (adjuvant):

Causes: As lack of oxygen.

Symptoms: Maximum blood pressure increased, minimum blood pressure decreased, rapid pulse, red face, sweating.

Treatment: Get rid of the cause, increase ventilation to CO2 emissions.

Heart stop:

Cause: Intoxication of anesthetics, common reflexes in thoracic surgery, X nerve stimulation.

Favorable factors: Lack of oxygen, excess CO2.

Symptoms: The neck circuit, the inguinal circuit could not catch, the heart could not hear the heart.

Management: Squeezing the heart outside the chest, or squeezing the heart in the chest (when opening the chest), infusion, using heart medicine.

Fast circuit, slow circuit: Handling according to the cause.

Hiccups:

Cause: Due to X-cord stimulation and choroid nerve, stomach stretch, hypertonic, pulling during surgery.

Treatment: Management according to the cause, aspiration, increase ventilation, relax muscles, atropine.

Hypothermia:

Due to the low operating room temperature, the wide operating area, exposing the viscera, cold blood transfusion.

Prevention and management: Keep operating room temperature to 25o, keep warm, use electric pins, apply warm compresses to intestines, warm infusion, warm blood.

If hypothermia is present: warm, breathe oxygen, give sedation.

Escape from charm

Vomiting: After anesthesia, due to the effects of anesthetics, vomiting often occurs or the gastric juice does not go away.

Precautions are key: Gastrointestinal aspiration, set head tilted, closely watched.

Upper respiratory tract obstruction:

Drop tongue, tongue pressed against glottis (common in the elderly, tooth loss, fat, children).

Take precautions to put in proper posture.

Cardiomyopathy:

Excess CO2 after anesthesia.

Loss of blood due to insufficient compensation.

Move lightly.

Precaution is key.

After surgery

Atelectasis: Common in the elderly and children.

Gray-green fever (Malignant fever): Common in children, people with personal history and family history of myopathy.

After surgery, high fever of 40-41oC, cyanosis, convulsions, increased muscle tone, high blood potassium, easy death.

Precaution: Do not increase the temperature during anesthesia, if using Halogen family anesthetic with breathing mechanical relaxants and atropine, it should be closely monitored.

Treatment: sedation, hypothermia, anticonvulsants, oxygen if needed, give artificial respiration.

Dantrolene is a special drug, however, it is expensive and not available in Vietnam.

Anesthetics and anesthetic complications

Classification of anesthetics

Divided into 2 main groups

Nature: Cocaine.

Synthesis: Divided into 3 groups.

Hydroxy group: Represented by Benzocaine (1900).

Ester group: Divided into 4 groups.

Ester of benzoic acid:

Piper Cain (Mytycaine).

Meprylcaine (Oracain).

Isobutane (Kinane).

Ester of para-amino benzoic acid:

Novocain (procaine).

Tetracaine (pontocaine).

Novocain (butterine).

Ravocaine (propoxycaine).

Nesacaine (2 chloropropane).

Esters of the amino amino benzoic acid:

Unacaine (Metabutathamine).

Primacaine.

Ethoxy benzoic acid esters:

Intracaine (diethoxyne).

Miscellaneous group:

Quinolinel group:

Dibucaine (Nupercaine)

Percaine.

Tonsil group:

Xylocaine (Lidocaine, lignocaine).

Mepivacaine (carbocaine).

Prilocaine (Dyncaine).

Bupivacaine (Marcaine).

The Cylaine Group:

Complications from anesthesia

Anesthetic poisoning:

Causes: Due to high doses injected into the bloodstream, the central nervous inhibitor under the escape shell inhibits causing seizures. In people who are anxious, shy, and easily irritated, complications easily occur, so it is necessary to have sedatives before anesthesia.

The body's response to an anesthetic is individual and depends on:

Dosage of anesthetic.

Concentrated anesthetic.

Properties of the drug (ester group).

Systemic conditions and mental factors (patient sensitivity).

Absorption into the blood.

Injection speed.

The ability and rate of decomposition of the drug.

Clinical manifestations:

At first there were symptoms of CNS stimulation.

Talk a lot, fear, excite, tongue is fishy.

Pulse increased; blood pressure increased (due to initial stimulation).

Then there is inhibition of the central nervous system.

Seizures (due to shell inhibition).

Slow, weak pulse (due to inhibition of conduction in the heart and decreased myocardial contractility).

Reduced blood pressure (due to vasodilation and decrease in myocardial contractility).

Yawning or sleeping (decreased perception).

Severe breathing can disturb or stop breathing.

Nausea or vomiting.

Sometimes the symptoms of poisoning happen too quickly with no signaling symptoms.

General treatment:

Sedation: Valium 0.2 mg / kg mach.

Thiopental 1.25% (5mg / kg body weight) is administered slowly intravenously.

Respiratory support with oxygen.

If convulsions for muscle relaxant-intubation artificial respiration.

Revive circulation with infusion, if necessary, for CaCl2, Ephedrine or Adrenaline.

Separate treatment:

If prilocaine type anesthetic (eitanest), it is necessary to give Pneumethylene 10% x 10 ml intravenously.

Prevention follows the following principles:

Prepare the patient mentally and mentally.

In the anesthesia used Valium, Barbituric.

Add vasoconstrictor to the anesthetic.

Use the recommended amount of anesthetic to achieve an anesthetic effect.

Use the minimum drug concentration to achieve an anesthetic effect.

Inject very slowly and monitor the patient.

Before injecting, always pull out the piston to see if it is in the bloodstream.

Choose the right medicine.

Allergies: Before diagnosing an allergic reaction, toxicity must be eliminated.

Symptoms are sudden, frantic at the time of injection, the patient has convulsions, loss of consciousness, pale face, slow pulse, drop in blood pressure.

Treatment: As poisoning, corticosteroids (100-200mg IV).

Allergy-anaphylaxis: Occupies 15 with anesthesia.

When anesthesia patient has asthma attacks, edema, rhinitis, fever, if the allergy is strong, it can drop blood pressure - Or occurs on the allergic site.

May occur as late as 12-24 hours after anesthesia (usually edema).

Treatment: Use antihistamines, corticosteroids, small adrenaline can be used under the tongue.

Complications due to vasoconstrictor drugs:

Depends on the response of each patient.

After anesthesia: Patients with palpitations, fear, anxiety, headache, rapid blood pressure increase is mainly preventive rather than treatment, give less vasoconstrictor drugs to anesthetics, often use billions rate 1/200000 ÷ 1/400000.

Reactions in place of the anesthetic solution:

Infection.

Local irritation due to the drug is not isotonic, overdue, low pH in the anesthetic area that is burning like burns.

The local resistance decreased; the wound was long healed due to poor nutrition.

Techniques of anesthesia:

Local anesthesia was first introduced in practice in 1884 by Koller. Since then, many anesthesia techniques have been studied and improved continuously. It becomes one of the methods of anesthesia in surgery, moreover it also works to relieve pain after surgery and chronic.

The techniques of anesthesia can be divided as follows:

Surface anesthesia.

Local anesthesia-class anesthesia.

Regional anesthesia.

Anesthesia in the bones.

Intravenous anesthesia.

Epidural (epidural), anesthesia through the sacrum.

Spinal anesthesia.

Nerve body anesthesia.

Common anesthetics are used for anesthesia:

The esters of para-amino benzoic acid: Novocain, tetracaine (pontocaine).

Amide group: Xylocaine (lignocaine, lidocaine), in which the amide family also has Bupivacaine (Marcaine), Mepivacaine.

Local anesthesia and lay anesthesia:

Define:

Local anesthesia is injecting anesthetic right into the area to be operated, wherever it is absorbed, the numbness will arrive. It is different from surface anesthesia in that it numbs not only the nerve tip, but also the deep and shallow.

Layer anesthesia is also a type of local anesthesia, but not a certain class, but in turn anesthesia from shallow to deep and anesthesia all layers for deep surgery.

The Vishinski method is the commonly used layered anesthesia method.

Vishinski’s principles of anesthesia.

The injection goes before the tip of the knife.

Take layers from shallow to deep.

Taking advantage of the elasticity of the scale, the cornea to push drugs away.

Respect the duration of action and spread of the anesthetic.

Vishinski solution:

Novocain 2.5g.

NaCl 5gr.

KCl 0.075g.

Adrenalin 0.005g.

Distilled water barely 1 liter.

We see in this solution some electrolytes so that it is relatively similar to the intercellular fluid so the drug does not stimulate in place, it can inject a large amount.

In addition, anesthetics can be used in different concentrations:

Xylocaine 0.25%, 0.5%, 1%, 2%, 5% ...

Novocain 0.25%, 0.5%, 1% ...

 Marcaine 0.25%, 0.5% ...

Point:

For software surgery.

To operate in some facial diseases, inguinal hernia, subcutaneous Kist herniation, toe, hand, tooth extraction, urology, ENT, eye.

To manipulate bones.

Relative indications:

Abdominal surgery (because it requires pulling, softening of muscles).

Some major surgeries.

Contraindications:

Patient is intolerant or allergic to the anesthetic.

Effect on the affected area (because of low effect and take bacteria away).

There is slightly gangrene.

Regional anesthesia - anesthesia for the brachial plexus:

Anatomy: The brachial plexus is composed of the primary branch of C5-C8 and D1 (T1). There are also branches D2, 3 sometimes D4.

The brachial plexus goes between the median and the anterior staircase muscle and then crosses the upper rib I, under the collarbone, enters the armpit.

The brachial plexus is located in the axillary sac and is associated with the subarachnoid artery and vein. Initially above, then in the artery and subarachnoid vein.

Indications for anesthesia:

For surgery, cut the upper limb.

To manipulate the shoulder joints, elbow joints.

Contraindications:

The needle puncture site becomes infected or cancerous.

Skill:

About preparing the patient: As part of preparation.

There are 4 main ways into the brachial plexus for anesthesia:

Living edge line (Kappis).

Sugar on the collarbone (Kulen Kampf).

Method of sugar anesthesia on the collarbone.

Let the patient lie on his or her back, hands down the body, head turned to the opposite side, and support the shoulder to poke the needle.

The needle puncture point: A point 1 cm apart from the midpoint of the collarbone, cutting a 1 cm line on the collarbone - or the angle created by the shallow neck vein and the upper margin of the collarbone.

Needles must always be fitted with a syringe containing anesthetic. Piercing the needle on the ribs 1. When you meet the shore on rib 1, lift the needle about 0.5 cm. Gently withdraw the plunger, if there is no blood, pump the medicine. Usually, the effect of numbness is about 15-20 minutes after pumping.

Anesthetics and dosage:

Xylocaine 25: 6-8mg / kg weight.

Marcaine 0.5%: 1-2mg / kg of weight.

The duration of action of the first dose of anesthetic is about 60 minutes to 90 minutes. Want to prolong more numbness time, inject doses at intervals.

Symptoms:

Inserting a needle into a blood vessel, injecting high dose drugs will cause poisoning.

The anesthetic is absorbed into the epidural space in the neck, causing respiratory paralysis.

Pneumothorax.

Nerve paralysis (usually reversible).

Anesthesia in the bones:

Theoretical basis of the experiment:

When garo chi then injected methylene blue into the wax bone, methylene blue permeates both the skin and the skin. It was found that after the injection, it usually followed the deep veins beyond the bone and then toward the base of the limb and from there spread the soft in the shallow. The time from injection to software release is about 3 minutes.

Means for anesthesia:

20ml syringe, anesthetic needle in the bone 6 cm long, 1mm in diameter, with a catheter to poke through the hard bone.

Garo.

Choosing the place to place the garo should be placed above the surgical site, where there are many muscles, on the bone wedge intended to poke the needle.

Choose a place to poke the needle.

Upper limb:

Convex arm bones.

Crankshaft.

The bone under the bone turns toward the back of the hand.

Crowns under the pillar.

The head of the knuckles.

Lower extremities:

Convex femur.

Fisheye (common ankle).

Top tibial plateau (medial tibial plateau is best).

Heel bone (outer surface).

First table vertebra.

The amount of anesthetic: With Vishinski, Novocain 0.25% solution.

Upper limb:

Table and wrist: 50-70ml.

Forearms: 80-100ml.

Elbow: 60-80ml.

Lower extremities:

Table and ankle: 70-90ml

Knees: 80-100ml

Thigh: 150-200ml.

With xylocaine should only use about 5mg / kg of whole-body weight.

Symptoms:

Intoxication of the anesthetic (due to the lack of tightness, rapid removal of the garo).

Paralysis of limbs temporarily due to garo, bitterly where garo.

Point:

The surgery is 10cm away from the base of the limb.

Patients over 5 years old.

Short surgery less than 1 hour.

Intravenous anesthesia:

Essentially, intravenous anesthesia is similar to anesthesia in the bone, but need venous anesthesia needles, it is best to insert polyene and then wrap garo to pressurize blood.

Choose a place-to-place garo above the surgical site towards the root of the limb, place the garo to press blood on the base of the limb - then put the garo to save during surgery.

Select a vein in the apical side, inject or insert polytan.

Medicines used:

Vishinski solution, Novocain 0.25%.

Xylocaine 0.25%, 0.5% or 1%.

Dose: Depending on the garo location for example with Vishinski solution.

Upper limb: 

If the mid-arm garo: 120ml.

1/3 between forearm: 50 ÷ 60ml

Lower extremities:

Garo 1/3 below the lower leg: 120-150ml.

Garo 1/3 below thigh: 150-200ml.

Garo 1/3 between thighs: 200-250ml.

With Xylocaine 0.25%:

Upper spending: 80-100ml.

Lower cost: 160-200ml.

In fact, with the upper limb, if the garo 1/3 below the forearm can use Xylocaine 2% solution x20 ÷ 15ml

Note: The veins with a diameter of less than 2mm have no valve, larger veins have valves. When the drug is pumped with strong pressure, the valve will be overcome, then the patient will be a bit dizzy (due to reflex).

Complications: As anesthesia in the bones.

Indication: To operate limbs with a short time (1 hour).

Conclusion: Anesthesia and anesthesia in the operating area requires accurate assessment of the patient's condition for appropriate indications. Particular attention should be paid to patients with severe fever, the elderly, children and people with combined illnesses.

Surface anesthesia

Skin surface anesthesia:

Medicines used:

Xylocaine: 2%, 5%, 10%.

Dicaine: 1%.

Thiocaine: 1%.

Percaine: 0.02%.

Carcaine: 0.25-0.5%.

Citanest: 4%.

Cocaine: 2%.

Bonin solution includes: (the same amount)

Cocain

Phenic acid.

Metol

How to use:

Use cotton soaked in anesthetic to absorb the mucosal surface.

Spray into dust (endotracheal anesthesia).

Drip (eye).

Complications: Mainly anesthetic poisoning.

Anesthesia of the nerves:

There is actually a method of regional anesthesia that selectively affects each of the regions that govern the nerves:

Upper limb:

Nerve rotation.

Cylindrical nerve.

Lower extremities:

The thigh nerves.

Nerve big hip.

Epidural anesthesia

Define:

Epidural (epidural) is the introduction of anesthetic into the epidural space to numb the spinal TK roots through it, thereby anesthetizing the peripheral regions that depend on these TK strings (so in fact is regional anesthesia). .

Anatomy of the epidural space:

From the skin to the epidural space, there must be layers: skin, subcutaneous tissue, posterior ligament, ligament, yellow ligament, epidural space.

Through each layer, there are different resistances, especially in the skin and the yellow ligaments.

The NMC cavity is located between the golden ligament and the sclera from the occipital to the sacral fissure. The sclera end at the same 2 but the terminal epidural cavity is at the same bone slot 5 cm from the top of the coccyx.

NMC cavity volume = 115-275 ml (adult). In some patients, the epidural space is not completely nailed, so the epidural space of the spinal cord connects with the epidural space in the brain.

Prepare the patient:

Careful examination of patient: spine, vertebrae, pulse, blood pressure (BP≤90 mmHg should not anesthesia).

Body hygiene: especially the back where the needle is to be poked.

Fasting, drinking like other surgeries.

Prepare the patient mentally.

Preparation for the drug:

The night before and the morning of surgery should give Gardena.

Pre-anesthesia: Atropine 0.01mg / kg body weight, Demerol 0.05mg / kg body weight.

Point:

Surgery under the diaphragm but outside the abdomen: urology, gynecology, perineum, lower extremities.

Surgery for the organs in the abdomen (approximate only).

Chest surgery (not very good). Epidural anesthesia + muscle relaxation + artificial respiration.

Surgery for head, neck, and upper extremities (not recommended).

Contraindications:

Skin infection of the back.

Sepsis.

Maximum blood pressure≤90 mmHg.

Circuit <60 times / min but using atropine circuit does not increase.

Are in Shock (because the remaining blood pressure is only a self-defense mechanism).

Drug allergy.

Spinal deformity.

Tuberculosis of the spine.

There is respiratory failure.

There is no means of artificial respiration.

Skill

Anesthetist:

Wash hands, dress and wear gloves like a surgeon.

Examine by yourself the drugs and means.

Patient posture:

Lie bent back shrimp (head bowed, back arched, thighs folded to the abdomen, legs folded into thighs, hands embraced knees).

Sitting on a table, with feet down in a front chair, this type of vertebrae is easy to identify but easy to fall requires someone to assist the patient.

Skin antiseptic:

Iodine alcohol then 700 white alcohol to clear iodine or use Betadine.

Determination of vertebrae:

There are 5 (landmarks in order):

Internal path 2 lateral pelvic crest pass through the burning slot l4-5 (in some cases through the burning body L4).

Vertebrae 12 with ribs 12.

If the patient sits upright with both arms down and down the body - Draw a pole line below the scapula ® will pass through the slit D9-D9 (T8-T9),

The line connecting the inside end of the scapula on both sides will pass under the spine of D3 (D3-D4).

When the patient is seated with the head bowed at most, the highest protruding spine is C7.

Select needle puncture position: (for reference):

Breast removal: D4-D6.

Chest: D7-D8.

Upper abdomen: D8-D9.

Lower abdomen: D10-D11.

Kidney ureter: D11-D12.

Lower limb: L3-L4-L5.

Genitals: L1-L2.

Prostate: L2-L3.

Pelvic bottom: L3-L4.

So never go beyond D4 because:

In the event that the sclera around the occipital hole is incomplete, the drug to the brain is dangerous.

Narrow epidural space above easily pokes into the subarachnoid cavity - spinal cord.

High up anesthetic works on the diaphragmatic nerve - respiratory paralysis.

Reality does not require exactly that because when the drug is injected into the intercostal space, the drug will spread upwards and downwards.

Middle needle puncture: D4-D5 can be operated in the chest (except pericardium must add anesthetic to the pericardium).

D7-D8 Surgery to organs in the upper abdomen.

D10-L1 Anatomy of the lower abdomen, urinary organs.

L2-L3 Surgery of the low urinary organs (prostate, bladder, lower extremities).

It is simpler, just 2 points in the back (high surgery), low lower waist and then spread medicine:

Change your posture.

Put Polytan and pump medicine (also works to relieve pain after surgery).

Anesthetics and dosage of anesthetic:

Xylocaine:

Under 18 years: 1-1.5% 6mg / kg.

Over 18 years - 70 years old: 2% 8mg / kg.

70 - 80 years: 1.5% 200-250mg (total dose).     

80 - 90 years: 1% 150mg (total dose).

Novocain: Solution used the same xylocaine, dose (mg) one and a half to 2 times xylocaine.

Decamine: 3%: 100mg + 33ml HTM 9%.

10-18 years: 15ml.

18-50 years old: 22-25ml.

> 50 years old: 2ml less for every 5 years old.

Ponto Caine 5%: adults 10-15ml.

Can be used: Ponto Caine 5% + Gelatin 5% + Adrenalin 1/100000 with the above dose can be numb for 6 hours.

Note: When the time of absolute anesthesia expires, if the surgery requires a lot of stretching, supplement with central pain relievers, the time of numbness can be prolonged (90-120 minutes).

Bupivacaine (Marcaine): 1.5-2mg / kg.

Catastrophe:

Putting the anesthetic into the subarachnoid cavity: Due to the perforation of the sclera, the cone deformity with the cerebrospinal water needle does not come out, the membrane puncturing the polytan.

Clinical:

At the earliest, the patient stopped breathing completely, his lips were pale.

Completely lost consciousness.

Pulse failed; blood pressure was not measured.

To solve:

Give artificial respiration with O2 immediately.

If HA <70mmHg for:

Infusion of saline serum 9/1000 ÷ 3g CaC2 drip.

Ephedrine 10-60mg or Adrenalin 1mg (intravenous phase).

Caffeine 1 ÷ 5 ampoules (intravenous).

If slow pulse <60 times / min for Atropine (infusion until circuit ≥ 80 times / min, then stop.

Guard:

Test several times, with respect to the dose of death (by dose of spinal anesthesia, xylocaine: 2mg / kg, wait 5 ').

Smoking the plunger before administering the drug.

During the injection process, the needle must be absolutely fixed.

Do not use very hard polytan and should be tested first.

Do not use the tip of the needle that is too pointed.

Hypotension.

Weak or stop breathing.

So cold.

Seizures, due to anesthesia poisoning:

Light: Valium 0.2mg / kg ™.

Heavy: Thiopental 1.25% -20ml.

Slow pulse: for atropine.

Headache.

Nausea, vomiting: Blood pressure should be checked.

Back pain: (1/400) due to the use of large needles.

TK: metamorphic anesthetic: low pH (considered as acid destroying TK), put Iot in, wrong drug (CaCl2).

(6 months with rapid recovery, 6 months ÷ 2 years, and behind for> 2 years without recovery.

Hiccups: During surgery or postoperative due to parasympathetic hyperparathyroidism or flatulence - diaphragmatic irritation.

Urinary retention: 1-3 days after order sonde will end.

Spinal meningitis:

Because the patient has an infection.

Because the procedure is not sterile

Perforation of the artery or small vein: When the needle is poked or the polyene is inserted, blood will flow out - management: reverse the needle, flush until the fluid clears, wait a while and then inject the anesthetic, if not changed to another method.

Discarding of polytan in the sclera: Due to reverse retraction of polyene.

Advantages:

Good numbness, deep numbness.

Little dry bleeding area.

The provincial patient can tell the patient to coordinate with the surgeon easily to detect complications (due to drugs, blood transfusion ...).

The intestines lie still during surgery, the bowel movements quickly return.

Gentle post-surgery.

Non-toxic to liver, kidney (heart disease, liver disease, high blood urea can cause epidural anesthesia).

In patients with high blood pressure can use small, scattered doses.

Convenient for mobile work.

Defect:

Technical is difficult.

Creates unnecessary numbness zones.

Patients are afraid to give mild anesthesia.

Caution is required when moving the patient.

Causes a drop in blood pressure.

High dose of anesthetic (4 times spinal anesthesia easy to poison, cost medicine)

And the feeling of touch.

Do not completely inhibit the feeling in the abdomen (when low surgery pulls the patient's appendix, ie epigastric region).

The feeling of pressure does not go away (Mache insertion, uncomfortable patient gauze). 

Spinal anesthesia

A few points about physiology:

When puncture of the spinal cord:

Cerebrospinal water pressure is decreased due to

Some cerebrospinal fluid (NNT) is drained out.

The sclera is poorly elastic, so when the needle is pulled out it does not seal the hole, making the NNT come out of the epidural space. Normal pressure NNT is 12cm H2O,

The pressure of NNT drops more or less due to

The amount of NNT is lost.

Big or small needle puncture hole.

The pressure difference between the epidural space and the subarachnoid cavity.

The body's response to a loss of NNT:

If the response of the spider tangles is poor, the recovery time is long.

If the spider tangles are stimulated, they will increase secretion, increasing the pressure of the skull.

The puncture action more or less causes epidural congestion (causing headache).

Diffusion phenomenon of the drug depends on the following factors:

The general rule of two liquids when mixed together:

At 37OC the drug was most diffused.

Amount of cerebrospinal fluid (much poorly diffused).

Drug concentration (high diffusion increased).

Proportion of drugs (density of NNT 1.003-1.009).

Note: When the patient is completely horizontal with the highest point of the spine where the low-density anesthetic is deposited is L3, the lowest score for which the low-density anesthetic remains is D5.

Effects of spinal anesthesia:

A small amount of anesthetic is absorbed into the spinal cord, but this amount is not enough to physiologically cross the spinal cord.

The anesthetic is absorbed into the TK roots from the point of origin to the inter-burning hole.

The result of anesthesia will inhibit sympathetic TK, parasympathetic, motor and loss of spinal reflex is blocked.

Prepare the patient:

As anesthesia.

Vehicle:

Like epidural anesthesia, but the other is the need for small, hard, pointed needles (often using the number 24,25,26) because small causes less cerebrospinal fluid drainage and headache damage).

Anesthesia (if added with Adrenalin 1/200000-time increased anesthesia 1.5 times).

Novocain: 5% Density 1,010x2ml Effective 90 '