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  1. 1. Prof. S.D.Khimich Vinnitsa National Medical University  LECTURE:  GENERAL, LOCAL AND REGIONAL ANESTHESIA
  2. 2. Anesthesiology is a science about the protection of organism from operative trauma  All kinds of anesthesia divided on general (narcosis) and local anesthesia
  3. 3. Narcosis is an artificial reversible state of the human organism characterized with inhibition of CNS (absence of consciousness) loss of sense, muscular relaxation & absence of some reflexes.
  4. 4. Anesthesia is produced by progressively increasing the amount of the anesthetic in the inspired air and thus in the blood and brain. Unconsciousness is one of its primary conditions
  5. 5. Relaxation of skeletal muscles, essential for carrying out certain operations, may be achieved by deep anesthesia but only for a short time since such narcosis is dangerous.
  6. 6. Preparing to the operation (preanesthetic medication)  Anesthesiologist must examine of patient before each operation. The tasks of examination are:  · General condition estimation;  · Peculiarities of anamnesis, connected with anesthesia;  · Clinical and laboratory data estimation;  · Determination of degree of operational and narcosis risk;  · Method of anesthesia selection;  · The character of premedication determination.
  7. 7. Premedication (preanaesthetic medication) –is introduction of medicinal substances before operation for decreasing of intraoperation and postoperation complications’ frequency.  The main medicinal substances for premedication are:  · Opiates;  · Sedatives;  · Neuroleptics;  · Antihistamines;  · Narcotic drug;  · Anticholinergic drug.
  8. 8. The main schemes of premedication are:  Before the urgent operation the narcotic drug and atropine (promedol 2% - 1,0, atropine – 0,01 mg/kg) are introduced;
  9. 9. Classification of narcosis  Inhalation narcosis – through respiratory ways the pharmaceutical substances are introduced. Aperture-mask, endotracheal and endobronchial narcosis are distinguished. In modern time usually the endotracheal narcosis is used.
  10. 10. Classification of narcosis  Noninhalation narcosis – the preparation are introduced not through respiratory ways, but intravenously (mainly) or intramuscularly.  Electroanesthesia  Combined anesthesia
  11. 11. Medicines for inhalative narcosis:  1.nitrous oxide (N2O) – colorless gas without smell, is kept as a fluid under pressure 50 atmospheres in black gas-bags.  2.Ethyl ether (anesthetic ether).  3.Methoxyfluran (penthran, inhalan).  4.Cyclopropane etc.
  12. 12. The administration of anesthetic results in progressive depression of the CNS , which may be preceded by varying degrees of excitation. These drugs first depress the cerebral cortex via the RAS (reticular activating system) and the basal ganglia and cerebrum.
  13. 13. Stages (or phase) of anesthesia:  1. Stage of analgesia  2. Stage of excitement  3. Surgical stage  4. Agonal stage (or period of recovery )
  14. 14. The I stage (analgesia)  – begins in 3-8 min after inhalation of ether & last 3-5 min and characterized by partial unconsciousness and diminution of sensitivity to pain.
  15. 15. The II stage (excitation, delirium)  – last 1-5 min and is characterized with the activation of all physiological processes – the patient is excited, breathing is deep and rare, uncontrolled motor-speech excitation occurs (patient try to run anywhere, to jump, to talk to anybody).
  16. 16. The III stage (surgical anesthesia) – the phase of surgical sleep is divided into 4 levels.  - The first level (III1) is characterized by superficial anesthesia – loss of sensitivity to pain, easy sleep begins…  - The second level (III2) – the level of corneal reflex and develops as the anesthesia deepens.
  17. 17. The III stage (continue)  - The third level (III3) – the level of pupil dilation. The pupils are slightly dilatated and their reaction to light is weakened. Anesthesia is conducted in this level when relaxants are employed.  The fourth level (III4) – the level of diaphragmatic respiration – is characterized with the inhibition of physiological functions. This level may transform to agony with the following death.
  18. 18. The IV stage  – the phase of awakening – is characterized with the reverse development of all the clinical symptoms.
  19. 19. Regional (Local) Anaesthesia Regional anaesthesia implies reversible blockade of pain perception or transmission by local anesthetic drugs, although physical agents such as cold or pressure can act similarly.
  20. 20. Topical anaesthesia is results from the application of certain local anesthetics to skin or mucous membranes (conjunctiva, oral, nasal, and anal).
  21. 21. Local Anesthetic Agents:  Cocaine Hydrochloride  Procaine Hydrochloride (Novocain)  Tetracaine (Pontocaine Hydrochloride)  Lidocaine (Xylocaine)  Dibucaine (Nupercaine Hydrochloride)  Piperocaine (Metycaine Hydrochloride)
  22. 22. Local anesthesia (LA) is a blockade in the zone of surgical intervention.  Regional anesthesia (RA) is the stopping of the painful impulsation proximal the field of operation.
  23. 23. Indications for conducting of local anesthesia: 1. Ambulatory surgical operations; 2. Small on volume surgical interventions; 3. In old and extreme age people with diseases of cardiac-vascular and respiratory systems. 4. In case of contra-indication to general anesthesia (narcosis).
  24. 24. Contra-indications for conducting of local anesthesia:  1. Raised sensitiveness of organism to anesthetic;  2. Mental affections;  3. Sharp nervous excitement;  4. Early child age (till 10 years);  5. The urgent surgical interventions, connected with acute bleeding;  6. Expressed fibrous changes of soft tissues;  7. Long-term operations on body cavities;  8. The refusal of the patient from local anesthesia.
  25. 25. Complications of local anesthesia (I):  Local: the damage by needle of anatomic formations or internal organs (nervous trunks, vessels, spinal cord, organs of pectoral or abdominal cavities), infectivity of soft tissues, bleeding, hematoma, inflammatory infiltrates, paresis, paralyses, peritonitis, etc.
  26. 26. Complications of local anesthesia (II):  General – connected with overdoses of anesthetic or raised sensitiveness of organism to it.  1. Light degree – vasomotor discords (dizziness, pallor, cold sweat, general weakness, tachycardia, nausea).  2. Middle degree – stinging of central nervous system (impellent flustering, hallucinations, cramps, vomit).  3. Heavy degree – violation of activity of life important organs and systems (collapse, stop of breathing and cardiac activity).  Allergic reactions are nettle rash, Kvinke’s swollen, bronchospasm, anaphylactic shock.
  27. 27. TYPES OF LOCAL AND REGIONAL ANESTHESIA  - Terminal;  - Infiltrative;  - Conduction;  - Intraosseous;  - Intravenous under tourniquet;  - Epidural;  - Spinal.
  28. 28. Terminal anesthesia is a simple and accessible method. It is realized by bringing the solution of anesthetic on mucous by the way of smearing, dispersion, dropping.  For terminal anesthesia anesthetics of amides group are used: 2% solution of piromecaine, 5% solution of lidocaine hydrochloride (xycain), trymecaine, marcaine.
  29. 29. Infiltrative anesthesia is made layer by layer introduction of the solution of anesthetic on each next operation stage.  For the infiltrative anesthesia often we are using 0,25-0,5% of solution of Novocain.  Fig.1. Infiltration anesthesia
  30. 30. Conductive anesthesia – method of regional analgesia, when the solution of the local anesthesia is put into the nervous trunk or interning proximally from the field of operation.  Recommended anesthetics are: 1-2% solution of lidocaine hydrochloride (xycaine), trymecaine, and marcaine. Rarely: 0,25% solution of dicaine, 1-2% solution of Novocain.
  31. 31. Professor Lukashewich (1886) from Kyiv tested the action of the solution of cocaine on himself and volunteers for conducting anesthesia on fingers (150 cases), made 36 surgical interventions in the cases whitlow.  Today this anesthesia is famous as anesthesia after Lukashewich- Oberst (fig.3). Anesthesia by Lukashewich-Oberst fig. 3)
  32. 32. Intraosseous and intravenous regional anesthesia Fig.4. Technique of intraosseous regional anesthesia  Fig.5. Technique of intravenous regional anesthesia
  33. 33. Epidural and spinal anesthesia is the method of conducting anesthesia, at which the analgesia with the help of local anesthetics is reached on the level of spinal radices (rootlets). Fig.6. Spinal anesthesia.
  34. 34. The solution of anesthetic is deposits in space, between hard cerebral membrane and clear space covering an osseous spinal channel.  Analgesic matters diffuse through the hard cerebral membrane and membrane of the spinal nerves into spinal fluid, then spreads through the intervertebral communications realizes paravertebral blockade of nerves.  The puncture of epidural space is made as a rule from the middle (between spinous processes or paramedial access), laterally on 1,5-2 cm, on the level of III – IV lumbar vertebra.
  35. 35. Complications of epidural anesthesia:  - Vascular collapse by the reason of paralysis of vasoconstrictors, redistribution of blood;  - Total spinal block is arises in the case of puncture of hard cerebral membrane, when the anesthetic in high concentration is reached the spinal bulb. The collapse breathing paralysis is coming.
  36. 36. Спасибо за внимание Thank for attention