Is it possible to wake up during anesthesia? Care of patients during the period of recovery from anesthesia and in the near future after surgery
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1. Place the patient in a prepared clean bed without a pillow.
2. Monitor pulse, respiration, blood pressure, body temperature.
3. Monitor diuresis.
4. Monitor the amount and nature of the discharge through the drains.
5. Maintain a list of dynamic monitoring of the patient.
6. Observe the postoperative wound.
7. After recovering from anesthesia, place the patient in a position that depends on the nature of the operation.
Narcosis is a state characterized by a temporary shutdown of consciousness, pain sensitivity, reflexes and relaxation of skeletal muscles, caused by the action of narcotic substances on the central nervous system.
Depending on the route of administration of narcotic substances into the body, inhalation and non-inhalation anesthesia are distinguished.
There are 4 stages:
I - analgesia.
II - excitement.
III - surgical stage, subdivided into 4 levels.
IV- awakening.
Stage of analgesia (I). The patient is conscious, but lethargic, dozing, answers questions in monosyllables. There is no superficial pain sensitivity, but tactile and thermal sensitivity is preserved. During this period, it is possible to perform short-term interventions (opening phlegmon, abscesses, diagnostic studies). The stage is short-term, lasts 3-4 minutes.
Stage of excitation (II). At this stage, the centers of the cerebral cortex are inhibited, while the subcortical centers are in a state of excitation: consciousness is absent, motor and speech excitation is expressed. Patients scream, try to get up from the operating table. The skin is hyperemic, the pulse is frequent, blood pressure is elevated. The pupil is wide, but reacts to light, lacrimation is noted. Often there is a cough, increased bronchial secretion, vomiting is possible. Surgical manipulations against the background of excitation cannot be carried out. During this period, it is necessary to continue saturating the body with a narcotic to deepen anesthesia. The duration of the stage depends on the condition of the patient, the experience of the anesthesiologist. Excitation usually lasts 7-15 minutes.
Surgical stage (III). With the onset of this stage of anesthesia, the patient calms down, breathing becomes even, the pulse rate and blood pressure approach the initial level. During this period, surgical interventions are possible.
Depending on the depth of anesthesia, 4 levels of stage III anesthesia are distinguished.
First level(III,1): the patient is calm, breathing is even, blood pressure and pulse reach their original values. The pupil begins to narrow, the reaction to light is preserved. There is a smooth movement of the eyeballs, their eccentric location. The corneal and pharyngeal-laryngeal reflexes are preserved. Muscle tone is preserved, so abdominal operations are difficult.
Second level (III,2): the movement of the eyeballs stops, they are located in a central position. The pupils begin to gradually expand, the reaction of the pupil to light weakens. The corneal and pharyngeal-laryngeal reflexes weaken and disappear by the end of the second level. Breathing is calm, even. Blood pressure and pulse are normal. A decrease in muscle tone begins, which allows for abdominal operations. Usually anesthesia is carried out at the level III,1-III,2.
Third level (III,3) is the level of deep anesthesia. The pupils are dilated, react only to a strong light stimulus, the corneal reflex is absent. During this period, complete relaxation of the skeletal muscles, including the intercostal muscles, occurs. Breathing becomes shallow, diaphragmatic. As a result of relaxation of the muscles of the lower jaw, the latter may sag, in such cases the root of the tongue sinks and closes the entrance to the larynx, which leads to respiratory arrest. To prevent this complication, it is necessary to bring the lower jaw forward and maintain it in this position. The pulse at this level is quickened, small filling. Arterial pressure decreases. It is necessary to know that conducting anesthesia at this level is dangerous for the patient's life.
Fourth level (III,4); the maximum expansion of the pupil without its reaction to light, the cornea is dull, dry. Breathing is superficial, carried out due to the movements of the diaphragm due to the onset of paralysis of the intercostal muscles. The pulse is thready, frequent, blood pressure is low or not detected at all. Deepening anesthesia to the fourth level is dangerous for the patient's life, as respiratory and circulatory arrest may occur.
Awakening stage (IV). As soon as the supply of narcotic substances stops, the concentration of the anesthetic in the blood decreases, the patient goes through all the stages of anesthesia in reverse order, awakening occurs.
Preparing the patient for anesthesia. The anesthesiologist is directly involved in preparing the patient for anesthesia and surgery. The patient is examined before the operation, while not only paying attention to the underlying disease, for which the operation is to be performed, but also clarifying in detail the presence of concomitant diseases. If the patient is operated on in a planned manner. then, if necessary, carry out the treatment of concomitant diseases, sanitation of the oral cavity. The doctor finds out and evaluates the mental state of the patient, finds out the allergic history. clarifies whether the patient has undergone surgery and anesthesia in the past. Draws attention to the shape of the face, chest, the structure of the neck, the severity of subcutaneous fat. All this is necessary to choose the right method of anesthesia and narcotic drug.
An important rule in preparing the patient for anesthesia is the cleansing of the gastrointestinal tract (gastric lavage, cleansing enemas).
To suppress the psycho-emotional reaction and inhibit the function of the vagus nerve, the patient is given special medication preparation - premedication before the operation. Sleeping pills are given at night, and tranquilizers (seduxen, relanium) are prescribed for patients with a labile nervous system a day before surgery. 40 minutes before surgery, narcotic analgesics are administered intramuscularly or subcutaneously: 1 ml of a 1-2% solution of promolol or 1 ml of pentozocine (lexir), 2 ml of fentanyl. To suppress the function of the vagus nerve and reduce salivation, 0.5 ml of a 0.1% solution of atropine is administered. In patients with an allergic history, premedication includes antihistamines. Immediately before the operation, the oral cavity is examined, removable teeth and dentures are removed.
INTRAVENOUS ANESTHESIA
The advantages of intravenous general anesthesia are the rapid introduction into anesthesia, the absence of arousal, and a pleasant falling asleep for the patient. However, narcotic drugs for intravenous administration create short-term anesthesia, which makes it impossible to use them in their pure form for long-term surgical interventions.
Derivatives of barbituric acid - sodium thiopental and hexenal - cause a rapid onset of narcotic sleep, there is no stage of excitation, and awakening is fast. The clinical picture of anesthesia with thiopental sodium and hexenal is identical.
Hexenal causes less respiratory depression.
Use freshly prepared solutions of barbiturates. To do this, the contents of the vial (1 g of the drug) are dissolved in 100 ml of isotonic sodium chloride solution (1% solution) before the onset of anesthesia. The vein is punctured and the solution is slowly injected at a rate of 1 ml over 10-15 seconds. After the introduction of 3-5 ml of the solution for 30 seconds, the sensitivity of the patient to barbiturates is determined, then the administration of the drug is continued until the surgical stage of anesthesia. The duration of anesthesia is 10-15 minutes from the onset of narcotic sleep after a single injection of the drug. The duration of anesthesia is provided by fractional administration of 100-200 mg of the drug. The total dose of the drug should not exceed 1000 mg. During the administration of the drug, the nurse monitors the pulse, blood pressure and breathing. The anesthesiologist monitors the state of the pupil, the movement of the eyeballs, the presence of a corneal reflex to determine the level of anesthesia. ·
anesthesia thiopental-sodium , respiratory depression is characteristic, and therefore the presence of a respiratory apparatus is necessary. When apnea occurs, it is necessary to start artificial lung ventilation (ALV) using a mask of a breathing apparatus. The rapid introduction of sodium thiopental can lead to a decrease in blood pressure, depression of cardiac activity. In this case, it is necessary to stop the administration of the drug. In surgical practice, anesthesia with barbiturates is used for short-term operations lasting 10-20 minutes (opening abscesses, phlegmon, reduction of dislocations, reposition of bone fragments). Barbiturates are also used for induction of anesthesia.
Viadril(predion for injection) is used at a dose of 15 mg / kg, the total dose is on average 1000 mg. Viadryl is more often used in small doses along with nitrous oxide. In high doses, the drug can lead to hypotension. The use of the drug is complicated by the development of phlebitis and thrombophlebitis. To prevent them, the drug is recommended to be injected slowly into the central vein in the form of a 2.5% solution. Viadryl is used for induction anesthesia, for endoscopic examinations.
propanidide(epontol, sombrevin) is available in ampoules of 10 ml of a 5% solution. The dose of the drug is 7-10 mg / kg, administered intravenously, quickly (the entire dose is 500 mg in 30 seconds). Sleep comes immediately - "at the end of the needle." The duration of anesthesia sleep is 5-6 minutes. Awakening is fast, calm. The use of propanidide causes hyperventilation, which appears immediately after loss of consciousness. Apnea can sometimes occur. In this case, it is necessary to carry out mechanical ventilation using a breathing apparatus. The disadvantage is the possibility of developing hypoxia during the administration of the drug. Mandatory control of blood pressure and pulse. The drug is used for induction anesthesia, in outpatient surgical practice for small operations.
Sodium oxybutyrate administered intravenously very slowly. The average dose is 100-150 mg/kg. The drug creates a superficial anesthesia, so it is often used in combination with other narcotic drugs, such as barbiturates. propanidide. More often, it is used for induction anesthesia.
Ketamine(ketalar) can be used for intravenous and intramuscular administration. The estimated dose of the drug is 2-5 mg / kg. Ketamine can be used for mononarcosis and for induction anesthesia. The drug causes superficial sleep, stimulates the activity of the cardiovascular system (blood pressure rises, pulse quickens). The introduction of the drug is contraindicated in patients with hypertension. Widely used in shock in patients with hypotension. Side effects of ketamine are unpleasant hallucinations at the end of anesthesia and upon awakening.
INHALYATION ANESTHESIA
Inhalation anesthesia is achieved with the help of easily evaporating (volatile) liquids - ether, halothane, methoxyflurane (pentran), trichloroethylene, chloroform or gaseous narcotic substances - nitrous oxide, cyclopropane.
With the endotracheal method of anesthesia, the narcotic substance enters the body from the anesthesia machine through a tube inserted into the trachea. The advantage of the method is that it provides free airway patency and can be used in operations on the neck and face. head, eliminates the possibility of aspiration of vomit, blood; reduces the amount of drug used; improves gas exchange by reducing "dead" space.
Endotracheal anesthesia is indicated for large, surgical interventions, it is used in the form of multicomponent anesthesia with muscle relaxants (combined anesthesia). The total use of several narcotic substances in small doses reduces the toxic effect on the body of each of them. Modern combined anesthesia is used for the implementation of analgesia, switching off consciousness, relaxation. Analgesia and unconsciousness are achieved using one or more narcotic substances - inhaled or non-inhaled. Anesthesia is carried out at the first level of the surgical stage. Muscle relaxation or relaxation is achieved by the fractional administration of muscle relaxants.
STAGES OF INHALYATION ANESTHESIA
Stage I- introduction to anesthesia. Introductory anesthesia can be carried out with any narcotic substance, against which a sufficiently deep anesthetic sleep occurs without arousal stage. Mostly barbiturates are used. fentanyl in combination with sombrevin, ground with sombrevin. Sodium thiopental is also often used. The drugs are used in the form of a 1% solution, they are administered intravenously at a dose of 400-500 mg. Against the background of induction anesthesia, muscle relaxants are administered and tracheal intubation is performed.
Stage II- maintenance of anesthesia. To maintain general anesthesia, you can use any drug that can protect the body from surgical trauma (halothane, cyclopropane, nitrous oxide with oxygen), as well as neuroleptanalgesia. Anesthesia is maintained at the first and second level of the surgical stage, and to eliminate muscle tension, muscle relaxants are administered, which cause myoplegia of all skeletal muscle groups, including respiratory ones. Therefore, the main condition for the modern combined method of anesthesia is mechanical ventilation, which is carried out by rhythmically squeezing a bag or fur, or using an artificial respiration apparatus.
Recently, neuroleptanalgesia has become the most widespread. With this method, nitrous oxide with oxygen, fentanyl, droperidol, muscle relaxants are used for anesthesia. Introductory anesthesia intravenous. Anesthesia is maintained by inhalation of nitrous oxide with oxygen in a ratio of 2: 1, fractional intravenous administration of fentanyl and droperidol 1-2 ml every 15-20 minutes. With an increase in heart rate, fentanyl is administered. with an increase in blood pressure - droperidol. This type of anesthesia is safer for the patient. fentanyl enhances pain relief, droperidol suppresses vegetative reactions.
Stage III- withdrawal from anesthesia. By the end of the operation, the anesthesiologist gradually stops the administration of narcotic substances and muscle relaxants. Consciousness returns to the patient, independent breathing and muscle tone are restored. The criteria for assessing the adequacy of spontaneous breathing are indicators of PO2, PCO2, and pH. After awakening, restoration of spontaneous breathing and skeletal muscle tone, the anesthesiologist can extubate the patient and transport him for further observation in the recovery room.
Methods for monitoring the conduct of anesthesia:
1. Measure blood pressure, pulse rate every 10-15 minutes. In persons with diseases of the heart and blood vessels, as well as in thoracic operations, it is especially important to carry out constant monitoring of cardiac activity.
2. Electroencephalographic observation can be used to determine the level of anesthesia.
3. To control lung ventilation and metabolic changes during anesthesia and surgery, it is necessary to conduct a study of the acid-base state.
4. During anesthesia, the nurse keeps the anesthesiology record of the patient.
COMPLICATIONS OF ANESTHESIA
1. Vomiting. At the beginning of anesthesia, vomiting may be associated with the nature of the underlying disease (pyloric stenosis, intestinal obstruction) or with the direct effect of the drug on the vomiting center. Against the background of vomiting, aspiration is dangerous - the entry of gastric contents into the trachea and bronchi. Gastric contents that have a pronounced acid reaction, getting on the vocal cords, and then penetrating into the trachea, can lead to laryngospasm or bronchospasm, resulting in respiratory failure with subsequent hypoxia - this is the so-called Mendelssohn's syndrome, manifested by cyanosis, bronchospasm, tachycardia.
2. Regurgitation - passive throwing of gastric contents into the trachea and bronchi. This occurs, as a rule, against the background of deep mask anesthesia with relaxation of the sphincters and overflow of the stomach or after the introduction of muscle relaxants (before intubation). Ingestion into the lung during vomiting or regurgitation of acidic gastric contents leads to severe pneumonia, often fatal.
To prevent vomiting and regurgitation, it is necessary to remove its contents from the stomach with a probe before anesthesia. In patients with peritonitis and intestinal obstruction, the probe is left in the stomach during the entire anesthesia, while a moderate Trendelenburg position is recommended. Before the onset of anesthesia, to prevent regurgitation, you can use the Selick maneuver - pressure on the cricoid cartilage posteriorly, which causes compression of the esophagus.
If vomiting occurs, the gastric contents should be immediately removed from the oral cavity with a swab or suction; in case of regurgitation, the gastric contents are removed by suction through a catheter inserted into the trachea and bronchi.
Vomiting followed by aspiration can occur not only during anesthesia, but also when the patient wakes up. To prevent aspiration in such cases, it is necessary to put the patient horizontally or in the Trendelenburg position, turn his head to the side. It is necessary to monitor the patient.
3. Respiratory complications may be associated with impaired airway patency. This may be due to a malfunction of the anesthesia machine. Before starting anesthesia, it is important to check the operation of the device, its tightness and the permeability of gases through the breathing hoses.
Airway obstruction may occur as a result of retraction of the tongue during deep anesthesia (3rd level of the surgical stage of anesthesia). During anesthesia, solid foreign bodies (teeth, prostheses) can enter the upper respiratory tract. To prevent these complications, it is necessary to protrude and support the lower jaw against the background of deep anesthesia. Before anesthesia, the dentures should be removed, the patient's teeth should be examined.
4. Complications during tracheal intubation:
1) damage to the teeth by the laryngoscope blade;
3) introduction of an endotracheal tube into the esophagus;
4) introduction of an endotracheal tube into the right bronchus;
5) exit of the endotracheal tube from the trachea or bending it.
The described complications can be prevented by a clear knowledge of the intubation technique and control of the position of the endotracheal tube in the trachea above its bifurcation.
5. Complications from the circulatory system.
1) hypotension - a decrease in blood pressure both during the period of anesthesia and during anesthesia - can occur due to the effect of narcotic substances on the activity of the heart or on the vascular-motor center. This happens with an overdose of drugs.
To prevent this complication, it is necessary to fill the BCC deficiency before anesthesia, and during the operation, accompanied by blood loss, transfuse blood-substituting solutions and blood.
2) cardiac arrhythmias (ventricular tachycardia, extrasystole, ventricular fibrillation) can occur due to a number of reasons: hypoxia and hypercapnia that occurred during prolonged intubation or insufficient mechanical ventilation during anesthesia; overdose of narcotic substances - barbiturates. halothane; use of epinephrine against the background of ftorotane, which increases the sensitivity of ftorotane to catecholamines.
To determine the rhythm of cardiac activity, electrocardiographic control is necessary.
Treatment is carried out depending on the cause of the complication and includes the elimination of hypoxia, a decrease in the dose of the drug, the use of quinine drugs.
Cardiac arrest is the most formidable complication during anesthesia. The reason for it is most often an incorrect assessment of the patient's condition, errors in the technique of anestezin, hypoxia, hypercapnia.
Treatment consists of immediate cardiopulmonary resuscitation.
6. Complications from the nervous system.
1) a moderate decrease in body temperature due to the effect of narcotic substances on the central mechanisms of thermoregulation and cooling of the patient in the operating room.
The body of patients with hypothermia after anesthesia tries to normalize body temperature due to increased metabolism. Against this background, chills occur at the end of anesthesia and after it. Most often, chills are observed after halothane anesthesia. To prevent hypothermia, it is necessary to monitor the temperature in the operating room (21-22 ° C), cover the patient, if necessary, infusion therapy, pour solutions warmed to body temperature, inhale warm moistened narcotic drugs, monitor the patient's body temperature.
2) cerebral edema is a consequence of prolonged and deep hypoxia during anesthesia. Treatment should begin immediately, following the principles of dehydration, hyperventilation, local cooling of the brain.
3) damage to peripheral nerves. This complication appears a day or more after anesthesia. Most often, the nerves of the upper and lower extremities and the brachial plexus are damaged. This occurs when the patient is not properly positioned on the operating table.
As part of the department of anesthesiology and resuscitation (this is currently practiced quite widely), there are recovery wards or awakening wards, where the patient stays for some time after almost any operation. As a rule, it is 2-3 hours. If a person woke up and we are sure that everything will be fine with him, we can transfer him in 30 minutes.
These chambers appeared in connection with respiratory failure in the early postoperative period. One of the well-known Western anesthesiologists said that at the present stage, people do not die from anesthesia, they die from asphyxia, that is, from a lack of oxygen.
At that moment, when a person came to his senses after the operation, it may seem that everything is fine with him. But there is a possibility of deepening anesthesia for various reasons. And so it must be under the supervision of specialists. We transfer him to the ward, where there is a doctor on duty, a nurse on duty. The patient is connected to a monitor that reads his cardiogram, heart rate, blood pressure and blood oxygen saturation. When the patient regains a clear consciousness, he is already transferred to the surgical or specialized department for further recovery. But they transfer only after the patient's vital signs become stable, that is, his pulse, pressure is normal.
As a rule, patients who have "passed" through general anesthesia "pass" through the awakening ward. It is necessary to know how his body will behave in the early postoperative period, how spontaneous breathing will be restored, because during general anesthesia, drugs are needed to turn off spontaneous breathing altogether, that is, transfer the patient's body completely to artificial ventilation of the lungs. The moment of transition from artificial ventilation of the lungs to one's own breathing is important.
Even after short-term surgical interventions, the anesthetist must observe the patient for at least 2 hours.
recovery from anesthesia (awakening)
Awakening begins when the anesthetist stops the drug. The return of consciousness coincides with the beginning of the restoration of adaptive mechanisms, with the possibility of the patient's active participation in the recovery process.
The awakening period requires the close attention of the anesthesiologist. During the operation, the body adapts to a certain extent to unusual conditions of existence: breathing with mixtures enriched with oxygen, mechanical ventilation, muscle relaxation and inhibition of reflexes. Upon awakening, the adaptive systems are again stressed, and their overload can lead to disaster. Therefore, during the awakening period, the anesthesiologist must check the function of all vital systems.
For this it is necessary:
- listen to the lungs in the presence of wet rales, suction the secret from the trachea and bronchi, clean the mouth and nose from saliva and mucus, check the integrity of the teeth;
- listen to heart sounds, measure blood pressure, check the sufficiency of replenishing blood loss, assess vascular tone, if necessary, replenish blood loss;
- determine muscle tone, the degree of recovery of protective reflexes - pharyngeal, cough, tracheal;
- determine the depth of anesthesia, the speed of its "relief".
After any anesthesia, the main thing is the restoration of adequate breathing and protective reflexes..
Any doubt about the usefulness of the respiratory function requires an objective check of the ventilation of the lungs and the necessary therapeutic measures.
Early restoration of adequate spontaneous breathing is an important measure to prevent postoperative pulmonary complications - atelectasis and pneumonia. A clinical indicator of the adequacy of spontaneous breathing is the absence of cyanosis when breathing air for 5-10 minutes, the correct rhythm of respiratory movements. An important sign of respiratory failure during this period is the participation in the act of breathing of auxiliary muscles, the displacement of the trachea with each breath ("diving"), swelling of the wings of the nose. In these cases, it is necessary to continue mechanical ventilation or, if indicated, to use antidotes of muscle relaxants, narcotic analgesics, respiratory analeptics.
With modern anesthesia, consciousness is restored early. However, one should not rush to wake up if complex dressings are to be applied, diagnostic puncture of the pleural cavity, bronchoscopy. After extremely traumatic operations, recovery from anesthesia should be especially gradual. .
If there are not enough well-trained staff in the postoperative department, an individual approach is needed to the issue of awakening the patient. After the operation, which, as can be expected, will be accompanied by severe pain, it is advisable to prolong the superficial narcotic sleep. Of course, this increases the responsibility for the life of the patient. Particular attention should be paid to ensuring free airway patency, the threat of violation of which constantly arises in the post-anesthetic period, until the protective reflexes - cough and pharyngeal - are fully restored..
Once upon a time, pain during operations was considered atonement for sins, and doctors who tried to get rid of it were considered charlatans or heretics. Today, not a single surgical operation is complete without anesthesia, and our generation, fortunately, has forgotten about the torments that patients experienced in the “pre-anesthetic” era. However, the state of narcotic sleep is still mysterious for a person.
It is difficult to imagine how surgical interventions were carried out before the advent of reliable means of pain relief. In those days, they joked that the operation needed two doses of alcohol: one for the patient, and the other for the doctor, so as not to be distracted by screams. Mortality of patients during operations reached 70%, largely due to pain shock.
Healers tried to solve the problem of pain by depriving a person of consciousness. To do this, they used any means available at that time: they beat them on the head, choked them, squeezing the carotid arteries, or released some of the blood until the patient lost consciousness. They used alcohol and narcotic substances, which clouded the mind and put the patient into a state of euphoria. Not surprisingly, only a few survived after such treatment.
Anesthesia was introduced into wide medical practice only in the middle of the 19th century and has been constantly improved since then. Now in the arsenal of anesthesiologists there are more than a dozen drugs that block pain receptors, stop the conduction of pain impulses along the nerves, and even disrupt the perception of pain at the level of the brain. Each of the methods and types of anesthesia has its own characteristics.
Local anesthesia
Local anesthesia is one of the simplest, fastest and, therefore, common types of anesthesia. The historical prototype of modern local anesthetics was coca leaf juice containing cocaine. This substance caused rapid numbness and allowed operations to be performed even in front of the eyes. Dangerous side effects of the drug soon became clear, and cocaine was replaced by safer synthetic drugs: dicaine, novocaine, lidocaine, procaine, which are still used in medicine.
The medicine is injected directly into the site of the future incision. The drug saturates tissues and blocks pain receptors, causing a feeling of numbness. There may be sensations of touch or pressure, but there should be no pain. Depending on the type of anesthetic, the effect of local anesthesia can last from 10-15 minutes to several hours.
Local anesthesia has received the greatest development in our country. Russian and Soviet doctors performed complex operations on the lungs, abdominal organs and even the heart under local anesthesia. Now, with the development of other types of anesthesia, local anesthesia is used mainly for small operations: treatment of panaritium, removal of lipoma, tooth extraction, etc.
Regional anesthesia
Regional anesthesia is anesthesia of an entire area of the body: a finger, hand, entire arm or leg. For these purposes, the drug is injected with a long needle into the projection of the nerve or nerve plexus, which is responsible for the work of the desired part of the body. Usually, along with anesthesia, immobilization occurs, since the motor and sensory fibers of the nerve pass in the same bundle.
The most time-consuming, but at the same time, the most common types of regional anesthesia are now: spinal and epidural. In both cases, the drug is injected into the space next to the body's largest nerve trunk, the spinal cord. The effect extends to the entire torso below the injection site, such as the legs and lower abdomen.
Epidural anesthesia is considered more "soft" and less often accompanied by complications. After the injection, the needle is replaced with a thin flexible catheter, through which, if necessary, a new portion of anesthetic is supplied, which allows prolonging the operation. However, epidural anesthesia is not applicable for urgent interventions, since the analgesic effect of it develops within half an hour. Spinal anesthesia works almost instantly, but is more difficult to perform. This is one injection, which is enough for 3-4 hours.
Both types of anesthesia are commonly used for pain relief during childbirth, caesarean section, and operations on the organs of the lower abdomen and lower extremities. The most common complication after spinal and epidural anesthesia is headache. This complication is not dangerous and usually resolves within 24 hours. To relieve headaches, conventional analgesics in tablets are used.
General anesthesia
Anesthesia or general anesthesia is the most difficult and responsible type of anesthesia. An anesthesiologist is introduced into anesthesia, who will be next to the patient throughout the operation to monitor his condition.
During anesthesia, the person is unconscious. Everything that happens to him at that moment is not stored in memory. Under the influence of a cocktail of drugs, muscles relax, the ability to move is lost and sensations completely disappear. This condition is completely reversible and lasts as long as the desired concentration of drugs for anesthesia is maintained in the body. These substances are administered through the respiratory tract - during mask or inhalation anesthesia, as well as by injection - intravenously or intramuscularly. Often these methods are combined.
The anesthesia itself usually consists of several stages. First, a person is placed on an operating table warmed with a special mattress. Hands and feet are fixed, since the introduction into anesthesia is often accompanied by a period of motor excitation. After, an induction anesthesia is given. To do this, use a mask with a respiratory mixture, which is brought to the face, or an intravenous injection is given. For easy and quick interventions, induction anesthesia is sufficient. If a complex operation is planned, then the depth of anesthesia is gradually increased by adding narcotic drugs.
The next step is tracheal intubation - the introduction of a special tube through the mouth into the respiratory tract. An artificial respiration apparatus is connected to this tube, since in a state of deep anesthesia a person cannot breathe on his own.
During the operation, the anesthesiologist constantly monitors the patient's life processes, usually with the help of special equipment that automatically measures the pulse, pressure, oxygen and carbon dioxide concentrations in the blood and exhaled air, records the electrocardiogram, as well as brain biopotentials. According to the latter, the doctor determines whether you are sleeping or not, whether you feel pain, that is, how effective anesthesia is. If something is wrong, the doctor increases or decreases the concentration of anesthetic drugs.
Intra-anesthetic spillage is one of the rarest, but often discussed, complications of general anesthesia. Such a complication occurs with an incorrect combination of the three main components of the anesthetic mixture:
- painkiller,
- sleeping pills
- drug to relax the muscles of the body.
The most severe consequences for the psyche occur when there is a shortage of the hypnotic element of the anesthetic cocktail, when pain sensitivity is awakened and restored, against the background of complete paralysis of the body: when a person cannot move to call for help.
According to statistics, you can wake up during anesthesia in 1 case per 19,000. At risk are people with severe obesity, diseases of the cardiovascular system, undergoing major heart surgery and women during caesarean section.
Can you sleep forever?
The risk of fatal complications after general anesthesia certainly exists, but it is small and decreases every year. Now, it is 1:200,000 - 1:300,000 cases in elective surgeries. Most often, tragic cases occur when surgeons and anesthesiologists have to work in a hurry, during emergency operations. Then the risk of errors and complications from the body increases.
Whether anesthesia is needed or not, and what it will be, is up to the doctor to decide. The personal preferences of the patient should not influence this choice. This rule is often violated in paid clinics, which work on the principle: who pays, he calls the music. Fearing pain, some of us “buy” anesthesia for ourselves in cases where it would be quite possible to get by with a safer method of anesthesia or not at all.
Especially often, people prefer to "lull" their children when visiting the dentist, fearing the tears and cries of their beloved child. Although they themselves in childhood pulled their teeth “by the string”. It is bad when the preparation for treatment is more difficult than the operation itself.
How can we revive personnel in medicine?
A rare case: a doctor wrote to the editor. Yes, not a simple one, but a children's anesthesiologist-resuscitator, doctor of the highest category Vladimir KOCHKIN. In addition, Vladimir Stanislavovich is the head of the department of anesthesiology and resuscitation, he is in charge of the operating unit of the Russian Children's Clinical Hospital (the famous RCCH). And his reflections are devoted not to routine internal problems, but to the subtleties and myths surrounding one of the most inconspicuous professions in medicine - an anesthesiologist-resuscitator.
We managed to communicate with Vladimir Stanislavovich and clarify some of his positions. From what kind of anesthesia "blows the roof"? What are these "tunnels" and "angels" that patients see when they receive anesthesia? Why do children need clowns before the operation and cartoons in the "awakening ward" after it?
“During anesthesia, a person is at risk - between life and “non-life”
It is unlikely that patients who have decided to “go under the knife” think about who will give them anesthesia and return (in which case) from the other world? They are more concerned about which surgeon will perform the operation. What is very upsetting anesthesiologists-resuscitators.
We are always in the shadow of the attending physician, - the anesthesiologist-resuscitator Vladimir Kochkin stated with regret in his message to the editor. - But the responsibility for life in many respects lies with us. As they often say: "The surgeon cut, did his job, sewed up and left." And the anesthesiologist-resuscitator always holds the thread of someone's life in his hands. But the gratitude of the patients will not wait. The attending physician for the patient is God, and the anesthesiologist is just an auxiliary tool.
Maybe few of the uninitiated know what kind of profession this is - an anesthesiologist-resuscitator? I asked Vladimir.
I think there is no need to explain for a long time: the name speaks for itself. In practice, the anesthesiologist solves two main tasks: to provide the necessary level of anesthesia and muscle relaxation (relaxation of skeletal muscles) during surgical operations, traumatic and painful manipulations, to ensure the safety of the patient on the operating table and to control procedures that require additional analysis of the patient's condition (blood transfusion, administration of contrast agents). substances in CT, etc.). Any operation is always stressful. Especially for a child. The task, as we see, is extremely important. Anesthesia is the protection of vital functions from operational stress. And resuscitation - "prosthetics" of vital functions. Saving people's lives will always be in demand.
But not every anesthesia can suit the patient. The dose is no less important: if you overdo it, then a person may not wake up. Is not it?
Any anesthesia is associated with risk. One of the sore topics for anesthesiologists is intraoperative awakening, when the patient suddenly wakes up in the middle of the operation. The phenomenon is rare and highly undesirable: anesthesia affects the patient only partially - and during the operation a person can regain consciousness and gain sensitivity. But his muscles remain paralyzed, and he is unable to scream or move to signal the surgeon. By the way, 70% of lawsuits in this area in the United States are related to this. There are no such statistics in Russia. I personally had only one case with a 10-year-old boy who said that during the operation he heard what they were talking about in the operating room. This is the main task of the anesthesiologist - to calculate and think over the anesthesia in such a way that the patient wakes up on time - not before the operation, not during it, but exactly when all pain manipulations are completed.
- What is used today to turn off a person's consciousness before an operation? Are there safe anesthetics?
I am categorically against ketamine, which flows like water in our country! In America, people who have received ketamine anesthesia are not allowed to work in government agencies. And in our country, ketamine is used for abortions and even for operations on children. Especially in the regions. In my department, this drug is prescribed in two cases: in emergency situations, when the patient is in shock, and in patients diagnosed with mental retardation, whom he can no longer harm. In the RCCH we abandoned it in 2005, in the USA it has not been used since 1999. Everyone knows about the negative properties of this drug, which gives disorders for more than six months. But what is a doctor to do when he has nothing else at hand? Therefore, anesthesiologists always take the consent of the parents before the operation and warn about the consequences.
I know that under the influence of anesthesia a person is at risk - between life and "non-life". Many patients after the operation say that they saw a tunnel while “falling asleep”. Think it's fantasy? Not at all. And during the operation with the use of halothane (inhalation anesthesia) I had a “vision” of a tunnel leading to a point. I was then 6 years old. I still remember. Is it the soul that flies or is the consciousness resisting its helplessness and building protective barriers? Hallucinations of this kind - with the vision of angels, with a journey through the other world, with turning the body in space, with a complete loss of coordination - happen, by the way, against the background of the use of ketamine. This is a rather old and, alas, common drug. Ketamine causes severe hallucinations and fear syndrome. A person after such anesthesia can stay in prostration for several days.
- Solid cons from this ketamine. Why then is it not abandoned altogether and replaced by something else?
The advantage of ketamine compared to, say, morphine-type drugs is that hydrochloride does not mimic any vital metabolic components in the human body, is completely excreted by the kidneys within a few hours after ingestion, and therefore does not cause either physiological addiction or “breaking” when stop taking. The trouble is that the psychological addiction to ketamine is much stronger than many other addictions - even those in which the metabolic withdrawal syndrome causes severe suffering when quitting a bad habit (smoking, alcohol, opiates). The only way I know to overcome the habit is to change my place of residence - moving to those countries or cities where the drug cannot be obtained. Living in a city where ketamine is readily available, the addict is almost completely unable to overcome his addiction, no matter what outpatient or inpatient treatment procedures are performed.
- Then what is the safest anesthetic? It's no secret that there are complications after anesthesia ...
During the existence of anesthesiology as a science, many drugs have been tried, some of them caused hallucinations, anaphylactic shock. But with all this, it must be said that the number of severe complications from anesthesia is 30% less than complications from operations. What exactly is anesthesia? The first is to protect the patient's psyche, turn off consciousness. But even when consciousness is turned off, a stream of pain impulses remains, you need to block them. Analgesia, blockade of pain impulses, is achieved either by the use of central analgesics (morphine, promedol and other synthetic drugs) or by regional (local) anesthesia. The concept of "general anesthesia" includes a complete shutdown of consciousness.
- Is anesthesia dangerous for young children? And what do they remember after anesthesia?
If a competent anesthesiologist and the right drug, this can in no way harm the child. Anesthesiologists pay particular attention to the free passage of their airways. Babies have very narrow airways, and therefore most often they are given the so-called endotracheal anesthesia, when a tube is inserted into the trachea through which they breathe. After anesthesia, children may experience impaired memory, consciousness, and in small patients, there may be a violation of the biological rhythm of sleep and wakefulness. It all depends on which drug was used. We now use inhalation anesthetics as widely as possible. Cognitive disorders (brain functions - thinking, memory, speech, etc.) after its use are minimal.
And after the operation, many do not remember anything at all. Someone talks about an unusual light - soft, pleasant, which envelops them. Someone hears music and voices.
“Kid forgets about upcoming surgery while playing with hospital clowns”
In the department of anesthesiology and resuscitation of the RCCH, headed by Vladimir Kochkin, there are also awakening wards, a playroom in which the child forgets about the upcoming operation, playing along with the hospital clowns. “How many copies were broken for the creation of these chambers! - says Vladimir Stanislavovich. - Thanks to the chief physician of the RCCH, Professor Nikolai Nikolaevich Vaganov, who, in violation of the existing instructions, went to organize these structures. Now they are included in the procedures and approved by law, but with the reservation "at the discretion of the head of the institution." Ours saw. Thank you.
- How do children behave before the operation?
You know, in our department, babies don't cry at all. They may whine a little, but to cry - from pain or fear - no! Why then do we need anesthesiologists? After all, we still perform the role of psychotherapists in parallel. Children are very different - both babies and teenagers. Capricious and patient. It is impossible to love everyone - that would not be true. But to console, caress, cheer - all the employees of my department are able to do this. It is very important that the child has a pleasant, joyful feeling before the operation. That is why in the preoperative ward we put good old cartoons on them, give them funny plush toys. All this helps the child to calm down.
After the operation, the children change. They grow older, like people who have coped with the most difficult task. It is very important to praise them. Children recover, leave, and then send gifts, their photos, congratulations on the holiday. After all, many of us are operated on more than once. I keep everything in my office… I have a real museum there. A lot of orphanage children come. They never cry and always go to the doctor with confidence. For them there are no strangers, for them everything is their own. They are very grateful patients.
There is another necessary condition that is strictly observed in my department - the child should stay with his parents as long as possible. Therefore, parents are both in the playroom and in the premedication ward (anesthesia room), they accompany the child to the operating room, and the children fall asleep in their parents' arms and wake up in their arms in the awakening ward. The child opens his eyes, and in addition to his parents he sees funny clowns. Konstantin Sedov - the first professional hospital clown - along with his devotees came to us a long time ago. What he does for sick children, no psychotherapist will do.
“I look at my colleagues and think: who is next to put the application on the table?”
Vladimir Stanislavovich, your profession is extremely difficult and responsible. And, as you say, not prestigious. Probably, there are few people who want to go to such a job?
And those who come, do not stand. The department I manage today has 14 doctors (at the beginning of the year there were 19); 40 nurses (six months ago there were 57). There is a shortage of personnel, and a very tangible one. Every morning I gather doctors, give them a plan of operations and my wishes, whom to put on which operation. I look at them and wonder who's next to put the application on the table?
- Is it about wages? In equipment? Or in something else?
Technically, our department is very well equipped, the regions never dreamed of such a thing. We have world-class equipment. And in terms of the quality of medical care, few can compare with us. The problem is different - the average salary of a pediatric anesthesiologist in Russia is two rates - a maximum of 25 thousand rubles. In our department, such a doctor receives 40-60 thousand rubles. But... This is still one of the lowest salaries of an anesthesiologist in Moscow. Adult anesthesiology specialists get more. So my doctors leave for adult departments. Regularly looking for replenishment, looking all over Russia. Mostly graduates of the medical faculty come to us, but I need pediatricians! You have to finish teaching, retraining, a lot of time is spent on interns. Today I have 4 residents and 6 interns.
- It is believed that the overall level of young doctors has now declined sharply. Why do you think?
Students read little, even in their specialty. Although today there are a lot of interesting materials about research, discoveries - just read. They don't read! As the anesthetists themselves joke, anesthesia is in many ways not a science, but an art. And, like any art, it has its own history, which goes far into the depths of centuries. It is wrong to think that our ancestors cut everything alive. At one of the conferences, I was given a challenge prize - an aspen log, the first "anesthetic". There is such a thing as "raush-narcosis" (anesthesia by stunning). Once, before a complex operation, the patient was beaten with a mallet on the back of the head, and the patient was turned off for 10-15 minutes. For the same purposes, the mandrake root was used (it has a psychotropic property). Then they switched to more "advanced" anesthetics - extracts from coca leaves. Cocaine quickly clouded the mind, but caused the same rapid addiction. Curare poison was also used (the Indians got it from the bark of a tree).
- Good specialists, as you know, are not born ...
In our area, it is not enough to know anesthesiology. Equally important is character. Personally, at the first meeting I can determine whether it will be a good anesthesiologist or not. Overly self-confident, as well as insecure, I immediately dissuade. There was a case in my practice: a doctor came to us with an ambulance. But he was so indifferent to the children that I soon suggested that he leave. And he was not friends with discipline. What is unacceptable in our business: an anesthesiologist-resuscitator must be ready for the unexpected every minute. And generally ready for anything.
By the way, the profession of Vladimir Kochkin, as he himself believes, was determined by mister chance. “Chance plays a big role in our lives,” he says. - But after all and the case "chooses" us not casually. I had a diploma of a pediatrician, and then I entered the residency, which I took place at the Children's Hospital named after N.F. Filatov. Professor V.A.Mikhelson, an outstanding pediatric anesthesiologist and resuscitator, one of the founders of the national school of pediatric anesthesiology and resuscitation, supervised the entire anesthesiology and resuscitation there. He became my teacher and godfather in the profession. For 16 years now I have been the head of the department at the RCCH and every day I conduct anesthesia. And the excitement at the entrance to the operating room is still there. And every day I tell my doctors: “Have you thought of everything? Ready for everything? If you don’t know how to save a child, it’s better not to go to the operating room!”
In Russia today there is a big problem with the staff of pediatric anesthesiologists and resuscitators. In regions, the deficit reaches 70%. There are only 240 pediatric anesthesiologists and resuscitators in Moscow and the Moscow region.