Classification of the physical condition of patients according to ASA. The physical status of patients according to the classification of the ASA (American Society of Anesthesiologists)

Tracheal intubation algorithm (algorithm for intubation of difficult airways) recommended by ASA:
1. The anesthesiologist must have a predetermined strategy with difficult tracheal intubation. The anesthesiologist's workflow, shown in , is a recommended strategy that will depend, among other things, on the proposed operation, the patient's condition, and the skills and preferences of the anesthetist.
Recommended strategy for difficult tracheal intubation:
Occurrence probability assessment six clinical problems , which can be singly or in combination: 1) difficulty with patient cooperation or consent 2) difficult mask ventilation 3) upper respiratory problem 4) complex laryngoscopy 5) difficult intubation and 6) difficult surgical access to the airways.
Considering Relative Advantages between clinical options for solving the problem: 1) conscious intubation or intubation after induction of anesthesia? 2) non-invasive or invasive (i.e. surgical or transcutaneous airway access)? 3) Video laryngoscopy as the primary approach to tracheal intubation? 4) retention of spontaneous ventilation or its termination?
Finding the preferred approach : 1) conscious intubation 2) can be easily ventilated but difficult to intubate 3) a life-threatening situation in which it is impossible to ventilate or intubate.
Finding Alternatives , which can be used if the main one does not work or is not feasible.
Uncooperative patient may limit difficult airway management options, especially those involving awake tracheal intubation;
Solving the problem of difficult airways in patients who refuse to cooperate with the anesthetist, may require a different approach (for example, attempts at intubation after induction of anesthesia), which cannot be considered as the main solution to the problem.
Operation under local anesthesia or regional anesthesia may be an alternative to tracheal intubation, but this approach does not represent a definitive solution to the problem of difficult airways and does not eliminate the need for a difficult airway intubation strategy;
Confirmation of tracheal intubation using capnography or expiratory carbon dioxide monitoring.

Tracheal intubation algorithm was developed by the American Society of Anesthesiologists (ASA) in 2013 and is recommended for practical use.

ASA STANDARDS FOR ANESTHETIC MONITORING

Approved by the American Society of Anesthesiologists (ASA) House of Delegates on October 21, 1986, current revision October 28, 2015.

apply to all types of anesthesia, although, in an emergency, proper life support measures take precedence. These standards may be exceeded at any time based on the decision of the responsible anesthetist. They are intended to improve patient safety, but this cannot guarantee any specific results. Basic standards for anesthesia monitoring are subject to revision from time to time as warranted by the development of new technologies and practices. They are applicable for both general anesthesia and regional anesthesia. This set of standards deals only with questions basic anesthetic monitoring , which is one of the components of anesthesia itself. In some rare or unusual circumstances, any of these monitoring methods may not be clinically practical, and proper use of the monitoring methods described may not detect adverse clinical incidents. Brief breaks in ongoing monitoring may be unavoidable. These standards are not intended for use in obstetric anesthesiology and pain management.

1. ASA STANDARDI

Qualified anesthesia personnel must be present in the operating room during general anesthesia, regional anesthesia and during monitoring anesthesia care.

A task

Due to the rapid change in the patient's condition during anesthesia, the anesthesiologist and nurse anesthetist must be constantly present at the patient's side to monitor the patient's condition and thereby ensure the safety of anesthesia. In the event that there is a direct danger to medical personnel, for example, radiation, remote monitoring of the patient may be required - in this case, all available measures must be used to ensure anesthetic monitoring. In the event that an emergency situation requires the temporary absence of an anesthesiologist responsible for anesthesia, then the decision of the anesthesiologist will depend on comparing the emergency situation with the state of the patient during anesthesia, and if the decision is made to leave the operating room, he should appoint an anesthesiologist temporarily responsible for anesthesia .

1. ASA STANDARD II

During all types of anesthesia, the following parameters should be constantly assessed: oxygenation, ventilation, circulation and body temperature of the patient.
oxygenation

A task

Ensuring adequate oxygen concentration in the inhaled gas mixture during anesthesia.

Methods

During general anesthesia using an anesthetic-respiratory apparatus, the oxygen concentration in the respiratory circuit should be measured using a gas analyzer equipped with an alarm system that is triggered when the oxygen concentration drops to the maximum allowable.*

During all types of anesthesia, a quantitative method of assessing oxygenation, such as pulse oximetry, should be used. * When using a pulse oximeter, pulse tones of varying intensity and a desaturation alarm should be heard by the anesthesiologist. * Proper lighting and access to the patient are necessary to assess the color of the skin. *

1. VENTILATION

A task

Ensuring proper ventilation during all types of anesthesia.

Methods

When performing general anesthesia, it is necessary to evaluate the adequacy of ventilation. Qualitative clinical signs such as chest excursion, observation of the counterlung, and lung auscultation are helpful. Continuous monitoring of exhaled carbon dioxide is considered necessary, unless this is inconsistent with the procedure or equipment. Quantitative monitoring of the volume of exhaled gas is highly recommended.*

After tracheal intubation or insertion of a laryngeal mask, their correct position should be verified by clinical assessment as well as expiratory carbon dioxide concentration. Continuous analysis of end-tidal carbon dioxide, using a quantitative method (capnography, capnometry or mass spectroscopy), should be carried out throughout anesthesia.

When performing mechanical ventilation, a device should be provided that can detect disconnection of the breathing circuit components. The device should give an audible signal if its alarm threshold is exceeded.

During regional anesthesia (without sedation) or local anesthesia (without sedation), the adequacy of ventilation should be assessed by continuous observation of qualitative clinical signs. During moderate or deep sedation, the adequacy of ventilation should be assessed by continuous observation of qualitative clinical signs and monitoring of exhaled carbon dioxide, unless this is inconsistent with procedure or equipment.

1. CIRCULATION

A task

Ensure adequate circulation during anesthesia.

Methods

Every patient should have continuous ECG monitoring from the start of anesthesia until transport from the operating room*.

During anesthesia, each patient should have their blood pressure and heart rate measured at least every five minutes.*

In addition to the above, at least one of the following methods should be used during general anesthesia: pulse palpation, auscultation of heart sounds, invasive blood pressure monitoring, peripheral pulse ultrasound monitoring, or plethysmography or oximetry.

1. BODY TEMPERATURE

A task

Maintaining an appropriate body temperature during anesthesia.

Methods

During anesthesia, constant monitoring of body temperature is necessary. If a change in body temperature is expected, then it must be measured.

Note that "periodic" is defined as "repeating regularly, often, in constant succession", while "permanent" means "continuous, without any interruption".

* In extenuating circumstances, the responsible anesthesiologist may refuse to comply with the requirements marked with an asterisk (*). If this is done, then this fact is recommended to be indicated (including for reasons) in a note to the medical documentation.

ASA RECOMMENDATIONS WHEN USING PROPOFOL (Diprivan)

It is not always possible to predict how an individual patient will respond to administration of sedatives . Due to the possibility of a rapid and dramatic change in the depth of sedation/anesthesia and the absence of antagonists, some drugs, such as propofol , require special attention. Although propofol is intended for moderate sedation when using it, patients should receive care similar to that required for deep sedation .

Members of the American Society of Anesthetists (ASA) believe that the best option is participation of the anesthesiologist in the observation for each patient, during anesthesia. However, when this is not possible, administer propofol only a highly qualified experienced doctor who is able to save * a patient whose level of sedation has become deeper than originally intended, i.e. entered into a state of anesthesia.**

• Physician responsible for use sedation/anesthesia should receive appropriate training to be able to cope with potential complications resulting from the use of sedatives. He must have the skill of resuscitation and understand the pharmacology of the drugs used. The doctor should be near the patient throughout the entire duration of the sedative drug and remain in a state of instant availability until the patient is fully awakened.
• Medical practitioner administration of propofola , should be able to detect disorders in the cardiovascular and respiratory systems, which is possible in a patient entering a state of anesthesia, and be able to provide assistance in case of complications. The doctor must be present next to the patient during the entire procedure and deal exclusively with the observation of the patient.
• At the introduction of propofol monitoring of the patient's condition should be carried out continuously. This will assess the level of consciousness, as well as detect early signs of hypotension, bradycardia, apnea, airway obstruction and/or desaturation. Blood oxygen saturation, heart rate and blood pressure should be monitored at regular and short intervals. Monitoring of exhaled carbon dioxide is also recommended because chest movement does not reliably detect airway obstruction or apnea.
• In addition to cardiac resuscitation equipment, age-appropriate equipment for airway management, oxygen enrichment and mechanical ventilation should be available.

In the "Warnings" section instructions for use of propofol (Diprivan®, AstraZeneca) states that administration of propofol for sedation or anesthesia "should only be performed by qualified anesthesiologists not involved in the surgical/diagnostic procedure." The patient must be under constant supervision, and doctors must have at their disposal equipment for artificial ventilation of the lungs, for enriching the air with oxygen, as well as for cardiopulmonary resuscitation.

In addition, some US states have separate regulations regarding the administration of propofol. There are different opinions when should propofol be used for sedation intubated, ventilated, critically ill patients.

Similar problems arise when other intravenous agents such as methohexital or etomidate are used for sedation. The introduction of a combination of drugs, including sedatives and analgesics, may increase the likelihood of an adverse outcome.

* To prevent a deeper than expected level of sedation in a patient, the intervention of an experienced physician is required, who is able to restore airway patency and conduct an extended set of resuscitation measures. The skilled clinician corrects the negative physiological effects of a deep level of sedation (eg, hypoventilation, hypoxia, and hypotension) and returns the patient to the originally planned level of sedation. It is not acceptable to continue procedures at an unplanned level of sedation.

** The AANA and ASA joint statement regarding the introduction of propofol, dated 14 April 2004, states: “ Whenever propofol is used for sedation/anesthesia, it should only be administered by persons trained in general anesthesia who are not simultaneously involved in surgical or diagnostic procedures. This limitation is consistent with the wording in the instructions for use of propofol. Failure to follow these recommendations may lead to an increased risk of serious harm to the patient's health or death.».

Approved by the American Society of Anesthesiologists 10/15/2014

Comment

If the anesthesiologist spinal or epidural anesthesia in sterile conditions without any interruption in the process, drugs are prescribed immediately, and everything happens under the direct supervision of a doctor, then labeling of sterile syringes is not required.

Rationale

Probability of introduction of an unintended (unscheduled) drug using an unmarked syringe is extremely small* if the anesthesiologist performs a continuous procedure and the drug is prepared under sterile conditions immediately before use. Marking and syringes can lead to breach of sterility , contamination of the anesthetic or needles, and/or unnecessarily protracted procedure in an emergency. From a patient safety point of view, this is not practical. .

* Comprehensive analysis of statistical data (National Anesthesia Clinical Outcome Registry (four million reported cases), Anesthesia Error Litigation Statistics (10,000 cases over 30 years) and Anesthesia Incident Reporting Information System (1,500 incident reports since 2011) G.)) did not reveal cases of erroneous administration of the drug due to incorrect labeling of the syringe during epidural or spinal anesthesia.

Approved by ASA on 10/17/2012

American Society of Anesthesiologists (ASA), as an organization of physicians that aims to improve the safety and quality of anesthesia care, considers it appropriate to state its opinion on regional anesthesia. This view is based on the premise that the most important issue in the provision of anesthesia care is patient safety.

Anesthesiology in all its forms, including regional anesthesia, is part of medical practice. Regional anesthesia includes diagnostic evaluation, consideration of indications and contraindications, choice of drug, as well as the implementation of corrective measures and treatment in case of complications. Thus, the successful administration of regional anesthesia requires both medical and technical competence.

The medical component includes:

• preliminary assessment of the patient's condition;
• development and appointment of an anesthesia plan;
• checking the availability of the necessary components of medicines (including lipid emulsion) and equipment;
• monitoring the course of administration of a local anesthetic or personal participation in the process, when necessary;
• physical accessibility for immediate diagnosis and treatment of complications;
• providing post-anesthesiological observation.

Technical requirements for regional anesthesia depend on the procedure to be followed.

The choice of the most suitable anesthesia method for a particular patient is made on the basis of a medical opinion and depends on the competence of the doctors involved in the procedure. Ideally, this should be done by a professional anesthesiologist. It is the responsibility of the attending physician to decide to interrupt or cancel a technically demanding procedure, to recognize complications, and to make changes to the treatment strategy that take into account the patient's condition, the procedures required, possible risks, consent issues, and the ability to provide appropriate post-procedure care. Solving issues associated with regional anesthesia should ideally be handled by an anesthesiologist who has the competence and skills necessary to work safely and effectively.

ASA RECOMMENDATIONS FOR INTRAVASCULAR CATHETERIZATION

Approved by ASA 06.10.13

Some patients undergoing anesthesia for various surgical interventions a more precise and sophisticated level of monitoring is required cardiovascular health than can be obtained using standard non-invasive methods. An arterial catheter, central venous catheter and/or Swan-Ganz catheter may be required to obtain additional and more accurate information necessary for safe and effective anesthesia and life support of the patient in the perioperative period.

Although the position American Society of Anesthesiologistsin (ASA) is that the data obtained from these invasive monitoring devices is important for anesthesia, there are several points of contention regarding the placement of catheters. The ASA has developed and continues to develop its Relative Value Guide®, which contains the latest comprehensive descriptors for all types of anesthesia services and is a comprehensive guide to billing and health insurance. Installation of invasive devices for monitoring has not been covered in this guide. In fact, the base unit values ​​for many of the anesthesia codes in which invasive control is currently common were created before widespread use of invasive devices and have not been changed since. In addition, the inclusion of additional baseline values ​​to account for invasive monitoring in only some anesthesia codes would make the entire relative scoring system inconsistent.

The placement of invasive hemodynamic monitors should be considered as a separate service because not all patients undergoing the same surgical procedure require the same degree of supervision. The need for invasive monitoring largely determined by the condition of the patient than the type of surgical intervention. For example, most patients undergoing bowel surgery do not require invasive monitoring, but patients with major intraoperative blood loss or comorbid cardiovascular disease have to resort to this method of monitoring. Likewise, most patients with carotid endarterectomy need an arterial catheter, but some who are healthier than average do not have one.

Use of invasive monitoring devices:

1. Arterial catheter (CPT code 36620). Placing a small catheter (usually in the radial artery) and connecting it to electronic equipment allows continuous monitoring of the patient's blood pressure. This form of control is often necessary for unstable patients who have undergone surgery for intra-abdominal pathology or trauma. Patients who underwent surgery on the heart, blood vessels, spine and brain are subject to frequent changes in blood pressure. Continuous monitoring greatly assists the anesthesiologist in the safe management of these patients. Arterial catheters also provide a reliable way to obtain arterial blood samples, thereby facilitating proper monitoring of blood gases, blood chemistry, and clotting disorders.
2. Central venous catheter (CPT code 36555 or 36556). Used for pressure control, fluid replacement, or drug infusion. The venous catheter allows the anesthetist to properly maintain and/or adjust the patient's circulating blood volume. This method is advisable to use for patients who have lost significant amounts of blood or fluid during surgery in general. An additional indication for the placement of a central venous catheter is the need to provide a reliable means for the rapid introduction of large volumes of fluid or blood, to create access in the absence of peripheral venous access, or to administer some drugs that are most effectively and safely administered directly into the central venous circulation.
3. Swan-Ganz pulmonary artery catheter (CPT code 93503). This multichannel catheter is inserted through one of the central veins into the right ventricle of the heart, from where it migrates with the blood flow to the pulmonary artery. The pulmonary artery catheter makes it possible to control the functioning of the heart and vascular system. Can be used to measure cardiac output as well as other important indicators of the cardiovascular system. The Swan-Ganz catheter is used for patients whose heart function is impaired or may be impaired before or as a result of a surgical procedure. In addition, some pulmonary artery catheters allow temporary cardiac pacing, which may be necessary for some patients with abnormal heart rhythms.

FATIGUE FACTOR OF THE ANESTHESIOLOGIST

From the state of health and well-being anesthesiologist directly depends on how well he will be able to cope with his professional duties and whether he will not expose his patients to unnecessary risk. An important factor in this matter is ensure optimal performance teams of anesthesiologists, which includes the elimination of the effect of fatigue (but is not limited to this).

Fatigue can jeopardize how patient safety and the health and well-being of the doctor. This is a complex aspect that depends on the individual doctor, the medical staff involved in patient care, and the clinic where medical care is provided. Among the factors contributing to the accumulation of fatigue are sleep deprivation, the severity of the patient(s), the number of patients per unit of time, working conditions in a given medical institution, personal stress, age, work organization, changes in the schedule, the number and duration of breaks, the opportunity to fully eat, etc.

Several competing interests usually prevent a fatigued physician from withdrawing from the care of patients. Likewise, these interests prevent him from questioning the ability of another clinician to act appropriately when the other clinician shows signs of fatigue.

Anesthesiologist teams should work within their organizational structures to develop and implement policies to combat fatigue, which may adversely affect patient safety. Taking into account the multifactorial nature of fatigue, this policy should be sufficiently flexible, taking into account the working conditions of a particular group or object. The rules developed should encourage employees to report their fatigue or suspicions of fatigue to a colleague without fear of any reprisals.

Knowing about the possible negative effects of fatigue will help increase the doctor's self-awareness and respond effectively to the situation both at the individual level and at the level of a group or organization. When developing a policy to combat fatigue, it will be helpful to consult the recommendations of relevant medical and non-medical sources.

ASA RECOMMENDATIONS FOR ENDOSCOPIC EXAMINATIONS

The position of the American Society of Anesthesiologists (ASA) is that "there are no circumstances under which it would be considered acceptable for a person to experience emotional or psychological discomfort or physical pain if this can be safely avoided by the intervention of a physician".

Anesthesiology is a separate discipline in medical practice. Its main task is to help patients during surgical, obstetric and other medical procedures by inducing them into a state of narcotic sleep and / or reducing their sensitivity to pain and emotional stress.

Therapeutic endoscopic procedures usually spend without anesthesia . However, there are conditions that make anesthesia necessary even for minor procedures. Examples of such conditions are the presence of a number of comorbidities, as well as mental or psychological barriers to cooperation with a doctor. Patients with a personal history of failure with moderate sedation may also need anesthesia.

The reason for the use of anesthesia may be long or painful procedures. These include polyp biopsy or resection, endoscopic retrograde cholangiopancreatography (ERCP), various biliary tract procedures, bowel dilatation with or without a stent, endoscopic resection, and other procedures that have the potential to cause discomfort.

Need decision a specific patient anesthesia is issued in a medical report. This should take into account all factors, potential risks and benefits, the wishes of the patient himself, the requirements or preferences of the doctor performing the main procedure, and the competence of the specialists involved.

ASA GUIDE TO AMBULATORY ANESTHESIOLOGY

Developed by the Committee for Ambulatory Surgical Care. Approved by the American Society of Anesthetists (ASA) on October 13, 1999, and amended on October 21, 2009; final version approved October 15, 2014.

This manual is intended for members of the American Society of Anesthetists (ASA) who provide outpatient anesthesia care (outpatient anesthesia). These recommendations aimed at increasing quality of anesthesia care and outpatient safety . Compliance with these principles cannot guarantee any specific results. These policies are subject to periodic review to keep them in line with changes in federal and state laws and advances in medical technology and practice.

ASA notes growing demand in private practice (first of all, we are talking about private clinics providing therapeutic, dental and orthopedic services) for specialists in the field of outpatient anesthesia. As such, the ASA Guidelines for Ambulatory Anesthesia and Surgery should be used in line with other standards and practice guidelines.

There are specific issues that ASA members must be aware of when using anesthesia in the outpatient setting. Unlike emergency hospitals and licensed outpatient surgical facilities, federal or local government oversight and control of private practices is currently virtually non-existent. In this regard, private medical practice should carefully study issues that are taken for granted in hospitals or licensed outpatient surgical facilities - management and organization, staffing, professional training, as well as fire safety, emergency management, emergency transfer of a patient to another medical institution, accounting and control over the use of narcotic drugs, etc.

Members of the ASA must be confident that every effort has been made to ensure patient safety and reduce the risk and liability of the anesthesiologist.

Administration

Service quality

• The institution must have chief physician or a governing body that sets policy and is responsible for the activities of the institution and its staff. The chief physician (or governing body) is responsible for the appropriateness of the equipment available and the professional competence of the staff for the type of service provided.
• The policy of the institution and the list of medical services provided should be recorded in the relevant documentation and reviewed annually.
• The chief medical officer (or governing body) must ensure that all local and federal regulations are followed.
• All healthcare workers (including nurses) must have a valid license or a certificate for the performance of their assigned duties.
• All personnel involved in the provision of medical care must have the qualifications necessary to perform this type of service - the appropriate level of education, professional training and experience.
• The anesthesiologist must work continuouslyb to improve the quality of their professional training.
• The chief physician (or governing body) must know and respect the basic rights of his patients. The latter should have access to a written document describing this policy.

Safety

• Healthcare facilities must comply with all federal and local laws, regulations, and rules related to fire safety, building integrity, accessibility, occupational health and safety, and medical and hazardous waste management.
• Medical institutions must comply with laws and regulations regarding the use, storage and accounting of narcotic drugs.

clinical care

Patient and choice of procedures

• The anesthetist must ensure that the procedure to be performed is within accepted medical practice and within the capabilities of the facility.
• The duration and degree of complexity of the procedure should allow the patient to recover before being discharged home.
• Patients who, for medical reasons or due to some other circumstances, have a high risk of complications should be referred to the appropriate medical facility for the procedure.

Surveillance in the perioperative period

• The anesthesiologist should adhere to the "Basic Standards for Preparatory Activities", "Standards for Anesthesiology Monitoring", "Guidelines for Postoperative Follow-up", and "Guidelines for Ambulatory Anesthesiology and Surgery" currently recommended. American Society of Anesthetists (ASA) .
• The anesthetist must be directly present in the operating room during the operation and be in a state of instant availability until the patient is fully recovered.
• Responsibility for the patient's discharge carried by the attending physician (therapist). This decision must be recorded in the medical records.
• Personnel trained in critical care (eg, ACLS, PALS) should be immediately available until all patients have been discharged home.

Equipment and monitoring

• All facilities should have, at a minimum, a reliable source of oxygen, suction, resuscitation equipment, and emergency medicines.
• The operating room should have sufficient space to accommodate all necessary equipment and personnel and allow prompt access to the patient, anesthesia machine (if available) and all instrumentation.
• All equipment must be checked and tested in accordance with the manufacturer's specifications.
• Backup power sources must be available to protect the patient in the event of an emergency.
• Any location where anesthesia is used should have a suitable anesthesia machine and equipment that allows the patient to be monitored in accordance with the ASA Standards for Anesthesia Monitoring, as well as documentation of routine preventive maintenance of the equipment in accordance with the manufacturer's recommendations.
• Health care facilities where anesthesia services are provided to infants and children should have the necessary anesthesia and resuscitation equipment appropriate for the size of small patients. The compliance requirement also applies to the medicines available here.

Emergencies and Patient Transfer

• All facility staff should be properly trained in emergency situations and regularly tested in this regard.
• There should be instructions on what to do in the event of serious cardiopulmonary complications of the patient's condition, as well as other internal and external emergencies such as fire.
• The healthcare facility should have the medicines, equipment, and written instructions needed in the event of complications from the use of anesthesia, such as a malignant hyperthermia crisis (fulminant form).
• The facility must have written instructions for the safe and timely transfer of a patient to another facility if necessary to save his life and preserve his health.

ASA GUIDANCE IN OBSERVICES

The recommendations given here regarding the use of neuraxial anesthesia in childbirth are intended to encourage improved patient care and cannot guarantee any specific results. They are subject to periodic revision, which is justified by the development of medical technology and practice.

Standard I

Neuraxial anesthesia can only be used in locations where resuscitation equipment and medications are available to deal with related problems. Resuscitation equipment should include (but not be limited to) oxygen sources, medical suction, equipment for airway management, tracheal intubation, and positive pressure ventilation, as well as drugs and cardiopulmonary resuscitation equipment.

Standard II

Neuraxial anesthesia must be administered by a qualified physician or under the medical direction of such a person. The right to conduct anesthetic procedures in obstetrics and manage the complications associated with them is given to the doctor by the institutional certification committee.

Standard III

Neuraxial anesthetics should not be administered until: 1) until the patient is examined by a qualified specialist; and 2) until an obstetrician with operative delivery privileges (via vaginal delivery or caesarean section) is available to supervise labor and manage possible complications, and who has knowledge of the condition of the mother and fetus.

In some cases, qualified personnel can perform an initial gynecological examination. The physician responsible for obstetric care of the patient should be informed about her condition so that he, having assessed the existing risks, can decide on the strategy for managing the delivery.

Standard IV

Intravenous infusion should be initiated prior to initiation of neuraxial anesthesia and maintained throughout the duration of the anesthetic.

Standard V

Neuraxial anesthesia for delivery requires that maternal vital signs and fetal heart rate be monitored and documented by a qualified professional. The monitoring technique, frequency of recording and additional monitoring should be selected taking into account the clinical condition of the mother and fetus, as well as in accordance with institutional policy. For extensive neuraxial block given in complicated labor, the standards of basic anesthetic monitoring should be applied.

VI standard

Neuraxial anesthesia used for caesarean section requires the use of basic anesthetic monitoring standards and the availability of a physician with obstetric privileges.

Standard VII

Qualified personnel capable of taking responsibility for neonatal resuscitation should be available. The main task of the anesthesiologist is to provide care for the mother. If an anesthesiologist is also involved in the care of the newborn, the benefit to the baby must be weighed against the risk to the mother.

Standard VIII

During neuraxial anesthesia until the patient's post-anesthetic condition is satisfactory and stable, a doctor with the right to manage anesthesia complications should be readily available.

Standard IX

All patients after neuraxial anesthesia should receive appropriate postanesthetic care. Following a caesarean section and/or a major neuraxial block, standards for basic postanesthesia care should be applied.

Standard X

ASA GUIDELINES FOR POST-ANESTHESIA CARE

Data ASA standards concerning post-anesthesia care are intended to improve the quality of patient care, but do not guarantee any specific results. They may be exceeded based on the decision of the responsible anesthetist. These standards are subject to periodic revision in the light of developments in medical technology and practice.

Standard I

All patients after general and regional anesthesia, as well as after anesthetic support of a surgical procedure, should receive appropriate postoperative monitoring.

1. An anesthetized patient should have access to a recovery room in the intensive care unit or another location where he will be provided with postoperative care. An exception can only be made at the direction of the anesthesiologist responsible for the patient.
2. The medical aspects of care in the intensive care unit (or equivalent unit) are governed by rules that have been reviewed and approved by the US Department of Anesthesiology.
3. The equipment of the intensive care unit and its staffing should meet the requirements of accreditation and licensing bodies.

Standard II

When transported to the intensive care unit, the patient should be accompanied by a member of the anesthesiological team who is knowledgeable about the patient's condition. During transport, the patient's condition must be continuously assessed and maintained.

Standard III

Upon arrival in the intensive care unit, the patient's condition should be re-evaluated. A member of the anesthesiologist team who accompanied the patient during transportation submits an oral report to the head nurse of the department

1. The patient's condition upon arrival in the intensive care unit should be documented.
2. Information about the patient's preoperative condition and the surgical / anesthetic procedures performed on him should be transferred to the head nurse of the intensive care unit.
3. A member of the anesthesiologist team must remain in the intensive care unit until the ward nurse assumes responsibility for caring for the patient.

Standard IV

The patient's condition should be continuously assessed in the intensive care unit

1. The patient must be continuously monitored using methods appropriate to his condition. Particular attention should be paid to monitoring oxygenation, ventilation, circulation, body temperature and level of consciousness. Quantitative methods for assessing oxygenation, such as pulse oximetry, should be used at the initial stage of the patient's recovery from anesthesia and until complete recovery. This rule does not apply to patients in the maternity ward who have had local anesthesia used during vaginal delivery.
2. An accurate written record of the patient's stay in the intensive care unit should be kept. It is recommended to use an appropriate scoring system for each patient – ​​at admission, at intervals and at discharge.
3. General medical supervision and coordination of patient care in the intensive care unit is the responsibility of the anesthesiologist.
4. It is recommended to ensure that the facility has a physician capable of managing complications and providing cardiopulmonary resuscitation to patients in the intensive care unit.

Standard V

The doctor is responsible for the discharge of the patient from the intensive care unit

1. The criteria by which a patient can be considered eligible for discharge from the department must be approved by the Department of Anesthesiology and the medical staff of the hospital. They may vary depending on whether the patient is transferred to a regular hospital room, to a short stay hospital, or to home.
2. In the absence of a discharge physician, the ICU nurse determines that the patient meets the discharge criteria. The name of the physician taking responsibility for the discharge should be recorded in the medical record.

Minimal sedation (anxiolysis)- This is a medical condition in which the patient normally responds to voice commands. Cognitive functions and coordination of movements may be impaired, but respiratory and hemodynamic parameters remain unchanged.

Moderate sedation / analgesia- due to the action of pharmacological agents, depression of consciousness, in which the patient purposefully** responds to voice commands or voice commands accompanied by light tactile stimulation. Adequate functioning of the cardiovascular system and spontaneous breathing are maintained.

Deep sedation / analgesia- drug-induced depression of consciousness, in which the patient cannot be easily awoken, but still responds purposefully ** to repeated or painful stimulation. Airway patency may be compromised, resulting in insufficient spontaneous breathing. The functioning of the cardiovascular system, as a rule, remains normal.

General anesthesia- due to the action of pharmacological drugs, a condition characterized by a complete loss of consciousness. The patient in this state does not even respond to pain stimulation. The ability to breathe independently is often impaired. Due to respiratory depression, the patient may require mechanical ventilation. The functioning of the cardiovascular system can also be impaired.

Changing the depth of sedation occurs continuously and evenly, so it is not always possible to predict the response of a particular patient to a particular drug. It follows that a doctor planning to achieve this level of sedation in his patient should be able to save*** him if the level of sedation becomes deeper than originally intended. For example, a clinician administering moderate sedation/analgesia should be able to save*** a patient entering a state of deep sedation/analgesia, and one scheduled for deep sedation/analgesia should be able to save*** a patient entering a state of general anesthesia .

* Monitoring anesthesia care does not describe the depth of sedation, but "a specific anesthesia service in which an anesthetist takes part in the care of a patient undergoing a diagnostic or therapeutic procedure."

*Reflex reaction to pain stimulus is not considered a purposeful response.

*** A deeper than expected level of sedation can be prevented by a physician experienced in airway management and advanced resuscitation. The skilled clinician is able to correct the negative physiological effects of a deeper than originally intended level of sedation (eg, hypoventilation, hypoxia, and hypotension) and return the patient to the originally planned level of sedation. It is not acceptable to continue the procedure at an unintended level of sedation.

The degree of risk of the operation must be determined on the basis of the patient's condition, the volume and nature of the surgical intervention. For this purpose, you can use the classification adopted by the American Society of Anesthesiologists - ASA (Table 2.7).

Table 2.7

RISK ASSESSMENT OF ANESTHESIA AND SURGERY

According to the severity of the somatic condition:

I (1 point) - patients in whom the disease is localized and does not cause systemic disorders (practically healthy);

II (2 points) - patients with mild or moderate disorders, which to a small extent disrupt the vital activity of the body without pronounced shifts in homeostasis;

III (3 points) - patients with severe systemic disorders that significantly disrupt the vital activity of the body, but do not lead to disability;

IV (4 points) - patients with severe systemic disorders that pose a serious danger to life and lead to disability;

V (5 points) - patients whose condition is so severe that they can be expected to die within 24 hours.

According to the volume and nature of the surgical intervention:

I (1 point) - minor operations on the surface of the body and abdominal organs (removal of superficially located and localized tumors, opening of small abscesses, amputation of fingers and toes, ligation and removal of hemorrhoids, uncomplicated appendectomy and herniotomy);

2 (2 points) - operations of moderate severity (removal of superficially located malignant tumors requiring extended intervention; opening of abscesses located in cavities; amputation of segments of the upper and lower extremities; operations on peripheral vessels; complicated appendectomy and herniotomy requiring extended intervention; trial laparotomy and thoracotomy, other interventions similar in complexity and scope;

3 (3 points) - extensive surgical interventions: radical operations on the abdominal organs (except those listed above); radical operations on the organs of the breast; extended limb amputations - transiliosacral amputation of the lower limb, etc., brain surgery;

4 (4 points) - operations on the heart, large vessels and other complex interventions performed under special conditions - artificial circulation, hypothermia, etc.

The gradation of emergency operations is carried out in the same way as planned ones. However, they are designated with the index "E" (emergency). When marked in the medical history, the numerator indicates the risk by the severity of the condition, and the denominator - by the volume and nature of the surgical intervention.

Choice of anesthesia method

The choice of anesthesia method is determined by the nature of the disease or injury, the localization of the pathological focus, the volume and duration of the proposed operation, the urgency of its implementation, the psycho-emotional state of the patient and the severity of functional disorders. In addition, the capabilities of the department and the professional training of the anesthesiologist are of great importance.

In general, the more severe the condition of the patient or wounded, the more reason for the participation of the anesthetist in his treatment. At the same time, the risk of complications from the chosen method of anesthesia should not exceed the risk of surgery. There are no "small" anesthesias in anesthesia practice. Any method, no matter how simple it may seem, is fraught with complications, especially in inexperienced hands. To prevent them, it is necessary to know well not only the advantages, but also the disadvantages of each method, the pharmacodynamics and pharmacokinetics of the drugs used, take into account in a timely manner all changes in the patient's condition that occur during the operation, meticulously observe the anesthesia technique. In any case, especially at the initial stage of professional activity, preference should be given to the most mastered method.

General anesthesia with tracheal intubation and mechanical ventilation (ALV) indicated when performing abdominal surgical interventions, during operations in the region of the facial skull, on the larynx and trachea, with non-abdominal interventions lasting more than 1-1.5 hours, if there is an unstable compensation of hemodynamic and respiratory disorders, if there are signs of decompensation of the respiratory and circulatory systems, with volume of surgical intervention, estimated at 2 or more points.

The choice of a specific method of anesthesia is determined primarily by the state of the water and electrolyte balance and the cardiovascular system. In particular, the simultaneous administration of large doses of droperidol ( neuroleptanalgesia), even during planned anesthesia, often causes the development of severe arterial hypotension due to its -adrenergic blocking action. In the presence of overt or latent hypovolemia (peritonitis, intestinal obstruction, blood loss, severe trauma or injury, etc.), the risk of disruption of compensatory reactions or aggravation of systemic disorders is especially high. Therefore, neuroleptanalgesia can be used only after the discrepancy between the capacity of the vascular bed and the volume of circulating blood has been eliminated, and also in the absence of severe myocardial weakness. The same applies to anesthesia involving the use of ganglionic blockers and diprivan. In such situations, preference should be given ataralgesia and other methods that do not cause cardiodepression and a sharp decrease in vascular tone.

General anesthesia with spontaneous breathing can be used for non-cavitary operations, especially on the extremities, surgical treatment of burn surfaces and extensive dressings lasting up to 2.5-3 hours. If there are signs of unstable compensation for hemodynamic and respiratory disorders, the duration of such anesthesia should be no more than 1-1.5 hours. This applies equally to both inhalation and non-inhalation anesthesia.

Anesthesia with ether is not recommended for lung diseases accompanied by bronchospastic syndrome, diabetes, hyperthyroidism, severe liver and kidney diseases. Contraindications to anesthesia with halothane are liver diseases, large uncompensated blood loss and severe cardiovascular insufficiency. Ketamine is not indicated for patients with stage 2-3 hypertension, epilepsy, psychomotor agitation, intracranial hypertension.

To regional anesthesia(epidural, spinal, plexus, conduction) also have their own indications and contraindications. epidural anesthesia It is used mainly in operations on the lower extremities and in the pelvic area, since here it can be used without combination with other methods. In surgical interventions on the organs of the chest and abdomen, it is usually combined with general anesthesia, using it as a component of analgesia and segmental autonomic protection. Contraindications for epidural anesthesia, in addition to unreplaced blood loss and severe dehydration, are spinal injury and previous diseases of the spinal cord.

spinal anesthesia with a single injection of an anesthetic, it finds its application, as well as epidural anesthesia, primarily in traumatology (operations on the lower extremities lasting up to 2 hours), urology (operations on the bladder, prostate), and also in proctology (hemorrhoidectomy). Its use should be avoided in patients of elderly, senile age and with hypovolemia of various origins.

Plexus and conduction anesthesia is most often used by anesthesiologists for surgical interventions on the upper and lower extremities lasting no more than 2-2.5 hours. The use of catheters to bring a local anesthetic to the nerve trunk or plexus allows you to maintain anesthesia for a longer time. Absolute contraindications to conduction and plexus anesthesia are the presence of an infectious process in the blockade area and septicopyemia. A relative contraindication is shock (2-3 degrees and a terminal state), in which the hypotensive effect of local anesthetics is always manifested.

When choosing a specific method of conduction anesthesia, one should proceed from the site of the operation and the zones of innervation of the skin and deep sensitivity of the corresponding nerves ( fig.2.5). To perform surgical interventions on the thigh, for example, it is necessary to anesthetize the femoral, sciatic, obturator nerves, as well as the external cutaneous nerve of the thigh, which are branches of the lumbar and sacral plexuses. During operations on the lower leg, it is enough to block the femoral and sciatic nerves.

Rice. 2.5. Zones of skin innervation of the lower limb (Pashchuk A.Yu., 1987):

1- sciatic nerve,

2- obturator nerve,

3- external cutaneous nerve

4- femoral nerve.

In those seriously injured in the lower extremities, techniques are preferred that allow anesthetizing the femoral, sciatic nerves and the lumbar plexus in general without turning the victim on his side or stomach.

Taking into account modern ideas about the reaction of the body to trauma and the essence of anesthesia, one should strive to use as often as possible combination of general and local(infiltration, regional) anesthesia. This makes it possible to guarantee the stability of the analgesic component of general anesthesia, to reduce the dosage of general and local anesthetics, to block not all, but only the most significant nerves for the operation area, to start the blockade at such a stage of the operation and anesthesia, when it is of the most significant importance and is not accompanied by adverse side effects. .

When performing surgical interventions in a planned manner or against the background of a stable condition of the sick and wounded, various kinds of blockades are resorted to immediately with the onset of anesthesia. At the same time, however, it is taken into account that the probability of hemodynamic disorders with this method of anesthesia is higher than with regional anesthesia in a "pure" form. Therefore, it is not recommended to use neuroleptanalgesia as the main (basic) anesthesia (except in combination with local infiltration anesthesia). In emergency operations, this kind of anesthesia should be approached very carefully. For example, when performing interventions on the organs of the chest and abdomen, especially in case of wounds and injuries, it is possible to use an epidural catheter only after the revision of the organs of the abdominal and thoracic cavities, elimination of the source of bleeding and deficiency of circulating blood volume.

The combination of local anesthesia (infiltration, regional) with the action of general anesthetics (combined anesthesia) provides for the achievement of the main analgesic effect by acting on the peripheral structures of the nervous system. Means of general action (opiates, non-narcotic analgesics, opioids, general anesthetics), used in small doses, make it possible to avoid the "presence of the patient at the operation" factor, to accelerate the onset of surgery without waiting for the development of a full-fledged peripheral nerve block. Such anesthesia is usually carried out for small and simple surgical interventions in patients with severe psycho-emotional lability and low reserves of the cardiovascular system.

Premedication

Before any anesthesia performed in a planned manner, it is necessary: ​​a) to talk with the patient about the upcoming anesthesia, obtain his consent to the chosen method, give recommendations on behavior in the immediate postoperative period; b) forbid him to eat before the operation (at least 5-6 hours before); c) advise the patient to empty the bladder in the morning before surgery and remove removable dentures; d) appoint premedication. In addition, if necessary, a cleansing enema is prescribed in the evening before the operation and in the morning.

Premedication(direct drug preparation) - the final stage of preoperative preparation. The choice of drugs for her, their dosage and method of administration depend on the initial state of the patient, his age and body weight, the nature of the surgical intervention and the chosen method of anesthesia. The purpose of premedication is, first of all, the removal of mental stress, providing the patient with normal sleep before surgery, facilitating the introduction into anesthesia, preventing unwanted neurovegetative reactions, side effects of drugs used for anesthesia, and hypersalivation.

Premedication most often consists of two stages: evening (on the eve of surgery) and morning (on the day of surgery). As a rule, 2-3 standard premedication schemes are used ( table 2.8), which, of course, does not exclude an individual approach to each patient. Sleeping pills, for example, are prescribed differentially depending on the nature of the patient's falling asleep and taking into account the anamnestic data on the effectiveness of the action of certain drugs on him. Increased caution is needed when choosing a dose of atropine in patients with heart defects (especially with mitral valve stenosis), with a tachysystolic form of atrial fibrillation. For debilitated patients, people of the elderly, senile and advanced ages, the doses should be reduced by at least one third.

Analgesics, especially narcotic ones, are usually prescribed only in the presence of pain. However, to create the effect of proactive analgesia (prevention of primary hyperalgesia), it is advisable to include non-steroidal anti-inflammatory drugs in premedication, which prevent excessive activation of nociceptive receptors by biologically active substances released during tissue damage.

Minimal premedication (Scheme 1) is intended for calm and balanced people who will have short-term surgical interventions. Moderate premedication (schemes 2 and 3) is preferable for patients with a stable mentality who are to undergo operations of moderate and increased difficulty. The maximum premedication in terms of volume (Scheme 4) is most often indicated for patients with severe emotional-vegetative lability, with neurasthenic and psychasthenic burden. If necessary, this scheme can be supplemented with ketonal or another drug of similar action. Doses of drugs can be changed taking into account the specific condition of the patient.

Table 2.8

Premedication schemes

When working with children, doses should be carefully selected taking into account age. For children under 5 years old, it is better not to prescribe premedication at all, having discussed all the details of preparing for the operation with their parents.

Premedication for emergency operations is usually reduced to the use of an anticholinergic (atropine at a dose of 0.01 mg / kg, if the heart rate does not exceed 90-100, or at half the dose - with severe tachycardia). According to the indications, any anesthetic drug is used in the usual dosages. With a high probability of vomiting and regurgitation, it is advisable to use an antacid in the form of a mixture of burnt magnesia (150 g), magnesium carbonate (25 g) and sodium bicarbonate (25 g). Assign it to 1-2 teaspoons in 1/4 cup of water 15-20 minutes before the start of anesthesia (this does not exclude the need to empty the stomach). Almagel can be used (2 spoons 30 minutes before anesthesia).

Should be remembered that after premedication it is necessary to forbid patients to get out of bed. They are taken to the operating room on a gurney.

Preparation of the workplace of the anesthetic

Brigades

The workplace of the anesthesiology team is equipped in operating rooms, dressing rooms, delivery rooms and diagnostic rooms, where surgical interventions and studies are carried out under general anesthesia. Its equipment must include:

Inhalation anesthesia apparatus (anesthesia block) with fur and bag
for manual ventilation;

Automatic ventilator;

Manual ventilator with Ambu bag type (one per operating room);

Movable anesthesia table with a set of medicines, antiseptics (alcohol, iodine) and accessories for anesthesia (laryngoscope, straight and curved blades, masks and air ducts of various sizes, a set of endotracheal tubes and conductors for them, a local anesthetic nebulizer, a mouth expander, a tongue holder, a manometric device membrane, phonendoscope, devices (systems) for blood transfusion and blood substitutes; forceps or Magill forceps, Kocher-type clamp, tweezers, scissors, kidney-shaped coxa, sticky patch, gastric tube);

Electric suction machine;

Rack for infusion system;

An electric defibrillator and a portable electrocardiograph (it is allowed to equip several workplaces equipped in one operating room with one device at once).

Pulse oximeter;

Capnograph;

Cardio-respiratory monitor;

Infusomat or syringe dispenser of medicinal substances;

Monitor for assessing neuromuscular conduction;

Arrow scales for determining the amount of blood loss.

When preparing the equipment for work, you should:

A - at the beginning of the working day:

Inspect gas cylinders, check their filling;

With a centralized supply of medical gases, check the pressure in the oxygen and nitrous oxide supply systems, make sure that there is enough oxygen and nitrous oxide in the reserve cylinders;

Check the grounding of the devices with a special wire;

Fill the adsorber with fresh chemical absorbent when using a closed or semi-closed breathing circuit;

Set up a system for ejecting exhaust gases outside the operating room;

B - before each anesthesia:

Turn on the ventilator and check the operation of its engine, making sure that it is in good condition - turn it off, if necessary - replace it;

Using hoses and adapters, assemble the inhalation anesthesia machine and the ventilator into a common breathing circuit;

Pour inhalation anesthetic into the evaporator of the inhalation anesthesia machine or, conversely, drain it from the evaporator;

Check the correct connection of the hoses, through which oxygen and nitrous oxide are supplied, to the anesthesia machine (unit); to do this, first open the oxygen rotameter of the apparatus and only then - the valve on the oxygen distribution line (if the hose is connected correctly, the rotameter float will rise up); subsequently, in the same way, check the connection of the nitrous oxide hose;

Check the tightness of the connection of the device with cylinders or with the oxygen and nitrous oxide supply system;

Turn on the ventilator again, check its operation in various modes, paying attention to the operation of signal and control lamps;

Check the operation of valves, dosimeters and the emergency oxygen supply system, purge the apparatus with an oxygen flow;

Check the reliability of the connection of the mask with the tee, and also whether the endotracheal tube connector fits the tee;

Check the tightness of the respiratory system, for which, when the device is running, block the air outlet from the tee opening with the palm or thumb of the hand (the causes of leaks can be the disconnection of hoses, loose connection of the adsorber, an open plug of the humidifier in “RO” type devices, etc.);

Check the pressure at which the safety valve operates; it must be at least 30 cm of water column;

Check the operation of the electric suction and the magnitude of the vacuum created by it (should be at least 0.5-0.7 kg / cm 2);

B - at the end of anesthesia:

Send replacement parts for disinfection;

G - at the end of the working day:

Replace distilled water in ventilator humidifier;

Clean, disinfect and sterilize used equipment.

Preparation of sterile stowage on the anesthesiologist's table. The anesthesia table is covered with a sterile sheet and sterile instruments and materials are placed on it:

200 ml jar (for 0.9% sodium chloride solution);

100 ml jar (for diluting barbiturates),

Syringes (optimally disposable):

Per 20 ml (for barbiturates);

Per 10 ml (for muscle relaxants);

Per 5 ml (for other medicines);

Needles for intravenous and intramuscular injections;

Balls (10 pcs.) and napkins (5 pcs.);

A jar of balls in alcohol.

Preparing accessories for tracheal intubation(laryngoscope, endotracheal tubes, connectors, conductors).

Laryngoscope: complete with it must be at least three blades of different sizes. They check the reliability of fixing the blade to the handle, the brightness and continuity of the glow of the light bulb when shaking the laryngoscope.

Endotracheal tubes: You should have at least three tubes of different sizes. Check the integrity of the inflatable sealing cuff, the compliance of the inner diameter of the tubes with the available connectors and conductors, while maintaining the sterility of the distal end of the tube.

Children, especially infants and young children (1-3 years old), are much more likely to resort to anesthetic support during even painless procedures and manipulations. Even a completely non-invasive intervention: an x-ray examination can cause a panic reaction in these children, which makes it impossible to perform it. Removing psycho-emotional stress in children without the use of pharmacological agents is almost impossible. Only about 10% of children aged 2.5 to 7 years can be "persuaded" to undergo such a painless and quick procedure as x-rays. Such an attitude towards medical manipulations can persist until puberty (10-12 years).

6.1. BASIC PRINCIPLES AND OBJECTIVES OF ANESTHETIC AID IN CHILDREN

The development of anesthesiology contributes to the development of surgery, the successes and new tasks of which, in turn, stimulate the development of anesthesiology, the development of new types, methods and means of anesthesia. To a large extent, anesthesiology contributes to the development of pediatric dentistry. At present, it is difficult to imagine the work of pediatric dentists without well-organized and effective anesthesia support.

The main principles of pediatric anesthesiology: protection of the child from any negative external influences, mental stress, fear, pain, trauma; recovery, management and maintenance of vital functions in critical situations. In response to any therapeutic effect, a child may experience a stress reaction of varying degrees due to psycho-emotional stress, fear, mental trauma, pain syndrome, changes in the homeostasis of the body - impaired breathing and hemodynamics, metabolic processes.

owls, biochemical changes, blood loss. The negative effects accompanying dental treatment: noise, vibration of the drill, a specific (frightening) type of instruments, traces of blood on a swab, pain - cause a negative reaction of the child, the degree of which depends on his individual psychological characteristics.

Therefore, the main task of anesthetic management in children is to ensure the calm behavior of the child, regardless of the nature and extent of the intervention; favorable mental and vegetative state; painlessness and atraumaticity of a variety of dental procedures.

When choosing a method of anesthesia, it is necessary to carefully consider the behavior of the child. The doctor should strive in advance to predict the behavior and condition of the child after communicating with him, performing anesthesia, during and after treatment. If you have any doubts about the choice of the method of anesthesia, consultation with doctors of other specialties is necessary to make a final decision.

Dental intervention using any method of anesthesia can be performed only with the full consent of the parents. It is impossible to persuade parents to carry out this or that anesthesia, to promise a quick and favorable outcome, the absence of adverse reactions and complications. Parents of children, especially those who are mentally unbalanced and with concomitant somatic pathology, should be warned about possible complications, the duration of the intervention and its outcome. They should be given clear explanations of the need to choose this type of anesthesia.

Anesthesia is a part of the treatment process, which largely determines its course and recovery period. Features of anesthesia in pediatric dentistry are associated with the specifics of dental interventions.

Congenital malformations of the face and jaws, diseases of the temporomandibular joint, tumors of the maxillofacial region, diseases of the teeth and oral mucosa create certain difficulties at the stages of anesthesia and complicate the control of the child's condition. In this regard, and especially in outpatient practice, it is very important to choose the type and method of anesthesia depending on the age of the child, the state of his psyche and endocrine system, general condition, concomitant diseases and the nature of their course; the degree of possible respiratory disorders caused by this disease

the proposed plan of his treatment, the volume and duration of the intervention, the comparison of the degree of anesthetic and dental risk. The degree of risk of using the chosen type of anesthesia should not be higher than the degree of risk of dental intervention.

6.2. PREPARATION FOR ANESTHESIA AND DENTAL INTERVENTION

Preparation for anesthesia and dental intervention consists of several stages. When it is carried out, many factors are taken into account related to the characteristics of dental diseases in children, their course; the vulnerability of the child's psyche and the presence of concomitant somatic pathology.

6.2.1. EXAMINATION OF THE CHILD. RISK OF GENERAL ANESTHESIA

An examination in preparing a child for dental intervention using any type of anesthesia is carried out taking into account age characteristics, general condition, the nature of the dental disease, the possible type of anesthesia and the interaction of all these factors in each case. To exclude complications during anesthesia associated with hypersensitivity or intolerance to drugs (primarily used for anesthetic management), the child's history is carefully ascertained from the parents, the presence of unusual reactions to various drugs, foods, and severe allergic status is clarified.

Particular attention is paid to signs of increased lability of the cardiovascular system, the child's tendency to faint, loss of consciousness in response to factors such as fear, pain. A clear understanding of the general condition of the child and the vital functions of the body determines the correct choice of the type and method of anesthesia.

After receiving the history data, the results of physical and ancillary studies, the necessary additional consultations and discussion of the features of the upcoming dental intervention, the anesthetist conducts an analytical assessment of all the obtained characteristics of the patient and determines the degree of risk of

variable anesthesia. Preoperative risk assessment is, in fact, the answer to the main questions: in what condition is the child who is planned to undergo anesthesia, and how dangerous is anesthesia in this condition? Currently, the risk assessment according to the American Association of Anesthesiologists (ASA) classification has become widespread. This scoring system is designed as a simple description of the patient's physical condition. Despite its apparent simplicity, it remains one of the few promising patient descriptions that correlate with the risk of anesthesia and surgery. This classification is used to determine the risk levels of general anesthesia, but, in our opinion, it is rational to use it when determining the risk of any type of anesthesia. The use of this classification allows a standard assessment of the degree of risk of anesthesia. In case of emergency surgical interventions, the index “E” (emergency) is added to the corresponding class. And although this description of the patient's physical condition clearly correlates with the risk of anesthesia, it should be borne in mind that these are far from the same thing. The ASA rating scale provides specific information to the anesthesiologist and orients him to the prevention of possible complications. (Table 15). On an outpatient basis, anesthesia should be performed for children with risk levels I and II,

rarely, in special cases, - III. Starting with risk degree III, therapeutic manipulations should be carried out in a hospital setting.

There are also domestic systems for assessing the degree of operational and anesthetic risk created for children (Table 16).

Table 16

Determination of the degree of operational and anesthetic risk in children (according to V.M. Balagin and S.Ya. Doletsky)

To determine the degree of operational risk, the scores corresponding to the patient's condition, his age and the traumatic nature of the operation are summarized. 1 point is added to the calculated amount if:

emergency operation;

Concomitant diseases;

Operations accompanied by difficulty in conducting anesthesia;

Operations in poorly adapted conditions.

I degree - 3 points: insignificant risk.

II degree - 4-5 points: moderate risk.

III degree - 6-7 points: medium risk.

IV degree - 8-10 points or more: high risk.

In accordance with this assessment system, on an outpatient basis, anesthesia can be performed for children with a risk degree of I (minor) and II (moderate) - rarely, in special cases - III (medium). Starting with risk degree III, therapeutic manipulations are carried out in a hospital setting.

After a decision is made to conduct an outpatient intervention under general anesthesia, the necessary preparation of the child is planned. The elements of this preparation really begin at the moment of the first contact with the child and his parents. There are several aspects to this preparation.

6.2.2. PSYCHOLOGICAL PREPARATION OF THE CHILD AND HIS PARENTS

The main thing for anesthesia and surgery is the correct psychological approach to the child and the appropriate approach to his parents. To achieve a calm behavior of the child, to provide increased motivation for treatment, the doctor must be able to create a favorable psychological contact with him, while showing maximum patience and endurance. Of great importance is the establishment of contact with the parents of the child. Restless behavior, tears of parents negatively affect the psycho-emotional state of the child and contribute to his uncontrollable behavior.

6.2.3. GENERAL SOMATIC TRAINING

It is necessary to find out and clarify all the concomitant diseases that the child has, the features of their course, the nature and effectiveness of the previous treatment. Its main task is to restore impaired functions. The nature of the applied therapeutic measures and pharmacological preparations in preparing a child for anesthesia and surgery depends on the characteristics of concomitant somatic diseases. Regarding the therapy used, appropriate consultations of specialists should be carried out and their recommendations should be obtained.

In diseases of the central nervous system, heart, lungs, liver, kidneys, endocrine system, with allergic reactions in children (especially with thymus hyperplasia), desensitizing therapy (calcium gluconate, antihistamines and hormonal drugs) is necessary.

Before surgery (especially in the oral cavity), performed under anesthesia, general somatic preparation should include sanitation of the oral cavity, nose, and nasopharynx. Concomitant diseases in these departments can cause various complications both during anesthesia (detachment of the adenoid tissue during nasopharyngeal anesthesia, injury of the tonsils, bleeding), and in the recovery period due to infection from the oral cavity into the trachea and lungs (bronchitis, pneumonia). The only exceptions are children with acute injuries and inflammatory diseases, operated on for emergency indications.

6.3. TASKS AND METHODS OF ANESTHESIA IN CHILDREN'S OUTPATIENT DENTISTRY

The goal of any type of anesthesia is to provide the best conditions for therapeutic manipulations and protect the patient from pain and stress. The main modern requirements are its adequacy and safety, for the implementation of which the following tasks should be followed:

I. Ensuring the calm behavior of the child during dental intervention

Implementation methods:

Properly conducted psychological preparation of the child and his parents;

Adequate premedication (use of sedative, anxiolytic and blocking unwanted autonomic reactions);

Ensuring full analgesia of the required duration;

Turning off consciousness during general anesthesia (affects simultaneously all components of the combat reaction).

II. Ensuring adequate anesthesia for the required duration

Implementation methods: local anesthesia; general anesthesia; combination of premedication with local anesthesia.

III. Observation of the functions of the child's body during dental intervention and anesthesia (monitoring)

Implementation methods: at the V All-Russian Congress of Anesthesiologists and Resuscitators (Moscow, 1996), the following monitoring standard was recommended - the minimum allowable volume during regional, conduction anesthesia or general anesthesia with preserved spontaneous breathing includes:

electrocardiography;

pulse oximetry;

Measurement of blood pressure by a non-invasive method;

Breathing rate control.

The use of monitoring volumes in the anesthetic management of outpatient dental interventions below these standards is unacceptable.

Proper monitoring of the functions of the child's body allows you to control the manageability of anesthesia, to determine in time, anticipate and, accordingly, block possible complications during anesthesia.

IV. Prevention of possible complications during treatment and anesthesia

Implementation methods:

A clear, competently collected anamnesis, preoperative clinical studies and a correct assessment of the initial state of the child based on them;

Prevention of aspiration of mucus, blood, vomit and foreign bodies: extracted teeth, roots, filling and impression materials;

The correct individual choice of methods and means of anesthesia - the type of anesthesia; the method of administration of pharmacological preparations - local anesthetics, hypnotics, tranquilizers, inhalation anesthetics, analgesics, etc. (the least toxic in children with minimal side effects), their dosages, taking into account their interaction in the child's body when used together;

Qualitative monitoring of body functions during treatment and anesthesia.

v. Creating conditions for the optimal provision of dental care to children

Methods - the choice of the type of anesthesia that provides:

Maximum convenience for the work of a pediatric dentist;

The possibility of providing any dental care to children in need of anesthesia, despite various concomitant somatic diseases;

Proper planning of dental intervention - the volume of stages and the sequence of their implementation;

Proper organization of the work of a dentist, taking into account the peculiarities of his work when applying various types of anesthesia;

Rapid rehabilitation of the child.

VI. Creation of conditions that create a minimal risk of adverse reactions and complications after the departure of children from the clinic

Implementation methods:

Correct assessment of the child's condition after the dental intervention and anesthesia before he goes home;

Appointment of adequate drugs in the postoperative period for pain relief, decongestant, anti-inflammatory and other necessary therapy.

All operations, including the extraction of teeth (deciduous and permanent) and their treatment, in children should be carried out under full anesthesia in accordance with all the rules adopted in dentistry. Only highly mobile milk teeth with resorbed roots can be removed using topical anesthesia. Electroanesthesia (transcutaneous electrical nerve stimulation) as an independent type of pain relief in children is ineffective, as it requires a conscious attitude and active assistance from the patient.

When treating teeth, physiological distraction methods can be used: video and audio analgesia, film demonstrations, reading fairy tales. This often helps to achieve a calm behavior of the child in the dental chair. There are reports of the use of hypnosis to obtain sedation in children for outpatient dental procedures. To reduce psycho-emotional stress, you can use medication preparation before dental treatment under local anesthesia and without it.

6.4. PREMEDICATION: PURPOSE, OBJECTIVES, MEANS

Modern anesthetic management is impossible without direct medical preparation for anesthesia - premedication. The foundations of premedication were formed at a time when almost all anesthetics were inhaled. Today, the main reason for the appointment of premedication is to make anesthesia and surgical intervention the least traumatic for the patient's psyche. Currently, in outpatient pediatric anesthesiology, depending on what kind of anesthesia will follow, premedication is used in two versions - as a preparation for general anesthesia or as a component of the so-called

combined anesthesia, leveling the shortcomings and complementing the subsequent local anesthesia. The difference in these variants of sedation is only in the selective and different in power effect on the components of the patient's pain reaction. When used as an actual anesthesia of anesthesia, the main task of premedication is the suppression of unwanted reflexes and autonomic stabilization; all other tasks are also important, but of subordinate importance. If local anesthesia is planned, then the main task is to suppress fear, increase analgesia and then suppress unwanted reflexes, autonomic stabilization, etc.

Anxiety and nervousness of the patient is the main factor that must be controlled in the preoperative period. The frequency of these manifestations is 40-80% in adult patients, and in childhood these symptoms of psycho-emotional stress are exacerbated by the age-related characteristics of the child's psyche.

The stress caused by the upcoming anesthesia and surgery negatively affects the patient's psyche and contributes to the production of stress hormones. The most common causes of preoperative stress are the feeling of isolation from parents, fear for one's health, fear for the outcome of the operation, an uncertain future, fear of anesthesia and discomfort in the postoperative period.

Indications for premedication - a feeling of anxiety and anxiety in the patient, the creation of amnesia and analgesia, vagolytic action and prevention of aspiration of acidic gastric contents and postoperative nausea and vomiting.

Premedication is prescribed at the end of the preoperative consultation of the patient by the anesthesiologist. During the preoperative consultation, the following tasks are solved:

1. Establishing a psychological relationship with the child and his parents.

2. Study of the anamnesis of life and the history of the present disease.

3. Examination of the patient; if necessary, the appointment of additional consultations and laboratory tests.

4. Evaluation of research results.

5. Drawing up a plan for anesthesia and dental intervention.

6. Communication of information about the upcoming intervention to the child and his parents, obtaining their consent to anesthesia and intervention.

7. Formulation of relevant preoperative recommendations and prescriptions.

The decision to use drugs for premedication and the choice of their combinations is purely subjective. There are many drugs used by various anesthesiologists.

Unfortunately, at the moment, premedication for outpatient dental interventions in children, especially if it is used as a component of combined anesthesia, has not been developed to such a level that it could be used by a dentist alone. After consulting an anesthesiologist, this task is facilitated, but there are still many unresolved issues for pediatric patients. When using premedication for general anesthesia, such moments are much less.

The main provisions that must be observed when conducting premedication:

Ideal premedication individual for each patient; the prescriptions are simple and easy to carry out, and the premedication is effective and timely, without side effects. Its main task is to eliminate the fear of the operation, while maintaining the patient's ability to cooperate.

The use of various drugs as part of premedication has specific goals:

1. Amnesia. Some benzodiazepines, such as midazolam (dormicum), diazepam, lorazepam, can cause both antegrade and retrograde amnesia. This effect can be beneficial for especially emotional patients, but unpredictable reactions are also observed.

2. Suppression of fear. A visit to the anesthesiologist and a conversation before the operation with a detailed explanation of the upcoming manipulations can sometimes be more effective than the appointment of tranquilizers.

3. Antacids. The purpose of their use is to reduce the residual volume of gastric contents (less than 25 ml) and increase the pH (> 2.5). H2 receptor antagonists in combination with antacids given immediately before induction will increase the pH of the gastric contents. Paradoxically, but true: the residual volume of gastric contents decreases with oral administration of 50-100 ml of water 2 hours before surgery.

4. Suppression of the gag reflex. Nausea and vomiting in the perioperative period is quite common; their prevention is a very important, although sometimes difficult task. All antiemetic drugs have side effects, which must be taken into account when prescribing them.

5. analgesia is most effective if done before pain occurs. If the pain does not bother the patient before the operation, then it is best to perform intravenous analgesia already during anesthesia.

6. Suppression of hypersalivation- the most important requirement for the safe use of anesthetics in standard dosages. This effect is highly desirable in ketamine anesthesia or oral surgery, but it can also have undesirable effects (sputum thickening or anticholinergic manifestations).

7. Stabilization of autonomic functions- pursues mainly the following tasks: a decrease in sympathetic-adrenal responses and a weakening of vagal reflexes. Induction of anesthesia and tracheal intubation may be accompanied by pronounced sympathetic-adrenal activity, which is manifested by tachycardia, arterial hypertension and an increase in the plasma concentration of catecholamines. Such reactions are undesirable in healthy patients and quite dangerous in patients with cardiovascular diseases, especially those accompanied by hypertension. In premedication, selective β-blockers are sometimes used to reduce such reactions.

Vagal bradycardia, which can reach a significant depth, manifests itself in the following situations:

Induction of anesthesia with halothane (halothane);

Repeated administration of the muscle relaxant suxamethonium (ditylin) often exacerbates bradycardia, which can lead to asystole;

Surgical stimulation of reflexogenic zones during surface anesthesia.

Anticholinergic drugs (atropine, metacin, glycopyrrolate) are used as part of premedication to weaken vagal reflexes.

8. Allergy prevention. Patients with an unfavorable allergic history or individuals with a certain hypersensitivity may receive premedication with H1 receptor antagonists.

ditch the day before surgery in combination with H2-receptor antagonists 1-2 hours before induction into anesthesia.

9. Continuation of specific drug therapy. An adverse effect during anesthesia occurs when the drugs usually consumed by the patient are canceled (or interrupted). These can be steroids, antihypertensive drugs, bronchodilators or antibiotics. They should form part of the prescribed premedication.

10. Addition to specific therapy. Prevention of infection or deep vein thrombosis may be required before surgery. For all patients who received steroids for a year before surgery, they are additionally included in premedication.

11. Application of "EMLA-kreani" to the place providing intravenous access 30-40 minutes before the intervention. Cream "Emla" is an eutectic solution of local anesthetics lidocaine and prilocaine in a ratio of 1:1. The term "eutectic" means that the melting point of this mixture of two anesthetics is lower than either of them alone. At a temperature of 25°C, the mixture of lidocaine and prilocaine passes from the oil form to the water-based form.

We tried to most fully present the goals of using drugs as part of premedication, depending on each specific case: patient characteristics, the nature and extent of dental intervention, and the main anesthesia used (narcosis, local anesthesia).

For premedication, intramuscular, intravenous, oral or rectal administration of drugs is used. Alternative routes are described in the anesthesia literature (eg, intranasal, sublingual, or buccal). If it is necessary to carry out premedication in a hospital, almost all methods of administering drugs can be used; on an outpatient basis, oral is preferable; intranasal and sublingual methods of drug administration, accompanied by a minimum of discomfort and inconvenience.

Based on their own clinical experience, the anesthesiologist can use sedatives, tranquilizers, antipsychotics, narcotic and non-narcotic analgesics, antihistamines and anticholinergics, drugs that affect gastric motility. Most often, a combination of two or more drugs from different groups is used. Doctors in Russia have not yet formed a single opinion

There is a lot of uncertainty regarding the options for drugs for premedication, so their choice often depends on the experience, knowledge and practical skills of the anesthesiologist.

Conventionally, two points can be distinguished in preoperative preparation: psychological and pharmacological.

Psychological preparation. The psychological moment of preoperative preparation is largely determined by the consultation of the anesthesiologist and his conversation with the patient. Even a brief description of the plan for anesthesia and surgery removes the patient's fear of the unknown and the need to be unconscious for some time. In 1987 T.H. Mades et al. reported that patients visited by the anesthetist before surgery were significantly calmer on the day of surgery. Preoperative preparation in the form of conversation and explanation is very effective in terms of eliminating anxiety in patients. In pediatric patients, preoperative conversation is effective in older age groups; at the same time, it is necessary to take into account age-related psychological characteristics that affect the amount of information communicated to the child. Psychological preparation depends entirely on the successful establishment of a psychological relationship with the child and his parents. Although a visit to the anesthetist significantly reduces the patient's anxiety, in most cases, medical premedication is also necessary, consisting of sedatives and antihistamines (for example, barbiturates, phenothiazine derivatives promethazine / diprazine, phenergan, pipolfen / and a piperazine derivative hydroxyzine / atarax, vistadril). However, most often preference is given to drugs that have both a sedative and anxiolytic effect, i.e. benzodiazepine derivatives.

pharmacological preparation. The correct choice of drugs for premedication provides the child and the medical staff with comfortable conditions at the time of the onset of anesthesia and intervention, minimal anxiety, no fear for the patient, and no psychological and physical stress for the staff. It is advisable to choose drugs that do not have significant side effects.

The most discussed issues in terms of premedication are the drugs themselves, the ways and time of their administration to the patient. Most often, they are given orally to the patient 60-90 minutes before anesthesia. Tableted forms of drugs are designed for absorption in the stomach and, to a greater extent, in the small intestine. We use for oral administration

ampouled forms of drugs and obtain the necessary effects after an average of 20-30 minutes, which, apparently, is associated with their absorption into the bloodstream in the mouth, esophagus and stomach. With intramuscular injection of drugs, at least 30-60 minutes are required for the full development of their action. Thus, when conducting premedication in outpatient practice, the most acceptable methods of administration are oral and intravenous.

It is necessary to note the features of the oral route of administration in children. The liver actively metabolizes drugs, so their doses for enteral administration are higher than for parenteral ones. Children do not like the irritating taste of medicine. The delayed recovery of consciousness after oral administration can be considered a disadvantage of this route of administration over others. A child, as a rule, rejects a bitter drug, so the best way is to dilute the calculated dose in syrup. In order to correct the unpleasant taste of midazolam, thick Syrpalta grape syrup was used abroad. Many anesthesiologists are still opposed to oral medication for the purpose of sedation, believing that the drug entering the stomach causes immediate secretion of gastric juice, which can become dangerous due to possible regurgitation and content aspiration. In recent years, this has been treated with less concern, especially in cases where the patient only needs sedation, and not anesthesia.

As an alternative route of drug administration in children, the intranasal method can be used. Comparing the effectiveness of different doses of intranasal midazolam (0.3-0.4-0.5 mg/kg), a number of authors noted a rapid and dose-dependent onset of sedation (maximum effect between 8 and 15 minutes). The duration of sedation varied from 25 minutes at a dose of 0.3 mg/kg to 60 minutes at a dose of 0.5 mg/kg. The onset of action with intranasal administration is shorter (3 times) than with oral administration, and the duration of action with oral administration is longer on average by 10 minutes. In children aged 8 months to 6 years, sublingual (sublingual) or buccal (cheek) methods of administration are also used, when intravenous midazolam mixed with thick strawberry syrup (1: 1) is placed under the tongue or buccal. This method of administration is no less effective than rectal, but more convenient.

It is noted in the special literature that children not only have a negative attitude towards intramuscular or intravenous administration of drugs,

but also respond differently to other routes of administration. So, from 2 to 5% of all young children reject the rectal route of administration, about 10% - oral, 1% refuse any route of administration. Approximately 1/3 of children require a long and persistent "persuasion" to the oral route of medication.

After analyzing the methods of using midazolam, A. Kogan et al. concluded that oral, rectal, intranasal and sublingual routes of administration of midazolam are approximately the same in terms of efficacy and safety.

Premedication on an outpatient basis. Often we hear statements that premedication in outpatients should be minimal, since powerful premedication increases the time of postanesthesia awakening of the patient. An analysis of the anesthesiology literature refutes this belief. W.C. Clarke and L. Hay reported that intramuscular premedication with meperidine and atropine did not increase the time of awakening of the patient after outpatient intervention. Newer studies have shown that premedication with short-acting narcotic analgesics (eg, intravenous fentanyl) may even shorten the time to awaken patients due to their analgesic properties and reduced need for anesthetic. In research E.B. Barr et al. 1992 and D.A.R. Boldy et al. 1988 reported a slight increase in the time of awakening the patient with the preoperative appointment of diazepam or hydroxazine. In pediatric outpatients, oral administration of diazepam or hydroxyazine only slightly increases the time to awaken patients. Premedication with a combination of diazepam, meperidine and atropine in pediatric practice has also shown positive opportunities in terms of ensuring the safety of anesthesia and practically did not increase the time of awakening. In work H.P. Platen et al., 1998 reported that oral diazepam and midazolam significantly reduced discomfort before surgery without any significant increase in wake-up time.

Midazolam is one of the most appropriate drugs for outpatient premedication due to the fact that its effect after intramuscular administration develops very quickly. Midazolam reduces the anxiety of patients before surgery and does not affect the time of awakening after short-term outpatient interventions. Compared

with a combination of morphine and scopolamine, midazolam has a much lower spectrum of side effects. Abroad, temazepam and lormetazepam, which are superior to all other benzodiazepines in the frequency of their use in outpatient practice, have proven themselves well as oral drugs.

Nausea and vomiting are the two most common problems in ambulatory anesthesiology. Etiological factors can be the patient's condition, assisted breathing (air in the stomach) and drugs (fentanyl, etomidate, isoflurane, nitrous oxide). Some researchers believe that droperidol is an effective antiemetic, but it can dramatically lengthen the patient's awakening time due to its rather pronounced sedative effect. Despite this, droperidol should be used in outpatients who are expected to be at high risk of postoperative nausea and vomiting. Metoclopramide can also be used alone or in combination with droperidol, either orally or parenterally.

In outpatient surgery, premedication cannot be dispensed with, since it is always necessary to create an appropriate psychological background for the patient and minimize the risk of possible complications. In outpatient dentistry, the use of premedication and against the background of its action of local anesthesia is the most promising type of anesthetic management.

Most anesthesiologists agree that the goal of modern premedication is an anxiolytic effect. It also remains relevant to prevent possible complications. The choice of the drug depends on the body weight, age of the patient, the severity of his condition and the characteristics of the upcoming treatment. The point of view of some doctors who use "standard premedication" is erroneous, since there are no two identical patients and two identical anesthesiologists.

6.4.1. DRUGS MOST COMMONLY USED FOR PREMEDICATION

To obtain effects that are the goal of premedication (relieving mental stress, sedation, preventing unwanted neurovegetative reactions, reducing salivation, bronchial

chial secretion, as well as increased action of anesthetic agents), a complex of pharmacological preparations is used.

Premedication for planned inpatient interventions most often consists of two stages. In the evening, on the eve of the operation, hypnotics are administered orally in combination with tranquilizers and antihistamines. For particularly excitable patients, these drugs are given again 2 hours before surgery. In addition, usually all patients are given anticholinergics and analgesics 30-40 minutes before surgery. If cholinergic drugs are not included in the anesthesia plan, then the appointment of atropine before the operation can be neglected, since the anesthesiologist always has the opportunity to administer it during anesthesia. It must be remembered that if it is planned to use cholinergic drugs (succinylcholine, halothane) or instrumental irritation of the respiratory tract (tracheal intubation, bronchoscopy) during anesthesia, then there is a risk of bradycardia with possible subsequent hypotension and the development of more serious cardiac arrhythmias. In this case, the appointment of anticholinergic drugs (atropine, metacin, glycopyrrolate, hyoscine) as part of premedication to block vagal reflexes is mandatory. In children, anticholinergic drugs with a milder effect should be used - metacin, glycopyrrolate.

For outpatient interventions, premedication is carried out in one stage (30-40 minutes before the start of anesthesia and surgery), but in some cases it can also be two-stage.

As a rule, the following drugs are used: M-anticholinergics- Atropine. For premedication, atropine is administered intramuscularly or intravenously at a dose of 0.01-0.02 mg/kg; the usual dose for adults is 0.4-0.6 mg. The anticholinergic properties of atropine can effectively block vagal reflexes and reduce the secretion of the bronchial tree (in atropine, this effect is less pronounced than in glycopyrrolate and scopolamine). In emergency cases, in the absence of venous access, a standard dose of atropine diluted in 1 ml of saline provides a rapid effect when administered intratracheally.

In children, atropine is used in the same doses. To avoid the negative psycho-emotional impact on the child of intramuscular injection, atropine at a dose of 0.02 mg / kg can be

given orally 90 minutes before induction. In combination with barbiturates, atropine can also be administered rectally using this method of induction of anesthesia. It must be remembered that the time of onset of action of atropine in children of the 1st year of life with bradycardia is longer, and in order to achieve a rapid positive chronotropic effect, atropine must be administered as early as possible.

There are few contraindications for the use of atropine. These include heart disease, accompanied by persistent tachycardia, individual intolerance, which is quite rare, as well as glaucoma, obstructive bowel disease and urinary tract, paralytic ileus, ulcerative colitis.

- Metacin. Metacin has a stronger effect on peripheral cholinergic receptors than atropine; it also has a more active effect on bronchial smooth muscles, more strongly suppresses the secretion of the salivary and bronchial glands. Compared with atropine, metacin has a less mydriatic effect, since it passes through the blood-ophthalmic barrier worse, and when used, it makes it possible to monitor changes in pupil diameter during the operation. For premedication, metacin is also preferable because it does not act on the central nervous system, increases the heart rate less, and significantly exceeds atropine in its bronchodilator effect.

The drug is contraindicated in glaucoma, prostate hypertrophy, acute disorders of the liver and kidneys, decreased motility of the gastrointestinal tract.

- Glycopyrrolate - prescribed in doses that make up half the dose of atropine. For premedication, children are administered 0.005-0.01 mg / kg; the usual dose for adults is 0.2-0.3 mg. Glycopyrrolate for injection is produced as a solution containing 0.2 mg/ml (0.02%). Of all the M-anticholinergics, glycopyrrolate is the most powerful inhibitor of the secretion of the salivary glands and glands of the mucous membrane of the respiratory tract. Tachycardia occurs when the drug is administered intravenously, but not intramuscularly. Glycopyrrolate has a longer duration of action than atropine (2-4 hours after intramuscular injection and 30 minutes after intravenous administration).

Narcotic analgesics

Recently, the attitude towards the use of narcotic analgesics in premedication has changed somewhat. They began to be abandoned if the goal is to achieve a sedative effect. This is due to the fact that when using opiates, sedation and euphoria occur only in some patients, while others may experience dysphoria, nausea, vomiting, hypotension, or respiratory depression of varying degrees. In this regard, opioids are included in premedication only in cases where their use is undeniably useful. First of all, this applies to patients with severe pain syndrome. In addition, the use of opiates can enhance the potentiating effect of premedication.

Antihistamines

They are used in premedication to prevent histamine effects in response to a stressful situation. This is especially true for patients with a burdened allergic history (bronchial asthma, atopic dermatitis, etc.). Of the drugs used in anesthesiology, for example, some muscle relaxants (d-tubocurarine, atracurium, mivacurium hydrochloride, etc.), morphine, iodine-containing radiopaque preparations, large molecular compounds (polyglucin, etc.) have a significant histamine-releasing effect. For premedication, first-generation antihistamines (diphenylhydramine, promethazine) are also used due to sedative, hypnotic, central and peripheral anticholinergic and anti-inflammatory properties.

-Diphenhydramine(diphenhydramine) has a pronounced antihistamine, sedative and hypnotic effects. As a premedication component, it is used in children in the form of a 1% solution in a single dose of 0.5-1.2 mg / kg intravenously and intramuscularly.

- Chloropyramine(suprastin) - an ethylenediamine derivative with a pronounced antihistamine and peripheral anticholinergic activity, the sedative effect is less pronounced. A single dose for children is 0.3-0.7 mg / kg as a 2% solution intravenously and intramuscularly.

- clemastine(tavegil) compared with diphenhydramine has a more pronounced and prolonged antihistamine effect, has

moderate sedation. Dose - 0.03-0.05 mg / kg as a 0.2% solution intramuscularly and intravenously.

Sleeping pills

Phenobarbital(luminal, sedonal, adonal). Long-acting barbiturate (6-8 hours). It has a sedative, hypnotic and anticonvulsant effect depending on the dose. In anesthetic practice, it is prescribed as a hypnotic on the eve of surgery at night at a dose of 0.1-0.2 g orally; in children, a single dose of 0.005-0.01 g / kg.

tranquilizers

- Diazepam(Valium, Seduxen, Sibazon, Relanium). Release form: tablets of 0.005 g and 0.5% solution in ampoules of 2 ml (5.0 mg / ml). It belongs to the group of benzodiazepines. Dose for premedication 0.2-0.5 mg/kg. It has a minimal effect on the cardiovascular system and respiration, has a pronounced sedative, anxiolytic and anticonvulsant effects, however, in combination with other depressants or opioids, it can depress the respiratory center. It is one of the most commonly used means for premedication in children. Assign 30 minutes before surgery at a dose of 0.1-0.3 mg/kg intramuscularly; 0.1-0.3 mg/kg orally; 0.075 mg/kg rectally. As an option for premedication on the operating table, intravenous administration is possible immediately before surgery at a dose of 0.1-0.15 mg/kg along with atropine.

- Midazolam(dormicum, flormidal). Release form: 0.5% solution in ampoules of 3 ml and in ampoules of 1 mg in 1 ml; tablets of 7.5 and 15 mg. Midazolam is a water-soluble benzodiazepine with a faster onset and shorter duration of action than diazepam. For premedication, it is used at a dose of 0.05-0.15 mg/kg. For induction into anesthesia, the dose is 0.15-0.2 mg / kg. After intramuscular administration, plasma concentration reaches a peak after 30 minutes. Midazolam is widely used in pediatric anesthesiology, as it allows you to quickly and effectively calm the child and prevent psycho-emotional stress associated with separation from parents. Oral administration of midazolam at a dose of 0.5-0.75 mg/kg (with cherry syrup) provides sedation and relieves anxiety by 20-30 minutes. After this time, the efficiency begins to decrease -

and after 1 hour its action ends. The intravenous dose for premedication is 0.02-0.06 mg/kg, with intramuscular injection - 0.06-0.08 mg/kg. Perhaps the combined introduction of midazolam - 0.1 mg / kg intravenously or intramuscularly and 0.3 mg / kg rectally. Higher doses of midazolam may cause respiratory depression. Midazolam is also used intranasally in doses of 0.3-0.4 mg/kg; this route of administration is characterized by a rapid onset of sedation (maximum effect between 8-15 minutes), duration from 25 minutes to 1 hour.

When using premedication, one should never forget that different children may perceive it and react to it differently, depending on their individual psycho-emotional state. One child develops indifference and drowsiness, the other does not have the expected reaction; sometimes so-called paradoxical reactions develop, leading to a deterioration in behavior, rather than calming the child, especially in the clinic. In these cases, correction of the drug effect or the choice of another method of anesthesia is necessary. Premedication is carried out under the supervision of a doctor or a nurse anesthetist; during it, it is necessary to carefully observe the behavior of the child.

All medicines can cause allergic reactions of a general or local nature, so their use in advance at home is undesirable. Premedication in children with dental diseases does not differ from that usually used in pediatric anesthesiology.

Multiple carious lesions of teeth in children with severe concomitant pathology is one of the indications for extraction and treatment of teeth using general anesthesia.

Multiple dental caries in a 3-year-old child. Contact with the patient is difficult - treatment under anesthesia is indicated.

Dental treatment under anesthesia.

Currently, the American Association of Anesthesiologists (ASA) risk assessment has become widespread, the use of which allows a standard assessment of the risk of anesthetic management. For emergency surgical interventions, an index is added to the corresponding class « E» (emergency). This classification assesses the physical condition of the patient, but it should be borne in mind that although there is an association between the risk of general anesthesia and the physical condition of the patient, this is far from the same thing. The risk of general anesthesia assesses the ability of a particular patient to tolerate a particular anesthetic in a particular setting.

On an outpatient basis, general anesthesia with I and II degrees of risk can be performed. Starting from the III degree of risk, medical manipulations should be carried out in a hospital.

In clinical practice, another classification is also used, which is based on the principle of assessing the general condition of patients, taking into account the degree emotional stress, the nature and severity of concomitant diseases, the age of patients. It reflects 5 degrees of risk of anesthesia (table).

Table

Risk classification of general anesthesia according to asa

Classification of degrees of anesthetic risk in outpatient surgical dental interventions

General anesthesia is subjected to:

I. Healthy people aged 16 to 60 without pronounced psycho-emotional stress.

II. Practically healthy people of all ages (including children) with an unbalanced psyche and pronounced psycho-emotional stress (manifestation of anxiety, a tendency to faint) before the intervention.

III. Patients with concomitant diseases, with minor functional and organic changes in various organs and body systems.

IV. Patients with concomitant diseases in the presence of pronounced functional and organic changes in various organs and systems of the body in the stage of compensation.

V.  Patients with gross organic changes in various organs and systems of the body in the stage of decompensation.

Assessment of the patient's condition should begin with a thorough, targeted collection of anamnesis in order to identify concomitant general somatic diseases and clarify the characteristics of their course, the therapy used by the patient (drugs and their dosages). History taking should be standardized.

The assessment of the psychophysiological state of the patient is carried out with the establishment of:

1) psychological status (personality type, attitude to the upcoming intervention, fear of intervention, anxiety).

A correct assessment of the patient's psychological status guides the doctor in the need for medical correction of the identified features and, in part, in choosing the type of anesthesia necessary for this patient. Fear and anxiety are due not only to the status of the patient, but also to the personality of the doctor, the degree of trust in him;

2) general condition :

patient's appearance (skin color). Particular attention should be paid to the color of the lips (cyanosis, anemia);

features of the oral mucosa, tongue, salivation, etc.;

metabolism (body weight, height, body temperature), taking into account the data of the physiological norm, age-related changes, the influence of concomitant pathology;

breathing (rate and rhythm of breathing, audible breath sounds, coughing, activity of the auxiliary respiratory muscles), shortness of breath;

blood circulation (pulse, blood pressure, blood circulation in the capillaries - a symptom of a white spot, the presence of edema, venous stasis), taking into account the data of the norm, as well as changes associated with age or the presence of concomitant pathology;

the ratio of indicators of respiratory and circulatory functions is normal (the ratio of the duration of inhalation and exhalation is 1: 2) and in the presence of concomitant pathology (shortness of breath, etc.).

What are the patient's chances of successfully undergoing surgery? The answer to this question is extremely important for all participants in the upcoming surgical intervention - the patient, the surgeon and the anesthesiologist. The degree of risk of surgery largely determines the patient's consent to surgery. The surgeon needs this information to select the scope and nature of the intervention. The anesthesiologist thus predicts the possibility of complications, determines the volume and chooses an adequate method of anesthesia. Operational risk assessment is an obligatory element of the diagnostic and treatment process, alarming the anesthesiologist and surgeon, and should be recorded in the medical history.

Any, even small, surgical intervention is fraught with certain dangers that must be foreseen and tried to prevent. The possibility of developing intra- and postoperative complications should be considered even before the start of the operation, at the same time they begin to take the necessary preventive measures.

The purpose of preoperative preparation is to reduce the risk of surgery as much as possible, prevent postoperative complications and reduce the patient's psychological stress.

Surgical Risk Predictionintervention

To judge the degree of danger of the operation, the concept of "operational risk" is introduced. However, many factors on which the successful outcome of the intervention depends make this concept very vague. These factors include both the physical condition of the patient himself and a number of other conditions, such as the experience and knowledge of the surgeon, the training and qualifications of the anesthesiologist, the presence or absence of special instruments and pharmacological agents, the quality of preoperative preparation and postoperative care. For obvious reasons, an objective account and analysis of all these factors for each patient is practically impossible. In this regard, when deciding on the prognosis of the operation, it is advisable to proceed from the concept of the “physical condition of the patient”, in the assessment of which the doctor relies on the entire set of data obtained during the preoperative examination.

The classification of the American Anesthesiologists Association (ASA), which is widely used in world clinical practice, is based on determining the patient's physical condition.

Classification of the patient's physical condition according toASA:

IClass∙ normal healthy subject;

IIClass∙ patient with mild systemic disorders;

IIIClass∙ patient with significant systemic disorders,

limiting activity, but not leading to

disability;

IVClass∙ a patient with a severe disabling disease,

which poses a threat to life;

VClass∙ a dying patient who may die within

next day even without surgery.

_______________________________________________________________

Eemergency operations denoted by the additional symbol " E",

added to the corresponding class.

The risk of an emergency operation is much higher than a planned one. This is due to the fact that the patient's condition in preparation for a planned operation can be improved by correcting metabolic and electrolyte shifts, eliminating anemia and hypoxia, and adequate nutrition. However, in acute situations, the risk of delay in surgical treatment often outweighs the benefits of preoperative preparation.

At the same time, when determining the degree of risk of surgical intervention, one cannot ignore the volume and nature of the upcoming operation. Naturally, the prognosis will be better even for a patient assigned to the third or fourth group, if he has a small intervention on the surface of the body. On the other hand, the chances of a successful outcome become less if a patient assigned to the first or second group is supposed to undergo a major operation on the abdominal organs. Therefore, the classification of the "physical condition of the patient" is supplemented by the type of the upcoming surgical intervention. In Russia, to determine the prognosis of surgery on the abdominal organs, the classification of V. A. Gologorsky is used:

BUT. Minor operations (opening superficial abscesses,

appendectomy, hernia repair, ligation and removal

hemorrhoids).

B. Operations of moderate severity on abdominal organs (cholecystectomy,

opening of an abdominal abscess).

AT. Major surgical interventions (resection of the stomach and

intestines).

G. Radical operations on the esophagus and advanced operations with

removal of several abdominal organs.

To clarify the patient's condition and the prognosis of the operation, various integral scales are used. In practice, the most accessible simplified system for assessing the severity of the condition and prognosis - SAPS (Simplified Acute Physiology Score) (Table 3. 1-3. 3). The sum of scores for 14 main clinical and laboratory parameters, ranked from 0 to 4 points, reflects the general condition of the patient and allows predicting mortality.

The sum of the Glasgow scale scores is 3-15. The final score is obtained by adding the scores for each of the three groups of features; in each group, the best of the identified reactions is taken into account.

Prevention of complications

The possibilities of surgery in the treatment of a huge number of diseases are constantly increasing. Various postoperative complications are an inevitable companion of high surgical activity. Complications that arise significantly worsen the results of surgical treatment, increase mortality, lead to a significant increase in the terms of hospitalization of patients and the total cost of treatment. In the preoperative period, the surgeon and the anesthetist, sometimes, despite the rather tight time pressure, are obliged to familiarize themselves in detail with the patient's condition and conduct his preparation, aimed, if not at the complete normalization of all functions, then at least at the elimination of the most dangerous violations of the activity of vital organs and systems.

Comprehensive preparation of the patient for surgery includes physiological and psychological support and involves the development of trust, which is necessary for an optimal doctor-patient relationship. Psychological preparation should take place simultaneously with physiological support aimed at correcting the patient's homeostasis disorders. Particular difficulties arise when preparing for an emergency operation. Although in this situation it is necessary to strive for the maximum possible correction of physiological parameters and discuss with the patient the benefits and risks of the upcoming operation, the possibilities of alternative methods of treatment and the predicted risk of surgical intervention. In addition to the surgeon's legal obligation to provide this information, the patient's informed consent process for surgery reduces patient anxiety and gains patient confidence.

When preparing patients for surgery, the surgeon and anesthesiologist may encounter mainly three types of disorders - chronic comorbidities, disorders associated with the underlying surgical pathology, and a combination of both.

Cardiovascular Complications

Cardiovascular disease is the main cause of perioperative complications and mortality. Risk of perioperative myocardial infarction or death due to cardiovascular complications in patients , undergoing extracardiac surgery increases significantly in the presence of the factors listed in tab. 3.4. The risk of postoperative complications is especially high in the first months after myocardial infarction. The combination of any three of the first six factors listed indicates a 50% chance of perioperative myocardial infarction, pulmonary edema, ventricular tachycardia, or death of the patient. The presence of one of the last three factors increases the risk of these complications by only 1%, while any combination of two of the last three increases the risk by up to 5-15%.

The degree of risk of developing postoperative complications can be determined by the sum of the scores (Table 3. 5). The risk of such life-threatening complications as perioperative myocardial infarction, pulmonary edema, and ventricular tachycardia becomes high in patients with a third degree of risk, and in patients with a fourth degree of risk, surgery is possible only for health reasons. The risk of anesthesia and surgery is especially high in patients with recent myocardial infarction. Only after at least six months this risk decreases. (Table 3. 6). The risk of developing life-threatening postoperative cardiac complications can also be assessed by the type of surgical intervention. (Table 3. 7).

Planned surgical interventions should not be performed in the first 6 months after myocardial infarction. Patients with coronary artery disease need adequate premedication to prevent activation of the sympathoadrenal system and an increase in myocardial demand for O2 (benzodiazepines, central a-adrenergic stimulants). ECG - monitoring in this category of patients is required. Signs of myocardial ischemia - negative T wave or high peaked T wave. Progressive ischemia - downward and horizontal depression of the ST segment. The rise of the ST segment above the isoline - spasm of the coronary arteries (angina) or myocardial infarction.

Invasive hemodynamic monitoring during surgery and up to 48 hours after surgery is indicated for severe CAD (ejection fraction< 40-50%), наличии факторов риска развития сердечно-сосудистых осложнений и при длительных и сложных операциях, сопровождающихся выраженной кровопотерей. Большинство периоперационных инфарктов миокарда с патологическим зубцом Q развивается в течение трех суток после операции, без патологического зубца Q - в первые сутки (мониторинг ЭКГ). Следует отметить, что боль за грудиной испытывает менее 50% больных, поэтому наиболее частым признаком инфаркта является необъяснимая артериальная гипотензия, за которой идут сердечная недостаточность и изменения психического статуса. Наиболее чувствительным и специфичным методом выявления послеоперационного инфаркта миокарда является ежедневная регистрация ЭКГ и определение МВ - фракции КФК.

Stable arterial hypertension with diastolic blood pressure less than 110 mm Hg. Art. , controlled by medication, does not increase the risk of cardiovascular complications. Patients with severe arterial hypertension (BP ³ 180/110 mm Hg) have a high risk of developing perioperative complications - myocardial infarction, acute cerebrovascular accident, acute renal failure and circulatory failure.

Taking antihypertensive drugs, especially b-blockers, should be continued until the morning before the operation. Stopping them abruptly is usually not dangerous if they can be resumed shortly after surgery. The most effective means of combating arterial hypertension in the perioperative period are sedative therapy, analgesics and oxygen. In severe arterial hypertension, intravenous infusion of sodium nitroprusside or nitroglycerin is carried out. Due to the fact that during and immediately after the operation there is a redistribution of fluid and a decrease in BCC, it is dangerous to use diuretics in the first 24-48 hours after the operation.

The presence of signs of heart failure (dyspnea, edema, liver enlargement, etc.) requires the use of cardiac glycosides, which are also useful for patients with atherosclerotic heart disease, especially the elderly. This tactic is justified by the presence of hidden heart failure in them. If time allows, it is necessary to resort to a rapid digitalization scheme: 0.007 mg/kg of digoxin in 15-20 ml of 5% glucose solution is slowly injected intravenously twice with a break of 30 minutes, followed by the introduction of 0.5 mg every 6 hours on the first day ; then they switch to maintenance therapy - 0.25 - 0.5 mg per day. In severe heart failure, the simultaneous administration of Lasix and potassium preparations is very useful.

Patients with cardiac arrhythmias rarely require special therapy. Before surgery, they continue to take previously prescribed antiarrhythmic drugs in selected doses; The last dose is in the morning before the operation. To eliminate ventricular extrasystole, first of all, violations of water-salt metabolism are corrected. In the case of supraventricular tachycardia, precipitating factors such as fever, hypoxia, and electrolyte disturbances are eliminated, as well as drugs that can cause tachycardia are canceled. Atrial fibrillation with pulse deficit is an indication for the use of cardiac glycosides. With frequent ventricular extrasystoles (5 or more extrasystoles in 1 min), intravenous administration of 4-5 ml of a 2% lidocaine solution is prescribed. Paroxysmal tachycardia can be treated with intravenous administration of lidocaine at the indicated dosage, anaprilin (obzidan, inderal) - 1 ml of a 0.1% solution. If necessary, the introduction of drugs is repeated until the effect is achieved. In patients with heart failure, excessive fluid administration causes decompensation, so diuretics are the means of choice in such a situation.

Acute surgical pathology can cause significant changes in the cardiovascular system, even in previously healthy individuals. These shifts become especially pronounced with increasing duration of the disease and are even more accentuated in patients with previous concomitant pathology of the circulatory organs. The extreme severity of the disorders creates a fairly clear clinical picture: the skin is pale gray in color, covered with cold sweat, acrocyanosis, more or less pronounced hypotension, tachycardia with a pulse of small filling and tension. More in-depth studies reveal hypovolemia and a decrease in cardiac output in such patients. The clinical picture corresponds to the hypodynamia syndrome observed in septic shock caused by peritonitis. In the presence of internal bleeding, these changes are accompanied by a decrease in hemoglobin and hematocrit. If there is no internal bleeding, despite a decrease in BCC and CO, hemoglobin and hematocrit remain at a satisfactory level or even increase. The longer the duration of the described syndrome, the harder it is to normalize the patient's condition.

Medical tactics in such cases is determined by the cause of cardiovascular disorders and differs significantly depending on the nature of the pathology. In the presence of peritonitis, intestinal obstruction, it is extremely important to try to stabilize hemodynamics before surgery. For this purpose, first of all, it is necessary to eliminate hypovolemia, for which it is possible to recommend the use of intravenous infusion of colloidal and saline solutions. If these measures fail to normalize blood pressure, then resort to intravenous infusion of sympathomimetics. Only after stabilization or at least improvement in hemodynamic parameters, the patient can be taken to the operating room.

The situation is different with internal bleeding. In this case, if the issue of diagnosis and the need for surgical intervention is resolved, the patient should be sent to the operating room without waiting for the effect of intravenous infusions. In such patients, superficial anesthesia in combination with intravenous infusion is the best method of resuscitation. As soon as the bleeding is stopped as a result of surgery, massive infusion therapy makes it possible to finally stabilize hemodynamics. Postponement of the operation in such cases is not justified. An important and sometimes decisive role in the stabilization of hemodynamics, both in the preoperative period and during and after surgery, is played by the normalization of the water-electrolyte balance and acid-base state. It should be borne in mind that against the background of uncompensated, mainly acidotic shifts, the use of analeptics and vasopressors is meaningless, since under these conditions their effect is not manifested or is sharply weakened.

Pulmonary complications

Will the patient's respiratory system cope with the load that it will have to endure during anesthesia, surgery and, especially, in the postoperative period? What should be done to help the patient survive the operation? This is a brief formulation of the tasks facing the anesthesiologist.

The risk of pulmonary complications is greatest in acute and chronic lung diseases, in smokers, obese patients, in thoracic or abdominal operations and in anesthesia lasting more than 3 hours. Narcosis can cause bronchospasm, so patients with bronchial asthma and other diseases accompanied by bronchospasm should be actively treated with bronchodilators before surgery to maximize lung function. Patients are advised to stop smoking 3-4 weeks before elective surgery. In case of recurrent or chronic bronchospasm, the treatment regimen selected for the patient should be continued in the perioperative period. If necessary, it is supplemented with antibiotic therapy. With prolonged use of corticosteroids, in order to avoid the development of adrenal insufficiency, additional doses of these drugs should be prescribed before, during, and after surgery. Before surgery, adequate premedication is necessary - benzodiazepines to remove the emotional component and atropine to block vagal bronchospasm. It is undesirable to use H2 receptor blockers (ranitidine, cimetedine), since blockade of H2 receptors in case of activation of H1 receptors during the release of histamine can cause bronchoconstriction. Sedative and narcotic drugs should be used with caution so as not to achieve depression of the respiratory center.

Patients with bronchial asthma in the acute stage (acute bronchospasm) requiring emergency surgical intervention are shown preoperative intensive therapy. It should be used b - adrenostimulants in the form of inhalation, if the patient did not receive them. With a status that has arisen against the background of the uncontrolled use of b - adrenostimulants, their administration should be stopped and therapeutic doses of corticosteroids (more than 500 mg of prednisolone) should be prescribed, in an extremely serious condition - in the form of pulse therapy with methylprednisolone (1000 mg). Eufillin is administered at a dose of 5-7 mg / kg as a bolus in saline for 10-15 minutes, followed by a constant infusion of the drug at a rate of 0.6 - 1.0 mg / kg per hour (2.5 ml - 2.4% solution) until the condition improves. Then, for another 6-8 hours, it is necessary to carry out maintenance therapy at the same dose (the maximum daily dose is 2 g).

In the postoperative period in patients with bronchial asthma and chronic obstructive pulmonary disease, it is often necessary to monitor the saturation of hemoglobin with oxygen and arterial blood gases. Sedative and narcotic drugs should be used with caution so as not to achieve depression of the respiratory center. Suppression of cough and disruption of the ascending flow of mucus from the bronchi leads to stagnation of sputum in the airways, blockage of the bronchi with mucus and the development of atelectasis. The number of therapeutic measures used for atelectasis includes physiotherapy, a change in body position that promotes sputum discharge, therapeutic exercises with special exercises (deep breathing, artificial cough).

It should not be considered that only concomitant respiratory diseases require attention. Often, respiratory disorders associated with the underlying pathological process come to the fore. This is especially true for patients with diffuse peritonitis, intestinal obstruction and pancreatic necrosis. The cause of respiratory failure in such patients is complex. The swollen intestine, raising the diaphragm, significantly limits the volume of respiratory movements. This also contributes to the pain syndrome. Of serious, if not paramount importance, are disorders of the water-electrolyte balance and acid-base state, manifested in the form of severe metabolic acidosis. The desire of the body to compensate for these shifts by increasing gas exchange is effective only at the beginning, followed by a rapid depletion of the compensatory reaction, the possibilities of which are also limited by the already mentioned mechanical reasons. Finally, in advanced cases, the initial stage of a shock lung may appear already at this stage. In such a situation, the patient will have a more or less pronounced pattern of respiratory failure, manifested in the form of cyanosis and frequent shallow breathing. In the study of blood gases, a significant decrease in oxygenation is mainly found, although hypercapnia can also be found in some patients.

An attempt to eliminate this syndrome in the preoperative period, until the main cause that led to the development of respiratory failure is eliminated, is doomed to failure. Some relief may come from emptying the distended stomach, pain medication, and oxygen therapy. However, these measures by themselves should in no case delay operations, since only the elimination of the pathological focus, followed by intensive therapy, can bring the patient out of a serious condition.

Kidney failure and urinary disorders

Diuresis should be monitored in the early postoperative period in all patients. This is easier to do if there is a catheter in the bladder. Therefore, patients who are in serious condition are catheterized. In the absence of a catheter, an alarming symptom is the absence within 8 hours after surgery. You should also pay attention to the presence of complaints of increased urination, pain and cramps during urination, urinary incontinence, discoloration of urine. The appearance of these signs may indicate the development of complications from the urinary system: acute urinary retention, acute renal failure, infectious complications.

Acute urinary retention usually complicates the course of the postoperative period in men of older age groups. Patients at risk for developing postoperative urinary retention include:

• with prostate adenoma, urethral stricture

and patients who previously noted urination disorders;

• after surgery in the anal area;
• after inguinal hernia repair.

Predisposing factors for postoperative urinary retention are:

• elderly and senile age;
• spinal anesthesia;
• strong pain;
• distention of the bladder.

In acute urinary retention, kidney function is not impaired and urine is produced in normal quantities, but bladder emptying is impaired. The condition may be accompanied by an urge to urinate and discomfort in the suprapubic region. Lack of urge to urinate is not a sign of anuria. In many patients, filling the bladder in excess of 600 ml is asymptomatic. You can determine the overflow of the bladder using percussion of the lower abdomen. A more reliable way to diagnose urinary retention is ultrasound or bladder catheterization.

Treatment of acute urinary retention is conservative - adequate anesthesia, prozerin intramuscularly, in the absence of effect - bladder catheterization. Early catheterization of the bladder in patients receiving large volumes of infusion prevents bladder distension and atony. If it is impossible to catheterize the bladder, a suprapubic puncture or epicystostomy is used.

With reduced urination, you need:

• check the presence of urine in the bladder;
• determine the level of blood pressure;
• determine the level of CVP;
• determine the levels of creatinine and potassium in the blood;
• stimulate diuresis with the introduction of diuretics.

Urinary excretion below 30 ml/hour in the postoperative period is usually associated with hypovolemia and a decrease in blood pressure, in rare cases - with renal failure, obstruction of the ureters or damage during surgery. If infusion therapy and vasoactive drugs restore normal levels of blood pressure and CVP, but do not lead to an increase in diuresis, this indicates true renal failure. This is also indicated by high levels of creatinine and potassium in the blood.

Acute renal failure after surgery usually develops against the background of initial organic changes in the renal parenchyma, which are most often observed in patients with glomerulonephritis and diabetes mellitus. In addition, the causes of this complication are nephrotoxic drugs, significant blood loss, sepsis, and prolonged crush syndrome. Measures to prevent this complication include control of hemodynamics, CVP, diuresis, prevention of hypotension and adequate compensation for blood loss.

The only remedy that has proven effective in the prevention and early treatment of acute renal failure is adequate replacement of fluid losses, as well as maintaining cardiac output (cardiac index - 4.5 l / min / m2) and mean blood pressure above 80 mm Hg. Art. The value of other measures, such as the use of osmodiuretics (mannitol) or saluretics (furosemide) without adequate replenishment of the BCC is very doubtful. Mannitol is recommended for patients with jaundice and a risk of developing hepatorenal syndrome, as well as for patients with rhabdomyolysis. In some cases of oliguric acute renal failure, when it is not possible to achieve diuresis by replenishing fluid losses, a certain effect can be achieved by intravenous administration of furosemide.

Fluid therapy in the presence of renal insufficiency should be carried out with great care, since fluid overload and pulmonary edema can quickly be caused. In renal insufficiency, excessive administration of sodium must be avoided, and solutions containing potassium are absolutely contraindicated. In this situation, fluid and electrolyte balance and acid-base balance should be maintained with diuretics or hemodialysis.

Electrolyte disorders can be a consequence of renal pathology. Hyperkalemia is typical of renal failure and is often associated with metabolic acidosis. In cases where the serum potassium concentration exceeds 6 mmol / l or changes in the ECG are observed, it is necessary to carry out a quick correction by administering:

• 10 - 20 ml of 10% calcium chloride solution;
• 50 ml of 50% glucose solution and 12 IU of insulin, followed by

infusion of 20% glucose solution with insulin;

• sodium bicarbonate for partial correction of metabolic

• hemodialysis or hemofiltration (hemodialysis over

effective for rapidly lowering serum concentrations

Patients receiving long-term diuretic therapy may experience hypokalemia. These patients require preoperative assessment of serum potassium concentration and its replacement.

In case of renal insufficiency, it is necessary to use drugs excreted mainly through the kidneys with caution. Many drugs are conjugated in the liver before being excreted in the urine. The active metabolite of morphine, morphine-6-glucucronide, accumulates in renal failure and may cause an increase in the duration of clinical effects after the use of morphine.

Liver failure

The liver is especially sensitive to hypotension and hypoxia. In the perioperative period, it is necessary to maintain a stable, as far as possible, cardiac output. During the operation, rapid and adequate replacement of blood loss and maintenance of the overall fluid balance are necessary.

Patients with liver failure require treatment in the ICU, with mandatory monitoring of hemodynamics, metabolism, hemostatic system, water and electrolyte metabolism. In their treatment, it is necessary to avoid the use of amino acids, fat emulsions, fructose. The function of the liver cell is supported by the infusion of glucose solutions, vitamins, hepatoprotectors and bowel cleansing. Coagulation factor deficiency is corrected by transfusion of fresh frozen plasma.

In preparation for surgery in patients with severe hepatic impairment, only mild premedication with benzodiazepines is preferable.

Bowel preparation for surgery

The intestinal mucosa protects the patient from the vast amount of pathogenic aerobic and anaerobic bacteria present in the colon and distal small intestine. Surgical destruction of this barrier can lead to infection of the abdominal cavity and suppuration of the surgical wound. Safe surgical operations on the intestine became possible only after the development of methods to reduce the content of bacteria and their activity. Clinical studies have shown that this can be achieved by mechanical bowel cleansing and the use of antibiotics active against both aerobic Gram-negative and anaerobic bacteria. .

Mechanical preparation

Mechanical methods of preparing the intestine for surgery are quite diverse:

• Diet:

slag-free,

Completely liquid.

• Laxatives:

Magnesium sulfate, 50% solution

Balanced Solutions -

Fortrans, Colite, Golitel

• Cleansing enema

A modern, more effective and convenient method is a complete antegrade lavage of the gastrointestinal tract, the so-called lavage. Ingestion of 3-4 liters of special balanced solutions as a laxative on the eve of the operation leads to a complete cleansing of the intestines.

Mechanical bowel preparation is used in preparation for all planned operations on the abdominal organs; this method is especially necessary for surgical interventions on the colon and rectum. This preparation facilitates surgical manipulations and accelerates the recovery of bowel function after surgery. Mechanical purge reduces residual faecal matter and increases the effect of antibiotics, but when used in isolation, does not reduce the bacterial content of the intestinal mucosa.

Gone are the days when patients were hospitalized for complete bowel preparation - now the patient comes to the surgical department the day before the operation, and part of the mechanical preparation begins before hospitalization. For two to three days before surgery, patients usually follow a liquid, slag-free diet, and the day before surgery they have their intestines cleaned. Currently, lavage is increasingly used for this purpose, which is preferably carried out in a hospital. Only in patients without heart failure, bowel lavage can be performed on an outpatient basis.

Often, adequate mechanical bowel preparation before emergency surgery is not possible, and in conditions such as perforation, gangrene, or bowel injury, mechanical bowel preparation is contraindicated. In this situation, parenteral administration of antibiotics is used to prevent septic complications.

Selective intestinal decontamination

There is no consensus on the best route of antibiotic administration for bowel preparation. Oral antibiotics and parenteral antibiotics equally reduce the number of bacteria in the intestine and the incidence of postoperative infectious complications. Ingestion of neomycin and erythromycin, introduced in 1972, is the most common regimen and continues to be used to this day. Orally appoint 1 g of neomycin and erythromycin by mouth at 13, 14 and 22 hours on the eve of the operation, if the operation is scheduled for 8 hours of the next day. If the scheduled operation is scheduled for a later time, change the schedule for taking neomycin and erythromycin. After taking the first dose of antibiotics, 19-20 hours should elapse before the start of the operation. More than three doses of antibiotics do not guarantee the best prophylactic effect, but contribute to the formation of resistant flora. More recent studies have shown that metronidazole replaces erythromycin with equal efficacy.

Parenteral antibiotics effective in preparing the colon for resection include cefoxitin, cefotetan alone or in combination with metronidazole or clindamycin. A significant advantage of intravenous antibiotic prophylaxis is the possibility of its use in emergency situations and the exact timing of drug administration, which is difficult to achieve when using neomycin and erythromycin. This is especially true in situations where the operation is delayed or unexpectedly postponed. The simultaneous use of oral and parenteral antibacterial drugs reduces the content of microorganisms on the colonic mucosa to the greatest extent. However, there is still no evidence that such a prophylaxis regimen significantly reduces the incidence of postoperative infectious complications.

A complete scheme of bowel preparation for operations on the colon and rectum:

2 days before surgery:

Slag-free or liquid diet

Magnesia sulfate 30 ml 50% solution orally 3 times a day -

10.00, 14.00 and 18.00,

Cleansing enema in the evening.

Before the operation:

Breakfast allowed - liquid diet,

Magnesium sulfate 30 ml 50% solution orally 2 times a day - 10.00

and 14.00 h or Fortrans 3-4 liters orally for 2 h starting from

Neomycin and erythromycin inside 1 gram 3 times a day -

13.00, 14.00 and 22.00,

After midnight, the patient is forbidden to drink.

On the day of surgery:

- Emptying the rectum at 7.00,

Cefoxitin 1 g IV 1 hour before skin incision

Metronidazole 100 ml 0.5% solution intravenously 1 hour before

skin incision.

Bowel preparation regimens for colon and rectal surgery change over time. The selection of the optimal scheme for preparing the intestine for surgery depends on the clinical situation and the capabilities of the medical institution. The preparation scheme using only intestinal lavage and preoperative single intravenous administration of an antibacterial drug seems to be convenient for the patient and medical personnel and, at the same time, quite effective and simple.

Intestinal paresis

The main function of the intestine - the absorption of nutrients - is disturbed in severe cases of paresis to the point of complete absence. Under these conditions, enteral nutrition not only does not lead to the entry of necessary substances into the blood, but exacerbates the overstretching of the intestinal wall and its hypoxia. Ischemia of the digestive tract leads to damage to enterocytes and functional insufficiency of the intestine. As a consequence of the inhibition of motility, evacuation disorders and the accumulation of large amounts of liquid and gases in the intestinal lumen serve. The slowing down of the passage of chyme is accompanied by a sharp change in the composition of the intestinal microflora and the intensive formation of toxic products.

Overstretching of the intestinal wall exacerbates disorders caused by enterocyte ischemia and is accompanied by an increase in intestinal permeability, translocation of bacteria and toxins through the glycocalyx membrane into the blood and lymph. In addition, the deposition of fluid in the intestinal lumen leads to a decrease in BCC, exacerbating hemodynamic disorders. That is why the prevention and treatment of intestinal incision deserves serious attention, which plays a particularly important role in the pathogenesis of the development of multiple organ dysfunction and anastomotic suture failure in patients after surgery.

Basic principles for the prevention and treatment of functional bowel insufficiency:

• normalization of water and electrolyte balance;
• decompression of the gastrointestinal tract;
• elimination of pain;
• parenteral nutrition;
• drug stimulation of intestinal motility

Pharmacological stimulation of intestinal motility involves the use of prozerin or ubretide; physiotherapy - the use of Bernard's diadynamic currents. An effective means of combating pain and postoperative intestinal paresis is long-term postoperative epidural anesthesia. Its use contributes to an earlier recovery of intestinal motility even after extensive abdominal operations. This can be explained both by an increase in splanchnic blood flow against the background of sympathetic blockade caused by epidural administration of local anesthetics, and by a decrease in the activity of the sympathetic nervous system, leading to an increase in sphincter tone and a decrease in peristaltic activity of the gastrointestinal tract.

If paresis persists for more than 48 hours, it is necessary to exclude the presence of such complications as peritonitis, abdominal abscess, mechanical intestinal obstruction.

Postoperative nausea and vomiting

Postoperative nausea and vomiting are common complications of any surgical intervention performed under general, regional or local anesthesia. These phenomena are especially typical for abdominal surgery, where their frequency ranges from 8 to 92%, averaging 20-40%. The risk of postoperative nausea and vomiting is especially high in women and persons suffering from motion sickness in transport (“seasickness”).

The negative psycho-emotional coloring of this complication forms in the patient a negative attitude towards the quality of medical care. In addition, vomiting can cause serious, even fatal, complications: from aspiration of vomit into the trachea, in patients with depressed consciousness or an unrecovered cough reflex, to divergence of the wound edges after laparotomy and hemodynamic disturbances, due to an increase in intra-abdominal, intrathoracic and intracranial pressure. Prolonged vomiting can cause dehydration and electrolyte imbalances. This complication significantly increases the time spent by patients in the awakening ward, the total duration of inpatient treatment and, accordingly, increases its cost, thus becoming an economic problem.

To prevent the development of postoperative nausea and vomiting syndrome, both medications and other means are used. Premedication is an important adjunct to local and regional anesthesia and anesthesia. It suppresses the fear and anxiety of the patient, increases the analgesic effect of anesthesia, reduces acidity and volume of the stomach, reduces salivation and mucus formation in the airways, reduces the effect of histamine and reduces postoperative nausea and vomiting. For premedication, tranquilizers (diazepam, midazolam), anticholinergics (atropine), narcotic (fentanyl, morphine) and antiemetics, antacids and histamine antagonists are used.

The addition of anticholinergics, such as atropine, to narcotic analgesics in premedication reduces the incidence of postoperative vomiting. Widespread use of anticholinergics and antihistamines, phenothiazines, buterophenones, benzodiazepines for the prevention of postoperative nausea and vomiting is not always possible due to the high likelihood of side effects: extrapyramidal disorders, psychosomatic discomfort, late recovery of neuropsychic status and an increase in the time spent in the postoperative ward.

5-HT3 antagonist drugs (tropisetron, ondansetron, granisetron, and dolasetron) have been successfully used to treat chemotherapy-induced emesis in cancer patients, as well as to prevent postoperative nausea and vomiting. Ondansetron (Zofran) and tropisetron (Navoban) are mainly used in clinical practice.

The duration of action of tropisetron is 24 hours. For the treatment and prevention of postoperative nausea and vomiting, tropisetron is prescribed at a dose of 2 mg intravenously at the stage of induction of anesthesia. Ondansetron for the prevention of postoperative nausea and vomiting is prescribed at a dose of 4 mg intravenously at the stage of induction of anesthesia.

Metoclopramide does not have sedative properties; it realizes its antiemetic effect partly through its effect on 5-HT3 receptors, partly by increasing the tone of the esophageal sphincter and accelerating gastric emptying.

Ephedrine, an indirect sympathomimetic, is effective in the treatment of vomiting resulting from hypotension during spinal anesthesia.

Regurgitation

One of the most formidable, often fatal complications in surgical patients is regurgitation - passive leakage of liquid contents from the stomach into the esophagus, oropharynx and respiratory tract. Regurgitation usually develops when the stomach is overfilled with liquid contents in patients who are unconscious for various reasons. The risk of regurgitation during induction anesthesia and tracheal intubation is especially high in patients with peritonitis, intestinal obstruction and gastrointestinal bleeding.

Regurgitation results in Mendelssohn's syndrome, atelectasis, and aspiration pneumonia. Mendelssohn's syndrome develops when aspiration of acidic gastric contents with a pH below 2.5. If the aspirated fluid has a pH above 2.5 (for example, bile), the consequences of its penetration into the respiratory tract are less dangerous. Clinically, the syndrome resembles an acute attack of bronchial asthma and develops immediately, or several hours after aspiration. The patient develops cyanosis, expiratory dyspnea, tachycardia with hypotension. On auscultation, loud whistling rales are clearly audible. Sometimes there is a picture of partial or total bronchospasm. X-ray reveal unevenly located areas of increased density ("variegated lung"). In severe cases, a rapidly progressive deterioration occurs with the development of pulmonary edema. In a less acute course, aspiration pneumonia subsequently occurs.

Treatment of the consequences of aspiration of gastric contents is by no means always sufficiently effective, and therefore all measures that can prevent the development of complications are especially relevant. First of all, to prevent regurgitation, it is necessary to empty the stomach through a gastric tube. During the induction of anesthesia and tracheal intubation - raising the head end of the operating table and applying the Sellick technique (energetic pressure with three fingers on the thyroid cartilage, while the esophagus is squeezed between the thyroid cartilage and the spine, preventing fluid from entering the oropharynx).

If regurgitation has already occurred, first of all, it is necessary to give the patient the Trendelenburg position and clean the oral cavity as much as possible with the help of suction and tupfers. If regurgitation occurs after the introduction of relaxants and the patient is in a state of apnea and relaxation, it is necessary to immediately intubate and inflate the cuff, and then proceed to clear the airways. To do this, after carrying out artificial ventilation and saturating the patient with oxygen, a catheter is inserted through the endotracheal tube and, if possible, the aspirated fluid is aspirated from the trachea and both main bronchi. Next, 5-10 ml of isotonic sodium chloride solution is poured into the trachea and aspiration is performed again. This procedure (lavage), alternating it with two to three minute periods of artificial ventilation, is repeated until a clear, uncolored liquid begins to flow from the trachea and bronchi. At the same time, the patient is injected intravenously with 5-10 ml of a 2.4% solution of aminophylline, and after the end of lavage, 5 ml of an isotonic sodium chloride solution with 500,000 units of penicillin (or another antibiotic) and 100 mg of hydrocortisone are poured into the trachea.

Diabetes control

Diabetes mellitus is one of the most serious and frequently occurring concomitant endocrinological diseases. Fifty percent of all diabetic patients undergo surgery during their lifetime. Perioperative morbidity and mortality in patients with diabetes is significantly greater than in patients without diabetes. Problems in the management of diabetic patients undergoing surgery are related to the fasting period and the metabolic effects of surgery. In the perioperative period, careful glycemic control is especially necessary to reduce proteolysis, lipolysis, lactate and ketone production.

Adequate patient management depends on the type of diabetes (insulin-dependent or non-insulin-dependent), the extent and urgency of surgery, and the time to restore oral nutrition.

Major surgery in a patient with non-insulin-dependent diabetes mellitus is an indication for switching to insulin. In cases where there is a minor operation, and the blood glucose level is less than 10 mmol / l, then specific therapy is not prescribed. The patient receives oral hypoglycemic drugs at the first meal.

The best control of diabetes is achieved by twice-daily administration of short-acting and intermediate-acting insulin. Younger patients may have a regimen with a single dose of ultra-long-acting insulin in the background along with short-acting insulin delivered in small doses using a pocket dispenser.

If emergency surgery is necessary, simultaneous administration of insulin and glucose is used to quickly normalize blood glucose levels. The combination of intravenous glucose solution with the addition of insulin to the vial is a safe precaution; none of the components can be accidentally introduced without the other and therefore the danger of hyperglycemia and, more importantly, hypoglycemia is eliminated. To ensure adequate intake of carbohydrates and energy without excessive volume, a 10% glucose solution is used. When the concentration of potassium in the patient's blood plasma is below 3 mmol / l, in addition to insulin, 20 mmol of potassium chloride is added to the glucose solution. Calculation of the dose of insulin at various levels of glucose in the blood is given in tab. 3.8.

In the postoperative period, 4-6 hour infusions of 10% glucose are continued along with 10 units of insulin (Humulin S) and 10 mmol of potassium chloride before eating through the mouth. When oral nutrition is restored, they switch to subcutaneous insulin in the dosage used before surgery. Monitoring of glucose levels in the postoperative period is carried out every 2 to 6 hours, and urea and electrolytes - daily.

The postoperative period for non-insulin dependent diabetes is the same as for non-insulin dependent diabetes. When resuming a natural meal, 8-12 units of soluble insulin are prescribed before each meal. Oral therapy for diabetes after surgery becomes possible when less than 20 IU of insulin per day is required to achieve normal glucose levels.

Operating wound infection

During surgical operations, despite the careful observance of the principles of asepsis and antisepsis, it is impossible to completely avoid exogenous and endogenous bacterial contamination of the surgical intervention area. Infection in the area of ​​surgical intervention is the most common type of postoperative complications. Most modern prophylactic regimens are designed specifically to reduce the risk of septic complications from the wound or infection of implanted materials, such as pacemakers, vascular and joint prostheses. Wound infectious complications are quite common, according to statistics they develop in 2% of cases of "clean" and in 30-40% of cases of "dirty" surgical interventions. The bacterial flora enters the wound from the air, skin and hollow organs of the patient, with blood flow from distant sources of infection, but sometimes it can be introduced by the hands of the surgeon with instruments, surgical linen or dressings.

To reduce the possibility of septic complications, it is necessary to eliminate as much as possible before surgery all possible risk factors and increase the patient's body's defenses. First of all, it is necessary to sanitize all distant foci of infection in the patient's body, eliminate staphylococcal colonization of the nose and completely cleanse the intestines.

Significantly reduces the risk of contamination of the patient with causative agents of hospital infections by reducing the period of preoperative stay of the patient in the hospital. This requires most of the examination and preparation to be done on an outpatient basis. The simplest and most affordable way is the correct preparation and processing of the surgical field. The common practice of shaving the skin before surgery is known to increase the incidence of wound infection in clean surgeries by 100%. It is more rational to refuse shaving and cut hair in the area of ​​surgical access.

In patients with comorbidities, it is necessary to minimize the dose of glucocorticoids, reduce preoperative antibiotic therapy, and strengthen control of diabetes. However, not all risk factors for infectious complications can be eliminated and the patient prepared for surgery. It is especially difficult to prevent the development of purulent-inflammatory complications in the postoperative period when performing emergency surgical operations. In such cases, the method of choice is the use of antibacterial drugs.

The task of antibacterial prophylaxis is to create bactericidal concentrations of antibiotics in tissues exposed to bacterial contamination during surgery - "antiseptic from the inside". The purpose of this method of prevention is not the complete eradication of microorganisms from the intervention area, but a significant reduction in the level of contamination, which helps prevent the development of infection. Studies have shown that infection in the wound develops when it is contaminated, reaching 10/5 degree of microbial bodies in 1 g of tissue.

Rational antimicrobial prophylaxis is based on four main principles:

• determination of indications for antibacterial prophylaxis;
• selection of an adequate antibiotic;
• the introduction of an antibiotic before the skin incision;
• discontinuation of antibiotic administration after surgery.

Septic complications risk assessment and definition

indications for antibiotic prophylaxis

Taking into account a large number of various factors contributing to the development of infection in the wound and their different significance in the development of septic complications, it is extremely difficult to determine the degree of risk in a particular patient. Antibacterial prophylaxis is undoubtedly indicated in patients who are likely to have significant bacterial contamination of the wound. First of all, this applies to patients undergoing operations on the organs of the gastrointestinal tract. Therefore, the easiest way to assess the risk of infectious complications during surgical interventions is based on the classification of surgical wounds, in which there are “clean”, “clean - contaminated”, “contaminated” and “infected or contaminated” wounds. (Table 3. 9).

In "clean" operations, antibacterial prophylaxis is not indicated. Only in cases where there are additional risk factors, such as the implantation of vascular prostheses, heart valves and pacemakers, the use of cardiopulmonary bypass, joint replacement, interventions for closed fractures, is a prophylactic antibiotic administered before the operation. Plastic surgery of external abdominal hernias using implants and mammoplasty are controversial indications for the prophylactic use of antibiotics. Antibiotic prophylaxis is indicated for all clean-contaminated, contaminated and infected wounds. In infected wounds after intraoperative prophylaxis, a course of antibiotic therapy is carried out.

Although the estimated degree of wound contamination is a decisive factor in the fate of the surgical wound, it does not take into account a number of other significant risk factors for the development of infectious complications. It is possible to more accurately determine the risk of septic complications by a combination of indicators. In clinical practice, to assess the risk of infectious complications after surgery and determine indications for prophylactic antibiotics, it is advisable to use a combined scale that takes into account not only the degree of contamination of the surgical wound, but also the severity of the patient's condition, and the expected technical difficulties of surgical intervention. (Table 3. 10).

The risk index of infectious complications is determined by the sum of the scores on the risk scale. This index is calculated for traditional open surgical interventions. When performing endoscopic surgical interventions, the risk of infectious complications in the surgical area is reduced by one point. With a risk index of 2 points or higher, a high risk of developing infectious complications is predicted. This is an indication for the prophylactic administration of antibiotics. (Table 3. 11).

The choice of antibacterial drug for prevention

The choice of a drug for the prevention of infection in a particular patient depends primarily on the expected composition of the microflora present in the surgical area, as well as a number of other factors. The most common causative agents of postoperative infectious complications are coagulase-negative and Staphylococcus aureus, enterococci and Escherichia coli. Somewhat less often, the disease is caused by Klebsiella, Proteus and some other gram-negative bacteria. During operations on the colon, pelvic organs and in the head and neck area, typical causative agents of infectious complications are anaerobic microorganisms, most often bacteroids.

An antibacterial drug for the prevention of infectious complications should:

• have bactericidal activity against probable pathogens of infectious complications;
• penetrate well into tissues - infection risk zones;
• maintain bactericidal concentration in the tissues during the entire period of the operation;
• have minimal toxicity;
• not affect the pharmacokinetic properties of drugs used for anesthesia;
• do not cause the rapid development of resistance of pathogenic microorganisms;
• be optimal in terms of cost / efficiency.

Cephalosporins serve as the drugs of choice for the prevention of infectious complications in a wide variety of surgical interventions (Table 3. 12). The advantages of these drugs are their wide antibacterial spectrum of action, safety and low price. Due to these features and the relative long-term bactericidal action, cefazolin dominates in a number of drugs for the prevention of surgical infections. The second generation of cephalosporins (cefuroxime, cefoxitin) serves as a prophylactic agent mainly in colorectal surgery and in abdominal trauma. Third-generation drugs (cefotaxime) are expensive, no more effective, and induce bacterial resistance. Their widespread use as a prophylactic agent does not have sufficient grounds. They can be used in cases of risk of polymicrobial infection - during operations on the colon and rectum, with penetrating wounds of the abdominal cavity and perforation of the appendix.

In most clean and clean-contaminated surgical interventions, along with the use of cephalosporins, it is also possible to use protected penicillins (amoxicillin + clavulanic acid). In cases of a high risk of infection with methicillin-resistant strains of staphylococcus and other problematic microorganisms, as well as in the presence of an allergy to cephalosporins, the use of reserve antibiotics, in particular vancomycin, as a prophylactic agent is justified.

Vancomycin- a very popular alternative for the prevention of surgical infections caused by gram-positive bacteria, but its widespread use should be avoided. Vancomycin is not very convenient for prophylaxis, since its administration may reduce blood pressure and even cardiac arrest. To avoid such complications, it must be administered very slowly: a safe infusion of 1 g of vancomycin requires at least one hour. The expansion of indications for the use of vancomycin has led to the emergence of vancomycin-resistant strains of enterococcus. Such strains of enterococcus are very difficult to treat, and their presence is fraught with the danger of the emergence of vancomycin-resistant staphylococcus aureus.

Vancomycin is used for primary prevention in cases of cephalosporin allergy, vascular prostheses and heart valves, joint replacements, and especially in cases where there is a risk of infection with methicillin-resistant strains of Staphylococcus aureus or epidermal Staphylococcus aureus. In these cases, a single dose administered immediately before surgery is sufficient for prophylaxis if the operation is continued for no more than 6 hours. For a longer operation, additional administration of an antibiotic is necessary. Prevention is completed after the introduction of two doses of the drug.

The considered recommendations on antibacterial prophylaxis are to some extent indicative and can be modified depending on the specific clinical situation, the "landscape" of the microflora of the surgical hospital and the availability of medicines.

Antibiotic prophylaxis regimen

The interaction between bacteria trapped in the wound and antibiotics administered for prophylaxis largely determines the course of the wound process. Experimental and clinical studies have shown that prophylaxis is most effective when the antibiotic penetrates the tissue before bacteria can enter after the skin incision. The effectiveness of prevention is significantly reduced with the introduction of antibiotics after the start of the operation, and their use 3 hours after the start of the operation does not give any effect. Optimal should be considered intravenous administration of an average therapeutic dose of an antibiotic 1 hour before surgery.

The current trend is to limit the duration of prophylaxis. Regimens consisting of only a single preoperative dose of antibiotic are as effective as longer regimens. In most situations, a single dose of an antibacterial drug immediately before surgery is usually sufficient to prevent infectious complications. However, if the operation lasts more than 6 hours, then additional administration of an antibiotic is necessary. The second dose can be administered 3-4 hours later (time corresponding to the half-life of the antibiotic used) from the start of prophylaxis. After two injections of antibiotic prophylaxis should be stopped. The benefits of a longer regimen have not been proven, although many surgeons still prefer prophylaxis for 24 hours or even longer, citing operational difficulties or contamination of the operating field. Prophylaxis regimens longer than 24 hours are unacceptable. Of course, with intraoperative identification of an infection, for example, with an unexpected discovery of a perforation of a hollow organ during surgery, the prophylaxis regimen can turn into a course of treatment.

It should be noted that the rational use of antibiotics is just one important aspect in an effective strategy for the prevention of infection associated with surgery. Early removal of tubes, drains, IV catheters, and invasive monitoring devices reduces the risk of infection with hospital microflora. Careful observance of asepsis rules, sparing surgical technique in tissue handling, reduction of the area of ​​coagulation necrosis, wound washing and strict consideration of indications for the use of drains and tampons is the best way to reduce the incidence of infectious postoperative complications.

Endocarditis and prosthetic infection

Surgical and endoscopic interventions on the oropharynx, respiratory tract, abdominal organs and genitourinary tract may be accompanied by transient bacteremia. In patients who have previously undergone heart valve implantation or vascular replacement, transient bacteremia can lead to the development of endocarditis or infection of the vascular prosthesis. To prevent such complications, it is necessary to use antibacterial drugs before the operation. For operations on the oropharynx and upper respiratory tract, it is recommended to use oral administration of 3 g of amoxiclav one hour before surgery and 1.5 g 6 hours after the first dose. In surgical interventions on the gastrointestinal tract, biliary tract and urogenital tract, 3 g of ampicillin and 80 mg of gentamicin should be administered intravenously one hour before surgery.

Hemorrhagic complications

Bleeding that occurs during a surgical operation often poses a threat to the life of the patient and always complicates the surgeon's actions. To reduce the risk of massive bleeding, it is necessary, first of all, to eliminate the patient's violations in the hemostasis system. In patients with initial disorders in the hemostasis system, the level of the missing factor should be increased to 100% for safe surgical operation. After the operation, during the first 4 days, it must be maintained at least 60%. The next 4 days (until the removal of sutures, probes and drains) it should be at least 40%.

For this purpose, transfusion of fresh frozen plasma or individual coagulation factors is usually used.

Recently, much more often have to deal with the pathology of the hemostasis system caused by the use of drugs that inhibit platelet function and the action of indirect anticoagulants. Drugs that affect platelet function are widely used in outpatient practice. Many patients take daily acetylsalicylic acid, clopidogrel, or ticlopidine as prescribed by a doctor to improve coronary blood flow and treat circulatory disorders in the lower extremities. Patients self-administer cheap and readily available non-steroidal anti-inflammatory drugs for headaches, arthritis, sports injuries, dysmenorrhea, and other conditions. A single dose of any of these drugs invariably reduces platelet function. Given that the normal half-life of circulating platelets is 7-10 days, it is recommended that these drugs be discontinued at least three days before surgery. For patients with reduced platelet counts, early withdrawal is desirable.

Often there are also patients who take warfarin for a long time to prevent thromboembolic complications after acute venous thrombosis, cava filter implantation or heart valve replacement. If it is necessary to perform any operation in such patients, indirect anticoagulants are canceled 4 days before the operation due to the high risk of intraoperative bleeding. During this period, antithrombotic prophylaxis is carried out with sodium heparin. (Fig. 3. 1). If an emergency operation is necessary, fresh frozen plasma is administered to quickly normalize hemostasis.

When predicting a large blood loss before surgery, selective embolization of arterial vessels supplying the organ to be removed is also used. A similar method of preventing massive bleeding is more often used in advanced and combined oncological operations, accompanied by the removal of a significant mass of richly blood-supplied tissues.

Secondary gastrointestinal bleeding

The redistribution of blood flow in various diseases and major operations leads to ischemia of the gastric mucosa and the destruction of the protective barrier that protects it from the action of hydrochloric acid. Back diffusion of hydrogen ions into the gastric mucosa leads to its ulceration and is often accompanied by gastric bleeding. The highest risk of developing gastrointestinal bleeding is in patients who have previously taken non-steroidal anti-inflammatory drugs, who suffer from peptic ulcer and erosive gastritis, and who are in serious condition due to various reasons:

• respiratory failure requiring mechanical ventilation;
• DIC;
• massive blood loss;
• sepsis;
• burns over 30% of the body.

Concomitant hepatic and renal insufficiency are additional risk factors for the development of stress lesions of the gastrointestinal tract and are also taken into account when determining indications for the use of pharmacological prevention of bleeding. (Table 3. 13).

Before performing planned surgical interventions, patients should stop taking non-steroidal anti-inflammatory drugs in advance, treat diseases of the stomach and duodenum, followed by endoscopic control.

In patients with a high risk of bleeding for prevention, reduce the acidity of the contents of the stomach or protect the mucosa with cytoprotectors. The duration of the prophylactic use of these drugs depends on the duration of the risk factor.

To reduce acidity, histamine H2 receptor blockers and proton pump inhibitors are prescribed. Given the age-related changes in the cardiovascular system, age over 65 years may be a contraindication for the use of H2-receptor blockers, which have a negative inotropic and chronotropic effect on the heart. Encephalopathy of any origin is also a relative contraindication to the use of H2 receptor blockers, since these drugs can affect mental status due to their action on histamine-like receptors in the central nervous system. Given the side effects of H2-receptor blockers, it should be recognized that the optimal pharmacological means of prevention is the use of proton pump inhibitors. Omeprazole is usually used.

The dosage of this drug depends on the "damaging significance" of the risk factor. In particular, in respiratory failure, coagulopathy and severe sepsis, the dose of omeprazole should be 40 mg 2 times a day intravenously. In the presence of etiopathogenetic factors of lesser significance, the dose can be reduced to 40 mg 1 time per day. For the prevention of stress ulcers, bolus intravenous administration (40 mg over 10 minutes) is more often used, and for the prevention of recurrence or treatment of bleeding, continuous intravenous administration: 80 mg of omeprazole for 15 minutes, then 8 mg / h for 72 hours, then 20 mg per os until final healing.

The integrity of the mucosa is maintained by cytoprotectors. A suspension of sucralfate (1 g of the drug is dissolved in 10-20 ml of sterile water) is injected into the stomach through a nasogastric tube every 6-8 hours. Sucralfate is comparable in effectiveness to H2-blockers and antacids, while the drug does not affect the bactericidal activity of gastric juice. An important role in preventing the formation of stress ulcers in the stomach is played by early tube enteral nutrition, especially when drugs are administered directly into the intestine.

Venous thromboembolic complications

Currently, PE is one of the most common causes of death after various surgical operations. It is known that five out of every 1000 adults undergoing surgery die from a massive pulmonary embolism. It has been established that in the vast majority of cases of pulmonary embolism, its source is the veins of the lower extremities and pelvis. The frequency of deep vein thrombosis in the absence of prophylaxis is very high and in some categories of patients reaches 50-60% ( rice. 3.2) . Much less often, the sources of PE are localized in the superior vena cava and its tributaries, as well as in the right parts of the heart. Adequate prophylaxis can significantly reduce the risk of thromboembolic complications that threaten the life of the patient.

Assessment of the risk of thromboembolic complications

The hypothetical risk of deep vein thrombosis and PE exists in every patient. However, in certain categories of patients, the risk of developing thromboembolic complications is different. Today, the risk of thromboembolic complications is assessed using well-known risk factors:

¨ thrombophilia;

¨ prolonged immobilization;

¨ trauma or surgery;

¨ malignant tumor;

¨ previous DVT or PE;

¨ the presence of a cava filter or catheter in a vein;

¨ varicose veins on the legs;

¨ chronic heart failure;

¨ age over 60;

¨ excess body weight;

¨ pregnancy, childbirth;

¨ the use of oral contraceptives;

¨ hormone replacement therapy in women.

Among the risk factors for the development of thrombosis, thrombophilia is in the first place. Its frequency in patients with deep vein thrombosis reaches 10%. Patients with congenital homozygous thrombophilia, in whom the risk of deep vein thrombosis and PE is particularly high, should definitely receive appropriate prophylaxis in accordance with the clinical situation. In addition to thrombophilia, a combination of two or more risk factors in a patient should guide the doctor to the possibility of thrombosis in a particular patient and to the need for appropriate individual prevention of this formidable complication.

Individual tactics for the prevention of venous thromboembolism depends on the degree of risk of thrombosis in a particular patient. For practical purposes, three degrees of risk for venous thromboembolic complications are usually distinguished: low, moderate, and high. Risk rates for postoperative deep vein thrombosis in surgical patients, with the exception of orthopedic and trauma patients, who are always at high risk, are presented in tab. 3.14.

Methods for the prevention of acute venous thrombosis

There are still no reliable ways to restore the antithrombogenic activity of the vascular wall. Therefore, the prevention of venous thromboembolism is based on the correction of two components of the Virchow triad - an increase in the rate of venous blood flow and a decrease in the rate of blood coagulation.

The effectiveness of various methods for the prevention of acute venous thrombosis is presented in rice. 3. 3.

Early postoperative activation of patients reduces venous stasis and the risk of thromboembolic complications. Patients who are indicated for prolonged bed rest are put on special elastic antithrombotic stockings and intermittent pneumatic compression of the lower extremities is performed. To reduce the rate of blood clotting, antiplatelet agents and anticoagulants are used. The effectiveness of these methods for the prevention of deep vein thrombosis is different. . The most effective ways to prevent venous thrombosis are to accelerate blood flow and anticoagulant therapy. The role of acetylsalicylic acid in the prevention of deep vein thrombosis remains controversial. Although the results of a meta-analysis of studies on this issue, presented by the Committee for the Study of Antiplatelet Agents, showed the ability of acetylsalicylic acid to reduce the incidence of deep vein thrombosis, the activity of this drug still seems to be insufficient.

Assessing the possibility of using direct and indirect anticoagulants in the prevention of acute postoperative venous thrombosis, it should be noted that the frequency of massive hemorrhagic complications during and after it is significantly higher with oral anticoagulants than with heparins. This does not allow the widespread use of this group of drugs for the prevention of deep vein thrombosis and pulmonary embolism in surgical patients. The optimal method of specific anticoagulant prevention of postoperative venous thrombosis should be considered the use of low molecular weight heparins: sodium enoxaparin, sodium dalteparin, calcium nadroparin.

Choice of prevention method

The choice of prevention method depends on the degree of risk of developing acute thrombosis. (Table 3. 15). In the low-risk group of venous thromboembolic complications, low-cost preventive measures that have long been known to doctors should be used: the earliest possible activation of patients and elastic compression of the legs, for which it is more preferable to use special antithrombotic stockings rather than elastic bandages.

A moderate risk of developing thromboembolic complications dictates the need for additional prophylactic administration of anticoagulants. Usually use small doses of heparin: 5,000 units. twice or thrice a day under the skin of the abdomen. Prophylactic subcutaneous low doses of standard heparin do not affect clotting rates and are safe and effective in patients at moderate risk. The first dose of the drug is administered 2 hours before surgery, and then every 12 hours after surgery for 6 days. Currently, in international clinical practice, preference is given to low molecular weight heparins, since they are more convenient to use, and the number of hemorrhagic complications is lower. For prophylactic purposes, one subcutaneous injection per day (the first injection should be given 12 hours before surgery) of such a drug, for example enoxaparin sodium at a dose of 20 mg at a moderate risk or 40 mg at a high risk of thromboembolic complications, is quite sufficient. It is fundamentally important to start prophylaxis before surgery, since in most patients thrombosis begins to form already on the operating table. Only in cases of danger of significant intraoperative bleeding, heparin prophylaxis can be started several (usually 6) hours after the completion of the surgical intervention.

An alternative recommendation for patients in this group is intermittent pneumatic compression, which should be initiated on the operating table prior to surgery and continued until the end of bed rest. This method of accelerating blood flow is advisable to use in patients with a high risk of bleeding and the risk of hemorrhages. This method of preventing deep vein thrombosis is the main one during neurosurgical and ophthalmic interventions, in which even minimal hemorrhage poses a huge risk, and anticoagulants significantly increase this risk.

With a high risk of thrombotic complications, it is advisable to combine the prophylactic administration of anticoagulants with methods for accelerating venous blood flow in the lower extremities.

After surgery, direct anticoagulants should be prescribed for at least 7-10 days. Their introduction is necessary until the complete mobilization of the patient. The need for long-term pharmacological prophylaxis may arise with persistent risk factors (impossibility of full recovery of physical activity, chemotherapy, estrogen therapy, etc.). In these cases, low molecular weight heparins are used or oral anticoagulants are used. In the immediate postoperative period, the appointment of indirect anticoagulants is not recommended due to the high frequency of hemorrhagic complications, at the same time, such drugs are successfully used in the late postoperative period, as well as in patients not undergoing surgical interventions.

In special cases (surgical intervention in patients with thrombosis of the ileocaval segment or on the background of pulmonary embolism), in addition to prescribing the above funds, consideration should be given to implanting a removable cava filter or plicating the inferior vena cava.

When determining the indications for surgery in each patient, it is always necessary to take into account the risk of surgery, including the likelihood of complications. The need for preoperative prevention of complications is currently beyond doubt: it saves the life and health of many patients. Preventing possible complications can seem like a very time-consuming and very expensive “pleasure”, since it requires certain costs. However, the treatment of developed complications is much more expensive and not always effective. That is why their prevention should be included in the treatment standards for all surgical clinic patients without exception.

A simplified system for assessing the severity of the condition and prognosis (SAPS)

(J.-R. Le Gall et al., 1984). Table 3. 1.

Glasgow Coma Scale* Table3. 2.

Predicting the probability of a lethal outcome by the systemSAPS.

Table3 . 3.

Risk Factors for Cardiovascular Complications

Table 3. 4.

The degree of risk of cardiovascular complications

(H. H. Weitz and L. Goldman, 1987) Table 3.5.

The risk of developing cardiac complications in various

types of surgery

(Eagle K. A. et al, 1996) Table 3. 7.

Dose of insulin in 500 ml of 10% glucose solution

at various blood glucose levels Table 3. 8.

The degree of contamination of the operation area

with various types of surgical interventionsTable 3.9.

Risk scale for infectious complications in the surgical area

Table 3. 10.

Risk index for infectious complications in the surgical area

and indications for prophylactic antibiotics

Table3 . 12.

Risk factors for gastrointestinal bleeding

(Cook D.J., 1994) Table 3. 13.

Risk levels for acute venous thrombosis

in surgical patients Table3 . 14.

* Minor operations: non-abdominal, less than 45 min.

Major surgeries: abdominal surgeries and all others

lasting more than 45 minutes.

** Risk increases with: infection, varicose veins, general

immobility.

Prevention of thromboembolic complications

at various degrees of risk Table 3. 15.

*These measures should be carried out in all patients without exception.