Local anesthesia in surgery. Anesthesia in outpatient surgery: indications, application, consequences The concept of local anesthesia and its types

Local anesthesia (aka local anesthesia) is the anesthesia of a certain part of the body in various ways while maintaining the patient conscious. It is mainly used for small operations or examinations.

Types of local anesthesia:

regional (for example, with appendicitis, etc.);
pudendal (during childbirth or after);
according to Vishnevsky or case (various methods of application);
infiltration (injections);
application (using ointment, gel, etc.);
superficial (on mucous membranes).

What will be the choice of anesthesia depends on the disease, its severity and the general condition of the patient. It is successfully used in dentistry, ophthalmology, gynecology, gastroenterology, in surgery for operations (opening boils, suturing wounds, abdominal operations - appendicitis, etc.).

From general anesthesia, local anesthesia during surgery is distinguished by ease of use, a minimum of side effects, a quick “withdrawal” of the body from the drug, and a small likelihood of any consequences after using the anesthetic.

Terminal anesthesia

One of the simplest types of local anesthesia, where the goal is to block receptors by cooling tissues (rinsing, wetting). It is widely used in the examination of the gastrointestinal tract, in dentistry, ophthalmology.

An anesthetic drug is moistened with a skin area at the site of the operated surface. The effect of such anesthesia lasts from 15 minutes to 2.5 hours, depending on the chosen agent and on what its dose will be. Its negative effects are minimal.

Regional anesthesia

With this type of anesthesia, a blockade of the nerve plexuses and the nerves themselves in the area of the operation is achieved. Regional anesthesia is divided into types:

Conductor. Often used in dentistry. With conduction anesthesia, the drug is injected with a thin needle near the nerve node or trunk of the peripheral nerve, less often into the nerve itself. The anesthetic is injected slowly so as not to damage the nerve or tissue. Contraindications for conduction anesthesia - children's age, inflammation in the area of needle insertion, sensitivity to the drug.
Epidural. The anesthetic is injected into the epidural space (the area along the spine) through a catheter. The drug penetrates to the roots and nerve endings of the spinal cord, blocking pain impulses. It is used for childbirth or caesarean section, appendicitis, groin surgery, chest or abdomen pain relief. But with appendicitis, this anesthesia takes time, which is sometimes not there.

Possible consequences, complications: decreased pressure, back pain, headache, sometimes intoxication.

Spinal cord (spinal). The anesthetic is injected into the subarachnoid space of the spinal cord, the analgesic effect is triggered below the injection site. It is used in surgery during operations on the pelvic area, lower extremities, with appendicitis. Complications are possible: pressure decrease, bradycardia, insufficient analgesic effect (in particular, with appendicitis). It all depends on how competently the procedure was carried out, which drug was selected. Also, with appendicitis, local anesthesia may be contraindicated (in case of peritonitis).

Note: sometimes, instead of using general anesthesia for appendicitis in the initial stage, laparoscopic surgery is possible.

Contraindications for spinal anesthesia: skin diseases at the injection site, arrhythmia, patient refusal, increased intracranial pressure. Complications - meningitis, transverse myelitis, etc.

Infiltration anesthesia

Typically, infiltration anesthesia is used in maxillofacial surgery and dentistry, sometimes in acute appendicitis. With the introduction of the drug into soft tissues or the periosteum, a blockade of receptors and small nerves occurs, after which it is absolutely painless for the patient, for example, teeth are removed. Infiltration anesthesia involves the following methods:

direct: the drug is injected into the area necessary for surgical intervention;
indirect: involves the same introduction of an anesthetic, but into the deeper layers of tissues, captures the areas adjacent to the operated one.

Such anesthesia is good because its duration is about an hour, the effect is achieved quickly, there is not a large amount of painkiller in the solution. Complications, consequences - rarely allergic reactions to the drug.

Anesthesia according to A. V. Vishnevsky (case)

This is also local infiltration anesthesia. An anesthetic solution (0.25% novocaine) directly begins to act on nerve fibers, which gives an analgesic effect.

How anesthesia is carried out according to Vishnevsky: a tourniquet is tightened above the operated area, then a solution is injected under pressure in the form of tight novocaine infiltrates until a “lemon peel” appears on top of the skin. Infiltrates "creep", gradually merge with each other, filling the fascial cases. So the anesthetic solution begins to affect the nerve fibers. Vishnevsky himself called such anesthesia "the method of creeping infiltration."

Case anesthesia differs from other types in that there is a constant alternation of a syringe and a scalpel, where the anesthetic is always one step ahead of the knife. In other words, an anesthetic is injected, a shallow incision is made. It is necessary to penetrate deeper - everything repeats.

The Vishnevsky method in surgery is used both for minor operations (opening wounds, abscesses) and for serious ones (on the thyroid gland, sometimes with uncomplicated appendicitis, amputation of limbs and other complex operations that cannot be performed by people with a contraindication to general anesthesia). Contraindications: intolerance to novocaine, disorders of the liver, kidneys, respiratory or cardiovascular system.

Pudendal anesthesia

It is used in obstetrics for suturing damaged soft tissues after childbirth. It is done by inserting a needle 7-8 cm deep on both sides between the posterior commissure and ischial tuberosity. Together with infiltration, it gives an even greater effect, therefore, instead of general anesthesia in such cases, operations have long been performed under local anesthesia.

Application anesthesia

An anesthetic drug is applied to the surface of the skin or mucous membranes without the use of injections. Ointment (often Anestezin ointment), gel, cream, aerosol - this set of anesthetics gives the doctor the choice of which pain medication to use. Disadvantages of application anesthesia: it does not have a deep effect (only 2-3 mm in depth).

It is used to ensure the painlessness of the subsequent injection (especially in dentistry). It is done at the request of patients who are afraid of pain: a gel (ointment) is applied to the gum or the skin or mucous membrane is sprayed with an aerosol. When the anesthetic takes effect, a deeper anesthetic injection is given. A side effect of application anesthesia is a possible allergic reaction to an aerosol, ointment, gel, cream, etc. In this case, other methods are needed.

Anesthesia for blepharoplasty

Local anesthesia is also used in some operations in plastic surgery. For example, with blepharoplasty - correction of the upper or lower eyelid. Before the correction, the patient is first intravenously injected with some kind of sedative, which gives a dulling of the perception of what is happening during the operation. Further, according to the points marked by the surgeon, injections are made around the eyes and operated on. After the operation, a decongestant ointment is recommended for the eyelids.

With laser blepharoplasty (eyelid smoothing), superficial anesthesia is also used: an ointment (gel) is applied to the eyelids and treated with a laser. At the end, a burn ointment or antibiotic ointment is applied.

The patient may also ask for general anesthesia for blepharoplasty if he experiences a whole range of negative emotions and fear of the upcoming operation. But if possible, it is better to carry it out under local anesthesia. Contraindications for such an operation are diabetes, cancer, poor blood clotting.

Anesthetic drugs

Preparations for local anesthesia are divided into types:

Complex ethers. Novocain, dikain, chlorprocaine and others. They must be administered carefully: side effects are possible (Quincke's edema, weakness, vomiting, dizziness). Complications are possible mainly local: hematoma, burning, inflammation.
Amides. Articaine, lidocaine, trimecaine, etc. These types of drugs have practically no side effects. Consequences and complications are practically excluded here, although a decrease in pressure or disturbances in the central nervous system are possible only in case of an overdose.

One of the most common anesthetics is lidocaine. The remedy is effective, long-acting, successfully used in surgery, but the consequences and complications from it are possible. Their types:

rarely - a reaction to lidocaine in the form of a rash;
swelling;
breathing difficulties;
rapid pulse;
conjunctivitis, runny nose;
dizziness;
vomiting, nausea;
visual impairment;
angioedema.

Indications for local anesthesia

If it is necessary to perform a minor operation, doctors often advise to solve the problem under local anesthesia in order to prevent some negative consequences. But there is also a whole set of specific indications for it:

the operation is small, it can be performed under local anesthesia;
refusal of the patient from general anesthesia;
people (usually the elderly) with diseases due to which general anesthesia is contraindicated.

Contraindications

There are reasons when it is impossible to operate under local anesthesia (negative consequences and complications may appear). Types of contraindications:

internal bleeding;
drug intolerance;
scars, skin diseases that impede infiltration;
age under 10 years;
mental disorders.

Under such conditions, only general anesthesia is indicated for patients.

Local anesthesia - what is it? This is the name of short-term, but strong pain relief, which occurs as a result of the interaction of soft tissue with an anesthetic (pain reliever).

Every day, doctors use such anesthesia for a variety of operations. It has a lot of characteristic features that you should know about.

What is local (local) anesthesia?

Another medically correct name for this procedure is local (local) anesthesia.

Usually it is used when carrying out minor, but rather painful operations, which would be quite difficult for a person to endure without additional anesthesia.

Areas of contact with an anesthetic agent - a skin area over which medical or cosmetic manipulations are planned, as well as other areas located under the epidermis layer.

The most commonly used injection method of local anesthesia. With this introduction, the active substance reaches the surface of the soft tissue, although in some situations a deeper immersion of the anesthetic is required.

The injection method uses extremely small syringes that have thin needles. Therefore, the injection will be quite painless, and will not cause the patient much discomfort and fear.

Types of anesthesia

Local anesthesia is most often used during operations. There are several types that have a different principle and mechanism of action on the human body.

Blockade of peripheral nerves

This method of anesthesia is very widely used in practice during the operation, as well as for a short period after it. It can be used as an independent pain relief technique, as well as in combination with other techniques.

The main principle of blockade of peripheral nerves is the injection of the necessary substance into the “right” place on the human body.

The active component of the analgesic is concentrated around the nerve endings, and acts directly on them.

Blockade of peripheral nerves can be performed only on an empty stomach, and only after verbally informing the patient, and his written consent.

Anesthesia of spinal roots

There are two main types of this anesthesia - spinal and epidural anesthesia. They are of the conductor type.

The main principle of action is to block the roots of the spinal cord without directly affecting its functionality.

Before conducting them, the doctor must conduct a psychological preparation for the patient without fail.

Spinal and epidural anesthesia have a lot in common.

These two types of anesthesia can be used as local, combined, and also (for example, when performing a caesarean section in women during artificial labor).

The second name for epidural anesthesia is epidural. How is local anesthesia done?

When the patient is guided through a catheter in the spine, an anesthetic will be injected. After that, the human body will be insensitive to pain for some time.

It is used to anesthetize the chest, groin, abdominal cavity, and legs. It is extremely rare to anaesthetize the area of the arms and neck, and never to anaesthetize the head.

Spinal anesthesia in its methodology is very similar to epidural. An interesting feature of this type of anesthesia is that it is carried out in the supine or sitting position, and during the operation the patient has the opportunity to communicate directly with the doctor.

Contraindication to epidural anesthesia, except for age, is height less than 150 cm.

Other types of local anesthesia

There are other types of local anesthesia:

Blocking of the receptor apparatus and its branches (terminal anesthesia, etc.).
Blocking the sensitive apparatus of a certain part of the limb by impregnating the operated tissue with an analgesic.

How does an analgesic work?

What to choose - local or general anesthesia? If the operation is simple, and the patient does not show signs of significant mental anxiety, then the doctor will prescribe him local anesthesia.

Before using local anesthesia, read about all its types in more detail, find out the difference between local and general anesthesia.

The teaching aid has been prepared in accordance with the State Educational Standard of Higher Professional Education in the specialty "Medicine". It defines the goal (learning the topic, presents literature sources recommended for self-preparation for classes, provides a block of information that contains generalized material on the topic, presents situational tasks, control questions, test programmed control that can be used when preparation for the lesson and to control the level of knowledge.

This teaching aid is intended for 3rd year students and teachers in the study of the topic "Local anesthesia" in the course of general surgery.

Editor: Doctor of Medical Sciences, Professor, Head of the Department of General Surgery, Yaroslavl State Medical Academy. Larichev Andrey Borisovich.

Reviewer: Candidate of Medical Sciences, Associate Professor, Head of the Department of Anesthesiology and Resuscitation of the Yaroslavl State Medical Academy Zabusov Alexey Viktorovich.

I. INTRODUCTION

Local anesthesia is one of the safest methods of anesthesia. With the development and widespread introduction of general anesthesia into clinical practice, its role has somewhat decreased. However, it is widely used in outpatient surgery. It occupies a worthy place in endoscopic examinations.

Local anesthesia, especially such types as spinal, epidural anesthesia, anesthesia of the brachial plexus, has firmly established itself among the main methods of modern anesthesia. If in the 50-70s of the last century, with the development and widespread introduction into clinical practice of general anesthesia, the role of local anesthesia decreased, then the last decade was marked by an unprecedented interest in it both in our country and around the world. This is explained by the development of new surgical technologies - reconstructive operations on the limbs and prosthetics of large joints, endoscopic operations in urology and gynecology, and new approaches to postoperative, obstetric, chronic pain, incl. in cancer patients. In all these areas of medicine, local anesthesia is the most effective and physiological, corresponding to modern concepts of proactive analgesia. At the same time, its progress is also associated with the emergence of new effective local anesthetics (bupivacaine, ropivacaine, etc.), disposable special low-traumatic needles for spinal anesthesia, thermoplastic epidural catheters and bacterial filters, which increased the reliability and safety of local anesthesia. , allowed to use it in children's practice and day surgery.

Local anesthesia by the method of creeping infiltration and novocaine blockades have a long and well-deserved tradition in domestic surgery thanks to the work of Academician A.V. Vishnevsky. In Yaroslavl, well-known surgeons Professor G.A. Dudkevich, A.K. Shipov. Distinguished by safety, relative simplicity and efficiency, these types occupy a worthy place in outpatient surgery, endoscopic examinations, in the diagnosis and treatment of surgical diseases and injuries. As a component of general anesthesia, local anesthesia is successfully used to block reflexogenic and shockogenic zones in the surgical area, reducing the body's need for general anesthetics and increasing the patient's protection from surgical trauma. This is especially important with modern approaches to surgery in oncology, with multiple injuries, when surgery is performed simultaneously on several organs.

In this regard, mastering the technique of local anesthesia, determining indications and contraindications for local anesthesia for the diagnosis and treatment of various diseases is currently relevant,

2. LESSON OBJECTIVE

To acquaint students with a modern view of local anesthesia, with its role and significance in practical surgery; to study the methods of local anesthesia, indications and contraindications for its implementation; to acquaint students with the main types of novocaine blockades.

3. SELF TRAINING

A. PURPOSE

AFTER LEARNING THE TOPIC THE STUDENT SHOULD KNOW

The role and importance of local anesthesia in surgical practice.
Types of local anesthetics.
Methods of surface anesthesia and indications for its use.
Infiltration anesthesia, preparations, features of the method and the role of domestic scientists in their development.
Conduction anesthesia, its features.
Spinal, epidural anesthesia, its technique.
The concept of novocaine blockades, types of novocaine blockades, indications for their use.
Mistakes, dangers and complications arising from the use of local anesthesia

AFTER STUDYING THE TOPIC, THE STUDENT SHOULD BE ABLE TO

Collect instruments for local infiltration anesthesia.

Lay the patient down for spinal and epidural anesthesia,

Lay the patient down for cervical vagosympathetic blockade according to A.V. Vishnevsky. Find the projection of the needle prick for the blockade.

Lay the patient down for lumbar novocaine blockade according to A.V. Vishnevsky. Find the projection of the needle prick for the blockade.

B. LITERATURE

L.V. Vishnevsky. Local anesthesia by the method of creeping infiltrate. Medgiz. 1942.

V.K. Gostishchev. General surgery. Moscow. Medicine 2001.

G.A.Dudkevich. Local anesthesia and novocaine blockade. Yaroslavl. 1986.

A.K. Shipov. Blockade of nerve nodes and plexuses. Yaroslavl, -; 1962.

Guide to anesthesiology. Edited by A.A. Bunatyan. M., "Medicine", 1996.

J. Morgan, M. Mikhail. Clinical anesthesiology, parts 1,2. M-SPb. 1999-2000 "

regional anesthesia. Return to the future. Collection of materials. Ed. A.M. Ovechkin. M. 2001

B. BLOCK OF INFORMATION

Humanity has long sought to alleviate suffering by all means. The ancient Egyptians, Chinese, Romans, Greeks used mandrake alcohol tincture, poppy decoction, and opium for pain relief. In Egypt, even before our era, crocodile fat mixed with the powder of its skin was used for local anesthesia, Memphis stone powder mixed with vinegar was applied to the skin. In Greece, a bitter root was used, a tourniquet was applied to compress tissues.

In the 16th century, Ambroise Pare received a decrease in pain sensitivity by compressing the nerves. Bartholinius in Italy and the Napoleonic surgeon Larrey used the cold to reduce soreness during surgery. In the Middle Ages, "sleepy sponges" were used, impregnated with Indian hemp, henbane, hemlock, mand-ragora.

Local anesthesia during surgical interventions received its "development after the work of our domestic scientist V.K. Anrep (1880). He studied the pharmacological properties of cocaine in experimental animals, pointed out its ability to cause anesthesia and recommended the use of cocaine in operations on people. Provodnikova anesthesia for operations on the finger was used by Lukashevich and Oberet (1886).A.V. Orlov used a 0.25-0.5% solution of cocaine for local infiltration anesthesia (1887). cocaine to infiltrate tissues during surgery.Brown (1887) suggested adding adrenaline to a solution of cocaine under local anesthesia to reduce bleeding from a wound and make it difficult for cocaine to be absorbed into the blood.Beer used spinal anesthesia in 1898. Eichhorn's discovery in 1905 of novocaine was met with great positively.

In the twenties, a significant contribution to the development and implementation of the method of spinal anesthesia in surgery was made by the largest domestic surgeon S.S. Yudin, successfully using it in surgical interventions that were difficult for that time.

A.V. Vishnevsky (1923-1928) developed a simple, affordable method of local anesthesia based on the principle of creeping infiltrate. The method was used with equal success in large and small operations for pure and purulent diseases. After the publication of his works, local anesthesia began to be used in almost all surgical interventions, both in our country and abroad.

A.V. Vishnevsky showed that hydraulic preparation of tissues allows better orientation in the vessels and nerves, better understanding of the anatomical relationships of tissues in the area of the surgical field. Layer-by-layer impregnation of tissues with novocaine solution takes time and waiting until anesthesia occurs. A solution of novocaine is injected slowly, when the tissues are cut, a significant part of the solution is removed with napkins and tampons. Practice has shown that with correctly performed anesthesia, the waiting time is the most minimal, more often, immediately after anesthesia, the operation is started.

In parallel with the development of methods of local anesthesia, there was an intensive study of the physiology and pathology of pain, the mechanisms of the formation of pain syndrome. At present, the important role of pain impulses from the surgical wound, which, having arisen during the operation, leaves a trace in the form of a long-term excitation of the neurons of the dorsal horns of the spinal cord, which is the basis for maintaining postoperative and chronic pain, has been established. It has been shown that the performance of operations of increased traumatism under general anesthesia, the use of strong narcotic analgesics after them (morphine, dilidolor) does not eliminate this impulsation. It, like a kind of "bombardment", attacks the spinal cord, disabling the physiological mechanisms of the body's own pain (antinociceptive) defenses. The use of local anesthesia under these conditions before surgery, and its maintenance in the postoperative period, makes it possible to reliably block this impulse, while maintaining the mechanisms of antinocicepsia. An illustration of these ideas is the operation of amputation of a limb with an inevitable injury to the nerve nerve trunks during neurotomy. Performing it under anesthesia without local anesthesia of the nerve trunks increases the frequency of occurrence of such a serious and difficult-to-treat complication as phantom pain after surgery. Back in 1942, the outstanding domestic neurosurgeon N.N. Burdenko in his monograph "Amputation as a neurosurgical operation" pointed out the importance and necessity of blocking the nerve trunks with local anesthetics before their intersection. Lacking modern for us ideas about the pathophysiology of postoperative pain, he, thanks to his clinical experience and intuition, approached the correct solution of a complex problem.

With a new approach to surgical pain, the concept of proactive analgesia has been formed. It provides for the creation of a full-fledged analgesia before the onset of the action of a painful stimulus. The stronger the pain effect, the more important is the blocking of pain impulses by local anesthetics before it reaches the neurons of the spinal cord. Narcotic analgesics administered intravenously block pain impulses mainly at the supraspinal level and cannot be considered as the only and reliable means of protecting the operated patient from pain.

PREPARATIONS FOR LOCAL ANESTHESIA

Anesthetics or local anesthetics include novocaine, trimecaine, lidocaine, mercocaine, swarms of willow caine, pyromecaine, etc. Anesthetics differ from other painkillers in that they act mainly on the peripheral receptor apparatus: spinal nerve roots, sensory nerve fibers and finishing them. Turning off the sensitivity under the action of anesthetics occurs in a known sequence. First, pain sensitivity disappears, then olfactory, gustatory, temperature and tactile.

Methods of administration of anesthetic substances: dermal, subcutaneous, regional, infiltration, epidural, epidural, spinal, conduction,

ganglionic, endoneural, paraneural. paravertebral, parasacral, transsacral, intra-arterial, intravenous and intraosseous. The most common method of administering an anesthetic is infiltration. Local anesthesia is used not only during operations, but also in the form of novocaine blockades.

NOVOCAINE ( novocainum)

p-Diethylaminoethyl ester of para-aminobenzoic acid hydrochloride.

Colorless crystals or odorless white crystalline powder. Let's very easily dissolve in water (1:1), we will easily dissolve in alcohol (1:8).

Novocaine is a local anesthetic drug. In terms of its ability to cause surface anesthesia, it is less active than cocaine, but much less toxic, has a greater breadth of therapeutic action and does not cause the phenomena of drug addiction characteristic of cocaine. In addition to the local anesthetic effect, novocaine, when absorbed and directly injected into the blood, has a general effect on opi-anism: it reduces the formation of acetylcholine and lowers the excitability of peripheral cholinergic systems, has a blocking effect on the autonomic ganglia, reduces spasms of smooth muscles, lowers the excitability of the heart muscle and the excitability of the motor areas of the cerebral cortex. In the body, novocaine is relatively quickly hydrolyzed, forming para-aminobenzoic acid and diethylaminoethanol.

Novocaine is widely used for local anesthesia, mainly for infiltration and spinal anesthesia. For infiltration anesthesia, 0.25-0.5% solutions are used; for anesthesia according to the method of A.V. Vishnevsky, a 0.125-0.25% solution is used; for conduction anesthesia - 1-2% solutions; for epidural anesthesia - 2% solution (20-25 ml), for spinal anesthesia - 5% solution (2-Zml).

When using novocaine solutions for local anesthesia, their concentration and amount depend on the nature of the surgical intervention, the method of application, the condition and age of the patient. It must be taken into account that with the same total dose of the drug, the toxicity is higher, the more concentrated the solution is. To reduce absorption into the blood and prolong the action of novocaine, a 0.1% solution of adrenaline hydrochloride according to I calla per 25 ml of novocaine solution is usually added to it.

LIDOCAINE ( Lidocainum)-

a-Diethiamino-2,6-i methyl acetanilide hydrochloride.

White crystalline powder, easily soluble in water and alcohol. amide type anesthetic,

Unlike novocaine, it is not an ester, it is metabolized more slowly in the body and has a longer effect. Trimeca-in belongs to the same group of local anesthetics. Lidocaine is a strong local anesthetic that causes all types of local anesthesia: terminal, infiltration, conduction. Compared to novocaine, it acts faster, stronger and longer. The relative toxicity of lido canna depends on the concentration of the solution. In fry concentrations (0.1%), its toxicity does not differ from the toxicity of novocaine, but with an increase in concentration to I -2%, toxicity increases by 40-50%.

TRIMECAIN ( Trimecainiim)

a-Diethiamino-2,4,6-trimethylacetanilide hydrochloride.

White or white with a slight yellow tint crystalline powder, which is easily soluble in water and alcohol.

In terms of chemical structure and pharmacological properties, tri-mecaine is close to lidocaine. It is an active local anesthetic, causes rapidly onset, deep and prolonged infiltration, conduction, epidural, spinal anesthesia; in higher concentrations (2-5%) causes superficial anesthesia. Trimecaine has a stronger and longer-lasting effect than novocaine. It is relatively less toxic, does not irritate.

PYROMECAINE ( pyromecainum)

2,4,6 - Trimethanilide - 1 - butyl - pyrrole idinecarboxylic -2 - "acid hydrochloride.

White or white with a slight creamy tint crystalline powder. Easily soluble in water and alcohol.

This drug is used in ophthalmology as a 0.5-2% solution, as well as in the study of the bronchi.

MARKAIN (BUPIVAKAIN)

A modern local anesthetic of the amide type, which contributed to the widespread use of local anesthesia. It is characterized by a slow onset of action compared to lidocaine, but a prolonged analgesic effect (up to 4 hours). It is used for all types of local anesthesia, most often for conduction, spinal and prolonged epidural anesthesia, incl. for postoperative pain relief. In eye surgery, it is used for retrobulbar anesthesia and anesthesia of the pterygopalatine ganglion. Causes predominantly blockade of sensory nerve fibers rather than motor ones. With accidental intravenous administration, it has a cardiotoxic effect, which is manifested by a slowdown in conduction and a decrease in myocardial contractility. Available in ampoules with 0.25%, 0.5% and 0.75% solutions.

ROPIVACAIN (naropnn)

A new local anesthetic homologue of bupivacaine. It retains its positive properties, but its cardiotoxicity is more pronounced. It is mainly used for conduction, epidural, epidural-sacral anesthesia. So, anesthesia of the brachial plexus with a 0.75% solution of ropivacaine occurs after 10-25 minutes and lasts more than 6 hours. For epidural anesthesia, 0.5-1.0% solution is used.

LOCAL ANESTHESIA BY THE METHOD OF CREEPING INFILTRATION ACCORDING TO A.V. VISHNEVSKY

The skin, subcutaneous tissue, and then deeper tissues are infiltrated with a novocaine solution. With infiltration anesthesia, tissues are stratified (hydraulic preparation). Creeping infiltrate consistently spreads, capturing all tissues, penetrates to the nerve endings and trunks.

For infiltration anesthesia, A.V. Vishnevsky proposed the following solution:

Novocaine - 2.5

Sodium chloride - 5.0

Potassium chloride - 0.075

Calcium chloride - 0.125

Adrenaline - 1:1000.0-X drops

Distilled water - 1000.0

The novocaine solution exhibits an analgesic effect, sodium chloride maintains isoionic, calcium has a stimulating effect on the body, reduces tissue swelling, potassium improves the functioning of the heart muscle, increases the permeability of the sheaths of nerve fibers, and therefore the novocaine solution penetrates better.

The simplicity of the method of anesthesia, the safety and non-toxicity of the drug contributed to the widespread introduction of this type of anesthesia. In addition, novocaine solution contributes to the normalization of metabolism and improves nervous trophism.

The advantage of the method of infiltrative anesthesia is as follows: harmless to the body, simple technique and methodology, most patients with various diseases can be operated on, hydraulic preparation of tissues is provided, which contributes to more careful handling during surgery, novocaine solution improves tissue trophism, the percentage of postoperative complications.

Anesthesia technique

Under sterile conditions, a syringe needle is injected, a 0.25% solution of novocaine is injected, the skin is tightly infiltrated until it turns white (a sign of capillary compression) and until “goose skin” (“lemon peel”) is formed. A second injection is made along the edge of this infiltrate, and so the infiltration continues throughout the site of the proposed operation. Then a tight infiltration of the subcutaneous tissue and deeper tissues is carried out. During the operation, the infiltration of tissues with a solution of novocaine continues as the tissues are cut.

The course of local anesthesia

The first period is the production of anesthesia.

The second period is waiting for 5-10 minutes.

The third period is complete anesthesia, lasting 1-2 hours (subject to re-infiltration as the tissues separate).

The fourth period is the restoration of sensitivity.

With local anesthesia, pain sensitivity is turned off, muscles relax at the injection site of novocaine. Local anesthesia is an anti-shock measure.

All complications associated with infiltration anesthesia can be divided into three degrees.

First degree: pale skin, cold sweat, dizziness, general weakness, dilated pupils, increased heart rate, nausea, weakened breathing.

Second degree: motor agitation, fear, hallucinations, convulsions, delirium, vomiting, increased heart rate, drop in blood pressure and weakening of breathing.

Third degree: frequent pulse of weak filling, arrhythmia, intermittent breathing, dilated pupils, loss of consciousness, convulsions.

Prevention of complications consists in applying a tourniquet to the anesthetized limb in order to reduce the absorption of novocaine solution. When excited, sedatives are prescribed. In severe cases, carry out artificial respiration, artificial ventilation of the lungs; with a deterioration in cardiac activity, caffeine, water-soluble cardiac glycosides can be administered.

TYPES OF ANESTHESIA

The isolation method of anesthesia according to R.R. Vreden is achieved by introducing an anesthetic solution along the incision line and somewhat wider.

Circle Anesthesia: An anesthetic is injected in a diamond shape surrounding the intended incision site. The method was developed by Hackenbruch in 1900.

Case anesthesia according to A.V. Vishnevsky is carried out by introducing a solution of novocaine under the skin, subcutaneous tissue and sequentially into muscle cases. With case anesthesia, less novocaine is consumed than with cross-sectional anesthesia, which significantly reduces intoxication.

Presacral anesthesia according to A.V. Vishnevsky, the skin and subcutaneous tissue are anesthetized in the middle between the coccyx and the buttocks and behind. Having felt the anterior surface of the sacrum with the end of the needle, 150-200 ml of novocaine solution is injected like a tight infiltrate, which "moisturizes" all the roots emerging from the holes in the sacrum.

Conduction (regional) anesthesia is carried out by bringing the anesthetic substance to the sensitive nerve perineurally, endoneurally or near the nerve. The most commonly used method is the perineural method. The nerve is surrounded by membranes, and weak solutions of novocaine do not have enough effect on it. Therefore, I-2% solutions of novocaine are often used in an amount of 20-30 ml.

Intercostal anesthesia is performed at a point located in the middle of the distance from the spinous processes of the thoracic vertebrae to the inner edge of the scapula. Starting from the first rib, a needle prick is made and a 0.25-0.5% novocaine solution is injected into the skin. Consistently this technique is repeated in each intercostal space. Intercostal anesthesia is used for fractured ribs and other severe chest injuries.

Spinal anesthesia (spinal, subarachnodal) is currently one of the main methods of anesthesia and is widely used in both traditional and endoscopic operations on the lower extremities, their joints and vessels, the pelvis, perineum, colon, in urology, gynecology in operative obstetrics. From the standpoint of proactive analgesia, it is advisable to combine it with general anesthesia against the background of mechanical ventilation during extensive and traumatic operations. For the first time, spinal anesthesia was performed by Beer in 1898, injecting cocaine into the subanachnoid space using a needle he proposed for this.

The mechanism of spinal anesthesia is based on segmental blockade of the posterior (sensory) and anterior (motor) roots of the spinal cord when a local anesthetic enters the cerebrospinal fluid, mixes with it, and lavages the roots. The blockade of the posterior roots causes complete analgesia, turning off temperature, tactile and proprioceptive sensitivity.

Since the anterior roots contain both motor fibers to skeletal muscles and sympathetic preganglionic fibers that maintain vascular tone, their blockade causes muscle relaxation and vasodilation. In cases of initial hypovolemia, the latter may be accompanied by a dangerous decrease in blood pressure, which requires intravenous administration of plasma substitutes and vasoconstrictors.

For spinal anesthesia, brands are used and, as an exception, novocaine. The time of its onset and duration depend on the type of local anesthetic. So, 5 ml of a 2% solution of novocaine cause anesthesia after 5 minutes lasting no more than 45 minutes, the same amount of lidocaine - a little more than 1 hour, with the introduction of 5 ml of a 0.5% solution of marcaine, anesthesia occurs after 10 minutes and lasts about 3 hours.

Perform spinal anesthesia in the position of the patient sitting or lying on his side. His head and back should be bent. The nurse must fix the position of the patient. At the level of the scallop line is the spinous process of the 1st lumbar vertebra. An injection is made after novocaine anesthesia under its spinous process, sometimes higher. The needle is placed between the spinous processes somewhat obliquely, taking into account the inclination of the spinous processes. Advance the needle slowly. With a puncture in the interspinal ligament, resistance is determined. Less resistance is determined by puncture of the dura mater. Mandrin should be removed after puncture of the interspinous ligament. A puncture of the dura mater feels like a puncture of parchment paper. When a liquid appears, it is necessary to stop the advance of the needle, attach a syringe with an anesthetic solution to it. Pump the cerebrospinal fluid into a syringe, then slowly inject the entire contents into the spinal canal. After that, the needle is removed, the injection area is treated, the patient is placed with his head up to prevent the anesthetic from flowing into the higher parts of the spinal cord. The standards of modern spinal anesthesia provide for the use of special disposable, especially thin needles (outer diameter of about 0.5 mm) - This causes less trauma to the dura mater, contributes to the rapid tightening of the post-puncture hole, preventing the outflow of cerebrospinal fluid into the epidural space and the appearance of headaches in patients.

Among other complications of spinal anesthesia, a significant spread of anesthesia upwards with a drop in blood pressure and respiratory disorders, urination disorders, and pain at the puncture site are possible.

Epidural anesthesia

The introduction of a solution, a local anesthetic, into the space between the yellow ligaments. the periosteum of the vertebrae and the dura mater causes its slow subshell penetration to the roots of the spinal cord, which, exiting between the vertebrae, are surrounded in the form of clutches by this meninges. Therefore, the development of symptoms of segmental root blockade with epidural anesthesia will be the same as with spinal anesthesia, but longer and requires a larger amount of anesthetic administered. So, with the epidural injection of 20 ml of a 2% solution of lidocaine, the full onset of anesthesia is observed no earlier than after 20 minutes, with its duration being about one and a half to two hours. The required duration of anesthesia (up to several days) can be achieved by administering maintenance doses of anesthetic through a catheter placed in the epidural space. Puncture and catheterization of the epidural space can be performed at different levels of the thoracic and lumbar spine, depending on the area of operation. For anesthesia, a 2% solution of lidocaine, a 0.5-0.75% solution of marcaine or naropin are used, trimecaine is used much less frequently. In order to avoid infection of the catheter during repeated administration of anesthetics, they are injected through a bacterial filter connected to the catheter.

This technique of prolonged epidural anesthesia has found wide application in various surgical interventions on the organs of the thoracic (including the heart) and abdominal cavity, pelvic organs, urinary organs, large vessels, both for operations and after them for the purpose of full anesthesia without narcotic analgesics, early restoration of intestinal motility, activation of the patient. It quite fully reflects the requirements for proactive analgesia, can be combined with both general and spinal anesthesia, can be carried out without turning off the patient's consciousness during surgery, or with turning it off, with spontaneous breathing and mechanical ventilation.

Out of connection with the operation, prolonged epidural anesthesia (blockade) is effective for chest injuries with multiple rib fractures, severe pancreatitis, peritonitis with severe intestinal paresis. In these conditions, it provides, in contrast to narcotic analgesics, not only complete pain relief without respiratory depression and coughing of the left reflex, but also blockade of sympathetic fibers, resulting in the elimination of vascular spasm, improvement of microcirculation, which leads to the restoration of impaired organ function . In addition, prolonged epidural anesthesia is used for labor pain relief, in the treatment of chronic pain in cancer and other diseases.

For epidural anesthesia, special Tuohy-type needles, labeled catheters, syringes, bacterial needles in sterile disposable packages are used. Like spinal anesthesia, it is performed under strict aseptic conditions. The position of the patient is sitting or lying down. After anesthesia of the skin, the needle is inserted between the spinous processes of the vertebrae to a depth of a fixed position, excluding its displacement from the center to the side. This position indicates the proximity of the needle to the yellow ligaments. A mandrin is removed from it, a sealed syringe with air is attached, which is constantly pressed while carefully moving the needle along with the syringe forward, feeling the air resistance to the piston. As soon as the needle passes through the entire thickness of the elastic yellow ligament and enters the epidural space, there is a loss of this resistance, a peculiar feeling of needle failure. This space is only 2-5 mm wide, partially filled with loose fatty tissue and veins that form plexuses. If the needle accidentally slips a little higher and damages the dura mater, then both the outflow of cerebrospinal fluid from the needle when the syringe is disconnected from it, and the entry of the anesthetic injected into the epidural space into the cerebrospinal fluid are possible, which is manifested by signs of spinal anesthesia. Therefore, to check the route of entry of the injected anesthetic through the needle, if no cerebrospinal fluid is released from it, a test dose of the anesthetic is injected, for example, 5 ml of a 2% lido-kaia solution, and its effect is observed for 5 minutes. If there are no signs of the onset of spinal anesthesia, a catheter is passed through the needle, the needle is removed and the anesthetic is injected fractionally (5 ml each) to the calculated dose and clinical effect of anesthesia.

Contraindications are the same as for spinal anesthesia.

Epidural-sacral anesthesia is caused by the introduction of an anesthetic solution through the sacral opening into the sacral canal. The anesthetic solution washes the sacral roots located in loose fiber. During epidural anesthesia, the position of the patient is knee-elbow. The hiatus sacra!is is felt for, a needle is inserted into this place, having previously anesthetized the skin and subcutaneous tissue. The needle is set at an angle of 20°, that is, in the projection of the passage of the sacral canal. Once in the hole, the needle is advanced 5 cm and 20 ml of a 2% solution of novocaine is injected.

NOVOCAINE BLOCKS

A.V. Vishnevsky considers novocaine blockade as the sum of the effects of a weak stimulus - novocaine solution on the peripheral and central nervous system. At the site of novocaine solution injection, inhibition occurs, blocking of nerve structures and slight irritation of the entire central nervous system, which affects the improvement of trophic function, especially in the focus of the pathological process. The use of blockades with a weak solution (0.25%) of novocaine in inflammatory diseases turned out to be very useful. In the phase of tissue edema after blockade, the inflammatory process may undergo a reverse development. In those observations where necrosis and suppuration have already developed, the infiltration of tissues around the purulent focus decreases, and the purulent focus is delimited earlier. Novocaine blockades are used for diagnostic and therapeutic purposes, as well as for the prevention of suppuration.

DELAYING RECOVERY

Cervical vagosympathetic blockade according to A.V. Vishnevsky

Cervical vago-sympathetic blockade by a closed method according to A.V. Vishnevsky is used for pleuropulmonary shock, severe injuries of the chest and its organs, during operations on the abdominal organs and in the postoperative period.

The blockade is performed on the operating table. The patient is placed on his back, turning his head in the opposite direction. A roller is placed under the shoulder blades, the hand on the side of the blockade is pulled down. The surgeon places the index finger of the left hand at the edge of the sternocleidomastoid muscle and displaces it and the organs of the neck inwards. The injection is made above the intersection of the muscle with the external jugular vein. First, a 0.25% solution of novocaine is injected into the skin with a thin needle, then a long needle is inserted through the resulting infiltrate, directed inwards and upwards, to the front surface of the spine. The needle is advanced inside, the posterior leaf of the vagina of the sternocleidomastoid muscle is pierced and 30-50 ml of a 0.25% solution of novocaine is injected in small portions of 2-3 ml, the syringe is often removed from the needle in order to avoid injury to large vessels. Lumbar (perinephric) novocannov blockade according to A.V. Vishnevsky

The blockade is carried out in the tissue surrounding the kidney by introducing novocaine in order to turn off a large number of nerve nodes, trunks and nerve endings and improve the regulatory function of the nervous system in the blockade zone.

The patient is laid on his side, with a roller placed under the lower back. A thin needle infiltrates the angle between the long muscles of the back and the 12th rib. Through the resulting infiltrate, a long needle is injected perpendicularly, with a prerequisite in front of the solution jet, a needle is inserted into the tissues, the posterior leaf of the renal fascia is pierced. The jet of novocaine starts to go very easily, and after the control removal of the syringe, the liquid does not flow back through the needle. This is an indicator of the correct insertion of the needle into the parsfrium. Introduced from 60 to 120 ml of 0.25% novocaine solution.

Among the complications that can occur during a parasphral blockade, it should be noted that the solution enters the kidney (in this case, the piston goes tight and blood enters through the needle); getting into a blood vessel (blood in a syringe); getting into the large intestine (intestinal soda, gases come from the needle).

Paraperitoneal neocann blockade according to G.A. Dudkevich

All organs of the abdominal cavity are associated with certain segments of the spinal cord. After the blockade of 8-9-10-11 thoracic nodes, pain stops or sharply decreases in acute cholecystitis and pancreatitis. The injected novocaine solution into the preperitoneal tissue washes the nerve endings of the 6-7-8-9-10-11 intercostal nerves. The blockade is successfully used in acute pancreatitis, acute cholecystitis, stomach ulcers, and cholelithiasis.

The blockade is performed at a point that is 3-5 cm below the xiphoid process of the sternum in the midline. After the introduction of novocaine into the subcutaneous tissue, the aponeurosis is punctured along the white line of the abdomen. under which 120 ml of a 0.25% solution of novocaine is injected. Case novokannovy blockade of the limb The position of the patient - on the back. With a thin needle, an injection of the skin on the anterior surface of the thigh. The skin is infiltrated with novocaine solution. At the site of anesthesia, the skin is pierced and the needle is passed to the bone and 60 ml of a 0.25% solution of novocaine is slowly injected. The same is repeated on the back of the thigh. A solution of novocaine slowly penetrates all the branches of the fascial sheets, blocking the nerve pathways. In the same way, a case blockade of the shoulder is carried out. On the lower leg and forearm, novocaine is injected under the fascia. Up to 200 ml of a 0.25% solution of novocaine goes to the thigh, up to 150 ml to the lower leg and shoulder. Short Novocaine Nerve Blockade

A short novocaine block is the most common way to treat boils, carbuncles, mastitis and other purulent diseases. Near the focus of inflammation, an injection is made with a thin needle and a novocaine solution is injected into the skin. A thin needle changes to a longer one and 60-120 ml of a 0.25% solution of novocaine is injected under the inflamed focus. After the blockade, pain and swelling decrease. If there is no suppuration, then the inflammation can regress. Often, penicillin or another antibiotic is administered along with novocaine. This treatment is indicated for purulent diseases of low prevalence (furuncle, carbuncle, hydradenitis, lymphadenitis, lymphangitis).

In addition to the listed novocaine blockades, there are: blockade of the sciatic nerve according to Voyno-Yasenetsky, subpectoral blockade according to L.V. Maraev, blockade of the cardio-aortic reflexogenic zones according to A.K. Shilov and G.A. Dudkevich; blockade of the stellate and upper thoracic paravertebral sympathetic nodes according to A.K. Shipov and others.

D. STUDY QUESTIONS

The concept of local anesthesia, its role and significance in surgical practice
Types of local anesthetics, their pharmacodynamics and far makoka netika

3. Name the drugs that prolong the action of novocaine.

4. The role of domestic scientists in the development of local anesthesia methods.

5. Anesthesia by lubrication, irrigation. Indications, contraindications, technique.

6. Local infiltration anesthesia. Indications, contraindications, technique.

Conduction anesthesia. Indications, contraindications, technique of execution. The drugs used for its implementation.
Spinal and perndural anesthesia. Indications, contraindications, technique. Drugs used for their implementation.

9. The concept of novocaine blockades, types of novocaine blocks.

10. Technique for performing cervical vago-sympathetic novocaine blockade. Indications and contraindications for its use.

11. Technique for performing lumbar novocaine blockade. Indications and contraindications for its implementation.

What is conduction anesthesia according to Lukashevich-Oberst?
Technique for performing intercostal novocaine blockade.
Indications and contraindications for its use.
Mistakes, dangers and complications arising from local anesthesia.

E. SITUATIONAL TASKS

1. The patient has subcutaneous panaritium 111 fingers of the left hand. Your choice of local anesthesia. The technique of its implementation.

2. The patient has fractured ribs, cyanosis, pain, shortness of breath, rapid pulse. What type of novocaine blockade can be applied.

Z. The patient is to undergo a herniotomy. What type of local anesthesia can be applied. The technique of its implementation.

E. RESPONSE BENCHMARKS

1. The patient needs to perform conduction anesthesia of the finger with a 2% solution of novocaine according to the Lukashevich-Oberst method. (see text)

2. In case of multiple fracture of the ribs and the presence of a pleuro-pulm clinic of disgraced shock, it is necessary to perform a cervical, vago-sympathetic blockade according to the method of A.V. Vishnevsky (see text).

3. During the operation of hernia repair under local anesthesia, local infiltration anesthesia is performed with a 0.25% solution of novocaine according to the method of tight creeping infiltrate according to A.V. Vishnevsky, (see text).

4. TEST CONTROL OF PREPARATION FOR THE LESSON

Indicate the correct answers to the questions

1. Local anesthetics include:

a) Nitrous oxide

b) Fluorotan

c) Hexenal

d) Novocaine

e) Barbamnl

2. What concentration of novocaine is used for infiltration anesthesia?

d) 2.0%
e) 5.0%

3. What solution is used to prepare novocaine?

a) Glucose solution 5%.

b) Calcium chloride solution 10%.

c) Electrolyte solution.

d) distilled water.

4. Neck vago-sympathetic blockade is indicated for:

a) Traumatic shock.

b) Pleuro-pulmonary shock.

c) Tumors of the mediastinum.

d) Bronchial asthma.

5. For lumbar blockade use:

a) Novocaine 0.25%

b) Lidocanno t 3%

c) Trimecaine 2%

6. To prolong the action of novocaine use: a) Atropine.

b) Papaverine.

c) adrenaline.

d) morphine.

Strong pain stimuli very quickly lead to nervous and endocrine regulation and the development of shock.

Pain occurs with all types of injuries (mechanical, thermal, radiation), acute and chronic inflammation, organ ischemia.

Mechanical, thermal, chemical, biological factors, damaging the cells, lead to the appearance of biologically active substances (histamine, serotonin, acetylcholine) in the tissues.

These biologically active substances cause depolarization of pain receptor membranes and the appearance of an electrophysiological impulse. This impulse, along thin myelinated and non-myelinated fibers, as part of peripheral nerves, reaches the cells of the posterior horns of the spinal cord, from here the second neuron of pain sensitivity begins, ending in the thalamus, where the third neuron of pain sensitivity is located, the fibers of which reach the cerebral cortex. This is the classic, so-called lemniscal pathway for conducting pain electrophysiological impulses.

In addition to the lemniscal pathway for the transmission of pain impulses along the periarterial sympathetic plexuses and along the paravertebral sympathetic chain. The latter path conveys pain sensations from the internal organs.

In the transformation of electrophysiological impulses in the sensation of pain, the cells of the cerebral cortex and visual tubercles are important.

Conductors of pain sensitivity give collaterals and send electrophysiological impulses to the reticular formation of the brain stem, excite it and the hypothalamus, which is closely associated with it, where the higher centers of the autonomic nervous system and endocrine regulation are located.

Clinically, this is manifested by psychomotor agitation, increased blood pressure (BP), increased heart rate and respiration.

If a large number of impulses come from the periphery, then this quickly leads to depletion of the reticular formation of the brain stem and the pituitary-adrenal system, giving a classic picture of shock with the suppression of all vital functions and even death.

Pain of moderate intensity, but lasting for a long time, stimulating the reticular formation of the brain stem, leads to insomnia, irritability, irascibility, intestinal motility disorders, gallbladder, ureter, arterial hypertension, ulceration in the intestine, etc.

There are two ways to deal with pain: one is associated with blocking the conduction of pain electrophysiological impulses along peripheral nerves from some part of the body - local anesthesia, the second is based on blocking the transformation of an electrophysiological impulse into a pain sensation in the brain. With this method, the reticular formation, the hypothalamus is also blocked and consciousness is turned off - general anesthesia or anesthesia.

Local anesthesia.

Local anesthesia is the elimination of pain sensitivity in a certain area of \u200b\u200bthe body by reversibly interrupting impulses along sensory nerves while maintaining consciousness.

The history of the development of local anesthesia goes back to ancient times. Even Avicenna used the cooling of the limbs as an anesthetic. Ambroise Pare recommended compression of blood vessels and nerves to anesthetize the limbs. For the first time, the local anesthetic cocaine hydrochloride was used for anesthesia of mucous membranes in ophthalmology by Keller in 1884. Domestic surgeon Lukashevich suggested cocaine anesthesia of the fingers. However, cocaine is a strong toxic agent, which caused the death of several patients. In 1889 Beer proposed spinal anesthesia.

In 1905, Eingorn discovered novocaine, a drug that expanded the range of surgical interventions. A.V. Vishnevsky in 1923-28 developed the technique of novocaine anesthesia - "blunt creeping infiltrate", which later received the name of the author.

Local anesthesia requires the following conditions: clarification of contraindications, knowledge of anatomy, use of the necessary concentrations and amounts of anesthetic, consideration of possible complications.

Defeat pain, relieve suffering; Medicine has been "fighting" against the enemies of human health for centuries: diseases. Many of them are related to surgical diseases, which are accompanied by unbearable pain, which local anesthesia helps to cope with.

Local anesthesia is a temporary loss of pain sensitivity of tissues at the site of anesthesia due to the blockade of pain receptors and the conduction of impulses along sensitive fibers. In this article, we will consider the types and methods of local anesthesia that are used in modern medicine, and talk about drugs.

In ancient times, infusions, decoctions, alcohol, ice, dope, poppy, special soporific sponges were used for pain relief, that is, everything that could at least dull the feeling of pain. More than 150 prescription drugs were used in Italy. Only with the discovery of the anesthetic properties of cocaine did the birth of local anesthesia become possible. Its significant drawback was high toxicity and pronounced dependence. Novocaine was later synthesized, and in 1905 Eichhorn used it for local anesthesia. A significant contribution to the development of this anesthesia was made by our compatriot A.V. Vishnevsky, who developed case anesthesia.

Scope of local anesthesia

Local anesthesia is used in many branches of medicine.

Now it is difficult to say where local anesthesia is not used, since it is used in all branches of medicine:

dentistry (removal, prosthetics);
surgery (surgeries on limbs, lower abdominal cavity, opening of abscesses);
urology (kidney surgery, prostatectomy, urography);
gynecology and obstetrics (various gynecological operations, labor pain relief, caesarean section);
traumatology (almost all surgical interventions);
proctology (various operations);
gastroenterology (gastroscopy and probing);
ENT operations;
ophthalmic surgeries and many others.

This is not a complete list of areas of application of local anesthesia, as it is used almost everywhere. Most likely, each of us at least once in a lifetime faced with this type of anesthesia.

Types of local anesthesia

Surface or terminal. The medicine is applied to the skin or mucous membranes superficially in the form of an ointment, gel, spray. It is used in dentistry, urology, ophthalmology, in ENT diseases, in the treatment of burns, trophic ulcers, etc. Preparations: Lidocaine, Trimecaine, Anestezin, Dikain, Pyromecain in concentrations from 0.4% to 4%. In children, a special cream is used for painless vein puncture: Emla.

infiltration anesthesia. This type of anesthesia is based on the injection of an anesthetic in the area of the surgical field. First, a thin needle anesthetic is injected intradermally, forming a "lemon peel". After that, with a longer needle, tissue infiltration is performed in layers. Thus, the nerve endings in the operation area are blocked. For this type of anesthesia, solutions with a concentration of 0.125-0.5% are used. Anesthesia according to Vishnevsky involves the use of the creeping infiltrate method: when a "lemon peel" has formed, the surgeon tightly injects the anesthetic solution into the subcutaneous fat. This anesthesia is strictly layered. Preparations: Novocaine, Lidocaine, Trimecaine.

Conduction (regional) anesthesia. This anesthesia includes conduction (stem, paravertebral, nerve plexus), novocaine blockades, as well as central blockades: spinal, epidural and caudal. Blockade of the nerve plexuses (plexus) and trunks is carried out under ultrasound control or with the help of a neurostimulator. First, the necessary nerve formations that need to be blocked are identified, and then an anesthetic is injected perineurally, on average up to 40 ml. This anesthesia is therefore called regional, which allows you to anesthetize any part of the body: arm, leg, jaw, etc. It is mainly used for surgical interventions on the limbs (orthopedics, traumatology, vascular surgery, surgery), as well as in maxillofacial surgery. Intravenous and intra-arterial local anesthesia are used very rarely. In the practice of a family doctor, conduction anesthesia according to Lukashevich-Oberst and therapeutic novocaine blockades are most often used in surgical, neurological and traumatological patients. The following anesthetics are used: Novocaine, Lidocaine, Bupivacaine, Naropin.

Spinal anesthesia. This anesthesia consists in the introduction of an anesthetic solution into the subarachnoid space of the spinal cord, due to which the spinal roots are blocked and pain impulses do not enter the spinal cord. It was first described in 1899 by A. Beer; it went through periods of both pronounced popularity and unfair oblivion. With the advent of new drugs for local anesthesia, more advanced thin puncture needles and the prevention of possible complications, this method of anesthesia is widely used for anesthetic management of surgical operations. It is used for surgical interventions in surgery (mainly the lower abdominal cavity, lower limbs), hip joint, Caesarean section, some urological operations, and is also more preferable in the gerontological group of patients who do not tolerate general anesthesia. Dripps research in the early 1960s demonstrated the absolute safety of this method, contrary to the public opinion that after this type of anesthesia "legs will be taken away." It is also supported by the fact that this anesthesia is also performed in newborns without any harm.

epidural anesthesia. This type of anesthesia also applies to the central blockade. The effects of this anesthesia were appreciated in many branches of medicine (surgery, traumatology, obstetrics, urology), and the possibility of long-term anesthesia with a catheter made this type of anesthesia indispensable in the treatment of cancer patients. If spinal anesthesia gives a complete blockade with a good motor block, then epidural anesthesia gives a differentiated block: from analgesia (which is successfully used to treat pain syndromes) to deep anesthesia with a good motor block. The severity of anesthesia depends on the anesthetic, its concentration and dose. This type of anesthesia is used in many surgical interventions, it is indispensable as pain relief during childbirth and during Caesarean section, as well as for the treatment of chronic pain syndromes. The technique of epidural anesthesia boils down to the fact that the anesthetic is injected into the epidural space, which is one of the formations in the spinal cord, and the dura mater is not punctured. Drugs: Prilocaine, Lidocaine, Mepivacaine, Bupivacaine, Ropivacaine.

caudal anesthesia. This is a type of epidural anesthesia, only at the level of the sacrum. This anesthesia is indicated for surgical operations and obstetric manipulations on the perineum and anorectal zone. The drugs used are the same as for epidural anesthesia.

Preparations for local anesthesia

For regional and local anesthesia, special preparations are used: local anesthetics. They are divided into the following groups:

esters (Chlorprocaine, Novocaine, Dicaine, Tetracaine);
amides (Bupivacaine, Lidocaine, Ropivacaine, Mepivacaine, Prilocaine, Etidocaine).

Most often used for infiltration anesthesia according to A.V. Vishnevsky. In terms of strength of action, it is in many ways inferior to modern anesthetics. With inflammation (abscesses, phlegmon) it practically does not have its effect. The concentration of the solution used varies from 0.125% to 0.5%.

Dekain. 15 times stronger in its anesthetic properties than novocaine. For anesthesia of mucous membranes, the concentration of the solution is from 0.25% to 2% solutions. The drug is very toxic, not used for other types of anesthesia.

Lidocaine(xylocaine). The drug is several times more toxic than novocaine, but nevertheless it is 4 times more potent than it. It is used for terminal (10%), infiltration (0.25% -0.5%), conduction (1% -2%), epidural (1% -2%) anesthesia. Begins to act in 5-8 minutes, the duration of anesthesia is up to 2 hours with the addition of adrenaline.

Trimecain. Beginning of anesthesia in 10 minutes, duration 2-3 hours. Just like lidocaine, it is used for terminal (2% -5%), infiltration (0.25% - 0.5%), conduction (1% -2%), epidural (1% -2%) anesthesia.

Bupivacaine(marcain). It is the most powerful and long-acting anesthetic. Begins to act in 20 minutes, duration of action - up to 7 hours. At the end of anesthesia, analgesia persists for a long time. It is used for infiltration, spinal, epidural, conduction anesthesia. This drug allows you to get a differentiated block: from anesthesia to analgesia. The concentration of the solution used is from 0.25% to 0.75%.

Naropin. A modern long-acting anesthetic. Begins to act in 10-20 minutes, duration up to 10 hours. It is used for epidural, infiltration anesthesia, with blockade of nerve trunks and plexuses, postoperative analgesia. The concentration of the solution used is 0.75% -1%.

Ultracain. It is mainly used in dentistry. The action begins in a few minutes, lasts up to 2 hours. For dentistry, it is used in special carpools.

Indications for local anesthesia

Small abdominal operations, operations on soft tissues;
severe comorbidity;
refusal of the patient from general anesthesia;
gerontological (age) group of patients.

Contraindications for the use of local anesthesia

Refusal of the patient;
allergy to anesthetics;
mental illness;
large volume of operation;
cicatricial tissue changes in the area of surgical intervention.

Complications

Complications can occur both with infiltration anesthesia (which is most often performed by surgeons, without the participation of anesthesiologists), and with central blockades, which are performed exclusively by anesthesiologists in the operating room, where there is all the necessary equipment to help if something goes wrong. This is due to the toxicity of the anesthetic itself, as well as when it accidentally enters the vessel. The three most common types of complications are:

damage to the central nervous system (the patient has unmotivated anxiety, tinnitus appears, there may be