Contraindications for surgical treatment. Contraindications for anesthesia What are relative contraindications for surgery

Childbirth is the most natural and most unpredictable process. Even a woman who becomes a mother not for the first time cannot predict exactly how her child will be born. There are many cases when a woman, despite the plans of doctors, gave birth safely on her own, but it happens that successful, at first glance, childbirth ended in an emergency caesarean section. Let's find out what are the indications (and contraindications) for a caesarean section.

Elective caesarean section

There is a division into absolute and relative indications for this operation.

Absolute indications for planned caesarean section

Absolute indications for caesarean section include reasons when natural childbirth is impossible or carries a very high risk to the health of the mother or fetus.

narrow pelvis

Sometimes the anatomical structure of a woman does not allow the child to pass through the pelvic ring: the size of the mother's pelvis is smaller than the presenting part (usually the head) of the child. There are criteria for the size of a normal and narrow pelvis according to the degree of narrowing.

With an anatomically very narrow pelvis:

• III-IV degree, the operation will be carried out in a planned manner;
• II degree of narrowing, the decision will be made during childbirth;
• I degree childbirth will take place naturally in the absence of other indications.

Mechanical obstacles interfering with natural childbirth

This may be uterine fibroids in the isthmus (i.e., in the area where the uterus passes into the cervix), ovarian tumors, tumors and deformities of the pelvic bones.

Threat of uterine rupture

It most often occurs when there is a scar on the uterus, for example, due to a previous caesarean section, as well as due to numerous previous births, when the walls of the uterus are very thin. The consistency of the scar is determined by ultrasound and its condition before and during childbirth.

placenta previa

Sometimes the placenta is attached in the lower third and even directly above the cervix, blocking the fetus's exit. This is fraught with severe bleeding, dangerous for the mother and child, and can lead to placental abruption. Diagnosed by ultrasound, the operation is prescribed for a period of 33 weeks of pregnancy or earlier if blood discharge is detected, indicating placental abruption.

In these cases, it is necessary to perform an operative delivery using a caesarean section, regardless of all other conditions and possible contraindications.

Relative indications for surgery

Chronic diseases of the mother

Cardiovascular diseases, diseases of the kidneys, eyes, diseases of the nervous system, diabetes mellitus, oncological diseases - in a word, any pathologies that can worsen during contractions and attempts. Such conditions include exacerbation of diseases of the genital tract (for example, genital herpes) - although childbirth in this case does not significantly aggravate the condition of the woman, but when passing through the birth canal, the disease can be transmitted to the child.

Certain complications of pregnancy that threaten the life of the mother or child.

The possibility of delivery through caesarean section is offered in severe forms of preeclampsia with dysfunction of vital organs, especially the cardiovascular system.

Recently, pregnancy after prolonged infertility or after in vitro fertilization has become a relative indication for delivery through caesarean section. Women who are carrying a long-awaited child are sometimes so worried because of the fear of losing him that, in the absence of physical disorders, they cannot “tune in” to the birth process in any way.

Malposition

Rupture of the anal sphincter in history

large fruit

A large child is considered to be a child whose birth weight is 4 kilograms or more, and if its weight is more than five kilograms, then the fetus is considered gigantic.

Emergency caesarean section

Sometimes the impossibility of spontaneous childbirth becomes known only at the time of contractions. Also during pregnancy, situations may arise when the life of the mother and the unborn child is at risk. In these cases, an emergency delivery by caesarean section is performed.

Persistent weakness of labor activity

If natural childbirth goes without progress for a long time, despite the use of medications that enhance labor activity, then a decision is made on a caesarean section.

Premature placental abruption

Separation of the placenta from the uterus before or during childbirth. This is dangerous both for the mother (massive bleeding) and for the child (acute hypoxia). An emergency caesarean section is being performed.

Presentation and prolapse of the umbilical cord

Sometimes (especially with the baby's foot presentation), the umbilical cord or its loops fall out before the widest part of the baby is born - the head. In this case, the umbilical cord is clamped and, in fact, the child is temporarily deprived of blood supply, which threatens his health and even life.

Clinically narrow pelvis

Sometimes, with normal dimensions of the pelvis at the time of childbirth, it turns out that the internal ones still do not correspond to the size of the fetal head. This becomes clear when there are good contractions, there is an opening of the cervix, but the head, with good labor activity and attempts, does not move along the birth canal. In such cases, they wait about an hour and, if the baby's head does not move forward, an operation is recommended.

Premature (before contractions) rupture of amniotic fluid in the absence of the effect of cervical stimulation

With the outpouring of water, regular labor can begin, but sometimes contractions do not begin. In this case, intravenous stimulation of labor is used with special preparations of prostaglandins and oxytocin. If there is no progress, then a caesarean section is performed.

Anomalies of labor activity that are not amenable to drug exposure

The operation has to be resorted to if the strength of the contractions is insufficient, and they themselves are very short.

Acute fetal hypoxia

In childbirth, the condition of the child is controlled by the heartbeat (the norm is 140-160 beats per minute, during labor - up to 180 beats per minute). The deterioration of the heartbeat indicates hypoxia, that is, a lack of oxygen. An emergency caesarean section is required to prevent intrauterine death of the child.

Previously undiagnosed threat of uterine rupture

The contractions are frequent and painful, the pain in the lower abdomen is permanent, the uterus does not relax between contractions. When the uterus ruptures, the mother and child show signs of acute blood loss.

Contraindications for caesarean section

There are no absolute contraindications to a caesarean section - after all, this is often the only way to preserve the health and life of a woman and her child.

However, there are contraindications in which a caesarean section is undesirable.

Fetal Health Problems

If it becomes clear that it is impossible to save the child (intrauterine fetal death, severe prematurity, malformations leading to early postnatal death of the child, severe or long-term fetal hypoxia), then the choice is made in favor of the mother's health, and natural delivery as opposed to traumatic surgery.

High risk of purulent-septic complications in the postoperative period

These include infections of the birth canal, purulent diseases of the abdominal wall; amnionitis (inflammation of the fetal membranes of an infectious nature).

Whether a pregnant woman needs a caesarean section can only be judged by the doctor observing her!

In any case, remember, no matter how your baby was born, naturally or through a caesarean section, it is important that both he and his mother are healthy!

Indications for surgery are divided into absolute and relative.

Absolute readings The operation considers diseases and conditions that pose a threat to the life of the patient, which can only be eliminated surgically.

Absolute indications for performing emergency operations are otherwise called "vital". This group of indications includes asphyxia, bleeding of any etiology, acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, acute pancreatitis, perforated gastric and duodenal ulcer, acute intestinal obstruction, strangulated hernia), acute purulent surgical diseases (abscess, phlegmon, osteomyelitis, mastitis, etc.).

In elective surgery, indications for surgery can also be absolute. In this case, urgent operations are usually performed, not postponing them for more than 1-2 weeks.

The following diseases are considered absolute indications for a planned operation:

Malignant neoplasms (cancer of the lung, stomach, breast, thyroid, colon, etc.);

Stenosis of the esophagus, the output of the stomach;

Mechanical jaundice, etc.

Relative indications for surgery include two groups of diseases:

Diseases that can be cured only by a surgical method, but not directly threatening the life of the patient (varicose saphenous veins of the lower extremities, uninjured hernia of the abdomen, benign tumors, cholelithiasis, etc.).

Diseases that are quite serious, the treatment of which can in principle be carried out both surgically and conservatively (ischemic heart disease, obliterating diseases of the vessels of the lower extremities, peptic ulcer of the stomach and duodenum, etc.). In this case, the choice is made on the basis of additional data, taking into account the possible effectiveness of a surgical or conservative method in a particular patient. According to relative indications, operations are performed in a planned manner under optimal conditions.

There is a classic division of contraindications into absolute and relative.

To absolute contraindications include a state of shock (except for hemorrhagic shock with ongoing bleeding), as well as an acute stage of myocardial infarction or cerebrovascular accident (stroke). It should be noted that at present, if there are vital indications, it is possible to perform operations against the background of myocardial infarction or stroke, as well as in case of shock after stabilization of hemodynamics. Therefore, the allocation of absolute contraindications is currently not fundamentally decisive.

Relative contraindications include any concomitant disease. However, their impact on the tolerability of the operation is different.

Urinary retention (inability to empty the bladder after at least one catheterization attempt);
- repeated massive hematuria due to BPH;
- renal failure due to BPH;
- bladder stones due to BPH;
- repeated urinary tract infections due to BPH;
- large bladder diverticula due to BPH.

Radical surgery for BPH performed by transurethral or open approach should be performed routinely after a complete clinical examination.

Many patients try to delay the operation by any means, enthusiastically meeting each new remedy for the conservative treatment of BPH. Often they neglect the relative indications for surgery and wait for absolute indications, one of which, the most common, is acute urinary retention. For this reason, almost every third patient with BPH begins treatment with a suprapubic urinary fistula for acute or chronic urinary retention. The presence of infravesical obstruction is an indication for surgical treatment.

The "gold standard" in the treatment of BPH worldwide is transurethral resection of the prostate. The use of epidural anesthesia has dramatically reduced the number of contraindications for surgical treatment. TUR is performed in patients whose prostate volume reaches up to 60 cubic meters. see. With a larger volume, which is measured by ultrasound with a rectal sensor, an open operation is indicated - adenomectomy.

At one time in the literature, the idea was carried out about the viciousness and inadmissibility of cystostomy, although now we can say with confidence that in a number of patients this operation is absolutely indicated. It is necessary for the removal of patients from the state of intoxication and for the sanitation of the urinary tract, as well as for the preoperative preparation of the patient (heart, lungs, etc.). The effect of cystostomy exceeds all the inconveniences associated with the temporary presence of suprapubic drainage.

When a patient presents with acute urinary retention and the diagnosis of BPH is established (after a rectal examination), we recommend that the surgeon on duty decide on the possibility of a radical operation in the near future. If there are no contraindications for TUR or adenomectomy, the patient should be referred for radical surgery as soon as possible. We do not recommend catheterization of the bladder for more than two days, as infection of the urethra and bladder occurs, which significantly complicates the postoperative period. If there are contraindications for performing a radical operation (state of the cardiovascular system, lungs, signs of renal failure, urinary tract infection), cystostomy, possibly puncture, should be performed and appropriate preoperative preparation should be performed.

Surgery remains the best and only choice for patients who developed serious complications of BPH. However, the analysis of long-term results after surgery shows that up to 25% of patients are not satisfied with the treatment, since they still have many symptoms of the manifestation of the disease. Almost every fourth patient after TUR notes frequent urination, 15.5% do not retain urine, and residual urine is determined in 6.2% of patients (Savchenko N. E. et al., 1998). A noticeable decrease in symptoms after surgical treatment is observed mainly in patients with severe forms of the disease and severe obstructive symptoms. In this regard, at the 2nd meeting of the International Conciliation Committee on the Problem of BPH (Paris, 1993), the following absolute indications for surgical treatment were defined: urinary retention (inability to empty the bladder after at least one catheterization attempt), repeated massive hematuria due to BPH, renal failure due to BPH, bladder stones due to BPH, recurrent urinary tract infections due to BPH, large bladder diverticula due to BPH.

In other cases, conservative therapy may be indicated, one of the types of which is drug treatment. It should be noted here that in the asymptomatic course of benign prostatic hyperplasia, the method of "cautious waiting" is fully justified, subject to an annual follow-up examination.

With the help of different types of anesthesia, surgeons can perform long and complex surgical interventions in which the patient does not feel any pain. Before carrying out any operation, it is necessary to conduct a complete examination of the patient in order to identify contraindications to anesthesia.

The main contraindications for general anesthesia

General anesthesia can be of three types: parenteral (intravenous), mask or endotracheal and combined. During general anesthesia, the patient is in a state of deep medical sleep and does not feel pain. For those patients who cannot be given this type of anesthesia, the anesthesiologist selects another anesthesia or the attending physician tries to cure them with conservative methods.

The anesthesiologist decides on the type of anesthesia for the patient

Below is a list of diseases in which general anesthesia is strictly prohibited:

1. Diseases of the cardiovascular system such as:

• acute and chronic heart failure;
• unstable angina, or exertional angina;
• acute coronary syndrome or myocardial infarction in history;
• congenital or acquired defects of the mitral and aortic valves;
• atrioventricular block;
• flickering arrhythmia.

1. Diseases of the kidneys and liver - are a ban for parenteral and combined general anesthesia, among them:

• acute and chronic liver or kidney failure;
• viral and toxic hepatitis in the acute stage;
• cirrhosis of the liver;
• acute pyelonephritis;
• glomerulonephritis.

1. Foci of infection in the body. If possible, the operation should be postponed until the infection is completely cured. It can be abscesses, cellulitis, erysipelas on the skin.
2. Respiratory system diseases such as atelectasis, pneumonia, obstructive bronchitis, emphysema, and respiratory failure. Also a contraindication is a cough with ARVI, due to laryngitis or tracheitis.
3. Terminal states, sepsis.

Diseases of the cardiovascular system are a contraindication to anesthesia

There is also a group of contraindications for children under one year old. It includes such diseases:

• rickets;
• spasmophilia;
• vaccination within two weeks prior to surgery;
• purulent diseases of the skin;
• childhood viral diseases (rubella, chickenpox, measles, mumps);
• elevated body temperature without an established cause.

Contraindications for spinal and epidural anesthesia

Spinal and epidural anesthesia is a type of regional anesthesia. In spinal anesthesia, the doctor injects the anesthetic directly into the spinal canal, at a level between the 2nd and 3rd lumbar vertebrae. At the same time, it blocks sensory and motor functions below the injection level. During epidural anesthesia, the anesthetic is injected into the epidural space, that is, not reaching the structures of the spinal canal. In this case, the area of ​​​​the body that is innervated by the nerve roots passing at the injection site is anesthetized.

In spinal and epidural anesthesia, the drug is injected into the spinal canal

Contraindications to these methods of regional anesthesia:

• Infectious diseases of the skin at the site of the proposed injection.
• Allergy to local anesthetics.

If the patient has a history of episodes of Quincke's edema or anaphylactic shock that occurred after the use of a local anesthetic, this type of anesthesia is categorically contraindicated! Moderate or severe scoliosis. With this pathology, it is technically difficult to perform this procedure and identify the injection site.

• Patient refusal. During surgical interventions using epidural or spinal anesthesia, the patient is conscious. He does not fall asleep during the operation. And there are times when people are afraid of such surgical interventions.
• Decreased arterial blood pressure. With hypotension, it is dangerous to carry out these types of anesthesia, since there is a risk of collapse.
• Violation of blood clotting. With hypocoagulation, this type of anesthesia can lead to the development of internal bleeding.
• Atrial fibrillation and atrioventricular blockade of the third degree.

Contraindications for local anesthesia

During local anesthesia, the anesthetic is injected locally into the area of ​​the planned operation. This type of anesthesia is most often used in anesthesiology. It is also used in surgery, when opening abscesses and felons, sometimes in gynecological and abdominal operations, when there are strict contraindications to other methods of anesthesia.

Local anesthesia is used on the part of the body that will be operated on

Local anesthesia should not be used in such cases:

1. With allergic reactions to local anesthetics. Before conducting local anesthesia, it is better to do an allergy test. In this way, the doctor can save the life of the patient and protect himself.
2. In acute renal failure, since these drugs are excreted by this organ.
3. When planning a long operation. The average time of action of a local anesthetic is 30-40 minutes. With repeated administration of the drug, there is a risk of overdose.

Before carrying out any surgical intervention, it is necessary to conduct a complete laboratory and instrumental examination of the patient to identify possible contraindications to anesthesia. If there are contraindications, the doctor, together with the anesthesiologist, chooses another method of anesthesia or tries to cure the patient with conservative methods.

Indications for surgery for Fallot's tetrad are actually absolute. All patients are subject to surgical treatment, especially in infants and patients with cyanosis, surgical intervention should not be postponed. Cyanosis, the sharpest hypertrophy of the right ventricle of the heart, continuously occurring changes in the anatomy of the right ventricle, its outlet section, in the structure of the lungs - all this necessitates the possible early surgical intervention, primarily in young children. If the defect proceeds with pronounced cyanosis, frequent dyspnea-cyanotic attacks, disturbances in general development, an urgent operation is indicated.

Contraindications to surgery are anoxic cachexia, severe cardiac decompensation, severe concomitant diseases.

Methods of surgical interventions

In the surgical correction of Fallot's tetrad, its radical correction is widely used, as well as palliative operations for certain indications.

The meaning of palliative operations (there are more than 30 types) lies in the creation of intersystem anastomoses to eliminate the deficit of blood flow in the pulmonary circulation.

Palliative operations allow the patient to survive the critical period, eliminate total arterial hypoxemia, increase the cardiac index, and under certain conditions contribute to the growth of the trunk and branches of the pulmonary artery. An increase in pulmonary blood flow increases

of course - diastolic pressure in the left ventricle, thereby contributing to its development before a radical correction of the defect.

Palliative bypass surgery improves the capacitive-elastic properties of the pulmonary arterial bed with an increase in the elasticity of the pulmonary vessels.

Among bypass palliative operations, the most common are:

1. subclavian - pulmonary anastomosis according to Blelock - Taussig (l 945) (Nobel Prize in 1948). It is the classic and most commonly used in the clinic. To apply it, synthetic linear prostheses Gore are used - Tech

2. anastomosis between the ascending aorta and the right branch of the pulmonary artery (Coogy - Waterston, 1962). This is an intrapericardial anastomosis between the posterior wall of the ascending aorta and the anterior wall of the right branch of the pulmonary artery

3. anastomosis between the trunk of the pulmonary artery and the aorta (Potts - Smith - Gibson, 1946)

When performing bypass operations, an important task is to create an adequate size of the anastomosis, since the degree of reduction in arterial hypoxemia is proportional to the amount of pulmonary blood flow. The large size of the anastomosis quickly leads to the development of pulmonary hypertension and. and small ones - to its rapid thrombosis, therefore, the optimal size of the anastomosis is 3-4 mm in diameter.

Operations are performed on a beating heart, access - anterior-lateral left-sided thoracotomy in the 3rd - 4th intercostal space.

Currently, palliative operations are considered as a stage of surgical treatment of patients with severe forms of the defect. They are not only a necessary measure, but also prepare the patient for a radical correction of the defect. However, the positive effect of palliative surgery is not permanent. With an increase in the duration of the existence of intersystemic anastomoses, deterioration in the condition of patients was absolutely reliably noted. This is associated with the development of hypofunction or thrombosis of the anastomosis, with the development of deformation of the branch of the pulmonary artery on the side of the anastomosis, often with the occurrence of pulmonary hypertension, the possible manifestation of bacterial endocarditis, the progression of pulmonary stenosis up to the development of occlusion of the outflow tract from the right ventricle. This leads to an increase in cyanosis, a deepening of polycythemia, and a decrease in arterial blood oxygen saturation. Over time, the question arises of a second palliative operation or a radical intervention, and these manifestations are indications for their implementation.

The use of endovascular surgery (balloon angioplasty, stenting, bougienage of residual stenoses) has become of particular importance in the preparation of patients at all stages of the surgical treatment of the defect, especially in recent years.

at the level of the mouth of the anastomosis, elimination of stenosis of the pulmonary artery valve, embolization of large aorto-pulmonary collateral anastomoses (BALKA).

Radical correction of TF, both initially and after palliative surgery, is a complex but effective surgical intervention. Currently, the emphasis in the surgical treatment of TF is shifted towards radical surgical intervention at an earlier age, including the neonatal period, due to the development and improvement of methods for ensuring the safety of open heart surgery (anesthesiology, EC, cardioplegia, intensive care and resuscitation).

Radical correction of TF consists in elimination of stenosis or reconstruction of the right ventricular outflow tract and closure of the ventricular septal defect. In cases of previously imposed intersystemic anastomosis - its elimination at the very beginning of the operation before connecting the heart-lung machine by isolating and tying or suturing the anastomosis from the lumen of the corresponding pulmonary artery.

A radical operation is performed under conditions of hypothermic cardiopulmonary bypass (28-30 degrees), pharmaco-cold or blood cardioplegia.

Elimination of stenosis of the outflow tract from the right ventricle: in 90 - 95% of cases, there is a need to expand the output section of the right ventricle, and therefore its longitudinal ventriculotomy is indicated. Infundibular stenosis of the right ventricle is revised, hypertrophied muscles are widely excised. Valvular stenosis is eliminated by dissecting the fused leaflets along the commissures. With a sharply changed valve, the elements of the latter are excised. To expand the outlet section, xenopericardial patches with an implanted monocusp are used, the dimensions of which vary (No. 14 - No. 18) in each case.

Closure of a ventricular septal defect. In TF, perimembranous and less often subaortic VSD is more common, which is closed with a synthetic or xenopericardial patch, fixing it to the edges of the defect both with separate U-shaped sutures on Teflon pads, and with a continuous suture.

How is the adequacy of defect correction assessed? For this purpose, pressure is measured in the inlet and outlet sections of the right ventricle, in the trunk and right pulmonary artery. The adequacy of the correction is assessed by the ratio of systolic pressure in the right and left ventricles. It should be no more than 0.7. High residual pressure in the right ventricle dramatically increases postoperative mortality.

Adequately performed radical correction of the defect allows to normalize intracardiac hemodynamics, increase physical

working capacity and already a year after the operation up to 75% - 80% of the norm for healthy children.

Recent studies indicate that even with good results, latent heart failure is detected in the long term, due to prolonged arterial hypoxemia affecting delicate structures in vital organs (in particular, in cardiomyocytes). From this follows an important practical conclusion that children should be operated on at an early age, in any case up to two years. Unsatisfactory results of the operation are due to incomplete correction of the defect, VSD recanalization, and hypertension in the pulmonary artery system.