Anticholinergics are used for sedation because. Performing premedication as prescribed by the doctor. Chemical preparations of other groups

Premedication is the medical preparation of the patient for surgery and anesthesia. Depending on the purpose, premedication can be specific and nonspecific. Specific premedication is used in patients with comorbidities and aims to prevent exacerbation of chronic diseases before, during surgery and in the early postoperative period. For this, various drugs are used - glucocorticoids and bronchodilators in patients with bronchial asthma, antiarrhythmics - in patients with cardiac arrhythmias, antihypertensives - in patients with arterial hypertension and so on. Specific premedication can be prescribed both a month before surgery (for planned interventions) and 10 minutes before surgery (for emergency interventions). Nonspecific premedication is used in all patients undergoing surgery and anesthesia. The purpose of non-specific premedication is to relieve mental stress, provide rest for the patient before surgery, normalize the level of metabolic processes, which reduces the consumption of general anesthetics, prevents unwanted neurovegetative reactions, side effects narcotic substances, general and local anesthetics, reduces salivation, bronchial secretion and sweating. This is achieved by using a complex of pharmacological preparations with a potentiating effect - hypnotics, antihistamines, narcotic analgesics, tranquilizers, M-anticholinergics. Non-specific premedication can be prescribed both 3 days before surgery (for planned interventions) and 10 minutes before surgery (for emergency interventions). Premedication can also be planned (before planned operation), and emergency (before emergency operations).

It should be noted right away that with the compensated state of the main organs and systems, their special preparation for the operation is not required.

Cardiovascular system requires training if available

1. arterial hypertension

circulatory failure

heart rhythm disorder.

Respiratory organs must be specially prepared for

chronic bronchitis (bronchitis of smokers)

emphysema

pneumosclerosis

bronchial asthma

pneumonia

urinary system requires preparation for chronic kidney diseases (pyelonephritis, glomerulonephritis; urolithiasis), prostate diseases (prostatitis; adenoma, cancer); this may lead to acute delay urine early postoperative period.

Gastrointestinal tract. Some chronic diseases: gastric and duodenal ulcers complicated by stenosis, tumors are often accompanied by disorders of the protein, water-electrolyte, acid-base state and volume of circulating blood. In cases of stenosis, a violation of the passage of food through the gastrointestinal tract is possible - then enteral tube nutrition or adequate parenteral nutrition is necessary, and gastric lavage through the tube with its subsequent complete emptying.

An enema is given to prepare the bowel. An enema is the introduction of various liquids into colon through the anus. They are used to remove intestinal contents or introduce a substance into the intestine. To prepare the intestines before a planned operation, there are other preparation methods in which the patient takes a special solution with microelements through the mouth, Fortrans, Forlax preparations.

After premedication and appropriate preparation of the patient in horizontal position on a gurney, accompanied by a nurse, is served in the operating room.

Allocate direct and indirect premedication. Indirect premedication most often consists of two stages. In the evening, on the eve of the operation, hypnotics are administered orally in combination with tranquilizers and antihistamines. For particularly excitable patients, these drugs are repeated 2 hours before surgery.

Direct premedication is carried out for all patients 30-40 minutes before surgery. It is mandatory to include in premedication M - anticholinergics, narcotic analgesics and antihistamines.

M - anticholinergics It must be remembered that if it is planned to use cholinergic drugs (succinylcholine, halothane) during anesthesia or instrumental irritation respiratory tract(tracheal intubation, bronchoscopy), then there is a risk of bradycardia with possible subsequent hypotension and the development of more serious disorders heart rate. In this case, the appointment of premedication anticholinergic drugs (atropine, metacin, glycopyrrolate, hyoscine) to block vagal reflexes is mandatory.

Atropine.Metacin. Scopolamine. The anticholinergic properties of atropine can effectively block vagal reflexes and reduce secretion bronchial tree. However, drugs in this group are potentially dangerous for rhythm disturbances, with thyrotoxicosis. For premedication, atropine is administered intramuscularly or intravenously at a dose of 0.01-0.02 mg/kg, the usual dose for adults is 0.4-0.6 mg. In children, atropine is used in the same doses. To avoid the negative psycho-emotional impact on the child of intramuscular injection, atropine at a dose of 0.02 mg/kg can be given per os 90 minutes before induction. In combination with barbiturates, atropine can also be administered per rectum when used this method induction anesthesia.

Narcotic analgesics. Recently, the attitude towards the use of narcotic analgesics in premedication has changed somewhat. The use of these drugs began to be abandoned if the goal is to achieve a sedative effect. This is due to the fact that when using opiates, sedation and euphoria occur only in a part of patients. Others, however, may experience unwanted dysphoria, nausea, vomiting, hypotension, or some degree of respiratory depression. Therefore, opioids are included in premedication when their use may be beneficial. First of all, this applies to patients with severe pain syndrome. In addition, the use of opiates can enhance the potentiating effect of premedication.

Antihistamines. In order to prevent allergic reactions, blockers of histamine H 1 receptors are used. Diphenhydramine- has a pronounced antihistamine effect, sedative and hypnotic effects. As a premedication component, 1% solution is used at a dose of 0.1-0.5 mg/kg intravenously and intramuscularly.

Suprastin- has a pronounced antihistamine and peripheral anticholinergic activity, the sedative effect is less pronounced. Doses - 2% solution - 0.3-0.5 mg / kg intravenously and intramuscularly.

Tavegil- compared with dimedrol, it has a more pronounced and prolonged antihistamine effect, has a moderate sedative effect. Doses - 0.2% solution - 0.03-0.05 mg / kg intramuscularly and intravenously.

According to the indications, it is possible to introduce into premedication sleeping pills (barbiturates and benzodiazepines). Phenobarbital(luminal, sedonal, adonal). Long-acting barbiturate 6-8 hours. Depending on the dose, it has a sedative or hypnotic effect, an anticonvulsant effect. In anesthetic practice, phenobarbital is prescribed as a hypnotic on the eve of surgery at night at a dose of 0.1-0.2 g orally, in children a single dose of 0.005-0.01 g / kg.

tranquilizers - have psychosedative, hypnotic and potentiating effects. Diazepam(Valium, Seduxen, Sibazon, Relanium). Dose for premedication 0.2-0.5 mg/kg. It has a minimal effect on the cardiovascular system and respiration, has a pronounced sedative, anxiolytic and anticonvulsant effects. However, in combination with other depressants or opioids, it can depress the respiratory center. It is one of the most commonly used premedication in children. It is prescribed 30 minutes before surgery at a dose of 0.1-0.3 mg / kg intramuscularly, 0.1-0.25 mg / kg orally, 0.075 mg / kg - rectally. As an option for premedication on the table, intravenous administration is possible immediately before surgery at a dose of 0.1-0.15 mg / kg along with atropine.

Antipsychotics, giving a psychosedative effect. Droperidol. Antipsychotic from the group of butyrophenones. Neurovegetative inhibition caused by droperidol lasts 3-24 hours. The drug also has a pronounced antiemetic effect. For the purpose of premedication, it is used at a dose of 0.05-0.1 mg/kg IM. Standard doses of droperidol (without combination with other drugs) do not cause respiratory depression: on the contrary, the drug stimulates the response of the respiratory system to hypoxia. Although patients appear calm and indifferent after premedication with droperidol, in fact they may experience feelings of anxiety and fear. Therefore, premedication cannot be limited to the introduction of one droperidol.

The basis of modern premedication is the use of a tranquilizer that has all the properties listed above. An example of such a drug is Midazolam(dormicum, flormidal). For premedication, it is used at a dose of 0.05-0.15 mg/kg. After i / m administration, plasma concentration reaches a peak after 30 minutes. Midazolam is a drug widely used in pediatric anesthesiology. Its use allows you to quickly and effectively calm the child and prevent psycho-emotional stress associated with separation from parents. Oral administration of midazolam at a dose of 0.5-0.75 mg/kg (with cherry syrup) provides sedation and relieves anxiety by 20-30 minutes. After this time, the effectiveness begins to decline and after 1 hour its action ends. The intravenous dose for premedication is 0.02-0.06 mg/kg, intramuscularly - 0.06-0.08 mg/kg. Perhaps the combined introduction of midazolam - at a dose of 0.1 mg / kg intravenously or intramuscularly and 0.3 mg / kg rectally. Higher doses of midazolam may cause respiratory depression.

Before any operation, the patient must be examined by an anesthesiologist. In case of emergency operations, the anesthesiologist is invited immediately after the decision on the need for surgery is made. During a planned operation, the anesthesiologist usually examines the patient the day before, in the presence of aggravating factors - in advance. Preferably, the pre-examination and anesthetic management should be carried out by the same anesthesiologist.

1. OBJECTIVES OF THE PRE-OPERATIVE EXAMINATION BY THE ANESTHESIOLOGIST

• grade general condition,
• identification of features of the anamnesis associated with anesthesia,
• evaluation of clinical and laboratory data,
• determination of the degree of risk of surgery and anesthesia,
• choice anesthesia method,
• determination of the nature of the necessary premedication.

1. PREMEDICATION

1. SIGNIFICANCE OF PREMEDICATION

• decrease in emotional arousal;
• neurovegetative stabilization;
• decreased response to external stimuli;
• creation optimal conditions for the action of anesthetics;
• prevention allergic reactions on the means used in anesthesia;
• decreased secretion of glands.

1. BASIC DRUGS

• Hypnotics (barbiturates: etaminal sodium, phenobarbital, benzodiazepines: radedorm, nozepam, tazepam).
• Tranquilizers (diazepam, phenazepam). These drugs have a hypnotic, anticonvulsant, hypnotic and amnesic effect, eliminate anxiety and potentiate the action of general anesthetics, increase the threshold pain sensitivity. All this makes them the leading means of premedication.
• Antipsychotics (chlorpromazine, droperidol).
• Antihistamines(diphenhydramine, suprastin, tavegil).
• Narcotic analgesics (promedol, morphine, omnopon). Eliminate pain, have a sedative and hypnotic effect, potentiate the action of anesthetics.
• Cholinolytic agents (atropine, metacin). The drugs block vagal reflexes, inhibit the secretion of glands.

1. PREMEDICATION SCHEMES

1. On the night before - sleeping pills (phenobarbital - 2 mg / kg) and tranquilizer (phenazepam - 0.02 mg / kg).
2. In the morning at 7 am (2-3 hours before surgery) - droperidol (0.07 mg/kg), diazepam (0.14 mg/kg).
3. 30 minutes before surgery - promedol 2% - 1.0, atropine (0.01 mg/kg), diphenhydramine (0.3 mg/kg).

Premedication before surgery is the preparation of the patient for anesthesia and surgical intervention with the help of medicines and other methods.

Premedication in adults

The most common goals for premedication in adults include:

• reduction of fear
• sedation
• amnesia
• analgesia,
• prevention of aspiration pneumonia,
• prevention of postoperative nausea and vomiting (PONV),
• humidification of the respiratory tract,
• maintaining hemodynamic stability.

You must also remember about:

• reimbursement of the need for corticosteroids,
• bronchodilator therapy,
• prevention of infection, allergic reactions.

Algorithm for premedication in adults

BUT. It is necessary to conduct a complete preoperative examination. The best option premedication takes into account the individual needs of each patient, in some cases premedication is not required. In fact, an informative and reassuring visit by the anesthesiologist before surgery can significantly reduce the patient's fear and anxiety. The plan of anesthesia, the type of surgical procedure and its urgency, the patient's stay in the clinic or his outpatient status influence the choice of premedication, as well as the pharmacodynamics and pharmacokinetics of the drugs used.

B. It is necessary to consider the use in premedication:

• sedatives,
• analgesics,
• means of preventing postoperative nausea and vomiting,
• antibiotic therapy.

Before using sedatives, you need to get informed consent patient. Benzodiazepines (midazolam, diazepam, and lorazepam) reduce anxiety, induce sedation and antegrade amnesia, and are most commonly used for premedication. Despite the relative rarity of side effects, they can cause depression of the central nervous system and respiration, especially in combination with other sedatives. Diazepam and lorazepam can cause prolonged sedation.

Opioid analgesics (morphine, meperidine, and fentanyl) provide preoperative analgesia and sedation. Caution should be exercised when prescribing these drugs to patients with kidney failure. Side effects include respiratory depression, orthostatic hypotension, nausea and vomiting, slowing gastric emptying, spasm of the choledochoduodenal sphincter and itching. Must be applied carefully sedatives in the elderly, as well as in patients with intracranial pathology, impaired consciousness, limited cardiac and pulmonary reserve, with a threat of airway obstruction, with unstable hemodynamics, in patients with a full stomach. Non-steroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors reduce the need for analgesics in the postoperative period. However, the use of NSAIDs carries a risk of impaired platelet function.

Prevention of postoperative nausea and vomiting usually involves the use of a combination selective antagonists 5-HT 3 receptors (ondansetron and dolasetron), metoclopramide (cerucal), dexamethasone or scopolamine. The use of droperidol has declined significantly since the U.S. Food and Drug Administration (FDA) issued its warning in 2001 regarding this drug. Anticholinergic drugs cannot be recommended for the prevention of aspiration. Glycopyrrolate is prescribed primarily to reduce salivation; it is especially effective in operations on the respiratory tract and in the planned fiber optic.

Many patients routinely receive antibacterial drugs for prevention surgical infection; they should be administered 1 hour before incision to achieve maximum concentration and activity.

AT. Premedication may be prescribed for specific concomitant pathology including gastroesophageal reflux disease (GERD), ischemic disease heart disease (IHD), congenital/acquired heart defects, bronchial asthma, latex allergy.

Premedication should be considered to prevent aspiration pneumonia in patients high risk. Maximum effect inhibitors proton pump(omeprazole, lansoprozole) and H2 blockers -histamine receptors(ranitidine and famotidine) develops after 30 minutes. Oral homogeneous antacids (sodium citrate) raise the pH of the gastric contents immediately. Metoclopramide accelerates gastric emptying.

β-blockers should be considered in patients at risk of myocardial ischemia, as perioperative β-blockade reduces the risk of cardiovascular events and mortality. Clonidine and dexmedetomidine are a2-adrenergic receptor agonists that cause sedation and hemodynamic stabilization by reducing central sympathetic stimulation. In patients with heart defects, prosthetic valves, or pacemakers, prophylaxis of endocarditis should be considered before performing appropriate operations.

Patients with bronchial asthma preoperative inhalations of albuterol and/or ipratropium are indicated.

When caring for patients with allergic reactions to latex, it is not recommended to use latex products. In the case of a reaction, the appointment of antihistamines and corticosteroids is indicated.

G. Most premedication drugs are given orally (po) or IV. Intramuscular injections may be painful, and mucosal absorption is sometimes unpredictable. When inhaled, the action begins within a few minutes. Selecting an appropriate appointment time ensures maximum efficiency. Usually, drugs are administered p / o 60-90 minutes, intramuscularly - 30-60 minutes, intramuscularly 1-5 minutes before surgery.

Premedication in children

feature childhood is the presence of anxiety in the patient and his parents. Taking into account the patient's age, body weight, drug intake, history, it is necessary to eliminate fear, achieve adequate analgesia, amnesia, prevent aspiration, reduce airway secretion, and block autonomic (vegetative) reflexes. Most children are admitted without venous access, so most of premedication is carried out alternative ways. The oral route is generally well tolerated, but the rectal route is widely used in many clinics. Intranasal administration of drugs is worse tolerated. Intramuscular injections are painful but can be used in non-contact patients.

Algorithm of premedication in children

BUT. Children aged 6 months to 6 years are worried about being separated from their parents or are afraid of the upcoming operation (that is, pain). Children over 6 years of age have a different worry, they are afraid that they will be "euthanized" as a pet. Teenagers worry about appearance and fear of losing control. Psychological preparation(preoperative visit to the hospital or induction in the presence of parents) makes it possible to avoid taking anxiolytics. It is especially difficult to communicate with children who have previously had anesthesia and have memories of the operation; they may require more intense sedation. In patients with significant cardiopulmonary impairment, sedation may be contraindicated.

B. Midazolam usually causes calmness in children, allowing them to be separated from their parents, 10-15 minutes after administration. Sedative effects short-term, however, in combination with sevoflurane, delirium may occur. Diazepam has a long duration of action. Barbiturates cause hyperalgesia and may exacerbate preoperative pain. Thiopental and methohexital are drugs short action, but are not desirable for use in day hospital surgery. Ketamine provides sedation and analgesia, but may cause dysphoria and excessive salivation. At oral administration effective in children resistant to midazolam; at intramuscular injection most suitable for non-contact patients. It is usually used in combination with midazolam and atropine. Clonidine α 2 -agonist has an anxiolytic and sedative action. There is a perioperative decrease in heart rate (HR), the need for anesthetics, the intensity of postoperative pain and nausea, vomiting, but it is possible to develop prolonged sedation and slow awakening. For sedation in hyperactive children can be used antihistamines, such as:

• hydroxyzine,
• diphenhydramine,
• chlorphiniramine.

AT. Fentanyl, morphine, meperidine, and sufentanil are narcotic analgesics used for sedation and analgesia, but their use is limited side effects. The use of fentanyl tablets, the absorption of which is carried out through the mucous oral cavity may cause itching, nausea, vomiting, and respiratory depression. The use of non-opioid analgesics (acetaminophen, ibuprofen, ketorolac, dextramethorphan) during surgery can reduce the intensity of postoperative pain.

G. In children with a history of gastroesophageal reflux disease or with a full stomach, aspiration prophylaxis may be required. Homogeneous antacids (sodium citrate) increase pH gastric juice. H 2 -histamine blockers (cimetidine and ranitidine) also increase the pH of gastric juice. Metoclopramide accelerates gastric emptying, increases the tone of the lower esophageal sphincter (may be blocked by atropine), relaxes the pyloric sphincter, and has antiemetic properties.

D. Anticholinergics (glycopyrrolate, atropine, scopolamine) are given to prevent bradycardia (associated with laryngoscopy and intubation, surgery, or succinylcholine) or to reduce airway secretions. These drugs can cause tachycardia, dry mouth and hyperthermia.

E. Antiemetics prevent postoperative nausea and vomiting. The 5-HT receptor antagonists metoclopramide and dexamethasone are more effective when used in combination than when taken alone.

AND. Children receiving glucocorticosteroid therapy for more than 7 days in the last 6 months require perioperative administration of glucocorticosteroids. Asthmatic patients are recommended to be treated with albuterol before anesthesia.

Premedication

is a direct drug preparation to prevent adverse effects anesthesia and surgery itself. She is final stage preoperative preparation conducted by a nurse. In each case, depending on the age and condition of the patient and the type of anesthesia chosen. However, in without fail it should include the following groups of drugs: sedative (sleeping pills, tranquilizers, neuroleptics ), antihistamines, parasympatholytics (M - anticholinergics, atropine), narcotic analgesics (morphine, promedol, omnopon, etc.). 30 minutes after premedication of the patient on a gurney, the nurse delivers it to the preoperative room and passes it from hand to hand to the operating room staff (nurse, sister - anesthetist).

Premedication is necessary for solving several problems:

· decrease in emotional arousal.

· neurovegetative stabilization.

· creation of optimal conditions for the action of anesthetics.

· prevention of allergic reactions to drugs used in anesthesia.

· decreased secretion of glands.

Basic drugs- for premedication, the following groups of pharmacological substances are used:

· sleeping pills (barbiturates: etaminal sodium, phenobarbital, radedorm, nozepam, tozepam).

· tranquilizers (diazepam, phenazepam). These drugs have a hypnotic, anticonvulsant, hypnotic and amnesic effect, eliminate anxiety and potentiate the action of anesthetics, increase the threshold of pain sensitivity. All this makes them the leading means of premedication.

· antipsychotics (chlorpromazine, droperidol).

· antihistamines means (diphenhydramine, suprastin, tavegil).

· narcotic analgesics (promedol, morphine, omnopon). Eliminate pain, have a sedative and hypnotic effect, potentiate the action of anesthetics.

· anticholinergics (atropine, metacin). The drugs block vagal reflexes, inhibit the secretion of glands.

Exists huge amount schemes for premedication. Their choice is based on the characteristics of each patient, the upcoming type of anesthesia and the volume of the operation, as well as the habits of the anesthesiologist. The following schemes of sedation are most widely used.

Before emergency surgery patients are injected with a narcotic analgesic and atropine (promedol 2% - 1.0, atropine - 0.01 mg / kg). According to the indications, the introduction of droperidol or antihistamines is possible.

Before elective surgery the usual scheme of premedication includes: At night the day before - sleeping pills (phenobarbital - 2 mg / kg) and tranquilizer (phenazepam - 0.02 mg / kg).

In the morning at 7 am (2-3 hours before surgery) - droperidol (0.07 mg/kg), diazepam (0.14 mg/kg).

30 minutes before surgery - promedol 2% - 1.0, atropine (0.01 mg / kg), diphenhydramine (0.3 mg / kg).

In some cases, an extended premedication regimen is required with the administration of drugs for several days and the use of pharmacological substances of other groups.

The importance of nurse competence in preparing a patient for surgery.

It seems to me that at present competence, professionalism nurse sounds more and more often and sometimes gains more and more weight due to the increased requirements for the quality of services provided by a nurse. This significantly changes the role of the nurse in the health care system and in relationships with patients. The concept of competence and professionalism significantly expands the possibilities for the participation of a nurse in the provision of assistance and subsequent treatment of the patient. She acts not as a simple executor of the will of the doctor, as it was before, but collects an anamnesis, puts provisional diagnosis and in the future constantly monitors the patient's behavior, informs the doctor about all changes, participates in doctor's rounds of patients.

LECTURE.

Topic: Surgical intervention (operation).

The role of knowledge about surgical intervention in the work of a nurse

Today, the time has come for major changes in nursing education, the role of the nurse has grown significantly. This is due to the practical need for professional and competent workers who are able not only to carry out doctor's prescriptions, but also to monitor patients, make decisions at each stage of treatment and care, that is, we need specialists who think and analyze a specific situation, who can concentrate medical services and direct them to achieve a quick and high-quality recovery.

1. The concept of emergency, planned and urgent surgery.

Surgical operation (operatio - work, action) called produced by a doctor physical impact on tissues and organs, accompanied by their separation to expose the diseased organ for the purpose of treatment or diagnosis, and subsequent connection of tissues.

The surgery consists of three main steps.: on-line access, on-line reception and final.

online access call the part of the operation that provides the surgeon with exposure of the organ on which the surgical technique is supposed to be performed.

Some accesses have special names - (laparotomy, lumbotomy, thoracotomy, craniotomy, etc.).

Operational reception - main stage an operation during which a surgical effect is performed on the pathological focus or the affected organ: opening the abscess, removing the affected organ or part of it (gallbladder, appendix, stomach, etc.). In some cases, operative access is also an operative technique, as, for example, when making incisions for drainage of cellular spaces or trepanation of the mastoid process with mastoiditis.

Name surgical operation often formed from the name of an organ or other anatomical formation and an operative technique. The following terms are used for this: -tomy" - dissection of an organ, opening its lumen (gastrotomy, enterotomy, choledochotomy, etc.); ""Ectomy" - organ removal (appendectomy, gastrectomy, etc.); "-stomy" - creation of an artificial communication between the organ cavity and the external environment, i.e. fistula (tracheostomy, cystostomy, etc.).

Analysis state of the art this issue indicates that the problem surgical intervention(operations), is still far from a final decision.

Whether we like it or not, but surgery is a pronounced form of aggression, to which the body reacts with a complex complex reactions, entitled - operational stress!

Their basis is high level neuroendocrine tension, accompanied by a significant intensification of metabolism, pronounced shifts in hemodynamics, a change in the function of the main organs and systems. Let's try to understand the complex picture of reflex and other reactions during surgery. The first most important target of aggressive influences is the central nervous system; disturbances in activity are no less important. endocrine system: increased release of catecholamines, corticosteroids, adrenocorticotropic hormone (ACTH), activation of the kallikrein-kinin and renin-angiotensin systems, increased production of antidiuretic and somatotropic hormones. Metabolic shifts are intensification carbohydrate metabolism(increased glycolysis). This is an incomplete list of reactions operational stress.

Currently, it is difficult to give a clear definition of a surgical operation, but the following definition is the most common: An operation is a mechanical effect on the tissues and organs of the patient, often accompanied by their separation to expose the diseased organ, performed for the purpose of treatment or diagnosis.

Before performing surgery, it is necessary to decide a large number of questions, and, above all, to establish indications and contraindications to the operation.

Establishing indications for surgery is one of the most difficult tasks, the right decision which is determined by comparing the expected result of the operation, possible complications with the results of existing non-surgical treatments. Exist absolute and relative indications for surgery.

2.Relative and absolute readings to surgical treatment.

Defined when only surgery can prevent death. Without surgery, the question of the life of the patient is called into question (with ongoing massive bleeding, perforation hollow organ, with obturation of the respiratory tract by a foreign body).

They are determined when the disease does not pose an immediate threat to the life of the patient, but the results of surgical treatment will be better than without surgery. In this case, both conservative and surgical treatment. At relative readings the discussion of all aspects of diagnosis should be especially thorough before the operation, this group of diseases can include (cosmetic, birth defects, deformities that cause mental suffering ). If it is necessary to perform a surgical operation, they also find out contraindications to its implementation: cardiac, respiratory, vascular insufficiency myocardial infarction, stroke, hepatic-renal insufficiency, severe violations metabolism, severe anemia.

Any surgical intervention is forced therapeutic measure , which, however, is not without reason called "surgical aggression". Operating injury, as a rule, leads to the emergence and development in the patient's body of a number of certain deviations from normal physiological processes, the severity of which depends on the initial state of the patient, the nature of the underlying and concomitant pathology, and the type of operation performed. Untimely, poor-quality or incomplete correction of these deviations, as in the course of the surgical intervention, and in the postoperative period can lead to the development various disorders hemodynamics, functions of external tissue respiration, water and electrolyte balance, acid-base balance, psyche, motility of the stomach and intestines, disorders various functions kidneys and liver. Thus, after an operation, especially a long and traumatic one, the body inevitably falls into in pathological condition –(numbness),he seems to freeze , which the famous French surgeon Rene Leriche called "postoperative stress."

3. History of the development of the doctrine of surgical intervention.

The first work on operative surgery wrote italian surgeon and anatomist B. Jeng in 1672. The founder of topographic surgery and anatomy as a science is the brilliant Russian scientist, anatomist and surgeon N. I. Pirogov. For the first time the Department of Operative Surgery and topographic anatomy appeared on his initiative at the St. Petersburg Military Academy in 1867, the first head of the department was Professor E. I. Bogdanovsky. Topographic anatomy and operative surgery have received special development in our country in the works of V. N. Shevkunenko, V. V. Kovanov, A. V. Melnikov, A. V. Vishnevsky and others.

According to N. N. Burdenko, the surgeon during the operation should be guided by three main provisions: anatomical accessibility, technical feasibility and physiological permissibility. This implies knowledge of topographic anatomy to perform an anatomically sound incision with minimal damage. blood vessels and nerves; operative surgery to select the most rational intervention on the affected organ, physiology to anticipate possible functional disorders during and after surgery.

One of the main methods of studying operative surgery and clinical anatomy is independent work on a corpse, which allows us to consider the relationship of organs and tissues, and also teaches us to identify anatomical objects by specific local features(depth of occurrence, direction of muscle fibers, relative position of organs, structure of fascia, etc.). But work on a corpse does not provide mastery necessary condition- stopping bleeding from damaged vessels, and therefore it is necessary to carry out surgical interventions on live animals, performed in compliance with all anesthetic requirements. Work on live animals makes it possible to master the skills and techniques of stopping bleeding, the ability to handle living tissues, and assess the condition of the animal after surgery.

AT last years thanks to the development computer graphics it became possible to model three-dimensional images of complex anatomical regions, reproduce them from different angles, at various stages of surgical intervention.

4. Stages of surgical intervention.

The success of surgical intervention to a certain extent depends on the methodology and sequence of all stages of the intervention. There are three successive stages of the operation:

1. Online access;

2. Operational reception;

- direct drug preparation, aimed at reducing emotional reactions, facilitate the onset of anesthesia and improve its subsequent course, should be individualized mainly in accordance with the age and preoperative condition of the patient.

In recent years, phenathiazine derivatives have become widely used for premedication before surgery, which enhance the effect of drugs and provide more favorable course anesthesia (potentiated anesthesia). The most acceptable scheme was the following. In the evening, the patient is prescribed sibazon (0.1-0.2 g), diprazine (0.05 g), in the morning, 2-3 hours before anesthesia, these drugs are repeatedly administered in combination with chlorpromazine (0.05 g) or without him; 40 minutes or 1 hour before anesthesia, atropine (1 ml of a 0.1% solution) and promedol (1-1.5 ml of a 2% solution) are injected subcutaneously.

Aminazine as a very strong sympatholytic, often causing tachycardia and a pronounced decrease in blood pressure, in some cases, for premedication before surgery, it is advisable to replace it with mepasin. The latter has a less pronounced side effect on the cardiovascular system. Weakened, especially elderly patients are more sensitive to the action of neurolytics. In these cases, the commonly used dose of chlorpromazine (50 mg) can permanently reduce arterial and increase venous pressure. It should also be borne in mind that phenathiazine derivatives significantly reduce sputum production, thicken it, and thus make it difficult to suction and actively evacuate when coughing.

Deep neuroplegia (pharmacological hibernation) achieved reintroduction neurolytic mixture, in addition to adverse effects on the condition of cardio-vascular system delays recovery after surgery cough reflex and active behavior of the patient in general, which is associated with the risk of atelectasis and the development respiratory failure. Experience has shown that in pulmonary patients it is advisable to use phenathiazine derivatives for premedication in moderate doses. At the same time, their ability to potentiate the action of drugs and inhibit pathological neuroendocrine reactions is sufficiently manifested without pronounced adverse side effects.

It would be wrong to assume that neurolytics play a leading role in premedication during anesthesia. Correct conduct anesthesia using muscle relaxants can be achieved good results and with conventional drug preparation with atropine and pantopon.

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