Absolute contraindications for surgery. Preparation, indications and contraindications for surgery. Anomalies of labor activity that are not amenable to drug exposure
Contraindications for surgical treatment.
According to vital and absolute indications, operations should be performed in all cases, with the exception of the preagonal and agonal state of the patient, who is in the terminal stage of a long-term current disease, leading inevitably to death (for example, oncopathology, liver cirrhosis, etc.). Such patients, according to the decision of the council, undergo conservative syndromic therapy.
With relative indications, the risk of surgery and the planned effect of it should be individually weighed against the background of concomitant pathology and the age of the patient. If the risk of surgery exceeds the desired result, it is necessary to refrain from surgery (for example, removal of a benign formation that does not compress vital organs in a patient with severe allergy.
126. Preparation of organs and systems of patients at the stage of preoperative preparation.
There are two types of preoperative preparation: general somatic skye and special .
General somatic training is carried out for patients with common surgical diseases that have little effect on the state of the body.
Skin should be examined in every patient. Rash, purulent-inflammatory rash exclude the possibility of performing a planned operation. Plays an important role sanitation of the oral cavity . Carious teeth can cause diseases that are severely reflected in the postoperative patient. Sanitation of the oral cavity, regular brushing of teeth are very useful for preventing postoperative parotitis, gingivitis, glossitis.
Body temperature before a planned operation should be normal. Its increase finds its explanation in the very nature of the disease (purulent disease, cancer in the stage of decay, etc.). In all patients hospitalized in a planned manner, the cause of the temperature increase should be found. Until it is detected and measures are taken to normalize it, the planned operation should be postponed.
The cardiovascular system should be studied especially carefully. If blood circulation is compensated, then there is no need to improve it. The average level of arterial pressure is 120/80 mm. rt. Art., may vary between 130-140 / 90-100 mm. rt. Art., which does not necessitate special treatment. Hypotension, if it represents the norm for this subject, also does not require treatment. If there is a suspicion of an organic disease (arterial hypertension, circulatory failure and cardiac arrhythmias and conduction disturbances), the patient should be consulted with a cardiologist and the issue of surgery is decided after special studies.
For prevention thrombosis and embolism determine the protombin index and, if necessary, prescribe anticoagulants (heparin, phenylin, clexane, fraxiparin). In patients with varicose veins, thrombophlebitis, elastic bandaging of the legs is performed before surgery.
Training gastrointestinal tract patients before surgery on other areas of the body is uncomplicated. Eating should be limited only on the evening before the operation and in the morning before the operation. Prolonged fasting, the use of laxatives and repeated washing of the gastrointestinal tract should be performed according to strict indications, as they cause acidosis, reduce intestinal tone and contribute to stagnation of blood in the vessels of the mesentery.
Before scheduled operations, it is necessary to determine the status respiratory system , according to indications, eliminate inflammation of the accessory cavities of the nose, acute and chronic bronchitis, pneumonia. Pain and the forced state of the patient after surgery contribute to a decrease in respiratory volume. Therefore, the patient must learn the elements of breathing exercises included in complex of physiotherapy exercises of the preoperative period.
Special preoperative preparation at planned patients can be long and voluminous, in emergency cases short-term and quickly effective.
In patients with hypovolemia, impaired water and electrolyte balance, acid-base state, infusion therapy is immediately started, including the transfusion of polyglucin, albumin, protein, sodium bicarbonate solution for acidosis. To reduce metabolic acidosis, a concentrated solution of glucose with insulin is administered. At the same time, cardiovascular agents are used.
In acute blood loss and stopped bleeding, blood, polyglucin, albumin, and plasma are transfused. With continued bleeding, transfusion is started into several veins and the patient is immediately taken to the operating room, where an operation is performed to stop the bleeding under the cover of infusion therapy, which is continued after the operation.
The preparation of organs and systems of homeostasis should be comprehensive and include the following activities:
improvement of vascular activity, correction of microcirculation disorders with the help of cardiovascular agents, drugs that improve microcirculation (reopoliglyukin);
fight against respiratory failure (oxygen therapy, normalization of blood circulation, in extreme cases - controlled ventilation of the lungs);
detoxification therapy - the introduction of liquid, blood-substituting solutions of detoxification action, forced diuresis, the use of special methods of detoxification - plasmaphoresis, oxygen therapy;
correction of disturbances in the hemostasis system.
In emergency cases, the duration of preoperative preparation should not exceed 2 hours.
Psychological preparation.
The upcoming surgical operation causes more or less significant mental trauma in mentally healthy people. Patients often at this stage have a feeling of fear and uncertainty in connection with the expected operation, negative experiences arise, numerous questions arise. All this reduces the reactivity of the body, contributes to sleep disturbance, appetite.
Significant role in psychological preparation of patients, hospitalized in a planned manner, is given medical and protective regime, the main elements of which are:
impeccable sanitary and hygienic conditions of the premises where the patient is located;
clear, reasonable and strictly observed internal regulations;
discipline, subordination in the relationship of medical staff and in the relationship of the patient to the staff;
cultural, caring attitude of the staff to the patient;
full provision of patients with medicines, apparatusswarm and household items.
Surgical interventions are divided into
▪ Life-saving surgery (eg, injuries complicated by internal or external bleeding; tracheostomy for upper airway obstruction; pericardial puncture for cardiac tamponade).
▪ Urgent (emergency) operations carried out within the shortest time from the moment of injury to prevent severe complications. To reduce operational risk, intensive preparation is prescribed before the operation. Depending on the nature of the pathology, the allowable time frame from the moment of admission to the clinic to the operation is, for example: - for embolism of the vessels of the extremities up to 2 hours; - with open fractures up to 2 hours. ▪ planned
Absolute readings to surgery ▪ Open injuries. ▪ Complicated fractures (damage to the main vessels and nerves). ▪ Risk of complications during closed reposition for fractures. ▪ Ineffectiveness of conservative methods of treatment. ▪ Soft tissue interposition. ▪ Avulsion fractures.
Relative readings. Planned interventions after injuries and previous surgical interventions (a preliminary outpatient examination of the patient is required).
For example: ▪ hip arthroplasty after a subcapital hip fracture; ▪ removal of metal structures.
When determining indications for surgical interventions, the following factors should be taken into account: - diagnosis of damage; - danger of damage; - prognosis without treatment, with conservative and surgical treatment; - the risk of surgery; - risk on the part of the patient (general condition, medical history, concomitant diseases).
In addition to complicated fractures and other life-threatening injuries requiring surgical intervention, the absolute and relative indications for surgery must be justified, and the intervention, c. on a case-by-case basis, may be delayed or rescinded.
Absolute contraindications:
- Severe general condition of the patient.
- Cardiovascular insufficiency.
- Infectious complications from the skin.
- Recent severe infectious diseases.
Relative contraindications may arise primarily due to the following risk factors:
- elderly age;
- premature baby;
- respiratory diseases (eg, bronchopneumonia);
- cardiovascular disorders (eg, unresponsive hypertension, BCC deficiency);
- impaired renal function;
- metabolic disorders (eg, uncompensated diabetes mellitus);
- blood clotting disorders;
- allergies, skin diseases;
- pregnancy.
Without taking into account these risk factors, the implementation of planned surgical interventions can lead to serious complications!
After the surgeon determines the indications for surgical treatment, the patient is examined by an anesthesiologist. The anesthesiologist prescribes additional studies to diagnose concomitant diseases and determines measures to stabilize impaired functions. The anesthesiologist is entirely responsible for the choice of the method of anesthesia and the implementation of anesthesia (after agreement with the surgeon).
Indications. Allocate vital indications (absolute) and relative. Indicating the indications for the operation, it is necessary to reflect the order of its implementation - emergency, urgent or planned. Emergency: o.appendicitis, o. surgical diseases of the abdominal organs, traumatic injuries, thrombosis and embolism, after resuscitation.
Contraindications. There are absolute and relative contraindications to surgical treatment. The range of absolute contraindications is currently sharply limited, they include only the agonal state of the patient. In the presence of absolute contraindications, the operation is not performed even according to absolute indications. So, in a patient with hemorrhagic shock and internal bleeding, the operation should be started in parallel with anti-shock measures - with continued bleeding, shock cannot be stopped, only hemostasis will allow the patient to be taken out of shock.
196. The degree of operational and anesthetic risk. The choice of anesthesia and preparation for it. Preparing for emergency operations. Legal and legal bases for conducting examinations and surgical interventions.
RISK ASSESSMENT OF ANESTHESIA AND SURGERY The degree of risk of surgery can be determined based on the patient's condition, the volume and nature of the surgical intervention, adopted by the American Society of Anesthesiologists - ASA. According to the severity of the somatic condition: I (1 point)- patients in whom the disease is localized and does not cause systemic disorders (virtually healthy); II (2 points)- patients with mild or moderate disorders that to a small extent disrupt the vital activity of the body without pronounced shifts in homeostasis; III (3 points)- patients with severe systemic disorders that significantly disrupt the vital activity of the body, but do not lead to disability; IV (4 points)- patients with severe systemic disorders that pose a serious danger to life and lead to disability; V (5 points)- patients whose condition is so severe that they can be expected to die within 24 hours. According to the volume and nature of the surgical intervention: I (1 point)- small operations on the surface of the body and abdominal organs (removal of superficially located and localized tumors, opening of small abscesses, amputation of fingers and toes, ligation and removal of hemorrhoids, uncomplicated appendectomy and herniotomy); 2 (2 points)- operations of moderate severity (removal of superficially located malignant tumors requiring extended intervention; opening of abscesses located in cavities; amputation of segments of the upper and lower extremities; operations on peripheral vessels; complicated appendectomy and herniotomy requiring extended intervention; trial laparotomy and thoracotomy; other similar by complexity and volume of intervention; 3 (3 points)- extensive surgical interventions: radical operations on the abdominal organs (except those listed above); radical operations on the organs of the breast; extended limb amputations - transiliosacral amputation of the lower limb, etc., brain surgery; 4 (4 points)- operations on the heart, large vessels and other complex interventions performed under special conditions - artificial circulation, hypothermia, etc. The gradation of emergency operations is carried out in the same way as planned ones. However, they are designated with the index "E" (emergency). When marked in the medical history, the numerator indicates the risk by the severity of the condition, and the denominator - by the volume and nature of the surgical intervention. Classification of operational and anesthetic risk. MNOAR-89. In 1989, the Moscow Scientific Society of Anesthesiologists and Resuscitators adopted and recommended for use a classification that provides for a quantitative (in points) assessment of operational and anesthetic risk according to three main criteria: - general condition of the patient; - the volume and nature of the surgical operation; - the nature of anesthesia. Assessment of the general condition of the patient. Satisfactory (0.5 points): somatically healthy patients with localized surgical disease or not associated with the underlying surgical disease. Moderate severity (1 point): Patients with mild or moderate systemic disorders associated or not associated with the underlying surgical disease. Severe (2 points): patients with severe systemic disorders that are associated or not associated with surgical disease. Extremely severe (4 points): patients with extremely severe systemic disorders that are associated or not associated with a surgical disease and pose a danger to the life of the patient without surgery or during surgery. Terminal (6 points): patients in a terminal state with severe symptoms of decompensation of the functions of vital organs and systems, in which death can be expected during surgery or in the next few hours without it. Estimation of the volume and nature of the operation. Minor abdominal or minor surgeries on body surfaces (0.5 points). More complex and lengthy operations on the surface of the body, spine, nervous system and operations on internal organs (1 point). Major or lengthy surgeries in various fields of surgery, neurosurgery, urology, traumatology, oncology (1.5 points). Complex and lengthy operations on the heart and large vessels (without the use of IR), as well as extended and reconstructive operations in surgery of various areas (2 points). Complex operations on the heart and great vessels with the use of IR and transplantation of internal organs (2.5 points). Assessment of the nature of anesthesia. Different kinds local potentiated anesthesia (0.5 points). Regional, epidural, spinal, intravenous or inhalation anesthesia with spontaneous breathing or with short-term assisted ventilation of the lungs through the mask of the anesthesia machine (1 point). Usual standard options for general combined anesthesia with tracheal intubation using inhaled, non-inhaled or non-drug anesthesia (1.5 points). Combined endotracheal anesthesia with the use of inhaled non-inhaled anesthetics and their combinations with methods of regional anesthesia, as well as special methods of anesthesia and corrective intensive care (artificial hypothermia, infusion-transfusion therapy, controlled hypotension, circulatory support, pacing, etc.) (2 points). Combined endotracheal anesthesia with the use of inhalation and non-inhalation anesthetics under conditions of IR, HBO, etc. with the complex use of special anesthesia methods, intensive care and resuscitation (2.5 points). Risk degree: I degree(minor) - 1.5 points; II degree(moderate) -2-3 points; III degree(significant) - 3.5-5 points; IV degree(high) - 5.5-8 points; V degree(extremely high) - 8.5-11 points. With emergency anesthesia, a risk increase of 1 point is acceptable.
Preparing for emergency operations
The amount of preparation of the patient for an emergency operation is determined by the urgency of the intervention and the severity of the patient's condition. Minimal preparation is performed in case of bleeding, shock (partial sanitization, shaving of the skin in the area of the surgical field). Patients with peritonitis require preparation aimed at correcting water and electrolyte metabolism. If the operation is supposed to be under anesthesia, the stomach is emptied using a thick tube. With low blood pressure, if it is not caused by bleeding, intravenous administration of blood substitutes of hemodynamic action, glucose, prednisolone (90 mg) should increase blood pressure to a level of 90-100 mm Hg. Art.
Preparing for emergency surgery. In conditions that threaten the life of the patient (wound, life-threatening blood loss, etc.), no preparation is carried out, the patient is urgently taken to the operating room without even taking off his clothes. In such cases, the operation begins simultaneously with anesthesia and resuscitation (resuscitation) without any preparation.
Before other emergency operations, preparations for them are still being carried out, albeit in a significantly reduced volume. After deciding on the need for surgery, preoperative preparation is carried out in parallel with the continuation of the examination of the patient by the surgeon and anesthetist. Thus, the preparation of the oral cavity is limited to rinsing or wiping. Preparation of the gastrointestinal tract may include evacuation of gastric contents and even leaving a gastric nasal tube (for example, in intestinal obstruction) for the duration of the operation. An enema is rarely given, only a siphon enema is allowed when trying to conservatively treat intestinal obstruction. In all other acute surgical diseases of the abdominal cavity, an enema is contraindicated.
The hygienic water procedure is carried out in an abbreviated form - a shower or washing the patient. However, the preparation of the surgical field is carried out in full. If it is necessary to prepare patients who came from production or from the street, whose skin is heavily contaminated, the preparation of the patient's skin begins with mechanical cleaning of the surgical field, which in these cases should be at least 2 times larger than the intended incision. The skin is cleaned with a sterile gauze swab moistened with one of the following liquids: ethyl ether, 0.5% ammonia solution, pure ethyl alcohol. After cleaning the skin, the hair is shaved and the surgical field is further prepared.
In all cases, the nurse should receive clear instructions from the doctor on how much and by what time she must fulfill her duties.
197. Preparation of the patient for surgery. Training goals. Deontological preparation. Medical and physical preparation of the patient. The role of physical training in the prevention of postoperative infectious complications. Preparation of the oral cavity, preparation of the gastrointestinal tract, skin.
The established diagnosis of esophageal cancer is an absolute indication for surgery - everyone recognizes this.
A study of the literature shows that the operability of patients with esophageal cancer is rather low and, according to various surgeons, varies widely - from 19.5% (BV Petrovsky) to 84.4% (Adatz et al.). The average figures for operability in the domestic literature are 47.3%. Consequently, approximately half of the patients are scheduled for surgery, and the second is not subject to surgical treatment. What are the reasons for such a large number of patients with esophageal cancer to refuse surgery?
First of all, this is the refusal of the patients themselves from the proposed surgical treatment. It was reported above that the percentage of patients who refused surgery in various surgeons reaches 30 or more.
The second reason is the presence of contraindications to surgical intervention, depending on the state of the already elderly organism itself. The operation of resection of the esophagus for cancer is contraindicated in patients with organic and functional heart diseases, complicated by circulatory disorders (severe myocardial dystrophy, hypertension, arteriosclerosis) and lung diseases (severe pulmonary emphysema, bilateral tuberculosis), unilateral pulmonary tuberculosis is not a contraindication, also as well as pleural adhesions (A. A. Polyantsev, Yu. E. Berezov), although they, no doubt, burden and complicate the operation. Diseases of the kidneys and liver - nephrosonephritis with persistent hematuria, albuminuria or oliguria, Botkin's disease, cirrhosis - are also considered a contraindication to surgical treatment of esophageal cancer.
The operation of resection of the esophagus is contraindicated and debilitated patients who have difficulty walking, severely emaciated, until they are taken out of this condition.
The presence of at least one of the listed diseases or conditions in a patient with cancer of the esophagus will inevitably lead to his death either during the operation of resection of the esophagus, or in the postoperative period. Therefore, with them, radical operations are contraindicated.
Concerning age of the patients appointed for operation, there are different opinions. G. A. Gomzyakov demonstrated a 68-year-old patient operated on for cancer of the lower thoracic esophagus. She underwent transpleural resection of the esophagus with a one-stage anastomosis in the chest cavity. After the demonstration by F. G. Uglov, S. V. Geynats, V. N. Sheinis and I. M. Talman, it was suggested that advanced age in itself is not a contraindication to surgery. The same opinion is shared by S. Grigoriev, B. N. Aksenov, A. B. Raiz and others.
A number of authors (N. M. Amosov, V. I. Kazansky, etc.) believe that the age over 65-70 years is a contraindication to resection of the esophagus, especially by the transpleural route. We believe that elderly patients with esophageal cancer should be carefully scheduled for surgery. It is necessary to take into account all changes in the age character and the general condition of the patient, take into account the scale of the proposed operation, depending on the localization of the tumor, its prevalence and the method of the surgical approach. Without a doubt, resection of the esophagus for a small carcinoma of the lower esophagus using the Savinykh method can be successfully performed in a 65-year-old patient with moderately severe cardiosclerosis and emphysema, while resection of the esophagus with a transpleural approach in the same patient may end unfavorably.
The third group of contraindications is due to the esophageal tumor itself. All surgeons recognize that distant metastases to the brain, lungs, liver, spine, etc. are an absolute contraindication to radical resection of the esophagus. Patients with esophageal cancer with distant metastases can only undergo palliative surgery. According to Yu. E. Berezov, Virchow's metastasis cannot serve as a contraindication to surgery. We agree that palliative but not radical surgery can be performed in this case.
The presence of an esophageal-tracheal, esophageal-bronchial fistula, perforation of a tumor of the esophagus into the mediastinum, lung are a contraindication to resection of the esophagus, as well as a change in voice (aphonia), indicating the spread of the tumor beyond the wall of the esophagus when it is localized in the upper thoracic or, less often, in the mid-thoracic region. Operation is contraindicated, according to some surgeons (Yu. E. Berezov, V. S. Rogacheva), in patients with significantly pronounced infiltration of the mediastinum by a tumor, determined by x-ray examination.
This group of contraindications, depending on the extent of the tumor of the esophagus, is determined by the technical impossibility of resection of the esophagus due to the germination of carcinoma in neighboring non-resectable organs or the futility of the operation due to extensive metastasis.
All other patients who have no contraindications undergo surgery with the hope of resection of the esophagus. However, as can be seen from Table. 7 (see the last column), resection of the esophagus can be performed not by all operated, but by 30-76.6%, according to various authors. Such a big difference in the given figures depends, in our opinion, not so much on the activity and personal attitudes of the surgeon, as Yu. E. Berezov believes, but on the quality of preoperative diagnostics. If you carefully study the patient's complaints, the history of the development of his disease, the data of clinical and radiographic studies, taking into account the localization of the tumor, its extent along the esophagus and mediastinal infiltration, then in most patients it is possible to correctly determine the stage of esophageal cancer before surgery. Errors are possible mainly r, but due to unrecognized metastases before the operation or underestimation of the stage of the process, which lead to trial operations.
When the stage of esophageal cancer is determined, then the indications are clear. All patients with esophageal carcinoma in stages I and II are subject to resection of the esophagus. As for patients with stage III cancer of the esophagus, we solve the issue of resection of the esophagus in the following way. If there are no multiple metastases in the mediastinum, in the lesser omentum and along the left gastric artery, then resection of the esophagus should be performed in all those cases where it is technically possible to perform it, i.e. the tumor has not sprouted into the trachea, bronchi, aorta, vessels of the lung root.
Almost all surgeons adhere to this tactic, and yet resectability, i.e., the number of patients who manage to perform resection of the esophagus, ranges from 8.3 to 42.8% (see Table 7) in relation to all those admitted to the hospital. On average, operability is 47.3%, resectability - 25.7%. The figures obtained are close to the average data of Yu. E. Berezov and M. S. Grigoriev. Therefore, at present, about one in 4 patients with esophageal cancer who seek surgical help can undergo resection of the esophagus.
In the hospital surgical clinic named after A. G. Savinykh of the Tomsk Medical Institute, since 1955, various operations have been used for resection of the esophagus in cancer, depending on the indications. Indications for the use of a particular method are based on the localization of the tumor and the stage of its spread.
1. Patients with cancer of the esophagus stage I and II, with the localization of the tumor in the thoracic region, resect the esophagus according to the Savinykh method.
2. In case of cancer of the upper and middle thoracic sections of the esophagus, stage III, as well as when the tumor is located on the border of the middle and lower sections, resection of the esophagus is performed according to the Dobromyslov-Torek method through the right-sided access. In the future, after 1-4 months, retrosternal-prefascial small-bowel esophagoplasty is performed.
3. In stage III esophageal cancer with tumor localization in the lower thoracic region, we consider partial resection of the esophagus with a combined abdomino-thoracic approach with a one-stage esophageal-gastric or esophago-intestinal anastomosis in the chest cavity, or resection of the esophagus according to the Savinykh method.
General anesthesia is an artificial immersion of the patient into sleep with a reversible decrease in all types of sensitivity due to the use of pharmacological preparations. Drugs used in anesthesia are called anesthetics. For anesthesia, inhalation and non-inhalation anesthetics are used.
Inhalation anesthetics- These are drugs that are injected into the patient's body directly through the respiratory tract, by means of gas. Inhalation anesthetics are used as monoanesthesia, i.e. using only gas, or as part of a combination with other drugs. The most commonly used inhalation anesthetics are nitrous oxide (NO), sevoflurane (sevoran), isoflurane, halothane, desflurane.
Non-inhalation anesthetics- These are drugs that are administered directly to the patient by a vein (intravenously). Drugs used for non-inhalation anesthesia: a group of barbiturates (sodium thiopental and hexonal), ketamine, propofol (Pofol, Diprivan), a group of benzodiazepines (dormicum). They can also be used as monoanesthesia, or as part of a combination (for example, propofol + sevoran).
Individually, each drug has its own spectrum of pharmacological effects.
With a combination of inhalation and non-inhalation anesthetics, anesthesia will be called general combined anesthesia.
General anesthesia is most often supplemented with two more important components - these are muscle relaxants and narcotic analgesics.
Muscle relaxants are pharmacological drugs administered intravenously that cause a reversible relaxation of all muscle fibers, with a further inability to contract. This component of anesthesia is necessary when it comes to a major operation, such as abdominal surgery, on the abdominal wall (stomach) and there is a need to perform tracheal intubation.
Tracheal intubation is a medical manipulation necessary to maintain airway patency. A tube is inserted through the mouth into the trachea. After that, the cuff at the tube is inflated to create an airtight circuit. The other end of the tube is connected through a system of circuits (hoses) to an artificial lung ventilation (ALV) machine.
In such a situation, the complete absence of independent muscle contractions by the patient is necessary.
Narcotic analgesics, such as fentanyl, are used as a component of anesthesia to completely relieve pain in a patient during surgery.
Indications for general anesthesia
Indications for general inhalation anesthesia (monoanesthesia): minimally invasive operations, i.e. operations with minimal damage to the skin, low access. Such operations include: removal of superficially located structures and neoplasms; gynecological operations in the form of curettage of the uterus; traumatological operations - reduction of dislocations; also heavy bandages.
Indications for General Non-Inhalation Anesthesia similar to gas monoanesthesia. They are supplemented by various instrumental studies (gastroscopy, colonoscopy).
Indications for general combined anesthesia with tracheal intubation and mechanical ventilation: surgical interventions of an average degree, these include - operations in the region of the facial skull; ENT operations; some gynecological operations; amputation of segments of the upper and lower extremities; operations in the abdominal cavity (appendectomy, cholecystectomy, hernia repair, etc.); diagnostic laparotomy, laparoscopy; in the chest cavity in the form of diagnostic thoracotomies and thoracoscopy. Major surgical operations: extended operations in the abdominal and chest cavities; extended limb amputations; brain surgery. As well as operations on the heart, spinal cord, large vessels and other complex surgical interventions that require additional special conditions - the connection of a heart-lung machine (AIC) or the creation of hypothermia conditions.
Contraindications for general anesthesia
Contraindications for elective general anesthesia are:
From the side of the cardiovascular system: recent (1-6 months) myocardial infarction, unstable angina or angina pectoris 4 functional class, low blood pressure, progressive heart failure, severe heart valve disease, conduction and heart rhythm disturbances, failure of the contractile function of the heart.
From the nervous system: psychiatric illnesses, severe injuries and brain contusions (1-6 months).
From the respiratory system: bronchial asthma in the acute stage, pneumonia, severe bronchitis.
Narcosis is not harmless and not safe, but the potential danger of anesthesia is thousands of times less than the harm that the disease bears if its surgical treatment is refused. Another thing is that the probable harm and danger of anesthesia can always be minimized, for this you just need to trust an anesthesiologist-resuscitator who knows his business.
Please note that there are no contraindications for emergency surgery and emergency anesthesia, and in cases of progression of the cancer patient's disease. In such situations, the conversation is about saving the patient's life, and not about assessing his contraindications.
Preparing the patient for the upcoming elective surgery under general anesthesia
Most often, all the preparation of the patient for a planned operation takes place immediately on the eve of the operation in the hospital. The day before, the anesthesiologist-resuscitator talks to the patient, collects an anamnesis, talks about the upcoming anesthesia, fills in the necessary medical documentation, takes the patient's written consent to anesthesia.
Your doctor will ask you if you are allergic to anything. Any allergies the patient has should be reported, especially to medications. Food allergies are also important. For example: a non-inhalation anesthetic - propofol (hypnotic) is produced on the basis of egg lecithin. Accordingly, for patients with an allergy to egg yolk, this drug will be replaced with another hypnotic, such as sodium thiopental, but this is an extremely rare situation.
Any manifestation of allergy is necessarily recorded in the medical history and is strictly not allowed to be taken or administered to the patient.
If you have a pathology of any system, and you are taking drugs according to the prescription of a specialist, then you must definitely inform your anesthesiologist-resuscitator about this, and then follow his instructions. The anesthesiologist-resuscitator either completely cancels your medication and you already resume it only after surgery, when you are allowed, or continue to take your medications according to the scheme that your specialist has developed.
The main preparation of the patient for the upcoming operation is to strictly comply with all the requirements of the anesthesiologist-resuscitator.
They include: in the evening before going to bed and in the morning - a ban on taking any food and water. In the morning, brush your teeth and rinse your mouth. Be sure to remove all jewelry: rings, earrings, chains, piercings, glasses. Remove removable dentures.
Another important component of preoperative preparation for the patient is premedication.
Premedication is the final stage of preoperative preparation. Premedication consists in taking pharmacological drugs to relieve psycho-emotional stress before surgery and improve the introduction to general anesthesia. The preparations can be in the form of tablets for oral administration, or in the form of injections for intravenous or intramuscular administration. The main groups of drugs for premedication are tranquilizers. They help the patient fall asleep quickly in the evening before the operation, reduce anxiety and stress. In the morning, these drugs are also prescribed for a softer and more comfortable introduction to anesthesia for the patient.
How anesthesia is done
Let's look at the example of general combined anesthesia with tracheal intubation and mechanical ventilation.
After the planned preparation of the patient for surgery, compliance with all the requirements of morning premedication, the patient, lying on a stretcher, accompanied by medical personnel, is fed into the operating unit. In the operating room, the patient is transferred from the gurney to the operating table. An anesthetic team consisting of a doctor and a nurse anesthetist awaits him there.
Mandatory, the first manipulation, with which it all begins, is obtaining vascular (venous) access. This manipulation consists in the percutaneous insertion of a sterile vascular catheter into a vein. Next, this catheter is fixed and a system for intravenous infusion with saline sodium chloride is connected to it. This manipulation is necessary in order to have constant access for the administration of drugs intravenously.
After that, a cuff is connected to the patient to change blood pressure (BP) and electrode sensors are connected to the chest for continuous recording of the electrocardiogram (ECG). All parameters are displayed to the doctor directly on the monitor.
After that, the doctor instructs the nurse to collect drugs. While the nurse is busy, the doctor begins preparations for introducing the patient into anesthesia.
The first stage of anesthesia is preoxygenation. Preoxygenation is as follows: an anesthesiologist-resuscitator connects a face mask to the circuit system and sets parameters with a high oxygen supply on the ventilator monitor, after which he applies the mask to the patient's face. At this moment, the patient needs to breathe as usual, take standard, normal life breaths and exhalations. This procedure lasts 3-5 minutes. After the nurse and the surgical team are ready, the introduction of the patient into anesthesia begins.
The first drug to be given intravenously is narcotic analgesic. The patient at this moment may feel a slight feeling in the form of dizziness and a slight unpleasant feeling in the form of a burning sensation in the vein.
After that, enter hypnotic drugs(non-inhalation anesthetic). The patient is warned that his head will now begin to spin and he will slowly fall asleep. There will be a feeling of heaviness of the head, facial muscles, a feeling of euphoria and fatigue. Time is counted in seconds. The patient falls asleep. The patient is sleeping.
The patient will not feel and remember further manipulations of the anesthesia team.
The next drug administered intravenously is a muscle relaxant.
After its introduction, the anesthesiologist-resuscitator performs tracheal intubation and connects the patient through the tube to the sealed circuit of the ventilator, turns on the supply of inhalation anesthetics through a special evaporator. After that, he checks the uniformity of the patient's breathing, using a phonendoscope (a medical device for listening to respiratory and heart sounds), fixes the endotracheal tube to the patient, and sets the necessary parameters on the ventilator. After the anesthesiologist-resuscitator has made sure that the patient is completely safe and checked everything, he gives the command to the surgical team to start the operation.
With inhalation monoanesthesia, the scheme is simplified.
The duration of the operation is determined by the qualification level of the surgical team, the complexity of the surgical intervention and the anatomical features of the patient.
Complications during general anesthesia
The main danger of any anesthesia is hypoxia (lack of oxygen consumption by the patient) and hypercapnia (an increase in the body of excess carbon dioxide). The causes of these severe complications can be: malfunction of anesthesia equipment, impaired airway patency, excessive immersion of the patient in anesthesia sleep.
There are also complications of anesthesia in the form of:
Retraction of the tongue, which contributes to impaired airway patency, most often this complication occurs when monoanesthesia is performed only with inhalation anesthetics using gas supply through a face mask;
Laryngospasm - closure of the vocal cords of the larynx. This complication is associated with a reflex reaction of the body to excessive irritation of the mucous membranes of the larynx, or excessive pain effects on the body during surgery with too superficial medication sleep;
- obstruction of the airways by vomiting during regurgitation. Regurgitation is the entry of stomach contents into the oral cavity and possible entry into the respiratory tract;
- respiratory depression- a complication associated with too deep immersion of the patient in anesthesia;
- changes in blood pressure and heart rate in the form of tachycardia (rise in heart rate) and bradycardia (decrease in heart rate), which is directly related to surgical intervention and the most painful stages of the operation.
Possible consequences of general anesthesia after surgery
The most common consequences are drowsiness, dizziness, weakness. They pass on their own. On average, after a planned, moderately severe operation without complications, patients come to a state of clear consciousness in 1-2 hours.
After general anesthesia, nausea and vomiting may occur. Treatment of this complication is reduced to the use of antiemetic drugs, such as, for example, metoclopromide (cerucal).
Headache (cephalgia) after anesthesia, it manifests itself in the form of a feeling of heaviness in the head and pressure in the temples. This consequence passes on its own and does not require additional use of drugs. If the headache does not go away, your doctor will most likely prescribe you analgin.
Pain in the postoperative scar (wound)- the most pronounced, frequent consequence of the operation, when the effect of anesthesia ends. Pain in the wound will persist until the formation of the primary scar, because. it is not the wound itself that hurts, but directly the skin that was cut. To prevent postoperative pain, during operations of moderate degree, it is sufficient to use antispasmodic, analgesic drugs. In some cases, stronger opioid drugs (eg, promedol, tramadol) may be used. In case of extensive operations, anesthesiologists-resuscitators perform catheterization of the epidural space. This method consists in inserting a catheter into the spine and prolonged pain relief by injecting local anesthetics into the catheter.
Rise or fall in blood pressure (BP). A decrease in blood pressure is typical for patients who underwent surgery with extensive blood loss and blood transfusions (multiple injuries, operations associated with internal and external bleeding). The total volume of circulating blood is gradually restored and the patient feels better the next day after the operation without additional medications. Elevations in blood pressure are typical for patients after operations on the heart and large blood vessels. Most often, such patients are already receiving the necessary treatment and their blood pressure indicators are under constant control.
Increase in body temperature is the norm and most often indicates the operation. It is necessary to pay attention only to an increase in body temperature if it has reached subfebrile numbers (above 38.0 C), which most likely indicates an infectious complication of the operation. In this situation, do not panic. Your doctor will definitely prescribe you antibiotic therapy and eliminate the cause of the fever.
In foreign literature, there are reports of the negative consequences of anesthesia in children, in particular, that anesthesia can cause the development of cognitive disorders in a child - impaired memory, attention, thinking, and learning ability. In addition, there are suggestions that anesthesia transferred at an early age may be one of the reasons for the development of attention deficit hyperactivity disorder. This leads to recommendations to postpone the planned surgical treatment of the child until the age of four, on the clear condition that the delay of the operation will not harm the child's health.
The well-coordinated and professional work of the anesthesiological and surgical teams guarantees a safe, painless, comfortable performance of any operation without any medical complications. A patient psychologically tuned to general anesthesia will only help the anesthesiologist-resuscitator to work efficiently. Therefore, it is important to ask all the questions of interest to the specialist before the operation and strictly follow the prescribed recommendations.
Anesthesiologist - resuscitator Starostin D.O.