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MindMap Gallery Surgery - Anesthesia
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Surgery - Anesthesia
Medical Surgery - Anesthesia Mind Map, which introduces pre-anesthetic preparation and pre-anesthetic medication, general anesthesia, epidural anesthesia, combined subarachnoid space and epidural space anesthesia, sacral canal anesthesia, and spinal canal Knowledge of anesthesia and local anesthesia.
Edited at 2023-07-31 10:24:41
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Surgery - Anesthesia
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- Outline
anaesthetization
Overview
clinical anesthesia
Intensive care
first aid resuscitation
pain treatment
Preparation before anesthesia and medication before anesthesia
Pre-anesthesia assessment
Medical history collection
Physical examination
laboratory tests
Physical Status Assessment Class (ASA)
Preparation before anesthesia
Correct or improve pathophysiological conditions
Hemoglobin＞80g/L
Albumin＞30g/L
Mental preparation
Gastrointestinal tract preparation
Fasting from easily digestible solid food for 6 hours
Avoid meat and fried foods for 8 hours
Anesthesia supplies, equipment and drug preparation
informed consent
Pre-anesthetic medication
Purpose
relieve tension
Raise pain threshold
Eliminate bad reflections
drug selection
Commonly used drugs
general anesthesia
General anesthesia medication
inhalation anesthesia
Physicochemical properties and pharmacological properties
Intensity is measured as minimum alveolar concentration (MAC)
The lowest alveolar concentration that prevents 50% of patients from shaking their heads during skin incision
Factors Affecting Alveolar Drug Concentrations
ventilation effect
concentration effect
cardiac output
blood/gas distribution coefficient
The concentration difference of anesthetics in alveolar and venous blood
Metabolism and toxicity
The lower the drug's metabolism, the less toxic it is
Commonly used inhalation anesthetics
nitrous oxide
Lower anesthesia performance
Not suitable for intestinal obstruction
Sevoflurane
Strong anesthetic properties
It has an inhibitory effect on the central nervous system and has a strong inhibitory effect on breathing.
Desflurane
Lower anesthesia performance
Very low liver and kidney toxicity
intravenous anesthetic (Compared with inhaled anesthetics, induction is faster and has no irritation to the respiratory tract)
Ketamine
Selectively inhibit brain communication pathways and thalamic-neocortical system, excite limbic system
The analgesic effect is significant and the action time is 15-20 minutes.
Increase cerebral blood flow, intracranial pressure and cerebral metabolic rate
Exciting sympathetic nervous system, little influence on breathing
Increase saliva and bronchial secretions, relax bronchial smooth muscle
etomidate
Short-acting hypnotic, no analgesic effect
Mainly used for induction of general anesthesia, nausea and vomiting are prone to occur after surgery
It can reduce cerebral blood flow, intracranial pressure and cerebral metabolic rate, and has little impact on heart function.
Propofol
Sedation, hypnosis, mild labor pain
The maintenance time is 3-10 minutes, and recovery is quick and complete after stopping the drug.
Can reduce cerebral blood flow, intracranial pressure and cerebral metabolic rate
It has a significant inhibitory effect on the cardiovascular system and respiratory system
midazolam
Short-acting anesthetic analgesia, increasing the dose can prevent anxiety, sedation, hypnosis, and anterograde amnesia
Cardiovascular system is less affected
Reduce intracranial pressure
Dexmedetomidine
Can produce withdrawal symptoms
muscle relaxants
Interference with normal neuromuscular excitatory transmission (acetylcholine) at the junction
Depolarizing muscle relaxants (representative drug succinylcholine)
continued depolarization
Myofibrillar tremors may occur during the first dose
Cholinesterase inhibitors cannot antagonize its muscle relaxant effect, but instead enhance it.
Non-depolarizing muscle relaxants (representing the drug tubecurare)
Binds to postsynaptic membrane acetylcholine receptors but does not cause postsynaptic membrane depolarization
The blockade site is at the neuromuscular junction, occupying the postsynaptic membrane acetylcholine receptors
The amount of acetylcholine released from the presynaptic membrane is not reduced, but it cannot function
No muscle fiber tremor before muscle relaxation occurs
Antagonized by cholinesterase inhibitors
Commonly used muscle relaxants
Succinylcholine
Quick onset of action, complete and short-lived muscle relaxation
Vecuronium bromide
Strong muscle relaxant effect, onset of action 2-3min, effect 25-30min
Used for endotracheal intubation under general anesthesia and maintaining muscle relaxation during surgery
Mainly suitable for patients with ischemic heart disease
Rocuronium
The muscle relaxant effect is weak, 1/7 of the VK effect and 2/3 of the action time.
cisatracurium
Action time 50-60min
The biggest advantage: Linchuan dosage does not cause histamine release
non-depolarizing muscle relaxants
Precautions
Establish artificial airway to assist breathing
No sedation or analgesia, needs to be combined with general anesthesia
The application of amber can cause a transient increase in blood potassium, intraocular pressure, and intracranial pressure, and is contraindicated in glaucoma.
Hypothermia prolongs action time
Some drugs have a histamine-releasing effect. Use with caution for allergies and asthma.
Non-depolarizing muscle relaxants are contraindicated in myasthenia gravis
Narcotic analgesics
Commonly used as opiates
morphine
addictive
Inhibit respiratory center
Has good sedative and analgesic effects
Pethidine (Meperidine)
Analgesic, sleeping, and relieving smooth muscle spasm. Not suitable for children under 2 years old.
Fentanyl
Central nervous system effects similar to opioids
The analgesic effect is 75-125 times that of morphine and lasts for 30 minutes.
remifentanil
Ultra-short-acting analgesics that can significantly slow down the heart rate
sufentanil
The analgesic effect is 5-10 times that of fentanyl, the time is 2 times longer, and it has an inhibitory effect on breathing.
Administration of general anesthesia
Induction of general anesthesia
Mask inhalation induction method
intravenous induction
Maintenance of general anesthesia
Inhalation anesthetic maintenance
intravenous anesthetic maintenance
Combined general anesthesia
Judgment of depth of general anesthesia
Management of respiratory tract
Maintain airway patency
endotracheal intubation
Transoral photopic intubation
Nasal intubation
Complications of endotracheal intubation
laryngeal mask
Complications of general anesthesia and their prevention and treatment
Reflux and aspiration
Once vomiting occurs, the head will turn to one side and the head will be lowered and the feet will be higher.
airway obstruction
upper respiratory tract obstruction
Mechanical obstruction is common
incomplete
Difficulty breathing with snoring
completely
Nose flaring and triple concavity sign
lower respiratory tract obstruction
Bronchospasm, endotracheal tube kinking
Ketamine and inhaled anesthetics have the effect of dilating the trachea and are the first choice for asthma patients
Slow intravenous injection of aminophylline 250-500 mg and hydrocortisone 100 mg
Insufficient ventilation
hypoxemia
hypotension
hypertension
Arrhythmia
High fever, convulsions, and convulsions
physical cooling
The specific drug for treating malignant hyperthermia is dantrolene
Local anesthesia
Pharmacology of local anesthetics
Chemical structure and classification of intermediate chains are different
Ester local anesthetics
Procaine
Tetracaine
Amide local anesthetics
lidocaine
Bupivacaine
Ropivacaine
Physicochemical properties and anesthetic efficacy
Dissociation constant pKa
Onset time: The larger the pKa, the more ions, and the longer the onset time.
fat soluble
The higher the fat solubility, the stronger the anesthetic effect
Bubi and tetracaine are the most fat-soluble
Lido medium
Procaine is the weakest
Protein binding rate
The higher the binding rate, the longer the action time
Absorption, distribution, biotransformation and clearance
absorb
drug dosage
injection site
Directly related to blood supply
Local anesthetic properties
Pu and Ding dilate blood vessels and accelerate drug absorption
Luo and Bu are easy to combine with protein, and the absorption rate slows down.
vasoconstrictor
distributed
First distributed to the lungs, and then quickly distributed to organs with better blood flow
Biotransformation and clearance
Amides are hydrolyzed by mitochondrial enzymes in the liver
Esters are hydrolyzed by plasma pseudocholinesterase
Adverse reactions
toxic reactions
Common causes
Excess
Inject into blood vessel
constitution
The injection site is rich in blood vessels
clinical manifestations
Mild symptoms: dizziness, drowsiness, chills, disorientation
Severe disease: Excitement is dominant in the early stage, followed by full suppression in the later stage
prevention
Give pre-anesthetic medication
diazepam
barbiturate
To avoid overdose, add an appropriate amount of epinephrine
treat
Stop taking medication and take oxygen
Mild toxicity: intravenous injection of diazepam 0.1 mg/kg or midazolam 3-5 mg can effectively prevent and control convulsions.
In case of convulsions or convulsions: Diazepam 1-2 mg/kg
Recurrent convulsions: endotracheal intubation after intravenous injection of 1-2 mg of succinylcholine
Hypotension: ephedrine or metahydroxylamine maintains blood pressure
Slow heart rate: Atropine
Respiratory and cardiac arrest: cardiopulmonary resuscitation, and intravenous administration of 20% fat emulsion 1.5 mg/kg at the same time, injection time >1 minute, continuous infusion of 0.25 ml/(kg.min) if necessary, maximum dose less than 12 ml/kg (using local anesthetic lipophilicity)
allergic reaction
Esters are more common and amides are less common
Stop medication, keep the respiratory tract open, use vasopressors appropriately, and add glucocorticoids and antihistamines at the same time
Commonly used anesthetics
Procaine
Weak, short-acting, safe, limited to 1g for adults
Tetracaine
Powerful and time-effective, adults are limited to 40mg for topical anesthesia and 80mg for nerve block.
lidocaine
Medium potency and duration, limited to 100mg for topical anesthesia and 400mg for local anesthesia and nerve block for adults.
Bupivacaine
Strong and long-lasting, suitable for labor analgesia (less crossing of the placenta), adult limit is 150 mg per time
Ropivacaine
Adults are limited to 150 mg at a time, suitable for epidural analgesia such as postoperative analgesia and delivery.
Local anesthesia method
topical anesthesia
Applied to mucosal surfaces to block nerves located beneath the mucosa
Instillation method for eyes, application method for nose, spray method for throat and trachea, and infusion method for urethra
local infiltration anesthesia
Injected into the surgical area
Precautions
Injecting liquid medicine requires a certain volume to create tension.
Reduce the concentration of the solution
Withdraw to avoid injecting into blood vessels
The concentration of epinephrine in the medicine is 1:200,000-400,000 (2.5-5ug/ml), which can slow down the absorption of local anesthetics.
area block
Inject around or at the base of the surgical site
nerve block
brachial plexus block
Suitable for upper limb surgery
interscalene path
shoulder surgery
High epidural block or total spinal anesthesia is prone to occur
supraclavicular path
prone to pneumothorax
Phrenic nerve palsy, recurrent laryngeal nerve palsy, and Horner syndrome may occur
axillary path
Forearm and hand surgery
Prone to local anesthetic toxic reactions
cervical plexus block
deep plexus block
anterior cervical block
interscalene block
superficial plexus block
Indications: Neck surgery such as thyroid surgery, tracheotomy
complication
local anesthetic toxic reactions
Accidental injection into the subarachnoid or epidural space
Phrenic nerve palsy
recurrent laryngeal nerve palsy
Horner syndrome
intercostal nerve block
Digital or toe nerve block
finger root block
intermetacarpal block
neuraxial anesthesia
Two anesthetic spaces, subarachnoid space block (spinal anesthesia), epidural space block
Anatomical basis of neuraxial anesthesia
spine and spinal canal
ligament
Spinal cord, meninges and cavities
Root dura mater, root arachnoid membrane and root pia mater
sacral canal
spinal nerve
Mechanism and physiology of spinal anesthesia
cerebrospinal fluid
Functions in diluting and diffusing local anesthetics during spinal anesthesia
drug action site
Spinal anesthesia: acts directly on the spinal nerve roots and surface of the spinal cord
Hard external anesthesia
Entering the root subarachnoid space through arachnoid villi
The medicinal liquid penetrates into the intervertebral foramen and blocks the spinal nerves at the paravertebral level.
Directly through the dura mater and arachnoid membrane into the subarachnoid space
Level of anesthesia and blockade
Acupuncture method to determine the range of skin pain loss
blocking effect
After sympathetic blockade, reduce visceral stretch response
Sensory nerve block, blocking pain transmission
Motor nerve block, producing muscle relaxation
anesthesia plane
Sympathetic nerves are blocked first, and the block level is 2-4 segments higher than the sensory level.
Final motor nerve block, the block level is 1-4 segments lower than the sensory level
physiological effects
effects on breathing
Ventilation can be maintained as long as the phrenic nerve (C3-5) is not blocked
Effect on circulation
hypotension
bradycardia
subarachnoid space block
Classification
Dosing method
one-shot method
continuous method
anesthesia plane
Below T10 is a low plane
Above T10 and below T4 is the mid-level
Up to T4 is a high plane
spinal anesthesia
The puncture point is generally the L3-4 space (the intersection between the highest point of the anterior superior iliac spine on both sides and the spine)
Commonly used drugs for spinal anesthesia
Procaine
Tetracaine
Bupivacaine
Adjustment of anesthesia level
Puncture gap
patient position
Injection speed
complication
intraoperative complications
blood pressure drops
The higher the level of anesthesia, the more obvious the decrease in blood pressure will be.
Respiratory depression
feel sick and vomit
The level of anesthesia is too high, exciting the vomiting center
Hyperactive vagus nerve, enhanced gastrointestinal motility
Retraction of abdominal viscera
Caused by other drugs during surgery
Postoperative complications
Headache after spinal anesthesia
2-7 days after anesthesia
It gets worse when you raise your head or sit up, and gets better when you lie down.
urinary retention
Neurological complications after spinal anesthesia
cranial nerve palsy
Onset occurs about 1 week after spinal anesthesia, similar to headache after spinal anesthesia
Severe headache, photophobia and dizziness, followed by strabismus and diplopia
Cerebrospinal fluid leakage, compressing cranial nerves
treat
Correct low intracranial pressure, give vitamin B and provide symptomatic treatment
Most patients recover spontaneously within 6 months
adhesive arachnoiditis
Chronic proliferative inflammatory reaction of pia mater and arachnoid membrane
Sensory impairment appears first, then gradually develops into sensory loss and paralysis
cauda equina syndrome
purulent meningitis
Indications and Contraindications
Indications
Lower abdominal, pelvic, lower extremity and anoroperineal surgery within 3 hours
Contraindications
central nervous system diseases
coagulopathy
shock
Skin infection at the puncture site
sepsis
spinal trauma or tuberculosis
acute heart failure or coronary heart attack
sacral anesthesia
A type of epidural block used for rectal, anal, and perineal surgery
Postoperative urinary retention is common
Combined subarachnoid and epidural space block
lumbar and hard joint
It not only has the advantages of rapid onset of spinal anesthesia, complete analgesia and muscle relaxation, but also has the ability to control the anesthesia plane during epidural anesthesia to meet the needs of long-term operations.
epidural anesthesia
No cerebrospinal fluid, blocking some spinal nerve conduction functions
epidural puncture
Resistance disappearing method
capillary negative pressure method
Commonly used anesthetics and injection methods
1.5-2% lidocaine, onset of action is 5-8 minutes, and lasts for 1 hour
0.25-0.33% tetracaine, onset of action 10-20min, maintenance 1.5-2h
0.5-0.75% bupivacaine, onset of action 7-10min, lasting 2-3h
Ropivacaine is commonly used at a concentration of 0.75%
Anesthesia level adjustment
local anesthetic volume
Puncture gap
Catheter direction
Injection method
Patient condition
complication
intraoperative complications
total spinal anesthesia
Most of the local anesthetic is injected into the subarachnoid space
local anesthetic toxic reactions
blood pressure drops
Sympathetic nerve blockade causes dilation of resistance and volumetric vessels
Slow onset of action, delayed blood pressure drop
Although the block level is high, if the level of anesthesia can be controlled to be relatively limited, the blood pressure will decrease slightly.
A larger dose of local anesthetic can aggravate the suppression of circulation
Respiratory depression
Affects movement of intercostal muscles and diaphragm
feel sick and vomit
Postoperative complications
Less numbness than spinal numbness
nerve damage
epidural hematoma
anterior spinal artery syndrome
pre-existing arteriosclerosis
The concentration of epinephrine in local anesthetics is too high
Prolonged hypotension during anesthesia
epidural abscess
The catheter is difficult to pull out or is broken
Indications
Various abdominal, waist, and lower limb surgeries below the diaphragm are not subject to surgery time restrictions
Contraindications
Similar to spinal anesthesia
Monitoring and management during and after anesthesia
Monitoring and management during anesthesia
Respiratory monitoring and management
Cycle monitoring and management
controlled blood pressure reduction
Monitoring and management of body temperature
Monitoring and management of anesthesia recovery period
monitor
Delayed recovery after general anesthesia
Maintain stable circulation, normal ventilatory function and adequate oxygen supply
Keep airway open
Maintain the stability of the circulatory system
Common causes of postoperative hypotension
hypovolemia
venous return disorder
Decreased vascular tone
cardiogenic
Common causes of postoperative hypertension
Postoperative pain, bladder retention, patient restlessness or vomiting
Hypoxemia and hypercapnia
Increased intracranial pressure, hypothermia
Have a past history of hypertension
Common causes of postoperative arrhythmias
Hypoxia, hypercapnia, pain, electrolyte imbalance
Common causes of postoperative myocardial ischemia
Hypoxemia, anemia, tachycardia, hypotension, and hypertension