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surgical anesthesia

Comprehensive Western Medicine, Surgery, General Surgery, Anesthesia. After the surgical anesthesia is completed, depending on the patient's condition and the specific conditions of the surgical anesthesia, the patient may have respiratory depression, nausea and vomiting, pain, agitation and other special conditions, and we need to take certain measures against them. A super comprehensive summary of knowledge that you absolutely can’t miss. They are all must-learn points!

Edited at 2021-06-02 20:26:16

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surgical anesthesia

ASA rating

Level I

really normal

II and

Compensation, but appears normal

Level III

Able to cope with normal life, such as cooking, etc.

Level IV

It's enough to cope with it and lead a normal life, but there is always the risk of death.

Class V

Will die within 24 hours

Preparation before anesthesia

Physical preparation

1. Correct anemia, Hb≥80g/L, correct malnutrition, Alb≥30g/L

2. hypertension

Preoperative blood pressure should be <180/100mmHg to prevent intraoperative hypotension.

Avoid the use of centrally located antihypertensive drugs (antihypertensive No. 0, discontinue medication for 1-2 weeks) to avoid refractory hypotension

Antihypertensive drugs (β-blockers, etc.) can be continued until the day of surgery. If the drugs are stopped too early, rebound hypertension will occur.

3. Diabetes: fasting blood glucose <8.3mmol/L, urine glucose or , urine ketones negative

4. If combined with heart failure, atrial fibrillation, cardioectasia, heart failure, arrhythmia, or mural thrombosis, digitalis drugs should be discontinued on the day of surgery.

Mural thrombi may also be seen in aneurysms

5. Complicated respiratory diseases: COPD patients, test blood gas, lung function, check chest X-ray, quit smoking for 2 weeks

For patients with acute and chronic pulmonary infections, effective antibiotics should be used for 3-5 days

Gastrointestinal tract preparation

No drinking: 2 hours

Fasting: Children: 4 hours for breast milk and 6 hours for non-breast milk; Adults: 6 hours for digestible foods and 8 hours for indigestible foods.

Comparative memory: perioperative period: fasting for 8-12 hours or h, fasting for 4h or 3h

Emergency surgery for people who have already eaten

Awake tracheal intubation and Sellik maneuver-induced tracheal intubation are the most effective methods to prevent aspiration.

Pre-anesthetic medication

Benzodiazepine (valium) sedatives: diazepam

Hypnotic: Phenobarbital (sedative, anticonvulsant)

Analgesics: Opioids (morphine, pethidine)

Anticholinergic: Scopolamine

local anesthetic

Classification

Depending on the intermediate chain

Esters: procaine, decaine

Amides: lidocaine, bupivacaine, ropivacaine

metabolism

Amides: Intrahepatic metabolism: Microsomal enzymes. When liver function is damaged, metabolism time is prolonged

Esters: Extrahepatic metabolism: Plasma cholinesterase. Metabolic time is prolonged in plasma cholinesterase deficiency

Mechanism

The site of local anesthetic blockade is mainly in the cell membrane and cytoplasm

BH ions can completely block Na access

performance

Dissociation constant (pKa): determines the dispersion performance and onset time. The higher the pKa, the worse the anesthetic effect.

negative effects

Fat solubility: The higher the fat solubility, the better the efficacy

Protein binding rate: determines the duration of action or whether it can be used for labor analgesia. The higher the better

positive effect

toxicity

Toxic reactions: Toxic reactions caused by exceeding the maximum amount of local anesthetics are the most common.

Hypersensitivity reaction: Toxic reactions can occur with small doses of local anesthetics. They are a special type of toxic reactions. Pay attention to distinguishing them from allergic reactions.

Common local anesthetic dosage

Procaine: 1000mg, least toxic

Tetracaine: Topical anesthesia: 40mg; Nerve block: 80mg

Lidocaine: topical anesthesia: 100mg; nerve block 400mg

Bupivacaine, ropivacaine: 150mg

Procaine: Little toxic reaction, lowest fat solubility, most susceptible to allergies

Decaine: has strong mucosal penetration ability and is often used for topical anesthesia. It has low dispersion performance and slow onset of action.

Kart pk strong

Lidocaine: Repeated use produces rapid drug resistance, strong dispersion ability, and rapid onset of effect

Bupivacaine and Bupivacaine: have high protein binding rate and an action time of 4-6 hours. They are used for postoperative patient-controlled analgesia; they rarely pass through the placenta and are suitable for labor analgesia.

Ropivacaine: The latest amide drug, which can effectively replace bupivacaine. It is less cardiotoxic than bupivacaine and has a high rate of placental integration. Low concentrations of ropivacaine cause sensorimotor dissociation and are suitable for labor analgesia

Epidural anesthesia

Drug concentration: determines depth of anesthesia

Drug volume (total amount after dilution): determines the plane and area of anesthesia

Drug dosage (dose of pure anesthetic): Increasing the dosage speeds the onset of action and prolongs the duration of action, providing maximum depth of sensory and motor blockade

Local anesthesia

topical anesthesia

Mucous membrane: Inject lidocaine gel into the urethra before inserting a urinary catheter

local infiltration

Puncture points: lumbar puncture, chest puncture, bone puncture, abdominal puncture, kidney puncture, etc.

area block

Multiple and multi-point anesthesia in the surgical area: removal of sebaceous cyst or subcutaneous lipoma

nerve block

Location: brachial plexus, cervical plexus, intercostal space, fingers or toes, lower alveolar

brachial plexus block

C5-8 or T1 anterior branch

intercostal groove path

space between anterior and middle scalene muscles

Applicable diseases: shoulders

Complications: high epidural anesthesia or total spinal anesthesia, local anesthetic toxicity, phrenic nerve or recurrent laryngeal nerve or cervical sympathetic nerve: Honer syndrome,

supraclavicular path

Indications: Nerve trunks of the brachial plexus

Complications: pneumothorax, local anesthetic toxicity, phrenic nerve or recurrent laryngeal nerve or cervical sympathetic nerve

axillary path

Indications: Forearm and hand (except the lateral anterior wall and thumb innervated by the lateral forearm cutaneous nerve)

Complications: local anesthetic toxicity

nerve block

Add epinephrine: local anesthetic: epinephrine = 1:200,000

100ml local anesthetic: 0.5mg epinephrine

Reason: Epinephrine can constrict blood vessels, delay absorption, prolong drug action time, and reduce toxicity.

purulent dactylitis

Adrenaline cannot be added during nerve block because there is a risk of finger ischemia and gangrene.

spinal anesthesia

Anesthesia method

anesthesia

Sequence of action: sympathetic nerves → sensory nerves → motor nerves → proprioceptive (deep) sensation

anesthesia side effects

respiratory system

Above: C3-5, phrenic nerve depression, abdominal breathing affected

Bottom: T1-2, twelve pairs of intercostal nerves are suppressed, thoracic breathing is affected

Total spinal anesthesia: quickly put on a ventilator

circulatory system

Negative cardiac myocardium or peripheral vasodilation, causing hypotension. Treatment: fluid rehydration, ephedrine (stimulates beta or alpha receptors)

Negative heart rate: slow heart rate. Treatment: Atropine or Iso

urinary system

Urinary retention in the bladder. Treatment: Indwelling urinary catheterization

digestive system

Nausea, vomiting, aspiration

No food or water before surgery. Indwelling gastric tube

Complications and contraindications of spinal anesthesia

Postoperative complications

Hypotension headache following cerebrospinal fluid loss

Treatment: Lie on your back without pillows for at least 6-8 or 12 hours; replenish fluid (crystalloid and colloid) to correct blood volume

Do not use hypertonic sugar water or mannitol for rehydration

Contraindications

High intracranial pressure after traumatic brain injury: spinal anesthesia can cause foramen magnum herniation

Complications and contraindications of epidural anesthesia

complication

Anesthesia mistakenly enters the subarachnoid space causing total spinal anesthesia

Provide respiratory (ventilator), circulatory (fluid replacement, vasopressor drugs: dopamine, epinephrine, noradrenaline) support

Taboo

Epidural anesthesia is contraindicated in patients with coagulation disorders (those who have not stopped taking aspirin for 1 week): otherwise, it will cause epidural hematoma to compress the spinal cord and lead to spinal cord paralysis.

general anesthesia

Classification

intravenous anesthetic

Reversible

Sedatives: cause loss of consciousness (sleep), which can be antagonized by flumazenil

Analgesics: make the pain disappear and can be antagonized by naloxone

Muscle relaxants: to relax muscles and can be antagonized by neostigmine

inhalation anesthetic

Adjustable

Acts faster than intravenous

The degree of CNS suppression by general anesthetics is related to blood concentration

Ether anesthesia is used for stage III level 2 surgery: such as abdominal surgery

CO2

Inhalation anesthesia, early manifestations of CO2 retention (excitement)

Telangiectasia, flushing, and nail bed flushing

Increased blood pressure and rapid pulse

Breathing becomes deeper and faster

increased muscle tone

Inhalation anesthesia, excessive CO2 discharge (suppression)

blood pressure drops

apnea

Muscle relaxants

It can only relax skeletal muscles and has no sedative and analgesic effect.

Depolarizing muscle relaxants

Mechanism of action: first excitation and then inhibition: continuous depolarization of the posterior membrane of the neuromuscular junction, resulting in muscle contraction after muscle twitching

Antagonist: Anticholinesterase: Neostigmine, enhances its stimulant effect

Drug: Succinylcholine

Contraindications: Hyperkalemia, elevated intragastrointestinal pressure (gastrointestinal obstruction), intraocular pressure (glaucoma), and intracranial pressure (cerebral edema)

non-depolarizing muscle relaxants

Mechanism of action: competes with acetylcholine to occupy the posterior membrane receptors at the neuromuscular junction. ACh released by the aneurysm protrusion during nerve excitation cannot work, and there is no muscle tremor before muscle sending.

Antagonist: Neostigmine

drug

Atracurium: excreted via the Hoffman pathway

Vecuronium bromide: can be used in patients with coronary heart disease and myocardial ischemia, without histamine releasing effect

Rocuronium bromide (Ecoson): the fastest onset of action, 60 seconds

Taboo

myasthenia gravis

sedatives

1. Midazolam (Liyuexi): can cause anterograde amnesia (inability to acquire new memories), without intraoperative adverse memories

2. Ketamine (K powder)

Dissociative phenomenon: confusion, loss of sensation, preservation of spontaneous breathing (compare memory: fentanyl: respiratory depression)

Basic intravenous anesthetics in children

Side Effects: Hallucinogenic Effects

3. etomidate

It has almost no effect on the circulatory system. It's a fat emulsion

4. Propofol emulsion injection (propofol)

Induction was rapid and recovery was complete. Fat emulsion.

Large doses can cause respiratory and cardiac arrest

5. Thiopental sodium

It can inhibit sympathetic nerves and relatively enhance the parasympathetic effect, causing bronchospasm and risk of suffocation.

analgesics

Opioids: remifentanil, sufentanil: especially suitable for patients with coronary heart disease

inhalation anesthetic

Inhaled ingredients: O2, N2O (laughing gas), analgesic and sedative drugs (halothane or fluorine)

Adverse reactions: hypoxia; inhalation anesthesia is contraindicated in patients with intestinal obstruction, pneumoperitoneum and bullous pneumothorax, as it will increase the pressure in the closed chamber.

Enflurane (Enflurane)

Can reduce intraocular pressure, beneficial for intraocular surgery (glaucoma surgery)

The EEG shows epileptiform seizures during deep anesthesia. People with a history of epilepsy should use it with caution.

Isoflurane

Strong anesthetic effect: high oil/gas ratio and high fat solubility.

MAC (minimum alveolar effective concentration): 50% of patients have no response to skin incision: 1.15%. (The lower, the better)

It has obvious dilation of peripheral blood vessels and can be used for controlled lowering of blood pressure.

However: using a mask for inhalation induction before intubation has an irritating smell and can easily cause the patient to cough and hold his breath.

Therefore, it is not commonly used clinically

Sevoflurane

Most commonly used clinically

Strong anesthetic effect: high oil/gas ratio or fat solubility

MAC：2%

It has an aromatic smell and can be induced by inhalation through a mask. The incidence of coughing and breath holding is very low.

Seven fairies, fragrant

Desflurane

It has little impact on circulation and is often used in cardiac surgery or non-cardiac surgery for patients with heart disease.

kind hearted

Mostly used in outpatient surgeries: low blood/gas distribution coefficient, less anesthetic absorbed into the blood, high controllability, and quick recovery

Induction and maintenance of general anesthesia

induce

Mask inhalation anesthetics or intravenous administration: propofol, etomidate, midazolam.

When the patient loses consciousness and enters anesthesia, a laryngeal mask or endotracheal intubation is performed after intravenous injection of muscle relaxants.

maintain

Static-inhalation combined general anesthesia

Intravenous anesthesia: analgesia, sedation, muscle relaxation

Inhalation anesthesia: O2, N2O, volatile anesthetics

General anesthetics for coronary heart disease

Viidirid

The only Rui, my heart

Vitamin: Vecuronium bromide

Etomidate

Ground: Desflurane

Rui: remifentanil