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anesthesiology
Anesthesiology is an important part of clinical medicine. It is a discipline based on physiology, pharmacology and polar molecular physiology. It studies the mechanism of anesthesia, the theory of pain physiological recovery, etc. The basic task of anesthesia is to eliminate pain and provide safety for smooth operation. Ensure the regulation and control of the patient's pathological and physiological conditions.
Edited at 2024-11-20 21:31:10
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anesthesiology
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- Outline
central theme
introduction
CC
Using drugs and other methods to temporarily render the patient's entire body or part of the body unconscious has achieved the goal of being painless.
subtopic
It is an important part of clinical medicine. It is a discipline based on physiology, pharmacology and polar molecular physiology. It studies the mechanism of anesthesia, the theory of pain physiological recovery, etc. The basic task of anesthesia is to eliminate pain and provide safety and regulation for the smooth operation of the operation. and controlling the patient's pathological and physiological conditions.
category
anesthesiology
clinical anesthesia
Severe disease detection and treatment
pain treatment
First aid and resuscitation
Anesthesia method
General anesthesia
intravenous anesthesia
inhalation anesthesia
Combined intravenous and inhaled anesthesia
local anesthesia
neuraxial anesthesia
subarachnoid block
epidural block
sacral block
nerve block
area block
local infiltration anesthesia
topical anesthesia
Fafafa
Pre-anesthesia condition assessment
The American Society of Anesthesiologists (ASA) divides the condition into five levels, which is an important reference value for disease judgment.
The body is healthy and well developed, and all organs are normal.
There were mild complications and the function was well compensated.
The complication is severe and the foot is limited in activities, but it can cope with daily activities.
Complications severely incapacitate daily activities and threaten life.
Regardless of surgery or not, life cannot be maintained for 24 hours for each patient.
Level 1 to 2 patients have good tolerance to anesthesia and surgery and are less risky. Although the organ functions of level 3 patients are within the compensatory range, their ability to tolerate anesthesia and surgery is weakened and the risk is greater, such as With adequate preoperative preparation, patients with Level 4 can tolerate anesthesia. Due to insufficient organ function compensation, anesthesia and surgery are very risky. Even if preoperative preparation is adequate, the perioperative mortality rate is still high. Level 5 patients are near death. For patients, anesthesia and surgery are extremely dangerous and should not be performed.
Preparations before anesthesia
Correct or improve pathophysiological conditions
Counting money should correct dehydration, electrolyte imbalance and acid-base balance imbalance in malnutrition.
Surgical patients often have medical diseases. Anesthesiologists should fully understand their pathophysiological changes and correctly evaluate their severity. If necessary, please ask internal medicine experts to assist in diagnosis and treatment.
People with heart disease who drink ice should pay attention to improving heart function.
For patients with a history of treating heart failure, atrial fibrillation, or significant heart enlargement with yellow-type drugs, the drug should be stopped on the day of surgery.
For those who take long-term beta receptor tissue agents to treat angina pectoris, arrhythmia and hypertension, it is best to stop taking the medicine 24 to 48 hours before surgery.
He Bin Hypertensive patients should control their blood pressure. It is safer to stabilize the systolic blood pressure below 180 mmHg and the diastolic blood pressure below 100 mmHg. Antihypertensive drugs should avoid the use of central antihypertensive drugs or enzyme inhibitors, which may occur during anesthesia. Hypotension and bradycardia, other antihypertensive drugs can be continued until the day of surgery.
For patients with respiratory system diseases, preoperative functional examination, arterial blood gas analysis and lung X-ray film are required.
Stop smoking for at least two weeks and perform respiratory function exercises.
New culture and chest physiotherapy to promote expectoration.
Apply effective antibiotics for 3 to 5 days to control chronic lung infections.
For patients with diabetes mellitus and penis, their fasting blood sugar should be controlled by surgery to be no higher than 8.3. The stranger's urine sugar should be lower than two home urine ketones and negative.
Patients with severe acidosis in the emergency department should lower their insulin, eliminate ketone bodies, and correct the acidosis before surgery.
For those who require immediate surgery, although insulin infusion can be supplemented during the surgery and poisoning corrected, the risk of anesthesia is significantly increased.
mental state preparation
Patients are inevitably nervous and anxious before surgery, and even have a sense of fear. This psychological state has varying degrees of physiological disturbance and has a significant impact during the entire surgery. Therefore, in the room, the patient is treated with rapport and encouragement. , eliminate their worries and anxiety, and strengthen doctor-patient communication.
When necessary, the anesthesia method can be adjusted as appropriate. If there are situations that may occur during the operation that are not necessary for the market, appropriate explanations should be given to the patient, and the patient's questions should be listened to and answered patiently to gain the patient's understanding, trust and cooperation.
Those who are too nervous and difficult to control should be treated with medication
Gastrointestinal tract preparation
The position should be routinely evacuated before surgery to avoid reflux of gastric contents, vomiting, and Wuxi that may lead to suffocation and aspiration pneumonia during the repair.
Preparation of anesthesia equipment and drugs
No matter what kind of anesthesia is performed, anesthesia machine, first aid equipment and medicines must be prepared.
During anesthesia, in addition to monitoring the patient's vital signs such as blood pressure, respiration, pulse and body temperature, the patient's vital signs such as pulse oxygen saturation, end-tidal carbon dioxide partial pressure, direct arterial pressure and central venous pressure should be selected according to the condition and conditions.
Before anesthesia is carried out, the prepared equipment and supplies should be inspected and verified again, mainly checking the degree of anesthesia and sealing, air source and pressure, and checking the anesthesia laryngoscope, tracheal tube and connecting tubes.
The medicines used in the book must be checked before use
Pre-anesthetic medication
The purpose of pre-anesthetic medication
A cortical and subcortical or limbic system produces a relaxation of consciousness, which can also significantly reduce the amount of anesthetics and improve the body's tolerance to anesthetics.
Improve control, block the transmission of pain stings to the central nervous system, weaken the pain response and enhance labor pain, making up for the insufficient analgesia of some anesthesia methods.
Reduce voluntary muscle activity, reduce oxygen consumption, reduce basal metabolic rate, use anesthetic dosage to reduce the side effects of anesthetic application, and reduce the smoothness of the anesthesia process.
It can reduce the acute weakening of autonomic neuropathy and reduce the excitability of parasympathetic reflexes, while catecholamines release antagonistic histamine and Xu Ruoxin body secretion activity ensures smooth respiratory tract and stable circulatory function.
drug selection
When taking medication before anesthesia, the type of medication, dosage, route and time of administration should be selected according to the anesthesia method and condition.
Patients under general anesthesia mainly use sedatives and anticholinergics. Those with severe pain can use home narcotic analgesics, which can not only relieve pain, but also enhance the effect of canine anesthetics.
Pony patients mainly use sedatives, and epidural anesthesia is very nervous or impossible, and it is necessary for the collaborator to provide analgesia.
If I choose to use a bottle of Sodium Pentate in a single bottle, will my right be exercised? Atropine should be used in patients with bradycardia before neuraxial anesthesia and undergoing upper abdominal or pelvic surgery, except for the contraindications for the use of atropine when traveling.
The dosage of sedatives for patients with coronary heart disease and hypertension can be appropriately increased. For patients with poor heart valve disease and severe illness, the dosage of sedatives and analgesics should be reduced, and the anticholinergic drug should be reduced to scopolamine.
The general condition is poor. The elderly and infirm patients with cachexia and hypothyroidism are sensitive to hypnotic sedatives and analgesics. The dosage should be reduced, while the dosage of young, strong and hyperthyroid patients should be increased.
For those who are nervous, oral hypnotics or sedatives can be taken before surgery to eliminate the patient's nervousness.
Routine pre-anesthetic medication
sedative hypnotics
Ethanol or acetaldehyde oxide belongs to the range of basic anesthetics such as chloral hydrate, etc.
Barbiturates mainly use long-acting Luminana, which is 100 to 200 mg per kilogram for sleep quality, and the small dose is 2 to 4 mg per kilogram, remembering two hours before anesthesia.
neuroleptics
Narcotic analgesics
Ma Fei
Ma Fei has the effects of improving strong control, sustaining metabolism and significantly changing the mental state. Remember that after 15 minutes, the blood circulation will increase by 53%. After ten minutes, emotional stability, anxiety, and psychological disappearance will appear. It means that after 60 minutes, the basal metabolic rate will significantly reduced.
Try to administer 0.15 to 0.2 mg per kilogram with 1 to 1.5 hours before anesthesia, remember, for children 2 to 7 years old, use 1 to 1.5 mg, for 8 to 12 years old, use 2 to 4 mg, remember.
Bronchospasm disease, diabetes, renal insufficiency, hepatic insufficiency in pregnancy are felt in the economy.
neuroleptic analgesics
benzodiazepines dzepam diazepam
The seventh shot is that if diazepam drugs act on the limbic system of the brain to react to emotions, they can selectively inhibit and relieve fear and anxiety, thereby guiding sleep and forgetfulness. They also have anticonvulsant and central muscle relaxant effects, which can reduce non-depolarization. Dosage of muscle relaxants and succinylcholine.
As a pre-anesthetic drug, diazepam is especially suitable for patients with poor general condition, poor circulatory function, heart disease shock and nervousness. When combined with scopolamine, diazepam has stronger hypnotic effect, and patients with severe neuropathy and neurotic patients can start taking low-dose medication after hospitalization. Can reduce their emotional reactions.
The commonly used dosage is 0.1 to 0.2 mg per kilogram. Take oral intramuscular or intravenous injection and then go to sleep 1 to 2 minutes later and maintain it for 20 to 50 minutes. Repeat the injection of 1/2 of the first dose as needed.
anticholinergic drugs anticholinergic drugs
atropine
The usual dosage of subcutaneous or intramuscular injection for adults is 0.4 to 0.8 mg. An increase in heart rate occurs in 5 to 20 minutes. At 45 minutes, the secretion of respiratory glands and salivary glands is significantly reduced, lasting for 2 to 3 hours. The entering dose is 11/2 minutes of the subcutaneous dose. Effect lasts about 30 minutes.
Scopolamine
The best effect is to use Dongfang's prison and Ma Fei together in a ratio of 125
For the inhibitory effect of body secretion, it is more effective than atropine.
The elderly, children or patients with severe pain may experience agitation and delirium as side effects after use.
The usual dose is 0.3 to 0.6 mg given subcutaneously or intramuscularly 30 minutes before anesthesia.
You can also take pictures to enhance the sedation effect of soldiers.
Things to consider immediately before anesthesia
In terms of patients, health conditions, mental status, special conditions, and patient complaints.
In terms of anesthesia, anesthesia implementation plan, intravenous infusion route, central venous pressure monitoring route, etc.
Anesthesia equipment Yangyuan nitrogen dioxide source, anesthesia machine, monitor, endotracheal intubation equipment, general equipment.
Drugs, narcotic drugs, auxiliary drugs, hormone drugs, first aid drugs.
Surgical plan, surgical site incision surgery, special requirements for anesthesia for urgent surgery, surgical position, measures to prevent surgical position injury, postoperative analgesia requirements, etc.
Intraoperative management, anticipated possible unexpected complications, emergency measures and treatment plans were comforted.
Commonly used anesthetics
general anesthesia
CC
subtopic
The anesthetic is inhaled through the respiratory tract or injected intravenously or intramuscularly into the body, stimulating the will of the central nervous system. The clinical manifestations include loss of consciousness, loss of pain throughout the body, amnesia, reflex suppression and a certain degree of muscle relaxation. This method is called general anesthesia.
Four elements of general anesthesia
I don't know how to relax, and I always react urgently.
general anesthetic
inhalation anesthetic
Inhalation anesthetics refer to drugs that are inhaled into the human body through the respiratory tract and produce general anesthesia. They are generally used for the maintenance of general anesthesia and sometimes for the induction of anesthesia.
An ideal anesthetic drug should meet the following conditions
The anesthetic effect is positive and has no accumulation effect.
Wide safety range
The anesthetic effect is strong and can be used at a much lower level.
It wakes up quickly, comfortably and smoothly.
It is chemically stable and does not produce toxic substances when in contact with other drugs.
The metabolism rate in the body is low and the metabolites are non-toxic.
No combustion explosiveness
Simple to manufacture, purify and cheap
Produce good muscle relaxation
Can inhibit bad autonomic nervous reflexes
to relax the bronchial tubes
No odor and no irritating effect on the airway.
Keep listening to the breathing cycle
Does not increase myocardial responsiveness to catecholamines
No toxicity to liver and kidneys
I am dependent and addictive
No carcinogenic or teratogenic effects
Physicochemical properties and pharmacological properties
The minimum effective alveolar concentration, mac, refers to the lowest alveolar concentration of a certain inhaled anesthetic that, when inhaled at one atmospheric pressure and important at the same time, can prevent 50% of patients from shaking their heads during skin incision and allowing the movement of limbs to respond.
MV c is the equivalent driving concentration of different anesthetics, which reflects the effectiveness of anesthetics. Is the smaller the mac? The smallest energy is stronger.
The distribution coefficient is the anesthetic concentration ratio when the anesthetic partial pressure reaches equilibrium among the two items. The distribution coefficients of muscle blood and blood are important factors in determining the community distribution and elimination of inhaled anesthetics.
The strength of inhaled anesthetics is directly proportional to the oil and gas distribution coefficient. The higher the oil and gas distribution coefficient, the greater the anesthesia intensity and the smaller the mac. The controllability of inhaled anesthetics is related to its blood gas distribution coefficient. The lower the blood gas distribution coefficient, the better. The easier it is for the partial pressure in the alveolar blood tissue to reach equilibrium, and therefore the easier it is to control the concentration in the central nervous system.
The transport process of inhaled anesthetics in the body
Physicochemical properties of inhaled anesthetics
Factors affecting anesthetic efficacy
Factors affecting alveoli, drug concentration.
When talking about fat, Effie refers to the concentration of inhaled anesthetics in the alveoli. Clinically, fab f1 is often used to compare the rising speed of the alveolar concentration of different drugs. The speed depends on the delivery oil of the anesthetic and the speed of uptake by the pulmonary circulation. Copper organ effect.
Ventilation effect, increased alveolar ventilation, accelerated AI, height and fab f1 rise rate.
Concentration effect: The concentration of inhaled drugs can not only affect the level of the drug, but also affect the rate of rise, which is called the concentration effect.
When the new displacement co and the pulmonary ventilation remain unchanged, the sale increases the blood flow of the pulmonary circulation and also increases the blood community medicine, which increases and relieves boredom.
Blood gas distribution coefficient, the higher the blood gas distribution coefficient, the more anesthetic materials will be absorbed into the blood, the anesthetic concentration in the bubble will increase, the anesthesia induction period will be prolonged, and the recovery from anesthesia will be slower.
The greater the concentration difference f AV f AV between the anesthetic drug in the alveoli and venous blood, the greater the amount of drug in the waste circulation community, and the more anesthetic drug will be taken away from the alveoli by the boiling blood.
Metabolism and toxicity
It is difficult to metabolize and absorb anesthetic drugs in their original state, and a small amount of them are excreted from the respiratory tract and excreted in the urine after being excreted by the kidneys. The cytochromes in the liver are not taken in some places. P450 is an important drug for oxidative metabolism.
Toxicity: Toxicity is related to the drug’s metabolic rate, metabolic intermediates and final metabolites. The lower the metabolic rate, the lower the toxicity. For those with chronic renal insufficiency or those who have not used induction drugs, use halogen Western drugs with caution.
Common inhalation anesthetics
nitrous oxide laughing gas dinitrogen oxide
The anesthetic property is weak, mac is 105%, it has a certain inhibitory effect on the myocardium, and has a contraction effect on the pulmonary vascular smooth muscle, which can cause an increase in cerebral blood flow, slightly increase the intracranial pressure, and affect the liver and kidneys.
Damn it, diffuse hypoxia can occur during the recovery period, which can increase the intracrine pressure in the body and is contraindicated by intestinal obstruction.
Avomi
It has strong anesthetic properties, with a mac of 1.7%, which can enhance the effect of non-depolarizing muscle relaxants.
It can increase cerebral blood flow and intracranial pressure in a consistent manner, and can be somewhat infertile and explosive inhibitors, inhibiting peripheral vasodilation metabolites, f, and nephrotoxicity, which can enhance myocardial sensitivity to catecholamines.
Clothes-finished clothes-obsessed
The anesthetic property is strong (mac is 1.15%), which can dilate cerebral blood vessels, increase cerebral blood flow and increase blood pressure, but can be used as an appropriate excessive antagonism at the same time. The inhibitory effect on the myocardium is light, the latest output is small, and the peripheral blood is significantly reduced. It can reduce vascular resistance, reduce arterial pressure, dilate coronary arteries, and may cause coronary steal and stimulate the stomach. Its relaxing effect on bronchial smooth muscle can enhance the effect of non-depolarizing muscle relaxants.
Anesthesia is maintained for 11 hours to maintain circulatory function. After stable drug withdrawal, recovery is faster, about 10 to 15 minutes. It has slight myocardial suppression but significant peripheral blood vessel dilation. Infants can be used for controlled blood pressure reduction.
Bully me and bully you
It has strong anesthetic properties, with an admitted mvc of 2%. It has an inhibitory effect on cns. Cerebral vasodilation can cause an increase in intracranial pressure. It has mild inhibition on myocardium. It can reduce peripheral vascular resistance and cause arterial pressure and cardiac output. When lowered by more than 1.5mm, it has a significant relaxing effect on the can, which may cause coronary blood flow. It is not irritating to the respiratory tract and does not increase secretions. It has a relaxing effect on the tracheal smooth muscle and can enhance the non-depolarizing muscle relaxant effect. and extend the action time.
The use of a mask has a very low incidence of choking and weapons, maintains a stable circulation during anesthesia, and ultimately ensures a smooth recovery process, and a low incidence of nausea and vomiting.
But when the temperature in the ash rises, decomposition can occur.
intravenous anesthetic
definition
Drugs that enter the body through intravenous injection and act on the central nervous system through blood circulation to produce general anesthesia are called intravenous anesthetics. Their advantages are fast induction, no irritation to the respiratory tract, and no environmental pollution.
Type of anesthetic tonight
Thiopental sodium
Ultra-short-acting, barbiturate intravenous general anesthetic solution is highly alkaline and easily penetrates the blood-brain barrier. Small-dose intravenous injection has a sedative and hypnotic effect. A slightly larger mass can make the patient fall asleep and reduce the brain's oxygen consumption. Reducing cerebral blood flow and intracranial pressure directly inhibits myocardial vasodilatation and lowers blood pressure. It also has a central respiratory depression effect. Sympathetic or parasympathetic nerve effects are relatively enhanced. Time and bronchial sensitivity are increased, which can easily cause laryngospasm. and bronchospasm.
Clinical application of general anesthesia to induce anesthesia for minor surgeries to control convulsions and basic anesthesia in children.
Subcutaneous injection can cause tissue necrosis, and intra-arterial injection can cause severe pain in arterial spasm and necrosis of distal limbs.
Ketamine
Both Shentong and Shentong are significant, which can increase cerebral blood flow, intracranial pressure and brain slope. Copper sulfate can excite sympathetic nerves, increase heart rate, blood pressure and pulmonary artery pressure. However, Yuantong can treat patients with hypovolemic shock and highly excited sympathetic nerves. Can exhibit myocardial depressant effect, round Tongtong can increase saliva and bronchial secretions and have a slight effect on bronchial smooth muscle relaxation. However, if the dosage is too large or the injection speed is too fast, other narcotic analgesics can cause significant respiratory depression and even apnea, so it should be Be particularly vigilant.
Clinical application can be used for induction of general anesthesia and is often used for basic anesthesia in children.
The main side effects include nightmares and psychosis in patients with transient apnea, as well as increased intraocular pressure and intracranial pressure.
Etomidate rice paper
The analgesic effect of short-acting hypnotic drugs can reduce brain flow, intracranial pressure and metabolic rate, but has little effect on heart rate, blood pressure and cardiac output, does not increase myocardial oxygen consumption, and has a mild coronary artery dilation effect.
Clinical application is mainly used for induction of general anesthesia, suitable for anesthesia of elderly, frail and critically ill patients.
The main side effects include myoclonus often occurring after injection, irritation to foreign bodies, nausea and vomiting, and adrenocortical function may be suppressed after repeated or continuous intravenous infusion.
Pruber's service is 10 points and it doesn't matter.
It has a sedative-hypnotic effect and a slight analgesic effect. It has a rapid onset of action and can completely reduce cerebral blood flow, intracranial pressure and brain metabolic rate after waking up after stopping the drug. It has a significant inhibitory effect on the cardiovascular system. The tributary sodium pentotal has a significant inhibitory effect on respiration, and the degree of inhibition is dose-related.
Clinical application is for intravenous general anesthesia, and induction is used for outpatient surgery. Anesthesia has great advantages.
Side effects have a stimulating effect on veins and a long-lasting inhibitory effect on breathing. The exchange of sodium pentotal is stronger. Artificial assisted respiration should be performed if necessary. The incidence of nausea and vomiting after anesthesia is about 2 to 5%.
Muscle relaxants
Classification
molecular structure
No matter how tired you are
Fat Tiger Hope
Vecubromide
Rocuronium
space likes
Isoquinolines
And Xuandong prison suddenly reduced
Akusian
miva likes
They are all crying!
Action time
short sleeves
lieutenant colonel
Long lasting
Mechanism of action
Neuromuscular union does not include the pre-protruding membrane, the post-protruding membrane and the protruding membrane between the anterior and posterior membranes. Under physiological conditions, when nerve excitement is transmitted to the motor nerve terminal, it causes the vesicles located in the presynaptic membrane to rupture. Acetylcholine is released into protruding muscles and combines with acetylcholine receptors in the postsynaptic membrane, causing muscle fibrosis and inducing muscle contraction.
Hormone drugs mainly interfere with the conduction of nerve impulses at the junction. According to different interference methods, hormonal drugs are mainly divided into two categories: depolarizing muscle relaxants and non-depolarizing muscle relaxants.
Urgent drug delivery is the abbreviation of skeletal muscle relaxants. Since Tongjianton was first used in clinical practice in 1942, emergency drug delivery has become an important part of general anesthesia. Hormone drugs can only paralyze skeletal muscles without producing anesthetic effects. They cannot It makes the patient's consciousness and feeling disappear without causing amnesia. Muscle relaxants not only facilitate the surgical operation, but also help avoid the harm caused by deep anesthesia.
Implementation of general anesthesia
Induction of general anesthesia
inhalation induction method
open drip approach
Mask inhalation induction method
Intravenous, induction method.
Maintenance of general anesthesia
Inhalation anesthetic maintenance
intravenous anesthetic maintenance
Combined general anesthesia
General anesthesia depth judgment
Complications and management of general anesthesia
local anesthesia
Local anesthetic pharmacology
Local anesthesia method
Effect on the body
Adults should fast for 12 hours and drink for four hours before elective surgery to ensure emptying.
Children should fast for 4 to 8 hours before surgery and drink water for 2 to 3 hours. Even sick patients should also give full consideration to gastric emptying.
For patients who need immediate surgery, even if regional tissue or spinal anesthesia is used, there is a risk of vomiting and Wuxi. When choosing general anesthesia, endotracheal intubation can be considered to avoid or reduce the occurrence of vomiting and aspiration.
For children, the dose is calculated as 0.01 mg per kilogram. If necessary, it can be increased to 0.02 mg per kilogram, but facial flushing will be obvious.