Efrem Osipovich Mukhin 1766 - 1850

Fedor Ivanovich Inozemtsev 1802 - 1869

Nikolai Ivanovich Pirogov 1810 -1881

Vladimir Aleksandrovich Negovsky 1909 – 2003

2. History of domestic anesthesiology and resuscitation

3. History of domestic anesthesiology and resuscitation

4. History of domestic anesthesiology and resuscitation

1. History of anesthesiology

General anesthesia

Anesthesia components

1. Stages of anesthesia (using the example of ethereal) Gwedel’s classification modified by I.S. Zhorov

2. Stages of anesthesia (using the example of ethereal) Gwedel’s classification modified by I.S. Zhorov

Stages of general anesthesia

1. Study of anamnesis

2. Study of anamnesis

3. Study of anamnesis

4. Study of anamnesis

Objective examination

Special studies

Risk assessment

1.ASA scale

1.ASA physical status scale

Mortality after anesthesia and surgery for each ASA physical status (emergency and elective)

premedication

Drugs used for premedication

Plan of conversation with the patient during the preoperative examination

Goals of pharmacological premedication

Induction of anesthesia

Maintenance of anesthesia

Recovery from anesthesia

1. Complications and difficulties

opens with negative pressure
36

It should be noted that this form of obstruction is not anatomical in origin - but physiological

Final prototypes Nunn used in his research*

Classification of sealing strategies using supraglottic airways:

2. Complications and difficulties

3. Complications and difficulties

1.Monitoring during anesthesia

2.Monitoring during anesthesia

3.Monitoring during anesthesia

Postoperative management

Infusion therapy The advent of infusion therapy revolutionized medicine, in other words, through infusion therapy, for the first time, it was possible to temporarily replace one of the very important functions of the body - the function of the gastrointestinal tract. The birthday of infusion therapy should be considered July 10, 1881. Landerer successfully infused a patient with a “physiological solution of table salt,” ensuring the immortality of this infusion medium.

Infusion therapy Back in 1830, there were attempts to introduce infusion therapy into the clinic for the treatment of cholera, but they were not successful, because a solution of sodium bicarbonate was used to correct losses, and at that time they were not even aware of ASR.

Infusion-transfusion therapy The next significant stage in the development of infusion therapy was the discovery of blood groups and the Rh factor. Since that time, infusion therapy began to be called infusion-transfusion, which implies the transfusion of blood and its components. Blood groups were discovered in 1900, and the Rh factor was discovered only in 1939; these discoveries significantly expanded the capabilities of medicine, primarily surgery.

The main reasons for prescribing intravenous infusion: Pre- and intraoperative fluid deficiency and blood loss Dehydration and hypovolemia Disturbances of blood coagulation and its oxygen capacity Disorders of water-electrolyte homeostasis Administration of drugs and nutrients

It is necessary to strive for the following intraoperative indicators: CVP 6 -10 cm water. st; Heart rate 60 -90 per minute; Mean blood pressure >70 mm. rt. Art. ; The wedge pressure in the pulmonary capillaries is 10 -15 mm. rt. st; Cardiac index 2.5 -4.5 l/min per 1 m2; Oxygen saturation >80%

The main components and purpose of intravenous infusion: Crystalloids (saline solutions) - replenishment of extracellular fluid and electrolytes Means for the correction of CBS: Sodium bicarbonate Colloidal solutions (artificial and natural) - replenishment of intravascular volume Blood products and fresh frozen plasma - “component” hemotherapy, replenishment of intravascular volume volume

Artificial colloidal solutions There are 3 main groups used: - Dextrans - Hydroxyethyl starch preparations - Gelatin preparations - Preparations based on polyethylene glycol

Hydroxyethyl starch preparations are an artificial glycogen-like polysaccharide that is obtained from corn starch. Tetrastarch (Venofundin 6% solution; Voluven 6% solution; Tetraspan 6 and 10% solution) Getastarch (Stabizol 6% solution) Pentastarch (Hemohes 6 and 10% solution; Infucol GES 6 and 10% solution p; Refortan N 6% solution and plus - 10% solution; HAES-steril 6 and 10% solution

Indications for HES: hypovolemia, prevention and treatment of hypovolemic shock. Contraindications: hyperhydration, renal failure, intracranial bleeding, severe hyperkalemia, children under 2 years of age, CHF.

Tetrastarch Drugs with an average molecular weight of 130,000 and a degree of substitution of 0.4. The effect lasts on average 4 hours. Adults 50 ml/kg; children and adolescents over 10 years old 33 ml/kg; children under 10 years of age and newborns 25 ml/kg. The maximum daily dose of a 10% solution is 30 ml/kg.

Getastarch A drug with an average molecular weight of 450,000 and a degree of substitution of 0.6 -0. 8. Volemic effect 100% within 4 hours. Give 500-1000 ml, maximum 20 ml/kg on the first day.

Pentastarch A drug with an average molecular weight of 200,000 and a degree of substitution of 0.5 6% isotonic solution, 10% hypertonic solution. Volemic effect 6% - 100%, 10% - 130140% within 4-6 hours. Enter 10% - 20 ml/kg, 6% 33 ml/kg or 5001000. The total dose is not more than 5 liters for 4 weeks.

Hyper. HAES Molecular weight 200000, degree of substitution 0.5 with addition of sodium chloride solution to 7.2%. Hypertonic isotonic solution. Injected once for 2-5 minutes, 4 ml/kg (250 ml for a patient 60-70 kg). Better in the central vein.

Dextrans are natural polysaccharides of bacterial origin that have undergone acid hydrolysis. High molecular weight dextrans Polyglucin; Polypher; Polyglucol; Rondferrin (stimulator of hemipoiesis after a course of chemotherapy and radiation therapy) Low molecular weight dextrans Reopolidex; Hemostabil Reopoliglyukin; Reomacrodex Dextran + mannitol = Reogluman Prolit

Polyglucin is a 6% solution of the medium molecular fraction of partially hydrolyzed dextran. Polyglucin has an average MW of 60,000 ± 10,000 and is a colorless or slightly yellowish liquid. The drug is sterile, non-toxic, pyrogen-free. Indication: hypovolemia and massive blood loss. In case of developed shock or acute blood loss - intravenous injection, 0.4–2 l (5–25 ml/kg). After increasing blood pressure to 80–90 mm Hg. Art. usually switch to drip administration at a rate of 3–3.5 ml/min (60–80 drops/min). For burn shock: in the first 24 hours, 2–3 liters are administered, in the next 24 hours - 1.5 liters. For children, in the first 24 hours - 40–50 ml/kg, in the next day - 30 ml/kg.

Polyfer is a modification of polyglucin. It contains dextran with an MW of 60,000 and iron in the form of an iron-dextran complex. Indications for use: prescribed for traumatic, burn, hemorrhagic, surgical shocks. Contraindications: the drug cannot be used in patients with traumatic brain injuries, pulmonary edema and circulatory failure. Injected intravenously in a stream of 400 to 1200 ml per day.

Polyglucol is a 6% solution of dextran with an MW of 70,000 ± 10,000 with the addition of salts balanced in ionic composition. Indications for use. Traumatic and burn shock, acute blood loss and various conditions accompanied by hypovolemia, combined with disturbances in water and electrolyte balance, as well as metabolic acidosis. Dosing: if the biological test is positive, the drug is administered in the amount of 400-1200 ml on the first day, 200-400 ml on the second. Contraindications: pulmonary edema, decompensation of cardiovascular activity, high blood pressure, traumatic brain injury with increased intracranial pressure, etc., individual intolerance.

Reopolyglucin is a 10% solution of low molecular weight dextran with reduced viscosity and an average MW of 35,000. Indications for use: prescribed for traumatic, surgical and burn shocks. Hypovolemia, violation of the rheological properties of blood, prevention of thrombosis. Contraindications: thrombocytopenia, with chronic kidney disease, as well as in patients for whom intravenous administration of large amounts of fluid is contraindicated. Individual intolerance. Intravenously 400-1200 ml/day and no more than 5 days. For children, the total dose should not exceed 15 ml/kg/day. During cardiovascular operations, children under 2–3 years of age are administered 10 ml/kg 1 time per day (for 60 minutes), up to 8 years - 7–10 ml/kg (1–2 times per day), up to 13 years old - 5–7 ml/kg (1–2 times a day), over 14 years old - adult dose. For detoxification, 5–10 ml/kg is administered over 60–90 minutes.

Reomacrodex is a plasma replacement agent based on dextran with an MW of 40,000. Indications for use. Microcirculation disorders in shock, burns, fat embolism, pancreatitis, peritonitis, paralytic ileus, traumatic and idiopathic hearing loss; slowing of arterial and venous blood flow with the threat of gangrene, Raynaud's disease, acute stroke; prevention of thrombus formation on grafts (heart valves, vascular grafts). If microcirculation is impaired due to shock or other reasons, 500 to 1000 ml (10–20 ml/kg) are administered dropwise; for circulatory disorders - intravenous drip from 500 to 1000 ml on the 1st day; the next day and every second day for 2 weeks - 500 ml. thromboembolism 500-1000 ml, 2-1 day 500 ml. Reactions and complications. Feeling hot, chills, fever, nausea, skin rash; anaphylactic reactions with the development of mypotonia and vascular collapse, oliguria are possible. Contraindications: thrombocytopenia, oligo- and anuria.

Reogluman is a 10% solution of dextran with an MW of 40,000 ± 10,000, with the addition of 5% mannitol and 0.9% sodium chloride. Indication: improvement of capillary blood flow, prevention and treatment of microcirculation disorders. The drug is indicated for traumatic, surgical, burn, cardiogenic shocks, accompanied by impaired capillary blood flow, for impaired arterial and venous circulation (thrombosis and thrombophlebitis, endarteritis and Raynaud's disease), to improve local circulation in vascular and plastic surgery, for detoxification purposes in burns, peritonitis and pancreatitis. Method of administration and dose. Reogluman is administered intravenously by drip, slowly. Start the infusion with 5–10 drops. /min for 10–15 min. After this, a break is taken to determine biological compatibility. If there is no reaction, continue administration at a rate of 30–40 drops. /min. 400-800 ml each. Contraindications. Excessive hemodilution (with a hematocrit below 25%), hemorrhagic diathesis, cardiac or renal failure, severe dehydration, allergic conditions of unknown etiology.

Hemostabil is a molecular dextran with mm 35000 -45000. Indications: Prevention and treatment of traumatic, surgical and burn shock; disorders of arterial and venous circulation, treatment and prevention of thrombosis and thrombophlebitis, endarteritis; for addition to the perfusion fluid during cardiac operations performed using a heart-lung machine; to improve local circulation in vascular and plastic surgery; for detoxification of burns, peritonitis, pancreatitis. Diseases of the retina and optic nerve, inflammatory processes of the cornea and choroid. Contraindications: Hypersensitivity, thrombocytopenia, kidney disease with anuria, CHF and other conditions in which it is undesirable to administer large amounts of fluid; fructose-1, 6-diphosphatase deficiency, pulmonary edema, hyperkalemia. Inject 400-1000 ml per day.

Promit is a dextran-based drug with an MW of 1000. Indications for use. Prevention of severe anaphylactic reactions to intravenous administration of dextran solutions. Method of administration and dose. Adults are injected intravenously with a bolus of 20 ml (for children - at the rate of 0.3 ml/kg body weight) of promite 1–2 minutes before the intravenous administration of dextran solution. If more than 15 minutes have passed, the drug should be re-administered. Contraindications. Use with caution during pregnancy and lactation.

Gelatin preparations are a denatured protein obtained from collagen of animal tissues. Gelatinol 8% solution Gelofusin 4% solution Modelel 8% solution – a preparation of deionized gelatin, one-time dose up to 2 l/day.

Gelatinol is an 8% solution of partially hydrolyzed gelatin. It is a clear, amber-colored liquid with an MW of 20,000, which foams easily when shaken and contains some amino acids. Indications for use: used for traumatic and burn shocks, as well as for the prevention of surgical shock. It is used as a means of restoring hemodynamics in case of severe blood loss, as well as for filling the heart-lung machine during open-heart surgery. Method of administration and dose. Prescribed intravenously (drip or stream) both once and repeatedly. It can also be administered intra-arterially. The total infusion dose is up to 2000 ml. Gelatinol infusions usually do not cause adverse side effects or complications in the patient. Contraindications. Administration of gelatinol is not indicated for acute kidney diseases. Volemic effect 60% within 1-2 hours.

Gelofusin is a solution of modified liquid gelatin for intravenous infusion. Indications for use: in case of hypovolemia to replenish blood volume, to prevent a possible drop in blood pressure during spinal or epidural anesthesia, hemodilution, extracorporeal circulation. Contraindications: hypersensitivity, hypervolemia, hyperhydration, severe heart failure, blood coagulation disorders Volemic effect within 3-4 hours, in the amount of 100% Administer up to 200 ml/kg, one-time up to 2000 ml.

Polyethylene glycol preparations. Polyoxidin - 1.5% solution of polyethylene glycol-20000 in 0.9% isotonic sodium chloride solution. Indications for use. Hypovolemic conditions due to acute blood loss, post-traumatic and surgical shock in adults. Method of administration and dose. Administered intravenously (stream or drip). Doses and speed of administration depend on the indications and condition of the patient. For various forms of shock, polyoxidine is administered intravenously in a stream until blood pressure rises to a physiological level, after which they switch to drip administration at a rate of 60–80 drops. /min. The dose of the administered solution is 400 – 1200 ml/day (up to 20 ml/kg). During operations, in order to prevent surgical shock, the drug is administered intravenously (60–80 drops/min), followed by jet administration with a sharp decrease in blood pressure. Contraindications. Traumatic brain injury accompanied by increased intracranial pressure; diseases for which intravenous administration of large doses of fluid is contraindicated.

Crystalloid solutions Ionic solution 5% and 10% glucose, potassium, magnesium Sodium chloride Disol Acesol Trisol Quantasol Plasma-Lit, Plasma_Lit with 5% glucose solution Ringer-Locke solution Hartmann solution

Crystalloids with antihypoxic action Mafusol (adults up to 2-3/day, children 3035 ml/kg/day; severe shock adults 1 l/day, children 15 ml/kg/day) Polyoxyfumarin (400-800 ml, max. up to 2 L/day, 1-3 days) Reambirin (adults 400-800 ml/day, children 10 ml/kg once a day. Course 2-12 days.)

Principles for calculating the volume of IT V = AF + TPP + D Where FP - physiological needs (1500 mlm 2 or 40 mlkg) TPP - current pathological losses, no matter how large they are, they must be compensated in full D - fluid deficits that arose earlier

Calculation of intraoperative infusion in adults Minor operations 3 -4 ml/kg*h Medium operations 5 -6 ml/kg*h Major operations 7 -8 ml/kg*h

Physiological fluid needs depend on body weight and are calculated as: body weight up to 10 kg – 4 ml/kg/h; 11 -20 – 2 ml/kg/h, more than 21 kg – 1 ml/kg/h On average, for a person weighing 70 kg, the infusion rate is 110/ml/h, and the infusion volume is 2640 ml/day.

Calculation of intraoperative infusion for children Minor surgery 5 ml/kg*h Medium surgery 7 -8 ml/kg*h Major surgery 10 -15 ml/kg*h

Lecture No. 16. Infusion therapy

Infusion therapy is a drip or infusion intravenously or subcutaneously of drugs and biological fluids in order to normalize the water-electrolyte, acid-base balance of the body, as well as for forced diuresis (in combination with diuretics).

Indications for infusion therapy: all types of shock, blood loss, hypovolemia, loss of fluid, electrolytes and proteins as a result of uncontrollable vomiting, intense diarrhea, refusal to take fluids, burns, kidney disease; disturbances in the content of basic ions (sodium, potassium, chlorine, etc.), acidosis, alkalosis and poisoning.

The main signs of dehydration of the body: retraction of the eyeballs into the orbits, dull cornea, dry, inelastic skin, palpitations, oliguria, urine becomes concentrated and dark yellow, the general condition is depressed. Contraindications to infusion therapy are acute cardiovascular failure, pulmonary edema and anuria.

Crystalloid solutions are able to replenish the deficiency of water and electrolytes. Use 0.85% sodium chloride solution, Ringer and Ringer-Locke solutions, 5% sodium chloride solution, 5-40% glucose solutions and other solutions. They are administered intravenously and subcutaneously, in a stream (in case of severe dehydration) and drip, in a volume of 10–50 or more ml/kg. These solutions do not cause complications, except for overdose.

The goals of infusion therapy: restoration of bcc, elimination of hypovolemia, ensuring adequate cardiac output, maintaining and restoring normal plasma osmolarity, ensuring adequate microcirculation, preventing aggregation of blood cells, normalizing the oxygen transport function of the blood.

Colloidal solutions are solutions of high molecular weight substances. They help retain fluid in the vascular bed. They use hemodez, polyglucin, reopoliglucin, reogluman. When they are administered, complications are possible, which manifest themselves in the form of an allergic or pyrogenic reaction. Routes of administration: intravenous, less often subcutaneous and drip. The daily dose does not exceed 30–40 ml/kg. They have detoxifying properties. They are used as a source of parenteral nutrition in cases of prolonged refusal to eat or inability to feed by mouth.

Blood and casein hydrolysins are used (Alvesin-Neo, polyamine, lipofundin, etc.). They contain amino acids, lipids and glucose. Sometimes there is an allergic reaction to the injection.

Rate and volume of infusion. All infusions from the point of view of the volumetric rate of infusion can be divided into two categories: those requiring and those not requiring rapid correction of the BCC deficiency. The main problem may be patients who need rapid elimination of hypovolemia. that is, the rate of infusion and its volume must ensure cardiac performance in order to properly supply regional perfusion of organs and tissues without significant centralization of the circulation.

In patients with an initially healthy heart, three clinical landmarks are most informative: mean blood pressure > 60 mm Hg. Art.; central venous pressure – CVP > 2 cm water. Art.; diuresis 50 ml/hour. In doubtful cases, a volume load test is performed: 400–500 ml of crystalloid solution is infused over 15–20 minutes and the dynamics of central venous pressure and diuresis are observed. A significant increase in central venous pressure without an increase in urine output may indicate heart failure, which prompts the need for more complex and informative methods of assessing hemodynamics. Keeping both indicators low indicates hypovolemia, then maintain a high rate of infusion with repeated step-by-step assessment. An increase in diuresis indicates prerenal oliguria (renal hypoperfusion of hypovolemic origin). Infusion therapy in patients with circulatory failure requires clear knowledge of hemodynamics and extensive and special monitoring.

Dextrans are colloidal plasma substitutes, which makes them highly effective in the rapid restoration of bcc. Dextrans have specific protective properties against ischemic diseases and reperfusion, the risk of which is always present during major surgical procedures.

The negative aspects of dextrans include the risk of bleeding due to platelet disaggregation (especially typical for rheopolyglucin), when it becomes necessary to use significant doses of the drug (> 20 ml/kg), and a temporary change in the antigenic properties of the blood. Dextrans are dangerous because they cause a “burn” of the epithelium of the renal tubules and are therefore contraindicated in cases of renal ischemia and renal failure. They often cause anaphylactic reactions, which can be quite severe.

A solution of human albumin is of particular interest, since it is a natural colloid of a plasma substitute. In many critical conditions accompanied by damage to the endothelium (primarily in all types of systemic inflammatory diseases), albumin is able to pass into the intercellular space of the extravascular bed, attracting water and worsening interstitial edema of tissues, primarily the lungs.

Fresh frozen plasma is a product taken from a single donor. FFP is separated from whole blood and immediately frozen within 6 hours after blood collection. Stored at 30°C in plastic bags for 1 year. Given the lability of clotting factors, FFP should be transfused within the first 2 hours after rapid thawing at 37°C. Transfusion of fresh frozen plasma (FFP) carries a high risk of contracting dangerous infections such as HIV, hepatitis B and C, etc. The frequency of anaphylactic and pyrogenic reactions during FFP transfusion is very high, so ABO compatibility must be taken into account. And for young women, Rh compatibility must be taken into account.

Currently, the only absolute indication for the use of FFP is the prevention and treatment of coagulopathic bleeding. FFP performs two important functions at once - hemostatic and maintaining oncotic pressure. FFP is also transfused in case of hypocoagulation, in case of overdose of indirect anticoagulants, during therapeutic plasmapheresis, in acute disseminated intravascular coagulation syndrome and in hereditary diseases associated with deficiency of blood coagulation factors.

Indicators of adequate therapy are clear consciousness of the patient, warm skin, stable hemodynamics, absence of severe tachycardia and shortness of breath, sufficient diuresis - within 30–40 ml/h.