Types of local anesthesia. Types of local anesthesia

Article for those who want to know detailed information about the dangers of anesthesia. Local anesthesia or general anesthesia brings greatest harm and danger to the human body?

Any intervention by surgeons today is performed using anesthesia. Such an achievement in medical field of the last century is one of the great ones, thanks to him the level of medicine has risen.

Surgery has now become not torture, but treatment, and mortality has noticeably decreased significantly. It is difficult to fully appreciate the importance and significance of anesthesia, but some patients still have considerable doubts about the safety of such an event. It is necessary to understand why anesthesia is dangerous. It turns out that a considerable number of anesthesiologists are of the opinion that anesthesia is rather dangerous. There are a considerable number of risks, and, naturally, sometimes it is not possible to avoid deaths.

The main and main causes of death from anesthesia, which specialists try to avoid whenever possible, include: heart failure, allergic reaction, respiratory failure, malignant hyperthermia and finally, the human factor. The cause of heart failure may well be an overdose of drugs intended for anesthesia, as well as other severe chronic diseases of cardio-vascular system. It should be noted that chronic diseases are much less likely to be identified due to fatal outcome than an excess of a drug during anesthesia.

Complications of various nature may cause allergic reaction. Of course, it is possible to conduct an individual sensitivity test. But this can only be done in the process local anesthesia. It will not be possible to carry out the test during general anesthesia, so the patient will have to be subjected to general anesthesia, with associated risks and difficulties for his body. Often the cause of the appearance respiratory failure there is difficulty in inserting an endotracheal tube or aspiration (throwing the internal contents of the stomach directly into the lungs).

Much less often pulmonary failure may cause obstructive bronchitis or bronchial asthma. It is very important to note that often common cause The occurrence of complications during anesthesia is also a human factor, not quite correctly or not carefully prepared process of surgical intervention. In the presence of a competent, qualified anesthesiologist, as well as necessary equipment In the clinic, the risk of anesthesia is minimized.

Many people think that local anesthesia is less harmless and harmful than general anesthesia. However, local anesthesia looks harmless only at first glance. In fact, novocaine is combined with adrenaline to cause a narrowing of the capillaries, which will subsequently provide a long-lasting anesthesia effect. Adrenaline causes an increase in speed heart rate, which negatively affects those who have cardiac problems. Novocaine, as well as other drugs that are its analogues, can cause quite serious allergies.

Local anesthesia may cause elevation blood pressure, or unexpectedly cause vascular spasms. Naturally, if the patient’s heart and blood pressure are all right, then local anesthesia does not threaten this person. If the patient has problems with blood pressure and heart, then local anesthesia is directly contraindicated for him. And therefore, any conscientious dentist, before using local anesthesia, should mandatory ask the patient about his condition. And most likely, having heard complaints, for example, about hypertension or heart problems, he will advise you to undergo general anesthesia rather than risk your health when using local anesthesia.

The development of anesthesiology has made a considerable leap, and today general anesthesia is not so dangerous for the lives of seriously ill people. However, it still remains a threat to human health, and, in particular, for the brain and for the preservation of normal mental activity and functioning. It has been noted that after undergoing general anesthesia, many patients experience a decrease in cognitive abilities. Memory lapses may appear, various behavioral changes may be noticed, and the sharpness of thinking is sharply dulled. Such symptoms may well last for several months.

Which anesthesia is better in one case or another? Every day, when planning anesthesia for their new patients, anesthesiologists again and again have to look for the answer to this question. Essentially, the definition best view anesthesia is the first task solved by the anesthesiologist. To make the final decision, many points are taken into account - this includes the type of upcoming surgical intervention, and the patient's health status, and personal experience anesthesiologist, and available opportunities. Carefully weighing each of these factors, the anesthesiologist first determines the possible options and then selects the best option.

In general, the very concept of “best anesthesia” includes many aspects, the most important of which are safety, harmlessness, simplicity, comfort and quality.

1. The safety of anesthesia is determined by the magnitude and severity of the risks of potential anesthesia complications. Most in a safe way pain relief is a greatest number risks associated with . It occupies an intermediate position, but its implementation is possible only during operations on the limbs. Methods of neuraxial anesthesia, which include epidural anesthesia, occupy a special position in the safety scale. Thus, in comparison with general anesthesia, spinal (epidural) anesthesia has obvious advantages (fewer complications) only in cases when it is performed in elderly people or in patients with diseases of the respiratory or cardiovascular systems.

2. Harmlessness of anesthesia. In essence, this point is very similar to the previous one, that is, everything said about the safety of anesthesia is applicable here. However, the surgical anesthesia performed can cause not only the complications described in the article about, but also a certain kind of consequences, the occurrence of which is not always associated with the anesthesia, for example, memory impairment, hair loss, changes in tooth enamel, etc. (read more in the article about). Therefore, from the point of view of harmlessness the best anesthesia In order of importance, local, conduction, spinal and epidural anesthesia are presented.

3. Simplicity of anesthesia. Some types of anesthesia require large quantity equipment and medications and, in addition, are more complex in terms of technical execution, while other types of pain relief are distinguished by their simplicity. The distribution of all types of anesthesia in order from simple to complex gives the following series: local anesthesia - spinal anesthesia - conduction and epidural anesthesia - intravenous and mask anesthesia - endotracheal anesthesia.

If the planned operation is carried out in a “large” clinic, then the aspect of “ease of anesthesia” does not have of great importance. If the operation is performed in a “small” hospital (for example, in a regional center), the most preferred options pain relief will be simple types of anesthesia.

4. Comfort of anesthesia. Despite the fact that some patients prefer not to hear or see anything during the operation (that is, to be under anesthesia), local and are still the most comfortable, since they are free from such side effects of the period of awakening from anesthesia as lethargy, drowsiness, dizziness, nausea.

The greatest physical satisfaction with anesthesia is observed when using anesthesia drugs that quickly leave the body, which means they contribute to the fastest awakening, such drugs include propofol, isoflurane and sevoflurane.

Thus, summing up all of the above, we can give the following answer to the question “ which anesthesia is better?" If there are no problems with the operation and the patient’s health condition, then the most optimal type of pain relief is local anesthesia, second place is occupied by regional methods of anesthesia (spinal, epidural, conduction) and only third place belongs to general anesthesia(intravenous, mask, laryngeal, endotracheal).

Much credit for the development of local anesthesia belongs to Russian scientists: V.K. Anrep, who discovered the local anesthetic properties of cocaine in 1880, A.I. Lukashevich, who began performing operations under conduction anesthesia in 1886, and especially A.V. Vishnevsky ( 1874—1948). He was a wonderful surgeon who did a lot for the development of general and military surgery. He developed the most safe method local anesthesia, thanks to which hundreds of thousands of wounded during the war were provided with the full necessary surgical care.

MECHANISM OF LOCAL ANESTHESIA

The main differences between local anesthesia and general anesthesia are the preservation of consciousness and the creation of an obstacle to the path of pain impulses below the brain or, more precisely, not above thoracic spinal cord. On this path, you can achieve both pain relief and eliminate other sensations - heat and cold, touch and pressure.

Anesthesia can be performed in the following areas: 1) the surface of the laryngeal mucosa. trachea, bronchi, urethra And Bladder(this is superficial, or terminal, anesthesia); 2) turning off pain receptors in the skin and other organs (infiltration and regional anesthesia); 3) along the course of a large nerve or nerve plexus (conductor anesthesia); 4) along the nerve roots outside the dura mater meninges(epidural anesthesia); 5) at the level nerve cells, conducting sensitivity in the spinal cord itself (spinal, or spinal anesthesia).

PREPARATIONS FOR LOCAL ANESTHESIA

We will focus on several of the most commonly used substances.

Novocaine(procaine). White powder with a bitter taste, highly soluble in water and alcohol. Novocaine is selectively absorbed nerve tissue and consistently turns off the feeling of cold, heat, pain and, finally, pressure. Active in alkaline tissue reactions. With inflammation (acid reaction in tissues), its activity decreases.

In the form of a 5-10% solution, it is used for anesthesia of mucous membranes, and a 1-2% solution for conduction anesthesia. It is practically not used for epidural and spinal anesthesia due to insufficient effectiveness.

Novocaine is most often used for infiltration anesthesia according to A.V. Vishnevsky.

Dicaine(pantocaine). It is 15 times stronger, but almost as many times more toxic than novocaine. It is used for anesthesia of mucous membranes in the form of 0.25; 0.5; 1 or 2% solutions, less often - for epidural anesthesia: 0.3% solution in fractional doses of 3-5 ml (but not more than 20 ml). The maximum single dose is 0.07 g.

Lidocaine(xylocaine). The drug is 2 times more toxic, but 4 times stronger and acts longer (up to 5 hours) than novocaine. For anesthesia of mucous membranes, 4-10% solutions are used, in ophthalmic practice - 2% solution, for conduction anesthesia - 0.5-2% solution (up to 50 ml), for epidural anesthesia - 2% solution (up to 20 ml), for infiltration anesthesia - 0.5-0.25% solutions (500 and 1000 ml, respectively). Maximum dose 15 mg/kg.

Trimekain(mesocaine). 1.5 times more toxic and 3 times stronger than novocaine. For infiltration anesthesia, use 0.25% and 0.5% solutions of 800 and 400 ml, respectively. For conduction anesthesia - 1% (100 ml) or 2% (no more than 20 ml due to sharp potentiation!) solutions. In the form of a 2.5-3% solution in an amount of 7-10 ml, it is used for epidural anesthesia, and for spinal anesthesia, 2-3 ml of a 5% solution is sufficient. The maximum dose is 10-12 mg/kg.

Bupivacaine(marcaine, anecaine). It is the most powerful and long-acting anesthetic of those discussed above (2-3 times greater than lidocaine). For epidural anesthesia it is usually used as a 0.5% solution. The main dose is 40-50 mg, with a maintenance dose of 15-40 mg. Available in 20 ml bottles (1 ml contains 2.5 or 5 mg of the drug) and 1 ml ampoules (contains 5 mg).

Naropin(ropivacaine). One of the most modern anesthetics. Forms of release of the drug: polypropylene ampoules containing 10 or 20 ml of solution different concentrations(0.2%, 0.75% and 1%), as well as infusion containers of 100 or 200 ml of 0.2% ropivacaine. Duration of action - up to 5 hours. Used for conduction and epidural anesthesia.

Ultracaine D-C Forte . 1 ml of the drug contains 40 mg of articaine hydrochloride and 12 mcg of adrenaline hydrochloride. The drug has low toxicity. Although the drug is intended for use in dental practice, there is currently experience in its use for epidural anesthesia.

PREPARATION OF THE PATIENT

The patient must be examined to exclude contraindications to local anesthesia (excitement, low contact, etc.). When clarifying the medical history, it is necessary to find out whether there have been previous reactions to local anesthesia.

It is necessary to prepare the patient psychologically: the safety and effectiveness of local anesthesia are explained to him.

It is necessary to carry out medication preparation, as with general anesthesia; It is advisable to include sedatives and antihistamines. Dentures are removed and the time of the last meal is checked. Prepare everything necessary to eliminate complications: anticonvulsants, a ventilator, an internal infusion system and vasoconstrictors.

ANESTHESIA OF THE MUCOUS (TERMINAL ANESTHESIA)

This method is often used in ophthalmology, otorhinolaryngology, pulmonology, urology; also used for tracheal intubation for prevention reflex reactions. For anesthesia, 4-8 drops are instilled into the conjunctiva and cornea, and 2-8 drops of a 2-5% trimecaine solution are instilled into the nasal mucosa. For anesthesia of mucous membranes bronchial tree 3 ml of 3% dicaine solution is sufficient.

CONDUCTION ANESTHESIA

Blockade brachial plexus . The patient lies on his back with a pad placed under his neck. The head is turned in the direction opposite to the blockade site. The needle point is 1 cm above the middle of the collarbone. The needle is inserted in the direction of the first rib. When the tip of the needle hits the nerve plexus, there is a feeling of a “shot” in the arm. After this, the needle must be pulled back 0.5 cm to avoid intraneural administration of the drug. For anesthesia, 40-60 ml of a 1% lidocaine solution or 0.25% marcaine solution is administered.

Blockade sciatic nerve . The patient is placed on the edge of the table. The solution is injected into a point located in the middle of the distance between the greater trochanter tibia and the tip of the coccyx.

Intercostal nerve block. After puncturing the skin, the needle is directed to the lower edge of the overlying rib and immediately, as soon as the tip of the needle touches it, the direction is shifted downward so as not to damage the vein and artery, but to inject the drug into the area of ​​the nerve located below them.

PARAVERTEBRAL ANESTHESIA

This is a type of regional local anesthesia. The essence of the method is a block with a local anesthetic nerve trunks at the point where they emerge from the intervertebral foramina. It is necessary to anesthetize not only the affected segment, for example with intercostal neuralgia, but also two segments above and below it. Solution local anesthetic injected separately into each segment. 5-10 ml of 0.5% novocaine solution is injected into the point chosen for injection. First, the skin and subcutaneous tissue are anesthetized. Then the needle is directed 4-5 cm lateral and slightly below the intended spinous process until it stops at the transverse process or rib. The needle is slightly removed and again moved forward and downward 1 cm under the rib towards the vertebral body. A local anesthetic is injected here.

With this method, you can get a needle into the pleura or abdominal cavity, injure the spleen or get into the subdural space. Therefore, you should carefully monitor the patient’s reactions and be prepared to deal with complications. But this method can be very useful for eliminating pain after lung surgery and multiple rib fractures.

EPIDURAL ANESTHESIA

The epidural space is located between the dura mater of the spinal cord and the inner surface spinal canal. It is filled with loose connective tissue, in which the venous plexuses are located; the posterior (sensitive) and anterior (motor) roots pass through this space spinal nerves. They need to be anesthetized.

The patient is placed on his side, with his legs brought to his stomach (the puncture can also be performed in a sitting position; in this case, a stand is placed under the legs, and the back is bent as much as possible). Depending on the desired level of anesthesia, the injection site is chosen: for anesthesia of the chest - Th 2 - Th3, the upper half of the abdomen - Th7 - Th8, the lower half of the abdomen - Th 10 - Th 11, the pelvis - L 1 - L 2, lower limbs- L 3 - L 4.

The puncture site is treated twice with alcohol (but not iodine!) and covered with sterile linen. A thin needle is used to anesthetize the skin and subcutaneous tissue. Then the needle for epidural anesthesia with an attached syringe filled with isotonic sodium chloride solution is inserted strictly according to midline in the intervertebral space. The needle is advanced without violence, only by pressing the 1st finger on the syringe plunger. While the needle passes through the ligaments, despite the pressure, the solution does not flow out of the syringe, but as soon as the end of the needle enters the epidural space, the resistance disappears and the solution begins to leave the syringe. Inject 1-2 ml isotonic solution sodium chloride, disconnect the syringe from the needle and make sure that it is positioned correctly (no blood or liquid should flow out of it). After this, 4 ml of local anesthetic solution (test dose) is administered, carefully observing the patient’s breathing, pulse and consciousness. 5 minutes after administration of the test dose, if there are no signs of spinal anesthesia, the main dose is administered, which is determined by the doctor individually for each patient.

For long-term anesthesia, special needles are used (for example, a Tuohy needle), through which a polyethylene or fluoroplastic catheter is inserted 2-4 cm upward into the epidural space. A solution of local anesthetic is injected through it during the operation as needed.

To prolong the effect of the local anesthetic, 1-2 drops of a 0.01% adrenaline solution are often added per 10 ml of solution. IN last years To enhance the effect of the local anesthetic, small doses of narcotic analgesics (morphine, promedol, fentanyl) are added to the solution. This allows you to reduce the dosage of local anesthetic and provide long-term postoperative analgesia.

Anesthesia after the administration of a local anesthetic does not occur immediately, but after a certain period of time, called latent or latent period. This interval varies for different local anesthetics, for example, for lidocaine or trimecaine it is 10-15 minutes, and for dicaine or bupivacaine it can reach 20-25 minutes.

The clinical picture of epidural blockade develops in the following sequence.

At first, the patient feels a feeling of warmth in the lower extremities, then a feeling of numbness, crawling “pins and needles” appears, and, finally, motor blockade occurs when the patient cannot lift his leg. True, this does not happen in all cases, more often in older people. The degree of development of the blockade is determined by injections with an injection needle. Anesthesia is considered sufficient when the patient ceases to distinguish between sharp and dull touch.

The effect of epidural anesthesia on the body.

central nervous system. Epidural anesthesia does not directly affect the central nervous system. However, the shutdown of a certain part of the body that occurs when it occurs leads to the development of the so-called deafferentation brain, i.e. removing the exciting effect of sensitive impulses coming from the periphery. As a result, brain inhibition occurs, which is manifested by drowsiness and a feeling of calm.

The cardiovascular system. By the time anesthesia sets in, a decrease in blood pressure usually occurs. This is a natural manifestation of epidural anesthesia, caused by the blockade of sympathetic nerve fibers, leading to dilation of blood vessels and capacity vascular bed. As a result, relative hypovolemia occurs, which leads to the development of hypotension. With high epidural blockade, bradycardia may develop as a result of depression sympathetic nerves hearts.

Respiratory system. With high epidural anesthesia, some respiratory depression is possible due to blockade of the intercostal muscles.

Epidural blockade has a bronchodilator effect, which is used in the treatment of status asthmaticus.

Digestive system . As a result of the sympathetic blockade that occurs during epidural anesthesia, intestinal motility increases. This effect is used in the treatment of intestinal paresis. On the other hand, this dictates the need for thorough cleansing of the intestines before planned operation, because involuntary defecation is possible.

From the outside urinary system Possible urinary retention. True, such complications are quite rare, and are more often caused by the action of narcotic analgesics, especially morphine.

SPINAL ANESTHESIA

A local anesthetic solution is injected with the patient sitting or on his side into the subarachnoid space. Use special thin (No. 24-26) needles. The puncture is usually performed between III and IV lumbar vertebrae. The needle passes through the same anatomical formations as with epidural anesthesia, but in addition it is necessary to puncture the dura mater. Entry into the subarachnoid space is determined by the flow of cerebrospinal fluid from the needle. After this, a local anesthetic solution is injected. Use a 5% solution of lidocaine (1.5 ml) or a 0.25-0.5% solution of bupivacaine (2-3 ml).

The clinical picture and effect on the body of spinal and epidural anesthesia are largely similar. Unlike epidural, the speed of blockade development during spinal anesthesia is higher (no more than 3-5 minutes). Failures and incomplete anesthesia occur less frequently. Spinal anesthesia gives very good muscle relaxation.

During spinal anesthesia, the density of the injected local anesthetic is important. If it is less than the density of the cerebrospinal fluid, the solution is called hypobaric; if it is equal to it, it is isobaric; if it is greater than the density of the cerebrospinal fluid, it is called hyperbaric. Knowing the density of the solution allows you to determine in which direction the local anesthetic will spread. Hypobaric solutions spread upward from the injection site, hyperbaric solutions spread downward, and isobaric solutions remain at the injection level.

INDICATIONS AND CONTRAINDICATIONS FOR EPIDURAL AND SPINAL ANESTHESIA.

Indications for epidural and spinal anesthesia in " pure form"are operations on the lower extremities, pelvic bones, pelvic organs, and anterior abdominal wall.

In combination with multicomponent anesthesia, they can be used for extensive and traumatic operations on top floor abdominal cavity, chest organs.

Epidural and spinal anesthesia are of great importance for the treatment of various pain syndromes in oncology, traumatology, cardiology, etc.

Contraindications are divided into absolute and relative. Absolute intolerance to local anesthetics, hypocoagulation, purulent diseases skin at the puncture site, shock, hypovolemia, hypotension. Relative contraindications are spinal deformities, obesity, some diseases nervous system.

COMPLICATIONS

I. Complications caused by the action of local anesthetic.

These complications can occur with any type of local anesthesia. Three types of complications are most likely to occur: damage to the central nervous system, cardiac conduction system and allergic reactions, as well as their combination. The occurrence and severity of complications depend on the following factors: 1 - the nature of the local anesthetic; 2 - its dose; 3 - type of local anesthesia; 4 - adding to the solution vasoconstrictor drugs.

The stronger the local anesthetic, the more dangerous it is: its strength decreases in the sequence sovcaine - dicaine - trimecaine - lidocaine - novocaine. The most dangerous are spinal, then epidural and regional anesthesia, performed near large vessels (plexus anesthesia).

CNS lesions. The patient becomes restless (less often drowsy), complains of dizziness, ringing in the ears, speech becomes slurred, and metallic taste, nystagmus can often be detected. Convulsive twitching occurs in individual muscles, and in the most severe cases- general convulsions. The latter are especially pronounced in respiratory and metabolic acidosis.

Hemodynamic disorders. The conduction system of the heart and vascular tone (sympathetic blockade) are most affected. Therefore, bradycardia appears (up to cardiac arrest) and blood pressure sharply decreases (up to cardiovascular collapse).

Allergic reactions. May be allergic dermatitis: the appearance of many red spots on the skin, sometimes on an edematous basis, itching, attack bronchial asthma, and in the most severe cases - anaphylactic shock.

Prevention. The main thing is to carefully collect anamnesis. At the slightest suspicion of intolerance to local anesthetics, you should either abandon this method altogether, or use it in preparation antihistamines, benzodiazepines (sibazon, relanium) and phenobarbital. It is very important to use a test dose of local anesthetic (inject it intradermally and evaluate the reaction), not to exceed a single maximum dose and stop anesthesia if there is a suspicion of exposure to large vessel(conduction anesthesia, epidural anesthesia) or into the cerebrospinal fluid tract (epidural anesthesia, paravertebral anesthesia).

Intensive therapy. If the central nervous system is predominantly affected, 2.5-5 mg of sibazone or (carefully!) 2% sodium thiopental solution is administered intravenously until the seizures are eliminated.

If hemodynamic disturbances occur, the patient is transferred to the Trendelenburg position and vigorous infusion therapy is administered. If necessary, vasoconstrictor drugs and glucocorticoid hormones (12 mg dexazone, 60 mg prednisolone) are administered.

In case of cardiac arrest, the entire complex of cardiopulmonary resuscitation is performed.

II. Complications of epidural and spinal anesthesia.

Complications of a traumatic nature. The mildest of them are injuries to the periosteum and spinal ligaments. Manifested by pain at the puncture site. They usually go away on their own within a few days. More serious complications- damage to the vessel possible education epidural hematoma, nerve root damage, puncture of the dura mater. A puncture of the dura mater, if diagnosed in a timely manner, usually does not lead to any serious health problems for the patient, with the exception of headaches that last for several days and are caused by the leakage of cerebrospinal fluid and a decrease in intracranial pressure.

Breathing disorders. This often happens with high epidural and spinal anesthesia, when the roots of the intercostal nerves are blocked. In this case, the only respiratory muscle the diaphragm remains. In these conditions, assisted ventilation is sometimes required.

Hemodynamic disorders. As mentioned above, hypotension is an almost constant companion to epidural and spinal anesthesia. A decrease in blood pressure by less than 40% of the initial value is not considered a complication and can be easily stopped by accelerating the infusion rate. If blood pressure decreases by more than 40%, more vigorous measures must be taken: massive infusion therapy, and if it is ineffective - the introduction of vasoconstrictor drugs, preferably ephedrine in a dose of 0.2-0.3 ml.

If the dura mater is punctured unnoticed and a full dose of local anesthetic is administered, a terrible complication can develop - a total spinal block, which is characterized by sharp decline Blood pressure, respiratory arrest. If not accepted urgent measures, death may occur. It is necessary to transfer the patient to mechanical ventilation. administration of vasopressors. powerful infusion therapy.

Purulent complications. If the principles of asepsis are not observed, the development of purulent epiduritis and meningitis is possible. Shown powerful antibacterial therapy, and in some cases - surgical intervention to open and drain the purulent focus.

Drugs used:

Local - anesthesia, achieved by the action of an anesthetic substance on the nerve endings and trunks at the site of surgery.

Local anesthesia is usually used in outpatient practice for small surgical interventions or diagnostic studies. Local anesthesia is used if there are contraindications to general anesthesia (anesthesia).

Methods of local anesthesia.

Superficial anesthesia involves applying anesthetics to the skin or mucous membranes and cooling. For this, chloroethyl and local anesthetic substances are used (1-5% solutions of cocaine, 10% solution of novocaine, 0.25-3% solutions of dicaine, 2-5% solutions of lidocaine and trimecaine and others).

Infiltration anesthesia. A thin needle is inserted into soft fabrics 0.25-0.5% solution of novocaine (or other more modern anesthetics), as a result of which the tissues in the area of ​​​​operation become saturated with a solution of local anesthetic and conduction is blocked nerve impulses. With infiltration anesthesia, not only pain relief is achieved, but also another goal - hydraulic tissue preparation, which greatly facilitates the surgeon’s manipulations and reduces blood loss.

Regional anesthesia - the anesthetic is injected in close proximity to the nerve trunk.

Types of regional anesthesia:
Conductive - the anesthetic is injected near the nerve ganglion, nerve plexus or trunk peripheral nerve(for example, when removing teeth).
Spinal (synonyms: lumbar, subdural anesthesia, subarachnoid anesthesia) is based on the introduction of an anesthetic into the subarachnoid space of the spinal cord. In this case, the sensitivity and function of organs receiving innervation below the injection site are temporarily lost. Similar anesthesia is used for operations on the stomach, intestines, liver and biliary tract, spleen, pelvic organs, lower extremities. Contraindications to spinal anesthesia: shock, severe, decreased blood pressure, severe pathology internal organs, inflammatory diseases skin at the site of the intended injection of the drug, spinal deformation, etc.
Epidural - anesthetics (lidocaine, bupivacaine, ropivacaine) are injected into the epidural space of the spine through a special catheter. Such anesthesia is practically safely used for analgesia of the chest, abdomen, groin area and legs, often used during childbirth. The advantage is the use of very small doses of anesthetics, rare side effects (nausea, decreased blood pressure, etc.)
Intravascular – intravenous anesthesia, which is used in operations on the limbs, when an anesthetic is injected into the limb on which a hemostatic tourniquet is applied. A type of intravascular anesthesia is.

Contraindications to local anesthesia:
- intolerance to local anesthetics;
- mental disorders of the patient;
- tissue damage ( rough scars, severe inflammation, preventing the implementation of infiltration anesthesia, bleeding).

Local anesthesia begins with (preparatory treatment, when the patient is injected with a 1-2% solution of promedol, 0.1% solution of atropine, 0.25% solution of droperidol or tranquilizers.

Complications of local anesthesia are extremely rare. There may be: agitation, hand tremors, allergic reactions, pallor, sweating, hypotension, decreased blood pressure, etc. A preliminary conversation with the patient (clarification of drug intolerance), careful adherence to the dosage and anesthesia technique helps to avoid complications.

Intravenous anesthesia.
Intravenous administration of drugs provides physiological sleep And good pain relief, eliminates feelings and fear. Such anesthesia is used for short, low-traumatic operations to ensure maximum patient comfort. Sometimes intravenous anesthesia is included complex pain relief(including mask with saving spontaneous breathing or transfer to artificial ventilation lungs).

Local anesthesia (also known as local anesthesia) – anesthesia of a specific area of ​​the body different ways while keeping the patient conscious. Mainly used for minor operations or examinations.

Types of local anesthesia:

• regional (for example, with appendicitis, etc.);
• pudendal (during childbirth or after);
• according to Vishnevsky or case ( various methods applications);
• infiltration (injections);
• application (using ointment, gel, etc.);
• superficial (on mucous membranes).

The choice of anesthesia depends on the disease, its severity and general condition patient. It is successfully used in dentistry, ophthalmology, gynecology, gastroenterology, in surgery for operations (opening boils, suturing wounds, abdominal operations– appendicitis, etc.).

Local anesthesia during surgery differs from general anesthesia in ease of use, minimal side effects, a rapid “departure” of the body from the drug and a small likelihood of any consequences occurring after using the anesthetic.

Terminal anesthesia

One of the most simple types local anesthesia, where the goal is to block receptors by cooling the tissue (rinsing, wetting). Widely used in examining the gastrointestinal tract, dentistry, and ophthalmology.

An anesthetic is moistened onto an area of ​​skin at the site of the operated surface. The effect of such anesthesia lasts from 15 minutes to 2.5 hours, depending on the chosen agent and what its dose will be. The negative consequences from it are minimal.

Regional anesthesia

With this type of anesthesia, a blockade of the nerve plexuses and the nerves themselves in the area of ​​​​the operation is achieved. Regional anesthesia is divided into types:

• Conductor. Often used in dentistry. During conduction anesthesia, the drug is injected with a thin needle near the nerve ganglion or trunk of a peripheral nerve, or less often into the nerve itself. The anesthetic is injected slowly to avoid damaging the nerve or tissue. Contraindications for conduction anesthesia – childhood, inflammation in the area where the needle was inserted, sensitivity to the drug.
• Epidural. The anesthetic is injected into the epidural space (the area along the spine) through a catheter. The medicine penetrates the roots and nerve endings spinal cord, blocking pain impulses. Used during childbirth or caesarean section, appendicitis, operations on the groin area, pain relief for the chest or abdomen. But with appendicitis, this anesthesia takes time, which sometimes is not available.

Possible consequences, complications: decreased blood pressure, back pain, headache, sometimes intoxication.

• Spinal (spinal). The anesthetic is injected into the subarachnoid space of the spinal cord, the analgesic effect is triggered below the injection site. It is used in surgery for operations on the pelvic area, lower extremities, and appendicitis. Possible complications: decreased blood pressure, bradycardia, insufficient analgesic effect (in particular, with appendicitis). It all depends on how competently the procedure was carried out and what drug was selected. Also, in case of appendicitis, local anesthesia may be contraindicated (in case of peritonitis).

Note: sometimes, instead of using general anesthesia for appendicitis, initial stage Laparoscopic surgery is possible.

Contraindications for spinal anesthesia: skin diseases at the injection site, arrhythmia, patient refusal, increased intracranial pressure. Complications – meningitis, transverse myelitis, etc.

Infiltration anesthesia

Typically, infiltration anesthesia is used in maxillofacial surgery and in dentistry, sometimes with acute appendicitis. When the drug is injected into the soft tissues or periosteum, receptors and small nerves are blocked, after which, for example, teeth are removed absolutely painlessly for the patient. Infiltration anesthesia involves the following methods:

1. direct: the drug is injected into the area required for surgical intervention;
2. indirect: involves the same injection of anesthetic, but into deeper layers of tissue, covering areas adjacent to the operated area.

This type of anesthesia is good because it lasts for about an hour, the effect is achieved quickly, and the solution does not contain a large amount of painkiller. Complications, consequences – rarely allergic reactions to the drug.

Anesthesia according to A. V. Vishnevsky (case)

This is also local infiltration anesthesia. The anesthetic solution (0.25% novocaine) directly begins to affect nerve fibers, which gives an analgesic effect.

How anesthesia is carried out according to Vishnevsky: a tourniquet is tightened above the operated area, then a solution in the form of tight novocaine infiltrates is injected under pressure until it appears on top of the skin. lemon peel" Infiltrates “creep” and gradually merge with each other, filling the fascial sheaths. This is how the anesthetic solution begins to affect the nerve fibers. Vishnevsky himself called such anesthesia “the method of creeping infiltration.”

Case anesthesia differs from other types in that there is a constant alternation of a syringe and a scalpel, where the anesthetic is always one step ahead of the knife. In other words, an anesthetic is injected and a shallow incision is made. You need to penetrate deeper - everything repeats itself.

The Vishnevsky method in surgery is used both for minor operations (opening wounds, ulcers) and for serious ones (on thyroid gland, sometimes with uncomplicated appendicitis, amputation of limbs and others complex operations which cannot be performed on people with a contraindication to general anesthesia). Contraindications: intolerance to novocaine, dysfunction of the liver, kidneys, respiratory or cardiovascular systems.

Pudendal anesthesia

Used in obstetrics for suturing damaged soft tissues after childbirth. It is done by inserting a needle 7-8 cm deep on both sides between the posterior commissure and the ischial tuberosity. Together with infiltration it gives an even greater effect, so instead of general anesthesia in such cases, operations have long been performed under local anesthesia.

Application anesthesia

The anesthetic drug is applied to the surface of the skin or mucous membrane without the use of injections. Ointment (often Anestezin ointment), gel, cream, aerosol - this set of anesthetics gives the doctor a choice of which painkiller to use. Disadvantages of topical anesthesia: it does not have a deep effect (only 2-3 mm in depth).

It is used to ensure painlessness of subsequent injections (especially in dentistry). It is done at the request of patients who are afraid of pain: a gel (ointment) is applied to the gums or the skin or mucous membrane is sprayed with an aerosol. When the anesthetic takes effect, a deeper anesthetic injection is given. By-effect topical anesthesia - a possible allergic reaction to an aerosol, ointment, gel, cream, etc. In this case, other methods are necessary.

Anesthesia for blepharoplasty

Local anesthesia is also used for some operations in plastic surgery. For example, with blepharoplasty - correction of the upper or lower eyelid. Before correction, the patient is first given intravenously some sedative, which dulls the perception of what is happening during the operation. Next, injections are made around the eyes at the points marked by the surgeon and surgery is performed. After the operation, decongestant ointment is recommended for the eyelids.

For laser blepharoplasty (eyelid smoothing), surface anesthesia is also used: ointment (gel) is applied to the eyelids and treated with laser. At the end, burn ointment or antibiotic ointment is applied.

The patient may also request general anesthesia for blepharoplasty if he experiences a whole set of negative emotions and fear of upcoming operation. But if possible, it is better to do it under local anesthesia. Contraindications for such an operation are diabetes, cancer, poor clotting blood.

Anesthetic drugs

Local anesthetic drugs are divided into types:

1. Esters. Novocaine, dicaine, chloroprocaine and others. They must be administered carefully: side effects are likely (Quincke's edema, weakness, vomiting, dizziness). Complications are possible mainly local: hematoma, burning, inflammation.
2. Amides. Articaine, lidocaine, trimecaine, etc. These types of drugs have virtually no side effects. Consequences and complications are practically excluded here, although a decrease in blood pressure or disorders of the central nervous system are possible only in case of an overdose.

One of the most common anesthetics is lidocaine. The drug is effective, long-acting, and is successfully used in surgery, but consequences and complications from it are possible. Their types:

• rarely - a reaction to lidocaine in the form of a rash;
• swelling;
• difficulty breathing;
• rapid pulse;
• conjunctivitis, runny nose;
• dizziness;
• vomiting, nausea;
• visual impairment;
• Quincke's edema.

Indications for local anesthesia

If it is necessary to perform a minor operation, doctors often advise solving the problem under local anesthesia in order to prevent some Negative consequences. But there is also a whole set of specific indications for it:

• The operation is minor and can be performed under local anesthesia;
• patient refusal of general anesthesia;
• people (usually elderly) with diseases for which general anesthesia is contraindicated.

Contraindications

There are reasons when you cannot operate with local anesthesia (negative consequences and complications may occur). Types of contraindications:

• internal bleeding;
• drug intolerance;
• scars, skin diseases that impede infiltration;
• age under 10 years;
• mental disorders.

Under such conditions, patients are indicated exclusively for general anesthesia.