IV. Table of contents of teaching

Local anaesthesia – it is the reverse loss of pain sensitiveness of fabrics on the limited areas of body, caused by action of different chemical matters, physical or mechanical factors on nervous fibres or segments of nerves.

Local anaesthesia has large specific gravity in clinical practice. Today 55 – 60% surgical interferences are executed under the local anaesthetizing. She takes above all seat in ambulatory-policlinic work during anaesthetizing of small operative interferences. It is related to simplicity of its use, relative unconcern, by absence of necessity in the sophisticated apparatus and special preparation of medical personnel. In wide confession of this method of anaesthetizing were instrumental the O.V.Vishnevskogo, O.O.Vishnevskogo labours and their followers.

Testimonies: in all case of contra-indications to the common anaesthetizing; serdechno-sosudistaya and pulmonary insufficiency, at the persons of declining and starcheskogo years, in ambulatory-policlinic practice.

Contra-indications: age to 12 – 14 years, the advanced individual sensitiveness to anestetikov, violation of psyche, presence of inflammatory processes in fabrics, square refusal of patient.

Now in surgical practice for local anaesthesia more frequent all are used by such preparations: novocaine in concentrations from 0,25 – 0,5% to 10 – 20%, lidokain in concentrations 0,25 – 0,5%, 1 – 2 – 10%, trimekain in concentrations 0,25 – 1 – 2%, dikain in concentrations from 0,25 – 0,5% to 1 – 2%, sovkain in concentrations 0,5 – 1% and others.

The mechanism of action of local anestetikov is conditioned by blocking of transmission of excitation in a scene them on nervous fibres, as a result there is anaesthetizing of all area, that by the inerviruyutsya given nerve and his ending. They cause an undepolarizing block, retaining membranes in the polarized state.

Classification.

Such types of local anaesthesia are distinguished: superficial infiltration and regional. To regional anaesthesia attribute: and) explorer, b) spinal epiduralnuyu, in) vnutrisosudistuyu (endarterial and intravenous), g) vnutrikostnuyu, d) anaesthesia of nervous interlacements, e) trunk anaesthesia and others.

Most widespread in clinical practice: superficial (terminal), infiltration and different types of regional anaesthesia. Rarer anaesthesia vnutrisosudistuyu, a vnutrikostnuyu, is used, anaesthesia by cooling.

Superficial anaesthesia – type of anaesthetizing, which is achieved by irrigation or greasing of mucus shells 1 – by a 2% solution of dikaina, 5% solution of ksikainu, 0,25 – 2% anestezina and some other anestetikami, which are able to be sucked in through mucous membranes. Such method is used in ophthalmology, otolaryngology, surgery, endoskopicheskie researches, before intubatsiey of trachea and others like that.

Infiltration anaesthesia. Preparation to the operation under infiltration anaesthesia is the same, as well as at general to anaesthetizing. Extraordinarily important preparation of psyche of patient. During the operation the role of "psychical narkotizatora" can execute one of students. Anaesthesia is begun with infiltration of ponderable place of dissection of skin by education, so-called, "lemon crust". For this purpose local anestetik enter vnutrikogno through a thin needle. Layer infiltration of fabrics is farther conducted on the proper depth and width, depending on the type of operation and volume of interference.

For infiltration anaesthesia a 0,25–0,5% solution of trimekaina or lidokaina is used mainly. Possible doses valid for one occasion for adults in the case of the use 0,5% solutions of novocaine – 500 ml, 0,25% - 750 ml., and on condition that solution is outpoured during the operation during dissection of fabrics, it can multiply his dose to 1000 – 1500 ml. For 1 o'clock of operation it is allowed to enter to 2,0 g novocaine; the doses of trimekaina valid for one occasion must not exceed 20 mg/kg, and lidokaina – 15 mg/kg.

Infiltration anaesthesia on the O.V.Vishnevskogo (1922) method connects in itself positive qualities of infiltration and explorer anaesthesia. A method is based on the anatomic features of structure of fatsialnih educations – cases. Solution 0,25% novocaines is brought into cases 5 – by a 10 ml syringe under constraint, spreads in them and penetrates to the nerves and their ending. O.V.Vishnevskiy named him the method of "tight creeping infiltrata". It follows to underline a value and prevalence of this method in clinical practice.

Spinal anaesthesia behaves to the type of regional anaesthesia. It is used for anaesthetizing of definite part of body or topographical area. At this type of anaesthetizing a 5% solution of novocaine, a 0,5-1% solution of sovkana or ksilokaina (to 70 mg.) is brought into subarahnoidalnoe space by the puncture of hard brain-tunic by means the special needle with well-assorted mandrenom (the Bira needle). Anestetik quickly contacts with nervous counterfoils and comes anaesthesia of all part of body below from the place of punktsii. More frequent than all an interval is a place for spinal punktsii between ІІІ – by the ІV or ІІ –ІІІ lumbar vertebrae. Duration of such anaesthesia from 1,5 to 3 hours. Introduction of anestetika to subarahnoidalnoe space higher from the level of the ХІІ pectoral vertebra can result in violation of activity of respiratory and sosudodvigatelnogo centers. Now spinal anaesthesia is used mainly in the case of operations on organs, that are subjacent from a diaphragm and lower extremities.

Complications of spinal anaesthesia can show up in the decline of bloody pressure, disorders of breathing and in the paralysis of bulbarnih centers. For the prophylaxis of complications recommend simultaneously with anestetikom to enter a 1,0–2,0% solution of caffeine, or 1,0 – a 5,0% solution of ephedrine.

In case of stopping of breathing or violations of cardiac activity necessary immediate intubatsiya of trachea and application of artificial ventilation of lights, the closed massage of heart, at the considerable falling of arterial pressure measures on blood transfusion and krovezameniteley are used.

Epiduralnaya anaesthesia – it is the variety of explorer anaesthesia. It is shown in the case of operative interferences on the lower departments of abdominal region, urology, proktologichnih operations and operations, on lower extremities. She is the method of choice at the persons of declining and starcheskogo years, at patients with serdechno-sosudistoy pathology, by violation of function of buds, liver, in obstetric practice. Epiduralnuyu anaesthesia is widely applied for the removal of posleoperatsionnoy pain, rapid renewal of peristalsis of bowels after the operations, in complex medical treatment of peritonitis, impassability of bowels, sharp pankreatita and others like that.

Execute Epiduralnuyu anaesthesia in position of patient sitting, or lying on a side with pinned against a stomach feet, an anaesthetic effect is achieved due to the blockade of counterfoils of spinal cord of anestetikom, entered in the periduralnoe space located between two sheets of hard brain-tunic and has the appearance of narrow crack, by the filled fatty fabric, lymphatic vessels and vein interlacement. The front and back counterfoils of spinal nerves pass through this space, it is not reported with a head and spinal brain, therefore anestetik does not affect these structures.

Punktsiya of epiduralnogo space can be executed on any department of spine, depending on the level of anaesthesia. A skin is anaesthetized at first. A thin needle without a syringe is entered between vertebrae, expressly on a back middle line on a depth 2–2,5 sm. before the collision with a yellow copula (resistance is felt). Then to the needle a syringe is tacked with izotonicheskim solution of chloride of sodium and bubble of air in him. Subsequent advancement of needle is controlled by the change of form of bubble of air at pressure on the piston of syringe. As soon as a needle gets in epiduralnoe space the resistance diminishes, solution is easily outpoured in fabric. If to disconnect a syringe and needle, from its opening a liquid must not flow out. Then enter 2–3 ml. liquids, that to move away a hard brain-tunic and prevent its perforation. In a needle a thin polihlorviniloviy catheter through which factiously enter anestetik during the operation and in a posleoperatsionnom period is placed. At first enter the test-dose of anestetika (1/3 from set) and through 3–5 mines. – all dose. More frequent a 2% solution of lidokaina (in a dose 5–10 mg/kg.), 2% solution of trimekaina, is here used (5 mg/kg.). Anaesthesia comes in 15–30 minutes and proceeds during 1,5–2 hour.

Complications meet rarely. Gipotenziya, disorders of breathing, nausea, vomiting, cramps, head pain is possible, traumatic radikulit in area of punktsii.

Other types of the modern anaesthetizing:

Neyroleptanalgeziya (NLA) – one of types of the combined anaesthetizing. An anaesthetic effect is achieved by combination of neyroleptikov (droperidola) and narcotic analgetikov (fentanil). A result shows up the decline of psychical and motive activity, state of indifference, by the thermoanaesthesia with saving of consciousness. It is used in combination with local anaesthesia or inhalation anesthesia. Stabilizes work of heart and vessels during implementation of traumatic stages of operation.

Electro-medicinal anaesthesia (electro-anesthesia, Lemon, 1902) one of types of the common anaesthetizing by means the action of electric current of definite frequency, tension and force on a cerebrum.

It is used in combination with anestetikami, protivosudorognimi and sedativnimi preparations. Anaesthetizing is characterized by the shutdown of consciousness, stability of gemodinamiki, by expansion of pupils. For conducting elektroanalgezii industry lets out such vehicles "Elektronarkon-1-1", "Lenar-1-1", "Electro-sleep-4Т", "EA-30-1-30-1". This method is used in obstetrics, at heavy toksemiyah, burns, at patients with an allergy, poisoning, diseases of the serdechno-sosudistoy system. Complication of electro-anesthesia: possible burns in the places of appendix of electrodes, cramp, head pain, gipertenziya.

Akupunkturnaya analgeziya – anaesthetizing by means igloukalivaniya (acupunctures). For this purpose mm use the special needles from stainless steel by a diameter about 0,4 bring Needle either into the "classic points" placed on, the so-called meridians in the distance from the place of implementation of operative actions, or under a skin on both sides from the operating field. The decline of pain sensitiveness (gipoanalgeziya) is achieved thanks to the irritation of the nervous ending. But at such method of complete anaesthesia does not come. Akupunkturnaya analgeziya is used, how the component of the combined anaesthetizing is in a posleoperatsionnom period, for the removal of pain syndrome, reduction of the use of narcotic analgetikov, and others like that. Possibilities of wide application of such method for anaesthetizing of operations are studied.