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The main components of general anesthesia:

1. Turning off consciousness. Inhalational anesthetics (halothane, isoflurane, sevoflurane, nitrous oxide), as well as non-inhalational anesthetics (propofol, midazolam, diazepam, sodium thiopental, ketamine) are used. 2. Pain relief. Narcotic analgesics (fentanyl, sufentanil, remifentanil), as well as regional anesthesia methods, are used. 3. Muscle relaxation. Muscle relaxants are used (ditilin, arduan, tracrium). Also distinguished special components anesthesia, for example, the use of a heart-lung machine during heart surgery, hypothermia, and more.

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Periods (stages) of general anesthesia.

1. Administration period (induction of anesthesia, induction). 2. The period of maintaining anesthesia (basic anesthesia). 3. Period of elimination (awakening).

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Induction anesthesia.

Anesthetics are administered by inhalation through a face mask (usually in children or with airway obstruction) using an anesthesia machine or intravenously through a peripheral venous catheter. The anesthesia (anesthesia-respiratory) apparatus is designed for ventilation of the lungs, as well as the administration of inhalational anesthetics. The dose of anesthetic is determined by body weight, age and condition of cardio-vascular system. Intravenous drugs are administered slowly, with the exception of patients at risk of regurgitation (emergency surgery, pregnancy, obesity, etc.), when anesthetics are administered quickly.

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During the period of maintaining anesthesia, intravenous, inhalational or combined administration of anesthetics continues. To maintain patency of the airway, an endotracheal tube or laryngeal mask is used. The procedure of inserting an endotracheal tube into the airway is called tracheal intubation. To carry it out, it is necessary to have endotracheal tubes of various sizes and a laryngoscope (an optical device designed to visualize the larynx; it consists of a handle and a blade).

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During the period of recovery from anesthesia, the supply of anesthetics to the patient is stopped, after which a gradual restoration of consciousness occurs. After the patient awakens (determined by the ability to follow simple commands, for example, opening the mouth), recovery muscle tone(determined by the ability to raise the head) and the return of respiratory reflexes (determined by the presence of a reaction to the endotracheal tube, coughing), tracheal extubation is performed (removal of the endotracheal tube). Before extubation, the gas mixture is replaced with 100% oxygen; if necessary, using a sanitation catheter, mucus is suctioned from the pharynx and tracheal tree (through an endotracheal tube). After extubation, it is imperative to ensure that the patient is able to maintain adequate breathing and, if necessary, use a triple maneuver, an oropharyngeal airway, and assisted ventilation. Also, after extubation, the patient is given oxygen through a face mask.

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Mask method

Drip and hardware method of administration

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Non-inhalational anesthesia

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Drugs used:

Ketamine Baryturates Propofol Sodium oxybutyrate Benzodiazepines

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Combined methods of general anesthesia

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Local anesthesia

Can be caused by chemical and physical factors. TO chemical factors includes the use of local anesthetics. Depending on the method of administration of the local anesthetic drug, there are: 1. Superficial (terminal, application), 2. Infiltration 3. Regional anesthesia. stem, plexus, intraosseous, intravenous, intra-arterial, ganglion (zpidural and subarachnoid anesthesia). TO physical factors This includes cooling the area of ​​intended surgery or damage with ice or chloroethyl.

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Advantages of local anesthesia: a) safety; b) simplicity of the technique (no participation of other persons or complex equipment is required); c) cheap. Disadvantages: a) it is impossible to control body functions during extensive traumatic operations, especially on the organs of the thoracic cavity; b) it is difficult to carry out an audit during operations on organs abdominal cavity, since there is no muscle relaxation; c) it is not always possible to achieve complete pain relief (surgeries in the area of ​​scar tissue, etc.); d) in patients with unstable mental health, maintaining consciousness during surgery is undesirable.

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In the clinical course of all types of local anesthesia, the following stages are distinguished: 1) administration of an anesthetic; 2) waiting (the effect of an anesthetic substance on the nerve elements of tissues); 3) complete pain relief; 4) restoration of sensitivity.

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SUPERFICIAL ANESTHESIA Superficial, or terminal, anesthesia is possible only during operations and manipulations on the mucous membranes, which are lubricated or irrigated with an anesthetic solution. Therefore, this method is mainly used in ophthalmology, otolaryngology and urology. For anesthesia, 0.25-3% solutions of dicaine, 5% solution of xicaine, 10% solution of novocaine are used. For superficial anesthesia of the skin, the method of freezing with chlorethyl is used. IN surgical clinic superficial anesthesia is most often used for bronchological examinations (bronchoscopy, bronchography, bronchospirometry) and medical procedures (endotracheal infusions medicinal substances), as well as esophagoscopy, gastroscopy and duodenoscopy.

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INFILTRATION ANESTHESIA The method of infiltration anesthesia according to A.V. Vishnevsky has become widespread. It is based on layer-by-layer tight infiltration of tissues, taking into account the spread of novocaine solution through the fascial sheaths - “tight creeping infiltration”. Weak solutions of novocaine are used - 0.25 and 0.5% solutions up to 1 or more liters per operation, and most of the solution flows out during the incision, which prevents intoxication. Infiltration anesthesia according to the method of A. V. Vishnevsky includes the following stages: intradermal anesthesia along the incision line using a thin needle with the formation of a “lemon peel”; tight infiltration of subcutaneous tissue; after incision of the skin and subcutaneous tissue, injection of novocaine under the aponeurosis; after dissection of the aponeurosis, muscle infiltration; after opening the abdominal cavity, infiltration of the parietal peritoneum. With anesthesia according to A.V. Vishnevsky, “the operation proceeds with a constant change of knife and syringe. Along with complete anesthesia, the tight creeping infiltrate also provides hydraulic tissue preparation.

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Regional anesthesia

Advantages of regional anesthesia methods 1. Reliable intraoperative anesthesia due to pharmacological control of pain at the spinal or peripheral level. 2. Effective autonomic blockade with minimal impact on homeostasis, endocrine-metabolic stability, prevention of pathological reflexes from the surgical field. 3. The ability to use controlled sedation of varying degrees, rather than turning off consciousness, which is mandatory when performing general anesthesia. 4. Reduction recovery period after anesthesia, increasing the comfort of the postoperative period (absence of nausea, vomiting, decreased need for narcotics, early recovery of mental function and motor activity). 5. Reduced incidence of postoperative pulmonary complications, more fast recovery functions gastrointestinal tract compared to what happens after combined general anesthesia. 6. Reducing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). 7. Maintaining contact with the patient during surgery. 8. After orthopedic and traumatological interventions performed under regional anesthesia, conditions for immobilization of the damaged limb are optimized. 9. The advantage of regional anesthesia in obstetrics seems even more significant: the woman in labor is psychologically present during childbirth in conditions of complete analgesia, there is no fetal depression, early contact between mother and newborn is possible. 10. Regional anesthesia eliminates the risk of developing malignant hyperthermia, which is triggered by relaxants and inhalational anesthetics. 11. Regional anesthesia has a lower potential for inducing a systemic inflammatory response and an immunosuppressive effect compared to general anesthesia. 12. Environmental feasibility of using regional anesthesia - reducing “pollution” of operating rooms. 13. When using regional anesthesia, a statistically significant shortening of the length of stay of patients in the ICU and the duration of hospital treatment was noted. In general, it should be noted that wide application Regional anesthesia makes it possible to rationally limit the “all indications” of combined endotracheal anesthesia and thereby avoid the undesirable consequences of this method.

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Basic methods of regional anesthesia

Peripheral blockades: Conduction anesthesia Brainstem anesthesia Plexus anesthesia Intra-osseous* Region Intravenous * Central segmental blockades: Subarachnoidal (spinal, subdural) Epidural ( epidural) caudal; lumbar; thoracic *intraosseous and intravenous regional anesthesia are practically not used and are currently of only historical interest.

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For regional anesthesia, the principle applies: the more proximal, the more effective, the more distal, the safer (Gileva V.M., 1995).

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Local anesthetics used for regional anesthesia. Lidocaine (lignocaine, xylocaine) is a kind of standard with which other anesthetics are compared. Lidocaine has a relatively short-lived analgesic effect, moderate potency and toxicity. It is widely used for peripheral blocks and EA. Bupivacaine (marcaine, anecaine, carbostezin) is a powerful long-acting anesthetic. Bupivacaine is used for all types of regional anesthesia - peripheral and central segmental blocks. When performing SA, marcaine, used in the form of iso- and hyperbaric solutions, has minimal local toxicity and is currently the drug of choice. Ultracaine (articaine) is a drug with a short latent period, like lidocaine, and a fairly long action, comparable to bupivocaine. Like bupivocaine, ultracaine can be used for all types of regional anesthesia. Ropivacaine (naropin) is used for conduction (blockade of trunks and plexuses) and epidural anesthesia. The combination of high anesthetic activity, low systemic toxicity and the ability to cause differential blockade makes ropivacaine the drug of choice in obstetric practice and for prolonged epidural anesthesia in surgery.

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Epidural anesthesia.

Advantages: 1.Long duration of anesthesia. For example: a single-stage injection of 2% r-ralidocaine into the epidural space provides an average duration of anesthesia of 90 minutes. 2. Possibility of postoperative analgesia. Opioids and local anesthetics can be administered through the epidural catheter for postoperative analgesia. 3. Less severe hypotensive reaction. This advantage is more clearly evident if catheterization of the epidural space has been performed. Disadvantages: 1. Danger of intravascular injection. 2. Danger of subarachnoid injection. 3.Lengthening the time between induction and the start of surgery. 4.Technical difficulties. The lumen of the epidural space is approximately 5 mm and good manual skills are required to identify it. Hard puncture meninges(occurs in 1–3% of cases) leads to severe post-puncture headaches. The frequency of inadequate anesthesia, according to various authors, is 3 – 17%. 5. Toxic effect of the anesthetic on the fetus. Relatively high doses of local anesthetic are used. Therefore, subtle physiological studies always reveal a certain degree of fetal depression, which worsens its adaptation. In fairness, it should be noted that with properly administered anesthesia, clinical signs of fetal depression are rarely detected.

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Spinal anesthesia.

Advantages. 1. During spinal anesthesia, manifestations of systemic toxicity of the drug are extremely rare. 2.Simpler implementation. The appearance of cerebrospinal fluid is an ideal reference for identifying the position of the needle. 3. Good quality of anesthesia. Spinal anesthesia, compared to epidural, provides a deeper motor and sensory blockade, which facilitates the surgeon’s work. 4. Quick onset. After administration of the anesthetic, the intervention can begin within 3 to 4 minutes. 5. When using standard dosages of anesthetic, spinal anesthesia, compared to epidural, has less individual variability in the extent of the anesthesia zone. 6. Spinal anesthesia is much cheaper than epidural and general anesthesia. Disadvantages: 1. Hypotension. Despite preventive measures, it is registered in 20–60% of cases. Eliminated by administration of ephedrine solution. Extended spinal anesthesia eliminates this disadvantage, but the high cost of the kit and the complexity of catheter installation make this technique inaccessible. Due to the higher frequency of neurological complications (compared to single-stage), the widespread use of prolonged spinal anesthesia in last years was suspended in a number of developed countries. 2. Limited duration. As already mentioned, the duration of anesthesia after a single injection of lidocaine is 60 - 70 minutes, which is sometimes really not enough and requires additional methods pain relief. Bupivacaine lasts for more than 2 hours. This time is quite enough for intervention. 3. Post-puncture headache. When using small-diameter needles (from 22 gauge and above - 0.6 - 0.3 mm), the incidence of post-puncture headache is comparable to the frequency of a similar complication during epidural anesthesia, and is approximately 1 - 2%.

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List of used literature

Sumin S.A., Rudenko M.V., Borodinov I.M. Anesthesiology and resuscitation. 2009 Moscow. http://studentmedic.ru http://onarkoze.ru

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General anesthesia, or general anesthesia, is one of the the most complex types pain relief. General anesthesia involves turning off the patient's consciousness. Other types of anesthesia do not involve simultaneous deep sleep, blackout and relaxation of the muscles of the whole body. Let's take a closer look at what general anesthesia is, what its advantages and disadvantages are, and whether it has complications.

What is anesthesia

• Anesthesia during surgery is an artificially induced deep sleep. During it the following phenomena occur:
• Deep inhibition of the central nervous system;
• Complete loss of consciousness and memory;
• Disabling or significantly decreasing reflexes;
• Complete absence of pain sensitivity.

Anesthesia is used to slow down the body's overall reactions to surgery.

Anesthesia refers to general anesthesia. If it is necessary to numb any part of the body, then we talk about local anesthesia. So, the main difference between general anesthesia and local anesthesia is precisely the shutdown of consciousness.

What are the components of general anesthesia?

Components of anesthesia are measures that help prevent or reduce certain pathological changes. There are 7 such components in total:

1. Complete blackout. For this purpose, anesthetic agents are used. Superficial inhalation anesthesia can often provide this.
2. Analgesia, that is, turning off pain sensitivity.
3. Neurovegetative inhibition. Here we are talking about suppressing excessive responses of the autonomic nervous system. For traumatic interventions, special antipsychotic drugs are used for anesthesia.
4. Muscle relaxation. Modern anesthesia is primarily the use of many drugs that help achieve the most optimal degree of muscle relaxation.
5. Maintaining necessary gas exchange. It is important for the anesthesiologist to prevent hypoxia and increased breathing.
6. Maintaining circulation is the most significant component of modern anesthesia. After all, during a surgical operation, the volume of circulating blood suffers to a greater extent, and the function of the heart and vascular tone to a lesser extent.
7. Metabolic control is the seventh component of general anesthesia. It is the most difficult to control.

As you can see, the components of general anesthesia are very important components of effective pain relief.

Pain relief methods

The following methods of anesthesia are distinguished:

• Inhalation anesthesia - an anesthetic substance is administered by inhalation through a mask. Previously, ether anesthesia was carried out this way, now other narcotic gases are used;
• Intravenous - the substance is administered intravenously through a catheter;
• Combined.

Depending on the condition of the respiratory tract and the patient’s ability to breathe normally, the question of the method of inhalation anesthesia is decided. Special devices are not used if the patient can breathe on his own or the operation lasts no more than half an hour. And if the patient’s breathing is inadequate, then endotracheal tubes are used. In such cases, an anesthetic substance is also administered intravenously. This multicomponent anesthesia is the most effective.

So, anesthesia methods involve various methods of administering an anesthetic substance. In modern surgery, multicomponent general anesthesia is mainly used.

What substances are administered for anesthesia?

General anesthesia is done using special drugs. Their actions are based on oppression unconditioned reflexes, consciousness, sensitivity and preservation of the functions of the respiratory and vasomotor center. Anesthetics are divided into inhalation and non-inhalation. For example, the latter substances are administered during curettage of the uterine cavity.

Inhalation agents for anesthesia are fluorothan, nitrous oxide, isoflurane, sevorane, desflurane, xenon.

These anesthesia agents have great advantages, primarily in the fact that they allow you to control the depth of anesthesia. But the disadvantages of their use are, in particular, the presence of an excitation stage and a toxic effect on the cardiovascular system, depending on the drug to a greater or lesser extent.

Inhalation drugs for anesthesia are introduced into the body using an anesthesia mask, as well as an endotracheal tube. For precise dosage of the drug, special equipment is used. The requirements for inhaled drugs are:

• high activity;
• a large ratio between the concentration required for surgical anesthesia and the concentration causing paralysis of vital centers of the brain;
• sufficient analgesic ability;
• no toxic effect on the kidneys and liver;
• long shelf life;
• no irritation of the respiratory tract.

Each of the means for inhalation anesthesia has its own advantages or disadvantages. But in general, none of the widely used anesthesia drugs fully meets all the necessary requirements. Thus, in particular, ether anesthesia has a pronounced stage of excitation. In addition, it causes deterioration of tissue circulation, nausea, vomiting, and negatively affects the heart. Not currently used.

Modern general anesthesia is carried out using the best means - Isoflurane, Sevoflurane, Desflurane. They are almost completely free of contraindications.

Non-inhalation agents for anesthesia it is used for intravenous administration, less often - for intramuscular and rectal administration. Nowadays, barbiturates and representatives of other pharmacological groups are mainly used. The difference in their use is that they do not provide an arousal stage. However, it is impossible to say unequivocally which anesthesia is better - it depends on each specific situation. So the anesthesiologist applies different types anesthesia depending on the type of operation, the patient’s condition, etc.

Complications of anesthesia

Complications of general anesthesia can be life-threatening. The main danger Any anesthesia means suffocation (asphyxia). It is always associated with an excess of carbon dioxide and insufficient oxygen supply to the body. Asphyxia also occurs when the trachea is blocked by vomit. Which leads to hypoxia (oxygen deficiency). Other complications include:

• Airway obstruction;
• Laryngo- and bronchospasm;
• Heart failure;
• Operational shock.

Non-inhalational anesthesia also causes complications. So, for example, if anesthesia is performed using Ketamine, the patient under anesthesia may experience hallucinations and psychosis upon awakening. Thiopental often causes allergies.

Contraindications to general anesthesia

Contraindications to anesthesia must always be taken into account when performing any operation. Please note that contraindications for anesthesia are relative. This means that if emergency surgery is indicated for a patient, it must be performed under general anesthesia. Relative contraindications for anesthesia are:

• Hormone-dependent operations;
• Cardiovascular pathologies;
• Bronchial asthma;
• Condition after asthma;
• Alcohol intoxication.

In any case, the doctor always takes into account contraindications for anesthesia so that the operation under anesthesia has as few complications as possible.

Non-inhalation anesthesia also has some contraindications. Thus, thiopental is contraindicated in patients with bronchial asthma. Ketamine anesthesia is not given to patients with coronary disease heart and mental disorders.

Anesthesia for laparoscopy

Anesthesia is indicated for laparoscopy. A feature of anesthesia during laparoscopy is the need for adequate ventilation and good muscle relaxation.

During anesthesia during laparoscopy, inhalation and non-inhalation anesthesia methods can be used. And the anesthesia technique for laparoscopy is the same as for other interventions.

Anesthesia for this type of intervention is used for successful diagnosis and treatment.

Effective pain relief during laparoscopy under anesthesia is done when:

• Removing the appendix;
• Removal of the gallbladder;
• Removal of ovarian cysts and other operations

Anesthesia is calculated depending on the time of laparoscopy. The peculiarity of laparoscopy is that the surgeon makes several punctures in the abdominal wall, through which a video camera and various manipulation instruments are inserted. The duration of laparoscopy is from 20 minutes to several hours. Complications after such an operation are extremely rare.

Features of anesthesia in gynecology

In gynecology, during abortion or uterine curettage, general anesthesia is required. Depending on the operation, multicomponent general anesthesia can be inhalational or intravenous.

Thus, curettage of the uterine cavity and abortion are performed under intravenous anesthesia. Local anesthesia is used to infiltrate the tissues around the cervix. Local anesthetic blocks well painful sensations in the area of ​​the uterus.

Some diseases of the uterus require deep anesthesia. In such cases, general anesthesia is no different from that used for other operations. For example, fibroids of the uterine body, when the uterus and appendages are removed.

The time the patient spends under general anesthesia depends on the pathology of the uterus and ranges from five minutes to several hours. Complications of anesthesia are extremely rare.

Complications after gynecological operations (hysterectomy, curettage, abortion, myomectomy), various types of abdominal surgery (laparoscopic or open operations) develop depending on the general condition of the body and its reaction to anesthesia.

So, anesthesia is not just deep sleep. This special condition body caused by the action of medications. With it, consciousness completely turns off, pain sensitivity disappears. Anesthesia is the prerogative of the anesthesiologist, since only he can ensure the normal course of this complex process while preserving vitality. important functions the body at the proper level.

Modern surgical intervention impossible to imagine without adequate pain relief. The painlessness of surgical operations is currently ensured by an entire branch of medical science called anesthesiology. This science deals not only with methods of pain relief, but also with methods of controlling body functions in critical condition, which is modern anesthesia. In the arsenal of a modern anesthesiologist who comes to the aid of a surgeon, there are a large number of techniques - from relatively simple ones (local anesthesia) to the most complex methods of controlling body functions (hypothermia, controlled hypotension, artificial circulation).

But it was not always so. For several centuries, stupefying tinctures were offered as a means of combating pain; patients were stunned or even strangled, and nerve trunks were tied with tourniquets. Another way was to reduce the duration of surgery (for example, N.I. Pirogov removed stones from the bladder in less than 2 minutes). But before the discovery of anesthesia, abdominal operations were not available to surgeons.

The era of modern surgery began in 1846, when chemist C. T. Jackson and dentist W. T. G. Morton discovered the anesthetic properties of ether vapor and performed the first tooth extraction under general anesthesia. Somewhat later, surgeon M. Warren performed the world's first operation (removal of a neck tumor) under inhalation anesthesia using ether. In Russia, the introduction of anesthesia techniques was facilitated by the work of F. I. Inozemtsev and N. I. Pirogov. The works of the latter (he performed about 10 thousand anesthesia during the Crimean War) played an extremely important role. Since that time, the technique of anesthesia has become many times more complex and improved, opening the surgeon up to unusually complex interventions. But the question still remains open about what anesthesia sleep is and what are the mechanisms of its occurrence.

A large number of theories have been put forward to explain the phenomenon of anesthesia, many of which have not stood the test of time and are of purely historical interest. These are, for example:

1) Bernard's coagulation theory(according to his ideas, the drugs used to induce anesthesia caused coagulation of the protoplasm of neurons and a change in their metabolism);

2) lipoid theory(according to her ideas, narcotics dissolve the lipid substances of the membranes nerve cells and, penetrating inside, cause a change in their metabolism);

3) protein theory(drugs bind to enzyme proteins of nerve cells and cause disruption of oxidative processes in them);

4) adsorption theory(in the light of this theory, drug molecules are adsorbed on the surface of cells and cause a change in the properties of membranes and, consequently, the physiology of nervous tissue);

5) theory of noble gases;

6) neurophysiological theory(most fully answers all the questions of researchers, explains the development of anesthesia sleep under the influence of certain drugs by phasic changes in the activity of the reticular formation, which leads to inhibition of the central nervous system).

In parallel, research was conducted to improve methods of local anesthesia. The founder and main promoter of this method of pain relief was A.V. Vishnevsky, whose fundamental works on this issue still remain unsurpassed.

Anesthesia- This is an artificially induced deep sleep with switching off consciousness, analgesia, suppression of reflexes and muscle relaxation. It becomes clear that modern anesthesia for surgical intervention, or anesthesia, is a complex multicomponent procedure, which includes:

1) narcotic sleep (caused by anesthetic drugs). Includes:

a) switching off consciousness - complete retrograde amnesia (events that happened to the patient during anesthesia are recorded in memory);

b) decreased sensitivity (paresthesia, hypoesthesia, anesthesia);

c) analgesia itself;

2) neurovegetative blockade. It is necessary to stabilize the reactions of the autonomic nervous system to surgery, since autonomic activity is not largely controlled by the central nervous system and is not regulated by narcotic drugs. Therefore, this component of anesthesia is carried out through the use of peripheral effectors of the autonomic nervous system - anticholinergics, adrenoblockers, ganglion blockers;

3) muscle relaxation. Its use is applicable only for endotracheal anesthesia with controlled breathing, but is necessary for operations on the gastrointestinal tract and major traumatic interventions;

4) maintaining an adequate state of vital functions: gas exchange (achieved by precise calculation of the ratio of the gas mixture inhaled by the patient), blood circulation, normal systemic and organ blood flow. You can monitor the state of blood flow by blood pressure, as well as (indirectly) by the amount of urine excreted per hour (urine flow-hour). It should not be below 50 ml/h. Maintaining blood flow at an adequate level is achieved by diluting the blood - hemodilution - through constant intravenous infusion of saline solutions under the control of central venous pressure (normal value is 60 mm H2O);

5) maintaining metabolic processes at the proper level. It is necessary to take into account how much heat the patient loses during surgery and provide adequate warming or, conversely, cooling of the patient.

Indications for surgical intervention under anesthesia determined by the severity of the planned intervention and the patient’s condition. The more severe the patient’s condition and the more extensive the intervention, the more indications for anesthesia. Minor interventions in relatively satisfactory condition of the patient are carried out under local anesthesia.

Classification of anesthesia along the route of introduction of the narcotic substance into the body.

1. Inhalation (a narcotic substance in vapor form is supplied to the patient’s respiratory system and diffuses through the alveoli into the blood):

1) mask;

2) edotracheal.

2. Intravenous.

3. Combined (as a rule, induction anesthesia with an intravenous drug followed by inhalation anesthesia).

First stage

Analgesia (hypnotic phase, Rausch anesthesia). Clinically, this stage is manifested by a gradual depression of the patient’s consciousness, which, however, does not completely disappear during this phase. The patient's speech gradually becomes incoherent. The patient's skin turns red. Pulse and breathing increase slightly. The pupils are the same size as before the operation and react to light. The most important change at this stage concerns pain sensitivity, which practically disappears. Other types of sensitivity are preserved. At this stage, surgical interventions are usually not performed, but small superficial incisions and reduction of dislocations can be made.

Second stage

Excitement stage. At this stage, the patient loses consciousness, but there is an increase in motor and autonomic activity. The patient does not give an account of his actions. His behavior can be compared to the behavior of a person who is heavily intoxicated. The patient's face turns red, all muscles tense, and the veins of the neck swell. From the outside respiratory system There is a sharp increase in breathing, and there may be a short-term cessation of breathing due to hyperventilation. The secretion of the salivary and bronchial glands increases. Blood pressure and pulse rate increase. Due to the strengthening of the gag reflex, vomiting may occur.

Patients often experience involuntary urination. The pupils dilate at this stage, their reaction to light is preserved. The duration of this stage during ether anesthesia can reach 12 minutes, with the most pronounced excitement in patients who have been abusing alcohol for a long time and drug addicts. These categories of patients require fixation. In children and women, this stage is practically not expressed. As anesthesia deepens, the patient gradually calms down, and the next stage of anesthesia begins.

Third stage

Stage of anesthesia sleep (surgical). It is at this stage that all surgical interventions are carried out. Depending on the depth of anesthesia, several levels of anesthesia sleep are distinguished. In all of them there is a complete absence of consciousness, but the systemic reactions of the body differ. Due to the special importance of this stage of anesthesia for surgery, it is advisable to know all its levels.

Signs first level, or the stage of intact reflexes.

1. Only superficial reflexes are absent, the laryngeal and corneal reflexes are preserved.

2. Breathing is calm.

4. The pupils are somewhat constricted, the reaction to light is lively.

5. Eyeballs move smoothly.

6. Skeletal muscles are in good shape, therefore, in the absence of muscle relaxants, operations in the abdominal cavity at this level are not performed.

Second level characterized by the following manifestations.

1. Reflexes (laryngo-pharyngeal and corneal) weaken and then completely disappear.

2. Breathing is calm.

3. Pulse and blood pressure at pre-anesthesia levels.

4. The pupils gradually dilate, and in parallel with this, their reaction to light weakens.

5. There is no movement of the eyeballs, the pupils are set centrally.

6. Relaxation of skeletal muscles begins.

Third level has the following clinical signs.

1. There are no reflexes.

2. Breathing is carried out only through movements of the diaphragm, therefore shallow and rapid.

3. Blood pressure decreases, pulse rate increases.

4. The pupils dilate, and their reaction to a common light stimulus is practically absent.

5. Skeletal muscles (including intercostal muscles) are completely relaxed. As a result, the jaw often sagging, the tongue may retract and breathing may stop, so the anesthesiologist always moves the jaw forward during this period.

6. The patient’s transition to this level of anesthesia is dangerous for his life, therefore, if such a situation arises, it is necessary to adjust the dose of the anesthesia.

Fourth level previously called agonal, since the state of the body at this level is essentially critical. Death can occur at any time due to respiratory paralysis or cessation of blood circulation. The patient needs a complex resuscitation measures. Increasing anesthesia at this stage is an indicator of the low qualifications of the anesthesiologist.

1. All reflexes are absent, there is no reaction of the pupil to light.

2. The pupils are maximally dilated.

3. Breathing is shallow, sharply rapid.

4. Tachycardia, thread-like pulse, blood pressure is significantly reduced, may not be detected.

5. There is no muscle tone.

Fourth stage

Occurs after stopping the supply of the narcotic. Clinical manifestations This stage corresponds to the reverse development of those during immersion in anesthesia. But they, as a rule, occur more quickly and are not so pronounced.

Mask anesthesia. With this type of anesthesia, an anesthetic in a gaseous state is supplied to the patient's respiratory tract through a specially designed mask. The patient can breathe on his own, or the gas mixture is supplied under pressure. When performing inhalation mask anesthesia, it is necessary to take care of the constant patency of the airways. There are several techniques for this.

2. Bringing the lower jaw forward (prevents tongue retraction).

3. Installation of an oropharyngeal or nasopharyngeal airway.

Mask anesthesia is quite difficult for patients to tolerate, so it is not used so often - for small surgical interventions, which do not require muscle relaxation.

Advantages endotracheal anesthesia. This is to ensure constant stable ventilation of the lungs and prevent blockage of the airways with aspirate. The disadvantage is the higher complexity of performing this procedure (if there is an experienced anesthesiologist, this factor is not particularly important).

These qualities of endotracheal anesthesia determine the scope of its application.

1. Operations with increased risk aspiration.

2. Operations using muscle relaxants, especially thoracic ones, in which there may often be a need for separate ventilation of the lungs, which is achieved by using double-lumen endotracheal tubes.

3. Surgeries on the head and neck.

4. Operations with turning the body on its side or stomach (urological, etc.), during which independent breathing becomes very difficult.

5. Long-term surgical interventions.

In modern surgery it is difficult to do without the use of muscle relaxants.

These drugs are used for anesthesia during intubated trachea, abdominal operations, especially during surgical interventions on the lungs (intubation of the trachea with a double-lumen tube allows ventilation of only one lung). They have the property of potentiating the effect of other components of anesthesia, therefore, when joint use the concentration of anesthetic may be reduced. In addition to anesthesia, they are used in the treatment of tetanus and emergency treatment of laryngospasm.

To perform combined anesthesia, several drugs are used simultaneously. This is either several drugs for inhalation anesthesia, or a combination of intravenous and inhalation anesthesia, or the use of an anesthetic and a muscle relaxant (for the reduction of dislocations).

In combination with anesthesia, special methods of influencing the body are used - controlled hypotension and controlled hypothermia. With the help of controlled hypotension, tissue perfusion is reduced, including in the surgical area, which leads to minimization of blood loss. Controlled hypothermia or a decrease in temperature of either the entire body or part of it leads to a decrease in tissue oxygen demand, which makes it possible to carry out long-term interventions with restriction or shutdown of blood supply.

Special forms of pain relief are neuroleptanalgesia– the use of a combination of a neuroleptic (droperidol) and an anesthetic drug (fentanyl) for pain relief – and ataralgesia – the use of a tranquilizer and an anesthetic drug for pain relief. These methods can be used for minor interventions.

Electroanalgesia– a special effect on the cerebral cortex with electric current, which leads to synchronization of the electrical activity of the cortex in ? -rhythm, which is also formed during anesthesia.

Carrying out anesthesia requires the presence of a specialist anesthesiologist. This is a complex procedure and a very serious interference in the functioning of the body. Correctly performed anesthesia, as a rule, is not accompanied by complications, but they still occur even with experienced anesthesiologists.

Quantity complications of anesthesia extremely large.

1. Laryngitis, tracheobronchitis.

2. Obstruction of the respiratory tract - retraction of the tongue, entry of teeth and dentures into the respiratory tract.

3. Atelectasis of the lung.

4. Pneumonia.

5. Disturbances in the activity of the cardiovascular system: collapse, tachycardia, other heart rhythm disturbances up to fibrillation and circulatory arrest.

6. Traumatic complications during intubation (injuries of the larynx, pharynx, trachea).

7. Violations motor activity gastrointestinal tract: nausea, vomiting, regurgitation, aspiration, intestinal paresis.

8. Urinary retention.

9. Hypothermia.

Introduction

Dictionaries define the term “adequate” as “completely appropriate.” In relation to anesthesia, this means meeting the requirements that all participants in a surgical intervention place on it: the patient does not want to “be present” at his own operation, the surgeon needs a “quiet” and conveniently located surgical field, the anesthesiologist seeks to avoid unwanted pathological reflexes, the toxic effect of anesthetics and finally, they all want a normal, uncomplicated operative and postoperative period.

Ensuring the “absence” of the patient during his own operation or a comfortable and “quiet” surgical field is an incomparably easier task than the main one facing the anesthesiologist. In this regard, we focus on the position of the anesthesiologist.

Analysis current state This issue indicates that the problem of the adequacy of anesthesia is still far from a final solution. It serves as the theme of the congresses of the beta All-Union Congress of Anesthesiologists and Reanimatologists. Riga, 1983), discussed at conferences. Obviously, the reason for the enduring relevance of this issue lies mainly in the unrelenting desire of anesthesiologists to reduce or completely eliminate the patient’s adverse reactions to surgical stress with the help of pharmacological agents and special techniques that produce minimal side and toxic effects.

Speaking about this problem, it is interesting to consider the most important questions:

1) what can or should be understood by “adequacy of anesthesia”;

2) what are the ways to achieve adequate anesthesia;

3) should we talk about the adequacy of anesthesia itself or should we evaluate the entire anesthetic management as a whole.

Whether we like it or not, surgical intervention is a pronounced form of aggression, to which the body reacts with a complex of complex reactions. They are based on a high level of neuroendocrine tension, accompanied by a significant intensification of metabolism, pronounced changes in hemodynamics, and changes in the function of major organs and systems. Obviously, anesthesia should reduce the severity of these reactions or completely prevent them. The more fully it achieves this, the more adequate it is.

It is very important that the cause of these reactions is not only pain impulses, but also mechanical, chemical irritations, blood loss, gas exchange shifts, which sharply enhance neurohormonal and reflex activity at all levels. In other words, we are talking not only about nociceptive effects and, accordingly, receptors, but also about a wide range of influences that go beyond the nociceptive system. To this must be added the often very pronounced shifts caused by the pharmacodynamic properties of the drugs used by the anesthesiologist.

Let's try to understand the complex picture of reflex and other reactions observed during surgery, since it is the presence or absence of these reactions as objective criteria that allows us to judge the adequacy of anesthesia.

The first and most important target of aggressive influences is the central nervous system. Unfortunately, in clinical practice, with the exception of EEG, we are deprived of other objective evidence of the CNS reaction. In addition, the increase in functional activity of the brain sometimes recorded on the EEG can be explained not so much by the inadequacy of anesthesia, but by the unique effect of a pharmacological drug, for example, ketamine. To some extent, studying the H-reflexes of motor neurons of the spinal cord can help in determining the reaction of the nervous system.

Equally important are disruptions endocrine system: increased release of catecholamines, corticosteroids, adrenocorticotropic hormone (ACLT), activation of the kallikrein-kinin and renin-angiotensin systems, increased production of antidiuretic and somatotropic hormones.

Activation and tension of regulatory systems cause more or less pronounced changes in the functions of various organs and metabolism. In first place, both in importance and in the attention paid by anesthesiologists, are hemodynamic reactions: fluctuations in blood pressure and heart rate, an increase or decrease in cardiac output and general peripheral resistance(OPS) and, in particular, microcirculation disorders. Kidney function undergoes significant changes: renal blood flow, glomerular filtration, and diuresis decrease. Systemic changes include an increase in blood coagulation activity and a decrease in immune reactivity.

Metabolic changes are the intensification of carbohydrate metabolism (increased blood glucose levels, increased glycolysis), a shift to the acidic side of the metabolic link of the CBS (increased content of lactic and pyruvic acids, negative BE values, changes in the content of tissue hormones (serotonin, histamine) and the activity of proteolytic enzyme inhibitors , disruption of energy metabolism at the cellular level.

This is not a complete list of stress reactions, the occurrence of which is possible against the background of inadequate anesthesia. Let us recall that some of them can also be initiated by anesthetics and other drugs used during anesthesia due to their specific pharmacodynamic properties.

The fact that the described reactions can characterize the degree of protection from surgical stress made it possible to use them for a comparative assessment of the adequacy of both regional and general anesthesia methods. Objective criteria for this include changes in hemodynamics, the content of various substances in the blood (hormones, biologically active substances, cyclic nucleotides, enzymes, etc.), EEG, indicators of kidney function, myocardial contractility, skin potential, results of automatic analysis of heart rhythm using a computer and etc. Naturally, the recorded indicators simplistically reflect the complex processes occurring in the body under the influence of operational stress. The use of either one or a complex of them does not exclude some approximate conclusions. Nevertheless, an approximate assessment of the adequacy of anesthesia using these criteria is certainly possible.

The optimism of the conclusion drawn is reduced by two circumstances that deserve discussion. The first concerns the practical capabilities of the anesthesiologist in assessing the adequacy of his anesthesia in a certain period. Unfortunately, most of the mentioned criteria allow us to judge the quality of anesthesia only retrospectively and characterize the method in general terms, and not specifically in in this case. It is advisable to use those signs that are simple and allow you to realistically assess the course of anesthesia. Such indicators include the color and moisture of the skin, pulse rate and blood pressure, and hourly diuresis. Warm, dry, normal color skin, absence of tachycardia and hypertension, diuresis not lower than 30-50 ml/h indicate a normal course of anesthesia. On the contrary, cold, moist marbled skin, tachycardia, hypertension (or severe hypotension), diuresis below 30 ml/h indicate trouble and require appropriate measures to be taken. Unfortunately, all these indicators are integral in nature and can reflect the impact various factors, and not just the disadvantages of anesthesia. Their assessment is largely subjective. At the same time, objective hardware methods require complex equipment both for recording indicators and for their evaluation.

Secondly, it is unclear how, based on changes in the value of the indicator, one can draw a conclusion about the adequacy or, conversely, inadequacy of anesthesia. For example, what do fluctuations in blood pressure between 10-15 and 20-25% indicate? Can an increase in catecholamine levels by 50% compared to the initial level be considered a negative phenomenon? What is an acceptable shift? Should we generally strive for absolute invariance of the indicator or should the goal be the elimination of only excessively pronounced pathological reflexes? The answers to these questions, as well as the ways to solve them, are ambiguous or unknown.

First of all, let's talk about a problem that receives undeservedly little attention. When the question of the significance of changes in the functions of various organs detected during anesthesia and surgery is decided, a comparison is made with the so-called normal values, i.e. indicators recorded at rest. Meanwhile, the conditions for the functioning of the body during surgery are completely different and place increased demands on the activity of the main systems and organs and the level of metabolism. One should proceed from the so-called stress norm and compare with it those indicators that are recorded during the operation. Naturally, the stress norm can differ significantly from the rest norm: to ensure a higher level of the body’s needs, a correspondingly higher level of operation of both regulatory and effector systems is necessary. Moderate stimulation of the neuroendocrine system, circulatory system, metabolic changes, etc. compared to rest. should be recognized as an appropriate reaction of the body. Its occurrence can be considered as the preservation of the reactivity and adaptive capabilities of the organism. Only going far beyond the stress norm indicates the activation of pathological reflexes, which should be blocked. The stress norm for each indicator has not yet been determined (this should be the subject of further research), but we can assume, for example, that a change in hemodynamic parameters within 20-25% is quite acceptable.

There is another point of view, expressed in recent years in the well-known fascination with gigantic doses narcotic analgesics, which should completely block all reactions to injury, which gave rise to calling this method “stress-free anesthesia”. Sharing the opinion about the benefits and advisability of using narcotic analgesics during anesthesia, we believe that the complete blockade of all reactions to injury, assumed by this method, is hardly justified, is accompanied by motor respiratory depression and requires the use of prolonged mechanical ventilation. In addition, an appropriate compensatory reaction may also be blocked (and this often happens) in the event of any complications.

Thus, maintaining the reactivity of the main regulatory systems and preventing only excessive pathological reflexes is the optimal solution to the problem of achieving the adequacy of anesthesia.

What are the ways to achieve this goal? Infatuation with this or that method or pharmacological agent does not at all indicate their advantages. More important is the principle that equips the anesthesiologist with flexible tactics to achieve adequacy of anesthesia. This principle is the concept of componential anesthesia, which can be considered as theoretical basis(a kind of philosophy) of all types of general anesthesia currently used.

It cannot be said that the concept of component anesthesia arose in empty space. For example, carrying out anesthesia with one anesthetic was based on the concept of depth of anesthesia, and even then it was already clear that by changing the depth of anesthesia, several problems could be solved (turning off consciousness, pain relief, muscle relaxation, etc.). Unfortunately, one goal came into conflict with another. The anesthesiologist was deprived of the ability to rationally manage anesthesia to achieve different goals, each of which required a different depth of anesthesia.

With implementation in clinical practice muscle relaxants, the anesthesiologist was able to control a specific function for the first time. Currently, perfect relaxation and control of the patient’s breathing are quite achievable, regardless of the level of anesthesia. Anesthesia began to be understood as the process of controlling many functions. It has gone far beyond the use of only narcotic drugs, turning into a complex set of measures that rightly received the name “anesthesiological benefit.”

What basic processes and functions should be monitored during anesthesia? The answer to this question is closely related to the objectives of anesthesia. During surgery the following must be provided:

1) mental (emotional) calm of the patient;

2) complete and complete anesthesia;

3) prevention and inhibition of unwanted pathological reflexes;

4) optimal level of exchange, primarily gases;

6) comfortable working conditions for the surgeon, mainly due to muscle relaxation.

Due to known conditions, these goals can be best achieved by using several substances that have a more or less directed and selective effect (the ideal is a pharmacological agent with a strictly targeted and single effect) on individual parts of the reflex arc. The stated provisions justify the so-called polypharmacy, which the anesthesiologist is forced to resort to, since there is no and, obviously, cannot be created a pharmacological agent that can fully and safely satisfy all the requirements for modern anesthesia at various levels. We are talking about selective anesthesia, in contrast to broad-spectrum anesthesia, which occurs with single-component anesthesia.

This understanding of the task facing the anesthesiologist led to the formulation of the concept of selective regulation of functions during anesthesia. According to this concept, anesthesia consists of several components, each of which is assessed and controlled by the anesthesiologist using specific techniques and pharmacological agents.

The components of modern general anesthesia are:

1) inhibition of mental perception (sleep);

2) blockade of pain (afferent) impulses (analgesia);

3) inhibition of autonomic reactions (areflexia or, more precisely, hyporeflexia);

4) turning off physical activity (myorelaxation);

5) control of gas exchange;

6) blood circulation control;

7) metabolism management.

These common components of anesthesia serve as its components for all operations. In some cases, in specialized areas of surgery (neurosurgery, cardiac surgery), it may be necessary to include additional components that A.3. Manevich (1973) proposed to call them specific.

The most valuable thing about the presented concept is the flexibility of tactics it provides. She doesn't dictate at all. mandatory application complex and multicomponent procedures and does not mean that anesthesiologists have completely abandoned technically simpler methods. On the contrary, the principle of individualization of pain relief has only now received its real embodiment in the possibility of using simpler or more complex techniques, depending on the needs of surgery. For short-term and low-traumatic interventions, more simple ways anesthesia, if in these cases they meet the stated requirements. On the other hand, a prerequisite for the success of complex, lengthy and traumatic operations is the use of combined anesthesia methods using a number of basic and auxiliary means that complement each other.

If, from the perspective of the concept of component anesthesia, we try to analyze some modern methods of anesthesia, we can come to the conclusion that the use of an analgesic in large doses as the only narcotic agent, as recommended in the “stress-free anesthesia” method, is as one-sided a solution as an attempt to adequately anesthesia using, for example, one inhaled drug. The use of analgesics is advisable to satisfy only one component of anesthesia - analgesia. An acceptable alternative is epidural anesthesia, which can provide complete analgesia.

In accordance with the concept of components, each of the components of anesthesia is characterized by a number clinical signs, which allow us to judge whether its depth is sufficient. Assessing these signs, the anesthesiologist takes certain measures in order to create optimal conditions for the patient. Main principle consists in the selection of pharmacological agents that have a selective effect on various parts of the reflex arc. Forgetting this principle deprives the concept of component-based anesthesia of any meaning. In this regard, the tendency to use for anesthesia absolutely unjustified complex combinations of many drugs that potentiate each other and cause excessively deep inhibition, which in some cases can lead to severe complications, is alarming. For example, we know of a case of using a mixture that included droperidol, propanidide, sodium hydroxybutyrate, seduxen, an analgesic, and barbiturate.

As clinical studies have shown, with rational use of the recommendations arising from the concept of components, any type of combined anesthesia based on inhalation agents or intravenous drugs can provide adequate conditions. Speaking about “adequacy”, one should be aware that this definition concerns not so much the anesthesia or anesthetic agent itself, but rather the entire anesthetic benefit and, therefore, largely (if not fully) reflects the experience and qualifications of the anesthesiologist, his skill, based on the concept of componential anesthesia, use the entire gamut of known pharmacological agents and anesthetic techniques.

Neuroleptanalgesia can serve as one of the recognized options for general anesthesia, carried out on the basis of the implementation of the component concept. Nitrous oxide in it plays the role of a hypnotic and partially analgesic, additionally administered fentanyl enhances analgesia, droperidol allows one to achieve hyporeflexia, muscle relaxants create muscle relaxation, against the background of which mechanical ventilation maintains an optimal level of gas exchange. As you can see, all components of anesthesia are presented. If in this combination we replace nitrous oxide with any one of the intravenous anesthetics or hypnotics in a dose that ensures sleep (for example, drip administration of barbiturate, sodium hydroxybutyrate or ketamine), then we will receive an acceptable alternative in the form of “pure” intravenous combined anesthesia.

Finally, we need to point out some advantages. First of all, the division of anesthesia into separate components, selectively regulated by an anesthesiologist, creates a fundamentally new methodological basis for the management of anesthesia. Having a certain tactical scheme, the anesthesiologist acts depending on the situation. The presence of such a scheme also determines the second advantage of this concept - facilitating the process of learning combined anesthesia in all its varieties.

Finally, one more aspect that may prove very important in the future. In recent years, researchers have been looking for ways to automate anesthesia. Consideration of anesthesia as a set of certain components should help in the practical solution of this issue. In fact, to achieve adequacy of anesthesia, it is necessary to provide its known components.

The result can be assessed in a binary system of the “yes - no” type, i.e. whether the required depth of the component is ensured. Information can be obtained on the basis of hardware registration, monitor observation and analysis of a set of signs that determine the required level and are the basis for programming the operation of the machine. It is necessary to compare the program, select or determine the value and limits of fluctuations of the main significant (“working”) features that serve as the basis for the operation of the computer. Research in this direction is very promising and will contribute to the complete automation of anesthesia.

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Under general anesthesia components should imply targeted measures of medicinal or instrumental influence aimed at preventing or weakening certain general pathophysiological reactions caused by surgical trauma or surgical disease. There are seven of these common components. The first of these is turning off consciousness, which is achieved with the help of one or another drug. It should be emphasized that to turn off consciousness, it is often enough to use superficial anesthesia. More often, the least harmless nitrous oxide or a combination of nitrous oxide with oxygen and 0.5-1% fluorothane by volume is used for this purpose. Superficial anesthesia, which turns off consciousness, simultaneously partially (depending on the type of general anesthetic) affects the following two components - analgesia and neurovegetative inhibition. Modern anesthesiology does not assign other tasks to a general anesthetic, since deep anesthesia itself is a unique form of aggression and causes pronounced changes in vital organs and systems.

Second component - analgesia, as stated above, is partially achieved by a general anesthetic. However, it should be emphasized that here we can only talk about suppressing the psycho-emotional component of pain while maintaining neurovegetative and neuroendocrine reactions to painful stimuli. To eliminate these reactions, modern anesthesiology uses specific strong analgesics, preferably short-acting. If the operations were not accompanied by pronounced pathophysiological disorders, then local anesthesia would be the ideal remedy for eliminating pain. The latter is currently used quite widely for small outpatient operations. Different kinds local anesthesia (conductor, perndural anesthesia) are used as an aalgesic component of general anesthesia in many medical institutions.

Neurovegetative inhibition- the third component of modern anesthesia. As the name implies, we are talking here about preventing excessive reactions of the autonomic nervous system, i.e. about their inhibition, suppression, but not blockade. The first two components of anesthesia to a certain extent reduce neurovegetative reactions, and for small-scale surgical interventions this may be sufficient. However, during traumatic operations it is necessary to use special neuroleptic drugs (droperidol), which, by causing neurovegetative inhibition, help preserve the body's compensatory mechanisms and a smoother postoperative period.

Fourth component- muscle relaxation and immobilization - allows you to create the necessary conditions to carry out the operation. With mononarcosis, the necessary muscle relaxation was achieved by significantly deepening it, which in itself is unacceptable for modern anesthesia. In this regard, to achieve multiplegine, special drugs began to be used - muscle relaxants, which temporarily relax the striated muscles and thereby make it possible not to increase the concentration of the general anesthetic in the blood deeper than the surface level. However, the use of muscle relaxants, as a rule, requires the presence of a fifth component - maintaining adequate gas exchange with the help of artificial ventilation lungs, since the respiratory muscles are exposed to the action of muscle relaxants. Maintaining adequate gas exchange is one of the main components of modern anesthesia. Actually, it was the absence of this component that for a long time hampered the development of thoracic surgery, because in the conditions of surgical pneumothorax the adequacy of gas exchange was out of the question. Rapidly developing hypoxia and hypercapnia negated the results of brilliantly performed operations. This one, it would seem. an insoluble problem that ceased to exist with the beginning of the era of muscle relaxants and artificial ventilation.

For small operations, which do not require complete muscle relaxation and do not significantly affect the function of external respiration, instead of artificial ventilation, you can use the method of assisted ventilation. As the name implies, this method is used while the patient is still breathing independently. During assisted ventilation, the anesthesiologist synchronously with the patient’s spontaneous inhalation injects an additional volume of the gas-narcotic mixture into the lungs either manually or (if the anesthesia machine has a unit for assisted ventilation with a switch-off system) automatically.

Maintaining adequate blood circulation- the sixth in a row, but one of the first most important components of modern anesthesia. During surgery, the circulating blood volume (CBV) undergoes the greatest changes; the pumping function of the heart and vascular tone are affected to a lesser extent. It should be emphasized that a decrease in blood volume may be associated not only, and sometimes not so much, with blood loss from surgical wound, how much with the deposition of blood in various organs, tissues and vascular venous collectors. The degree of deposition can sometimes reach such great magnitudes that the patient develops a typical picture of hemorrhagic shock during surgery without visible signs of external bleeding.

From here it is obvious that anesthetist to assess BCC, one should be guided not so much by the measurement of external blood loss, but by special methods for determining BCC or (in their absence) clinical data. Today, all anesthesiologists are well aware of this, who, during any operation of even moderate complexity, make timely replenishment of the deficit of blood volume, or rather, try to prevent a significant decrease in blood volume. This is achieved by preliminary (even before blood loss!) administration of blood and blood substitutes, or by special methods, aimed at reducing tissue bleeding (artificial hypotension, postural ischemia). It is thanks to this approach that the operational shock occurs. which was most often associated with a sharp decrease in BCC, i.e. which was essentially hemorrhagic shock, is beginning to disappear wherever there is a modern anesthesiological service.

Important for adequate blood supply a large array of peripheral tissues (mainly muscles) has a state of small arterial and venous vessels, t.s. vessels providing the so-called adequate microcirculation. As mentioned above, disruption of microcirculation is facilitated by excessive adrenergic reactions that accompany any traumatic operation. By providing neurovegetative and neuroendocrine inhibition with the special means indicated above, the anesthesiologist thereby prevents microcirculatory disorders and promotes adequate peripheral blood supply.

More difficult to manage cardiac output. To regulate cardiac output, modern anesthesiology has a complex of cardiotonic agents that enhance contractility myocardium. Methods of mechanical and electrical influence are also used (counterpulsation, electrical stimulation of the heart), and in some cases a transition to artificial circulation. With the introduction of membrane oxygenators into clinical practice, anesthesiologists were able to perform long-term artificial circulation and thereby control cardiac output not only during the operation itself, but also for 2-3 weeks.