Assessment of the initial state of the patient. Anesthesia

Before neurosurgery the patient's condition needs to be assessed. Some parameters of the condition assessment are common for all patients who are to undergo surgery or other surgical interventions, but certain groups of patients require a special or more detailed examination. This chapter will not consider the general principles of preoperative preparation of patients, but only the features characteristic of neurosurgical patients. This article is about elective neurosurgical operations. The same principles apply to emergency operations, although time constraints lead to certain changes. Features of preparing patients for some specific types of intervention will be discussed in the following articles on the MedUniver website.

Tasks of preoperative assessment of the patient's condition

Preoperative examination performs five overlapping functions:
Determining the urgency of surgical treatment.
Timely assessment of the patient's condition and preoperative drug therapy, which may affect the technique of anesthesia and surgery.
Identification of patients whose condition can be improved by the treatment of comorbidities before surgery.
Identification of patients requiring special postoperative care
Informing patients about the benefits and risks of the chosen anesthetic technique, pain management and postoperative care. Although these principles are more relevant to the organization of elective operations, they apply to urgent and emergency operations as well.

Peculiarities organizations preoperative examination depends on many factors specific to each clinic. However, there are general principles:
Timeliness of preoperative assessment of the patient's condition. There should be sufficient time between the pre-operative examination and the date of the scheduled operation to complete the examinations and evaluate the results, so that all issues can be resolved in time. But at the same time, if the time interval between the examination and the operation is too long, neurological symptoms may progress.

Multidisciplinary approach in preoperative assessment of the patient's condition. Preoperative preparation includes not only medical aspects, but also issues that are usually solved by nursing staff, such as social adaptation, fears and concerns about the disease and the upcoming operation. The surgeon and the anesthesiologist may have different requirements for the organization of the process, so they must participate in the preparation.
Some clinics may employ specially trained nurses who perform the duties of both a nurse and a surgeon and anesthesiologist, however, more often, the duties of an anesthesiologist are performed to some extent by residents.

Documentation in preoperative patient assessment. Medical records should be clear and unambiguous. The system should function in such a way that it is always possible to early identify patients with significant overlapping diseases or abnormalities identified during the study. There should be agreed recommendations on thromboembolism prevention, the use of appropriate investigation methods, and the continuation (or discontinuation) of certain drugs (aspirin, clopidogrell, NSAIDs, warfarin).

History and examination. Regardless of who conducts the preoperative examination, it is necessary to highlight the key parameters that are especially important in neuroanesthetic practice.
Patient airway. Undoubtedly, it is important to note the history of difficulties during intubation. Patients with degenerative diseases of the lower spine may also have disease in the cervical spine, which may cause limited movement or be associated with myelopathic symptoms on movement. Postponed surgery on the cervical spine can lead to fixation of the cervical spine in a position that precludes direct laryngoscopy.
Have a large number patients with a brain injury, there is a concomitant injury to the cervical spine.

In many patients with acromegaly obstructive sleep apnea (OSA) is noted, some may also have sleep apnea of ​​central origin. Treatment of acromegaly does not necessarily reverse the anatomical changes predisposing to OSA.

The patient's respiratory system. Patients with myelopathy of the upper cervical segments associated with internal or external compression of the spinal cord may have significant breathing difficulties. They can be difficult to recognize due to physical activity limitations caused by neurological deficits.

In patients with damage to the bulbar structures associated with their neurological disease (tumors of the cerebellopontine angle, multiple sclerosis, syringomyelia/syringobulbia) or depression of consciousness, there is a risk of aspiration, which can often be prevented with careful examination and careful history taking.

Cardiovascular system of the patient. Hypertension is quite common in neurosurgical patients. Most often it is essential arterial hypertension, but sometimes it is associated with the neurosurgical disease itself or with its therapy, for example, with an acute increase in ICP, acromegaly, hypo- or hyperthyroidism; prescribing corticosteroid therapy.

Development of arterial hypertension in the perioperative period is a risk factor for the occurrence of bleeding after craniotomy, therefore, if time permits, it is necessary to adjust blood pressure. Neurosurgical emergencies such as intracranial hematoma, TBI, SAH, and spinal cord injury can lead to serious cardiovascular events. These issues will be discussed separately in the following chapters.

Patient's nervous system. Before anesthesia, a careful assessment of the patient's neurological status should be carried out, which is necessary mainly for the postoperative period. It is also necessary to assess the mental state of the patient. If the patient has impaired consciousness, the details of his history should be clarified with relatives, friends, or the attending physician.

Symptoms increased intracranial pressure include headache when changing body position (postural headache), worse in the morning, coughing or sneezing, accompanied by vomiting. Other symptoms include papilledema, unilateral or bilateral mydriasis, III or IV cranial nerve palsy, absence of brainstem reflexes (or, if severe, systemic hypertension, bradycardia, and Cushing's triad respiratory failure). You also need to evaluate the Glasgow Coma Scale.
The frequency and type of seizures should be described along with other known precipitating factors.

Endocrine system of the patient. Many patients suffer from type 2 diabetes. It is necessary to control glycemia, especially in patients who have recently been prescribed corticosteroids.
Patient's blood system. It is necessary to find out whether the patient or the family has cases of hematomas with minor injuries, prolonged bleeding, and other characteristic signs of clotting disorders. Liver disease should be considered as a risk factor for coagulopathy. You should also identify risk factors for venous thromboembolism and try to eliminate them.

If the operation was not accompanied by severe complications and the tactics of the anesthesiologist were correct, the patient should wake up immediately after completion of the operation, as soon as the drug is turned off.

If the operation was long and anesthesia was carried out with ether, then the supply is reduced even in the second half so that by the end of it the anesthesia weakens to a level close to awakening. From the moment when the surgeon starts suturing the wound cavity, the supply of the narcotic substance stops completely. Without turning off the apparatus, the oxygen supply is increased to 5-6 liters per minute with the simultaneous opening of the exhalation valve. The beginning of the awakening of the patient is determined by the anesthesiologist, depending on the course of the surgical intervention and the characteristics of the course of anesthesia. The skill and experience of the anesthesiologist tell him at what point it is necessary to turn off the apparatus.

Proper management of the patient in the post-anesthetic period is no less important than the anesthesia itself and the operation. Particularly responsible is the transition from the artificial maintenance of the most important functions of the body, which is carried out by an anesthesiologist, to the natural activity of the body after anesthesia. With the correct course of the operation and anesthesia, as well as with the correct withdrawal from it, by the end of the operation, the patient fully recovers active spontaneous breathing. The patient responds to irritation of the trachea with a tube, consciousness is restored, he fulfills the request of the anesthesiologist to open his eyes, stick out his tongue, etc. During this period, the patient is allowed to be extubated. If anesthesia was carried out through a tube passed through the mouth, then before the onset of extubation, it is necessary to prevent biting of the tube with the teeth. For this, mouth expanders and dental spacers are used. Extubation is most often performed at a certain moment when the tone of facial muscles is clearly restored, the pharyngeal and laryngeal reflexes are clearly restored, and the patient begins to wake up and react to the tube as if it were a foreign body.

Before removing the tube from the trachea, as already mentioned, mucus and sputum should be carefully aspirated from the oral cavity, endotracheal tube and trachea.

The decision to transfer the patient from the operating room to the ward is determined by his condition.

The anesthesiologist must make sure that breathing is adequate and that there are no violations of the function of the cardiovascular system. Respiratory failure most often results from the residual action of muscle relaxants. Another cause of acute respiratory failure is the accumulation of mucus in the trachea. Inhibition of the act of breathing sometimes depends on oxygen starvation (hypoxia) of the brain with low blood pressure and a number of other reasons.

If, at the end of the operation, the patient's blood pressure, pulse and respiration are satisfactory, when there is full confidence that there will be no complications, he can be transferred to the postoperative ward. With low blood pressure, insufficiently deep breathing with signs of hypoxia, patients should be detained in the operating room, since the fight against complications in the ward always presents significant difficulties. Moving the patient to the ward in conditions of respiratory and circulatory disorders can lead to serious consequences.

Before delivering the operated patient to the ward, he should be examined. If the patient is wet from sweat or contaminated during the operation, it is necessary to wipe him thoroughly, change his underwear and carefully transfer to a gurney.

Transferring the patient from the operating table should be done by skilled nurses under the guidance of a nurse or doctor. In shifting the patient, two or (when shifting very heavy, overweight patients) three persons participate: one of them covers the shoulder girdle, the second puts both hands under the pelvis and the third under the extended knee joints. It is important to instruct inexperienced caregivers that they should all stand on one side of the patient when carrying.

When transporting from the operating room to the ward, it is imperative to cover the patient so that cooling does not occur (this is especially true for the elderly). When shifting the patient to a gurney or stretcher, and then to the bed, the position of the patient changes. Therefore, one must be very careful not to raise the upper body, and especially the head, too much, since with low blood pressure anemia of the brain and respiratory distress can occur.

The anesthetist and the doctor who observed the patient during the operation and anesthesia should enter the patient's room, observe how he is transferred from the gurney to the bed, and help to put him down correctly. The ward nurse must be aware of the nature of the surgical intervention and must also monitor the correct and comfortable position of the patient. After general anesthesia, the patient is laid completely flat on his back, without a pillow, and sometimes with his head down to prevent vomit from flowing into the airways.

If it is cold in the ward, then you need to cover the patient with heating pads, cover them warmly. In this case, overheating should not be allowed, since as a result of increased sweating, dehydration occurs.

The nurse must ensure that the patient, overlaid with heating pads, does not have a burn. She checks the temperature of the heating pad by touch, avoiding applying it directly to her body.

In the patient room, a constant supply of humidified oxygen is established. Pillows filled with oxygen should always be at the nurse's hand. In some surgical departments and clinics, special oxygen chambers are organized in which patients are placed after thoracic surgery. The oxygen cylinder is located in the ward or on the lower floor, where there is a control panel, from there oxygen is sent through pipes to the wards and is supplied to each bed. Through a thin rubber tube inserted into the nasal passages, the patient receives a metered amount of oxygen. For humidification, oxygen is passed through the liquid.

Oxygen after surgery is necessary due to the fact that when the patient switches from breathing a mixture of drugs with oxygen to breathing with ambient air, acute oxygen starvation with cyanosis and increased heart rate may develop. Inhalation of oxygen by patients significantly improves gas exchange and prevents the occurrence of hypoxia.

Most patients are transferred to the recovery room with a drip infusion of fluid or blood. When shifting the patient from the table to the gurney, it is necessary to lower the stand as much as possible, on which the vessels with the infused blood or solutions were located, so that the rubber tube is stretched as little as possible, otherwise, with careless movement, the needle may be pulled out of the vein and it will be necessary to perform venipuncture or venesection on the other limb again . An intravenous drip is often left until the morning of the next day. It is needed for the introduction of the necessary drugs, as well as for the infusion of 5% glucose solution or saline. It is necessary to strictly take into account the amount of fluid administered, which should not exceed 1.5-2 liters per day.

If anesthesia was carried out according to the intubation method and the patient did not come out of anesthesia for various reasons, in these cases the tube is left in the trachea until the patient fully awakens. The patient is transferred from the operating room to the ward with the endotracheal tube not removed. Immediately after delivering it to the ward, a thin tube from the oxygen system is connected to the tube. It is necessary that in no case should it cover the entire lumen of the endotracheal tube. For the patient during this period, the most careful observation should be established, since serious complications are possible due to biting the tube, pulling it out with an inflated cuff or a tamponed oral cavity.

For those patients who need to continue the oxygen supply after surgery, it is recommended to replace the oral tube with a tube inserted through the nose. The presence of a tube allows you to remove sputum that accumulates in the trachea by sucking it through a thin tube. If, however, you do not monitor the accumulation of sputum and do not take measures to remove it, then the presence of a tube can only harm the patient, since it deprives him of the opportunity to get rid of sputum through coughing.

The nurse anesthetist who participated in the anesthesia should remain at the patient's bedside until full awakening occurs and the danger associated with the use of anesthesia has passed. Then she leaves the patient to the ward nurse, gives her the necessary information and appointments.

For the postoperative patient, it is always necessary to create favorable conditions. It is known that when a nurse is in the ward, the very fact that she is nearby brings relief to the patient. The sister constantly monitors the state of breathing, blood pressure, and pulse, and in case of changes, immediately informs the anesthetist and surgeon. During this period, the patient should not be left unattended for a single minute, in view of the fact that unpleasant complications may arise associated both with the production of the operation itself and with anesthesia.

In the post-anesthetic period, in patients in a state of post-anesthetic sleep, when positioned on the back, tongue retraction is possible. Proper holding of the jaw is one of the responsible tasks of the anesthetist nurse. To prevent the retraction of the tongue, and at the same time, difficulty in breathing, the middle fingers of both hands wind up around the corner of the lower jaw and push it forward and upward with a slight pressure. If before that the patient's breathing was wheezing, now it immediately becomes even and deep, cyanosis disappears.

Another danger a sister should be aware of is vomiting. A great danger for the patient is the ingress of vomit into the respiratory tract. After a long operation and anesthesia, the patient must be under continuous supervision of medical personnel. At the time of vomiting, it is necessary to support the patient's head, turn it to one side, substitute a barrel-shaped basin or a prepared towel in a timely manner, and then put the operated person in order. The sister should have tongs with gauze balls to wipe her mouth, or if there is none, then in case of vomiting, you need to put the end of the towel on your index finger and wipe the buccal space with it, freeing it from mucus. With nausea and vomiting, the patient should be warned to refrain from drinking for some time.

It should be remembered that all medications to prevent vomiting after anesthesia are ineffective, so the most faithful helpers in this are peace, clean air and abstinence from drinking.

One of the frequent companions of the early postoperative period is pain. The pain expected in connection with the operation, especially in combination with the emotion of fear, was left behind. It would seem that the patient's nervous system after the completed operation should be in a state of complete rest. However, such a state in the postoperative period does not always occur, and here the pain factor associated with the operation begins to act with particular force.

Painful irritations, coming primarily from the surgical wound, are especially disturbing for patients in the first days after surgery. Pain has an adverse effect on all physiological functions of the body. To combat local pain, the operated seeks to maintain a fixed position, which causes excruciating tension in him. During operations on the organs of the chest and the upper floor of the abdominal cavity, pain limits the movement of the muscles involved in the breathing process. In addition, pain prevents the recovery of the cough reflex and expectoration of sputum, sometimes for many hours and days. This leads to the accumulation of mucus that clogs the small bronchi, as a result of which conditions are created for the development of pneumonia in the postoperative period, and in the next few hours after anesthesia and surgery, acute respiratory failure of varying degrees may occur. If the pain lasts for a long time, then painful irritations exhaust the patient, upset sleep and the activity of various organs. Therefore, the elimination of pain in the early postoperative period is the most important therapeutic factor.

To eliminate local pain in connection with the operation, there are many different techniques and means. In order to reduce the pain syndrome in the next few hours after the operation, before closing the chest, a paravertebral blockade is performed from the side of the parietal pleura of 2-3 intercostal nerves above and below the surgical wound. Such a blockade is carried out with a 1% solution of novocaine. To prevent pain in the area of ​​surgical incisions of the chest and abdominal walls, an intercostal blockade of the nerve conductors with a 0.5-1% solution of novocaine is done on the operating table.

In the first days after the operation, those operated on, mainly because of pain in the wound, and partly because of the uncertainty about the strength of the sutures or any other complications, are very cautious, timid and do not dare to change the position given to them.

From the first day after the operation, patients should actively breathe and cough up sputum in order to prevent pulmonary complications. Coughing promotes the expansion of the lungs and prepares patients for the motor regimen.

To eliminate postoperative pain, various narcotic and sedative drugs are widely used - morphine, promedol, scopolamine mixtures, and, more recently, neuroplegics. After low-traumatic surgical interventions, pain sensations are significantly reduced from the use of these substances. However, in most cases (especially after very traumatic operations), the effect of drugs is ineffective, and their frequent use and overdose lead to respiratory and circulatory depression. Prolonged use of morphine leads to addiction, to drug addiction.

An effective method of dealing with postoperative pain was the use of therapeutic anesthesia, proposed by professors B. V. Petrovsky and S. N. Efuni. Therapeutic anesthesia or self-narcosis according to the method of these authors is carried out in the postoperative period with nitrous oxide and oxygen in such ratios that are practically completely harmless. This mixture, even at a very high concentration of nitrous oxide (80%), is completely non-toxic. The method is based on the following principles:

1. the use of a drug that does not have a depressing effect on the vital functions of the patient;
2. ensuring sufficient pain relief in the postoperative period;
3. normalization of respiratory function and hemodynamic parameters;
4. the use of nitrous oxide with oxygen, which does not excite the vomiting and cough centers, does not irritate the mucous membranes of the respiratory tract and does not increase the secretion of mucus.

The technique of self-narcosis briefly boils down to the following. After setting nitrous oxide and oxygen at a ratio of 3:1 or 2:1 on dosimeters, the patient is invited to pick up a mask from the anesthesia machine and inhale the gas mixture. After 3-4 minutes, pain sensitivity disappears (while maintaining tactile sensitivity), consciousness becomes clouded, the mask falls out of the hands. With the return of consciousness, if the pain reappears, the patient himself reaches for the mask.

If the operation was performed under endotracheal anesthesia, then often small pains are felt when swallowing and talking. This is due to the presence of infiltration of the mucous membrane of the larynx (from the endotracheal tube), pharynx (from the tampon). In the presence of such phenomena, the patient's speech should be limited, various inhalations and gargling with an antiseptic solution should be used.

Patient care in the postoperative period is extremely important, not without reason there is an expression "the patient came out." In the organization of care and in its practical implementation, the nurse is directly involved. At the same time, accurate, timely and high-quality fulfillment of all doctor's prescriptions is very important.

The stay of patients in the postoperative ward in the first days requires especially careful monitoring by doctors. In recent years, along with the surgeon, the anesthesiologist has also been directly involved in the management of the immediate postoperative period, because in some cases it is much easier for him than for the surgeon to find out the causes of certain complications, and since the preoperative period, he carefully monitors the dynamics of the functional state of the patient. Along with this, the anesthesiologist is well acquainted with the measures for the prevention and treatment of the most common respiratory and cardiovascular disorders in patients.

Taking into account the possibility of acute respiratory failure, the anesthesiologist in the first postoperative hours should have everything necessary for tracheal intubation and artificial ventilation of the lungs at the patient's bedside.

If respiratory failure becomes protracted, the patient cannot cough up sputum well - it becomes necessary to perform a tracheotomy. This small operation usually greatly improves the conditions for gas exchange. It not only allows you to reduce the harmful space of the respiratory tract, but also creates conditions for the suction of sputum from the bronchi. Through the tracheotomy cannula, controlled or assisted breathing can be undertaken at any time.

Blockage of the tracheotomy tube with a secret occurs when the patient has abundant sputum. Given that after a tracheotomy, the patient cannot effectively cough up sputum, it must be very carefully aspirated periodically.

Chapter 1. PREPARATION FOR ANESTHESIA AND OPERATION

The active participation of the anesthesiologist in the examination and treatment of seriously ill patients begins already in the preoperative period, which greatly reduces the risk of anesthesia and surgery. During this period it is necessary to: 1) evaluate the patient's condition; 2) find out the nature and extent of the surgical intervention; 3) determine the degree of risk of anesthesia; 4) take part in the preparation (preliminary and immediate) of the patient for surgery; 5) choose a rational method of anesthesia for the patient.

Assessment of the patient's condition

If the patient is in critical condition or is at risk of developing it, the anesthesiologist should examine him as soon as possible. The main sources of obtaining information allowing

to get an idea of ​​the patient's condition is a case history. conversation with the patient or his close relatives, physical data. functional, laboratory and special studies.

Along with the formation of a general idea of ​​the disease. the causes of its occurrence and dynamics, the anesthesiologist must find out the following information, which is of great importance in preparing for and conducting anesthesia:

1) age, body weight, height, blood group of the patient:

2) concomitant diseases, the degree of functional disorders and compensatory capabilities at the time of examination:

3) the composition of the last dose of ts-rapII, the duration of administration and dose of drugs, the date of withdrawal (this is especially true for steroid hormones, anticoagulants, antibiotics, diuretics, antihypertensives, antidiabetic drugs, β-stimulants or (3-blockers, hypnotics, analgesics, including narcotic ones), the mechanism of their action should be refreshed in memory;

4) allergic history (whether the patient and his immediate family had unusual reactions to medications and other substances; if so, what is their nature);

5) how the patient underwent anesthesia and surgery, if they were performed earlier; what memories of them remained; were there any complications or adverse reactions;

6) the time of the last fluid and food intake;

7) for women - the date of the last and expected menstruation, its usual nature, for men - is there any difficulty in urinating;

8) the presence of occupational hazards and bad habits;

9) characterological and behavioral characteristics, mental state and level of intelligence, pain tolerance: emotionally labile patients require special attention and vice versa. closed, "withdrawn into themselves."

During (risical examination, attention is paid to:

1) the presence of pallor, cyanosis, jaundice, deficiency or excess of body weight, edema, shortness of breath, signs of dehydration and other specific signs of the pathological process;

2) the degree of impairment of consciousness (adequacy of the assessment of the situation and the environment, orientation in time, etc.); in an unconscious state, it is necessary to find out the cause of its development (alcohol intoxication, poisoning, brain injury, diseases - renal, uremic, diabetic hypoglycemic or hypermolar coma);

3) neurological status (completeness of movements in the final limbs, pathological signs and reflexes, pupillary reaction to light, stability in the Romberg position, finger-nose test, etc.);

4) anatomical features of the upper respiratory tract with re\i. to determine if there may be problems maintaining their patency and intubation during anesthesia.

5) diseases of the respiratory system, manifested by an irregular shape of the chest, dysfunction of the respiratory muscles, displacement of the trachea, changes in the nature and frequency of breathing. auscultatory picture and percussion sound over the lungs:

6) diseases of the cardiovascular system, especially accompanied by heart failure in the left- (low blood pressure, tachycardia, reduced stroke volume and cardiac index, signs of stagnation in the pulmonary circulation) and pro-ventricular type (increased CVP and enlarged liver, oyuki p ankle and calf areas)

7) the size of the liver (enlargement or shrinkage due to alcohol abuse or due to other reasons), spleen (malaria, blood diseases) and in general alive i a (its increase can be caused by obesity, a large tumor, swollen intestines, ascites);

8) the severity of the saphenous veins of the extremities to determine the location and method of access to the venous system (puncture, catheterization)

Based on the study of the anamnesis and physical data! examination of the patient, the anesthesiologist determines the need for additional studies using functional laboratory diagnostic methods II, including special methods

It should be remembered that no amount of laboratory research can replace the analysis of data obtained when determining the history of the disease and assessing the objective status. However, when preparing for anesthesia, it is necessary to strive for the most complete examination of the patient,

If surgery is performed under general anesthesia with spontaneous breathing in patients under 40 years of age, and in a planned manner and for a disease that is localized and

does not cause systemic disorders (practically healthy), volume

examination may be limited to determining the blood type and Rh factor, taking an electrocardiogram and roentgenoscopy (i raffia) of the chest organs, examining "red" (the number of erythrocytes, hemoglobin index) and "white" (the number of leukocytes, leukogram) blood, blood coagulation systems by the simplest methods (for example, according to Duque). urinalysis The use of general anesthesia with grachep intubation in such patients

additionally requires the determination of hematocrit. assessment of liver function at least by the level of bilirubin and the concentration of total protein in

blood plasma

In patients with mild systemic disorders that slightly disrupt the vital activity of the body, the concentration of basic electrolytes (sodium, catium, chlorine), nitrogenous products (urea, creatine) is additionally examined. transampnases (ACT, ALT) and alkaline phosphatase in blood plasma

With moderate and severe systemic disorders that impede the normal vitality of the organism, it is necessary to provide for studies that allow a more complete assessment of the state of the main life support systems, respiration, blood circulation, excretion, and osmoregulation. In particular, in such patients it is necessary to evaluate the concentration of calcium and magnesium in the blood plasma, to investigate protein fractions, isoenzymes (LDP, LDP, LDH-;

etc.), osmolality, acid-base state and hemo-gas system.

To clarify the degree of gas exchange disorders, it is advisable to investigate the function of external respiration, and in the most severe cases - Pco2, Po2, S02. More deeply it is necessary to understand the state of central hemodynamics.

Currently, the assessment of the central hemodynamics is carried out primarily on the basis of a study of the stroke volume of the heart II minute volume of blood circulation. It is believed that the measurement of these indicators with acceptable accuracy is possible not only using invasive, but also non-invasive methods (rheography and echocardiography). Studies have shown that in order to evaluate and compare the main hemodynamic parameters, it is necessary to use not absolute values, but reduced to body surface area. The average values ​​of these indicators are as follows (x + u):

Both quantities contain a standard error, which serves as a criterion for assessing the significance of discrepancies in the results of specific measurements. At the same time, the deviation of the indicator from the average value by one sigma is considered as random, from one to two - moderate, from two to three - pronounced, and more than three - critical.

How to assess the one-time performance of the heart in this case is presented in Table 1. I.

It should be remembered that the magnitude of the shock index and the criteria for its evaluation allow us to characterize only the work of the heart as a pump. without evaluating its effectiveness. Therefore, based on the assessment of IA, it is hardly possible to speak only about a decrease in the one-time performance of the heart. not heart failure

TtioJiima I !

Evaluation of one-time performance of the heart

These standards apply to all types of anesthesia care, although appropriate life-sustaining measures are preferred in emergencies. These standards may be supplemented at any time at the discretion of the responsible anesthesiologist. They are aimed at providing qualified care to patients, however, their observance cannot serve as a guarantee of a favorable treatment outcome. These standards are subject to revision from time to time due to advances in technology and practice. They apply to all types of general, regional and controlled anesthesia. In certain rare or unusual circumstances, 1) some of these monitoring methods may not be clinically feasible and 2) appropriate use of the described monitoring methods may not prevent adverse clinical developments. Short breaks in continuous monitoring may be unavoidable (note that "permanent" is defined as "regularly and frequently repeated in constant rapid succession", while "continuous" means "continuous, without any interruption in time"). Under compelling circumstances, the responsible anesthesiologist may waive requirements marked with an asterisk (*); in the event that such a decision is made, a record of this (including justification) should be made in the medical record. These standards are not intended for use in the management of pregnant women during labor or pain management.

STANDARD I

Qualified anesthesia personnel must be present in the operating room during the entire time of all types of general, regional anesthesia and controlled anesthesia care.

Target:
Due to the rapid change in the patient's condition during anesthesia, qualified anesthesia personnel must be constantly present in the operating room to monitor the patient's condition and provide anesthesia care.

Where personnel may be exposed to direct, known hazards, such as exposure to x-rays, periodic monitoring of the patient from a distance may be required. Certain precautions must be taken during monitoring. If any new emergency requires the temporary absence of the anesthesiologist responsible for administering anesthesia, he should decide how important this emergency is compared to the condition of the patient under anesthesia, and appoint a specialist who will be responsible for administering anesthesia during his absence. .

STANDARD II

During all types of anesthesia, it is necessary to constantly assess the oxygenation, ventilation, circulation and temperature of the patient.

oxygenation

Target:
Ensuring an adequate concentration of oxygen in the inhaled gas mixture and blood during all types of anesthesia.

Methods:
1. Inhaled Gas Mixture: Whenever general anesthesia is administered using a breathing apparatus, the oxygen concentration in the breathing circuit must be determined with an oxygen analyzer that gives a low oxygen alarm.*
2. Blood oxygenation: Quantitative methods of oxygenation assessment, such as pulse oximetry, should be used for all types of anesthesia.

Ventilation

Target:
Ensuring adequate ventilation of the patient during all types of anesthesia.

Methods:
1. Adequate ventilation should be ensured in each patient during general anesthesia, which must be constantly evaluated. Although qualitative clinical signs such as chest excursion, counterlung observation, and lung auscultation are relevant for this assessment, quantitative monitoring of CO₂ and/or exhaled gas volume is mandatory.
2. After tracheal intubation, it is necessary to verify the correct position of the endotracheal tube in the trachea by clinical assessment and determination of CO₂ in the exhaled gas mixture. Continuous determination of end-tidal CO₂ should be carried out from the moment of intubation to extubation or transfer to the recovery room using quantitative methods such as capnography, capnometry or mass spectrometry.
3. When ventilation is provided by a breathing apparatus, continuous use of a monitor is required to detect leaks in the breathing circuit. It should give an audible alarm.
4. When performing regional and monitored anesthesia, it is necessary to evaluate the adequacy of ventilation, at least by constantly monitoring clinical signs.

Circulation

Target:
Ensuring adequate blood circulation in the patient during all types of anesthesia.

Methods:
1. For each patient during anesthesia, continuous monitoring of the ECG should be carried out from the beginning of anesthesia until the moment the patient is transferred from the operating room.*
2. Each patient should have their blood pressure and heart rate measured and assessed at least every five minutes during anesthesia.*
3. In addition to the above, the circulatory function should be constantly assessed in each patient during anesthesia using at least one of the following methods: pulse palpation, cardiac auscultation, monitoring of the intra-arterial pressure curve, ultrasonic monitoring of the peripheral pulse, plethysmography or oximetry .

Body temperature

Target:
Maintaining an appropriate body temperature during all types of anesthesia.

Methods:
Devices for monitoring the patient's body temperature should be easily accessible and ready for use. Temperature should be measured if a change is expected or suspected.

STANDARDS FOR REGIONAL ANESTHESIA IN OBSTETRICS

These standards refer to the administration of regional anesthesia or analgesia when local anesthetics are administered to a woman during labor or delivery. They are aimed at providing qualified assistance, but cannot serve as a guarantee of a favorable outcome. Since the drugs and equipment used in anesthesia can change, these standards need to be interpreted in each institution. They are subject to revision from time to time due to developments in technology and practice.

STANDARD I

Regional anesthesia should only be started and administered in a facility where the appropriate resuscitation equipment and medications that may be required to eliminate anesthesia problems are available and ready for use.

The list of resuscitation equipment should include: oxygen supply and suction, airway maintenance and tracheal intubation equipment, positive pressure ventilation devices, and medicines and equipment for cardiopulmonary resuscitation. Depending on local possibilities, the list can be expanded.

STANDARD II

Regional anesthesia must be performed by a licensed physician and carried out by him or under his supervision.

The physician must obtain permission to perform and further manage the administration of anesthesia in obstetrics, as well as to manage the complications associated with anesthesia.

STANDARD III

Regional anesthesia should not be performed before: 1) examination of the patient by a qualified specialist; and 2) maternal, fetal, and labor frequency evaluations by an obstetrician who is prepared to manage the delivery and manage any complications associated with it.

Under certain circumstances, as determined by the department protocol, qualified personnel may perform an initial pelvic examination of the woman. The doctor responsible for caring for a pregnant woman should be informed of her condition so that he can decide on further actions, taking into account the risk.

STANDARD IV

Intravenous infusion should begin prior to the start of regional anesthesia and be maintained throughout its duration.

STANDARD V

When performing regional anesthesia during labor or delivery through the birth canal, it is necessary that a qualified specialist monitor the vital signs of the woman in labor and the fetal heart rate, and also record them in the medical records. Additional monitoring, corresponding to the clinical condition of the woman in labor and the fetus, is carried out according to indications. If extensive regional blockade is performed for complicated vaginal delivery, standards for basic anesthetic monitoring should be applied.

STANDARD VI

The administration of regional anesthesia for caesarean section requires the application of basic anesthetic monitoring standards and the ability to immediately call in a doctor specializing in obstetrics.

STANDARD VII

In addition to the anesthetist supervising the mother, it is necessary to have qualified personnel who will take responsibility for resuscitation of the newborn.

The primary responsibility of the anesthesiologist is to provide care for the mother. If it is required that this anesthetist be involved in the care of the newborn for a short time, the benefit that these actions can bring to the child must be weighed against the risk to the mother.

STANDARD VIII

When performing regional anesthesia, it is necessary to be able to attract a qualified specialist who will deal with the medical treatment of complications associated with anesthesia until the state after anesthesia becomes satisfactory and stable.

STANDARD IX

All patients during the recovery period after regional anesthesia should be provided with appropriate anesthetic support. After caesarean section and/or major regional blockade, post-anesthetic management standards should be applied.

1. The post-anesthesia care unit (PONS) should be prepared to receive patients. Its layout, equipment and personnel must meet all regulatory requirements.
2. If a department other than the OPNI is used, the woman should be given equivalent care.

STANDARD X

Liaison should be established with a physician capable of treating complications and performing cardiopulmonary resuscitation in the postanesthetized patient.

STANDARDS OF MANAGEMENT AFTER ANESTHESIA

(Approved October 12, 1988, last amended October 19, 1994)

These standards apply to the provision of post-anesthesia care in all departments. These may be supplemented at the discretion of the responsible anesthesiologist. The standards are aimed at providing qualified care to patients, but cannot guarantee a favorable outcome of treatment. These standards are revised from time to time as technology and practice evolve. Under compelling circumstances, the responsible anesthesiologist may waive requirements marked with an asterisk (*); if such a decision is made, an entry (including justification) should be made in the medical record about this.

STANDARD I

All patients after general, regional or monitored anesthesia should be provided with appropriate care.

1. After anesthesia, patients should be admitted to the Post-Anesthetic Surveillance Unit (OPN) or to another unit capable of providing the same qualified care. All patients after anesthesia should be admitted to the DRCU or its equivalent, except in special cases, due to the order of the responsible anesthesiologist.
2. The medical aspects of the care provided in the DPNS should be governed by rules that are reviewed and approved by the Department of Anesthesiology.
3. The layout, equipment, and personnel of the OPNS must meet all regulatory requirements.

STANDARD II

A patient who is being transported to the DRCU should be accompanied by a member of the anesthesia team who is aware of their condition. During transportation, constant monitoring and necessary medical treatment of the patient should be carried out, corresponding to his condition.

STANDARD III

After the patient has been delivered to the DRCU, the patient's condition should be reassessed, and the accompanying anesthesia team member should verbally communicate the patient's information to the DRCU nurse in charge.

1. The condition of the patient upon admission to the emergency department should be reflected in the medical records.
2. Information about the preoperative condition of the patient and the nature of the provision of surgical / anesthetic care should be transferred to the nurse of the OPNN.
3. A member of the anesthesia team must remain in the EDNS until the nurse in that department takes over the responsibility of caring for the patient.

STANDARD IV

The PDNS should continuously assess the patient's condition.

1. The patient must be observed and monitored by methods appropriate to his condition. Particular attention should be paid to monitoring oxygenation, ventilation, circulation and body temperature. Quantitative oxygenation measures such as pulse oximetry should be used in initial recovery from all types of anesthesia.* It is not necessary to use this method in parturient women recovering from regional anesthesia for labor pain relief and vaginal delivery.
2. The course of the post-anesthetic period must be accurately reflected in the medical records. It is desirable to use an appropriate scoring system for assessing the condition of each patient upon admission, after a certain period of time (before discharge) and at discharge.
3. The overall medical direction and coordination of patient care in the DOI is the responsibility of the anesthetist.
4. Patients with AKI should be provided with ongoing care from a specialist in the management of complications and cardiopulmonary resuscitation.

STANDARD V

The physician is responsible for transferring the patient from the anesthesia care unit.

1. The discharge criteria used must be approved by the medical staff of the anesthesiology department. They can be different depending on whether the patient is transferred to one of the departments of the hospital, to the intensive care unit, to the short stay unit, or is discharged home.
2. In the absence of a discharge physician, the PDNS nurse must decide whether the patient's condition meets the discharge criteria. The name of the physician taking responsibility for the discharge of the patient must be included in the medical records.

When preparing for local anesthesia, attention should be paid to the patient, explaining to him about the advantages of local anesthesia. In a conversation with the patient, it is necessary to convince him that the operation will be painless if the patient reports the appearance of pain in time, which can be stopped by adding an anesthetic. The patient must be carefully examined, especially the skin, where local anesthesia will be performed, since this type of anesthesia cannot be performed with pustular diseases and skin irritations. The patient needs to find out allergic diseases, especially allergies to anesthetics. Before anesthesia, measure blood pressure, body temperature, count the pulse. Before premedication, the patient is asked to empty the bladder. 20-30 minutes before surgery, premedicate: inject 0.1% atropine solution, 1% promedol solution and 1% diphenhydramine solution 1 ml intramuscularly in one syringe. The purpose of premedication is to reduce the patient's emotional arousal, neurovegetative stabilization, prevention of allergic reactions, decrease in glandular secretion, and decrease in response to external stimuli Barykina N.V., Zaryanskaya V.G. Nursing in surgery. - Rostov-on-Don "Phoenix", 2013-S.98 .. After the sedation, bed rest must be strictly observed until the end of local anesthesia.

After local anesthesia, it is necessary to lay the patient in the position required by the nature of the operation. If there are violations of the general condition (nausea, vomiting, pallor of the skin, lowering blood pressure, headache, dizziness), then lay the patient down without a pillow.

After any type of anesthesia, the patient must be observed for two hours: measure blood pressure and body temperature, count the pulse, examine the postoperative bandage. In case of complications, it is necessary to provide medical assistance and urgently call a doctor.

With a drop in blood pressure, it is necessary to lay the patient horizontally, inject intramuscularly 1-- ml of cordiamine, prepare before the doctor arrives 1% mezaton solution, 0.2% norepinephrine solution, 5% glucose solution, 0.05% strophanthin solution or 0.06% corglycone solution, prednisolone or hydrocortisone.

The nurse must clearly and correctly carry out the nursing process in stages:

1. Nursing examination and assessment of the patient's situation.

Since local anesthesia still has a small percentage of complications, the nurse needs to find out if there are any contraindications to this type of anesthesia.

In a conversation with the patient, she explains the purpose and benefits of local anesthesia, obtaining consent for its implementation. Having collected the necessary subjective and objective information about the patient's health status, the nurse must conduct an analysis, fill out the documentation in order to use it as a basis for comparison in the future.

2. Diagnosing or identifying the patient's problems.

During local anesthesia, the following nursing diagnoses can be made:

I decrease in motor activity associated with the introduction of local anesthetic solutions;

I nausea, vomiting associated with the emerging complication.

I pain associated with the restoration of sensitivity after surgery;

I fear of possible complications.

After the formation of all nursing diagnoses, the nurse sets their priority Barykina N.V., Zaryanskaya V.G. Nursing in surgery. - Rostov-on-Don "Phoenix", 2013-p.100..

3. Planning the necessary care for the patient and the implementation of the plan of nursing interventions.