Stages of anesthesia. General anesthesia: indications, conduct, types and stages, rehabilitation, complications Drugs affecting the central nervous system

Regulating the depth and duration of general anesthesia is possible, but for this it is necessary to determine what stage of anesthesia the patient is currently in.

The stages of anesthesia in animals and humans always develop naturally, and they are specific to each drug or their combinations. The action of all anesthetics is fundamentally the same.

The classic concept of “clinical anesthesia” (manifestations of signs of anesthesia, previously cited in the literature) has undergone significant changes in meaning due to the simultaneous use in practice of several drugs with multidirectional effects that complement each other. This makes it difficult to assess the depth of anesthesia and its adequacy to surgical trauma. The clinical picture is described in detail using the example of inhalation anesthesia with ether. There are four main clinical stages of anesthesia. Let's consider stages I and III.

In stage I - stages of analgesia(intoxication, stadium incipiens, hypnotic phase - according to V.S. Galkin) the anesthetized patient loses orientation in the environment. He gradually falls into a dormant state, from which he can be easily awakened by a loud sound. At the end of this stage, consciousness turns off and analgesia occurs.

Stage I of anesthesia is characterized by a gradual blackout of consciousness, which, however, does not turn off completely. Tactile and temperature sensitivity and reflexes are preserved, pain sensitivity is sharply weakened (hence the name of the stage). The pupils are the same as before the onset of anesthesia or are slightly enlarged and react to light. Pulse and breathing are somewhat rapid. During the analgesia stage, short-term surgical operations and interventions are performed (incision, opening, reduction of dislocation). It corresponds to the concept of “stunning” (rausch anesthesia). With ether anesthesia in combination with relaxants and other drugs, major operations, including intrathoracic ones, can be performed at this stage.

As anesthesia continues, stage II occurs - excitation(stadium excitationis), when all physiological processes are activated: agitation is noticeable, noisy breathing, rapid pulse, all types of reflex activity intensify. At this stage, inhibition develops in the cerebral cortex, resulting in inhibition of conditioned reflex activity and disinhibition of subcortical centers.

The patient's behavior resembles a strong degree of alcohol intoxication: the subconscious is turned off, motor excitation is pronounced, accompanied by increased muscle tone. The veins of the neck are full, the jaws are clenched, the eyelids are closed, the pupils are dilated, the pulse is rapid and tense, blood pressure is increased, cough and gag reflexes are strengthened, breathing is rapid, short-term cessation of breathing (apnea) and involuntary urination are possible.

Stage III - sleep stage, or tolerant(stadium tolerans, surgical, endurance stage) - begins due to the development of inhibition in the cortex and subcortex. Excitation stops, physiological functions stabilize. In practice, all anesthetics are selected so that this stage is the longest.

The activity of the centers of the medulla oblongata is preserved. Pain sensitivity disappears first on the back, then on the limbs, chest, and abdomen. The condition of the pupil is very important during this period: if the pupil is narrow and does not react to light, this indicates the correct course of anesthesia. Pupil dilation and the appearance of a reaction to light precede the patient's awakening; dilation of the pupil in the absence of a reaction to light serves as the first important signal of impending respiratory arrest.

Important indicators of the depth of anesthesia, along with the pupillary reflex, are changes in breathing, blood circulation, skeletal muscle tone, and the condition of the mucous membranes and skin. A big role here is played by the results of special studies (if it is possible to carry them out): encephalography, oxygemometry, electrocardiography, etc. In stage III, different authors distinguish 3...4 levels.

Superficial level of stage III (III-1 - level of movement of the eyeballs) is characterized by the fact that the movement of the eyeballs is preserved, the pupils are constricted, and react to light. Only superficial reflexes are absent. Breathing is even, rapid, pulse is slightly increased, blood pressure is normal, skin is pink. The patient is in a state of calm, even sleep, the corneal, pharyngolaryngeal reflexes are preserved and muscle tone is slightly reduced. Short-term and low-traumatic operations can be performed.

Average level III stage (III-2 - level of corneal reflex) is characterized by the fact that there is no movement of the eyeballs, the pupils are constricted, and the reaction to light is preserved. Breathing is slow. Blood pressure and pulse are normal. Sometimes after exhalation there is a slight pause. Reflex activity and muscle tone disappear, hemodynamics and breathing are satisfactory. Abdominal surgery can be performed without the use of muscle relaxants.

On deep (3rd) level of stage III (III-3 - level of pupil dilation) the toxic effect of ether is manifested - the pupils gradually dilate, their reaction to light fades, the conjunctiva is moist. The rhythm and depth of breathing is disrupted, costal breathing weakens, and diaphragmatic breathing predominates. Tachycardia intensifies, the pulse increases somewhat, and blood pressure decreases slightly. Muscle tone is sharply reduced (atony), only sphincter tone is preserved. The skin is pale. This level is acceptable for a short time with mandatory assisted breathing.

On 4th level III stage (III-4 - level of diaphragmatic breathing) extreme depression of physiological functions is manifested; the pupils are dilated, there is no reaction to light, the cornea is dry. Paralysis of the intercostal muscles progresses, costal breathing is absent, contractility of the diaphragm decreases, diaphragmatic breathing is rapid and shallow. Blood pressure decreases (hypotension), the skin is pale or cyanotic. Paralysis of the sphincters occurs.

As anesthesia deepens, IV agonal stage(stadium agonalis). Paralysis of the respiratory and vasomotor centers occurs: shallow, intermittent breathing with long periods of apnea, up to a complete stop; arrhythmia, fibrillation and cardiac arrest are consistently observed; the pulse is threadlike at first, then disappears; blood pressure drops rapidly and death occurs.

With the action of other anesthetics, these same stages are expressed somewhat differently. For example, with intravenous administration of barbiturates in stage I, the patient quickly falls asleep calmly, breathing is slightly depressed, laryngeal and pharyngeal reflexes are increased, and hemodynamics are stable. In stage II, the pupils are slightly dilated, reflex activity is preserved, respiratory arrhythmia appears, sometimes leading to short-term apnea, and there may be motor reactions to pain. In stage III, the reaction to pain completely disappears, moderate muscle relaxation is observed, breathing becomes shallow, myocardial function is somewhat depressed, resulting in hypotension. With further intensification of anesthesia with barbiturates, apnea and asystole are observed. This also happens with rapid administration of these drugs in high concentrations.

It is neither possible nor necessary to describe the clinical manifestations of anesthesia for all drugs and their combinations. The clinical picture of inhalation anesthesia with ether most fully reflects all stages, and on its basis it is possible to monitor and evaluate the body’s response to other drugs in each specific case.

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Anesthesia is a condition characterized by a temporary loss of consciousness, pain sensitivity, reflexes and relaxation of skeletal muscles, caused by the effect of narcotic substances on the central nervous system.

There are 4 stages: I - analgesia, II - excitement, III - surgical stage, divided into 4 levels, and IV - awakening.

Analgesia stage (I). The patient is conscious, but lethargic, dozing, and answers questions in monosyllables. There is no superficial pain sensitivity, but tactile and thermal sensitivity is preserved. During this period, it is possible to perform short-term interventions (opening phlegmons, ulcers, diagnostic studies). The stage is short-term, lasting 3-4 minutes.

Excitation stage (II). At this stage, inhibition of the centers of the cerebral cortex occurs, while the subcortical centers are in a state of excitement: there is no consciousness, motor and speech excitation is expressed. The patients scream and try to get up from the operating table. The skin is hyperemic, the pulse is rapid, and blood pressure is elevated. The pupil is wide, but reacts to light, lacrimation is noted. Often there is a cough, increased bronchial secretion, and vomiting is possible. Surgical manipulations cannot be performed against a background of agitation. During this period, it is necessary to continue saturating the body with a narcotic drug to deepen anesthesia. The duration of the stage depends on the patient’s condition and the experience of the anesthesiologist. Excitation usually lasts 7-15 minutes.

Surgical stage (III). With the onset of this stage of anesthesia, the patient calms down, breathing becomes even, pulse rate and blood pressure approach the original level. During this period, surgical interventions are possible. Depending on the depth of anesthesia, there are 4 levels of stage III anesthesia.

First level (III, 1): the patient is calm, breathing is even, blood pressure and pulse reach their original values. The pupil begins to narrow, the reaction to light is preserved. There is a smooth movement of the eyeballs and their eccentric location. The corneal and pharyngolaryngeal reflexes are preserved. Muscle tone is preserved, so performing abdominal operations is difficult.

Second level (III, 2): the movement of the eyeballs stops, they are located in a central position. The pupils begin to gradually dilate, the reaction of the pupil to light weakens. The corneal and pharyngolaryngeal reflexes weaken and disappear by the end of the second level. Breathing is calm and even. Blood pressure and pulse are normal. A decrease in muscle tone begins, which makes it possible to perform abdominal operations. Usually anesthesia is performed at level III, 1-III, 2.

The third level (III, 3) is the level of deep anesthesia. The pupils are dilated, react only to a strong light stimulus, and there is no corneal reflex. During this period, complete relaxation of skeletal muscles occurs, including intercostal muscles. Breathing becomes shallow, diaphragmatic. As a result of relaxation of the muscles of the lower jaw, the latter may sag; in such cases, the root of the tongue sinks and closes the entrance to the larynx, which leads to respiratory arrest. To prevent this complication, it is necessary to bring the lower jaw forward and maintain it in this position. The pulse at this level is rapid and of low filling. Blood pressure decreases. You need to know that performing anesthesia at this level is dangerous for the patient’s life.

Fourth level (III, 4): maximum dilation of the pupil without reaction to light, the cornea is dull and dry. Breathing is shallow, carried out due to movements of the diaphragm due to the onset of paralysis of the intercostal muscles. The pulse is threadlike, frequent, blood pressure is low or not detectable at all. Deepening anesthesia to the fourth level is dangerous for the patient’s life, as respiratory and circulatory arrest may occur.

Agonal stage (IV): is a consequence of excessive deepening of anesthesia and can lead to irreversible changes in the cells of the central nervous system if its duration exceeds 3-5 minutes. The pupils are extremely dilated, without reaction to light. There is no corneal reflex, the cornea is dry and dull. Pulmonary ventilation is sharply reduced, breathing is shallow and diaphragmatic. Skeletal muscles are paralyzed. Blood pressure drops sharply. The pulse is frequent and weak, often not detectable at all.

Recovery from anesthesia, which I.S. Zhorov defines it as the stage of awakening, which begins from the moment the supply of anesthetic stops. The concentration of the anesthetic in the blood decreases, the patient goes through all stages of anesthesia in reverse order and awakens.

Signs of the first level, or 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.

The second level is 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.

The 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.

The fourth level was 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 requires a complex of resuscitation measures. Deepening of 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.

Coming out of anesthesia. Coming out of anesthesia or awakening is no less important stage than induction of anesthesia and maintenance of anesthesia. During recovery from anesthesia, reflexes are restored in patients, but gradually, and for some time they may be inadequate. This is associated with the occurrence of a number of complications of anesthesia, which forces anesthesiologists to continue monitoring the patient after the end of the operation.

Complications of anesthesia. In some cases, the patient may experience nausea, vomiting, and headache for about three days from the moment of recovery from the anesthesia state. Increased excitability, insomnia, and inexplicable panic are possible.

Intraanesthesia awakening is awakening during surgery. May not be noticed by the anesthesiologist. In various cases, the patient may experience pain, hear sounds, and also remember events that happen to him (during surgery). Intraanesthetic restoration of consciousness is a complication of anesthesia that does not pose an immediate threat to human life, but can cause psychological problems, including mental disorders.

General anesthesia, or anesthesia, is a state of the body that is characterized by a temporary shutdown of a person’s consciousness, pain sensitivity and reflexes, as well as relaxation of skeletal muscles caused by the effect of narcotic analgesics on the central nervous system. Depending on the route of introduction of narcotic substances into the body, inhalation and non-inhalation anesthesia are distinguished.

1. Theories of anesthesia

Currently, there are no theories of anesthesia that would clearly define the narcotic mechanism of action of anesthetics. Among the existing theories of anesthesia, the most significant are the following. Narcotic drugs can cause specific changes in all organs and systems. During the period when the body is saturated with a narcotic analgesic, a certain stage is observed in the change in the patient’s consciousness, breathing and blood circulation. Therefore, stages are distinguished that characterize the depth of anesthesia. These stages manifest themselves especially clearly during ether anesthesia. Distinguish

4 stages:

1) analgesia;

2) excitement;

3) surgical stage, divided into 4 levels;

4) stage of awakening.

Analgesia stage

The patient is conscious, but there is a certain lethargy, he is dozing, and answers questions in monosyllables. Superficial and pain sensitivity are absent, but as for tactile and thermal sensitivity, they are preserved. At this stage, short-term surgical interventions are performed, such as opening phlegmons, ulcers, diagnostic studies, etc. The stage is short-term, lasting 3-4 minutes.

Excitation stage

At this stage, the centers of the cerebral cortex are inhibited, and the subcortical centers at this time are in a state of excitation. In this case, the patient’s consciousness is completely absent, and pronounced motor and speech agitation is noted. The patients begin to scream and attempt to get up from the operating table. There is hyperemia of the skin, the pulse becomes frequent, and systolic blood pressure rises. The eye pupil becomes wide, but the reaction to light remains, and lacrimation is noted. Coughing, increased bronchial secretion, and sometimes vomiting often occur. Surgical intervention cannot be performed against the background of agitation.

During this period, you should continue to saturate the body with the narcotic to enhance anesthesia. The duration of the stage depends on the general condition of the patient and the experience of the anesthesiologist. Typically, the duration of excitation is 7-15 minutes.

Surgical stage

With the onset of this stage of anesthesia, the patient calms down, breathing becomes calm and uniform, heart rate and blood pressure approach normal. During this period, surgical interventions are possible. Depending on the depth of anesthesia, there are 4 levels and III stages of anesthesia. First level: the patient is calm, the number of respiratory movements, the number of heartbeats and blood pressure are approaching the original values. The pupil gradually begins to narrow, its reaction to light is preserved. There is a smooth movement of the eyeballs and an eccentric location. The corneal and pharyngolaryngeal reflexes are intact. The muscle tone is preserved, so abdominal operations are not performed at this level. Second level: the movement of the eyeballs is stopped, they are fixed in a central position. The pupils dilate and their reaction to light weakens. The activity of the corneal and pharyngolaryngeal reflexes begins to weaken with a gradual disappearance towards the end of the second level. Breathing movements are calm and even.

Blood pressure and pulse values become normal. Muscle tone decreases, which allows abdominal surgery to be performed. Anesthesia is usually carried out during the first and second levels. The third level is characterized as deep anesthesia. In this case, the pupils of the eyes are dilated with a reaction to a strong light stimulus. As for the corneal reflex, it is absent. Complete relaxation of the skeletal muscles, including the intercostal muscles, develops.

Due to the latter, breathing movements become superficial or diaphragmatic. The lower jaw droops as its muscles relax, the root of the tongue sinks and closes the entrance to the larynx. All of the above leads to respiratory arrest. In order to prevent this complication, the lower jaw is brought forward and held in this position. At this level, tachycardia develops, and the pulse becomes low in volume and tension. Blood pressure levels decrease. Carrying out anesthesia at this level is dangerous for the patient's life. Fourth level; maximum dilation of the pupil with no reaction to light, the cornea is dull and dry. Considering that paralysis of the intercostal muscles develops, breathing becomes superficial and is carried out through movements of the diaphragm.

Tachycardia is typical, with the pulse becoming thread-like, frequent and difficult to detect in the periphery, blood pressure is sharply reduced or not detected at all. Anesthesia at the fourth level is life-threatening for the patient, as respiratory and circulatory arrest may occur.

Awakening stage

As soon as the administration of narcotic medications is stopped, their concentration in the blood decreases, and the patient goes through all stages of anesthesia in reverse order, awakening occurs.

2. Preparing the patient for anesthesia

The anesthesiologist takes a direct and often primary role in preparing the patient for anesthesia and surgery. It is mandatory to examine the patient before surgery, but not only the underlying disease for which surgery is to be performed is important, but also the presence of concomitant diseases, which the anesthesiologist asks about in detail. It is necessary to know how the patient was treated for these diseases, the effect of treatment, duration of treatment, the presence of allergic reactions, and the time of the last exacerbation. If a patient undergoes surgical intervention as planned, then, if necessary, correction of existing concomitant diseases is carried out. Sanitation of the oral cavity is important in the presence of loose and carious teeth, as they can be an additional and unwanted source of infection. The anesthesiologist determines and evaluates the patient’s psychoneurological condition.

For example, in schizophrenia, the use of hallucinogenic medications (ketamine) is contraindicated. Surgery during psychosis is contraindicated. If there is a neurological deficit, it is first corrected. An allergy history is of great importance for the anesthesiologist; for this purpose, intolerance to drugs, as well as food, household chemicals, etc. is clarified. If the patient has a burdened allergic anemnesis, not even to medications during anesthesia, an allergic reaction may develop, up to anaphylactic shock. Therefore, desensitizing agents (diphenhydramine, suprastin) are introduced into premedication in large quantities. An important point is whether the patient has had previous operations and anesthesia. It turns out what kind of anesthesia was used and whether there were any complications.

Attention is paid to the somatic condition of the patient: face shape, shape and type of chest, structure and length of the neck, severity of subcutaneous fatty tissue, presence of edema. All this is necessary in order to correctly select the method of anesthesia and narcotic drugs. The first rule of preparing a patient for pain relief during any operation and when using any anesthesia is cleansing the gastrointestinal tract (the stomach is washed through a probe, cleansing enemas are performed). To suppress the psycho-emotional reaction and inhibit the activity of the vagus nerve, before surgery, the patient is given medicinal preparation - premedication. Phenazepam is prescribed intramuscularly at night.

Patients with a labile nervous system are prescribed tranquilizers (Seduxen, Relanium) a day before surgery. 40 minutes before surgery, narcotic analgesics are administered intramuscularly or subcutaneously: 1 ml of 1-2% promolol solution or 1 ml of pentozocine (lexir), 2 ml of fentanyl, or 1 ml of 1% morphine. To suppress the function of the vagus nerve and reduce salivation, 0.5 ml of a 0.1% atropine solution is administered. Immediately before the operation, the oral cavity is examined for the presence of removable teeth and dentures, which are removed.

3. Intravenous anesthesia

The advantages of intravenous general anesthesia are the rapid introduction of the patient into anesthesia. With this type of anesthesia there is no excitement, and the patient quickly falls asleep. But narcotic medications that are used intravenously create short-term anesthesia, so they cannot be used in their pure form as monoanesthesia for long-term operations. Barbiturates - sodium thiopental and hexenal - can quickly induce narcotic sleep, while there is no arousal stage, and awakening is rapid. The clinical pictures of anesthesia performed with sodium thiopental and hexenal are similar. Hexenal has a less inhibitory effect on the respiratory center. Use freshly prepared solutions of barbituric acid derivatives. The contents of the bottle (1 g of the drug) are dissolved before starting anesthesia in 100 ml of isotonic sodium chloride solution (1% solution). A peripheral or central (according to indications) vein is punctured and the prepared solution is slowly injected at a rate of 1 ml over 10-15 s. When a solution in a volume of 3-5 ml is introduced, the patient’s sensitivity to barbituric acid derivatives is determined within 30 s. If no allergic reaction is observed, then continue administration of the drug until the surgical stage of anesthesia. From the moment of the onset of narcotic sleep, with a single injection of an anesthetic, the duration of anesthesia is 10-15 minutes. To maintain anesthesia, barbiturates are administered in fractions of 100-200 mg of the drug, up to a total dose of no more than 1 g. During the administration of barbiturates, the nurse records pulse, blood pressure and respiration. The anesthesiologist monitors the condition of the pupil, the movement of the eyeballs, and the presence of the corneal reflex to determine the level of anesthesia. Anesthesia with barbiturates, especially sodium thiopental, is characterized by depression of the respiratory center, so an artificial respiration apparatus is necessary. When breathing stops (apnea), artificial lung ventilation (ALV) is performed using a breathing apparatus mask. Rapid administration of sodium thiopental can lead to a decrease in blood pressure and cardiac depression. In this case, the administration of the drug is stopped. In surgery, barbiturate anesthesia as mononarcosis is used for short-term operations that do not exceed 20 minutes in duration (for example, opening abscesses, phlegmons, reducing dislocations, diagnostic procedures, repositioning bone fragments). Derivatives of barbituric acid are also used for induction of anesthesia.

Viadryl (Predion injection) is used at a dose of 15 mg/kg, with an average total dose of 1000 mg. Viadryl is mainly used in small doses together with nitrous oxide. In large doses, this drug can cause a decrease in blood pressure. A complication of its use is the development of phlebitis and thrombophlebitis. In order to prevent their development, it is recommended to administer the drug slowly into the central vein in the form of a 2.5% solution.

Viadryl is used for endoscopic examinations as an introductory type of anesthesia. Propanidide (Epontol, Sombrevin) is available in ampoules of 10 ml of 5% solution. The dose of the drug is 7-10 mg/kg, administered intravenously, quickly (the entire dose is 500 mg in 30 s). Sleep comes immediately - “at the end of the needle.” The duration of anesthesia sleep is 5-6 minutes. Awakening is quick and calm. The use of propanidide causes hyperventilation, which occurs immediately after loss of consciousness. Sometimes apnea may occur. In this case, mechanical ventilation should be performed using a breathing apparatus. The negative side is the possibility of hypoxia developing during the administration of the drug. Monitoring blood pressure and pulse is necessary. The drug is used for induction of anesthesia in outpatient surgical practice for minor operations.

Sodium hydroxybutyrate is administered intravenously very slowly. The average dose is 100-150 mg/kg. The drug creates superficial anesthesia, so it is often used in combination with other narcotic drugs, such as barbiturates - propanidide. Most often used for induction of anesthesia.

Ketamine (ketalar) can be used for intravenous and intramuscular administration. The estimated dose of the drug is 2-5 mg/kg. Ketamine can be used for mononarcosis and for induction of anesthesia. The drug causes shallow sleep, stimulates the activity of the cardiovascular system (blood pressure rises, pulse quickens). Administration of the drug is contraindicated in patients with hypertension. Widely used for shock in patients with hypotension. Side effects of ketamine can include unpleasant hallucinations at the end of anesthesia and upon awakening.

4. Inhalation anesthesia

Inhalation anesthesia is carried out using easily evaporating (volatile) liquids - ether, fluorothane, methoxy flurane (pentran), trichlorethylene, chloroform or gaseous drugs - nitrous oxide, cyclopropane.

With the endotracheal method of anesthesia, the narcotic substance enters the body from the anesthesia machine through a tube inserted into the trachea. The advantage of the method is that it ensures free passage of the airways and can be used for operations on the neck, face, head, and eliminates the possibility of aspiration of vomit and blood; reduces the amount of drug used; improves gas exchange by reducing “dead” space.

Endotracheal anesthesia is indicated for major surgical interventions and is used in the form of multicomponent anesthesia with muscle relaxants (combined anesthesia). The combined use of several drugs in small doses reduces the toxic effects on the body of each of them. Modern mixed anesthesia is used to provide analgesia, switching off consciousness, and relaxation. Analgesia and loss of consciousness are carried out through the use of one or more narcotic substances - inhaled or non-inhaled. Anesthesia is carried out at the first level of the surgical stage. Muscle relaxation, or relaxation, is achieved by fractional administration of muscle relaxants.

5. Stages of anesthesia

There are three stages of anesthesia.

1. Introduction to anesthesia. Induction of anesthesia can be carried out with any narcotic substance, against the background of which a fairly deep anesthetic sleep occurs without a stage of excitement. They mainly use barbiturates, fentanyl in combination with sombrevin, and promolol with sombrevin. Sodium thiopental is also often used. The drugs are used in the form of a 1% solution and administered intravenously at a dose of 400-500 mg. During induction of anesthesia, muscle relaxants are administered and tracheal intubation is performed.

2. Maintaining anesthesia. To maintain general anesthesia, you can use any narcotic that can protect the body from surgical trauma (fluorotane, cyclopropane, nitrous oxide with oxygen), as well as neuroleptanalgesia. Anesthesia is maintained at the first and second levels of the surgical stage, and to eliminate muscle tension, muscle relaxants are administered, which cause myoplegia of all groups of skeletal muscles, including respiratory ones. Therefore, the main condition of the modern combined method of pain relief is mechanical ventilation, which is carried out by rhythmically compressing the bag or fur or using an artificial respiration apparatus.

Recently, neuroleptanalgesia has become most widespread. With this method, nitrous oxide with oxygen, fentanyl, droperidol, and muscle relaxants are used for anesthesia.

Intravenous induction anesthesia. Anesthesia is maintained by inhalation of nitrous oxide with oxygen in a ratio of 2: 1, fractional intravenous administration of fentanyl and droperidol, 1-2 ml every 15-20 minutes. If the pulse increases, fentanyl is administered, and if blood pressure increases, droperidol is administered. This type of anesthesia is safer for the patient. Fentanyl enhances pain relief, droperidol suppresses autonomic reactions.

3. Recovery from anesthesia. Towards the end of the operation, the anesthesiologist gradually stops administering narcotics and muscle relaxants. The patient regains consciousness, spontaneous breathing and muscle tone are restored. The criterion for assessing the adequacy of spontaneous breathing is the indicators PO2, PCO2, pH. After awakening, restoration of spontaneous breathing and skeletal muscle tone, the anesthesiologist can extubate the patient and transport him for further observation to the recovery room.

6. Methods for monitoring anesthesia

During general anesthesia, the main hemodynamic parameters are constantly determined and assessed. Blood pressure and pulse rate are measured every 10-15 minutes. In persons with diseases of the cardiovascular system, as well as during thoracic operations, it is necessary to conduct constant monitoring of the function of the heart muscle.

Electroencephalographic observation can be used to determine the level of anesthesia. To monitor ventilation and metabolic changes during anesthesia and surgery, it is necessary to study the acid-base state (PO2, PCO2, pH, BE).

During anesthesia, the nurse keeps a patient’s anesthesiological record, in which she necessarily records the main indicators of homeostasis: pulse rate, blood pressure, central venous pressure, respiratory rate, mechanical ventilation parameters. This card records all stages of anesthesia and surgery, and indicates the doses of narcotic substances and muscle relaxants. All drugs used during anesthesia, including transfusion media, are noted. The time of all stages of the operation and administration of drugs is recorded. At the end of the operation, the total number of all drugs used is indicated, which is also reflected in the anesthesia card. A record is made of all complications during anesthesia and surgery. The anesthesia card is included in the medical history.

7. Complications of anesthesia

Complications during anesthesia can arise due to improper anesthesia technique or the effect of anesthetics on vital organs. One of these complications is vomiting. At the beginning of the administration of anesthesia, vomiting may be associated with the nature of the dominant disease (pyloric stenosis, intestinal obstruction) or with the direct effect of the drug on the vomiting center. Against the background of vomiting, aspiration is dangerous - the entry of gastric contents into the trachea and bronchi. Gastric contents that have a pronounced acidic reaction, reaching the vocal cords and then penetrating the trachea, can lead to laryngospasm or bronchospasm, which can result in respiratory failure followed by hypoxia - this is the so-called Mendelssohn syndrome, accompanied by cyanosis, bronchospasm, and tachycardia.

Regurgitation, the passive reflux of gastric contents into the trachea and bronchi, can become dangerous. This usually occurs against the background of deep anesthesia using a mask when the sphincters are relaxed and the stomach is full or after the administration of muscle relaxants (before intubation).

Ingestion of acidic gastric contents into the lungs through vomiting or regurgitation leads to severe pneumonia, often fatal. To avoid vomiting and regurgitation, it is necessary to remove the contents from the stomach using a probe before anesthesia.

In patients with peritonitis and intestinal obstruction, the probe is left in the stomach throughout the entire anesthesia, and a moderate Trendelenburg position is necessary. Before starting anesthesia, the Selick method can be used to prevent regurgitation - pressing posteriorly on the cricoid cartilage, which causes compression of the esophagus. If vomiting occurs, it is necessary to quickly remove gastric contents from the oral cavity using a tampon and suction; in case of regurgitation, gastric contents are removed by suction through a catheter inserted into the trachea and bronchi. Vomiting followed by aspiration can occur not only during anesthesia, but also when the patient awakens. To prevent aspiration in such cases, the patient must take a horizontal or Trendelenburg position and turn his head to the side. The patient should be monitored.

Complications from the respiratory system can occur due to obstruction of the airway. This may be due to defects in the anesthesia machine. Before starting anesthesia, it is necessary to check the functioning of the device, its tightness and the passage of gases through the breathing hoses. Obstruction of the airways can occur as a result of tongue retraction during deep anesthesia (level III surgical stage of anesthesia). During anesthesia, solid foreign bodies (teeth, dentures) may enter the upper respiratory tract. To prevent these complications, it is necessary to advance and support the lower jaw during deep anesthesia. Before anesthesia, the dentures should be removed and the patient’s teeth examined.

Complications during tracheal intubation performed by direct laryngoscopy can be grouped as follows:

1) damage to teeth by the laryngoscope blade;

3) insertion of an endotracheal tube into the esophagus;

4) insertion of an endotracheal tube into the right bronchus;

5) the endotracheal tube comes out of the trachea or is bent.

The described complications can be prevented by clear knowledge of the intubation technique and control of the position of the endotracheal tube in the trachea above its bifurcation (using lung auscultation).

Complications from the circulatory system. A decrease in blood pressure both during the period of induction of anesthesia and during anesthesia can occur due to the effect of narcotic substances on the activity of the heart or on the vascular-motor center. This happens with an overdose of narcotic substances (usually fluorotane). Hypotension may appear in patients with low blood volume with optimal dosage of narcotic substances. To prevent this complication, it is necessary to replenish the deficit of blood volume before anesthesia, and during an operation accompanied by blood loss, transfuse blood replacement solutions and blood.

Heart rhythm disturbances (ventricular tachycardia, extrasystole, ventricular fibrillation) can occur due to a number of reasons:

1) hypoxia and hypercapnia that occurred during prolonged intubation or insufficient mechanical ventilation during anesthesia;

2) overdose of narcotic substances - barbiturates, fluorotane;

3) the use of adrenaline against the background of fluorotane, which increases the sensitivity of fluorotane to catecholamines.

To determine heart rhythm, electrocardiographic monitoring is needed. Treatment depends on the cause of the complication and includes eliminating hypoxia, reducing the dose of the drug, and using quinine-type drugs.

Cardiac arrest becomes the most dangerous complication during anesthesia. It is most often caused by improper monitoring of the patient's condition, errors in anesthesia technique, hypoxia, and hypercapnia. Treatment consists of immediate cardiopulmonary resuscitation.

Complications from the nervous system.

During general anesthesia, a moderate decrease in body temperature is allowed as a result of the influence of narcotic substances on the central mechanisms of thermoregulation and cooling of the patient in the operating room. After anesthesia, the body of patients with hypothermia tries to restore body temperature through increased metabolism. Against this background, at the end of anesthesia and after it, chills appear, which is observed after fluorotane anesthesia.

To prevent hypothermia, it is necessary to monitor the temperature in the operating room (21-22 °C), cover the patient, if infusion therapy is necessary, transfuse solutions warmed to body temperature, and inhale warm, moistened narcotic drugs. Cerebral edema is a consequence of prolonged and deep hypoxia during the period of anesthesia.

Treatment should be immediate, it is necessary to follow the principles of dehydration, hyperventilation, and local cooling of the brain.

Damage to peripheral nerves.

This complication occurs a day or more after anesthesia. The nerves most often damaged are the nerves of the upper and lower extremities and the brachial plexus. This is the result of an incorrect position of the patient on the operating table (abduction of the arm more than 90° from the body, placing the arm behind the head, fixing the arm to the arc of the operating table, placing the legs on holders without padding). The correct position of the patient on the table eliminates tension on the nerve trunks. Treatment is carried out by a neurologist and physiotherapist.

Drugs affecting the central nervous system

Anesthetic agents.

These include substances that cause surgical anesthesia. Narcosis is a reversible depression of central nervous system functions, which is accompanied by loss of consciousness, loss of sensitivity, decreased reflex excitability and muscle tone.

Anesthetics inhibit the transmission of nerve impulses at synapses in the central nervous system. CNS synapses have unequal sensitivity to drugs. This explains the presence of stages in the action of anesthesia.

Stages of anesthesia:

1. stage of analgesia (stunning)

2. stage of excitement

3. stage of surgical anesthesia

Level 1 – superficial anesthesia

Level 2 light anesthesia

Level 3 deep anesthesia

Level 4 ultra-deep anesthesia

4. stage of awakening or agonal.

Depending on the route of administration, they distinguish between inhaled and non-inhaled narcotic drugs.

Inhaled drugs.

Administered through the respiratory tract.

These include:

Volatile liquids - ether for anesthesia, fluorothane (halothane), chloroethyl, enflurane, isoflurane, sevoflurane.

Gaseous substances – nitrous oxide, cyclopropane, ethylene.

This is an easily administered anesthesia.

Volatile liquids.

Ether for anesthesia– colorless, transparent, volatile liquid, explosive. Highly active. Irritates the mucous membrane of the upper respiratory tract, depresses breathing.

Stages of anesthesia.

Stage 1 – stunning (analgesia). The synapses of the reticular formation are inhibited. Main sign– confusion, decreased pain sensitivity, violation of conditioned reflexes, unconditioned reflexes are preserved, breathing, pulse, blood pressure are almost unchanged. At this stage, short-term operations can be performed (opening an abscess, phlegmon, etc.).

Stage 2 – excitement. The synapses of the cerebral cortex are inhibited. The inhibitory influences of the cortex on the subcortical centers are activated, and excitation processes predominate (the subcortex is disinhibited). “Revolt of the subcortex.” Consciousness is lost, motor and speech arousal (singing, swearing), muscle tone increases (patients are tied up). Unconditioned reflexes increase - coughing, vomiting. Breathing and pulse are increased, blood pressure is increased.

Complications: reflex cessation of breathing, secondary cessation of breathing: spasm of the glottis, retraction of the tongue, aspiration of vomit. This stage of ether is very pronounced. It is impossible to operate at this stage.

Stage 3 – surgical anesthesia. Inhibition of spinal cord synapses. Unconditioned reflexes are inhibited and muscle tone decreases.

The operation begins at level 2 and is performed at level 3. The pupils will be slightly dilated, almost do not react to light, the tone of skeletal muscles is sharply reduced, blood pressure decreases, the pulse is faster, breathing is less, rare and deep.

If the dosage of a drug is incorrect, an overdose may occur. And then level 4 develops - ultra-deep anesthesia. The synapses of the centers of the medulla oblongata - respiratory and vasomotor - are inhibited. The pupils are wide, do not react to light, breathing is shallow, pulse is fast, blood pressure is low.

When breathing stops, the heart may still beat for some time. Resuscitation begins, because there is a sharp depression of breathing and blood circulation. Therefore, anesthesia must be maintained at stage 3, level 3, and not brought to level 4. Otherwise, the agonal stage develops. With the correct dosage of narcotic substances and stopping their administration, it develops Stage 4 – awakening. Restoration of functions proceeds in the reverse order.

With ether anesthesia, awakening occurs within 20-40 minutes. Awakening is replaced by a long post-anesthesia sleep.

During anesthesia, the patient's body temperature decreases and metabolism is inhibited. Heat production is reduced . Complications that may occur after ether anesthesia include: pneumonia, bronchitis (ether irritates the respiratory tract), degeneration of parenchymal organs (liver, kidneys), reflex respiratory arrest, cardiac arrhythmias, damage to the conduction system of the heart.

Ftorotan – (halothane) – colorless, transparent, volatile liquid. Non-flammable. Stronger than ether. Does not irritate mucous membranes. The arousal stage is shorter, awakening is faster, sleep is shorter. Side effect– dilates blood vessels, reduces blood pressure, causes bradycardia (atropine is administered to prevent it).

Chloroethyl– stronger than ether, causes easily controlled anesthesia. Comes quickly and goes quickly. Flaw– small breadth of narcotic action. Has a toxic effect on the heart and liver. Used for Rausch anesthesia(short anesthesia for opening phlegmons, abscesses). Widely used for local anesthesia, applied to the skin. Boils at body temperature. Cools tissues, reduces pain sensitivity. Apply for superficial pain relief during surgical operations, myositis, neuralgia, sprained ligaments and muscles. Do not overcool tissues, because there may be necrosis.

When general anesthetics are introduced into the body, a natural phasing pattern has been established in the clinical picture of general anesthesia, which is most clearly observed when using ether. Manifestations of anesthesia with other anesthetics develop similarly, but the division of manifestations into stages is less pronounced. Knowledge of the clinical picture of each stage helps the anesthesiologist when performing general anesthesia. The most widely used classification of stages of anesthesia is Gwedel A., modified by I.S. Zhorov. (Fig. 2.1).

Classification of stages of anesthesia (according to A. Guedel):

I. Stage analgesia begins from the moment of inhalation of ether vapor. After a few minutes, loss of consciousness occurs: speech becomes incoherent, drowsiness appears. The facial skin is hyperemic. The pupils are the original size or dilated and react to light. Breathing is rapid and irregular. Heart rate increased, blood pressure slightly increased. Tactile and temperature sensitivity is preserved, pain sensitivity is weakened, which allows short-term manipulations.

II. Excitation stage begins immediately after loss of consciousness and is characterized by speech and motor excitation. The skin is hyperemic. The eyelids are closed, the pupils are dilated, the photoreaction is preserved, the ciliary reflex is absent; lacrimation and swimming movements of the eyeballs appear. Breathing is frequent and arrhythmic. Heart rate and blood pressure are increased. The cough and gag reflexes are strengthened. Muscles are tense, trismus. When stimulating the larynx and pharynx, laryngospasm is possible. During this stage, ventricular fibrillation of the heart may develop, and rarely, involuntary urination and vomiting.

III. Surgical stage

III1. Against the background of restful sleep, muscle tone and laryngeal-pharyngeal reflexes are still preserved. The pupils are constricted and react to light; corneal reflex preserved; slow movements of the eyeballs. Breathing is even, somewhat rapid. Heart rate is increased, blood pressure is at the initial level.

Ш 2. The skin is pink, the mucous membranes are moist. The pupils are constricted, the photoreaction is preserved; there is no corneal reflex; eyeballs are fixed. Breathing is even. Heart rate and blood pressure at baseline. Laryngeal and pharyngeal reflexes are absent. Muscle tone is reduced.

III3. The appearance of signs of toxic action of the anesthetic. The skin is pale pink. The pupils are dilated, the photoreaction is weakened; dry cornea. Breathing is diaphragmatic, rapid. Heart rate increased, blood pressure decreased. Muscle tone is reduced.

Sh 4 . The appearance of signs of anesthetic overdose. The skin is pale cyanotic. The pupils are sharply dilated, there is no photoreaction. Only diaphragmatic breathing is preserved - shallow, arrhythmic. Heart rate is sharply increased, the pulse is frequent, thread-like; Blood pressure dropped sharply. If the anesthetic continues to flow, further depression of respiration and circulation occurs and a terminal condition develops. This level is unacceptable in clinical practice.

IV. The awakening stage occurs after the cessation of the anesthetic and is characterized by the gradual restoration of reflexes, muscle tone, sensitivity and consciousness in the reverse order.

Rice. 2.1. Classification of stages of anesthesia (according to A. Guedel)

2.3. CONCEPTS OF ANESTHETIC MANAGEMENT OF OPERATIONS

Any surgical intervention performed for life-saving reasons with the best intentions, however, is a certain form of aggression to which the body reacts with a complex of complex homeostatic processes. General adaptation syndrome, as the final manifestation of the stress reaction, develops during any operations and manifests itself to varying degrees.

Until a certain historical period, the main task of anesthesia was considered only to eliminate pain. For a long time, this was quite sufficient, since good pain relief allowed surgeons to significantly expand the range of operations they performed. Subsequently, when surgical approaches to most organs of the human body were developed, the need arose to solve not only anatomical, but also anatomical and functional problems. At the same time, it has become possible to rely not only on the patient’s strength, but also to artificially help the body overcome dangerous functional disorders that arise during surgery and in the immediate postoperative period. Anesthesia began to include elements of functional therapy, which became crucial in most major operations, and in seriously ill patients - in any interventions. It is these facts that allowed drug addicts (ether-providers) to transform into general specialists.

Numerous studies have established that the neurophysiological mechanisms of pain are quite complex. It turned out that eliminating only the perceptual component of the pain reaction (psycho-emotional sensation of pain) does not exhaust the fullness of the consequences that develop in response to damage; it is impossible to prevent the development of neurohumoral reactions in response to severe trauma (surgery) due to local activation of one or another structure of the nervous system, since the impact on the cortical and subcortical formations responsible for the formation of nociceptive impulses (suprasegmental level) does not exclude the implementation of a segmental response through motor neurons of the dorsal horns of the spinal cord. Peripheral (primary) hyperalgesia reduces the effectiveness of narrow segmental (spinal) effects and blocks the conduction of impulses along primary afferents (regional methods of anesthesia). All this led to the understanding of the need to give anesthesia multi-level nature, involving effects on various parts of the nervous system: the receptor field, primary afferents, segmental and suprasegmental levels.

Complete suppression of nociception using medications in a living person is, in principle, unattainable. The anesthesiologist can only modulate the nociceptive flow, as well as reduce the information pattern of other factors of aggression (blood loss, hypoxemia, acidosis, etc.) in order to reduce the severity of the body's response to injury. Consequently, with a strong exciting start, a response is inevitable and it is inversely proportional to the effectiveness of the defense. An example of an extreme version of poor protection is the development of shock during wounds and injuries. At the same time, the performance of planned surgical interventions in a hospital environment, which in terms of the severity of aggression can be equated to wounds and injuries, against the background of adequate anesthesia, is not accompanied by critical disorders of life support systems, although they are manifested by a general adaptation syndrome. Accordingly, deterioration in the quality of anesthesia shifts the vector of the stress reaction towards extremely negative manifestations.

When determining the usefulness of anesthesia, it would be a mistake to limit it only to the adequacy of the analgesic component. It is necessary to take into account that the general flow of disturbing impulses going to the central nervous system during injury comes from multimodal afferentation from nociceptors, baro-, chemo- and other receptors that respond to changes in the internal environment of the body during injury

(cut) tissues, bleeding, changes in blood flow, acid-base status, etc. This dictates the need for an integrated approach to protection, which is focused on maintaining various homeostatic processes during surgery, especially in cases where, as a result of a pathological process, the body's adaptive capabilities are depleted. Therefore, during anesthesia, it is important not only to reduce or eliminate hemodynamic disorders and provide antinociceptive protection, but also to implement an intensive care plan if it was carried out in the preoperative period.

It is known that manifestations of the stress reaction are realized in the form of neurogenic and humoral responses. Modulating both without eliminating the cause is ineffective. Data have been accumulated regarding primary peripheral sensitization and secondary central hyperalgesia (in the terminology of Academician Kryzhanovsky G.N. - pathological algic system), providing for the possibility of repeated stimulation of nociceptive receptors. These factors are the basis for a proactive approach in anesthesiological practice aimed at preventing excessive activation of neurohumoral mechanisms.

Thus, modern ideas about the pathophysiology of pain and the formation of a stress response in response to injury (surgery) determine a number of provisions that are of fundamental importance for justifying anesthesia tactics:

the main efforts of the anesthesiologist should be aimed at the afferent part of the reflex arc, as well as at reducing the iatrogenic activation of the mechanisms responsible for efferent impulses;

elimination of the psycho-emotional sensation of pain must be combined with blockade of the autonomic neuronal and motor components of nociceptive afferentation and with activation of the antinociceptive system through the combined use of general and local anesthetics with analgesics;

during the process of anesthesia, it is necessary to minimize the inhibition of the physiological mechanisms of antinociception and the reactivity of the main regulatory systems;

considering the surgeon’s actions in the surgical wound as additional damage, and taking into account the ability of the nociceptive system to self-activate, one should achieve deafferentation and activation of the antinociceptive system before causing a traumatic effect;

anesthesia in seriously ill patients must be combined with a single tactic and strategy with intensive therapy carried out by an anesthesiologist in the pre- and postoperative periods.

Goals of modern anesthesia care: ensure mental (emotional) peace of the patient, exclude the “presence of the patient at his own operation”, prevent emotional reactions accompanying pain; eliminate the perceptual component of pain, reduce the nociceptive flow from the surgical wound to a safe (non-stressful) intensity level along its entire route (from peripheral receptors to central brain structures); prevent unwanted pathological reflexes and excessive tension in the activity of functional systems; support and, if necessary, adjust the activities of life support systems; create comfortable conditions for the surgeon to work (position of the patient on the operating table, muscle relaxation, collapse of the lung, etc.).

To achieve these goals, anesthesia (“de-spiriting”), analgesia, neurovegetative protection, shutdown of motor activity, and various

methods of intensive therapy (ventilation, infusion-transfusion, cardiotropic, vascular therapy, etc., including specific ones used in specialized areas of surgery). The completeness of the use of these techniques and the methods for achieving the final result depend on the specific situation (disease, individual characteristics of the patient and his condition, the nature of the surgical intervention, etc.). Taken together, these factors determine prinselective regulation principle functions in the anesthesia process, which forms the basis concepts of multicomponent anesthesia(abroad they use the term “concept of multimodality”). According to this concept, anesthesia management consists of separate components, each of which can be used (or not used) by the anesthesiologist depending on the problems encountered before the upcoming operation. This approach provides flexibility in tactics and makes it easier and better to solve specific problems by using several means that have a more or less targeted and selective effect.

The concept of multicomponentism has replaced the one that had been dominant for many years concepts of depth of anesthesia. It provided for the solution of several problems (turning off consciousness, pain relief, muscle relaxation) due to the sequential deepening of anesthesia with one anesthetic and was largely due to the prevalence of inhalation drugs in the arsenal of anesthesiologists. Its implementation in practice has always been accompanied by the danger of an anesthetic overdose with the spread of inhibition to vital regulatory centers. Currently, the concept of depth of anesthesia is outdated, but this does not mean that inhalational anesthesia itself is outdated. Focus on multicomponentity allows the use of inhalation anesthesia as a component of general anesthesia and the use of other means and techniques as components to increase its effectiveness and safety.

New knowledge in the fields of neurophysiology of pain and the formation of the general adaptation syndrome allows us to detail the actions of the anesthesiologist in the pre-, intra- and immediate postoperative period.

Preoperative period. Unaddressed preoperative emotional stress can lead to a significant decrease in the pain threshold, the release of stress hormones with subsequent activation of hemodynamic and endocrine reactions, and increased tolerance to the action of anesthetics (Osipova N.A. et al., 1994, 1998). One of the most important points in the anesthesiologist’s tactics is to create psychological peace for the patient by finding mutual understanding with him, explaining the essence of the upcoming anesthesia, and adequate pre-medication using sedatives (especially benzodiazepines). Eliminate the occurrence of pain when performing preoperative invasive examinations and manipulations, especially immediately before anesthesia (including during catheterization of peripheral and central veins, epidural space). Traumatic operations are preceded by the use of agents that can reduce the effect of peripheral and central sensitization - non-steroidal anti-inflammatory analgesics that inhibit the release of prostaglandin E 2, and, if indicated, drugs.

Intraoperative period. The most intense effects are used to prevent the flow of nociceptive impulses from going beyond reasonable limits. The anesthesiologist has broad powers to correct stressful hemodynamic and other reactions. This allows you to use the most

effective doses of ataractics, neuroleptics, central analgesics (opiates and opioids) and other drugs, without fear of their side effects (respiratory depression, decreased blood pressure, etc.). At the same time, according to the proactive approach, the proper depth of anesthesia is achieved before the traumatic effect is applied (including tracheal intubation), and not as hemodynamic signs of inadequacy of anesthesia appear.

The modern arsenal of drugs allows the anesthesiologist to achieve a reduction in nociception by using inhibitors of prostaglandin and kininogenesis (aprotinin), NMDA receptor blockers (low doses of ketamine), as well as by blocking primary afferents (local infiltration and regional anesthesia). Attention is paid to correcting the increased activity of stress-limiting systems by introducing natural metabolites of mediators, their synthetic analogues, antioxidants, and adrenergic agents. The multilevel nature of anesthesia makes it possible to implement combined anesthesia.

Postoperative period. Methods are used to ensure deafferentation, for example, prolonged epidural and other types of blockades, drug pain therapy. If possible, avoid the use of drugs with suprasegmental action (synthetic analogues of endogenous opiates) so as not to interfere with the central regulatory mechanisms to provide a coordinating role over homeostatic functions. The nature of postoperative pain syndrome is largely due to excessive prostaglandin and kininogenesis in traumatized tissues. These processes can cause the pathological course of the wound process (excessive swelling, aseptic inflammation of the operated tissues) with the development of complications (anastomositis, leakage of anastomotic sutures, necrosis), therefore, the first-line drugs when choosing drug pain relief are non-steroidal anti-inflammatory drugs, the use of which in such situations is pathogenetic justified.

Highly qualified anesthesiologist helps to understand the wide range of possibilities of influence on the patient’s body and prevent the transformation of multicomponentity into polyingradency and polypharmacy.