When and who invented anesthesia? Ether for anesthesia: features of use for general anesthesia.

Basic properties of ether. Ether is the most widely used narcotic substance. Colorless, clear liquid with a unique and pungent taste that quickly evaporates at room temperature. The combination of ether with oxygen forms an explosive mixture. Ether should be stored in a place protected from light in hermetically sealed bottles, since it decomposes in light, heat and a humid room. Ether that is known to be unclean should not be allowed to be used. The simplest tests for its purity are as follows:

a) Sample with filter paper. After the ether applied to the paper dries, there should be no stains or odor left.

b) Test with litmus paper. The redness of blue litmus paper when lowered into ether diluted in water indicates the poor quality of the ether.

For anesthesia, you need to use only medical ether with the inscription - Aether purissimae pro narcosi.

Ether is a strong narcotic substance, although its narcotic effect manifests itself rather slowly and gradually. The rate of onset of anesthesia depends on the concentration of ether vapor in the inhaled mixture and on the individual sensitivity of the patient to this substance. On average, after 10 minutes from the start of inhaling ether vapor, the stage of excitation develops. The duration and strength of the effect of anesthesia on patients varies under the same conditions. To reach the surgical stage, the inhaled mixture must contain 15-20 vol.% ether vapor. These figures correspond to the maximum opening of the dosimeter of the UNA-1 and UNAP-2 devices. With such a concentration of ether in the inhaled mixture, in a physically developed patient, the surgical stage occurs on average after 20 minutes. But an excessive increase in the inhaled concentration of ether during the period of induction of anesthesia is unsafe, since reflex cardiac arrest may occur. To maintain anesthesia, it is often enough to open the evaporator dosimeter to 5-6 vol.%. This corresponds to 2-3 divisions of the evaporator of these devices.

Ether anesthesia has a number of disadvantages:

1. The narcotic effect of ether manifests itself slowly - after 15-20 minutes. Therefore in in case of emergency It may be necessary to use other drugs.

2. Sleeping with ether alone is very painful for the patient, bad smell causes a feeling of suffocation and anxiety.

3. During saturation with ether, the mucous membranes of the respiratory tract are irritated, the secretion of the salivary and bronchial glands increases, and coughing, laryngeal spasm, and vomiting can be caused.

4. With ether anesthesia, the stage of excitation is more pronounced than with other drugs.

5. Awakening of the patient after inhaling ether vapor occurs slowly (also depends on the depth and duration of anesthesia). During this period, there may be vomiting and respiratory depression. The ether is excreted from the body mainly through the lungs (90%), and the rest through the kidneys and sweat glands.

Essential anesthesia with a mask. Considering the property of ether to irritate Airways and increase mucus secretion, atropine must be administered before anesthesia. The patient is first explained that during euthanasia he may feel an unpleasant odor, sometimes suffocation, but that he should not be afraid of this, try to breathe deeper, then anesthesia will come faster.

A gauze pad with holes for the mouth and nose is placed on the patient's face. This provides protection for the eyes from ether. To avoid facial burns, especially in children, it is necessary to lubricate it with Vaseline.

More often, an Esmarch mask is used, which is brought to the patient’s face at a distance of 4-5 cm and ether begins to drip onto it. After 30-40 minutes, the mask is applied so that it covers the nose and mouth, while continuing to drip the drug, first at a rate of 45-50 drops per minute, and then gradually over 4-5 minutes at a rate of 120-130 drops. Too hasty increase in ether supply leads to a sharp defensive reaction sick. If coughing and choking appear at this time, you need to slightly reduce the feed rate and increase it again after the cough disappears.

From the moment the patient’s consciousness becomes confused, one should not only increase the speed of drops, but even pour the ether onto the mask in a thin stream. The supply of a high concentration of ether using the mask method should be accompanied by careful monitoring clinical signs depth of anesthesia in order to detect a possible overdose in time.

With the continued supply of ether, 7-8 minutes after the start of anesthesia, the patient begins to move his arms and legs sharply, tries to rip off the mask, and shouts something. The pupils are most often dilated, breathing becomes irregular, the pulse quickens, arterial pressure in most cases it increases sharply. At this time, you should not reduce the supply of ether, but, on the contrary, increase it. The arousal stage lasts 3-6 minutes. As anesthesia deepens, all these phenomena disappear and the third, surgical stage begins. Breathing becomes slow and deep, pulse slows down, reflexes are absent, including corneal and pupillary. Coming complete relaxation the patient's muscles.

These signs indicate that a sufficient depth of anesthesia has been achieved and the operation can begin. In the future, it is advisable to maintain anesthesia at stage (III 1 -III 2). The ether is fed into the mask at 10-15 drops per minute. In this case, the patient's condition is strictly controlled. Blood pressure is periodically measured, breathing and pulse are monitored.

The art of the narcotizer is to, having achieved saturation of the body, maintain the right level uniform drug concentration. Vivid eye reflexes, decreased muscle relaxation and the appearance of a motor reaction of the patient indicate a weakening of anesthesia, which will interfere with the continuation of the operation. If the conditions for the operation have not worsened, the anesthesia should not be deepened.

If the anesthesia has reached deep stage(III 3), it is necessary to suspend the supply of ether until it becomes less deep again. It is important to promptly identify and evaluate signs indicating excessive deepening of anesthesia.

Signs of overdose with mask anesthesia are: dilation of the pupils in the absence of their reaction to light, absence of the corneal reflex, significant decrease blood pressure, decreased breathing, pallor of the mucous membranes and skin, cold sweat. In this case, you must immediately remove the mask and allow the patient to breathe oxygen. In cases of difficulty breathing, it is necessary to carry out artificial respiration through a mouth-to-mouth or mouth-to-nose apparatus.

All symptoms of a drug overdose should not be allowed to appear. Only with the appearance of some of them is the anesthesia immediately weakened and measures are taken to improve the patient’s condition.

By the end of the operation (15-17 minutes), the supply of ether stops. They continue to keep the mask on for some time, and then the patient breathes outside air.

The clinical picture of ether anesthesia can be divided into 4 stages:

1 stage- stage of analgesia (hypnotic according to V.S. Galkin). Occurs 3-5 minutes after the start of anesthesia. It is characterized by a gradual darkening of consciousness (up to its switching off), incoherent speech, incorrect answers to questions, etc.

Tactile and temperature sensitivity and reflexes are preserved, but pain sensitivity is sharply weakened. The skin of the face is hyperemic, the pupils are the same as before anesthesia or slightly dilated, and react to light. Pulse and respiration are somewhat rapid, blood pressure is stable.

In the analgesia stage, short-term surgical operations and interventions are performed (opening abscesses, reducing a dislocation, etc.). This stage corresponds to stunning (rausch anesthesia).

In 1954, Artusio proposed dividing stage 1 of anesthesia sleep into 3 phases. I the beginning of euthanasia - there is no complete analgesia and no amnesia. II - complete analgesia and partial amnesia, III - complete analgesia and complete amnesia. Moreover, unlike deep anesthesia ( III degree) compensatory reactions of the body are preserved. The use of muscle relaxants allows longer operations to be performed during the analgesia stage. However, negative side is exhaustion compensatory mechanisms, as well as complete preservation of consciousness.

If anesthesia is interrupted at this stage, the patient quickly wakes up. If you continue to give ether with oxygen, the second stage begins.

2 stage - stage of excitement. 1.5-3 vol. % ether. It occurs 6-8 minutes after the start of anesthesia. The duration of this stage is 1-12 minutes. It is caused by the development of inhibition in the cerebral cortex, resulting in inhibition of conditioned reflex activity and disinhibition of subcortical centers, possibly with their positive induction (V.S. Galkin).

The patient's behavior at this stage resembles strong degree alcohol intoxication: consciousness is turned off, motor excitation is pronounced. The face turns sharply red, the veins of the neck are tense, the jaws are clenched, the eyelids are closed, the pupils are dilated, and the reaction to light is preserved. The pulse is increased, blood pressure is increased. Kashleva and gag reflexes strengthened. Due to hyperventilation and the development of hypocapnia, respiratory arrest is possible. Involuntary passage of feces and urine is possible.

Sometimes motor excitement is so strong that several people have difficulty keeping the patient on the table.

As anesthesia deepens, the patient calms down, the muscles relax, breathing becomes even, the pupils narrow, the patient goes into next stage sleep third.

Stage 3 - stage of anesthesia sleep (surgical operations). It occurs as a result of the development of inhibition in the cortex and subcortex.

Clinically, stage 3 is characterized by a complete loss of consciousness, sensitivity, muscle tone, and suppressed reflexes. Sensitivity first disappears on the back, limbs, chest, abdomen and, in last resort on the face.

The condition of the pupil is very important for this stage: if the pupil is narrow and does not react to light, then anesthesia sleep proceeds normally, without complications. The dilation of the pupil and the appearance of a reaction to light is the first and important signal about a threatening stop in the patient’s breathing, i.e. there is an overdose of a narcotic substance.

IN 3 stages anesthesia is isolated 4 levels:

First level(III 1 - level of movement of the eyeballs). Excitation, which was in stage II, ceases and occurs restful sleep against the background of deep and uniform breathing. The eyeballs make slow circular movements or are fixed eccentrically. The pupil is narrowed to normal sizes, reacts clearly to light. Active corneal and pharyngolaryngeal reflexes are preserved, the latter complicating tracheal intubation. Reflexes from the eyelids and skin reflexes fade away. Blood pressure pulse is close to normal. Muscle tone is preserved, therefore abdominal operations difficult without muscle relaxants.

Second level(III 2 - level of corneal reflex). The movements of the eyeballs disappear, they are moist, the gaze seems to be directed forward. The pupils are constricted, the reaction to light is preserved. The corneal reflex disappears by the end of the III 2nd level. Breathing is even and deep with a tendency to slow down. Blood pressure and pulse at preoperative levels. The mucous membrane is moist, the skin of the face is pink. Muscle tone is reduced - abdominal surgery can be performed in normal conditions. If muscle relaxants are used, anesthesia can be performed on level III 1 (first level).

Third level(III 3 - level of pupil dilation). At this level it begins to clearly appear toxic effect ether on the body. The pupils at the end of level III 3 dilate and do not respond to light, which indicates paralysis of the smooth muscles of the iris and the onset of hypoxia.

Eyes become dry. Breathing is shallow, diaphragmatic predominant, rapid. Severe tachycardia, blood pressure drops. Muscle tone is extremely reduced, only sphincter tone is preserved. Pallor of the skin appears. It is permissible to bring it to level III 3 in an extreme situation, and in a short time, no more than 10 minutes. Required artificial ventilation lungs.

Fourth level(III 4 - level of diaphragmatic breathing). The pupils are extremely dilated, the cornea is dry and dull. Paralysis of all sphincters occurs. Costal breathing is absent, only diaphragmatic breathing is preserved. The breathing is shallow, the inhalation is short, the exhalation is lengthened, followed by a pause. Blood pressure is low, the pulse is weak and thready. Against the background of blanching of the skin, cyanosis appears.

The patient should not be at this level of anesthesia under any circumstances, because the patient is on the verge of life and death!!!

The slightest deepening or the slightest continuation of anesthesia at this III-4 level can lead to the last, agonal stage of anesthesia, when paralysis of the respiratory and vasomotor centers occurs in the medulla oblongata.

IV degree - atonal stage. This stage is characterized by cessation of breathing, pulse disappears, blood pressure cannot be determined, clammy sweat, grey colour skin, sphincter gaping, involuntary passage of feces and urine. After breathing stops, the heart stops after 2-3 minutes and clinical, then biological death occurs.

In a clinical setting, anesthesia is never brought to a super-deep level, maintaining it at level III 1-III 2. Therefore, from the point of view practical application in the clinic, it is necessary to highlight the stage of awakening (instead of the agonal stage).

Awakening stage. After termination narcotic substances the patient begins to wake up and goes through the stages of anesthesia in reverse order: III 2 - III 1 - (without excitation stage) - I - return of consciousness.

Depending on a number of factors (duration and depth of anesthesia, the age of the patient, the nature of the disease), the duration and nature of the awakening stage can vary: from several minutes to several hours, even days. After awakening, the patient needs careful observation.

Complications with ether anesthesia: Can be divided into two groups:

1. During anesthesia
2. In the post-anesthesia period

Complications during anesthesia can arise as a result of:

1. Incorrect anesthesia technique.
2. Malfunctions of the anesthesia machine.
3. Serious condition sick.

Complications

1. Asphyxia - cessation of breathing. Asphyxia due to mechanical problems airway patency - mechanical asphyxia; asphyxia due to paralysis of the respiratory center - of central origin.

Mechanical asphyxia can occur when foreign bodies enter the respiratory tract: vomit, tampons, blood, mucus, dentures, tongue retraction.

Clinic of asphyxia - sharp cyanosis, cessation of breathing, dilated pupils with loss of reaction to light, drop in blood pressure, cardiac arrest.

Treatment: remove the obstruction in the respiratory tract (remove foreign body, suck out blood, mucus, etc., up to tracheostomy).

Asphyxia- extremely severe complication anesthesia During planned and emergency operations It is important to ensure its prevention: the patient’s stomach is emptied before surgery with a probe and active suction. For warning copious discharge mucus and saliva are injected with 0.5-1 ml of 0.1% atropine solution.

Asphyxia may result from laryngospasm or bronchospasm. Occurs at the beginning of anesthesia due to irritating effect narcotic substance. In these cases, stop giving the narcotic substance, give oxygen, IV 0.1% atropine 0.5-1 ml, muscle relaxants.

Asphyxia of central origin is the result of an overdose of ether.

1. Stop broadcasting.
2. Artificial respiration with a sufficient flow of oxygen and air.
3. Inject intravenously drugs that stimulate the respiratory center (lobeline, cititon, etc.).
4. Cardiovascular drugs.

Methods of artificial respiration:

1. Sylvester's method. The patient lies on his back, arms are pulled up and behind the forearms - inhale, after 3 seconds the arms are raised and lowered to chest- exhale, 14-16 movements per minute.
2. Laborde method. They irritate the respiratory center by rhythmically pulling up the tongue 12-16 times per minute.
3. An effective method of artificial respiration is blowing air into the patient’s lungs "mouth to mouth" "mouth to nose" through the endotracheal tube. With this method, inhalation is active; carbon dioxide in the exhaled air irritates the respiratory center.

IN clinical settings, like artificial respiration, mechanical respiration is effective, which provides active inspiration.

Breathing apparatus types DP-1, DP-2, DP-3, RO1, RO-2, etc.

Heart failure

The most severe complication of ether anesthesia. The reasons are varied:

1) overdose of ether, damage to brain centers;
2) dystrophic process in the myocardium with muscle damage and nerve pathways hearts;
3) reflex cardiac arrest due to irritation of the vagus nerve during surgery;
4) fibrillation of the ventricles of the heart;

Clinic: the pulse disappears, heart sounds cannot be heard, the pupils dilate, the muscles relax, the wound stops bleeding.

1. Stop broadcasting
2. Heart massage (closed, open)
3. Continue artificial respiration, ensuring good oxygenation
4. Strophanthin IV, calcium chloride, strychnine, cordiamine
5. Intracardiac 1 ml of 0.1% adrenaline
6. For ventricular fibrillation - an electric defibrillator
7. IV, IV - 5% glucose, blood replacement fluids, vascular tonics - mezaton, norepinephrine, etc.
8. Intra-arterial blood injection according to V. A. Negovsky at a pressure of 200-250 mm. rt. Art. A strong increase in pressure in the aorta and heart is an irritant that causes heart contractions.

Vomit - A common complication of anesthesia is a reflex from the mucous membrane of the stomach, where the ether enters, irritating it and causing vomiting.

Vomiting is dangerous due to the possibility of aspiration of gastric contents into the respiratory tract (regurgitation) and the development of asphyxia and bronchospasm.

Actions: lower the head end of the table; turn your head to the side; suck out the contents from the oral cavity and nasopharynx; deepen anesthesia.

Complications due to malfunction of the anesthesia machine

1. A narrow and long breathing hose creates poor flow of the breathing mixture
2. Breathing valves do not work well
3. Poor tightness of the connections of the breathing circuit of the anesthesia machine
4. Too high pressure(15-20 mm Hg), with which the narcotic mixture is supplied, compresses the pulmonary vessels and impairs gas exchange, creating a danger of rupture of the lung parenchyma

The device needs to be repaired or replaced.

Complications due to the severity of the patient’s condition

They can be very diverse. Prevention: a thorough examination of the patient’s condition before surgery and preoperative preparation. For example, diseases of the cardiovascular and respiratory systems.

Complications in postoperative period.

1. From the respiratory system (bronchitis, pneumonia, thromboembolism pulmonary artery and its branches).

If complications develop, it is necessary additional treatment. Prevention: active management of the postoperative period, exercise physical therapy, breathing exercises, coughing up sputum, using antibiotics, inhaling bronchodilators.

2. From the heart (acute heart failure). The reasons are the toxic effect of ether on the myocardium.
3. From the liver (acute liver failure or severe liver dystrophy).
4. From the kidneys (oliguria, albuminuria). Increases specific gravity urine, red blood cells and white blood cells appear.
5. Metabolic disorders. Particularly suffers carbohydrate metabolism, acidosis develops. Clinically manifested by headache, nausea, vomiting, confusion. It is necessary to administer a 3-4% solution of soda, glucose and insulin intravenously.

Suffering water-salt metabolism (profuse sweating), dehydration and hypochloremia develop.

It is necessary for the patient to administer sufficient quantity liquid in the form of 5% glucose, saline solutions, containing K, Ca, Na ions. Monitor diuresis - the daily amount of urine.

When narcotic substances are introduced into the body, a natural staged pattern of their influence on the central nervous system has been established. nervous system, which is most clearly manifested under ether anesthesia. Therefore, it is the stages of ether anesthesia that are methodically used in practical anesthesiology as a standard.

Of the proposed classifications, the most widely used is the Gwedel classification.

Stage I - stage of analgesia. It usually lasts 3-8 minutes. Characterized by gradual depression, and then loss of consciousness. Tactile and temperature sensitivity, as well as reflexes, are preserved, but pain sensitivity is sharply reduced, which allows short-term surgical operations (rausch anesthesia) to be performed at this stage.

The stage of analgesia is divided into three phases according to Artrusio (1954): the first phase is the beginning of euthanasia, when there is not yet complete analgesia and amnesia; the second phase is the phase of complete analgesia and partial amnesia; the third phase is the phase of complete analgesia and amnesia.

Stage II - stage of excitation. Begins immediately after loss of consciousness, lasts 1-5 minutes. It is characterized by speech and motor excitation, increased muscle tone, pulse rate and blood pressure against the background of lack of consciousness. This is due to the activation of subcortical structures.

Stage III - stage of anesthesia sleep (surgical). It occurs 12-20 minutes after the start of anesthesia, when, as the body is saturated with the anesthetic, inhibition deepens in the cerebral cortex and subcortical structures. Clinically, the phase is characterized by the loss of all reflexes.

In the surgical stage there are 4 levels.

The first level of the surgical stage (III 1) is the level of movement of the eyeballs. Against the background of restful sleep, they remain muscle tone and reflexes. The eyeballs make slow circular movements. Pulse and blood pressure are at baseline levels.

The second level of the surgical stage (III 2) is the level of the corneal reflex. The eyeballs are motionless, the pupils are constricted, the reaction to light is preserved, but the corneal and other reflexes are absent. Muscle tone is reduced, hemodynamics are stable. Breathing is even, slow.

The third level of the surgical stage (III 3) is the level of pupil dilation. The pupil dilates, the reaction to light sharply weakens. Muscle tone is sharply reduced. The pulse quickens and a moderate decrease in blood pressure begins to appear. Costal breathing weakens, diaphragmatic breathing predominates, shortness of breath reaches 30 breaths per minute.

The fourth level of the surgical stage (III 4) - the level of diaphragmatic breathing - should not be allowed in clinical practice, as it is a sign of overdose and a harbinger fatal outcome! The pupils are sharply dilated, there is no reaction to light. The pulse is threadlike, blood pressure is sharply reduced. Breathing is diaphragmatic, shallow, arrhythmic. If you don't stop feeding narcotic drug, vascular paralysis occurs and respiratory centers and the agonal stage develops with clinical signs of respiratory and circulatory arrest.

During the operation the depth general anesthesia should not exceed level III 1 - III 2, and only for a short time is it permissible to deepen it to III 3!

Stage IV is the stage of awakening. It occurs after the anesthetic supply is turned off and is characterized by a gradual restoration of reflexes, muscle tone, sensitivity and consciousness, displaying the stages of general anesthesia in reverse order. Awakening lasts from several minutes to several hours, depending on the patient’s condition, duration and depth of anesthesia. The entire stage is accompanied by sufficient analgesia.

Thus, at present, surgical operations are performed in the third stage of anesthesia (level III 1 - III 2), and short-term interventions can be carried out in the first stage - analgesia.

Intravenous anesthesia. Basic drugs. Neuroleptanalgesia.

In addition to inhalation administration of narcotic drugs into the patient’s body, there are also intravenous, subcutaneous, intramuscular, oral and rectal methods. However wide use received only intravenous route.

In all intravenous anesthesia Intravenous anesthesia itself, central analgesia, neuroleptanalgesia and ataralgesia can be distinguished. The advantages of intravenous anesthesia are technical simplicity and sufficient reliability.

Intravenous anesthesia, like other types of anesthesia, is rarely used independently in the form of mononarcosis. Despite the variety of properties of drugs for intravenous anesthesia, the main manifestation of their action is the switching off of consciousness, and the suppression of the reaction to external stimuli, that is, the development of general anesthesia as such occurs secondary to the background of deep narcotic depression of the central nervous system. The exception is ketamine - powerful analgesic, the effect of which manifests itself with partially or completely preserved consciousness.

Barbiturates (hexenal, sodium thiopental). Used for induction of anesthesia and short-term anesthesia for minor operations. 1-2 minutes after intravenous administration mental arousal is relieved, some speech excitation occurs, but the phase of motor excitation is practically absent. After 1 minute, clouding and loss of consciousness occur, and a little later hyporeflexia develops.

Propanidide is an ultra-short-acting non-barbituric anesthetic. Used for induction, as well as for short-term surgeries and endoscopic studies. Anesthesia occurs almost at the tip of the needle. The functions of the central nervous system are restored extremely quickly. This allows the drug to be used in outpatient practice.

Sodium hydroxybutyrate (GHB). It is used in seriously ill patients, as it has extremely low toxicity and also has a moderate antihypoxic effect. However, it does not cause complete analgesia and muscle relaxation, which makes it necessary to combine it with other drugs.

Ketamine. Has a great therapeutic breadth action and low toxicity, which makes it one of the most popular means for intravenous anesthesia. Analgesia occurs 1-2 minutes after administration of the drug. Sometimes there is no loss of consciousness, which makes verbal contact possible, which patients then do not remember due to developing retrograde amnesia. Ketamine can be considered a true analgesic. A characteristic feature of the drug is its hallucinogenicity.

Diprivan (propofol). It has a short effect and is one of the drugs of choice for induction of anesthesia, but requires additional analgesia.

Central analgesia. The complex of central analgesia techniques is based on the principle of multicomponent general anesthesia. In this case, analgesia plays a dominant role. Due to the pronounced analgesia achieved by introducing narcotic analgesics, somatic and autonomic reactions to pain turn off or become less pronounced. High doses drugs lead to respiratory depression, which is why mechanical ventilation is required during and after surgery. For such anesthesia, in addition to narcotic analgesics, induction drugs and muscle relaxants are used. The central analgesia method cannot be routinely used in clinical practice; its use requires specific clinical situations. The main drugs for central analgesia are morphine, piritramide (dipidolor), promedol.

Neuroleptanalgesia- a method of general intravenous anesthesia, in which the main drugs are a powerful antipsychotic and a strong central analgesic. Since these drugs do not have sedative properties, nitrous oxide is used to turn off consciousness. There is an official mixture of fentanyl and droperidol (1:50) - thalamonal, which is usually used for premedication at the rate of 1 ml per 20 kg of patient body weight. Fentanyl and droperidol can also be mixed in the same syringe. For induction, droperidol (0.25 mg/kg) and fentanyl (0.005 mg/kg) are used, i.e. 1 ml of droperidol and fentanyl per 10 kg of body weight. All drugs are administered intravenously slowly (1 - 2 ml/min) in a 2-3 times dilution. Before induction of fentanyl, tubarin is administered in a test dose (5 mg) or Arduan (1 mg), which prevent the occurrence of muscle rigidity caused by fentanyl and prevent muscle fibrillation after the administration of muscle relaxants of a depolarizing type of action. Induction is performed against the background of breathing a mixture of nitrous oxide (70 %) and oxygen (30%), tracheal intubation - against the background of total myoplegia.

Anesthesia is maintained with fractional injections of fentanyl and droperidol, 1-2 ml every 15-30 minutes. 20-30 minutes before the end of the operation, the administration of drugs is stopped. When placing the last stitches on surgical wound stop the supply of nitrous oxide. After 5-10 minutes the patient regains consciousness. In the immediate postoperative period, trembling, marbling or pallor of the skin, cyanosis, motor agitation, neurodyslepsy (feeling internal anxiety, discomfort, fatigue, melancholy), hypertension and tachycardia. These phenomena are eliminated by the introduction of aminazine, seduxen, pipolfen, calcium chloride.

Modern combined intubation anesthesia. The sequence of its implementation and its advantages. Complications of anesthesia and the immediate post-anesthesia period, their prevention and treatment.

Currently, the most reliable, controllable and universal method of general anesthesia is combined intubation anesthesia. In this case, a combination of the effects of various general anesthetics, muscle relaxants and neuroleptanalgesia is carried out.

For the first time, Faraday (1818) drew attention to the “intoxicating” properties of diethyl ether vapor and the probable possibility of using them for pain relief. The first operation under ether anesthesia was performed in 1842 by the American surgeon Long, but he did not report his observation. On October 16, 1846, dentist Morton, with the participation of chemist Jackson, successfully demonstrated ether anesthesia in Boston. This date is considered the birthday of anesthesiology.

In Russia, the first operation under ether anesthesia was performed at the Moscow University clinic by F.I. Inozemtsev on February 7, 1847. A week later, his experience was repeated by N.I. Pirogov. From then until the mid-1970s, ether was the most commonly used anesthetic.

Ether anesthesia has been well studied. These circumstances, as well as the pronounced phase nature of the course, served as the basis for the fact that ether anesthesia in anesthesiology is considered to be the “standard”, comparing all other inhalational anesthetics in terms of strength, toxicity, and phase character of the course of anesthesia with ether. Due to its pronounced toxicity, the presence of an excitation phase during anesthesia, and flammability, ether has completely fallen out of use in modern anesthesiology. However, due to its wide range of therapeutic effects, it continues to be one of the safest inhalational anesthetics. It is included in the “List of vital and essential medicines”, approved by order of the Government of the Russian Federation of April 4, 2002 No. 425-r.

To understand the genesis of symptoms developing during ether anesthesia, it is necessary to remember that various functions and reflexes are carried out by various structures and systems of the brain. The clinic of anesthesia, in fact, consists of a sequence of inhibition and sometimes activation of reflexes, the centers of which are localized in specific anatomical structures. How can we explain that different parts of the brain are not simultaneously subjected to inhibition caused by the anesthetic?

Numerous studies conducted by the schools of Jackson and I.P. Pavlov have shown that phylogenetically young structures of the central nervous system are less resistant to the action of any irritants, including anesthetics, than more ancient ones. Thus, inhibition of brain structures during anesthesia occurs as if from top to bottom. - fromyoung to older in the following sequence:

subcortical centers

brain stem

At the same time, it should be noted that young brain structures have greater “plasticity” - they respond faster and differentiate (that is, with a larger set of reflexes) to any irritation. As an example, we can compare the innumerable set of functions of the cerebral cortex and the small arsenal of centers medulla oblongata. At the same time, the most sophisticated functions of the cortex, such as intellect, are subject to rapid fatigue, and not a single researcher has been able to subject the vasomotor center to fatigue, even in an experiment.

Ether ( diethyl ether) is a colorless transparent liquid with a boiling point of 35ºС. When exposed to light and air, it decomposes to form toxic products, so it is stored in a dark, airtight container. It and its vapors are highly flammable and explosive. The ether has high narcotic activity and great breadth therapeutic action. Under the influence of ether, the secretion of the salivary and bronchial glands increases, the tone of the bronchial muscles decreases, and irritation of the membranes of the respiratory tract occurs, accompanied by cough, laryngospasm, and bronchospasm. The drug also irritates the mucous membrane of the stomach and intestines, which leads to nausea and vomiting in the postoperative period. Inhibition of peristalsis contributes to the development of postoperative intestinal paresis

As already mentioned above, ether anesthesia has a pronounced phasic flow, reflecting the sequence of distribution of inhibition through the structures of the brain. Currently, the classification of phases by Guedel, developed by him in 1920 - 1937, is generally accepted. He was the first to propose a graphical display of the phases of the course of anesthesia.

First phase - analgesia (I)- characterized only by partial inhibition of the cerebral cortex, leading to loss of pain sensitivity and retrograde amnesia. The complete absence of neurovegetative blockade and reliable methods of stabilizing anesthesia at this level (attempts were made by Artusio, McIntosh) make the analgesia phase practically unsuitable for any lengthy and traumatic surgical procedures. The presence of analgesia and neurolepsy (the first two components of anesthesia) allows for short-term, low-traumatic interventions (reduction of a dislocation, opening of a superficial abscess, etc.).

The analgesia phase begins from the moment the inhalation of ether vapor begins, the concentration of which in the inhaled gas mixture is 1.5-2% by volume. There is a gradual darkening of consciousness, loss of orientation, speech becomes incoherent. The skin of the face is hyperemic, the pupils are of normal size and actively react to light. Breathing and pulse are increased, blood pressure is slightly increased. Tactile and temperature sensitivity and reflexes are preserved, pain sensitivity gradually fades away. In the normal course of anesthesia, its duration is 3–8 minutes, after which loss of consciousness occurs and the second phase of anesthesia begins.

Second phase - excitement(II)- characterized by progressive depression of the cerebral cortex, which is manifested by a lack of consciousness and motor-speech excitation due to the absence of the inhibitory influence of the cortex on the subcortical centers. Surgical manipulations are impossible due to motor-speech agitation.

Skin sharply hyperemic, eyelids are closed, pupils are dilated, the reaction to light is preserved, lacrimation and involuntary swimming movements of the eyeballs are noted. The muscles, especially the chewing ones, are sharply tense (trismus). Cough and gag reflexes are strengthened. The pulse is increased, arrhythmias are possible, blood pressure is increased. Involuntary urination and vomiting may occur. The concentration of ether in the gas mixture during the excitation phase is increased to 10-12% by volume in order to quickly saturate the body with anesthetic vapors. The average duration depends on age and physical condition patient and is 1-5 minutes. Motor-speech excitation lasts longer and more actively in physically strong individuals and alcoholics (persons sensitized to neurotropic poisons).

The third phase is surgical- divided into 4 levels: III 1, III 2, III 3, III 4. It comes in 12-20 minutes. After the start of inhalation of ether vapor. With its onset, the concentration of anesthetic in the gas mixture is reduced to 4-8 vol.%, and subsequently - to maintain anesthesia - to 2-4 vol.%

Level 1 - movements of the eyeballs – III 1 – got its name from the characteristic clinical manifestation – eyeballs make slow, smooth, uncoordinated movements. This level is characterized by the spread of inhibition to subcortical structures (globus pallidus, caudate body, etc.) and complete inhibition of the cortex, as a result of which motor-speech excitation ends.

A restful sleep ensues. The breathing is even, somewhat rapid, the pulse is also somewhat rapid, even. BP at baseline. The pupils are evenly constricted and react to light. Skin reflexes disappear.

At the same time, the preservation of the corneal and pharyngeal reflexes (see below) indicates that the brain stem has not yet been affected by the inhibition process, i.e. There is no neurovegetative blockade. These data allow us to characterize level III 1 as superficial anesthesia, the depth of which (in the absence of potentiation means, i.e. mononarcosis) is insufficient to perform traumatic operations.

Level 2 - corneal reflex – III 2 - got its name from the disappearance of the corneal reflex, which is an important anesthetic symptom. The reflex is that when the cornea is irritated (touched with a thread from sterile gauze), the eyelids close.

To understand the importance of this clinical sign, it is necessary to become familiar with the reflex arc. The afferent part is carried out by the first branch of the trigeminal nerve. The nuclei of the V pair of cranial nerves are located along almost the entire trunk. Sensitive nuclei lie in the anterior part of the pons and medulla oblongata. The efferent part of the reflex - the closing of the eyelids is carried out by contraction m. orbicularis oculi which is innervated by motor fibers n. facialis(VII pair of cranial nerves). The source of these fibers is the motor nucleus nucl. motorius VII, located in the dorsal part of the bridge. The disappearance of the corneal reflex indicates that inhibition has reached the brain stem, that is, the Thalamus and Hypothalamus are blocked by the anesthetic. The influence of pain impulses on the autonomic nervous system is eliminated, which indicates the achievement of the third most important component of anesthesia - neurovegetative blockade. At this level, traumatic and prolonged operations on “shockogenic” areas and organs become possible.

Breathing is even, slow. Pulse and blood pressure are at the initial level. The mucous membranes are moist. The skin is pink. The eyeballs are fixed. The pupils are of normal width, the reaction to light is preserved. Muscle tone is significantly reduced. At the same time, already at this level there is a tendency to accelerate heart rate and decrease blood pressure; breathing becomes more superficial, which indicates the beginning of the influence of the anesthetic on the deeper structures of the brain, in particular on the regulatory systems of the vasomotor and respiratory centers of the medulla oblongata.

Level 3 - pupil dilation III 3 - characterized by inhibition of the pupillary reflex.

The afferent part of the reflex is represented by the optic nerve, along which impulses travel to the superior quadrigeminal, where they switch to the paired small-cell parasympathetic nucleus of Yakubovich, which gives rise to n.oculomatorius fibers that contract the circular muscle of the iris. Inhibition of the pupillary reflex indicates a further spread of inhibition down the brain stem. The appearance of a symptom of pupil dilation and a decrease in its reaction to light is an alarm signal for the anesthesiologist, indicating that inhibition has already affected most of the brain stem. It has been established experimentally and clinically (for brainstem strokes) that blockade of the brainstem at the level of the pons leads to cessation of breathing and circulation. Signs of inhibition of the medulla oblongata centers at this level are already completely obvious. Tachycardia and a tendency to hypotension indicate an increasing deficit of blood volume due to vasoplegia. Breathing becomes increasingly shallow and is maintained mainly through the diaphragm. Function external respiration at level III 3 it is decompensated, which requires auxiliary ventilation. At this level, the laryngeal reflex is completely inhibited, making intubation possible without the use of muscle relaxants.

Among other symptoms of the third level, dry mucous membranes (conjunctiva) and a sharp decrease in muscle tone should be noted.

Level 4 - diaphragmatic breathing – III 4 - characterized by extreme depression of all vital functions, complete areflexia, requiring immediate cessation of the anesthetic supply, oxygen ventilation, use of vasopressors and compensation for the deficit of blood volume. Should not be allowed in anesthesiological practice.

The pupils are dilated and do not react to light. The cornea is dry and dull. Breathing is shallow, arrhythmic, only due to the diaphragm. Pulse is thready, blood pressure is low. The skin is pale, acrocyanosis. Sphincter paralysis occurs.

Fourth phase - awakening (IV) characterized by the reverse development of the described symptoms within 5-30 minutes, depending on the depth of anesthesia achieved. The stage of excitement is short-lived and weakly expressed. The analgesic effect persists for several hours.

Complications of ether anesthesia are mainly associated with the development of asphyxia of various origins. Phases II and II may develop laryngeal and bronchospasm under the influence of irritating ether vapors. Reflex apnea of the same origin is less common. Described isolated cases vagal cardiac arrest under the influence of ether vapor ( nervus vagus innervates part of the epiglottis). Asphyxia can develop as a result of vomiting and aspiration of gastric contents (reflexively, in phases I and II) or passive regurgitation of gastric contents and retraction of the root of the tongue at level III 3-4.

Nikolai Ivanovich Pirogov is rightly considered the “father of Russian surgery”, the founder of military field surgery. Pirogov was the first in the world to use ether anesthesia in war conditions. October 16, 1846 is a significant date not only in the history of surgery, but also in the history of mankind. On this day, a large surgery under full ether anesthesia. Dreams and aspirations that seemed unrealistic just the day before came true - complete pain relief was achieved, muscles were relaxed, reflexes disappeared. The patient plunged into deep dream with loss of sensitivity. Hypnotic effect ether (in the old days it was called “sweet vitriol”) was known back in 1540 to Paracelsus. At the end of the 18th century, inhalation of ether was used to relieve pain from consumption and intestinal colic. However, the scientific basis for the problem of pain relief belongs to Nikolai Ivanovich Pirogov, then to the Russian scientist A. M. Filamofitsky, dean of the medical faculty of Moscow University, and anatomist L. S. Sevryuk. They tested the effect of ether on the nervous system, on the blood, checked the dosage, duration of action of ether anesthesia, etc. Like any innovation, ether anesthesia immediately found both overly ardent adherents and prejudiced critics. Pirogov did not join any camp until he tested the properties of ether in laboratory conditions, on dogs, on calves, then on himself, on his closest assistants and, finally, on a massive scale on the wounded on the Caucasian front in the summer of 1847. With the energy characteristic of Pirogov, he quickly transferred anesthesia from the experiment to the clinic. He performed his first operation under ether anesthesia on February 14, 1847 in the 2nd Military Land Hospital, on February 16 he operated under ether anesthesia in the Obukhov hospital, on February 27 in Petropavlovsk (St. Petersburg).

Having further tested ether anesthesia on healthy people, repeatedly on himself and having the material of already 50 operations under ether anesthesia, Pirogov decided to use ether anesthesia in military field surgery - directly when providing surgical care on the battlefield. At this time, the Caucasus was a constant theater of military operations (there was a war with the highlanders), and Pirogov left for the Caucasus on July 8, 1847, with the main goal of testing on large material the effect of ether anesthesia as an anesthetic. On the way to Pyatigorsk and Temir-Khan-Shur, Pirogov introduces doctors to esterization methods and performs a number of operations under anesthesia. In Ogly, where the wounded were housed in camp tents and there was no separate room for operations, Pirogov began to specifically operate in the presence of other wounded in order to convince the latter of the analgesic effect of ethereal vapors. Such visual propaganda had a very beneficial influence on the wounded, and the latter were fearlessly anesthetized. Finally, Pirogov arrived at the Samurt detachment, which was located near the fortified village of Salta. Here, near Saltami, in a primitive infirmary, which consisted of several huts made of tree branches, covered with straw on top, with two long benches made of stones, also covered with straw, kneeling, bent position, the great surgeon had to operate. Here, under anesthesia, Pirogov performed up to 100 operations. Thus, Pirogov was the first in the world to use ether anesthesia on the battlefield. During the year, Pirogov performed about 300 operations under ether anesthesia (in total, 690 of them were performed in Russia from February 1847 to February 1848). Pirogov’s mind works tirelessly to improve the methods and techniques of anesthesia. He offers his own rectal method of anesthesia (injection of ether into the rectum). For this purpose, Pirogov designs a special device and improves the design of existing inhalation devices. Becomes an active promoter of anesthesia. Trains doctors in anesthesia techniques.

Pirogov outlined his research and observations in several articles: “Report on a trip to the Caucasus” in French. In 1849, the “Report” was published as a separate publication in Russian. Personal experience Pirogov by this time was about 400 anesthesia with ether and about 300 with chloroform.

Thus, the main objective Pirogov's scientific journey to the theater of military operations in the Caucasus - the use of anesthesia on the battlefield - was achieved with brilliant success. In progress experimental study ether anesthesia, Pirogov also injected ether into the veins and arteries, into the general carotid artery, to the inner jugular vein, V femoral artery, femoral vein, portal vein. The method of intravenous anesthesia with pure ether, as is known, has not become widespread. However, Pirogov’s idea about the possibility of introducing a narcotic drug directly into the blood was subsequently brought to life with great success. As is known, Russian scientists, pharmacologist N.P. Kravkov and surgeon S.P. Fedorov (1905, 1909) resurrected Pirogov’s idea of intravenous anesthesia, proposing to inject the hypnotic substance hedonal directly into a vein. This good way the use of non-inhalation anesthesia, even in foreign manuals, is known as the “Russian method”. The idea of intravenous anesthesia belongs entirely to Nikolai Ivanovich Pirogov and later to other Russian scientists who were involved in the development of this issue, and not to Flourens and, especially, to Or (the latter used intravenous anesthesia with chloral hydrate in 1872) or Burckhardt (in 1909 he resumed experiments injection of ether and chloroform into a vein for the purpose of anesthesia), as, unfortunately, not only foreign, but also some domestic authors write about this. The same should be said regarding the priority of intratracheal anesthesia (injected directly into the windpipe - trachea). In most manuals, the founder of this method of anesthesia is the Englishman John Snow, who used this method of pain relief in an experiment and in one case in the clinic in 1852. However, it has been precisely established that in 1847, i.e. exactly five years earlier, this method of anesthesia was experimentally The method was successfully used by Pirogov, as eloquently evidenced by the protocols of Pirogov’s experiments.