anestezia generala curs
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Principii de anestezieRaluca Ungureanu
Clinica ATI, Spitalul Clinic de Urgenta Bucuresti
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Cuprins
Istoric Definitie Principii de anestezie
generala Anestezia loco-regionala
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Istoric
1842 Dr. W. Morton – eterul ca anestezic
1853 Dr. John Snow – cloroformul 1878 – se descopera sonda de
intubatie 1885 – cocaina pt. anestezie locala 1934 – thiopental 1842 – utilizarea curarelor ⇒ “Age of
Anesthesia”
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Componentele anesteziei
Premedicatie: reducerea anxietatii, sedare, amnezie, analgezie, scaderea raspuns
autonom Tipul anesteziei
Generala Inductie: inhalatorie vs. intravenoasa Mentinere: balansata; relaxante musculare Trezirea
Loco-regionala: tehnica, substante AL Monitored Anesth Care: suplim O2, sedare
Management intraoperator: Monitorizare/ pozitionare/ terapie fluidica
Postoperator: combatere durere Terapie intensiva resp./cv
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Definitia anesteziei generale
Depresia reversibila a SNC indusa de medicamente avand ca efect absenta raspunsului si a perceptiei ca urmare a stimularii dureroase
Triada anestezica clasica: Pierderea constientei (somn, amnezia) Analgezie Relaxare musculara/ imobilizare la stimulare
Meninerea homestaziei (reducerea raspunsului autonom ureroasa)
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Principiile AG
Minimizarea efectelor adverse directe sau indirecte ale substantelor sau tehnicilor anestezice
Mentinerea constantelor fiziologice in timpul actului chirurgical
Imbunatatirea prognosticului postoperator
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Agenti anestezici inhalatori
Administrarea de gaze/vapori pe calea sistemului respirator pentru inducerea si mentinerea anesteziei
Farmacocinetica – preluare, distributie, eliminare Farmacodinamica –
Minimum Alveolar Concetration(MAC): conc. alveolara a agentului inhalator ce inhiba orice miscare ca urmare a stimului chirurgical la 50% din pacienti
Locul de actiune Maduva spinarii Sistemul reticulator activator ascendent Cortex cerebral
Mec. actiune: creste inhibitia GABA a SNC, antagonist rec NMDA (?)
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Protoxid de azot
Gaz inert, metabolizare minima Inodor, insipid, neinflamabil MAC>105%, potenta scazuta Solubilitate mica, inductie si trezire
rapida Bun analgezic, slab hipnotic,
necesar asociere cu alt volatil pt anest chirurgicala
Siguranta : e⇑ fect minim resp, cv Toxic: inhiba metionin sintetaza
(AND), metabolism vit B12
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Halotan
Lichid volatil, stabil, neinflamabil Potenta , MAC=0,75%⇑ Hipnoza buna Solubilitate in tes adipos si revenire din
anestezie prelungita Inhiba raspunsul simpatic baroreflex –
hipovolemia Sensibilizeaza cordul la catecolamine –
aritmogen Toxic: necroza centrolobulara hepatica
(imuna)
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Sevoflurane
Solubilitate scazuta – inductie rapida
Miros placut, neiritant – inductie pe masca (VIMA)
Depresie cardiaca si respiratorie minima
Reactii adverse putine Relativ scump
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Anestezice intravenoase
Clasificare Hipnotice:
Barbiturice Benzodiazepine Propofol Etomidat Ketamina
Opioide
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Circuitul anestezic
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Thiopental
Barbituric Hidrosolubil, alcalin Supresia SNC dependent
de doza cu scaderea ratei metabolice cerebrale – rec. GABA
Depresie resp. si cv doza dependenta (venodilatatie, depresie miocardica directa)
R. adv: necroza cutanata, redistributie din depozite
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Etomidat
Structur similara ketoconazol
Deprima SNC direct si agonist GABA: ↓CBF, ICP, CMRO2
Inhiba ax cortico-adrenalian (11 beta hidroxilaza)
Doza 0,2-0,4 mg/kg
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Benzodiazepine
Sedare, amnezie, anxioliza, anticonvulsivant
Antagonist: flumazenil Mec. act. – potenteaza rec.
GABA
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Ketamina
Derivat de fenciclidina Anestezie disociativa: analgezie
profunda, amnezie, r. psihomimetica, halucinatii,
cosmaruri- diminuate prin adm de benzodiazepine
epileptogena
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Opioide (narcotice)
SNC: analgezie, sedare, euforie, depresie respiratorie, greata, varsaturi, mioza, prurit, rigiditate musculara,
GI: spasm sfincter Oddi, ↓evacuare gastrica Retentie urinara Morfina (1), mederidina (0,1), fentanyl (100), Remifentanyl (durata f scurta – metabolizat prin hidroliza de catre
esteraza plasmatica)
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Anestezia loco-regionala
Locala Regionala I.V. Plexala Epidurala Rahidiana
Sensibilitatea nervoasa
Vegetativ>senzitiv>motor
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Anestezia loco-regionalaClasificare AL
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Anestezia loco-regionalaMecanism actiune AL
Blocarea canal de NaForma neionizata: penetreaza membrana celularaForma ionizata: blocare intracelulara a canal Na
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Anestezia loco-regionala
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Anestezia de conducereSpinala vs. peridurala (epidurala)
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Anestezia de conducereSpinala vs. peridurala (epidurala)
Contraindicatii: Coagulopatie Soc, sepsis Refuz pacient Afectiuni neurologice Stenoza aortica severa Hipertensiune intracraniana
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Anestezia de conducereSpinala
Complicatii Cefalee post punctie durala
Tratam: AINS, hidratare, patch epidural cu sange autolog
Hematom epidural Infectie