Lesson 1.
Asepsis and antisepsis. Surgical manipulations and operative surgical technique. Surgery operation.
General anesthesiology and intensive care.
1. BRIEF SKETCH HISTORY OF SURGERY
Surgery derives its name from two Greek words: χειρ, which means “hand” and εργώ – “work.” In ancient times, surgery was regarded as needlework, considering her craft. Over the years it has evolved, improved and turned into a real science, which occupies a leading position among other medical disciplines. Even in ancient manuscripts Sushruta states that “surgery first and best of all the medical sciences, the precious gift of heaven and eternal source of glory.” M. Bidloo indicates that surgery – this “object is created on the basis of experience and knowledge of composite good study of the human body to restore and maintain unnaturally modified random diseases of the body and its beauty, which is achieved by applying hand outside, use of drugs inside, and tools” .
According to some philosophers and historians (Jean-Jacques Rousseau, Richter et al.), Primitive man did not need medical attention. In their view, the life of prehistoric man held in full communion with nature, generous gifts which she enjoyed a carefree, had good health, not known diseases and suffering. However, the difficult living conditions, food production in prehistoric man causing various diseases. In the skeletons of people who lived in ancient times, show signs of illness and surgery.
Slave system characterized by intensive development of industrial relations than primitive. Thus there opportunities for division of labor and its specialization, having different crafts, artisans in society distinguished professionals, including doctors. Appears writing (cuneiform, hieroglyphics) that promotes the emergence of medical texts, works.
Initial surgery foundations were laid by physicians of ancient
Proceedings of the medicine, including surgery, found in ancient
Talking about surgery ancient Greeks, we caot name a famous physician of the time of Hippocrates. Without accurate information about anatomy and human physiology, Hippocrates laid the initial empirical basis of scientific surgery. He developed a rational for that time treatment of wounds, fractures, described tetanus, sepsis identified, straighten sprains and more. Before the operation doctors Hippocrates demanded scrupulous cleanliness, close shave operating margins. During the surgery, he applied digested and filtered water, clean cloth, sponge, dry leaves, wine, alum and copper salt. Fracture immobilization served by buses, extracting. Hippocrates operated tools with copper for steel while the Greeks did not know. How serious attitude Hippocrates to practice medicine, says one of his aphorisms: “Life is short, art is long time fleeting, experience dangerous, difficult decision.” Between this and the later statement aphorism school Asclepiades (126-56 BC), the art is short and life is long, there is a big difference. Since scientific nihilism student Asclepiades Tessalus concludes that medicine can be studied for 6 months.
Hippocrates
So it is not surprising that graduates of this school called “donkeys Tessalusa.” After the conquest of
Galen Celsus
Based on scientific discoveries and inventions of the XIX century., There is rapid progress in the industry, while successfully developing and biological science that provides the basis for medicine. It would seem that there are all conditions for the rapid development of theoretical and practical surgery. Yet this did not happen. There were three major obstacles to this. This lack of methods to control pain, the inability of surgeons to prevent wound infection, stop bleeding and to replenish the lost blood. All this led to the fact that the consequences of surgery in the first half of the XIX century. were significantly worse than in the second half of the XVIII century. This was due to several reasons: hospitals were overcrowded, dominated incredible negligence and harm the treatment of more than helps to patients. In surgical wards raged erysipelas, septic and putrid infection in maternity hospitals hundreds of women died from puerperal fever. In
These dire consequences surgeries due primarily complete ignorance of Bacteriology and foundations antisepsis and asepsis.
The turning point in this respect it was only after the discovery by Louis Pasteur and the introduction in 1867 by the British surgeon Joseph Lister based system of measures aimed at preventing infectious complications of wounds. The latter and the honor of opening antiseptics. In the late nineteenth century. along with antiseptics Bergman and Shimmelbush in surgical practice was introduced antiseptic methods aimed at preventing the penetration of infection into the wound. Further development of surgery associated with the introduction of surgical practice inhalation anesthesia.
Louis Pasteur
In 1800, the English chemist Davy anesthesia for various manipulations and operations proposed the use of invented it gas – nitrous oxide (“laughing” gas). But you were only 40 years to an English dentist
Important role in the development of surgery in the second half of the nineteenth century. played by Mikhail Ivanovich Pirogov (1810-1881). First, it is known as the founder of a prominent surgeon military field surgery. His book “Beginning of the total military field surgery and is now considered a first-class work. In it he stresses the importance sorting injured, requires immobilizing injured limbs, applies to this end casts first involves the submission of medical care in wartime women. Earlier by Louis Pasteur, he made the assumption that the festering wound complications caused living pathogens, which he called “miasma.” In this regard, he created a special department in the clinic for patients infected by “miasma hospital.” N. Pirogov launched plastic bones, developed methods for ligation of vessels (his doctoral thesis devoted racking abdominal aortic aneurysm at in the groin). substantial contribution to the development of N. Pirogov topographic anatomy. M. Since Pirogov Russian surgery was on his feet and has made
Pirogov M. I.
many new, instructive and original in the treasury of world surgery. Following the death of Pirogov his body was embalmed and kept it out in a special sarcophagus in a small chapel in the
The world imperialist war led to stagnation in the development of peaceful surgery, while adding to concern military field. Today the operation on the skull, chest, lungs, heart, is a great achievement. Every year thousands of people are saving surgeons from imminent death. XX century. gave the world great scientists. Names Fedorova Oppel, Spasokukotsky, Bakulyeva, Kera, Kyorte, Trendelenburg, lexer, Sauerbruch, Billroth, Kocher, Mayo brothers, Kraylya and many other scientists associated with major achievements in different areas of surgery.
And although many still issues and problems of modern surgery requires further improvement, comprehensive study, now it has reached such a development, which our teachers and predecessors could only dream of.
Exceptional impact on the development of surgery is the introduction of surgical anesthesia practice new methods that allow to carry out complex intervention with minimal risk, new medical devices and instruments. Modern skilled surgeon is – a doctor with a broad worldview that combines surgical expertise with knowledge of pharmacology, physiology, therapy, anatomy, biochemistry and others.
2. DEVELOPMENT OF SURGERY IN
In Kievan Rus medicine that would have led doctors were not. In cities among the various professions were those who were engaged in treatment. For most of them it was not the main and additional earnings. Only with the increase of the urban population (during most of the population of ancient Kyiv reached 100 thousand) a demand for medical care, which contributed a significant amount of people for whom medical business was the main occupation, often hereditary. The basis of knowledge of these doctors – artisans was a century of experience folk empirical medicine with elements of mystical nature. Even in these times some of them “specialized” in the treatment of wounds, fractures, throwing blood, others – on plots teeth, eye treatment, obstetric and more.
In earlier collections of laws (“Ruska Pravda”, XI century). Mention doctors and reward them for treatment.
Along with the doctors of indigenous artisans in some princely courts, practiced in cities and visiting doctors – strangers from the East and West. They are introduced to our doctors with medical practices in their countries and in turn borrowed our therapeutic agents, including the use of medicinal plants.
Due attention paid medical case Princess Olga. She founded in
The first prominent female doctor
In the heyday of Kievan Rus were special working medical content, which submitted information on the treatment of diseases as the basis of centuries of empirical experience of our people, and from written sources of ancient scholars that came to us from other countries.
The oldest case of surgical treatment that is mentioned in written sources, is excision of the tumor, made in 1076 Svyatoslav Yaroslavich.
In the XIII century. in Lviv, which was occupied by Mongols, medicine has evolved further, organized the first public hospital. In the XIV century. in
In royal Polish and Ukrainian lands subordinate drug case was overlooked and controlled by the state government. The broad masses of the population served is not qualified doctors and doctors-artisans, barbers said was known.
Also shop barbers in large villages engaged in medical practice many persons in the shops for one reason or another were not included. They called them “the cobbler” (private traders). Between these groups continually waged struggle. After the abolition of serfdom right medical care for the rural population was concentrated in the city council, where the leading role belonged to the landowners, the gentry. In
In 1805
In the second half of the XIX century. Surgical Clinic medical universities in Kharkiv and Kyiv become real centers of surgical science and practice in
V. Karavayev M. Sklifosovsky M. Volkovych
Six years after the founding of
Within 48 years the department of surgery at the medical faculty at the
The country has organized new surgical schools associated with such eminent surgeons as M. Volkovych, O. Krymov, O. Vyshanevskyy, BV, J. Ishchenko Kolomichenko M. et al. Ukrainian surgeons surgeons along with other nationalities actively participated in the heroic struggle of our people against Nazi Germany. Through their selfless work 72% of the wounded managed to return to the ranks of the fighters.
O. Krymov M. Kolomiychenko O.O. Shalimov
Organization of health care held at the front by the landmark principle was first developed during the First World War, a professor of
Important role in the military health service, the organization of treatment and care of wounded played Soviet women (40% of front-line doctors, paramedics 43%, 40% saninstruktoriv and nurses).
After the war in
In the 50 years begins forming anesthesia service in
In 1965 was organized KNDI kidney and urinary tract (Urology), which became the center of scientific and organizational urological care in the country. It is headed by Academician AF Vozianov, president of the Academy of Medical Sciences of Ukraine.
M. Amosov Luke Woyno-Yasenetsky
Purulent surgery found developed in the works of the famous scientist V. Woyno-Yasenetskyy. Along with surgical activities, he paid great attention to the spiritual mentoring. In 1921, after becoming Archbishop of Simferopol and Taurian, it continues to operate many, consults and teaches physicians.
In addition, conscientiously perform their duties as archbishop. His work has brought a lot to the problem of purulent surgery.
According to religious beliefs scientist was persecuted by the Soviet authorities, repeatedly arrested, sitting in prison, was in exile. Archbishop Luke died in 1961 at 85 years of age. Buried in
HYGIENE AND ORGANIZATION OF WORK in surgical hospital
The organization of medical care, including surgery, the citizens of
On mass surgical care show hundreds of thousands annually performed in
The basis of the modern system of surgical care in
The organization of surgical care includes ascending, primary health care, skilled and specialized surgical care. Surgical care is divided into an ambulance, or emergency, which require patients with acute illnesses and injuries, and planned, carried out for patients with chronic illnesses.
Primary medical emergency patients with acute surgical diseases and injuries made in outpatient health posts in the district and rural hospitals – in villages and in towns and equated localities – surgeon clinics, doctors and emergency station crews, mostly specialized, stations “ambulance”. Patients with minor injuries, acute type, which do not require surgery or the latter can be successfully performed by doctors of these stages, and patients with acute illnesses that do not require hospitalization, primary care provided in these stages are actually qualified and are completed. The essence of primary care patients with acute surgical diseases and injuries in rural clinics and district hospitals, as well as help in clinics cities, in those cases where the patient requires such assistance, by its nature, exceeds the amount programmed for the surgeon and clinic goes beyond its responsibilities, is examining a patient at disposition paramedic or doctor (including medicinal-ovarian-surgery clinic) means for establishing probable or, sometimes, an accurate diagnosis and referral of the patient to the surgical department district or central hospital with the definition of transport which the patient must be addressed. In most cases, carrying machine station “ambulance” or machine “ambulance” very hospital in which the patient guides. Less can be requested aircraft – helicopter or plane even if the life of the patient mortal danger. Patients with surgical polyclinics cities sent to the appropriate surgical department district or municipal hospitals, or through the station “ambulance” (by calling the last machine) – acute internal diseases, or (rarely) – urban or own transportation in case of acute lung diseases and injuries.
In clinics cities and towns that have surgical rooms and offices, patients with minor superficial injuries and uncomplicated acute diseases (small wounds of the soft tissues of the body are limited to burns, furuncles, abscesses, subcutaneous felon, etc.) is also a qualified surgical care.
Qualified emergency and planned surgical care for patients with the most common acute abdominal disease (acute appendicitis, incarcerated hernia, acute cholecystitis, perforated gastric and duodenal ulcers, gastric bleeding, pancreatitis, acute intestinal obstruction, etc.) and with injuries organs of this cavity, injuries soft tissue, purulent processes, as well as patients with chronic abdominal cavity and some other organs is in general surgical wards of central district hospitals, urban and regional, rarely – in the district where there is a surgical department and appropriate interventions for these conditions (qualified surgeon , means for accurate laboratory and instrumental diagnostics and anesthesia required). In large cities, including regional centers, along with district and city hospitals to ensure patients of skilled surgical means, the latter is also the regional hospitals to patients who are sent here from district hospitals respective region.
The rapid development of surgery in the last half century, by which the human body does not remain out of reach for hands and surgeon of a scalpel, made it virtually impossible surgeon mastery of all the arsenal of modern diagnostic and surgical diseases perfect technique surgery for all organs and parts of the human body.
This led to the need for differentiation, division of surgery (and other broad areas of medicine) into separate disciplines and sections. Thus was launched surgeons specialize in certain sections of Surgery and Surgical emerged specialized institutions that provide patients with specialized surgical care.
Yes, surgery has long been separated into independent disciplines traumatology and orthopedics, oncology, urology, neurosurgery. Earlier became independent field of ophthalmology, otolaryngology and dentistry. In the postwar period, has undergone further surgery even deeper differentiation. In some disciplines evolved surgery lung and bronchus, esophagus surgery, cardiac surgery, vascular surgery, rectal (proctology), gastroenterology, surgical endocrinology. The process of differentiation surgery to separate sections ongoing. Already exist, such as herniology and other clinical departments. All regional and large urban hospitals are practically surgical departments of all the major sections of surgery (thoracic, neurosurgical, surgical gastroenterology, shelepno-facial, otolaryngology, ophthalmology, burn, vascular or even cardiovascular et al.), Which is specialized surgical help sick people from villages and cities.
Ethical and deontological requirements for personnal
Beginning medical emblem is the serpent – bearer of health and wisdom. This emblem characterizes the objective side of our profession. Along with it, there is another, less well-known symbol, testament, which already reflects the inner essence of medical practice. He left us his famous Dutch surgeon, Mayor of Amsterdam Nicolaas van Tulpa-Tulpius (1599-1674). It lit candle. “Shining way, burns himself.”
And this covenant remained loyal to the last hours of his life many doctors. Do not count all these humble, unknown medical workers who in the name of service to the suffering man worked at the epicenter of epidemics, died of typhus, showed great sacrifice on the fronts of the war, guerrilla detachments behind enemy lines in Nazi death camps, Stalin’s torture chambers and finally – in modest circumstances ordinary, everyday work in peacetime.
History of medicine knows many cases of self-sacrifice scientists, who for the sake of good people gave their property, health and even life. Not to mention the case with great sacrifice, truly Spartan endurance and loyalty to high ideals of Medicine, who presented at the last stage of his life known Russian surgeon, innovator Dr. W. Oppel.
In 1931, during the development of creative forces, VA Oppel found a malignant tumor of the maxillary sinus. When the tumor began to grow in the eye, sharply raised the question of surgery – resection of the upper jaw with enucleation of the eye. With courage hearing decision about surgery doctors, V. Oppel took avtotrening. Tying handkerchief eye, which is subject to removal, he taught himself to operate in the new environment. Indeed, shifting the operation and left with one eye,
The term “ethics” is derived from two Greek words: deon – proper, fit, and logos – word doctrine. Translated, it means “the doctrine of duty,” “doctrine of good.”
Care, nursing or hipurhiya (from Gr. Hypuria – to help, to serve) – a process that consists of a set of measures that provide comprehensive patient care, establishment of proper hygienic conditions conducive uncomplicated disease, accelerate recovery, alleviate suffering and prevent complication and timely reporting them, and performing medical appointments.
Nursing – an integral part of treatment. Many patients, especially surgical, does not itself recover, their nurse. Care is divided into general and special.
General maintenance – is the sum of measures that require any patients regardless of the nature of their disease (pathology), age, sex, etc.. Among the general measures distinguished:
a) the maintenance of hygienic facilities, beds and furniture, the patient, his clothes, utensils, toiletries, etc.;
b) strict implementation of all doctor’s appointments (compliance procedures and techniques regimen of drugs);
c) monitor the progress of the disease, the patient and inform the doctor about a change in his condition;
d) feeding the patient. Actions medical personnel associated with specific diseases or actual injury and
treatment constitute special care.
Nursing is younger sisters (nurses) who do not have special medical education, and nurses with special health, including higher education. Younger nurses take care of him or those items that do not require special medical knowledge relating to providing care to center the patient, his personal hygiene, nutrition and more.
These objectives are to ensure proper hygiene and sanitation chambers, beds, clothes, proper hygienic condition of the patient (washing, washing, dressing, translation and transportation, etc.), feeding patients, cleaning toilets and helping patients in the exercise physiological acts, cleaning and disinfection of toilets and utensils for excrement, etc..
Although listed duties carried out by persons without medical training, they need them to appropriate knowledge, skills and conscientious attitude. Teaching younger sisters meeting their responsibilities conduct sisters with medical education. Recently, along with the control and direction of the work of younger nurses have a wide range of duties of care, monitoring of patients and their treatment is performed by a doctor. They are distributed and administered medications, including by injection, perform many medical procedures – impose compresses, mustard, put cans, washed stomach, put an enema, etc., carry out strict monitoring of patients and inform physicians about the changes in his body.
Immediately the work of nurses with special education department manages older sister.
All those who care for the sick, should be familiar with their duties and their meaning and role in the overall treatment process, place and time of treatments, care for adequate hygienic and functional status of their place of work. Nursing requires both the ability to perform a variety of hygienic and therapeutic measures, and moral, fair and compassionate treatment of the patient. It must be highly professional, ethical and aged. Merciful, humane treatment of the patient is no less important than professional skills. This truth is proved as practical medicine for centuries, and physiological studies, especially IP Pavlov and his disciples and followers, as a second system of the brain, based on the word – signal signals. Mental state of the patient always depressed due to the influence of the central nervous system of anatomical and functional disorders in the body and forced to move due to illness (often sudden and prolonged, as is the case with trauma and acute surgical diseases) in the unusual position (with the exception of the usual atmosphere and employment, household inconveniences and restrictions, and often the inability to self-realization and physiological acts).
Many patients suppresses feelings of shyness as necessary to carry out physiological acts in the presence of staff or patients or neighbors for their help. Therefore, careful execution personnel – nurses and nurse – their duties and friendly attitude to help the patient eliminate many negative effects caused by the disease.
The whole set of measures of treatment and care should be based on the principles of safety-stimulated regime, laws of physiology and especially on such fundamental positions it as traumatic impact of unusual irritants of various kinds on the body, and, conversely, stimulative effect irritants, not beyond the physiological range on organ function, including regenerative and reparative processes. Maintenance of therapeutic agents at the optimal level of physiological parameters of the life of the patient, including its major systems – the nervous, cardiovascular and respiratory, providing favorable conditions for recovery.
Creating a patient good, optimistic spirit, faith in a favorable course of the disease, which is largely confirmed by the good care and sympathetic attitude toward the patient, is an important and honorable duty of medical workers in hospitals and clinics.
General maintenance includes the following subsections:
• environmental health;
• Personal hygiene, prevention of hospital infection;
• personal hygiene of the patient;
• disinfection of patient discharge;
• hygiene underwear;
• hygiene gear and visitors;
• Hygiene transport;
• food hygiene.
Environmental health is a prerequisite for therapeutic interventions and their effectiveness. Ski chamber, in which the patient and her space, heating, lighting, air quality (ventilation) must comply with hygienic standards in all respects. It should be light, well ventilated, well in winter, but not excessively heated. Windows Chamber should have curtains to protect patients from direct solar radiation. Floor in the ward should be covered with linoleum, which enables her wet cleaning and silent movement of personnel, especially at night.
Personal hygiene. Staff that cares for the sick, especially to be hygienically educated, healthy and tidy. Each participant care should be familiar with hygiene rules within their duties. Without this requirement, it can become a mediator in the transmission of infection to the patient, externally, particularly from himself and from other patients, that of intrahospital. In staff regularly check the condition of health. Patients and bacilli-carrier not allowed to work until they have recovered. Nurses and nurses before becoming to work, dress up in the hospital in the form of separate, designated premises (rooms). Staff are not allowed to carry out their functions in the shoes and clothes that he enjoys outside the hospital. Clothing nurses or nurses should be neat laboratory coats and scarves are clean, hair – hidden under the scarf or hat, shoes – soft and clean. Decorations hands (fingers) and manicures are not allowed. Nails should be cut short. Pleasant View staff has on patients with good effect, creating in them optimistic. Personal hygiene is of exceptional importance for the prevention of hospital infection. Compliance nurses rules of sanitation and asepsis in the performance of their duties (use gloves during all procedures that can facilitate the transfer of infection from one patient to the other, hand washing after each treatment procedure, avoiding the use of unsterile instruments and devices during invasive procedures and intraorganic – injection, gastric lavage, setting enemas, dressing, etc.) and the maximum use of tools, clothing, appliances and other disposable – the most important measures to prevent the spread of in-infection.
Hygiene patient. Prevention of bedsores.
Before becoming a hospital patient is sanitized. He takes a shower in the receiver, then disguised in a hospital gown. Seriously ill staff washes in the bathroom. Some, especially the terminally ill, only disguised (wearing hospital clothes, patients with home clean clothes are still in it). Patients with the presence of head lice or nits wash them and cut their head Lysol. If you find clothes clothing lice patient sent to fumigatory for processing. Clean clothes or stored in a hospital cell, or give to relatives of the patient. The department provides the patient with a set of clean bed linen. In the morning after a night of sleep walking patients wash in a special toilet and washing his bedridden patients younger nurses, patients who can sit in bed,
Bedsore
poured from a pitcher in his arms and they wash themselves, brush their teeth, and rubbing lying (face, hands) dipped towel or cloth. There needs to be monitored, especially in critically ill after surgery for mouth, nose, eyes. Oral cavity patients rinsed 1% solution of potassium permanganate or sodium permanganate, and teeth and gums nurse rubbed seriously ill gauze ball. Eyes sick washed cotton-gauze ball dipped digested water or isotonic sodium chloride solution, and the presence of bacterial inflammation of the conjunctival sac last instilled solution or applied ointment containing sulfonamides (20-30% sulfatsil naitrium) or antibiotics. Catching ill shave themselves, and lying barber shaves, observing all preventive measures against infection. For patients walking in the restrooms (separate for men and women) create conditions for washing of after defecation and washing for the evening and clean areas genitals. Lying patients tempting younger nurses. To do so, buttocks patient substituted vessel and sister one hand pours a pitcher or better with Esmarch quart warm water on the crotch of the patient, and the second, which keeps on kortsang swab, wash the skin around the anus and labia. Completes procedure washing of drying skin clean cloth. Along with cleaning the skin from pollution skin Seriously ill in areas of bone interventions – buttocks, shoulder, spine, five – wipe camphor alcohol (ethyl or 60%). This, as well as frequent turning of the patient in bed, smoothing underneath sheets (smoothing it folds), etc. are important measures to prevent bedsores. Weekly ill replace underwear and linens and wash them. Underwear, contaminated wound or other secretions, change request. Patients should always be based on a clean and dry laundry. To prevent pressure ulcers in critically ill, especially the elderly, patients with diabetes need underlay under the buttocks rubber wheels and under five – cotton-gauze or foam pads often return them, changing body position. In recent years, to prevent bedsores widely used special aerial multi sectional and other mattresses. In patients, especially obese should prevent diaper rash, dermatitis and skin infection by rubbing inguinal folds, folds on the abdomen and under the breasts 56-70% ethyl alcohol, sprinkle talcum these places or tooth powder or – by the appearance of dermatitis – lubricated with ointment zinc oxide paste or Lassara. The situation of the patient in the bed should be physiological, that provide the most relaxing of all muscle groups. This reduces the energy costs of his body and promotes optimal implementation functions of all organs and systems. It meets the requirements of the position on the back with a slight lifting the head and elongated legs. Lodge legs patients should not be, because it promotes thrombosis leg.
However, the characteristics of the disease and the patient often require (in order to alleviate the disease and prevent complications) of the patient is somewhat different from the typical physiological conditions. Thus, patients with peritonitis have Fovlera position: head high and knees bent legs (below the knee enclose rollers that do not give the body the patient slides down). This provision provides intraabdominal fluid draining from the upper half of the lower abdominal, pelvic, in which the peritoneum less it sucks compared to the phrenic. In addition, the accumulation of pus in it is easier to diagnose and treat.
In some states the patient with prolonged nausea and vomiting, especially after anesthesia, the patient is placed on his back, his head turned slightly to one side. In the horizontal position (without raising the head end of the bed) should also be patients with bleeding and anemia after bleeding. This position promotes blood flow (oxygen) to the brain and heart. In contrast, patients with respiratory failure become half-sitting position (orthopnea). With increased head are also patients after operations on the oropharynx and neck. Hygiene patient may be at an appropriate level, subject to his care beds, bedding, clothes, clothing, care and transportation, that is all that surrounds the patient. Bedside daily wipe clean with wet rags and periodically disinfected with 3% solution of chlorine bleach or Lysol. Winders and litter must be kept clean and in case of contamination of fluids – disinfected. Before transporting patients wheelchairs or stretchers covered with dry clean sheet. Patient during transport (transfer) is also covered with a clean sheet or blanket.
Important and technically complex the replacement underwear and bedclothes in seriously ill.
Most do younger nurses. Underwear, including a shirt, on a seriously ill patient change it. First roll her on her back and then the front, to the level of the blades and axillary areas. Then raise the patient’s head, pulling a shirt over it, releasing first the trunk, and only then remove from the hands alternately. If the shirt spacious, then it after lifting the torso can be removed first with each hand separately, and then, after raising the head of the patient, transfer through the head and trunk release. Wear a shirt so. Initially, her
Replacement underwear on patient
head on an extending neck, then alternately pull the sleeves up and lowered down on the trunk, pulling the bottom edge and simultaneously raising thoracic trunk. This makes the second or nurse, or one and the same with the other hand. Changing dirty underpants begin with lowering them from the trunk on the thigh. First, remove them from the healthy leg and gently with the patient. Wear clean underpants first on affected leg, and then – to others.
To replace the bedclothes of the patient first turn sideways and liberated Patients often bed sheets twisted in roller (from edge of the bed toward the patient). Then put in place dirty minimized half roller to the back of the patient clean sheet. The patient was overturned on its back on a clean half-sheets, roller dirty sheets extracted from the patient carefully and in its place (in the spread with half) deploying removed from the patient to the second half of the bed roller clean sheets. In patients whose condition does not allow them to turn aside (strict bed rest), dirty sheets gently pull and clean – enclose, which is only possible with the participation of two nurses.
Hygiene reclining patient to ensure that it provides special dishes for the timely implementation of the physiological acts – bowel movements and urination, retention which negatively affects the physical condition of the patient, especially in the nervous and cardiovascular systems, as well as mental state. For bowel patients isolated (on request) bedpan and urine for – urinal. Last pure store usually in the House under the bed of the patient, so that he could use it himself (and for the most seriously ill patients – even on a separate nightstand), covering with clean cloth. Bedpans stored in desinfected form in special cabinets or on shelves in the toilet. Younger nurses serving sick during defecation or urination, working in the appropriate attire – oilcloth or plastic apron, rubber or plastic gloves. They underlying patient under buttocks and buttocks oilcloth (during defecation) and it put a bedpan. During urination not need underlay under the patient protective waterproof cloth. After patients shipments sister ship immediately withdraws or urinal and covering their oilcloth, refers to the toilet, where either immediately pours into the toilet or leaves for examination by a doctor or disinfect. After emptying this same sister tempted patient wipes skin around the anal opening, and then takes out from under him oilcloth. In the absence of patient self-defecation he put a cleansing enema. This procedure takes a nurse. After enema defecation occurs at the same sanitation provision as independent. Patients, especially elderly men after surgery in the abdominal cavity often delay urination. In cases where the patient has the urge to urinate and urine produce not more than 6 hours, you can enter the bladder catheter to withdraw it. But this procedure should be a doctor. However, in some cases the same medical ward sister at the request of the patient can lead a soft catheter urine, especially if the urethra obstructions. It should strictly observe the rules of asepsis. Younger nurses during patient care in the exercise of defecation and urination are cloth, aprons and disposable gloves, which are then destroyed.
It should be emphasized that although the majority of procedures to ensure the health of patients and their bedclothes and perform younger nurses (no special medical education), their work should be carried out under the direct supervision and with the participation of nurses with medical education.
Important role in providing quality care play learning his craft younger sisters nurses with special training, respectful attitudes from the past and physicians caring for them.
Work nursing staff in a surgical department.
1. Regulations on the surgical department and its planning.
Modern surgical department – is a complex medical complex, normal activity is regulated by the relevant sanitary norms. Surgical department recommended place in separate rooms facing the south, southeast or southwest. This orientation department creates conditions for lighting wards natural sunlight, with a sufficient dose of ultraviolet rays, which adversely affects a variety of infectious agents.
The main requirement for the surgical department – its isolation from other hospital departments. General surgery office district and city hospitals has admissions department, wards for patients (hospital), additional rooms (dining room, manipulation, nurse, etc.). Operational and dressing unit.
Admissions department.
Admissions department functioning by type sanitary inspection, where they spent roughing patients. Admissions department consists of registry, Cabinet initial evaluation of patients, shower, bathroom, cells for clothes, toiletries. In some hospitals in the admissions department create 1-2 diagnostic ward and isolation for infectious patients. Review of patients spend on a couch covered with oilcloth, which after review of each patient wipe damp cloth with disinfectant solutions. After examination of patients, the study of wounds and change bandages staff washing their hands with warm running water and soap for 3 min and handles hand solutions bactericidal drugs (0.2% solution of chlorine, 0.1% dezokson-1, 760 ethanol, 0, 5% solution of chlorhexidine in 700 ethanol, sterylium et al.).
In the emergency department patient hold sanitary processing (hygienic shower, bath), disguised in a hospital gown (robe, underwear, slippers). When urgent hospitalization of the patient is carried out sampling of blood, urine and other body fluids for analysis.
Surgery department
In large hospitals a specialized department for 30-40 beds to assist patients with vascular, endocrine, pulmonary and others. pathology. To prevent transmission of septic infection from one patient to another, it is desirable to have a clean surgical department and department of surgical infection. They need to be isolated from one another, have a separate inventory, equipment and staff. If you caot make a separate department for septic patients assign separate chambers and dressings. In these circumstances, it is important to cleanliness and order in the department. All the work plan so that initially conduct operations, then perform clean dressing patients, and only after all – purulent dressings (dressings order). The composition of the surgical department includes wards for patients, operating unit, dressings, manipulation and additional rooms (toilet, bathroom, dining room, pantry, laundry room, staff, sterilization, etc.)
Wards should be spacious, the rate of 6.5-
ward for patient
Surgical department must be equipped with central water system (cold, heat water), central heating, sanitation and purge ventilation. Hygienic standards of air in the chamber is 27-
manipulation diner-room Nursing post place
Nursing post place, usually in a hallway near the wards. On the table nurse on duty should be a light or audible alarm, telephone, desk lamp, etc..
In manipulation are:
• cabinets for medicines and sterile syringes labeled “domestic”, “injection”, “outer”, which closes with a key;
• table for dressing box with sterile material and antiseptics (alcohol hlorheksedyn, iodinol et al.)
• safe storage and potent drugs;
• refrigerator for intravenous solutions;
• sink with a towel;
• couch and chairs.
Workplace sisters surgical department shall refrain in perfect order. The nurse must strictly observe the rules of personal hygiene, be neatly dressed in a clean gown, hat or scarf. When the injection or intravenous infusion should be required to use a mask and rubber gloves.
All work in the surgical department based on the principles of security and treatment regimen. The patient must be surrounded by attention and care of medical personnel. Hospitalized patients in the department accompanied by a nurse or nurse admissions department. Another nurse at the direction of the head office or another surgeon places the patient in one of the chambers. All the terminally ill and those requiring urgent surgical care (acute diseases of the abdominal cavity, abdominal trauma, chest, etc.)., Delivered in surgical ward on a gurney. Patients who need immediate surgery, is sent to the department for intensive treatment for preoperative preparation or directly to the operating room. All medical personnel should build their working day under the regime of the surgical department.
Exemplary compliance, order and discipline in the department elevates mood and causes the patient confidence in a quick recovery. All patients must adhere to hospital treatment, the recommendations of the doctor. They are familiar with the mode of surgery department in the emergency department, which is painted in by hospital. For violations of patients discharged from hospital.
In the surgical department of the leadership of nurses and nurses carries nurse who is directly subordinate head of department, takes his instructions on care and services to patients and takes full responsibility for the work of nurses. Given its remit, that job is people who have worked as a nurse for at least 3 years and are usually those who have certified the first category. This nurse surgical department appoints and dismisses the
Function senior nurse surgical department:
1. Conducts appropriate selection of nurses with their psychological compatibility.
2. Prepares work schedules nurses and flight.
3. Provides normal operation department through timely replacement nurses and nurses who could not go to work due to illness or other reasons.
4. Keeps timeliness and clarity of execution doctor appointments.
5. Keeps the use, storage, distribution, copying mechanism and control of medicines, medical instruments and items of care.
6. Keeps the rules of storage and accounting of narcotic drugs.
7. Ensures implementation of internal regulations department, the principles of medical-protective regime.
8. Held under the control diet for patients is a la carte food orders, according to the dietary tables, monitors the quality of cooked food and its distribution.
9. Keeps records of acceptance and discharge of patients, a report on the movement of patients in the department, presents the admission and outpatient department data about the availability of beds.
10. Participates in the Board of Nursing Hospital nursing conferences.
Requirements ward nurse surgical department:
A nurse in the department of services to patients department reports directly to residents in part of the routine work – older sister branch. She is responsible for the timely and correct implementation of medical appointments, quality care for patients in wards or her assigned office (dressings, manipulation).
The post of ward nurse administered nurses from the first level of accreditation.
Duties ward nurse surgical department:
1) hospitalized patients, validation of their sanitization, familiarize the patient with the rules of the house;
2) collection of material for research (blood, urine, feces) and send it to the lab;
3) prepare patients to perform diagnostic tests (endoscopy, radiography, ECG, etc..) And support or transport them to various diagnostic offices;
4) faithful implementation of all doctor appointments, which are included in the special lists of appointments;
5) should be present on rounds physician reporting to him about all the changes that have occurred in the state of the patient during rotation;
6) measurement body temperature (morning and evening) and recording temperature data sheet;
7) measurement of pulse rate, blood pressure, breathing, of daily diuresis and post this data doctor;
8) surveillance of the wound (bandages) and discharge of drainage;
9) careful and close supervision of the patient, if necessary, immediately giving him first aid (CPR, indirect massage heart stop bleeding);
10) monitor compliance by patients assigned to diet preparation proportional requirements feeding critically ill, quality products that bring families;
11) supervise the work of the technical process (nurses, cleaners) and compliance measures for hygienic and sanitary conditions in the unit (change of clothes, prevention of pressure sores, skin care, oral patients and others.)
12) carefully maintaining medical records, which include magazine reception and transmission duty magazine. Medicament and portion requirements leaves medical appointments, temperature leaves others.
For the faithful performance of duties surgical nurse in a short period of time it is necessary to examine a large section of general surgery, learn the basic surgical diseases, their diagnosis and treatment, especially the care of patients. Medical assistance is a sacred duty of every health worker, regardless of its level of education and profession. Inattention or unjustified failure to perform its obligations leads to legal liability.
Requirements for dressings should be the same as the operating (bright room, the ceiling of which should be painted with oil paint, walls and floor are lined with tiles).
The dressing should keep the premises clean. Table for instruments and dressings cover as well as in the operating room.
Tools serves forceps. Ligation is carried out only within the tool. Instruments are sterilized in the same dressings or sterilization room operating unit. Dressings should be provided with a central cold and warm water. Optimum temperature should be 18-20 ° C. The dressing should not be foreign objects, clothes, except for table dressings, table for instruments and dressings, cabinets for medicines and instruments and chairs for patients. When conducting dressings must consider the degree of purity wounds of patients. Patients with complications, purulent wounds bandaged least. At the end of the day conducting wet cleaning dressings and exposure to ultraviolet rays. In large surgical wards, usually has two dressings – for “clean” and “septic” patients.
Dressing room
Function dressing nurse:
1. Performs assigned doctor-intern manipulations that are allowed to perform nurse.
2. Accompanies seriously ill after manipulations performed in house.
3. Strictly adhering to the rules of asepsis and antisepsis.
4. Prepares to sterilize and sterilize bandages and instruments in accordance with the operating instructions.
5. Provides systematic bacteriological control dressings, instruments, placing dressing room.
6. Provides systematic replenishment, inventory, storage and control spending medicines, dressings, instruments and clothes.
7. Instructs nursing staff dressings and controls its operation.
8. Maintains accounting records.
9. Systematically increase their professional qualifications.
10. Participates in sanitary – educational work.
In order to prevent festering disease and compliance with sanitary norms of bacteriological laboratory sanitary station, which is subject to the medical establishment has once in 15-20 days bacteriological control of air pollution (operating, dressings, wards), quality control disinfection treatment hands of personnel, material and sterile surgical instruments. Control of microbial contamination of air in operating and dressings spend once a month. Dirty air in the chamber and dressing can be determined using sedimentation, filtration and method of shock air. Sedimentation principle of the method is that the microorganisms that are in the air, settle on a horizontal surface. For this study the use of Petri dishes with nutrient medium (2% agar) that during the 15 minutes are left open at predetermined locations operating or dressings. After that, the Petri dish is placed in a thermostat at 24 h and counted the number of colonies that grew. Filtration method of research is to draw 10-
Modern operation room
In the operating number of colonies of microorganisms on 1m3 of air should not exceed 500 hours and 1000 – during and after the operating. For dressings and preoperative allowed no more than 1000 colonies 1m3 in the air to work. In addition, the sample volume of
Crops of the hands, usually spends elder sister operating so that the staff did not know when and whom he will serve. Drill results should be discussed and always match with a frequency of postoperative complications. This control improves the quality of handwashing staff and reduce the number of postoperative complications.
In addition to the mandatory daily monitoring the effectiveness of sterilization in an autoclave (dressings, linen) with standard vials or sulfur to every 10 days seeding with sterilized material. Particular attention should be given to the quality of sterilization of suture material. Crops of silk, catgut should be performed prior to sterilization and its storage at least once in 10 days. To control the sterility of the hands of medical personnel, dressings and sutures older operating sister should have a special magazine.
To identify and sanitation carriers of pathogenic 1-2 times a year to all employees of the surgical department doing swabs from the nose and throat swabs special. Revealed carriers of pathogenic infections dignity without fail. In the absence of positive results from the treatment of chronic inflammatory diseases of the upper respiratory tract and oral cavity employees transferred to another job.
Observation and care after surgery for head, face and neck
Operations on the head, its soft tissues performed in surgical wards general. Because these interventions are performed, or in the case of open injuries (wounds) of soft tissues of the head without brain damage or mild forms of shaking it, or pathological processes or diseases of soft tissues (burns, tumors and tumor formation – atheroma, dermoid cyst) , caring for such patients is virtually indistinguishable from the care of patients operated in other parts of the body.
Mostly watched as bandages, soaking her color liquid wets the bandage – blood or light pink liquid, and the provisions of dressing on the wound. Soft tissues of the head is very well supplied blood in them, so bleeding after operations on the head is more likely than in the case of operations on the surface of the soft tissues and other body parts.
Strong soaking bandages should call the medical ward sisters above all suspicion of significant bleeding from the wound, it should inform the surgeon or doctor-intern. For minor bleeding according to the decision of the doctor dressing can be replaced with a new or old floor impose additional dressing material and other aids (applying bag of sand, a bubble of cold water or other burden). For bleeding that can be caused by insufficient mechanical hemostasis, rarely – bleeding disorders, and may continue, especially in patients with possible variations in blood coagulation system, considerable time and after changing bandages and other measures of conservative nature, or cases of bleeding after subcutaneous hematoma, mostly required operational audit wounds – taking the patient to another operating table, removing stitches from the wound and stop the bleeding or remove the hematoma – bleeding vessel ligation (ligaturing) thermocoagulation others. However, not only common complications are possible in the operated on soft tissues head. Through anatomical and physiological characteristics of operations on the head more often in patients with possible reactions common type of injury and anesthetics as dyspeptic phenomena (nausea, vomiting or dizziness) or so-called orthostatic collapse (decrease in blood pressure and fainting during a brief lifting of bed, go into the standing position).
In patients operated on the wound of the head, with a history of brain dysfunction may develop later in the postoperative period of severe brain damage syndrome – compression of his hematoma. This is accompanied by such symptoms as headache, growing, slow pulse, dilated pupils, and eventually unconsciousness and convulsions. Therefore, patients operated on soft tissue injuries and a possible concussion syndrome, it is necessary in the postoperative period very closely observe carefully listen to their complaints, periodically determine the pulse and determine its frequency and occurrence of even minor changes in the health condition of the patient to inform the doctor.
Surgical interventions on the head, usually performed in specialized neurosurgical departments, including craniotomy with manipulating the brain or cranial cavity revision of intervention in meninges belong to very complex operations with possible various complications in the postoperative period – swelling of the brain infection (meningitis or meninho-encephalitis, brain abscess, sepsis), traumatic epilepsy, bleeding in the cranial cavity and the outer like. All these complications cause significant disruption of the brain and the mechanisms that regulate different body systems, including respiration, circulation, metabolism, digestion and others. The immediate postoperative period in these patients is often complicated by vomiting, which may have dual genesis – as a result of traumatic irritation centers medulla (parasympathetic) and chemical, drug. Therefore resuscitation distance of patients after surgery lay on his back, turning his head away (in the event of vomiting patient immediately put to the side). This prevents aspiration of vomit and asphyxia. Often these patients are observed and complications such as mental and motor stimulation (including convulsions and traumatic epilepsy), during which patients can pluck the bandage. Therefore, nurses should timely notice all abnormalities in patients with head trauma or postoperative period and inform the doctor immediately for appropriate action.
Care after surgery in the facial area (which is preferably carried out under local anesthesia or intravenous narcotic) performed on tumors, trauma and inflammatory processes, almost a little different from care after surgery on soft tissues in other parts of the body. After these operations, especially the inflammatory processes (anthrax lips, abscesses, boil), patients should eat only liquid and semi-liquid food, talk less.
Operations in the mouth and oral part of the pharynx (cleft lip and palate, tumors, cysts, removal of teeth, jaw resection, tonsillectomy, autopsy and retropharyngeal abscesses, etc.) difficult and dangerous, so patients require more maintenance, especially to prevent aspiration of saliva, blood, tissue particles in the respiratory tract, as it may cause asphyxia or pneumonia and lung abscess, etc..
Operations on the palate malformations and tumors tongue, tonsils, jaw, jaw osteomyelitis is usually performed under general anesthesia, and therefore in the postoperative period, especially in the first few hours it should strictly observe the patient in intensive care and resuscitation to release his condition anesthesia . Patients should lie flat without a pillow with head turned to one side – to prevent asphyxia tongue or vomit. Under the chin and mouth should be put gauze or a piece of cotton wool for draining saliva mixed with blood. Pain after surgery should be complete, but one that does not inhibit respiration (without opiates). Patients should receive oxygen through a nasal catheter. Inhibition of cough, salivation and secretion of bronchial glands important for normal postoperative period (creates calmness, improves breathing reduces the risk of aspiration and asphyxia). His introduction of reach of small doses aminazine and atropine sulfate.
Patients operated in the area of the mouth under local anesthesia, immediately after surgery put aside slightly tilted his head to his chest (to facilitate passive saliva and blood). Under the chin put the tray in which the flow of saliva and blood.
On the second day after surgery patients operated in the area of the mouth, rinsed the last 0.001% solution of potassium permanganate and wipe with a cotton ball dipped in this same solution teeth. Later, rinse your mouth with water can be digested with sodium bicarbonate (1-2% solution).
Infants operated on cracks palate and lips, naturally fed breast milk (rarely) or introduced through the nose into the stomach probe mother’s milk or infant sterile mixture.
Adult patients fed or sterile liquid cooled to room temperature food or the same food through a tube (nasogastric).
Operations on the neck and its organs perform both under general anesthesia or under local anesthesia. Because nursing is slightly different and depends on full-time release of patients from the state of anesthesia.
Drainage from wounds removed after 24 – 48 hours and sutures removed early – after 4 – 5 days.
Infection of wounds in the neck after surgery for non-infectious (noninflammatory) disease is rare due to good blood supply to tissues and organs of the neck.
After operations on the neck on inflammation (phlegmon) and penetrating injuries nature should pay attention to the general condition of the patient, especially body temperature and pain of it spreading to the mediastinum (mediastinitis) and also on the bandage, including soaking her blood or saliva. Latest evidence of bleeding or penetrating trauma of the esophagus.
In the presence of esophageal fistula patients fed by injections into the stomach through the nose (or gastrostomy) probe, which pour liquid dish. The bandage patient with esophageal or tracheal fistula (after hysterectomy larynx or tracheostomy) should be changed often, and lubricate the skin paste Lassara and ointments. containing corticosteroids for the prevention and treatment of dermatitis and maceration of the skin.
Patients with pathological processes in the neck, mainly with tumors of various tissues and organs of (larynx, thyroid gland), stenosis of the larynx different origins, including bilateral paralysis of inferior laryngeal nerve, and patients with brain injuries is often shown tracheostomy ( temporary or permanent). In this case, the nurse must follow in order to Tracheostomy tube was placed correctly and periodically clean it of mucus and pus through their aspiration catheter. If the mucus is too thick, dilute its introduction into the trachea 3% solution of sodium bicarbonate (2-3 ml) or chymotrypsin. Sister should be able to replace the inner tube in case of blockage or loss of the trachea. If you have any difficulty performing this procedure, the nurse must promptly inform the doctor.
OBSERVATIONS AND CARE Patients with damage to the musculoskeletal system
In general surgery department usually being treated several patients with diseases of the musculoskeletal system. Often these are people who are hospitalized urgently with bone fractures or dislocations of joints, seriously ill, requiring special treatment and special care. In most cases, this recumbent patients who are on extraction, or fixed cast limbs.
Caring for trauma patients has a number of features. Staff who care for these patients should know the dynamics of the pathological process, know exactly which bone is damaged, opened or closed fracture, which is state of the vessels and nerves of the limbs after injury, whether poor circulation in the limbs, which is an operation done and what anesthesia. Patients with fractures of the spine or pelvis is placed on a shield (usually wood), which cover the net beds. It should be smooth, without cracks and fissures. Before connecting the shield needs to be sanitized (pour boiling water, spray disinfects, what solution or sprinkle powder). On the shield is placed a thin mattress and cover it with a sheet, under which sometimes lay oilcloth. Because these patients lie motionless for a long time, we must ensure that they do crease formed on the sheet that put pressure on the skin. Often use prefixes to the bed, which put the injured limb.
At the turn of the cervical spine stretching exercise for the head special loop (Glisson) with thick fabric or leather, it buckles and straps fastened to the neck and chin. By tying lace loops that are moving through the block, and it hung burden. To counterbalance the head end of the bed slightly raised. At feeding time the patient front of the loop bud, so he could chew.
At the turn of the femoral or tibial skeletal often used (in combination with sticky patch or kleol) traction. Limb is placed in a special splint curved in hip and knee joint position.
For any method of stretching should monitor the status labels provisions limb choice burden bones that act (to bedsores), the provisions of spokes. One of the most common treatments for fractures is Cast. For this purpose, gypsum, which when mixed with water becomes a mass that hardens in 5-7 minutes. This property is used for the manufacture of gypsum plaster bandages, which immobilized limb. We must remember that in time they can shift and press on soft tissues, causing pain, and eventually – and bedsores. Sometimes in such cases, divide the plaster cast and pushes her to the edge of extinction of pain. Particular attentioeeds patients in the first hours after Cast as likely to develop complications such as compression of blood vessels and nerves. Otherwise, it can lead to paralysis, paresis, necrosis of the distal limb. Tightly imposed bandage can cause sores, tissue necrosis, until gangrene. To prevent this complication should carefully heed-automatically adjust to patient complaints (pain in limb, tingling, coldness), watch the distal extremities, which should be open. The appearance of pain, blanching and cold fingers or cyanosis – a signal that you should immediately cut plaster and eliminate the cause of complications. Ending with an applied plaster cast should be slightly raised, to avoid stagnation. Upper limb should hang.
In the case of open fractures and wounds that are imposed cut in a window plaster bandage should monitor the temperature of the body, the appearance of pain in the wound, blood picture. If the third or fourth day of fever body was sore, take control wounds.
After surgery on the bone and then imposing cast, make sure that the bandage is soaked with blood. If the plaster cast of the patient on the back compresses the chest and difficult breathing under it at chest level enclose a bag of sand. Patching thus rises, releasing the chest. In the treatment of traumatic lesions of the bone plays an important role physiotherapy. it should be done from the very first days after the beginning of the extraction or Cast. While fixing injured bones have cut muscles make movements in the joints, even fixed plaster cast.
Early movements prevent the development difficult to move in joints, muscle atrophy after removing skeletal extraction or cast. In this period should be physiotherapy procedures, medical gymnastics, massage.
Asepsis. Antisepsis.
When the source of infection is aware of, reproduction of microorganisms. In relation to the patient (injured) possible exogenous (outside the body) and endogenous (inside it) Sources of surgical infection.
The main source of exogenous infection are patients with purulent-inflammatory diseases, at least – animals. From patients with purulent-inflammatory diseases germs get into the environment (air, surrounding objects, hands of medical personnel) with pus, mucus, phlegm and other secretions. Failure to comply with certain rules of conduct, operation mode, special processing methods objects, tools, hands, dressings germs can enter the wound and cause suppurative inflammation. Microorganisms get into the wound from the environment in different ways: contact – when faced with a wound infected subjects, instruments, dressings, operating whiteness air – with ambient air in which microorganisms are; Implantation – infection at left in the wound for a long time or permanently certain items (sutures, bone fixators and other implants) infected while performing surgery or as a result of violations of sterilization.
Animals as a source of surgical infections play a smaller role. In processing the carcasses of diseased animals possible anthrax infection. From the feces of animals in the environment can get tetanus germs, gas gangrene. On the surrounding objects in the ground a long time these microorganisms are in the form of spores. At random injuries they may get into the wound with the earth, scraps of clothing and other objects and cause specific inflammation.
The source of endogenous infection is chronic inflammatory processes in the body as outside operations (skin diseases, teeth, tonsils, etc..) And in bodies, which made intervention (appendicitis, cholecystitis, osteomyelitis, and others.), And the oral microflora mouth, intestine, respiratory, urinary and others. Ways to infection with endogenous infection – contact, hematogenous, lymphogenous.
Contact the wound infection is possible in violation of surgical technique, when the wound can get fluid, pus, intestinal contents, or when transferring micro instruments, swabs, gloves failure due precautions. Since inflammation located outside operations, microorganisms can be entered with lymphoma (lymphogenous way of infection) or bloodstream (hematogenous route of infection).
Aseptic methods struggles to exogenous infection methods antiseptics – with endogenous infection, particularly that penetrated into the body from the external environment, as it happens at random injuries. For successful prevention of infectioeed to struggle waged on all stages (source of infection – infection of ways – the body) by a combination of methods of asepsis and antisepsis.
To prevent infection environment for the source of infection – the patient with purulent-inflammatory diseases – necessary in the first place arrangements: treatment of such patients in special departments of surgical infections, operations and dressings in separate operating and dressing; availability of qualified personnel for treatment and care. The same rule exists for surgery in an outpatient setting: receiving patients, treatment, and ligation operations performed in special offices.
Asepsis.
Drugs that have antibacterial effect on purulent microflora, divided into 2 groups of chemotherapeutic agents (see antiseptic) and chemicals for disinfection and sterilization.
Drugs that are used for disinfection and sterilization are used to prevent getting an infection in the wound, that is to fight infection in the ways of its transmission. Some chemical antibacterial agents may be used as a chemotherapeutic and facilities for disinfection and sterilization (eg, chlorhexidine, hydrogen peroxide, etc.)..
With chemicals for disinfection and sterilization is widely used in surgery iodine 5% and 10% alcohol solution used for lubricating the skin around the wound, treatment of superficial wounds and abrasions, surgical field. Iodine is part of the solution of iodine to sterilize catgut.
Yodonat (Iodonatum) contains about 4.5% of free iodine before use it was diluted with distilled water 1:4,5. Apply for processing surgical field.
Povidone-iodide – iodine compound of polivinilpirrolidone containing 0.1-1% solution of iodine. Use hands to handle, operating margins.
Chloramine B (chloraminum) used in a 1 – 2-3% solution for disinfection of hands, objects nursing, nonmetallic tool premises.
Formic acid in combination with hydrogen peroxide (pervomur drug C-4) is designed to handle hands before surgery. Prepare a special solution (see Preparation of hands before surgery). The drug is also used to handle surgical instruments and rubber gloves.
Mercury dichloride, or sublimate (Hydrargyri dichloridum). In 1:1000 concentration used for disinfection gloves items care. Gloves prevent the solution Sulima on I h, then extracted with sterile forceps, dried on a sterile table and lace talc. The method used in the outpatient setting. Application limited by toxicity of the drug.
Ethyl (Spirilus aethylicus) is used as a 70% or 96% solution for the treatment of hand, operating margins, optical instruments, suture material.
Formalin (Formatinum) – solution containing 36.5-37,5% formaldehide. Applied as a 0.5-5% solution for disinfection of gloves, instruments, catheters, drains.
Triple solution – powerful disinfectant, which is composed of formalin –
Carbolic acid (Acidum carbolicum), son. – Phenol (Phenolum). Apply a 3 ~ 5% solution for disinfecting objects nursing.
Lysol (Lyzolum). At a 2% solution, used to disinfect care items.
Dehmitsyd (Degmicidum) containing 30% dehmitsynu (quaternary ammonium compounds). Apply a 1% solution (ie, dilution 1:30) for processing surgical field and hand surgery.
Rokkal (Roccal) – 5% or 10% solution mix alkildimetilbenzilammoniya fluoride. Apply for sterilizing tools (1:1000 dilution; exposition -30 min), rubber gloves, drainage (in dilution 1:4000; exposure – ’24). In order to prevent corrosion of instruments added sodium carbonate at the rate of
Chlorhexidine is available as bigluconate (Chlorhexidinibigluconas). or hibitan. Available in a 20% solution. To handle operating margins and disinfect instruments solution diluted with 70% ethanol relative to 1:40. The resulting 0.5% aqueous-alcoholic solution treated the operative field 2 times at intervals of 2 min. Instruments are sterilized by dipping them in a solution of 2 min.
Fighting microflora on air routes of infection
Surgical hospital includes several major functional units, operating unit, wards surgical department, dressings, procedural and others.
Success prevent exogenous infection in surgical patients is possible if an integrated approach in all phases of patient’s stay in hospital: admissions department – surgical treatment – diagnostic rooms – dressing room – operating.
All work on preventing surgical hospital exogenous injection begins with the separation of patients with “pure” and “pus”. Patients with purulent-inflammatory diseases hospitalized in surgical septic (infectious) surgical departments that are completely isolated from the net outlets. In these works his staff have their dressings, operational, procedural facilities for performing injections, infusions, taking blood for laboratory tests, etc.). This unit should be in a separate room. If only one surgical unit in it excrete special wards for infected patients, wards are located in one of it (bay) with a surgical dressing in the same compartment.
In the emergency department, where the initial review and examination of those admitted immediately share the flow of patients with “pure” and “pus”. In the emergency department perform sanitary and hygienic processing, which involves washing patients (hygienic bath or shower) and dressing them. Under certain conditions (pediculosis, scabies) conduct special treatment and disinfection and disinsection underwear.
In the surgical department to maintain sanitary regime conducted daily wet cleaning with the use of antiseptics and
The main way of infection of wounds in the operating room – contact (about 90%), only 10% of cases of infection is by air. Each member of the surgical team, despite special training for surgery, sterile operating underwear, compliance mode, emit into the air up to 1500 organisms per minute. By 1-1.5 hours of one surgical team bacterial contamination of air in operating increased by 100%. Allowable number of microorganisms in
Surgical hospital includes several major functional units: operating unit, surgical department, dressings, procedural.
Operating unit – a set of facilities for special operations and activities that provide them. Operating unit should be located in a separate building or wing of the building, connected by a corridor of the surgical department, or on a separate floor of a multistory building surgery.
Most are separated by a transaction to perform surgery to “clean” and “septic” patients, although it is more expedient to provide a separate, isolated operating unit with purulent surgical wards.
Operating unit is separated from the surgical departments special vestibule – often a part of the corridor, which leave room operating unit general regime. To ensure sterility in the operating mode of the block allocated special functional space.
1. Zone sterile operating mode combines, preoperative and sterilization. In areas of this zone is carried out: in the operating room – direct operations, in preoperative – trained hand surgeon for surgery in Sterilization – sterilize instruments needed during surgery or reused.
2. The area of strict regime includes such facilities as changing rooms, consisting of rooms for undressing staff shower facilities, cabins for donning sterile clothing. These facilities are consistently, and the staff goes out of the cab for easy dressing or through the corridor of the preoperative. In this same area includes storage space for surgical instruments and apparatus, narcosis apparatus, medical office blood transfusion room for another team, senior operating sisters, sanitary unit for personnel operating unit.
3. Zone limited regime, or technical area, integrates production facilities to ensure the operating unit: there are equipment for air conditioning, vacuum units for operating supplies oxygen and Drug, here are substation battery for emergency lighting, photo lab for the manifestation X-ray films.
Mode operating unit assumes its limiting visits, in the sterile zone regime must be surgeons that only involved in the transaction, and their assistants, operating sisters, anesthesiologists and anesthetists, nurse for the current operating cleaning. The area sterile regime allowed students and doctors interns. Workers operating unit wear special clothes: gowns or jackets and pants, different colors of clothing employees of other departments.
Control for regime sterility operating unit conducted periodically by bacteriological examination of air operating, swabs from walls, ceilings, apparatus and appliances. For planting I take once a month on Sundays, in addition, do selectively seeding with arms unit employees to control sterility.
Sterile operating mode is achieved by preventing entry here from other areas of microorganisms and their distribution. Special device operating unit using a clean gateway in front of the operating room, preparing the patient for surgery (washing, changing clothes, shaving hair in the operating field), preparation for operations personnel (as dressing, use sterile linen, donning shoe covers, slippers, masks scrubbing) significantly limit the penetration of microorganisms into the operating room.
Microorganisms in the air pas subjects rarely found in isolation – they mainly fixed on microscopic particles of dust. Therefore, thorough removal of dust, as warning its penetration into the operating, reduce the degree of microbial contamination.
In operating under the following cleaning: previous, current, postoperative, and final general.
Before the operation a damp cloth wipe all items, appliances, window sills, remove dust settled per night (pre-cleaning). In the lobby operations constantly clean napkins, which fell to the floor, balloons, tools (current cleaning). In the interval between operations when the patient taken from the operating, cleaning clothes, tools, wipes soaked solution antiseptics, wipe become operational and cover it with a sheet, floor wipe with a damp cloth (cleaning postoperative). At the end of the day conducting final cleaning, which includes wet cleaning with wiping ceiling, walls, window sills, and all items of equipment, floors using disinfectant solutions (1-3/6 solution of hydrogen peroxide and detergents, etc..) And subsequent inclusion germicidal lamps.
At the end of the week perform general cleaning operating. Start it with disinfecting operating: ceiling, walls, all subjects floor sprayed with disinfectant solution, and then remove it by rubbing. After this is total wet cleaning and include germicidal ultraviolet (UV) lamp. General cleaning can be extraordinary – if dirty operating pus, intestinal contents, after surgery in patients with anaerobic infection (gas gangrene).
For exposure to air and objects that are in the operating room, using floor (mobile), wall, ceiling germicidal UV lamp
In germicidal lamps to disinfect the air in the operating room can be used aerosols bactericidal substances sprayed with a special device type “Dezinfal” as bactericides using a mixture containing 3% hydrogen peroxide and 0.5% lactic acid. Cuts should be made before, at least – not less than 2 h before surgery.
Warning – air pollution in the operating achieved mechanical ventilation system carried out by feeding air from outdoors or through its recycling, With tidal ventilation air is blown through the filters in the operating room. Together with the dust that settles on the filters, settle and microbes. The air coming out of the operating room through natural cracks. This direction of flow prevents penetration of air pollution from neighboring operating rooms, including surgical departments. In the absence of a centralized system of air purification from dust and germs can be used special mobile air purifier (Vopr-1, 5). For 15 minutes of the apparatus of microbes in the operating reduced 7-10 times.
To perform certain procedures (such as organ transplantation, which requires further use of immunosuppressive drugs, prosthesis implantation, surgery for extensive burns) use operating with laminar flow sterile conditioned air (Fig. 2). Number of microorganisms in these operating ten times lower than conventional air conditioning system. Laminar flow ensures an hour 500-fold air exchange, which is injected under pressure 0.2-0.3 atm through a special filter, which is the ceiling of the operating room, and out through the holes in the floor. This creates a continuous vertical flow: a sterile operating incoming air, and directed his stream carries bacteria that get into the air from the patient or from people involved in the operation. Laminar air flow can be both vertical and horizontal.
Fig. 2. Operating with laminar air movement.
I – filter 2 – air flow, 3 – fan, 4 – to filter, 5 – hole of the external air, 6 – perforated floor.
In older operating possible to install special Boxing-insulator with laminar air flow: wall box made of plastic or glass do not reach the floor, and pumped through the filter ceiling sterile air creates a vertical laminar flow, which replaces the existing air in the box in the gap that formed between its walls and floor (Fig. 3).
Fig. 3. Boxing-isolator with laminar air flow, install in the operating room.
Anti-microbial resistance in the stages of wound infection
To prevent contact infectioeed to be sterile everything. Honour faces wound. This is achieved by special processing operating linen, dressings and sutures, gloves, tools. treatment of hand surgery and operational scratch. Sterilization (sterifix – sterile) – full exemption from microorganisms of all items, solutions and materials. Disinfection involves the destruction of pathogenic microbial flora. Sterilization suture material aimed at preventing a contact and implants infected wounds.
Sterilization of instruments, dressings and linen includes the following basic tenets: 1 – presterilization preparing material: II – laying and preparation for sterilization: III – Sterilization: IV – Storage of sterile material. All these steps are performed in accordance with industry standard “Sterilization and disinfection of medical devices.”
Sterilization of instruments.
Stage I presterilization preparing. Its goal – a thorough mechanical cleaning tools, syringes, injectioeedles, transfusion systems, removal of pyrogenic substances and destroy hepatitis B virus. Staff should work in rubber gloves.
Used, but not infected instruments thoroughly washed under running water brushes in a separate bowl for 5 minutes (instruments contaminated with blood, wash immediately, avoiding drying blood) and then soaked for 15-20 minutes in one of the special cleaning solutions, heated to 50 ° C. Syringes handle disassembled.
Composition cleaning solutions: solution A – peryhidrol ’20 detergent (like “News”, “Progress”, “knave” and others.)
After soaking instruments are washed in the same solution ruff, brushes (carefully cultivated locks, cloves, notches), then for 5 min, rinsed with warm water and within minutes washed in distilled water. Then the tools and syringes placed in dry heat sterilizer at 85 ° C for drying, after which they are ready for sterilization.
Instruments and needles contaminated with pus or intestinal contents in advance placed in enameled container with 0.1% solution diocidum or 5% Lysol solution for 30 min. Then in the same solution to wash ruff, brushes, rinse under running water and immersed in one of the cleaning solutions, carrying out further processing by the method described above.
Instruments after the operation carried out in patients with anaerobic infection, soaked for 1 hour in a special solution consisting of 6% hydrogen peroxide and 0.5% solution of detergent (washing powder), then wash the brush in the same solution and hot water boiled for 90 min. Only then prepare instruments for sterilization as well as not infected tools. After I day (time for germination of spores) they are subjected to autoclaving or boiling.
Needle, injecting needles after use washed using a syringe with warm hollow, and 1% sodium bicarbonate, needle washed with 0.5% solution of ammonia. Then the needle boil for 30 minutes. in 2% sodium bicarbonate, and after 8-12 hours. – Again one that distilled water for 40 min and dried, then dried needles rope by blowing ether or alcohol using a syringe or rubber bulb. Needles contaminated with manure, thoroughly washed, rinsed them lumen running water, then placed on I h in 5% solution of Lysol, Lysol additional rinsing channel using a syringe or rubber bulb, and subjected to further processing the same as not contaminated manure needle.
Systems for transfusion of blood or drugs require careful handling to prevent posttransfusion reactions and complications. In modern terms used single system for transfusion, sterilized at the factory. System is reusable immediately after blood transfusion or drug) drug dismantled – separated glass parts, rubber dropper and stove. thoroughly washed with running water, stretching fingers rubber tube (for better removal of residual blood). Parts of the system is lowered by 2 h. heated at 60 ° C special solution containing 1% sodium bicarbonate and 1% solution of ammonia. Then part of the system is washed with running water and boiled in water, distilled, 30 min, again washed with water, stretching rubber tube, and re-boiled for 20 minutes in distilled water. After this system mounted and packaged for sterilization.
Rubber gloves. Recently, more likely to use gloves single use, sterilized at the factory. If necessary, re-use gloves, contaminated blood, washed, without removing the hands. running water to completely remove blood, dried with a towel and placed for 30 minutes in a 0.5% solution of ammonia or detergent solution (A or B). Then wash thoroughly under running water, hang to dry on a rope, and then packaged for sterilization.
Rubber gloves are contaminated with pus or intestinal contents, be destroyed. In extreme need them washed in running water and put in the washing solution for 45 min, then – in 5% Lysol solution for 30 min. washed in a solution of Lysol, rinse under running water and packaged for sterilization. These gloves can be used for operation in purulent dressings.
To complete the removal of blood from the subject, passed presterilization processing, use benzidin test: the subject put 3 drops of 1% solution of benzidine and hydrogen peroxide. The occurrence of blue-green color indicates the traces of blood left on the subjects. In that case required re-treatment.
Stage II to sterilize instruments in dryheat sterilizers placed in metal boxes, stacking them vertically in a single layer. Syringes disassembled wrapped in 2 layers of special thick paper. Covers of boxes sterilized along. Lately, mainly used syringes single use, sterilized at the factory.
For steam sterilization under pressure in steam sterilizers (autoclaves) tools wrapped in a towel or cotton cloth on the type of package and placed on a metal grid or complete. For certain common operations toolkit prepared in advance ( operations on the lungs, heart, bones, blood vessels), put on a special grid and wrapped in a sheet as a package.
The cylinder and piston syringe placed separately in gauze napkins and wrapped in a piece of cotton fabric in a package that is placed in a sterilization box (biks). When the mass sterilization of syringes in autoclaves (centralized sterilization) use special styling, sewn from cotton fabric with pockets. In the pocket is placed syringes disassembled along – needles and tweezers. Each packing contains up to 5 syringes. Boxes wrapped in cotton diapers in a package and placed in the sterilizer.
Powdered latex gloves lace talc (outside and inside), teach gauze pairs wrapped in cloth and placed in a separate biks.
Assembled system for blood tested for strength rubber tubes, the density of their connections with glass detail and matching pavilions cannula needle. System roll into a 3-2 rings, avoiding inflection rubber tubes wrapped in a large gauze and then – towel and lay in a sterilization box.
Stage III – sterilization. Sterilization instruments, syringes (with a mark on the syringe 200 ° C), needles, glassware made in dry heat sterilizers (Fig. 4). Subjects freely placed on the shelves sterilizer in metal boxes (with cover removed) and include heating. When you open the door brought the temperature to 80-85 ° C for 30 min. dried – remove the moisture from the inner surfaces of cabinets and items sterilized. Then the door closed, bring the temperature to the desired (80 ° C), supporting it automatically, and sterilized for 60 min. After switching off the heating system and reduce the temperature to 70-50 ° C open door sterilizer and sterile instrument close lid metal box with tools. After 15-20 minutes. (After complete cooling sterilizer) camera unloaded.
Fig.4. Dry heat sterilizer
When working with dryheat sterilizer must comply with security measures: the machine must be grounded, after sterilization should open oven door only when the temperature drops to 70-50 sec. Do not use a defective machine.
Sterilization instruments, syringes, blood transfusion systems can be performed in a steam sterilizer (autoclave) (Fig. 5). Packaged items are placed in the sterilization chamber (drum). Seli package enclosed in sterilization chamber, their lattice wine was opened. Drum or other packing placed loosely to couple distributed evenly.
Surgical instruments and syringes sterilized for 20 min. at 2atm corresponding temperature 132,9 ° C. Time to start counting sterilization after achieving an appropriate pressure. Rubber gloves system for blood transfusion, rubber drainage tubes are sterilized at 1.1 atm (steam temperature of 120 ° C) for 45 min. When unloading the autoclave cover the hole in sterilization chamber.
Fig. 5. Steam sterilizer (autoclave).
a – side view, b – front view; I – thermometer, 2 gauge, 3 – heat source, 4 introductory valve, 5 – exhaust valve, 6 outer wall of the sterilizer, 7 – inner wall sterilizer. I atm = 1.013 105 Pa.
Methods of sterilization in steam sterilizers, dry heat and should be regarded as basic. Boiling method of sterilization used in small hospitals where there is no centralized sterilization. Use stationary or portable electric boilers, which can sterilize instruments, syringes, needles, pieces from glass, rubber drains, catheters, gloves.
In kettle pour distilled water to raise the boiling point of water and the destruction of bacteria added
Tools disassembled placed on a special grid and lower hooks on the bottom of the kettle, leaving the handle hooks outside, and close the heater cover. Sterilization time – 40 minutes after boiling oxen. After sterilization mesh with the tools i pull hooks, bark drain and transfer to a special table covered with a sterile sheet, folded in 4 layers. Operating sister lays tools on a large operating table.
Syringes and needles are sterilized separately from the tools, disassembled (boiling in distilled water without adding sodium bicarbonate), 45 min. Syringes and needles day lumbar puncture and intravenous infusions boiled in water twice distilled without adding sodium bicarbonate.
Instruments, syringes and needles contaminated with pus, stool, after special pretreatment sterilized by boiling for 90 min. in a separate boiler.
Instruments, syringes and needles used in patients with gas gangrene, be diligent treatment and subsequent fractional sterilization by boiling. They boiled for I h., Extracted from the boiler and leave at room temperature for 12-24 h. (For germination of spores), and then re-sterilized by boiling for 1 h. (Fractional sterilization).
The basic method of sterilization of rubber (drains, catheters, gloves) – autoclaving. In exceptional cases, they are subjected to boiling for 15 min.
Fig. 6. Camera for gas sterilization.
Sterilization of instruments and objects that are not subject to heat treatment (endoscopes, torakoskopes, laparoscopes, instruments or apparatus blocks for artificial circulation, hemosorption), carry a special gas sterilizer GPA-250. The items to be sterilized, placed in sealed sterilization chamber (Fig. 6). Exposure time – 16 hours. at 18O C Sterilization can also be a mixture of ethylene oxide and methylene bromide at a temperature of 55o C for 6 h.
Sterilization of instruments and optical devices (laparoscopes, torakoskopes) can be carried out in alcoholic solution of chlorhexidine and pervomur. With such sterilization (chemicals) used metal boxes with lids, which prevents evaporation of the drug and air pollution areas in the absence of special dishes using an enamel or glass. Tools pour solution (so that it completely covers them) and close the lid.
In cases of emergency wheo sterilization of instruments in any of these ways, using the method of firing. In a metal bowl or tray pour 15-20 ml. alcohol, several tools are placed on the bottom and pour alcohol. The method is not reliable burning, fire and explosive (the presence of oxygen, steam narcotic gases in the air indoors), so it resorted to in exceptional cases, strictly observing fire safety measures.
Cutting tools (scalpels, scissors) with conventional methods of sterilization are not sharp because it is conducted almost without heat treatment. After preparing to sterilize instruments immersed in 96% ethanol for 30 min. or triple the solution for 3 h. Allowed only a short boiling cutting tools. Scalpels are placed in a separate grid, their blades wrapped in gauze and boil without adding sodium bicarbonate for 40 min. then placed in 46% ethanol for 30 min.
Stage IV sterile material storage. Sterile material is stored in a special room. Should not be kept in the same room sterile and sterile materials. Sterility material in drums (if not opened) stored for 48 h. If the materials were placed in a linen package (towels, prostyni, diapers) and for sterilization enclosed in drums ( systems for blood transfusion, rubber drains, syringes). they can be stored in these drums to 3 days. With centralized sterilization syringes retain sterility within 25 days.
Sterilization of dressings, operating underwear stage I – before sterilization training material. By dressings include gauze balls, napkins. tampons, turundas, bandages. Apply them during surgery and bandaging for draining wounds, stop bleeding or tamponade for draining wounds. Dressings prepared with gauze and cotton, at least – with viscose and lignin. He must possess the following properties:
1) to be biologically and chemically intact, has no negative impact on the healing process;
2) have good water absorbency:
3) be minimally loose as threads separated, may remain in the wound as a foreign body;
4) be soft, pliable, not injure tissue;
5) easily sterilized and not losing their properties;
6) be cheap to manufacture (including large consumption of material). The rate of year on I surgical bed –
Dressings prepared with gauze, which previously cut into pieces. Marla up, pidkruchuyuchy edges inward to avoid free edge. Material prepare for the future, adding to its reserves as spending. For ease of calculation spent th operation of its material placed before sterilization in some way: balls-in gauze bags on 50-1000 pieces, napkins – in connection with 10 pieces. Dressings, bandages but not contaminated with blood, after applying burn.
By operating underwear include surgical gowns, bedsheets, towels, masks, caps, shoe covers. Materials for their production are cotton fabric – calico, canvas. Operating underwear reusable should have a custom label and seem to wash separately from other laundry in special bags. In robes should not be pockets, belts, sheets should be filed away. Dressing, prostyni, diapers, towels for sterilization are in the form of rolls, so they could easily be turned around when in use.
Stage II – Bearings and training material for sterilization. Dressings and operating laundry placed in sterilization chamber (Fig. 7). In the absence sterilization chamber allowed sterilization in linen bags.
Fig.7. Sterilization chamber.
When universal conclusion in sterilization chamber (bag) stir material intended for one small typical operation (appendectomy, herniotomy, flebektomy et al.). At the conclusion of purposeful sterilization chamber (bag) provide the necessary set dressings and operating laundry before designated for specific operations (pulmonectomy, resection of the stomach and so on.). At the conclusion of the species in sterilization chamber placed certain type dressings or linen (drum with bathrobes, drum with napkins drum with balls, etc.).
First check serviceability sterilization chamber, then stir deployed its bottom sheet, the ends of which are outside. Dressings are placed vertically in sectors bundles or packages. Material placed loosely to provide access pair is placed inside the sterilization indicators mode (maximum thermometers, fusible substance or test tube with the test microbe), edge sheets wrapped, drum close lid. To cover sterilization chamber affix card of cloth with date of sterilization and family who made it.
When sterilization in the bag dressings or linen placed loosely, bag tied laces, dipped it in drum. If necessary, use the material bag stir on a stool, nurse solves top bag, separates the edges and moves downward. Operating sister unleashes inner bag sterile hands, opens it and takes out the material.
Stage III – sterilization. Handling the autoclave is allowed only with a permit inspections with a mark in the passport system, to work with the autoclave allowed the person who passed the minimum technical manual in the autoclave and had a permit. Working with autoclave requires the precision of the instruction manual apparatus. You must comply with the general safety rules.
– Necessarily ground steam sterilizer with electric heating;
– Do not start work on the defective unit;
– During not leave the machine unattended;
– Do not fill up the water during the sterilizer;
– After sterilization disconnect the heater from the mains and valve cover inlet steam sterilization chamber with pairform;
– Open the lid sterilization chamber only after the needle gauge drops to zero.
The countdown begins sterilization after reaching the set pressure. Dressings and operating underwear sterilized for 20 min. at a pressure of 2 atm. (temperature of 132,9 ° C).
Stage IV – Storage of sterile material After sterilization, drums removed, immediately close the play and carry them on a special table for sterile material. Drums stored in cabinets locked in a special room. Allowable storage time dressings and linen if drum not revealed – 48 hours. since the end of sterilization. Dressings and linen, sterilized in bags, store up to 24 hours.
Control of sterility
Control of sterility of the material and mode of sterilization in autoclaves made direct and indirect ways. Direct method – bacteriological, sowing with dressings and laundry or use of bacteriological tests. Planting is carried out as follows: in the operating reveal biks, small pieces of gauze moistened isotonic sodium chloride, repeatedly spend on underwear, then pieces of gauze dipped in a test tube, which is sent to the bacteriological laboratory.
For bacteriological tests using tubes with known spore-forming pathogenic bacterial cultures are dying at a certain temperature. The tubes are placed inside biksa, and after sterilization is extracted and sent to the laboratory. Absence of growth indicates sterility microbial material. This test is carried out every 10 days.
Indirect ways to control sterility of the material used constantly at each sterilization. This use of certain substances melting point: benzoic acid (120 ° C). resorption (119 ° C), antipyrine (110 ° C). These substances are produced in capsules. They are also used in test tubes (
Objective of the indirect methods of control mode of sterilization is thermometry. In each sterilization chamber between material that is sterilized, put I -2 thermometer. These figures reflect the maximum temperature, but do not indicate the exposure time (during which period the temperature was maintained at drum), and therefore this method does not exclude the direct control of sterility using bacteriological tests.
Sterilization apparatus for inhalation anesthesia
Apparatus for mechanical ventilation and inhalation anesthesia can cause cross-infection of patients and distribution of nosocomial inspection. Infection with respiratory patients is fraught with the development of postoperative inflammatory complications, pneumonia, bronchitis, tracheitis, pharyngitis. In this regard, disinfecting anesthesia and respiratory equipment – one of the important measures asepsis, aimed at preventing contact and inhalation infection of the respiratory tract of the patient.
To prevent such complications should perform the following basic recommendations.
1. Endotracheal tube should be single use sterilization to be carried out in a cold way to the factory.
2. After anesthesia of mechanical ventilation devices, respiratory circuit elements are processed antiseptic chemicals. Devices processed in assembled form. Can be used 0.5% alcoholic solution of chlorhexidine bigluconate: 1 ml. 20% aqueous chlorhexidine dissolved in 40 ml. 96% ethanol. The mixture is poured into the evaporator or humidifier anesthesia apparatus for artificial ventilation. Ventilation is carried out by semi-enclosed loop for I h. at speed gas outflow
As an antiseptic in such situations, you can use 40% aqueous solution of formaldehyde (formatin). For this evaporator or humidifier instigate 100 ml. formalin and spend ventilation for 20 min. Then remove the remnants of formalin, pour a solution of ammonia and continue ventilation until complete disappearance of the smell of ammonia.
For sterilization apparatus assembled applicable gas metol (using ethylene oxide) or UV irradiation.
3. If the devices are used in patients with purulent diseases, tuberculosis lung or airway spend disassembly respiratory circuit
(Remove the hose, connecting elements, valve cover boxes, respiratory accurate, adsorbers). All parts must wash under running warm water, then soaked in a hot detergent solution L or B (see Sterilization instruments) for 15 min., In the same solution every detail washed cotton-gauze pad for 30 min. Then rinsed running, and then with distilled water. Actually sterilization processing components spend 0.5% aqueous chlorhexidine, placing them in a capacity for 311 min. or 3% hydrogen peroxide solution (80 min.), or 3% solution of formaldehyde (30 min.). In the latter case, when infected with Micobacterium tuberculosis exposure increased to 90 min. The best option – use in such situations, plastic hoses, masks, disposable.
After treatment with antiseptics flew thoroughly washed with sterile water for 10 min. dried, and stored under aseptic conditions for use.
Sterilization of endoscopic equipment
The problem of infection in endoscopy is crucial due to the risk “of infection of patients and staff virulent microorganisms.
The main stages of sterilization of endoscopic instruments and tools is their mechanical cleaning, washing, presterilization processing and sterilization, drying and storage.
To clean endoscopes using solution A or B (see Sterilization instruments).
After endoscopy with the endoscope immediately remove contamination (gastric, intestinal juice, reduce, blood, etc.). Mechanically using detergents (solution A or B): from the outer surface with cloth napkins, with channels (biopsy, surgical) – a special brush, and by submitting them enough air, water or a solution of neutral soap, hard endoscope disassembled before cleaning.
For processing endoscopes using 0.5% aqueous or alcoholic solution of chlorhexidine bigluconate, 70% ethanol, 2.5% solution of aldehyde drug “Saydeks”, 3% and 6% solution of hydrogen peroxide at a temperature of 20 + -2 ° C.
Besides immersion method may also 3x wipes clean the outer surface of the working part of the endoscope (sequentially, first one cloth dipped heavily in an antiseptic solution, then, after filling channel endoscope solution for 15 min. – Another and a third).
Parts of the endoscope handle antiseptic solutions by immersion in an enamel or glass container, cover, just parts dipped rigid endoscopes (except optical instruments and parts flexible parts fibroendoskopes). In recent years there have beeew, so-called over tight fibroskopiv model that can be completely immersed in an antiseptic solution. Channels filled with a solution with a syringe or electric pumps.
Designed specifically for install presterilization cleaning and sterilization of flexible endoscopes, which differ in volume disinfectant that is poured into a special bath.
Remains of antiseptics removed from endoscopic equipment through one distilled oxen, passing it through the channels of the endoscope and washing it out. Then, by repeated air supply through the endoscope channels remove excess water.
Sterilization of endoscopic equipment can be carried in the chamber for gas sterilization using ethylene oxide or mixtures of ethylene oxide and methylene bromide.
Endoscope placed in sterile bags with thick cotton stored upright in special cabinets.
Preparation hands before operation
Preparation of hands – an important means of preventing contact infection. Surgeons, surgical dressings and sisters must constantly worry about the cleanliness of hands to care for the skin and nails. The greatest number of microorganisms accumulate under the nail, iail ridges, cracks in the skin. Hands care involves preventing cracks and calluses, trimming of nails (they must be short), deburring. The work associated with contamination and infection skin, need to take the gloves. Proper hand care should be seen as a step in preparing them for surgery. Scrubbing any way begins with mechanical treatment.
The classic way to handle arms are ways Fyurbrinhera, Alfeld. Spasokukotsky-Kochergina. Ways Fyurbrinhera, Alfeld have only historical significance. Method Spasokukotsky-Kochergina can be used as forced as it is not possible to apply modern methods. The method involves mechanical cleaning hands 0.596 solution of ammonia. Hand wash basins in 2 to 3 minutes. cloth; consistently perform movements as when washing brush, starting with fingers of his left hand. In the 1st wash hand basin to the elbows, in the 2nd – to the border of the upper and middle thirds of the forearm. After washing hands opoliskuyut solution of ammonia and hands lifted up, so that drops of water trickled down to the elbows. Leather Hand dried with sterile towels, first both hands (this napkin throw), then successively lower and middle third of the forearm.
Skin disinfectant wipes moistened with 96% alcohol, treating twice for 2-5 min. hands and lower third of the forearm, then – the ends of the fingers and nail ridges, nail bed and skin folds fingers smeared with 5% alcoholic solution of iodine.
Modern methods of treatment involving their hands clean by washing with soap and running water or with liquid detergent and further processing of chemical antiseptics.
Scrubbing pervomur (preparation C-4), Pervomur – a mixture consisting of formic acid and hydrogen peroxide. First prepare the main solution comprising 81 ml. 85% formic acid and 171 ml. 33% solution of hydrogen peroxide. These parts are mixed in a glass bottle with a ground glass stopper and transferred in the refrigerator for 2 hours., Occasionally shaking the bottle. The interaction of formic acid and hydrogen peroxide is formed pervomur, which has a strong bactericidal effect. With the number of basic solution can be prepared
Scrubbing with chlorhexidine bigluconate. Available in a 20% aqueous solution. To handle hands prepared 0.5% alcohol solution: to 500 ml. 70% alcohol is added 12.5 ml. 20% solution of chlorhexidine bigluconate. Pre wash their hands with soap and running water, dried with sterile towels or towel, and then within 2-3 minutes. rubbed with a gauze pad soaked prepared solution.
Scrubbing agents AHD, evrosept. These products contain preservatives such as ethanol, chlorhexidine. A few milliliters of the solution was poured on her hands and rubbed into the skin of the hand to the middle third of the forearm twice for 2-3 min.
Accelerated processing techniques hands used in ambulatory practice or internally ( military field) conditions. For rapid disinfection of hands using film-forming gel, featuring a strong bactericidal effect. It consists polivinilbutrol and 96% ethyl alcohol. Hand wash with soap and water and thoroughly dried. On hand pour 3-4 ml tseryhelyu thoroughly for 10 minutes with wet their finger nail bed and cushions, hand and lower forearm. Bent fingers are kept in diluted position for 2-3 minutes until the skin is formed film cerigel possessing protective and antibacterial properties. After surgery film is easily removed with gauze balls soaked with alcohol.
Scrubbing can be done by rubbing the skin 96% ethanol for 10 min (method Bruna) for 3 min or 2% alcohol solution of iodine.
Preparation of the operative field
Previous training is intended operating section (operating margins) starts before the operation and includes general hygienic bath, change clothes. On the day of surgery is performed shave dry place directly in the operational access, then wipe the skin with alcohol.
Before the surgery on the operating table field operations are widely smeared 5% alcoholic solution of iodine. Immediately place the operation isolated sterile linens and again smeared with 5% alcoholic solution of iodine. Before and after the imposition of suturing the skin it is treated the same alcoholic solution. This method is known as a way Hrossiha-Filonchykova. To handle surgical field using such iodine as iodonat, Betadine.
When intolerance iodine skin in adults and children processing operating field spend 1% alcoholic solution of brilliant green (Bakkal way).
To handle surgical field using 0.5% alcohol solution hibitan (chlorhexidine bigluconate), as well as for treatment of hand surgery before the operation.
In emergency operations training surgical field is shaving hair, skin treatment 0.5% solution of ammonia, and then one of the methods described above.
INFECTION PREVENTION OF WOUNDS
Infection by air or by contact caused by short-term action while executing certain surgical procedures (ligation, surgery, medical manipulation, diagnostic methods). When entering the microflora of materials (grafting infected organism) that are implanted, it is in the human body during your stay implant. Last, as a foreign body, supports the inflammatory process develops, and treatment of this complication will be unsuccessful until, at least until rejection or removal of the implant (ligatures, prosthesis, body). Possible from the very beginning (through the formation of a connective tissue capsule) isolation of microorganisms with the formation of an implant infection “dormant”, which can be after a long time (three months, years).
To materials that are implanted in the human body include suture, metal clips, brackets, and vascular prostheses, joints, fabric with polyester, nylon and other materials, human and animal tissues (blood vessels, bone, dura mater, skin) organs (kidney, liver, pancreas, etc.)., drains, catheters, shunts, coffee filters, vascular spiral and others.
All implants must be sterile. Sterilization was carried them in different ways (depending on the type of material), but with the following conditions: UV irradiation, autoclaving, chemical, gas sterilization, boiling. Many dentures come in special packaging, sterilized at the factory UV irradiation.
Most important in causing implantation infection has suture. There are more than 40 types. For connecting tissue during surgery using threads of different origin, metal clips, brackets.
Apply thread as the absorbable and non-absorbable. Natural fibers that dissolve are strings of catgut. Extension of shelf dispersal catgut achieved impregnation threads metals (chrome, silver catgut). Use sinthetic fibers that dissolve with Dekson, Vickrey, oktsilon and others. To those that are non-absorbable threads of silk, cotton, horsehair, flax, to synthetic – strands of nilon, poliester, Dacron, nilon, ftorlon and others.
For sewing fabrics used atraumatic suture. He is a seam thread, pressed into the needle, so when puncturing tissues, carrying it through the punctured channel fabric not injured..
Suture material must meet the following basic requirements:
1) have a smooth, flat surface and cause a puncture in additional tissue damage;
2) manipulator possess properties – good glide in the tissues, be flexible (enough extensibility warns of davlennya and tissue necrosis at their rising edema);
3) be strong in the node, do not have hygroscopic properties and swell;
4) be biologically compatible with living tissues and cause an allergic reaction in the body;
5) the destruction of threads should coincide with the timing of wound healing.
Suppuration of wounds is much less when using sutures that have antimicrobial activity due to their structure imposed antimicrobials (letylan-polyester, ftorlonovi, acetate and other threads, nitrofuran drugs that contain antibiotics, etc.). Synthetic filament containing antiischemic the means have all the benefits such as sutures and at the same time provide antibacterial activity.
Suture material is sterilized at the factory. Atraumatic suture material produced and sterilized in special packaging, the usual stuff – in ampoules. Atraumatic thread in packaging and ampouling skeins of silk, catgut, nylon stored at room temperature and use as needed. Metallic suture material (wire, brackets) are sterilized in an autoclave or by boiling, linen or cotton thread, from polyester, nylon – in an autoclave. Silk, nylon, polyester, linen, cotton can be sterilized by the method of Kocher. This is a forced method, and it provides a thorough mechanical cleaning suture material with hot soapy water. Coils are washed in soapy water for 10 min., Changing the water twice, then washed free of detergent, dry sterile towel and wound on a special glass coil, which is transferred into jars with ground glass stopper and pour ether for 24 h. for degreasing, and then translated into banks with 70% alcohol for the same period. After extraction with alcohol silk boil for 10-20 minutes. in a solution of mercuric chloride 1:1000 and shift in airtight jars, closing with 90% alcohol. After 2 days of conducting bacteriological control, with a negative result of planting material is ready for use. Synthetic filament can be sterilized by boiling for 30 min.
Sterilization of catgut. Heat treatment catgut does not apply in the factory it is sterilized UV rays; basically just such yarns are used in surgery. However, you can sterilize catgut in a hospital setting. Sterilization of catgut chemical means involves a preliminary degreasing, which rolled rings catgut strings moving in jars hermetically sealed with ether for 24 hours. When sterilization by Kdaudius air from the jar drained and flooded the ring suture 10 day aqueous iodine (iodine net –
Gubarev method involves sterilization of catgut alcoholic solution of iodine (pure iodine and potassium iodide –
Sterilization prosthesis designs sutures. The method of sterilization in a hospital determined by the type of material from which the implant is made. Yes, metal structures (paper clips, brackets, wires, plates, pins, screws, spokes) sterilized at high temperature and dry heat closet autoclave, boiling (if not cutting surgical instruments). Prostheses complex structures consisting of metal, plastic (heart valves, joints), sterilized by chemical antiseptics (eg, chlorhexidine) or gas sterilizers.
Prophylactic implantation of infection in organ and tissue transplantation involves taking organs under sterile conditions, ie close to the operational work. Careful adherence to aseptic thus involves the preparation of hands and clothes surgeons sterile operating underwear, processing surgical field, sterilization of instruments, etc. The body was taken under sterile conditions (after washing it with sterile solution, and if necessary, washing the blood vessels and ducts – from biological fluids), stir in a special sterile sealed container, coated with ice, and transported to the site of transplantation.
Prostheses of polyester, nylon and other synthetic materials (vessels, heart valves, mesh to strengthen the abdominal wall during herniotomy etc.). Sterilized by boiling or placing them in antiseptic solutions. Prostheses, sterilized in an antiseptic solution should be thoroughly washed with sterile isotonic sodium chloride solution before implanting them in humans.
Hospital infection
Hospital or nosocomial infection raises the frequency of complications of diseases or operations of which is associated with infection of patients in the surgical hospital.
The original source of infection – patients with purulent diseases.
Microorganisms through objects, air, laundry in the surgical patient can move from one patient to another. Frequent aureus, Escherichia coli, Proteus, synehniyna coli. Microbial flora is highly resistant to antibacterial agents. In frail operated patients this flora can cause the development of septic complications. Infection is possible with both exogenous and endogenous sources of where nosocomial flora came before: nasopharynx, pharynx, the skin of the patient. Perhaps the development of mass illness (complications) – an outbreak of hospital infection.
To combat this infection are important organizational measures: strict sanitary treatment department: closing offices thorough sanitization during outbreaks of infection: shortening the pre-and postoperative patients stay in hospital; rational antibiotic therapy (changing antibacterials, bacteriological monitoring of the therapy ), using combined methods of antisepsis, the use of closed drainage techniques, and others.
The problem of AIDS in surgery
Distribution of AIDS among the population threatens contamination of surgical personnel of hospitals in contact with the blood of infected patients during operations, dressings, injections, injections, punctures, taking blood samples, the diagnostic procedures and others.
Preventive measures include early identification of infected patients, for which all patients surgical hospitals examined for AIDS. In order to identify and isolate patients. Clinical examination included such manifestations of disease, such as pneumonia, Kaposi’s sarcoma, the presence of immune deficiency, diarrhea, weight loss, candidiasis of the respiratory tract. Emergency blood analysis for AIDS antigen to confirm or reject the diagnosis of patients in this group.
Important for prevention has been widely used syringes, instruments, systems for intravenous infusion disposables.
Antisepsis
There are mechanical, physical, chemical and biological antiseptics.
Mechanical antiseptic
The basis of mechanical antiseptics is the removal of infected, festering wounds, purulent focus nonviable tissue, pus, fibrin, which is the habitat and nutrition microbial flora. We know that healthy tissue is not damaged under septic organisms and does not contain it. Removing gangrenous tissues, although there is not a direct and indirect effect on the microflora contributes to sterilize wounds.
Options include mechanical antiseptics primary surgical treatment of infected wounds, which aims excision edges, sides and bottom of the wound within healthy tissue. However dissected tissues removed from the wound bleeding, bruising, blood clots, foreign microbody and microflora that is in them. The earlier performed such an operation, the more likely to achieve sterility of the wound.
If the infected wound began to multiply microbial flora, possibly at late or incomplete primary surgical treatment, or a wound from the outset is purulent character (after opening the abscess, phlegmon) used secondary surgical treatment of wounds. Excision edges, sides, bottom of the wound does not hold, and removed from it by mechanical means (scalpel, scissors, vacuuming, washing liquid stream under pressure) necrotic tissue, pus, fibrin, reveal pus pocket. It also removes microbial flora and although sterility wounds caot achieve the number of microorganisms in it decreases and creates favorable conditions for wound healing.
Any wound dressing is mechanical elements antiseptics. Remove soaked with blood, pus bandages, swabs, wound lavage fluid jet, lying freely remove necrotic tissue sequestration, dry wound balls and swabs help remove it from the microbial flora, the amount of which decreases by 10-20 times.
Physical antiseptic
Methods of physical antiseptics based on the use of the laws of capillarity, water absorption, diffusion, osmosis of laser UV.
Draining wounds, purulent lesions (abscesses) establishes conditions for the outflow backpack contents into the environment (in the bandage, special dishes with antiseptic solutions). As drainage in the treatment of wounds used gauze swabs. Swabs in various sizes made from strips of gauze and loosely injected into the wound, due to its hygroscopic tampon absorbs blood, fluid, pus. Draining properties last up to 8 hours., Then it can become a “cap” that clogs the wound and that violates the outflow of fluid from the wound. To improve draining properties dressings, swabs moistened with hypertonic (5-10%), sodium chloride, and helps create high osmotic pressure, which increases the outflow of fluid from the wound in a bandage.
In addition to regular tampon used tampon Mikulycha, injected a large wound in gauze and thread sewn to its middle. Cloth placed at the bottom and the walls of the wound, forming a “bridge”, which is filled with gauze. When tampons impregnated wound content are removed, leaving the gauze-free cavity is filled with new tampon. Tampons are changed several times to stop the outflow of pus, and then pulling at the thread and remove the cloth.
Drainage can be performed with rubber, polyhlorviniles and other tubes of different diameters, which are inserted into the wound cavity abscess, joint (with septic arthritis), pleura (with purulent pleurisy), the abdominal cavity (with purulent peritonitis). Manure, which formed tissue breakdown products, and with them the germs one or more drainage allocated in a bandage.
After draining the wound or purulent cavity injected chemical antiseptics, antibiotics, enzymes.
For a more active washing wounds and purulent cavities in them (except for drainage outflow wound content) insert another tube and on it injected an antibacterial agent, with whom decomposition products of tissue, blood and fibrin isolated from wounds by drainage (Fig. 8). Thus, the combined methods of physical and chemical antiseptics, creating conditions for flow-flushing drainage. This method is also used in the treatment of purulent pleurisy and peritonitis. To improve the efficiency of the method as a washing solution using proteolytic enzymes that promote faster melting nonviable tissue. (Enzymatic method flow dialysis).
Fig 8. Cleansing drainage (E), active aspiration of the wound (b)
If drained cavity is sealed (wound sewn seams, empyema, suppurative arthritis, abscess cavity), apply active aspiration (vacuum drainage). Dilution and drainage can be created using a syringe Janet, which removes air from airtight cans connected to the drainage, or by using suction or three cupping waterjet system.
Fig. 9. Device for treatment of wounds in abacterial environment.
1 – input filter, 2 compressor 3 – bacterial filter, 4 – duct, 5 – insulator (camera), 6 – Castle prison.
This is the most effective method of drainage, it also reduces cavity wounds, most of its closure and the elimination of inflammation, and with pleural empyema – smoothing exudate pull your lungs.
Bactericidal effect provides low frequency ultrasound. In liquid medium (wound closed cavity) ultrasound shows the physical and chemical properties. In an environment that was subjected to ultrasonic action creates the effect of cavitation – a shock wave in the form of short pulses with the formation of cavitation bubbles. Simultaneously, under the influence of ultrasound ionization of water to form ions under the influence of which microbial cells suspended in redox processes. Ultrasonic cavitation is used for treatment of wounds.
Chemical antiseptics
1 – Groups haloides
Iodine – 1-5% alcohol tincture, antiseptic topical use. Used for treatment of the skin around the wound with ligation for treatment of bruises, scratches and surface wounds. It has a pronounced tannic action.
Iodine + Potassium iodide – 1% solution, “blue iodine.” Antiseptic for external application: for washing wounds, gargling throat.
2. Salts of heavy metals
Sulema – at a concentration of 1:1000 for disinfection of gloves, care items, as a step in the sterilization of silk. Currently, due to the toxicity of its almost not apply.
Oxycianid mercury – sanitizer. As the concentration of 1:10 000, 50 000 suitable for sterilization of optical instruments.
Silver nitrate – antiseptic external application. In the form of 0,1-2,0% solution used for washing the conjunctiva and mucous membranes. 5-20% solution has a pronounced effect and cautery is used for treatment of excessive granulation acceleratioavel scarring in infants and others.
Silver proteinate – antiseptic topical use, has astringent action. Used for lubricating mucous membranes, flushing the bladder with inflammation in it.
Zinc Oxide – antiseptic external application. Included in the many powders and pastes that have anti-inflammatory effect, prevents the development of skin maceration.
3. Alcohols
Ethanol – disinfectant (sterilizing suture material handling tools) and antiseptic external application (scrubbing surgeon and operating margins, at the edges of the wound dressings, for compresses, and others.). 70% alcohol has antiseptic effect, and 96% tannic.
4. Aldehydes
Formalin – 37% formaldehyde solution. Strong disinfectant. 0,5-5,0% solution used to disinfect gloves, drains, tools. Effective against echinococcus. Also used in fixation of preparations for histological examination. In the dry form suitable for sterilization in gas sterilizers, including optical instruments.
Lysol – strong disinfectant. 2% solution used to disinfect items care facilities, soak contaminated instruments. Nowadays hardly used because of the high toxicity.
5. Colorants
Brilliant green – antiseptic external application. 1-2% alcohol (or water) solution used for the treatment of superficial wounds and abrasions of the oral mucosa and skin.
Metyltioniniya chloride – an antiseptic external application. 1-2% alcohol (or water) solution is used to handle superficial wounds and abrasions of the oral mucosa and skin. 0.02% aqueous solution – for washing wounds.
6. Acids
Boric Acid – an antiseptic external application. 2-4% solution – one of the main products for washing and treatment of purulent wounds. Can be used in powder form, is a member of powders and ointments.
Salicylic Acid – an antiseptic external application. It has keratolytic action. Apply as crystals (tissue lysis), part of the powders, ointments.
7. Meadows
Ammonia – antiseptic external application. Earlier 0.5% solution used for treatment of hand surgery (method Spasokukotsky-Kochergina).
8. Oxidizing
Hydrogen peroxide – an antiseptic external application. 3% solution – the main drug for washing septic wounds with dressings. Properties: Antiseptic (active agent – atomic oxygen) hemostatics (helps stop bleeding), deodorant, causes foaming, which improves cleaning wounds. Included in the pervomura (means for processing the hands of the surgeon and surgical field). 6% solution of hydrogen peroxide – disinfectant.
Potassium permanganate – antiseptic external application. 2-5% solution is used to treat burns and bedsores (owns coagulation and tanning effect). 0,02-0,1% solution washed wounds and mucous membranes. Has a pronounced effect deodorizing.
9. Detergents (surfactants)
Chlorhexidine – antiseptic external application. 0.5% alcohol solution suitable for treatment of hand surgery and surgical field. 0.1-0.2% aqueous solution – one of the main drugs for washing wounds and mucous membranes, treatment of purulent wounds. Included in the solution for handling hands and operating field (plyvasept, Ahd-spetsyal).
10. Derivatives of nitrofuran
Nitrofural – antiseptic external application. 1:5000 solution – one of the main drugs to treat septic wounds, eye injuries and mucous membranes.
Nitrofurantoin, furazidin, furazolidone – chemotherapeutic agents, so-called “uroantiseptic” In treatment of urinary tract infections, used in the treatment of intestinal infections.
11. Derivatives of 8-oxyhinolin
Nitroxoline – chemotherapeutic agent, uroantiseptic. Apply with urinary tract infection.
Loperamide, attapulhit – chemotherapeutic agents, used in intestinal infections.
12 – Derivative hinoksalinu
Gіdroksi metilhіnoksilіndіoksid – antiseptic external application. 0.1-1.0% aqueous solution used for washing septic wounds, mucous membranes, particularly the ineffectiveness of antibiotics and other antiseptics. When sepsis and severe infections can enter and intravenously.
13. Tars, resins
Birch tar – antiseptic external application. Included as a component of the Vishnevsky ointment that is used in the treatment of purulent wounds (except antiseptic effect, stimulates growth of granulation).
14. Nitroimidazole derivatives
Metronidazole – a broad spectrum of action. Effective relatively protozoa, Bacteroides and parts of anaerobes.
15. Herbal antiseptics Hlorophilipt, ektericid, baliz, calendula – mainly used as antiseptic for external use washing superficial wounds, mucous membranes, skin treatments. Has anti-inflammatory effect.
16. Sulfonamide
Sulfonamides – chemotherapeutic agents with bacteriostatic action. Apply to inhibit various foci of infection in the body, usually tablets drugs. Is also a part of ointments and powders for external use. Tableted drugs have different duration, from 6 years to 1 day.
Antibiotics
Antibiotics – a substance that is a product of microorganisms that inhibit the growth and development of certain groups of other microorganisms. This is the most important group of pharmacological agents that are used for the treatment and prevention of surgical infection.
History of antibiotics begins in the XIX century. In
Monassein described the ability of fungi to inhibit the growth of bacteria. In 1872, AG Polotebnov reported positive results from using the mold for the treatment of purulent wounds and later II Mechnikov, exploring the phenomenon of phagocytosis, first suggested the use of saprophytic bacteria to kill pathogens.
Italian doctor B. Hozio isolated from the fungus Penicillium culture mikofenol acid that causes bacteriostatic action on anthrax. It was actually the world’s first antibiotic, but broad application had not been received. At the beginning of XX century were marked with antibiotics culture Pseudomonas aeruginosa, but their effect was unstable, volatile substances were. Then followed the “era of penicillin.”
In 1913, Americans Alsberh and Black isolated from the fungus Penicillium genus antimicrobial substance – penicillanic acid, but the production and clinical use of the drug did not happen because of World War II. In 1929, Englishman Fleming grew fungus Penicillium notalum, able to destroy streptococcus and staphylococcus, in 1940. group of scientists at
First native Penicillin was obtained in 1942 by Academician Z. Yermolyevoy of the fungus Penicillium crusrosum, whose performance was higher English.
The emergence of penicillin caused a real revolution in surgery and medicine in general. After several injections recovering patients, more recently doomed. It seems that all kinds of diseases caused by germs losers in doctors began some euphoria, but it soon became clear that many strains are resistant to penicillin, and these strains began to show more and more.
Scientists are discovering new group of antibiotics. In 1939 he received the gramicidin Dubos. In 1944 Shatts, Boogie and Waksman isolated streptomycin, thereby dramatically reduce mortality from tuberculosis. In 1947, Ehrlich received chloramphenicol. In 1952, Mack Hupre – erythromycin. In 1957 Umizava – kanamycin. In 1959 Senen – rifampicin. In 50 years in the laboratory of G. Flora was obtained first antibiotic from a fungus Cephalosporum, which began to put a large group of modern antibiotics – cephalosporins. But with all antibiotics has beeoted a similar pattern – are increasingly began to form resistant strains of these bacteria. In recent decades created new group of antibiotics, more effective in dealing with modern surgical infections (fluoroquinolones, carbapenems, glycopeptides).
The main groups of antibiotics
Below are the major groups of antibiotics. In parentheses are the mechanism and spectrum of action and possible complications.
I. Beta-lactams
1. Penicillins (inhibit cell wall synthesis, mainly broad spectrum of activity):
• semi: oxacillin, ampicillin, amoxicillin;
• Prolonged: benzathine benzylpenicillin, benzylpenicillin benzathine benzylpenicillin prokain + + benzylpenicillin, benzathine benzylpenicillin benzylpenicillin + prokain;
• Combined: ampicillin + oxacillin, amoxicillin + clavulanic acid, ampicillin – sulbactam.
Clavulanic acid and sulbactam – penicillinase inhibitors, synthesized by microorganisms.
2. Cephalosporins (violating cell wall synthesis, a wide range of actions, nephrotoxic in high doses):
• the generation cephalexin. cefazolin;
• II generation cefamandole, cefoxitin, cefaclor, cefuroxime;
• III generation ceftriaxone, cefotaxime, Cefixime, ceftazidime:
• IV generation ‘, cefepime.
3. Karbopenem (violation of cell wall synthesis, a wide range of actions):
• meropenem;
• Combined: imipenem + tselastatyn sodium Tselastatyn – enzyme inhibitor that affects the metabolism of the antibiotic in the kidneys.
4. Monobaktam (violating cell wall synthesis, a wide range of actions):
II. Other
5. Tetracycline (inhibit ribosome function microorganisms, broad spectrum of activity):
• tetracycline;
• semi: doxycycline.
6. Macrolides (violating protein synthesis in microorganisms, hepatotoxic, the effect on the gastrointestinal tract):
• erythromycin, troleandomitsin, azithromycin, clarithromycin.
7. Aminoglycosides (violating cell wall synthesis, a wide range of actions, oto-and nephrotoxic):
• the generation streptomycin, kanamycin, neomycin;
• II generation gentamicin;
• III generation tobramycin, sizomycin;
• semi: amikacin, netilmicin.
8. Chloramphenicol (violating protein synthesis in microorganisms, broad spectrum of activity, suppress hematopoiesis):
• chloramphenicol.
9. Rifampicin (violating protein synthesis in microorganisms, a wide range of actions that cause hypercoagulability, hepatotoxic):
• rifampicin.
10. Antifungal:
• levorin, nystatin, amphotericin B, fluconazole.
11. Polymyxin B (effect on Gram-negative bacteria, including Pseudomonas aeruginosa).
12. Linkozaminy (violating protein synthesis in microorganisms):
• lincomycin, clindamycin (in an anaerobic environment).
13. Fluoroquinolones:
• III generatioorfloxacin, ofloxacin, ciprofloxacin, pefloksatsina, enofloksatsyn;
• IV generation levofloxacin, sparfloxacin.
14. Glycopeptides (changing permeability and cell wall biosynthesis, RNA synthesis of bacteria, a wide range of actions have nephrotoxicity. Affect hematopoiesis):
• vancomycin, teicoplanin.
Some of the most common antibiotics – beta-lactam. In contact with these antibiotics some microorganisms begin to synthesize an enzyme that cleaves them (penicillinases, cephalosporinases or-lactamase 1, 3, 5, and so on.).
Least often bacteria synthesize these enzymes for new drugs last generations, which determines their high activity and broad spectrum of activity. In addition, antibiotics are additionally injected lactamase inhibitors (clavulanic acid, sulbactam).
In addition to the classification presented in groups, antibiotic drugs are divided into broad and narrow spectrum antibiotics.
There are antibiotics first stage, or the first row (penicillins, macrolides, aminoglycosides), the second stage or the second row (cephalosporins, semisynthetic aminoglycosides. Amoxicillin + clavulanic acid, etc..).
There are short and prolonged antibiotic action. So, to maintain bactericidal concentrations in plasma benzylpenicillin should be given every 4 h, and ceftriaxone (III generation cephalosporins) – 1 per day.
Complications of antibiotic
Antibiotic treatment and has features. First of all it is connected with the possibility of certain complications. The main complication of antibiotic therapy following:
• allergic reactions;
• toxic effects on internal organs;
• overgrowth;
• the formation of resistant strains of microorganisms. Allergic reactions may have typical symptoms: allergic rash (urticaria), angioedema, respiratory failure, bronchospasm – until the development of anaphylactic shock. The relatively high frequency of complications related to the fact that drugs are of biological origin and cause other bowls response microorganism.
Major options toxic effect on the internal organs indicated in the above diagram the major groups of antibiotics. Often disturbed hearing, kidney function and liver.
Development dysbiosis often occurs in children as well as long-term use of high doses of antibiotics, especially broad-spectrum antibiotics.
The most visible, but very unpleasant complication – the formation of resistant strains of microorganisms, which leads to inefficiency further antibiotic these pharmacological agents.
Features of antibiotic treatment associated with exposure to the type of drug, dose and duration of administration of the multiplicity of its application on the effectiveness of treatment and the possibility of complications. Not least important are the availability and cost of the drug. Classic principles of rational antibiotic therapy following:
• Use antibiotics only under strict indications.
• Designate the maximum therapeutic or, in severe infections, subtoxic dose preparations.
• Observe frequency of administration during the day to maintain a constant bactericidal drug concentrations in plasma.
• Apply antibiotic courses with a duration of 5-7 to 14 days.
• When selecting an antibiotic based on the results of sensitivity studies microflora.
• Change the antibiotic in its inefficiency.
• Consider synergism and antagonism in the appointment of a combination of antibiotics, as well as antibiotics and other antimicrobial drugs.
• When prescribing antibiotics to pay attention to the possibility of side effects and toxicity.
• To prevent complications of allergic carefully collect allergy history.
• The long-term courses of antibiotics administered antifungal drugs for the prevention of dysbiosis, and vitamins.
• Use the optimal route of administration. There is superficial (eye injuries), intracavitary (input into the chest, abdomen, joint cavity) and deep (intramuscular, intravenous, intraarterial and endolymphatic injection) antibiotics and oral way.
If the patient’s severe infection, with empirical therapy should prescribe antibiotics or a combination of the first stage (eg, semi-synthetic penicillin ampicillin and aminoglycoside gentamicin) or carry out the second stage of antibiotic monotherapy (usually cephalosporins II and III generation, at least – modern macrolides). Only with particularly severe infection and failure of other drugs used reserve antibiotics – fluoroquinolones and carbapenems. When empirical therapy should be considered local (regional) features of frequency distribution of microorganisms and their resistance. An important factor – developed an infection in the hospital (nosocomial infection) or outside it.
When causal treatment drug choice depends on the result of microbiological studies (abjection and determine its sensitivity to antibiotics).
In modern surgery proved high efficiency of the so-called step therapy – early switch from parenteral antibiotics to oral dosage forms of the same group or close to the spectrum.
Preparing patients for operation. Caring for patients in the postoperative period.
OPERATION
Operation – mechanical action on tissues and organs for therapeutic or diagnostic purposes.
Classification:
Operations are diagnostic and therapeutic.
Diagnostic – biopsy (Fig. 1), puncture cavities, laparoscopy, diagnostic laparotomy, sensing of the heart.
Fig 1. biopsy
Therapeutic – all activities directed at eliminating pathological focus: appendectomy, cholecystectomy, gastric resection, and others.
Operations may be radical and palliative.
Radical – directed at complete removal of pathological focus (appendectomy (Fig. 2), intestine resection, hernioplasty et al.).
Fig 2. Apendyktomy.
Palliative – pathological focus is not removed, or removed completely, directed only at facilitating the patient (gastrostomy in esophageal cancer, bypass or stoma with colon cancer).
For urgency:
1. Planned – executed at any time, they can be put off for an uncertain future. Cholecystectomy with utilities, hernioplasty under normal hernia, etc.
2. Urgent – performed in the first days after admission, the deposition of operations for the long term can lead to disease progression and deterioration of the patient. For example, malignant tumors. acute cholecystitis, if not removed within 1-2 days, to operate urgently. Gangrene foot, especially moisture, requires desintoxication and infusion therapy for 1-2 days, then amputation urgently.
3. Urgent (emergency) operations – run in the first minutes and hours from the time of admission (injury, bleeding, acute appendicitis, incarcerated hernia, perforated ulcers). These operations are performed for health indications.
Operations may be single stage and multistage.
One-stage – appendectomy, resection of the stomach.
MULTI – operation by the severity of the patient is performed in two or more stages. Thus, the tumor of the colon with intestinal obstruction at the 1st stage is carried out either bypass or unloading stoma. After stabilization of the patient perform the 2nd stage – removal of part of the colon tumor.
Operations on purity divided into 4 groups:
1. Aseptic operations – planned surgery without opening the lumen of a hollow organ (hernioplasty, removal of the spleen (Fig. 3), operations for heart defects, etc.)..
Fig 3. splenectomy
2. Conditionally – clean, when disclosed lumen cavity body (gastric resection, cholecystectomy (Fig. 4) with utilities).
Fig 4. Cholecystectomy
3. Infected – when the inevitable hit contents of hollow organs in the wound: epitsystostomy, gastrotomy (Fig. 5), enterotomy.
Fig 5. gastrotomy
4. Purulent – infected (peritonitis, abscesses (Fig. 6), cellulitis, purulent fistula, etc.).
Fig 6. Disclosure of brain abscess
In addition, isolated primary operations and repeated operations.
Repeated intervention is the most complex, performed by specialists of high category. These operations included the prefix “re”. Relaparotomy – repeated laparotomy, in connection with the development of intraabdominal complications after laparotomy; retoracotomy; reamputation – with gangrene after amputation stump, stump with osteomyelitis.
Preoperative preparation.
The concept of the preoperative period
This is the time (period) from the date of admission of the patient to the surgical department to perform the operation. Depending on the nature of the manifestation of the disease, it can last from a few minutes or hours (wounded heart, large vessels, acute appendicitis, and so on.) To several days (gastric cancer, goiter, bronchiectasis, etc.)..
The main purpose of the preoperative period is to conduct activities to reduce operational risk and prevention of postoperative complications.
The main objectives of the preoperative period are:
1) diagnosis;
2) identification of hits, urgency and nature of fulfillment operations;
3) Preparing the patient for operation.
All preoperative period divided into:
1. Diagnostic period during which clarify the diagnosis, establish indications for surgery. In diagnostic study period as a condition spare capacity of major organs and systems of the patient that is being prepared for surgery.
2.Period proper preoperative preparation, which includes a set of therapeutic interventions aimed at reducing the severity of disease, improvement of major organ systems, increased reactivity.
In elective surgery preoperative preparation time depends on the patient and the nature of the next operation. During the preoperative preparation of patients examined thoroughly, find out the possible contraindications to surgery. All patients must be carried out: blood grouping and Rh factor, complete blood count, urinalysis, biochemical studies: determination of glucose in the blood, Coagulation, protein level, ECG and X-rays of the chest.
Scheduled operations caot be done at higher temperatures, the presence of purulent diseases (abscesses, cellulitis, pyoderma, furunculosis, etc.)., Tonsillitis, acute upper respiratory tract. Always held dental health.
In order to reduce the period of stay in the surgical wards, patients who postipayut for planned operations, pass a comprehensive examination in the outpatient procedure.
Patients with concomitant diseases of the cardiovascular system, lungs, endocrine diseases and others. requiring special inspection. Thus, diabetes examined glucose in urine and blood, in violation ability of blood clot investigate coagulation (prothrombin, duration and bleeding time, platelet number, etc.)..
Duration of preoperative preparation in conventional elective surgery (hernia, appendectomy, etc.), if the patient’s condition is satisfactory, negligible (1-2 days). In serious condition of the patient and a significant amount of the next surgery preoperative preparation Longer in seriously ill – to 1-1.5 month.
The operation was performed after the normalization function of internal organs, to ensure the safety of the operation and to prevent the development of postoperative complications.
Patients who come to emergency operations, due to the limited time cook very quickly – within a few hours, and during operations for health indications, such as tracheotomy, they are immediately taken to the operating room.
Preoperative preparation is different depending on the volume of transactions, the nature of the disease, age and condition of the patient. So, preparing patients for operations on the digestive tract is different from preparing for operations in the chest cavity. There are the features in preoperative preparation urological, trauma, neurosurgical and other patients
RISK ASSESSMENT METHOD anesthesia.
Any concomitant disease which increases the risk of anesthesia, can be found in the survey and examination of the patient. Particular attention should be paid to examination of the cardiovascular, respiratory and urinary systems. Thus, in those patients who have recently (1-2 months ago), myocardial infarction, surgery should be delayed, the risk of repeat heart attack is doubled if the surgery is performed in the first 4-6 weeks, but decreased significantly over the next 6-12 months.
The day before surgery, the surgeon visited the patient confirms the indications for surgery. Before surgery the patient visits the anesthesiologist.
Patients typically introduced to plan the procedures to be taken to its introduction into anesthesia, and warn about where it will be located at the end of surgery and awakening after anesthesia, ie, in a general ward or intensive care.
Classification of degrees of anesthesia and operating risks by VA HOLOHORSKYM
I. Somatic status of patients.
Patients without organic pathology or local disease tub without systemic disorders.
Patients with mild or moderate systemic disorders, related or not are connected with surgical pathology that violate moderate activity.
Patients with severe systemic disorders associated or not with surgical pathology, significantly inhibiting activity.
Patients with very severe systemic disorders, related or not forthem with surgical pathology that constitute danger ment for life.
Patients whose preoperative condition so serious that could result in death within days even without surgery.
II. The severity of surgical intervention.
A. Small operations on the body surface and hollow organs (disclosure boil, uncomplicated appendectomy and hernioplasty, hemorrhoidectomy, amputation of fingers, etc.).
B. Operations medium volume (amputation of limb segments, disclosure boils in body cavities, complex appendectomy and hernioplasty, peripheral vascular surgery).
V. surgery large volume (radical surgery of the chest and abdomen, enlarged limb amputation).
G. Operations on the heart and great vessels.
D. Emergency surgery.
For example: young patients without concomitant patho logy prepare for planned surgery for calculous cholecystitis. The degree of operational risk it will be IB. In biochemical examination he found high levels of blood glucose, diagnosed diabetes under compensation tion. The risk – IIB. When you need emergency surgery in the same patient’s risk will be IIBD.
Early postoperative period. Early postoperative complications and their treatment
Postoperative period is called the period of treatment the patient from the end of surgery to recovery.
The main challenges faced by medical personnel after surgery are:
1) treatment and care of patients;
2) Prevention and treatment of possible complications;
3) early rehabilitation.
Phases of postoperative
Postoperative period – this time from the end of the operation the patient to recovery and rehabilitation or transfer it to a group of disability. Depending on the severity of the disease, the size and nature of operations, the postoperative period may last from several days to several months. There are early postoperative period – the first 5-6 days after surgery; late postoperative period – to discharge the patient from hospital; remote postoperative period – to a full recovery and restore its ability to work or transfer to disability group.
In the postoperative period should carefully monitor the status and function of the major organs and systems as surgery and anesthesia lead to relevant pathophysiological changes in the body. Under the influence of surgery and anesthesia changing intensity of metabolic processes disturbed balance of catabolism (the accumulation of toxic products in the body due to the collapse of substances and cells) and anabolic (set of processes aimed at the formation of organic substances – components of cells and tissues).
During the postoperative period are three phases (stages): catabolic, anabolic and reverse development.
Catabolic phase. The duration of this phase – 3 – 4 days. Severity of the disease depends on the severity and volume operations, type of anesthesia, their duration and intensity of postoperative treatment (inadequate, unbalanced treatment, the presence of complications). It should be noted that the catabolic phase is primarily a defensive reaction of the organism, which aims – to increase body resistance due to energy and plastic materials. On the one hand, this is due to increased breakdown of proteins, fats and carbohydrates, on the other – the significant amount of toxic substances, which leads to acidosis (changes in acid-base status), disruption of redox processes in tissues and organs (liver, kidney , heart, etc.)., which negatively affects the overall operated patients.
Anabolic phase. Its length – 4 – 6 days. During this period begins active synthesis of protein, fat, glycogen (carbohydrate material), increasing amount of energy and plastic materials. Clinical features of this phase is to improve the general condition of the patient, reduce pain, normalization of body temperature, the appearance of appetite. Improves the cardiovascular system, the respiratory system. Restored activity of the gastrointestinal tract, intestinal peristaltic contraction, begin to depart gases.
Phase reverse development. Clinically, it is characterized as a period of recovery. In this phase, improves health of patients, appetite and normalize the function of internal organs: heart, lungs, liver, kidneys, etc.. Duration anabolic phase – 2-5 weeks. Its progress depends on the severity of the disease, the amount transferred operation, duration catabolic phase. She completed the restoration of body weight, complete wound healing and the formation of a reliable postoperative scar.
Changes in the patient associated with surgical trauma
In the postoperative period may develop some metabolic functions and internal organs. They tend to occur in seriously ill patients after complicated operations. After the smaller operations such as routine hernia or appendectomy, these changes are expressed slightly and do not require special treatment.
1. Violation of protein metabolism. One of the serious violations of homeostasis operated patients is a violation of protein metabolism. In the body of a healthy person weighing
2. Disorders of lipid metabolism. Postoperatively, marked changes occur and fat metabolism. For its correction using mostly fat emulsion (venolipid, intralipid, emulsan et al.), Which is the energy source of unsaturated fatty acids (linoleic, linolenic, arachidonic, and others.) That ensure the normal functioning of body cells, inhibit catabolic processes. It should be noted that caloric fat is 2.5 times higher than that of protein and carbohydrates. Fat emulsions poured at a rate of 1.5 –
3. Carbohydrate metabolism after surgery. In 90% of patients in the first 2-3 days of sugar in the blood is reduced and there is hypoglycemia. With 3-4th day watching increase blood glucose (hyperglycemia), sometimes glucosuria, which is associated with an increase in its formation and decreasing absorption. With 2-3rd day the amount of glucose in the blood is reduced and there is hypoglycemia. Note that the number of substances in the body depends on the intensity of metabolic processes and methods of their separation from the body. This is in violation of the carbohydrate metabolism in the body mainly accumulate oxidized products that reduce backup alkalinity and affect blood pH. Changing the pH of blood by only 0.3-0.4 units (normal pH – 7,35-7,45 ED) in any direction leads to a pronounced violation of enzymatic activity, redox processes in the body that can result in death patient.
Timely, correct and intensive preoperative preparation, careful nursing, and correction of carbohydrate metabolism (introducing a sufficient quantity of 5-10% glucose with insulin at the rate of 1 IU of insulin on glucose 4-
4. Violations of water-electrolyte metabolism cause many complications in patients after surgery. There are three forms of disorders of water metabolism:
1) real deficit caused by insufficient flow of water in the body;
2) the excess water caused by the mismatch between revenues and its withdrawal from the body;
3) redistribution of water in some parts of the body associated with changing ratios of electrolytes.
After an operation and rehabilitation of the patient are three periods of observation of the patient. After a short period of immediate postoperative observation anesthesiologist in restorative ward to ensure normalization consciousness, respiration, blood pressure, pulse, and if no hits for his transfer to the department of intensive care, the patient is transported in a general ward. After discharge from the surgical department patient may still require supervision and rehabilitation of a surgeon. It is provided during outpatient treatment in the clinic, sanatorium or program of gradual recovery in activity in rehab.
Oral Care. After the operations required diligent oral care. If dry mouth is recommended systematic rinsing with water and lubricating mucosal vaseline oil.
To prevent inflammation of the parotid glands should rinse your mouth with warm water and lemon juice. The nursing staff must follow to ensure that patients are regularly cleaned teeth.
Care. All patients should daily wash hands and face. Seriously ill wash nanny. It should monitor the purity skin seriously ill.
To prevent bedsores lying sick enclose inflatable rubber wheels, regularly (2-3 times a day), rubbed the back, pelvis and sacrum camphor alcohol. We must change the position of the patient in bed. When the initial signs of bedsores altered skin smeared 5-10% solution of potassium permanganate.
To prevent intertrigo should systematically wipe 0.1% solution of potassium permanganate and powder talc inguinal and axillary areas, navel, women – folds under the breasts.
Especially should carefully monitor the purity of the perineum. After defecation perineal area washed with a cotton swab with warm water or a 0.1% solution of potassium permanganate. Women of the night washed crotch.
The time when the patient is allowed to get out of bed, depending on the severity and nature of the operation, its condition and the postoperative course. Iormal condition of the patient and no complications after appendectomy, hernioplasty he was allowed to get up at 1-2-day. After more sophisticated operations (gastric resection, cholecystectomy, and others.) – 3-4th day as directed by your doctor. After operations on the thoracic cavity, the extremities for fractures, injuries of blood vessels, nerves, etc. permitted to get up at different times individually for each patient.
Care bandage is one of the main duties of nurses. We follow closely to dressing well rested and not exposed to the wound. If bandage slid off and the wound exposed, you should immediately make dressing. Dressing can be a little leak blood in the first day after surgery. In these cases it lightly grease an alcoholic solution of iodine. When the impregnation bandages blood should immediately call a doctor and take measures to stop the bleeding.
The bandage change in the first three days after surgery and removal of sutures. When purulent wound dressings do often depending on the state and wound dressings.
Removal of sutures. Sutures are removed in most patients at the 7-8th day, children can be removed earlier – to 5-6th day after surgery in elderly and frail patients with sutures removed later – on 10-12-th day.
Eating a patient after surgery. Dining patient after surgery depends on the nature of it. When operations on the abdominal organs, usually during the first day are not allowed to drink.
Later in 5-7 days patients prescribed a liquid, easily digestible food (soup, pureed soups, yogurt, liquid porridge, pudding, soft-boiled egg, etc.).. Diet set depending on the nature of the disease and surgical intervention. So, after surgery for gall bladder prescribed liver diet after surgery for stomach ulcers over – ulcer diet, etc.
To quench your thirst rubbed lips and mouth moist cotton wool.
After operations on the stomach and intestines at 2-day permitted to drink warm boiled water a teaspoon per hour. On the 3rd – 4th day after surgery in the recovery of peristaltic activity intestinum patients can eat soup, pudding, soft-boiled egg in the next few days – liquid semolina, pureed soups. Crackers can eat on the 5-6th day.
After operations gall bladder and liver patients prescribed liver diet. give to eat from 2-3rd day, designate a small portion of the liquid, pureed food.
Diet patients after operations on the small intestine following: drink permitted on the 2nd day, further small portions for 5-7 days produce liquid foods (soup, soft-boiled egg, pudding, etc.). Crackers can eat for 7-8th day.
After operations on the large intestine, patients prescribed a liquid, easily digestible food for 5-7 days. In the same period to delay emptying give opium tincture (5-10 drops 3 times a day).
During the first days after appendectomy patient can drink, ranging from 2-day prescribed liquid foods, crackers, 3-4th day – white bread.
After removal of the hernia operations on extremities patients prescribed overall diet.
After radical surgery on the esophagus sick for five days are on parenteral nutrition. At the 6-day allowance to drink small sips and then gradually prescribed liquid diet.
Diet patients after operations on the chest, lungs and heart consists of liquid, easily digestible food with plenty of protein, carbohydrates and vitamins. During the first 3-5 days should limit the amount of food to prevent complications of the heart and gastrointestinal tract.
After operations on the lungs in patients with 5-7-day, if there are no complications, appointed overall diet.
DIRECT afteoperation care for pation
Diagnosis and treatment of major life threatening complications that may arise during this period, is functional duty doctor department of intensive care together with the surgeon.
Airway obstruction. Airway should always be kept clean and passable. The main causes of obstruction following.
1. Tongue may occur in unconscious patients after general anesthesia. Loss of muscle tone leads to the tongue to the posterior pharyngeal wall and may increase spasm of masticatory muscles during exit from the unconscious state. Complicating factor of various manipulations of anesthesia may be injury tongue or soft tissues of the mouth or throat.
2. Foreign bodies such as dentures and broken teeth, secretions and blood, stomach contents or intestines – frequent source of airway obstruction. Before the surgery, dentures should be removed and taken precautions to prevent aspiration of gastric contents.
3. Laryngospasm can occur during mild loss of consciousness and increase with inadequate anesthesia.
4. Laryngeal edema can occur in young children after traumatic intubation attempts or during infection (epihlosyt).
5. Compression of the trachea may occur during surgery on the neck and especially dangerous when hemorrhage after thyroidectomy or remodeling vessels.
6. Bronchial obstruction and bronchospasm may develop due to ingress of foreign body aspiration or irritating substance, it could be an allergic reaction to medication or complication of asthma.
Attention doctors should aim to identify and eliminate the cause of airway obstruction as a matter of extreme urgency. When satisfactory patency airways hypoxia may be due to complications from after venting complications mismatch between ventilation and perfusion. Since this is usually a good job anesthesiologists, venting lung gas mixture with a high oxygen content. Determined by gas analysis of blood.
Myocardial ischemia. Postoperative heart failure may increase in the early period, especially in patients with a history of previous heart disease, myocardial ischemia. Patients with ischemia may complain of squeezing chest pain. In the period of recovery of consciousness may be the only symptom of hypotension. If suspected ischemia, ECG performed immediately and the measures for continuous monitoring of cardiac activity (kardiomonitoring).
Respiratory failure. Respiratory failure is defined as the inability to maintaiormal partial pressure of oxygen and carbon dioxide (PO2 and PCO2) in arterial blood. Determination of blood gas should be conducted in the dynamics in patients with previous respiratory diseases. Normal PO2 – more than 13 kPa at age 20, decreases in patients up to 60 years to about 11.6 kPa; respiratory failure accompanied by a value less than 6.7 kPa. Severe hypoxemia clinically evident cyanosis of skin and mucous membranes, with independent breathing – severe dyspnea.
FEATURES postoperative period in patients elderly.
People senile require special attention and approach. The reaction to the disease process they delayed and less pronounced resistance to drugs normally reduced. In the elderly significantly reduced pain sensation and therefore complications arising without symptomatic may occur. So should listen carefully to the patient himself assesses the development of the illness, and therefore need to change therapy and treatment.
Usually in elderly patients gavage, drainage, depriving them of mobility are removed as soon as possible, to minimize intravenous fluids. Their early rise from bed after surgery for abdominal, lower limbs, which is the prevention of many complications.
Postoperative management in general surgical ward
TOTAL CARE
After returning the patient to the ward regularly, almost every hour or every 2 hours, the control pulse, blood pressure and respiratory rate. Patients who underwent complicated surgery on the stomach or intestines, shown hourly emissions control by nasogastric tube, diuresis and selections from the wound. Observations carried nurse under the supervision of the attending physician, surgeon or another (if necessary and other consultants).
In most hospitals survey patients medical personnel to ascertaining its condition, health and dynamics of basic life functions carried out in the morning and evening. Worries that suddenly appeared, disorientation, inappropriate behavior or appearance – often the earliest manifestations of complications. In these cases, pay attention to the state of general circulation and respiration, pulse, temperature and blood pressure levels. All data is monitored and recorded in medical history. The need for conservation probes, catheters decided on the basis of monitoring renal function and bowel, full tour of the chest. Thoroughly researched chest, sputum examined.
Lower limbs inspected for appearance of swelling, pain calf muscle, skin discoloration. In patients receiving intravenous fluids, controlled liquid equilibrium. Everyday determined plasma electrolytes. Intravenous infusion terminated as soon as the patient begins to drink liquids on their own. A few days of fasting in the first days after the operation caot bring a lot of damage, but enteral (tube) or parenteral nutrition is always necessary if the strike lasts more than a day.
For some patients, painful and depressing problem after surgery may be insomnia, and it is important to recognize and promptly treat such patients (including silence, the mode of communication with staff and relatives).
Caring for patients after operations on the abdominal organs.
Anterior abdominal wall and stomach examined daily to detect excessive swelling, muscle tension, pain, of wounds – leakage from the wound or where drainage is installed. The main types of complications in this group of patients: the slow recovery of peristalsis bowel anastomosis failure, bleeding or abscess formation.
The presence of intestinal noises, self discharge gas and the appearance of stool indicates restore peristalsis. If after the intervention was delivered nasogastric tube, he kept open constantly (which facilitates the discharge of gases) and allows further draining the intestine. Passive drainage may be supplemented by continuous or intermittent suction content. The probe is stored to reduce the amount of hourly aspiration and can be removed when there is self discharge gases and there is a chair (usually 5-6 days). Nasogastric tube causing inconvenience to the patient and should not be kept for longer thaecessary.
CARE FOR WOUND.
Frequent dressing is not always necessary in the treatment of surgical wounds, after planned operations in the absence of pronounced pain in the wound, the normal temperature of the patient’s wound may look back in 1-2 days, but it should be examined daily in detecting even small signs of infection: redness , swelling, increasing pain.
Draining wounds done to prevent the accumulation of fluid or blood and allows you to control any selection – in insolvency anastomosis cluster of lymph or blood. Many surgeons in recent years prefer to use closed drainage vacuum system with a small force of aspiration (corrugated vacuum drainage produced by the domestic industry) after operations on vessels. Usually drain is removed when the amount of fluid received each day, reduced to a few milliliters.
Skin sutures traditionally not removed until such time as the wound heals completely. Terms of healing depends on many factors. Thus, appropriate early removal of sutures in the neck or face (3-4 days) to prevent the formation of unsightly scars. Then place sutures can be pasted sticky strips (like plaster) to avoid differences and better healing. On exposed skin (face, neck, upper and lower limbs) are preferred subepidermal sutures placed absorbent or non-absorbent synthetic fibers. If the wound becomes infected, you will need to remove one or more sutures prematurely, the wound edges are raised, running drainage.
The difference between the edges of wounds of the abdominal wall is rare and mostly in patients who underwent surgery for a malignant tumor. This process is supported by factors such as hypoproteinemia, vomiting, prolonged paresis and intestinal bloating, purulent wound and pulmonary complications.
To distinguish the wound edges characteristic sudden discharge from the wound a large number of serous fluid. On examination, the wound is eventeratsiya with protruding loop of intestine or omentum fragment. In these cases, the operating conditions is replaced internal organs and the wound closed nodal seams.
Complications in the early postoperative period
Long-term intravenous irritant drugs or solutions may cause bruising, hematoma, phlebitis or venous thrombosis. Intravenous catheters, which are placed in large veins should be securely sealed to prevent air embolism. Arterial catheters or accidental needle punctures the artery – the most common cause of damage. This can lead to arterial occlusion and even gangrene because most damage is diagnosed late.
Nerve paresis may be caused by stretching or compression of the maierve trunk or extravascular administration aggressive solution. Most damaged ulnar nerve in the elbow fossa, radial nerve on the shoulder and brachial plexus in the supraclavicular area.
Development nerve paresis may occur in an awkward position the patient on the operating table – long limbs or local compression of compression with the patient on the side or stomach. Following precautions to prevent nerve paresis of limbs in the early postoperative period.
CARDIO-PULMONARY COMPLICATIONS.
In the early postoperative acute heart failure is the most common complication. In patients with coronary artery disease or valve defects, arrhythmia surgery after massive phenomenon can be observed heart failure. The reason for its increase may be excessive in volume intravenous infusion of fluids in the early postoperative period, which can be avoided by carrying out monitoring of central venous pressure. Heart failure treatment is to avoid the further fluid overload, diuretics and cardiac prescribing drugs.
Once the patient is fully recovered consciousness after anesthesia, the major problems of the respiratory system may collapse lung and pulmonary infection. Exponentiating factors in their development may reduce the mobility of the diaphragm, general lethargy, abdominal wall tension and pain in the wound. Occurrence of complications prevents explanation patient having to go to bed, breathe deeply and of cough. Great importance is attached physiotherapy, coughing and deep breathing with simultaneous use of small doses of analgetics. This abdominal wall in the wound must be maintained using a temporary bandage. Bronchospasm eliminated inhalation bronchodilator drugs, and hypoxia treated with oxygen through a mask or nasal tube. Antibiotic therapy administered after bacteriological examination of sputum.
Renal failure.
Acute renal failure after surgery may be the result of prolonged hypoperfusion of the kidneys, which may result from hypovolemia, sepsis, or transfusions of incompatible blood. Patients with previous renal disease and jaundice are particularly susceptible to the condition of renal ischemia and more likely to develop acute renal failure. The importance of monitoring hourly urine output necessitates bladder catheterization, all patients who performed major surgery, as well as those who are at risk of developing renal failure.
Early diagnosis and treatment of bacterial and fungal infections are also important in preventing renal failure. Acute renal failure is characterized by oliguria combined with low specific gravity of urine (less than 1010). Oliguria in combination with high concentrations of urine suggests that kidney function, but inadequate blood supply to them. This is to show to the introduction of more liquid. Rapid infusion of saline increased urine output in these patients, but careful inspection eliminates the cause of hypovolemia ( bleeding).
Local anesthesia
Local anesthesia – return loss of pain sensitivity of tissues in limited areas. Achieved as a result of the termination of impulses in sensory nerve fibers or blockade of receptors.
Local anesthesia is the most secure methods of pain relief. With the development and widespread introduction into clinical practice of general anesthesia, its role is somewhat diminished. However, in an outpatient surgery is widely used. A decent place it occupies during endoscopic studies.
Local anesthesia, especially following his species as spinal, epidural anesthesia, anesthesia of the brachial plexus, occupies a prominent place among the basic methods of modern anesthesia. If the 50 – 70 years of the last century with the development and widespread introduction into clinical practice of general anesthesia, the role of local anesthesia has declined, the last decade has been marked by an unprecedented interest in him both in our country and around the world. It explains how the development of new surgical technologies – reduction surgery and prosthetic limbs of large joints, endoscopic surgery in urology and gynecology and new approaches to post-surgical, obstetric, chronic pain, including in cancer patients. In all these fields of medicine local anesthesia is the most effective and physiological, such as to comply with moderotions of anticipatory analgesia. At the same time its progress associated with the advent of effective local anesthetics (bupivacaine, ropivacaine et al.), Disposable little traumatic special needles for spinal anesthesia, epidural catheters and thermoplastic bacterial filter that increased the reliability and safety of local anesthesia, allowed to apply his pediatric practice in and day surgery.
Local anesthesia by creeping infiltration and novocaine blockade has a long and well-earned tradition in home surgery thanks to the work of academician A. Vyshnevskoho.
Mankind has long sought by all means to alleviate the suffering of patients. The ancient Egyptians, Chinese, Romans, Greeks used alcohol for analgesia mandrake tincture, decoction of opium. In
In the XVI century Ambroise Pare reduced pain sensitivity by compression of the nerves. Bartolini in
Local anesthesia during surgical interventions has been developed after the work of our national scientist Dr. Anrep (1880). He studied the pharmacological properties of cocaine on experimental animals, pointed to its ability to induce anesthesia and recommended the use of cocaine in operations on humans. Anesthesia during surgery on the finger used Lukasiewicz and oberst (1886). A. Orlov used the 0.25 – 0.5% solution of cocaine for local infiltration anesthesia (1887). In 1891, advertising and Shleyh reported using weak solutions of cocaine for infiltration of tissues during surgery. Brown (1887) suggested that when the local anesthetic added to a solution of cocaine epinephrine to reduce bleeding from wounds and hinder the absorption of cocaine in the blood. Beer in 1898. used spinal anesthesia. Opening Eyhhornom in 1905. Novocaine was met very positively.
In the twenties, a significant contribution to the development and introduction of spinal anesthesia surgery method introduced domestic Surgeon SS Yudin, successfully using it at that time for complex surgery.
A. Vyshnevskyy (1923 1928h.h.) Developed a simple, affordable way of local anesthesia on the principle of creeping infiltration. The method was applied with equal success in both large and small operations with clean and festering diseases. After the publication of his works local anesthesia were used for almost all surgical interventions, both in our country and abroad.
A. Vyshnevskyy showed that hydraulic dissection of tissues to better navigate the vessels and nerves better understand the anatomical features of tissues in the surgical field. Layered fabrics impregnated novocaine solution takes time and waiting until the anesthesia. A solution of novocaine injected slowly in terms of tissue removed much of the solutioapkins and tampons. Practice has shown that when properly executed anesthesia waiting is minimal.
In parallel with the development of methods of local anesthesia was intensive study of the physiology and pathology of pain mechanisms of formation of pain. Currently understood the important role of pain impulses from the wound, which emerged during surgery, leaving a long trail of excitation of neurons posterior horns of the spinal cord, which is the foundation and support of postoperative chronic pain. Shown that operations increased trauma under general anesthesia, followed by the application of strong narcotic analgesics (morphine) not resolved impulses. It is a kind of “bombing” attacks the spinal cord, bringing down the physiological mechanisms of analgesic own defense system. Application of these conditions of local anesthesia before the operation, support her in the postoperative period can reliably block this pulsation, saving mechanisms antinocyception. An illustration of these ideas is the operation of amputation of imminent injury nerve trunk neurotomy. Performing her under anesthesia without local anesthetic nerve roots after surgery increases the incidence of such serious complications for the patient as phantom pain. Back in 1942 the outstanding domestic neurosurgeon NN Burdenko in his monograph “Amputation as a neurosurgical operation” pointed out the importance and obligation of blockade of nerve trunks of local anesthetics before they cross. Lacking modern for our ideas about the pathophysiology of postoperative pain, he thanks his clinical experience and intuition came to the correct solution to complex problems.
With the new approach to operational pain form an idea of anticipatory analgesia. It involves creating a complete analgesia to the beginning of the pain stimulus. The stronger effect of pain, the greater significance becomes block pain impulses local anesthetics before passing it to the spinal cord neurons. Narcotic analgesics, introduced intravenously, block pain impulses mainly on supraspinales level and caot be considered as a single and reliable remedy for pain operated patient.
Physiological and pharmacological features of local anesthesia
Molecules of all local anesthetics consist of three main components: the lipophilic part hydrophilic amine and medium chain. Lipophilic part allows local anesthetic to penetrate the fatty cell substrates in the nervous tissue hydrophilic (amine) part provides a breakdown of the molecule and its penetration through interstitial fluid ierve.
Highly anesthetics have balanced properties. In particular, if the agent is not expressed hydrophilic part or deprived of it, it can only be used for applications, ie surface. The effectiveness of any anesthetic depends on many factors, of which the core is COR tissues. Normally, the pH of the interstitial fluid is 7.3 – 7.4, pH anesthetic ranged from 3.8 to 6.5. If you shift the pH to the acid side, much of the anesthetic exposed cations, ensuring the effectiveness of its action. When the inflammatory process of tissue pH drops to 6.0 or lower, thus decreasing the number of anesthetic that penetrates the nerve and cations that are in excess, it does not exhibit the desired activity. Thus, the effectiveness of any anesthetic depends on the pH of the tissue.
Neurophysiology.
At the heart of local anesthetic are stopping impulse conduction in sensory nerve fibers and receptor blockade. Anesthetic effect on the nervous membrane depolarization prevents her, watching the nerve impulse. Nerve cells are directly or indirectly involved in the metabolism and nourish the nervous membrane, which is responsible for the generation and transmission of momentum. Membrane transmits impulses from the periphery to the center. If the pulse propagation is interrupted, it eliminated the pain. The membrane is a bimolecular lipid cover, located between monomolecular layers polypeptides (the latter consisting of protein, fat and protein membranes separated ions aksoplazma and extracellular fluid).
When the metabolism of nervous membranes monitored concentrations of various ions in the interstitial fluid. Changing ionic ihradiyentiv leads to depolarization and changes its direction of propagation of the pulse. High resistance of the membrane to external factors in pathological conditions associated with the violation of the passage through it of potassium, sodium, chloride, which normally usually penetrate unhindered.
Nerve fibers surrounded by a layer of myelin, which is located on the nerve in the form of a cylinder consisting of lemmocytes (Schwann cells) and protects it from external influences. Myelin is a barrier removals, and local anesthetics are not always able to get through it. Myelin layer interruptions, laid bare nerve membrane. These breakthroughs are known as nodes. In these places anesthetic solutions easily diffuse into the nerve membrane, causing nerve blockade.
Distribution pulse. Electrical impulses are potential membrane that is changing rapidly, spreading from pressure points by type depolarization waves called action potentials. At rest, the outer surface of the membrane is charged positively, internal – negative. If you have any incentive she slowly grows to a certain level, called the threshold of nerve fibers. When the threshold reaches a critical level, there is depolarization. If the critical level is reached, the momentum does not appear (illustration of the principle of “all or nothing”). After reaching the threshold potential difference increases, and then going repolarization, and the membrane potential returns to its original level observed at rest. Depolarization and repolarization occur over the entire length of the nerve fibers. Nervous membrane that is dormant, is a barrier to sodium ions. During depolarization the sodium ion moves in the membrane to sodium channels. Changing the potential leads to the release of potassium ions (“sodium pump”). This is a new action potential and reduction potential difference across the membrane.
All the above can be expressed as a summary: according to modern ideas, the transfer of excitation and permeability depend on the state of the cell. Distribution pulse is divided into three phases: polarization, depolarization and repolarization. At the first stage, the intracellular concentration of potassium than sodium concentration that prevents negative potential (resting potential) on the inner surface of the membrane, which is supported by intracellular anions. Stable and position of sodium ions, since they caot enter the cells as a result of the polarization of the membrane at this point little penetrating for sodium. Later, when the resting potential is reduced to the corresponding threshold is increased permeability to sodium ions, which under the influence of ionic and electrostatic Ingredients pass into the cell. The result is depolarization of the membrane potential and there is a positive action, facilitating impulse along nerve cells. Following the excitement comes the refractory period in which the membrane potential is reduced to the value of the resting potential. In the state of repolarizatioeuron prepared to accept and hold a regular pulse.
The mechanism of action of local anesthetics is to distribute braking pulses and changes in membrane permeability to sodium ions and prevent its depolarization. Just changing the permeability of the membrane for potassium ions, but to a lesser extent. Under the influence of local anesthetics varies propagation velocity pulse, and thus achieved a threshold potential. In fact, the phenomenon of depolarization associated with the promotion of sodium ions through sodium channels. It is believed that the effect of local anesthetics performed by changing the permeability of sodium channels neural membrane. Lidocaine, procaine bind receptors that are located on the outer surface of the nerve membrane in sodium channels.
Emergence of action potential leads to the spread of excitation to other parts of the nerve fibers to penetrate into aksoplazm sodium ions and potassium ions exit (“sodium-potassium pump”). This process is regulated by calcium ions, with increasing concentration in the extracellular fluid which increases membrane threshold. It is known that local anesthetic remedies act as synergists calcium.
Due to the development of inflammation in the tissues through which the injected local anesthetic blockade of the sodium channel occurs on the outer surface of the membrane. The same effect can be observed with toxic effects on membrane receptors.
Thus, a number of stages in the development of the action potential, under the influence of local anesthetics on the fabric:
– Binding to receptors in the nerve membrane;
– Reducing the permeability of the nervous membrane to sodium ions;
– Slowing depolarization, leading to blockade threshold voltage (threshold potential is not there);
– Termination of the action potential, leading to the blockade of the pulse signal in the nerve.
As a local anesthetic action affects the membrane of nerve fibers at the injection is its diffusion through various layers of connective tissue.
The concentration of anesthetic should be sufficient to enable it to overcome Ranvera nodes. The greatest difficulties arise diffusion in contact with epineurium that is the connecting base. The outer shell epineurium forms jittery “shield” that protects nerve from external influences. Approximately 5000 nerve fibers occupy an area of 1 mm. All these structures act as barriers to the movement of anesthetic to the nerve fibers. Sufficient concentration of anesthetic solution allows him not only to penetrate the nerve fiber, but it provides a complete blockade. With modern local anesthetics can achieve this goal without violating the integrity or destruction of nerve.
Currently, the blockade of nerve fibers can be divided into three stages:
– Elimination of pain and temperature sensitivity;
– Exclusion of tactile sensitivity;
– Exclusion proprioreceptive sensitivity while motor conduction of impulses, ie the development of muscle relaxation.
Restore different types of sensitivity runs in reverse order: first appear random muscle contractions and proprioreceptive feeling then restored protopathic sensitivity and least – epicritical. In that case, if you want to continue the blockade by repeated injections, a new batch of anesthetic solution is applied to the nerve trunk at a time when the recovery begins function of some external fibers. The process goes in the opposite direction, and the blockade can achieve faster with less volume of anesthetic solution and lower its concentration in comparison with the original.
Local anesthesia is divided into several types:
1. Terminal.
2. infiltration
3. conduction
4. Regionals: paravertebral
5. intercostal
6. truncal
7. Sacred
8. Cerebrospinal (subarachnoid)
9. Peridural (epidural)
10. Intraosseous.
11. Intravenous regional
12. Perirenal blockade.
DESCRIPTION drugs for local anesthesia
Novocaine (Novocainum)
Sol. Dietilaminetylici para-aminobenzoic acid ester hydrochloride.
Colourless crystals or a white crystalline powder, odorless. Very easily soluble in water (1:1), easily soluble in alcohol (1:8).
Novocaine is a local anesthetic drug. With the ability to cause superficial anesthesia, it is less active than cocaine, but much less toxic, has a wide range of therapeutic effects and causes of phenomena characteristic of cocaine addiction. In addition to local anesthetic action Novocain during absorption and directly injected into the blood makes the overall impact on ophanizm: reduces the formation of acetilcholine and reduces the excitability of peripheral choline reactive systems makes a blocking effect on the autonomic ganglia, reduces spasms of smooth muscles, reduces anxiety and irritability of the heart muscle motor zones cortex. In the body of novocaine relatively rapidly hydrolyzed to form para-aminobenzoic acid and dietylaminoetanol.
Novocaine is commonly used for local anesthesia, mainly for infiltration and spinal anesthesia. For infiltration anesthesia used 0.25-0.5% solution, for anesthesia by the method A. Vyshnevskoho used 0,125-0,25% solution, for anesthesia – 1-2% solutions, for peridural anesthesia – 2% solution (20-25ml) for spinal anesthesia – 5% solution (2-Zml).
When using solutions of novocaine local anesthetic concentration and their number depends on the nature of surgery, method of application, condition and age of the patient. Please note that at the same total dose of drug toxicity is higher, the more concentrated is the solution. To reduce the absorption into the blood and the extension of novocaine to it usually adds 0.1% solution of epinephrine hydrochloride 1 drop in 25 ml of novocaine.
Lidocaine
White or almost white crystalline powder. Very easily soluble in water, in alcohol. The chemical structure ksylocain relates to derivatives acetyl anilide. Unlike novocaine it is not ester, slowly metabolized in the body and works longer than Novocain. Due to the fact that in its metabolism in the body is the formation of para-aminobenzoic acid, he discovers antisulfanilamide effect and can be used in patients receiving sulfanilamide preparations. This group of local anesthetics is trimecaine. Near them on the structure piromecaine. Together with the local anesthetic lidocaine activity has pronounced anti-arrhythmic properties. Lidocaine – a strong local anesthetic agent that causes all kinds of local anesthesia: a terminal, infiltration, conductor. Compared with novocaine he is faster, stronger and longer. The relative toxicity of lidocaine is dependent on the concentration of the solution. At low concentrations (0.5%), it is not significantly different for toxicity of novocaine, with increasing concentrations (1% and 2%) increased toxicity (40 – 50%). For infiltration anesthesia used 0.125%, 0.25% and 0.5% solutions, for anesthesia of periferic nerves – 1% and 2% solutions, for epidural anesthesia – 1% – 2% solution, for spinal anesthesia – 2% solutions. Number of solution and the total dose of lidocaine depend on the type of anesthesia and the nature of surgery. With increasing concentration of total dose of lidocaine reduced. When using a solution of 0.125% maximum solution of 1600 ml and a total dose of lidocaine hydrochloride – 2000 mg (
Product: 1% solution in ampoules of 10 ml of 2% solution in ampoules of 2 and 10 ml, 10% solution in ampoules of 2 ml. Storage: List B. In the dark spot: Abroad lidocaine also produced in aerosol form for local (surface) anesthesia in dentistry, otolaryngology, surgery – when changing bandages, opening abscesses, etc. Aerosol can contains 750 doses of 10 mg lidocaine. Number sprayed drug depends on the surface to be pain. Adults should not exceed a dose of 200 mg, which is 20 sprays, the children – according less. Do not allow to enter spray in eyes.
Trimecaine (Trimecainiim)
α-Dietyamin-2 ,4,6-trimetilacetanilide hydrochloride.
White or white with a weak yellow white crystalline powder that is readily soluble in water and alcohol.
The chemical structure and pharmacological properties similar to lidocaine trimecaine. He is an active local anesthetic agent that is rapidly advancing, deep and prolonged infiltration, conduction peridural, spinal anesthesia, at higher concentrations (2-5%) causes superficial anesthesia. Trimecaine reveals a stronger and longer effect than procaine. It is relatively less toxic, not irritant.
Piromekain (Pyromecainum)
White or white with a mild creamy white crystalline powder. Easily soluble in water and alcohol.
This drug is used in ophthalmology as 0.5-2% solution, as well as the study of the bronch.
Markain (bupivacaine)
Modern amide-type local anesthetic, which contributes to a wide spread of local anesthesia. Characterized by delayed onset of action compared with lidocaine, but prolonged analgesic effect (up to 4 hours). Suitable for all kinds of local anesthesia, often for conduction, prolonged spinal and epidural anesthesia, including for postoperative analgesia. In eye surgery is used for retrobulbar anesthesia and anesthesia pterygopalatine ganglion. It is mainly a blockade of sensory nerve fibers. In case of accidental intravenous reveals cardiotoxic effect, manifested conduction slowing and decreased myocardial contractility. Available in capsules of 0.25%, 0.5% and 0.75% solutions.
ROPIVAKAIN
A new local anesthetic bupivacaine analogue. Keeps its positive qualities, but it is less pronounced cardiotoxicity. Used mostly for wiring, epidural, epidural-sacral anesthesia. Thus, brachial plexus anesthesia 0.75% solution ropivakain occurs in 10 – 25 minutes and lasts for more than 6 hours. For epidural anesthesia using 0.5 -1.0% solution.
Anesthesia – “surface of anesthesia” (Bunyatyan AA, 1982) is achieved by direct contact anesthetic agent with a cloth body. Saw chloroethyl the skin surface causes significant cooling of the treated areas of skin and loss of pain sensitivity, which makes it possible to disclose small abscesses, hematomas. But a full surgical treatment in this type of anesthesia is almost impossible. Terminal anesthesia used in ophthalmic, dental, urological practice. Achieved by lubricating mucosal surfaces, anesthetic instillation in the conjunctival sac or urethra.
Infiltration anesthesia (Fig. 7) – allows even large volume transactions. For this purpose, the method of “creeping infiltration” by A. Vyshnevskomu. This method is based on the anatomical features of the structure of the body caused by a “case” (NI Pirogov). The method is layered, progressive tissue infiltration of local anesthetic solution (Fig. 1), changing the cut, then re-made tissue infiltration 0.25% novocaine solution surrounding the body which is subject to surgical intervention.
Fig. 7. Infiltration anesthesia
Regional anesthesia – is achieved by the introduction of anesthetics in the area of large nerve trunks, plexus or roots of the spinal cord that can achieve reduction in pain sensitivity topographical area corresponding to the zone of innervation of the nerve trunk that blocked or plexus.
Novocaine blockade. In surgery widely used novocaine blockade 0.25% solution of novocaine on Vishnevsky, mainly for the prevention and treatment of shock.
Novocaine blockade relieves severe irritation and thereby helps to normalize physiological functions.
There vagosympathetic cervical, lumbar (perirenal) novocaine blockade.
Technique of novocaine blockade.
For the neck vagosympathetic blockade (Fig. 8) the patient is put on the back, under the shoulder blades enclose a small roller and head turning in the opposite direction.
Fig. 8. vagosympathetic blockade by AA Vishnevsky
First make intradermal anesthesia thieedle on the edge of the upper and middle thirds of the posterior surface sternocleidomastoideus muscle. Then typed in 10-gram syringe with a long needle 0.25% solution of novocaine, pierce the skin in the specified point and slowly pushing the needle toward the anterior surface of the spine and slightly upward before entering novocaine solution and then advancing the needle.
For blockade of the neurovascular bundle (vagus and sympathetic nerves) using S0 – 50 ml 0.25% solution of novocaine.
For the perirenal novocaine blockade of the patient is placed on the opposite side and below the waist enclose roller. Do anesthetic skin in the lumbar region at a point located along the bisector of the angle between the XII edge and the edge of the lumbar muscles slightly forward from the end edges (Fig. 9).
Fig. 9. Perirenal novocaine blockade
Fills a 0.25% solution of novocaine 10-20-gram syringe with a long needle, which pierced strictly perpendicular to the skin. Gently pushing the needle into the lumbar region, before introducing a small portion of the solution of novocaine. This needle gradually pierce the muscles and the back piece renal fascia. In perinephric space injected 60-100 ml 0.25% solution of novocaine, which washes sun and renal nerve plexus, lumbar sympathetic nerve trunk kidney and blood vessels.
Paravertebral blockade – is used for lumbago, aggravation of chronic radiculitus, fractures of the spine. The needle is inserted at a point located at 1-
Intercostal blockade – is the introduction of anesthetic agents in the intercostal space. This blockade is carried out with rib fractures, bruises chest, intercostal neuralgia. When rib fractures, the introduction of anesthetic directly into the fracture site.
Truncal anesthesia – most commonly used in surgical interventions on the extremities, as well as transportation and closed reposition fractures. Anesthetic is injected directly into the nerve that innervates the appropriate area.
Sacral anesthesia – is a kind of paravertebral and used for small volume operations.
Anesthesia jaw area. For anesthesia dental procedures can also be used regionary block. Usually 1-2% solution of novocaine, trimecaine, lidocaine, xylocaine.
Spinal anesthesia (subarachnoid) – achieved by introducing the anesthetic solution in the subarachnoid space after puncture of the dura mater in the caudal part of the lumbar spine. Usually injected 2% lidocaine solution at a dose of 1 mg / kg. To improve and extend the time of analgesia can enter 1 ml fentanyl. The level of input – between 2-3 or 3-4 lumbar vertebrae (Fig. 10). Above puncture caot, because the risk of damage to the spinal cord (it ends at around and lumbar vertebrae.) Pain relief occurs within 3-5 minutes. Time spinal anesthesia without fentanyl – 40-60 min., With fentanyl – 90 – 120 min.
Fig 10. Epidural anesthesia
Side Effects:
1. Lowering blood pressure – warned the rapid introduction of 1000 – 1500 ml crystalloids.
2. Liquor hypotension syndrome: through the pierced hole in the dura mater flowing liquor, its pressure decreases, causing severe headaches before closing hole (average 7 – 14 days). To avoid the need to carry out fine needle puncture, preferably “pencil” type, cut the needle should be directed along the spine, the needle does not cut the fibers of the dura mater, and “moved apart” them.
Contrindications for the spinal anesthesia are divided into two groups: absolute and relative.
Absolute Contrindications:
1. pustular skin back diseases;
2. low blood pressure;
3. spinal deformity;
4. organic lesions of the central nervous system;
5. hypersensitivity to local anesthetics.
Relative contraindications much more:
1.dekompensation cardiac activity,
2. severe general condition,
3.kaheksy,
4. infancy,
5. chronic pathological processes in the spine that hinder anesthesia.
Epidural anesthesia (Fig. 11) is a variant of conduction anesthesia caused by pharmacological blockade of spinal roots. When epidural anesthesia anesthetic solution injected into the space between the outer and inner layer of the dura mater and blocks the roots covered with dura mater.
Fig. 11. Epidural anesthesia
First entry of cocaine into the epidural space was made Corning in 1885, for 14 years before Bier, this event went unnoticed and was honored resonance due to the fact that he wrongly assessed mechanism Corning received his anesthesia, suggesting that anesthetic was in a venous plexus and through hematogenous reached the spinal cord.
In 1901Mr. Cathelin informed about the possibility of anesthesia when injected cocaine into the epidural space through the sacral hole. However, only in 1921, Pages received segmental anesthesia when injected anesthetic into the epidural space of the lumbar spine. In the first epidural anesthesia used in urologic practice Holtsov BN (1933). In operative gynecology this method is widely applied MA Alexandrov, in operations on the abdominal organs – IP Izotov in thoracic surgery – VM Tavrovskiy. Epidural anesthesia is a great way anesthesia during operations on the lower extremities. Epidural anesthesia provides complete pain relief, muscle relaxation and minimal bleeding, this method creates optimal conditions for surgery.
Epidural anesthesia is common in urologic practice. Excellent anesthesia, muscular relaxation creates conditions of comfort during operations on the stomach, intestine, biliary tract, liver and spleen prolonged epidural anesthesia used in the treatment of peripheral vascular lesions of the lower extremities (excluding sympathetic innervation causes vasodilatation, improved circulation) and to stimulate intestinal paresis of the gastrointestinal tract.
Contraindications for the epidural anesthesia are the same as for spinal anesthesia.
Physiological effect of epidural anesthesia – total result of simultaneous exclusion of sensitive, motor and sympathetic fibers in the area of innervation blocked roots.
The technique of epidural anesthesia.
In the supine position on the side, or sitting, in sterile conditions at the required level, transmitting pain skin. Tuohy needle (with rounded ends) is puncture between the vertebrae, gradually pushing the needle. Absorbed by 1.5-
Due to the fact that high epidural anesthesia may be accompanied by depression of respiration, providing necessary auxiliary and artificial ventilation with oxygen.
Continuous epidural anesthesia can be provided catheterization of the epidural space. This epidural space punktuyut thick needle through which the catheter is carried out. The catheter is fixed to the skin patch. For surgical anesthesia using 2% lidocaine solution (mean dose 6.4 mg / kg) of lidocaine epinephrine added at a dilution of 1/200 000 (1 drop per 10 ml) for extension of time of anesthesia, together with adrenaline, you can add 1 -2 ml fentanyl or 0.5 – 1 ml of morphine or 1 – 2 ml clonidine. These drugs improve anesthesia, prolong the duration of epidural anesthesia. Possible side effects of narcotic analgesics – skin itch (blocked by neuroleptics), complications – respiratory arrest when injected at a high level.
In conducting the epidural anesthesia in the elderly and in patients with hypovolemia, may reduce blood pressure. Introduction of 1000-2000 ml saline at a rapid pace prevents this complication.
Intraosseous anesthesia.
At 2-5 minutes provide limb elevated position for reduce blood filling. Next on the chosen spot impose broad band rubber band or cuff of the device measuring blood pressure to stop blood flow. The usual needle transmitting pain of soft tissue and periosteum on bone puncture site by introducing 2.10 ml. 0.5% district novocaine. A special needle (needle for intraosseous anesthesia or shortened needle for lumbar puncture) puncturing bone in the area of epiphysis, retiring at 0.5-
Fig 12. Intraosseous anesthesia.
Signs of correct needle into the bone are:
1) feeling a crunch and overcoming resistance when piercing the cortical layer epiphysis.
2) strong fixatioeedle.
3) pain when you type the first portion of the solution and leakage from the needle drops stained with blood.
Anesthesia occurs within 2-5 minutes. after the solution and stored to remove tourniquet. About the beginning of anesthesia can be judged by the offensive “ marbling ” skin. Depending on the size of the limb segment consumes 90 – 100 ml of anesthetic. Conducting intraosseous anesthesia for fractures differs some features. With the introduction of solution into the distal epiphysis broken bone it almost all the results in bruising and quality of anesthesia other tissues remains low. For a better pain relief solution should be entered in the distal bone located and only as an exception – in the damaged.
Technique of certain types of local anesthesia.
Technique of local anesthesia.
Local anesthesia requires compliance with strict asepsis to avoid infecting tissue. Surgeon washing hands as he does before surgery. On the table for instruments covered sterile towel, put sterile anatomical tweezers, cotton bud and some gauze balls, squirt, thick and thin needle to it, a bottle with a solution of novocaine with thick long needle. Along with sterile table placed bottles with novocaine 1.2%, 0.5% or 0.25%. For each patient open a separate vial of Novocain solution. It should use a fresh solution of novocaine. Before the introduction of the solution doctor should make sure that he introduces.
The blockade is the fracture of long bones.
Impressions: closed fractures of long bones.
Technique: The projection of the line of fracture away from major vessels and nerves puncturing place fracture and end needle is applied to the bone. Spillage in hematite (the appearance of blood in the syringe piston at procrastination) injected 20 – 40 ml of 1% solution of novocaine. When multiple fractures each block change, it is necessary to take into account higher single dose of novocaine (1% – 100 ml).
Circular block cross-section of the extremities.
Impressions: open (gunshot) and closed fractures of long bones, prevention and turnstile shock syndrome long time compression when removing the tourniquet, extensive burns limbs and frostbite.
Technique: proximal to the fracture site (bundle) circularly from several points injected into the soft tissue at the depth of the bone 0.25% novocaine solution in an amount of 250 – 500 ml, depending on the thickness of the limb segment at the blockade. Every time the needle is introduced perpendicular to the skin in the radial direction.
Novocaine blockade packs for AV Vishnevsky.
Based on the solution of novocaine in fascial Cases limb muscles, which are vascular and nerve bundles. Introduced in case Novocaine washes nerve trunks and blocks holding them in pain impulses. Proper implementation of closure involves good knowledge of topographic anatomical location fascial pouch (Fig. 13).
Impressions: closed and open fractures of limbs, burns and frostbite of the extremities.
Technique: needle is injected to the bone away from large vessels and nerves, and then tighten to 0.5 – 1 sm at this depth injected 0.25% novocaine solution of 50 – 100 or more depending on the amount of muscle . In the presence of multiple covers of each block. Novocaine solution under some pressure washes bone penetrates the loose tissue, blocking the nerves that go into them.
Fig. 13. Novocaine blockade packs for AV Vishnevsky.
General anesthesia
The development of modern anesthesiology began in the early eighteenth century. and is connected with the name of the French scientist Lavoisier Anthony, who has studied gases Humfri Daviy English chemist who first studied the effect of nitrous oxide (laughing gas) and the English physician Horace Wales, who tested the tool on itself and was first used in
Extremely important for the development of anesthesiology had American chemist Charles Jackson of Boston, who discovered ether as an anesthetic, experiments dentist William Morton, who tried the action of the drug on himself and surgeon D. Warren, who was the first in the world October 16,
Important role in the development of anesthesiology played a British obstetrician James Young Simpson, who first used for anesthesia delivery chloroform and November 14, 1847 reported their findings of the Medical Society of Edinburgh. Since then began a rapid search of different drugs and routes of their administration, which continues today. A great contribution to the development of anesthesiology introduced MI Pirogov, which is one of the first in
In 1902, French scientist Lemon conducted experiments to develop electronarcosis on animals. This type of anesthesia is now widely used in combination with analgesics, sedatives and anticonvulsants. It was later developed a method anesthesia by needles in combination with analysts. Now, with large operations in the lungs, heart, blood vessels using artificial hypothermia (cooling) using a controlled circulation and ventilation.
General anesthesia (anesthesia, from Greek inarcao – grow torpid) – a state of deep artificial sleep, which is characterized by a temporary loss of consciousness, pain sensitivity and some reflex reactions by using different drugs.
There are several theories of the mechanism of anesthesia.
1. Lipid theory is based on the fact that drugs dissolve fats and fat-like substances in the brain tissue, thus penetrate the cells of the central nervous system and inhibit its activity. However, not all drugs and gases dissolve fats.
2. Adsorption theory, according to which drugs are adsorbed on the surface of nerve cells and alter their physical and chemical properties (broken enzymatic metabolism, etc.). Strength of the drug is directly proportional to the cell surface that adsorbed drug.
3. Theory breach of redox processes – drug effects resulting from violation of redox processes in the brain tissue. Fabrics lose their ability to absorb oxygen.
4. Neurogenic theory – drug effects associated with the braking action on the cerebral cortex and subcortex it. The process of developing a reflex inhibition under the influence of impulses from different receptors.
5. Membrane theory of anesthesia based on subcellular molecular level. Narcotic substances cause depolarization of cell membranes, impair the permeability of sodium ions, thereby violating the generation of excitation and action potential.
Depending on the routes of administration of drugs in the body distinguish inhalation anesthesia and noingalation. To ensure inhalation anesthetic drugs administered through the airways.
Noingalation perform anesthesia intravenously, intramuscularly, through the rectum (rectal anesthesia).
Depending on the depth of anesthesia distinguish the following types of anesthesia, both superficial and deep.
Depending on the method of distinction:
1) mononarcosis when using one substance (ether, ftorotan, pentron);
2) mixed anesthesia when used a mixture of drugs that are similar in their action;
3) combined anesthesia, which is used not only a mixture of drugs, but also different ways of administration (intravenous + inhalation).
Combined anesthesia consists of entrance, main (supportive), and extra base.
Induction of anesthesia is used to quickly enter the patient into a state of sleep.
Main (supporting) anesthesia performed on stage throughout the operation (ether ftorotan etc.).
Additional anesthesia is used to deepen the principal.
Basic anesthesia is used to start or simultaneously with the main (inhalation anesthesia + NFA) anesthesia.
For the duration distinguish complete anesthesia (with injuries and major operations) and part-time, or (Rausch-anesthesia, with short-term interventions – disclosure of pustules, reposition dislocations, etc.).
For the inhalation anesthesia using volatile (those that evaporate) and gaseous drugs.
Volatile drugs.
Ether (Aether pronarcosi) – transparent volatile liquid with a peculiar odor and a burning taste. Easy engaged. His release in bottles orange 100 ml. Store in a dark place, away from the fire. Using ether sleep occurs in 10-20 minutes and lasts 30-40 minutes after cessation of inhalation. Ether is a drug that causes inhibition of nerve cells, the medulla oblongata, liver and kidneys. Air under the influence of the sun and the air becomes unusable. To check the purity of the ether using different samples:
1) after evaporation of the filter paper should not smell;
2) after evaporation of the lenses should not be precipitate;
3) litmus paper should turn blue (does acidic reaction);
4) by mixing 10 ml of ether with 1 ml of 10% potassium iodide and exposed for 1 h. should not be color.
Chloroform (Chloroforneium) – transparent volatile liquid that decomposes when exposed to light. His release in bottles of orange glass 50 ml and store in a cool dark place. On the mechanism of action of chloroform is much stronger than air. The drug is toxic, is excreted by the kidneys. To check the purity of the sample used the following: 1) after evaporation of the filter paper should not be a smell, 2) moistened litmus paper should not blush.
Ftorotan (Phthorothanum), flyuotan, narkotan – clear liquid with a pleasant odor. Do not burn or explode. Much stronger than air, but also more toxic. After 1-2 min from the start of anesthesia patient loses consciousness and surgical stage occurs within 3-5 minutes and is accompanied by relaxation of striated muscles. It is often used in a mixture of nitrous oxide during surgical interventions on the lungs, abdominal organs.
Pentran (Pentran), metoksylfluron, inhalan – clear liquid with a characteristic fruity smell, is not involved and did not explode. Tends to penetrate the rubber products anesthesia apparatus, followed by diffusion, and therefore it should stop filing for 10-20 minutes until the end of the operation. By its action is much stronger than ether or chloroform. Pentran produce 50 ml and store in a dark orange sealed vessel.
Trichlorethylene (Trichlorethylenum), trylen – drug transparent volatile liquid with a peculiar odor. It is stored in bottles in a cool dark place. Has a pronounced analgesic narcotic effect. It is used mainly in short-term operations in dental and obstetric practice.
Etran (Etran), penfluran – its effect is similar to ftorotan. Provides rapid induction of anesthesia without the express excitement. Can be combined with intravenous anesthetics, nitrous oxide. Produced and stored in dark glass containers 50 ml (List B).
Gaseous drugs.
Nitrous oxide (Nitrogenium oxydulatum) – laughing gas, odorless, does not explode, but when combined with ether and oxygen supports combustion. Gas stored in a gray metal cylinders in a liquid state under pressure 50 atm. Nitrous oxide – an inert gas, the body does not enter into chemical reactions and is excreted unchanged in the lungs. For anesthesia is used in combination with oxygen in the ratio 1:1, 2:1, 3:1, 4:1 (70-80% nitrous oxide and 20-30% oxygen). Without oxygeitrous oxide is toxic. Therefore, reducing the amount of oxygen in the mixture is less than 20% is not acceptable.
Cyclopropane (Cyclopropanum) – flammable gas. It may explode. It is used in combination with oxygen, nitrous oxide, ether, etc.. Anesthetic action fast. Cyclopropane has no toxic effects on the liver, kidneys, cardiovascular system. Due to the positive impact on hemodynamics, it is often used in traumatic shock.
The main purpose of inhalation anesthesia is to ensure not only reliable anesthesia, loss of consciousness, and reliable and relaxing muscles (relaxation). Relaxed muscles by exercising muscle relaxant (muscle).
Muscle relaxants (curare-type drugs).
Muscle relaxant called drugs that have the ability to block the transfer of excitation in the neuromuscular junction of skeletal and respiratory muscles. The type of actions are divided into:
1. Nodepolarizing (d-tubocurarine, arduan, pavulon, trakrium etc.) – these drugs are antagonists of acetylcholine, they paralyze neuromuscular transmission and relate to real curariform substances.
Arduan (Arduanum) – white crystalline powder in capsules 4 mg, it is used in various surgical procedures at a rate of 0,04-0,06 mg / kg, these doses the drug causes in 2-3 minutes complete relaxation that lasts up to 50 minutes. Residual effect arduan removed Neostigmine.
Trakrium (trakrium) – solution for injection ampoules 2.5-5 ml. Trakrium injected bolus dose of 0.3-0.6 mg / kg, which causes a temporary (within 15-35 minutes) relaxation of respiratory and skeletal muscles. Complete neuro-muscular blockade is itself after 35 minutes.
2. Depolarizing drugs cause muscle relaxation by depolarization, similar to that of excessive amounts of acetylcholine, resulting in conduction of excitation from nerve to muscle. Preparations of this group quickly decompose and cause a short-term effect. The most common drug is ditilin.
Ditilin (Dithylinum) used in 1-2% solution at a rate of 1-2 mg / kg. After 10-15 seconds after entering ditilin appear fibrillar twitching of facial muscles, neck, limbs, which lasted over 10-15 seconds, and then comes complete relaxation of muscles for 5-7 minutes.
3. Mixed drugs can cause antidepolarizing and depolarizing action. Of these, the most commonly used imbretyl.
Imbretyl (Imbrethil) comes in ampoules of 2 ml of 0.2% solution. After intravenous injection (0,04-0,07 mg / kg) comes complete relaxation of skeletal muscles, which lasts 30-40 minutes. The drug is poorly excreted, so repeated doses should be significantly reduced.
On the mechanism of action of muscle relaxants are distinguished:
– Short-term muscle relaxation;
– Periodic muscle relaxation;
– Partial muscle relaxation;
– Total muscle relaxation.
Intermittent relaxation, usually used during intubation, during endoscopy, reposition sprains and fractures.
Periodic relaxation exercise muscle relaxants with a short period of when you want to create the largest muscle relaxation during surgery.
Partial relaxation is used when you want to relax your muscles, not excluding breathing. For this purpose, use small doses of tubocurarine chloride or dyplacin.
Pervasive relaxation exercise using nodepolarizing relaxants prolonged action and is used in large operations on the organs of the chest and abdominal cavities.
Today, under inhalation anesthesia performed all complex operations.
Contraindications to inhalation anesthesia divided into absolute and relative.
Absolute contraindications are:
– Absence of oxygen
– Intolerance of drugs
– Faulty equipment,
– Concomitant diseases and conditions, from which death can occur:
1) cardiovascular system in the stage of decompensation, hypertension, intractable drug therapy, hypotension associated with anemia, intoxication;
2) respiratory diseases with severe pulmonary insufficiency – acute pneumonia;
3) liver disease with severe it functional impairment;
4) kidney disease with impaired function;
5) severe anemia;
6) diseases with a marked increased intracranial pressure (tumors, cysts, etc.).
Relative contraindications are listed above diseases, but with less severe functional impairment.
Preparing the patient for anesthesia coincides with general preparation for surgery.
Before the surgery, each patient should: check the status of the oral cavity (available in her false dentures removed) to measure temperature and body weight, see your eyes (to determine their shape, size of the pupils, their reaction to light), check the airway (nasal passages); identify the mobility of the mandible, neck, pulse count and measure blood pressure; collect history (allergy, Transfusion) to determine blood type, Rh factor, wash stomach; insert a catheter into the bladder and release urine.
After this is sedation, which is based in the introduction for 30-40 min before surgery 0.1% solution of atropine sulfate at the rate of 0.01 mg / kg, narcotic analgesic (1% solution – 1 ml promedol or 2% solution – 1 ml omnopon etc.) and antihistamines (diphenhydramine, suprastin, diazolin et al.).
Mask inhalation anesthesia.
For the inhalation mask (Fig. 14) anesthesia today use only rubber mask with inflatable stoppers that tight-fitting mouth and nasal openings. For the mask anesthesia should cook spatula, gag, tongue holder, electric pumps, cylinder of oxygen. Anesthetics spend drip method. However, this type of anesthesia are rare today, mainly used to perform small surgeries, reduction of dislocations, reposition the bones.
Fig. 14. Mask for inhalation anesthesia.
Endotracheal anesthesia
Endotracheal anesthesia became most prevalent in surgery with operations on the organs of the thoracic and abdominal cavities, urology, traumatology, neurosurgery, vascular surgery. Endotracheal anesthesia carried out with the help of tubes, which are inserted into the airways (Fig. 15, 16).
Fig. 15. Introduction laryngoscope
Fig 16. Intubation using laryngoscope through the mouth
To use anesthesia laryngoscope (Fig. 17) (tool for examination of the pharynx and larynx login)
Fig. 17. Laryngoscopes with straight and curved blade
Apparatuses for inhalation anesthesia. For the inhalation anesthesia using several types of anesthesia apparatus (AN-4, UNA-1, PO-5, “Polinarkon”) (Fig. 18, Fig. 19). Despite different design features all modern anesthesia apparatus consists of four main blocks: the cylinder with gear, evaporator, dosimeter system supply gas. Cylinders are designed for gases. To recognize cylinders paint over them in different colors: blue – oxygen, gray – nitrous oxide, red – cyclopropane. Each cylinder has a pressure regulator – special gear. Dosimeter – a device that controls the flow rate of gas is measured in liters per minute for anesthesia. Vaporizers – a device that is used for different drugs (ether, ftorotan, etron etc.), the number of which is dosed with a special regulator in volume percentage.
Breathing circuit is designed to provide the patient with oxygen and drugs. It consists of corrugated tubing, system valves, absorber (absorber of carbon dioxide) breathing bag, mask, endotracheal tube.
Fig. 18. Anesthesia apparatus “Polinarkon” Fig. 19. Apparatus for mechanical ventilation
Depending on the method of anesthesia distinguished:
1) open the way when drug substance is mixed with air and exhaled too in the air, contaminating operating;
2) half-way when the drug substance is mixed with oxygen and exhale is in the air. The difference of this method from the previous is that drugs can be added;
3) half-way – a bottle breath, exhale partially adsorber, partly in the atmosphere;
4) closed way – inhale and exhale completely isolated from the environment. Gaseous mixture exhaled after the release of carbon dioxide in the absorber again goes to the patient
Clinical course of anesthesia.
The most common is the clinical course of inhaled ether anesthesia, which emit under anesthesia. Stage is called a period of anesthesia, which has characteristic clinical features, depending on the degree of depression of the central nervous system.
There are 4 stages of anesthesia:
1. Phase analgesia characterized by gradually increasing diffuse inhibition cortex, resulting dimming of consciousness, incoherent language against the background of sharply weakened pain sensitivity, pupils dilated, respond well to light, his face red, the tone of skeletal muscles maintained. Tactile and temperature sensitivity indicated. At this stage you can carry small surgery, dressings.
2. Phase excitation occurs in 5-6 min after the start of anesthesia. Because diffuse inhibition in the cerebral cortex and subcortical centers inhibition occurs so-called “riot subcortex.” Consciousness marred patient, there comes a pronounced motor excitation, increased tone of skeletal muscles. Patients behave as intoxicated, are trying to jump off the table. Their faces are flushed, pupils dilated, jaws compressed, rapid breathing, increased blood pressure, heart rate accelerated. To operate such patients in this stage can not. Should continue inhalation anesthetic.
3. Phase drugs (surgical) sleep occurs when inhibitory processes include measles and subcortical centers of the brain. The patient calms down, face gaining normal color, eyes narrowed, breathing becomes equal to fade all kinds of sensitivity, relax muscles and depressed reflexes.
For ease of observation of patients this stage of anesthesia is divided into four levels:
a) Level I – superficial anesthesia (level movement of the eyeballs), which is characterized by the preservation of corneal reflex, the disappearance of superficial reflexes and decreased tone of skeletal muscles. In this phase, you can perform minor surgery;
b) The second level – the average depth of anesthesia (corneal reflex level of extinction). This constricted pupils not reacting to light. Breathing is slow, skeletal muscle tone is decreased. This level is optimal for a variety of surgical operations without muscle relaxants, except surgical interventions on the upper abdomen and chest;
c) The third level – deep anesthesia (level of pupil dilation), characterized by the beginning dilated pupils, pale face, muscle tone is sharply reduced, the predominant type of diaphragmatic breathing, exhale longer than the inhale, blood pressure decreases. This level of anesthesia allowed for a short time (less than 30 min) in combination with artificial respiration and oxygen inhalation;
d) The fourth level – extremely deep anesthesia, characterized in that the patient’s condition worsens, the pupils dilate, the cornea becomes dull, pupils no longer respond to light. Pulse becomes frequent, weak filling. Blood pressure declines rapidly. Comes sphincter paralysis, respiratory and vasomotor centers, which leads to death. This level is not acceptable.
In modern anesthesia with the use of muscle relaxants operations are performed in the third stage of 1-2 levels.
4. Phase awakening, or withdrawal from anesthesia, characterized by disinhibition of subcortical centers and bark. All the signs of narcosis disappear restored reflexes, sensitivity, muscle tone and consciousness. After a full restore spontaneous breathing and consciousness Anesthesiologist spends Extubation (removal of endotracheal tube). Before swallowing reflex patient head turn sideways, periodically clean the mouth napkins and aspirators. To prevent the tongue in the oropharyngeal airway inserted. In the postoperative period to relieve pain periodically injected analgesics.
Complications of inhalation anesthesia.
The most dangerous is respiratory failure, which leads to hypoxia. The main causes of hypoxia include: airway disorders, depression of the respiratory center due to an overdose of drugs problem in the equipment.
Violation of the airway may result from: tongue and epiglottis; laryngo-and bronchospasm; mechanical airway obstruction (vomitus, napkins, etc.).
The main features of violation airway is noisy breathing, muscle tension torso, bluish lips, face, torso.
With tongue and epiglottis to:
1. Prominence to the lower jaw, using triple reception Safar, including:
a) mouth opening injured finger wrapped handkerchief (gauze cloth on clamps) release it from existing foreign bodies and fluids (vomit, sputum, algae, plug jaws, blood clots, etc.) (Fig. 20);
Fig. 20. I Stage reception Safar
b) rejecting the maximum head backwards, resting under the neck impromptu roller (eg own forearm). In the majority of victims tongue stops to close the entrance to the upper respiratory tract (Fig. 21);
Fig. 21. II Stage reception Safar
c) removing the lower jaw to the front (Fig. 22).
Fig. 22. III Stage reception Safar
2. With the ineffectiveness of this method behind the tongue enter air duct length is equal to the distance from the corner of the mouth to the angle of the mandible. End ductwork forward first toward the palate to push the tongue, and then return to the root of the tongue.
Laryngospasm caused by hypoxia, stimulation of mucosal anesthetics, blood, vomit. For prevention should not prevent hypoxia during surgery, and to provide effective analgesia.
In case of laryngospasm, bronchospasm must enter 1 ml of 1% solution of atropine sulfate, aminophylline, diphenhydramine, corticosteroids, with no effect should hold tracheal intubation, mechanical ventilation.
Mechanical obstruction of the respiratory tract caused by falling into the airway lumen gastric contents (regurgitation and aspiration), dentures, blood etc..
Prevention of this complication lies in thorough preparation for surgery of the digestive tract.
Cardiac arrest is the most dangerous complication during anesthesia. The signs of this threat are:
– Pale skin,
– Pulse is determined
– A sharp decrease in blood pressure,
– Dilated pupils, lack of reaction to light.
Prevention of this complication is the introduction of atropine sulfate, proper conduct of anesthesia, constant supervision of the pulse rate, blood pressure. It uses heart rate (Fig. 23).
When cardiac arrest immediately conduct a closed heart massage, during operations on the abdominal organs can be done through the diaphragm indirect heart massage, and in some cases perform thoracotomy, perikardotomy and open cardiac massage. Along with this should be performed and mechanical ventilation.
Fig. 23. cardiomonitor
To prevent complications of inhalation anesthesia is necessary:
1) carefully prepare the patient for surgery;
2) closely monitor the patient during anesthesia and surgery;
3) promptly identify and provide adequate medical care (administration of drugs, artificial ventilation, transfusion of blood products hemodynamic action, etc.).
Features care after inhalation anesthesia.
After surgery and removal of the patient from anesthesia it is placed in a separate ward or department for intensive care. First prepare functional bed, give him a proper position. Prepare a hot-water bottle, feeding apparatus moist oxygen system for intravenous infusion, aspirator, tonometer with phonendoscope, sterile syringes, a set of drugs needed for intensive care. Along with this for resuscitation prepare napkins, gag, tongue holder, air duct, laryngoscope, endotracheal tube apparatus for Ventilator toolkit Tracheostomy, defibrillator, etc.. After the normal operations of the patient laid on his back without a pillow. The feet are placed hot water bottles, moist oxygen flow establish, conduct intravenous infusion therapy. Observe the pulse, respiration, skin color, measure blood pressure. All these data are recorded in the map individual observations. Depending on the patient record the data in 15, 30 or 60 minutes.
Remember that after anesthesia, conducted a long-acting muscle relaxants may occur late apnea, which is usually preceded by drowsiness, muscular weakness, shallow breathing or rekuraryzation – complete relaxation of skeletal muscles. In these cases, you should immediately establish inhaling oxygen enter Neostigmine (Antidote muscle), atropine. The reasons for the sharp decrease in blood pressure, accompanied by collapse, can be painful shock, blood loss, acute heart failure, adrenal insufficiency. Depending on the reasons that caused the reduction in blood pressure are different means of intensive therapy. After using inhalation anesthesia, due to blockage of the bronchus with mucus or blood may be lung atelectasis. Atelectation area prone to lung inflammation. To eliminate atelectasis spend bronchoscopy, breathing exercises (abdominal and thoracic), cough, inflating rubber toy or camera with the ball (increasing air pressure in the lungs contributes to its smoothing).
Noingalation anesthesia and its species.
Noingalation anesthesia depending on the routes of administration may be intravenous, intramuscular, subcutaneous, intraosseous, rectal et al.
Intravenous anesthesia is used primarily as an introductory basis, and anesthesia. For this purpose, thiopental sodium (sodium salt 5 (1-methylbutyl)-5-ethyl-2-thiobarbituric acid) 2-2.5% solution. It is introduced slowly over several minutes, with the rapid introduction collapse may occur. The maximum dose of 1000 mg. Anesthesia occurs within 2-3 minutes without phase excitation. Disappears pain sensitivity, the patient faints. There is a first level III anesthesia. To maintain anesthesia patient periodically injected 10-15 ml of the same solution. Awakening occurs within 10-15 min after cessation of hexenal. Antagonists of thiopental sodium overdose is Bemegride. Thiopental sodium is contraindicated in kidney, liver and cardiovascular system. It can cause allergic reactions (rash, breathlessness, tachycardia, laryngospasm), and therefore it is not recommended to use in patients with allergic conditions. During surgery possible tongue and asphyxia.
For anesthesia when performing small surgical interventions using sodium hydroxybutyrate. This medication has a marked sedative, original drug and a weak analgesic effect. Basically it is used for induction of anesthesia and combined. After intravenous injection at a dose of 75-150 mg / kg dream occurs within 5-10 minutes and lasts 30-40 minutes.
Good anesthetic for intravenous injections and intramuscular is ketamine. This product is produced in a 1% solution in bottles of 20 ml. It is used in short small operations in combination with endotracheal anesthesia. Ketamine creates a pronounced analgesia and minimal impact on the function of major brain structures.
Neuroleptic analgesia – a kind of condition which develops analgesia, a sense of indifference and lethargy. To do this, use a narcotic analgesic – fentanyl (1 ml – 0.05 mg) and neuroleptic – droperidol (1 ml – 2.5 mg) or a mixture of fentanyl and droperidol titled “talamonal.” Use two options: Neuroleptic analgesia with preserved breathing and Neuroleptic analgesia in conjunction with endotracheal intubation, mechanical ventilation and relaxation .
Ataralgesia. Combining tranquilizer diazepam with fentanyl, pentazacine called ataralgezia. On the mechanism of action of this method of anesthesia similar to Neuroleptic analgesia.
REFERENCES:
1. Кіт О.М., Ковальчук О.Л., Пустовойт Г.Т. Медсестринство в хірургії. Тернопіль; «Укрмедкнига», – 2002.
2. Петров С.В. Общая хирургия . Москва; «Геотар Медиа», – 2010.
3. Панцырев Ю.М. Клиническая хирургия. М., 1988
3. Хегглин Ю. Хирургическое обследование (перевод с немецкого). М., 1990
4. Общая хирургия: Учеб. пособие. /Г.П. Рычагов, П.В. Гарелик, В.Е. Кремень и др.; под ред. Г.П. Рычагова, П.В. Гарелика, Ю.Б. Мартова.-Мн.: Интерпрессервис; Книжный Дом, 2002.-928с.
Prepared by:
DB Fira.
