What is it - a modern anesthesia? Regional panegyric of
A little bit anatomy... The spine column consists of 7 cervical, 12 chest and 5 lumbar vertebras with a sacrum and a tailbone, adjacent to them.
In front there are massive bodies of vertebras , and shoots form the vertebral channel passing from the first cervical to the last sacral vertebra.
From within in the vertebral channel the long bag (rather - a stocking) formed by sheaves and covers settles down. This bag is filled with special cerebrospinal fluid - likvory in which the spinal cord floats.
It begins from the first cervical vertebra and comes to an end at the level of an interval between the first and second lumbar vertebras as it is well visible in drawing.
Anatomic the spinal cord is divided into cross segments, according to number of vertebras.
The spinal nerves leaving a backbone through lateral openings depart from each segment on the right and at the left.
But the spinal cord is shorter than a backbone !
Yes. And therefore below the first lumbar vertebra nerves go down and leave through “the“ openings, according to number of a segment.
The bunch of nerves which is freely floating in a likvor forms so-called “a horse tail“ .
That`s it this remarkable fact that the spinal cord comes to an end rather highly, does possible safe regional (it - neuroaxial) anesthesia .
All manipulations are carried out below the second lumbar vertebra.
Over a firm brain cover (in Latin Dura mater) and under the Yellow sheaf (Ligamentum flavum) - in drawing it for some reason blue - is the space filled with fat. 4 mm - in the widest place - exactly in lumbar department.
The epi prefix in Latin means “over...“. Over the Silly woman a mater - epiduralny .
On the way from a spinal cord outside nerves surely pass through this most epiduralny space.
One more gift of the nature to medicine.
If to fill with local anesthetic epiduralny space, it by all means will block nerves.
As takes place actually.
For the first time spinal anesthesia in that look as it is known to us now, was applied by the famous German surgeon Augustus Bir in 1897.
As local anesthetic he used cocaine.
Epiduralny anesthesia was for the first time described in 1921 by Fidel Peydzhes and irrespective of him - Akhilly Dogliotti in 1931.
Long enough regional anesthesia was not so widely applied - cocaine led to serious complications. And the risk of infections was big. And an infection in a hermetic cavity with such most delicate contents - it is awful and presently, and then, to antibiotics...
Situation sharply changed when new local anesthetics were synthesized: novocaine, ksilokain, trimekain, bupivakain... Then came up with idea of disposable tools. And business went!
Has to note what with spinal and epiduralny anesthesia is connected any fears and dense delusions hardly no more, than with an anesthesia. You will sometimes hear it... though throw a coin: to cry or laugh?
I will not spend time for transfer of horror films, and I will just tell about these remarkable ways of disposal of pain. I declared a panegyric in heading.
Spinal anesthesia becomes very simply. The patient is stacked sideways and ask to curl up (an embryo pose) or to sit down and to be bent as much as possible. It is important that the back was most bent - awned shoots of vertebras disperse as furs of an accordion, opening more convenient access.
The doctor does by a thin needle local anesthesia in an interval between the second - the third or third - the fourth lumbar vertebras (it is felt as the easiest prick) and carries out a long needle more deeply, getting through sheaves and covers. At some moment he feels “a failure in emptiness“ and stops, and the needle begins to come out transparent liquid.
( to Leave - it is strongly told. The needle is so thin that you will be tired to wait until the sound drop is gathered. ) Having convinced by
that where went, there and got, the doctor enters solution of local anesthetic through a needle.
Operation of Cesarean section, for example, requires even 2 (two) milliliters of 0,5% of solution of a markain.
The needle is taken. In total. It is enough to anesthetize all lower body for a couple of hours.
Epiduralny anesthesia is technically more difficult. From the same access it is necessary to get to very narrow epiduralny space and to carry out there a catheter: a tubule from special plastic (polyair the block amide) only 0,8 mm thick. Special needles (Tuohy`s needle) are for this purpose developed.
Despite some complexity, epiduralny anesthesia was widely adopted. Its main advantage is that it can be prolonged beyond all bounds long.
As required on a catheter local anesthetic is added, and the patient does not suffer from pain, keeping absolutely clear consciousness and physical activity. And it is sometimes the most important factor of recovery.
Some lack of epiduralny anesthesia is its some “sluggishness“ - it is necessary to wait for occurrence of effect from 10 to 20 minutes - and not absolute efficiency.
The reasons of a partial or total failure can be a little.
Without being late on their transfer, I will tell that the advantage of “epiduralka“ is so high that sometimes (if there is opportunity) it is worth repeating procedure and to achieve anesthesia.
Spinal anesthesia works very quickly - in only a few minutes - and very effectively tears off pain. The most usual expression on a face of the patient - the greatest surprise. Here just eyes climbed on a forehead from wild pain... And suddenly - the total rest and pleasant heat in legs.
It is possible to prolong spinal anesthesia too, but it is usually not done - the risk is too big. Arrive differently: combine spinal and epiduralny anesthesia.
At first reach by Tuohy`s needle epiduralny space, through it pass a thin needle in subduralny (it couple millimeters deeper). Enter an anesthetic dose, and then carry out an epiduralny catheter.
Thus both problems are solved at once: speed and reliability of anesthesia and opportunity to prolong it for any reasonable term.
Since there were disposable sets for regional anesthesia, infectious complications - the most terrible consigned to the past at this type of anesthesia.
The place of a prick is processed in the same way as the operational field, and laid over by sterile sheets. The anesthesiologist works in a mask and sterile disposable gloves. In some clinics the vestments in a sterile dressing gown are accepted. But it is already overcaution.
It is necessary to refer its controllability to advantages of epiduralny anesthesia .
Having established a catheter (it flexible, after fixing with a sticker and plaster it does not hinder the movements at all), it is possible, regulating the volume and speed of supply of the anesthetizing solution, to try to obtain anesthesia of any necessary depth and level (height of a painless zone) - from legs to a thorax.
Besides, the patient, and is more often - the patient - the woman in labor, can independently operate the anesthesia. In hands it is given the remote control with the one and only button. While the device gives solution according to the entered program, it can, having pressed the button, to receive an extraordinary portion.
“Abuse“ is impossible here as in the program restrictions for executions of requirements are introduced.
I usually speak: “Press when you want, and you will receive when it is possible“.
Disagreements do not happen. On the contrary, confidence that the health in own hands, leads to much smaller consumption of the anesthetizing substances.
have some contraindications to regional anesthesia.
On the first place - refusal of the patient.
Further infectious diseases of skin in the place of alleged manipulation, violation of coagulability of blood, sepsis follow...
And still rather rare, but well-known to the anesthesiologist of trouble.
Regional anesthesia does not influence intensity of patrimonial activity in any way. The duration of delivery does not change.
But if there are obstetric troubles, they also are eliminated simply and without serious consequences: the simple additive of anesthetic creates ideal conditions for absolutely painless solution of obstetric problems.
And if there is a need for urgent operation, then, in fact, everything is already ready: the anesthesiologist adds more concentrated solution, and forward - fortunately motherhood.