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ANESTHESIA- INTENSIVE CARE
Intensive care area in SOMESAN CLINIC is has three specialist doctors Dr. CÂMPAN CLAUDIA, Dr. STOICOVICI ADRIANA and Dr. PĂUȘAN ALINA.
SPECIALITY HISTORY
Surgical anesthesiology, as medical preoccupation, has a precise birth date: 16 October 1846, when William Green Morton has his first demonstration of anesthesia with diethyl ether, anesthesia under which the surgeon John Collins Warren operates Gilbert Abbott for a bucco-lingual vascularized tumor.
On the current territory of Romania, anesthesia with diethyl ether, sulphuric like it was called then, was introduced by some surgeons in the first months of the following year. So, in "Temesvarer Wochenblatt", from 13 Feb. 1847, the article "Uber die Einatmung des Schwefelethers bei chirurgischen Operiationene; um dem Kranken jedem Schmerzgefuehle unzugaenglich zu machen.." (Over the inhalation of sulphuric ether , in surgical operations, for prevention of any pain..), in which the execution of an anesthesia with sulphuric ether is reported, by the surgeons Dr. Mathyus Musil (1806-1850), in the military hospital from Timisoara, in 5 Feb. 1847, for an intervention of thigh amputation, on the patient "Nicola Muntyan" (Nicolae Munteanu).
Also, around that date, an anesthesia with ether, from the city of Iasi is mentioned in the newspaper "Albina" No.12 from 9 Feb. 1847, pages 54-56, in an article that was probably written by Gheorghe Asachi, it is mentioned that in Saint Spiridon hospital, an ether anesthesia was performed for an thigh amputation, by Dr Gh. Cuciureanu, A. Bendelea and L. Russ (senior). There are assumptions that the date of this anesthesia could be before the date of the Timisoara anesthesia. In 8 of March 1847, it is mentioned in "Vestitorul Romanesc" no.19, page 76, the first ether anesthesia from 21 Feb., in Bucuresti, "Coltea" hospital, also for a thigh amputation, by Dr. Demetrius Vartidi and Farm. Johann Franz Traugott Rissdoerfer. In 22 Feb. 1847, an ether anesthesia is administrated in Tg. Mures, by Dr. Johann Rummel, also in the military hospital, and in Cluj by Dr. Bogdan Abraham Pattantyus in "Carolina" hospital, the news was published in "Termeszetbarat" No.33 from 11 of March 1847. The ulterior development of anesthesia was without doubt, the realization of the surgeons who, beside the problems regarding surgical pathology, O.R environment, were preoccupied by the development and diffusion of anesthesia techniques. We can not talk about specialized anesthesiologists, in Romania, only after the 2nd World War. In England they already have appeared (J. Sow, J. T. Clover and others). specialty, but it's associated with anesthesia: Anesthesia-Intensive Care.
In the intensive care units, patients with life threatening tainted functions or injured organs are admitted. From this reason, the intensive care units are very well equipped: ventilation equipment for respiratory function supply, dialysis equipment for renal function supply, different types of monitors for many parameters observation (arterial pressure, ventricular failure, blood saturation in CO2 and oxygen, blood pH measurement, heart cavities pressure etc.).
The anesthesia activity and intensive care activity are performed by a complex medical team, formed from: doctors, nurses, sanitary auxiliary personnel and other categories of trained and authorized personnel, in conformity with the rules.
Intensive care includes: diagnosis, prevention and treatment of all acute insufficienty of vital functions. The specific treatment measures are addressed to patients that are in life threatening situations.
The AIC activity can be performed:
a) in the hospital:
-in the operation block: O.R or pre-anesthesia room;
-outside the O.R;
b) in AIC bed component, situated in a clear location and destined exclusively to this activity;
in ambulatory: pre-anesthesia consult and pain therapy.
AIC activity outside the O.R refers to assuring the necessary conditions for some diagnosis manoeuvres and/or non surgical therapies that necessitate anesthesia and that take place in:
a)radiology and medical imaging laboratory (C.T unit, angiography, MRI etc.)
b)laboratory/compartments of functional explorations (cardio-respiratory, digestive function);
c) other structures that are justified.
EPIDURAL ANESTHESIA
The technique for locoregional anesthesia consists in injecting an anesthetic solution in epidural space (between the vertebra and the dura mater, the most exterior meningeal cover).
It can be made in the cervical, dorsal, lumbar or sacral area.
Indications - In the lumbar area, the epidural in indicated during the gynecology operations, urinary or inferior limbs operations, rarely in digestive operations (appendectomy, for example). It is used, also, in debilitated patients, to diminish the post-operation pains, in the next two days after the operation, and during deliveries, to diminish natural delivery pains, or to perform a C-section. Cervical or dorsal epidural allows thyroid operations,oto-rhino-laryngologie, and breast carotid arteries .
Contraindications - Absolute contraindications are coagulation disorders and anticoagulants administration, hypovolemia (blood volume decrease) and hemorrhage. Relative contraindications are fever and any infectious condition in the moment of anesthesia, spinal cord malformations, and also some cardiac diseases.
Technique - The injected product impregnates the nerve roots and anesthesiate the nerves that conduct the pain sensation. The number of blocked nerves depends of the quantity of injected liquid. An epidural is appropriate for 2-3 hours operations; after that time, the patient feels difficulties in handling the immobilization, and claims for a sedative. In exchange, when the dosage is smaller (natural delivery or post-operation analgesia), the epidural can last for more hours, even one or two days.
Course - Patient position is chosen after his condition and the anesthesiologists habits: to get the injectin, the patient can sit down, lay on his side, with his calves brought to his chin. In women that are in labor, the epidural is administrated in the moment when the dilatation in between 3 and 5 cm. A strict disinfection of the injection spot is necessary, followed by a local anesthesia that allows the desensitization of the skin. The injection is made after an intravenous perfusion in put and under arterial pressure and cardiac rhythm control.
Secondary effects - An epidural can trigger a decrease of the arterial pressure and/or shiver during the intervention, and also a urine transitory retention after the intervention, which necessitates a gall bladder probe. Headache, very rare, are treated with pain killers and rest. An epidural hematoma, an exceptional event if the contraindications are respected, can bring an inferior limbs paralysis and necessitates an emergency surgical treatment .
GENERAL ANESTHESIA
Suspension of general sensibility ensemble of the organism, general anesthesia is used on a large scale during surgical interventions. It is also used during painful or long exams, with the sole purpose to make the patient more comfortable and to assure a good technique quality. It is obtained due to the use of different anesthesia that is administrated on respiratory, digestive or venous way, and that brings a complete loss of consciousness .
Criteria - general anesthesia associates three types of action:
-narcosis (loss of consciousness, or deep sleep), which is due to an anesthesia agent, either by inhaling (in the past ether, today Nitrous oxide or halogenated agents ) , or by intravenous way (barbiturates, ketamine, etomidate, and recently diprivan);
-analgesia (pain disappearance) which is obtained due to the morphine substances such as phenopheridine and fentanyl);
- curarization (use of a curare) that allows muscular relaxation or paralysis .
Course:
-before the operation, it is essential that the anesthesiologist and the patient meet. This meeting gives the possibility, to the doctor, to establish a psychological contact with the patient (to calm his worries, by explaining how the intervention is going to work), to know his and his family surgical history (reaction to previous anesthesia, treatments, allergies, alcoholic intoxication etc.) and also to make a complete clinical exam. To all this, sometimes it is added complementary exams like urea measuring and blood glycemia, search for sugar and albumine in urine, EKG and lung X-ray. In the evening before the operation, the patient is left without food, to avoid vomit during operation. With an hour or two before the operation, it is administrated, to the patient, a sedative and a belladonna extract, that give the possibility to avoid cumbrous reactions (hypersalivation, cardiac deceleration or vomit).
-during operation, falling asleep (or anesthesia induction) is made by administration of an anesthesia agent, more often by intravenous injection, the gas anesthesia inhalation. Inhalation anesthesia consists in application, on the patients face, of a mask that is connected to a balloon with a gas admixture of oxygen (30% minimum), and nitrous oxide (70% minimum), associated with a volatile halogen (halothane). The intravenous injection consists in introducing in blood circulation of an anesthesia hypnotic agent and after it is mainly added a curarization product (that suppresses the action of motor nerves over the muscles), and an analgesic product of morphine type when the pain needs to be diminished. Maintaining intravenous anesthesia is made either by re-injecting anesthesia agents periodically, or inhalation of a volatile anesthesia. General anesthesia necessitates a permanent observation of vital functions, respiratory and circulatory, on the entire intervention. The anesthesiologist controls the arterial pressure, and, if necessary, makes an adapted perfusion. He watches the sleep depth , that needs to stay in surgical stage, meaning regulate breathing and muscular relaxation.
-after the operation, the patient is taken in a special room, called "awakening room". It is very important that the awakening is observed, because ,very often in that moment, anesthesia accidents (tongue accidents) or surgical act related occur. The patient is not brought inn his room only after a consciousness normal condition and sufficient reflexes are found. Though, use of some drugs such as benzodiazepine, often provoke an post-surgery amnesia, the patients does not remember the first awakening, has the impression that he only woke up in his room. A time is needed, a couple of hours, before the patient can drink, and the eat.
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