home Endocrinology General anesthesia in gynecology. Anesthesia and anesthesia

General anesthesia in gynecology. Anesthesia and anesthesia

The specificity of anesthesia in gynecology is determined by the peculiarities of the topographic-anatomical location of the internal genital organs and the presence of extragenital pathology in the majority of operated women.

It is known that during gynecological operations performed by laparotomy access, especially during extirpation of the uterus with appendages, Wertheim surgery, on the uterine appendages, surgical manipulations are associated with long-term traumatization of extensive reflexogenic zones of the pelvis, intestines, bladder, rectum, large vascular formations and retroperitoneum. space.

The presence of extragenital pathology should correctly guide the anesthesiologist when choosing more safe type anesthesia, and also provide for the prevention of possible complications both during anesthesia and during postoperative period.

IN last years There has been a generally accepted trend - a move away from anesthesia in favor of combined types of general anesthesia. In this case, the basis is nitrous oxide, and all other anesthetics are used as an additional component (ether, fluorothane, etc.).

On modern stage The division of general anesthesia into inhalation and non-inhalation (intravenous) in gynecology should be considered conditional, since inhalation anesthetics are never used in their pure form and require combined use with other anesthetics for subsequent anti-stress protection from surgical trauma. Thus, general anesthesia in gynecology should be carried out according to the principle of multicomponentity.

Hypnotic (narcotic) drugs, divided into inhalation and non-inhalation, are characterized by a general neuropharmacological mechanism of action, leading to loss of consciousness, assessment of external stimuli, without affecting the conduction of pain impulses to the structures of the central nervous system. Agents for intravenous general anesthesia are represented not only by hypnotics, but also by psychotropics, including benzodiazepine tranquilizers and antipsychotics.

The most numerous group of intravenous hypnotics (narcotics), among which, over more than half a century of history of general anesthesia, few have stood the test of practice.

Most wide use received barbiturates, steroid anesthetics (viadril, predion), propanidine (sombrevin, epontol), etonidate, propofol (diprivan).

In recent years, propofol has taken the leading place, due to its characteristics it promotes rapid onset of sleep (30-40 s), has rapid clearance and half-life (30-60 min), ultra-short action (3-5 min), lack of accumulation, the ability repeated administration without the risk of postoperative depression and easy to manage.

The only drawback of diprivan is its vagotropic effect, manifested in bradycardia and a tendency to hypertension.

To reduce the incidence of such complications, the use of fentanyl is recommended. Taking into account its vagotropic effect, the drug must be used in reduced doses (0.25-0.5 ml of 0.005% solution) in combination with diprivan. The most justified combination of Diprivan with Calypsol, and in microdoses (0.25-0.5 ml).

In case of initial tachycardia (arrhythmia), it is advisable to combine diprivan with clonidine, also in reduced doses (0.01% - 0.25-0.5 ml).

The most common type of anesthesia is pain relief for induced abortion.

Anesthesia is carried out with calypsol (1-1.2 mg/kg body weight), diprivan (4-8 mcg/ml) or a combination of diprivan with microdoses of fentanyl (0.05-0.025 mg) and calypsol (25-12.5 mg). This combination ensures a stable course of anesthesia without significant hemodynamic disturbances. At later stages (more than 12 weeks), non-inhalational anesthesia is maintained by inhalation of nitrous oxide and oxygen in a ratio of 1:3. Similar anesthesia is performed during diagnostic curettage of the uterine cavity and during hysteroscopy.

For other gynecological operations performed via laparotomy, combined endotracheal anesthesia with muscle relaxants and mechanical ventilation is necessary.

The most generally accepted scheme for this anesthesia involves the following stages - premedication, induction of anesthesia and tracheal intubation, maintenance of main anesthesia.

Premedication is the direct pharmacological preparation of the patient, carried out to create the most optimal background before surgery. It includes intramuscular injection promedol 20-40 ml, atropine (0.5-1 mg), antihistamines (diphenhydramine 20-40 mg, etc.) 30 minutes before surgery.

In the presence of extragenital pathology, premedication can be supplemented with the administration of ataractics or neuroleptics to achieve a more pronounced sedative effect and prevent complications of reflex origin.

In the presence of pathology of the cardiovascular system, respiratory organs, and other systems (kidneys, liver), premedication is supplemented with a number of pharmacological agents, purposefully influencing the correction of existing violations, namely the use cardiovascular drugs, vasodilators, etc.

In the presence of allergic reactions, long-term use glucocorticoid premedication is supplemented by administration prophylactic doses steroid hormones (prednisolone 30-60 mg, hydrocortisone 125-250 mg).

IN emergency situations premedication is carried out by intravenous administration of drugs. In this case, the dose is determined individually, taking into account the initial condition of the patient.

Induction of anesthesia is achieved according to the generally accepted scheme. For this purpose, ketamine (calypsol, ketalar), propofol (diprivan) are used.

The advantages of induction of anesthesia are well known - the speed of onset of narcotic sleep, the absence of an arousal stage, and a reduced incidence of complications such as vomiting and nausea. It is advisable to simultaneously inhale nitrous oxide with oxygen (in a ratio of 1:1 or 2:1) during induction of anesthesia. This makes it possible to significantly reduce the dose of non-inhalational anesthetics. In addition, optimal oxygenation is achieved, which reduces the risk of possible respiratory and hemodynamic dysfunction.

The optimal level of depth of induction anesthesia is stage III. Upon reaching this stage, depolarizing relaxants are administered (ditilin, listenone, etc. at a dose of 1-1.5 mg/kg).

Against the background of achieved muscle relaxation, tracheal intubation is performed using endotracheal tubes with an inflatable cuff. It is necessary to perform anesthesia before tracheal intubation. vocal cords lidocaine or lubricate the tubes with a 1% dicaine solution.

Tracheal intubation can be performed blindly or using laryngoscopy. During intubation, the patient's head can be in the classic position or in the Jackson position. In the classic position, the head is in the same plane as the body and tilts back during intubation. At the same time, the neck muscles tighten, and the distance between the incisors and the glottis increases. In the Jackson position, the head is placed on a pillow 10 cm high with the chin pulled upward. In this position, the neck muscles are relaxed, and the distance from the incisors to the glottis is reduced.

Sometimes, if necessary, the head end of the table is lowered to place the line of the incisors and glottis in one horizontal plane. When intubating using direct laryngoscopy, the device is taken into left hand, right hand The patient's mouth opens and the blade is carefully inserted. The patient’s upper and lower lips should not be pinched between the blade and the teeth. If artificial prostheses are present, they are removed before surgery.

The blade is inserted into the throat midline or slightly to the left of it, leaving the tongue to the left of the blade. The root of the tongue is pressed upward (anteriorly). In this case, the laryngoscope blade moves from a vertical to a horizontal position.

When using a straight blade, the subglottis is picked up by the blade and shifted upward (anteriorly). After this, the glottis is clearly visible and the endotracheal tube is inserted to a depth of 3-4 cm, the cuff is inflated and the tube is connected to the device.

The correct placement of the tube is verified by bilateral auscultation of the lungs. Correct tracheal intubation ends with loose oral tamponade or fixation of the endotracheal tube.

The period of maintaining anesthesia should include its optimal depth, adequate ventilation, and muscle relaxation. Adequate depth of anesthesia is maintained in stage III1-2. Artificial ventilation lungs is carried out both hardware and manually.

Anesthesia machines are multifunctional and have the following components:

Inlets (input rates) for medical gases that come from cylinders or through a stationary gas distribution system;

Pressure regulators (reducers) that reduce gas pressure;

Safety mechanism for low oxygen pressure, equipped with an alarm;

Supply valves and dosimeters that regulate the flow rate of medical gases;

Vaporizers, in which medical gases are mixed with vaporized inhalational anesthetics;

The outlet pipe for supplying the breathing mixture to the breathing circuit.

Modern anesthesia machines are equipped with spirometers, pressure sensors in the breathing circuit, an oxygen analyzer and other necessary components that ensure the safety of anesthesia.

Both inhalational (nitrous oxide, fluorotane guoflurane, penitran, ether, enflurane, etc.) and non-inhalational (ketamine, diprivine, etc.) anesthetics, as well as narcotic drugs, are used as anesthetics.

The generally accepted principle is combined endotracheal anesthesia with nitrous oxide and oxygen with neuroleptics, ataralgesia, and electroanesthesia.

For short-term manipulations, maintaining anesthesia is possible with nitrous oxide in combination with fluorotane (in the ratio of N2O to O2 - 3:1 or 2:1, fluorotane 0.25 - 1-2 vol.%, etc.). This type of anesthesia is easy to manage and allows you to provide everything the necessary conditions for performing gynecological operations.

The method of choice may be the use of other inhalational anesthetics as one of the components of anesthesia, namely ether (2-4 vol.%), methoxyflurane with maximum concentration in the inhaled mixture about 3%, desflurane, etc.

Relative contraindications are profound dysfunction of the liver, kidneys, and cardiovascular system.

In such situations, it is possible to use mask inhalation anesthesia.

However this type anesthesia is carried out using a hardware method, which allows for a more accurate dosage of both the anesthetics used and oxygen.

The safety of its implementation is ensured by the skill of performing anesthesia with a mask method, a clear orientation in the clinic of the course of anesthesia at stage III1-2, knowledge of possible complications and ways to prevent them.

When performing anesthesia during gynecological operations, one should take into account the features female body and the difficulties that the surgeon encounters while working on the organs of the lower floor of the abdominal cavity.
According to E.V. Merkulova (1975) and N.N. Rasstrigin (1978), patients with benign and malignant neoplasms of the genital organs are characterized by a large number of concomitant extragenital diseases of the cardiovascular system (hypertension, chronic ischemic heart disease, etc.), lungs and parenchymal organs. Often, especially in menopause and menopause, the condition of patients is aggravated endocrine pathology, caused by dysfunction of the ovaries and manifested primarily by obesity and a tendency to diabetes mellitus. In addition, patients in this group are characterized by pronounced psycho-emotional instability.
Performing gynecological operations is complicated by technically difficult access to the pelvic organs, the presence adhesive process, which is a common consequence of frequent inflammatory diseases in women, the need to manipulate in a richly innervated and vascularized area. Often operations have to be performed against the background of severe anemia (in patients with menometrorrhagia, submucous uterine fibroids, etc.) or severe intoxication due to peritonitis or purulent tubo-ovarian formations.
Most often in gynecological practice, anesthesia is performed during planned standard operations for benign tumors uterus (to the extent of conservative myomectomy, supravaginal amputation or hysterectomy; the latter operation is sometimes performed through vaginal access) and ovaries (to the extent of removal of the uterine appendages, resection of the ovaries, etc.). The most severe, lengthy and traumatic operations are associated with the removal of purulent tubo-ovarian formations, as well as with widespread endometriosis, in which the bladder, intestines and omentum are involved in the process. Operations performed for urogenital fistulas are often no less complex.
Emergency operations are usually caused by bleeding (disturbed ectopic pregnancy, metrorrhagia with submucosal location of myomatous nodes), peritonitis, uterine perforation during artificial termination of pregnancy.
A special group consists of minor interventions: artificial termination of pregnancy, diagnostic entry into the uterine cavity, endoscopic examinations.
When choosing an anesthesia method, one must proceed from the nature of the surgical intervention, the patient’s condition, and the qualifications of the anesthesiologist. Today, when even highly qualified gynecologists do not know the method of local infiltration anesthesia, one has to choose between endotracheal general anesthesia, long-term epidural anesthesia and various options for intravenous anesthesia with spontaneous ventilation.
Typical operations, as a rule, can be performed under both endotracheal general anesthesia and epidural anesthesia. If possible, the patient's wishes should be taken into account when choosing an anesthetic method. The presence of pulmonary pathology and diseases of parenchymal organs makes epidural anesthesia the method of choice.
Emergency operations due to bleeding and uterine perforation should be performed under endotracheal general anesthesia. The method of choice in patients with severe intoxication is a combination of long-term epidural and endotracheal anesthesia.
Minor surgical interventions and painful diagnostic procedures can be performed under intravenous or inhalational (a mixture of nitrous oxide and oxygen) anesthesia.
For the purpose of premedication during endotracheal general anesthesia, sedatives (diazepam at a dose of 0.15 mg/kg) or antipsychotic drugs in combination with narcotic analgesics and atropine or metacin. These agents can be administered intramuscularly 30 minutes or intravenously 5-10 minutes before the start of anesthesia.
The most commonly used premedication options are: 1) promedol (0.3-0.5 mg/kg) + diphenhydramine (0.15 mg/kg) + atropine (0.5-1 mg), 2) fentanyl (1-2 mcg/kg) + droperidol (0.07-0.15 mg/kg) + metacin (0.5-1 mg); 3) fentanyl (1-2 mcg/kg) + diazepam (0.15-0.3 mg/kg) + atropine (0.5-1 mg). If necessary, premedication includes steroid hormones, cardiac glycosides, etc.
If in patients without significant extragenital pathology, who are in satisfactory condition, the type of anesthetic for induction of anesthesia is not particularly important, then in case of a burdened allergic history, propanidide should be abandoned, and in case of initial anemia and hypovolemia, preference should be given to ketamine. It is advisable to maintain anesthesia by inhaling a mixture of nitrous oxide and oxygen (3:1 or 2:1) in combination with drugs for neuroleptanalgesia.
When performing epidural anesthesia, the technique of which for gynecological operations practically coincides with the technique of long-term epidural anesthesia for caesarean section, premedication includes subcutaneous administration of 0.5-1 mg of atropine and 25-50 mg of ephedrine.
During emergency operations performed for impaired ectopic pregnancy or perforation of the uterus with injury to large arterial trunks, the severity of the patient’s condition is determined by massive intra-abdominal bleeding. The faster the bleeding is stopped, the greater the chance of recovery for the patient. In such a situation, there are no contraindications to the immediate start of the operation and, therefore, to anesthesia. Emergency preparation to anesthesia, carried out during the deployment of the operating room, includes providing reliably functioning access to two to three vessels, infusion therapy to maintain blood pressure above critical levels, administration of steroid hormones, etc. Pre-medication includes antihistamines and atropine. The anesthetic of choice for induction of anesthesia in these patients is ketamine. In case of massive blood loss, prolonged mechanical ventilation in the postoperative period should be carried out until hemodynamics are stabilized, hypovolemia is corrected, water-electrolyte balance disorders and hemostasis are corrected.
In patients with purulent tubo-ovarian formations of the uterine appendages, the surgical risk is maximum. Severe intoxication and disturbances of homeostasis complicate the maintenance of the functions of vital organs at safe level during surgery and in the postoperative period.
With the help of combined anesthesia (long-term epidural anesthesia in combination with endotracheal general anesthesia), the amount of administered drugs and the depressive effect of anesthesia itself can be significantly reduced.
Preparation for surgery consists of using antihistamines, cardiac glycosides, infusion therapy with the inclusion of protein blood substitutes and media that have a pronounced rheological effect, correction of water and electrolyte disorders. Premedication is carried out with atropine and ephedrine, administered subcutaneously. Then catheterization of the epidural space is performed at the level of Tx-Cili L1-n, after which the first dose of a 2.5% trimecaine solution or a 2% lidocaine solution in a volume of 25-30 ml is administered fractionally. For induction of anesthesia, use a 1% barbiturate solution at a dose of 150-250 mg or ketamine at a dose of 1-1.5 mg/kg. After transfer to mechanical ventilation, anesthesia is maintained with a mixture of nitrous oxide and oxygen (2:1 or 1:1). With an adequate epidural block, the consumption of muscle relaxants is significantly reduced (80-120 mg of ditilin per hour of surgery). The use of epidural anesthesia involves increasing the volume of infusion during surgery. To ensure adequate pain relief in the postoperative period, it is advisable to inject narcotic analgesics into the epidural space - morphine (up to 3 mg) or omnopon (up to 8 mg).
The method of choice for pain relief during artificial termination of pregnancy and diagnostic procedures (laparocentesis followed by laparoscopy, hysteroscopy, etc.) are options for intravenous general anesthesia.
In cases where the duration of manipulation should not exceed 5 minutes, it is possible to use propanidide according to the following scheme. For the purpose of premedication, diazepam (10 mg), atropine (0.5-1 mg), fentanyl (1-2 mcg/kg) and droperidol (0.07-0.15 mg/kg) are administered intravenously, and then 10 ml of 5% propanidide solution mixed with 10 ml of 10% calcium gluconate solution. For longer manipulations, as well as in patients bronchial asthma, allergic manifestations, initial arterial hypotension after the premedication described above, ketamine is used at a dose of 1-1.5 mg/kg. In somatically healthy pregnant women, when performing a medical abortion, paracervical anesthesia can be combined with autoanalgesia with a mixture of nitrous oxide and oxygen using anesthesia machines NAPP type.
However, with any method, the anesthesiologist must be prepared to immediately begin mechanical ventilation and switch to endotracheal anesthesia, since there is always a danger of complications and a significant expansion of the scope of surgical intervention.
BIBLIOGRAPHY
Abramchenko V.V., Lantsev E.A. Caesarean section in perinatal medicine.-
L.: Medicine, 1985.
Kokhnover S.G. Seduxene-ketamine induction anesthesia for caesarean section // Anest. and resuscitation - 1985. - No. 4. - P. 60-63.
Kulakov V.I., Merkulov E.V. Pain relief during labor and obstetric operations// Question ocher mat. -1984.-No. 9.-S. 51-56.
Manevich L.E. Long-term epidural anesthesia in obstetrics and gynecology // Anest. and resuscitation - 1985. - No. 3. - P. 8-10.
Rasstrigin N.N. Anesthesia and resuscitation in obstetrics and gynecology. - M.: Medicine, 1978.
Rasstrigin N.N. Induction and maintenance of general anesthesia with ketamine in high-risk parturients // Anest. and resuscitation - 1986. - No. 6. - P. 7-10.
Savelyeva G.M. Resuscitation and intensive care of newborns.-M.: Medicine, 1981.
Semenikhin A.A., Shvetsov N.S., Legetskaya L.M. Comparative characteristics of long-term epidural blockade with trimecaine and morphine for pain relief in labor // Obstetrics. and Gyn.-1987.- No. 2.- S. 26-28. Slepykh A.S. Abdominal delivery.-L.: Medicine, 1986 Moir D. D. Pain relief in childbirth.- M.: Medicine, 1985.
Hodgkinson R. Maternal Mortality // Obstetric Analgesia and Anesthesia/Ed. G. F. Marx and G. M. Bassell. - New York, 1980.
Shnider S. M., Levinson G. Obstetric Anesthesia // Anesthesia/Ed. D D. Alfery.- New York, 1981 - Vol. 2

Intravenous anesthesia is now used everywhere for short-term gynecological and surgical operations. The duration of such surgical interventions should not exceed 10-15 minutes. The analgesic effect occurs a maximum of a minute after the administration of narcotic substances.

Indications for intravenous anesthesia

In gynecology, this type of general treatment is used, as well as for the following manipulations:

Suturing of soft tissues in case of rupture of the birth canal;
Application of obstetric forceps;
Manual separation of the placenta and discharge of the placenta;
Curettage of the uterus in the postpartum period;
Manual examination of the uterine cavity and other indications.

In addition to gynecology, intravenous anesthesia is used in other areas of medicine for the following indications:

Correction of dislocations;
Electropulse therapy;
Splinting the injured limb;
Tracheal intubation.

Ketamine use

This drug is primarily used for intravenous pain relief. The main feature of this analgesic is imminent attack narcotic effect (40 seconds after administration). The effect of ketamine lasts 10 minutes, while the patient is in a state where some areas of the brain are depressed and others are excited. During sleep, the following indicators are noted: heart rate increases; rises cardiac index; cardiac output increases; blood pressure rises.

This analgesic is contraindicated for women in labor and pregnant women with severe forms of gestosis (a syndrome manifested by pathological weight gain, edema, etc.), as well as those with labile psyche(characterized by extreme mood variability, unpredictable switching of emotional state). Other contraindications for the use of ketamine include:

Cerebrovascular accident;
Epilepsy;
Severe hypertension ( high blood pressure on one of the sections of the circulatory system);
Eclampsia in severe disorders of normal circulation.

The undeniable advantage of ketamine is its negligible effect on the child and fetus. In addition, ketamine anesthesia relaxes the bronchial musculature and improves pulmonary blood flow, making it the most suitable option for patients with a history of various diseases bronchi.

The consequences of using anesthesia with ketamine include the following unpleasant moments:

Involuntary movements of arms and legs;
Hallucinations;
Bad dreams;
Delirium (impaired consciousness).

Use of sombrevin

Intravenous anesthesia with the use of this anesthetic is rarely used, the reason for this was the numerous consequences of the use of sombrevin. Here are some of them:

As you can see, the consequences of using sombrevin are very serious, so preference should be given to either other narcotic drugs or another type, for example.

Use of barbiturates

Such narcotic drugs include sodium thiopental and hexenal. The effect of the drugs after intravascular administration lasts about 20 minutes. In order to prepare a solution of barbiturates, mix 1 gram of the drug with 100 ml of 1% sodium chloride solution. The resulting solution is injected at a rate of 1 ml in 10 seconds. After administering three milliliters of the drug, medical personnel determine the patient’s sensitivity to barbiturates. Further, its intravascular administration continues until complete anesthesia.

Advice: this type of intravenous anesthesia is characterized by respiratory depression, therefore the presence breathing apparatus in the operating room a prerequisite.

Indications for the use of barbiturates include such surgical interventions as opening abscesses, repositioning bone fragments, reducing dislocations, phlegmon (acute purulent inflammation). In addition, indications for the use of barbiturates are convulsive syndrome due to tetanus, cocaine overdose, and status epilepticus.

Using viadril

It is recommended to slowly administer this drug into the central vein in the form of a 2.5% solution. Viadryl is considered a difficult anesthetic to control, which is why it is used simultaneously with nitrous oxide. The use of Viadril is complicated by some of its consequences. These consequences include the development of thrombophlebitis (formation of blood clots).

Contraindications to intravenous anesthesia

Inflammatory diseases of the nasopharynx;
Severe heart failure;
Pregnancy;
Severe kidney and liver failure;
Allergic reactions.

Despite some consequences of using intravenous anesthesia, it is more acceptable compared to inhalation anesthesia. Its main advantages are the onset of an analgesic effect within a moment after the administration of anesthetics, as well as the convenience of induction and the absence of the need to use complex medical equipment. Currently, scientific developments are underway to improve narcotic drugs for intravenous anesthesia, which will avoid many of the negative consequences of its use.

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Ministry of Health of Ukraine. KhNMU. Department of Medicine emergency conditions, anesthesiology and intensive care

Essay

on the topic: Anesthesia in gynecology

Performed:

student 1st year 5 courses

1 medical faculty

Mayboroda O.M.

Kharkov 2012

The most common operations in gynecology are abortion and uterine curettage. The average age of patients is 20-40 years, and 90% of them do not have any concomitant diseases. Considering that the range of gynecological operations is quite large, therefore the types of anesthesia used in gynecology vary greatly.

As in other branches of surgery, There are four types of anesthesia in gynecology: general anesthesia (or anesthesia), sedation, regional anesthesia, local anesthesia.

Minor surgical interventions in gynecology are performed under local anesthesia, sedation or intravenous anesthesia. Large operations in gynecology, they are performed under anesthesia (general anesthesia) or regional types of anesthesia (spinal, epidural anesthesia).

Vacuum (vacuum aspiration), taking an aspirate from the cavity, puncture of the posterior fornix, curettage of the uterus (separate diagnostic curettage) or abortion are most often performed under local anesthesia or intravenous anesthesia.

With local anesthesia, tissues around the cervix are infiltrated (paracervical anesthesia) with a local anesthetic, which subsequently blocks pain during manipulation of the cervix. When performing local anesthesia in gynecology, the most commonly used local anesthetics are lidocaine, novocaine or ultracaine.

Considering some risk of solution getting into local anesthetic V blood vessel When performing local anesthesia in gynecology (in particular, paracervical anesthesia), some gynecologists do not use this type of anesthesia, and the minor surgical interventions described above are performed under some sedation or without any anesthesia at all. Gynecologists do not have the skills to conduct classical sedation (this requires special knowledge), which is why the word “some” is used in the phrase “some sedation”. This sedation is either an intramuscular injection of a tranquilizer (diazepam), which somewhat relieves the feeling of anxiety, but not pain, or an intramuscular injection of an analgesic (ketorolac, diclofenac, promedol), which provides only a slight reduction pain during surgery.

Intravenous anesthesia, which is a type of general anesthesia used in gynecology, causes the patient to fall asleep and feel no pain during surgery.

Large-scale gynecological operations (laparoscopy, surgery on the uterus and its appendages, treatment of urinary incontinence, etc.) are most often performed under general anesthesia, less often under regional anesthesia. The implementation of these types of anesthesia in gynecology is no different from their implementation in other surgical specialties, therefore they detailed description can be read in the sections: general anesthesia, regional anesthesia. The choice of anesthesia will be determined by the specific type of surgery and the patient's condition.

Anesthesia for curettage

Curettage is a surgical procedure performed for diagnostic or therapeutic purpose, in which curettage of the uterine cavity is performed. The most common indications for curettage are bleeding, polyps, uterine hyperplasia and abortion.

The curettage procedure is performed under anesthesia, sedation or local anesthesia.

Anesthesia for curettage carried out only by an anesthesiologist. At the same time, local anesthesia or sedation is most often performed by the operating gynecologist. As a rule, sedation performed by gynecologists during curettage has little resemblance to the anesthesiological technique of the same name. So, with this sedation, painkillers from the group of narcotic analgesics (promedol) or a tranquilizer (diazepam) are administered intravenously in a small dose. The administration of these drugs in large (and therefore effective) doses is associated with the risk of respiratory failure, the correction of which requires the skills of another profession - an anesthesiologist. Therefore, gynecologists administer these drugs during curettage in small quantities, obtaining only a minor clinical effect.

The second option for anesthesia during curettage is local anesthesia. Local anesthesia does not provide absolute blocking of pain, but greatly dulls them. The essence of local anesthesia during curettage is the introduction of a local anesthetic into the tissue near the cervix. Not all gynecologists prefer local anesthesia when performing curettage, since its implementation is associated with some risk of the local anesthetic solution entering the blood vessels surrounding the cervix, leading to loss of consciousness, convulsions and heart rhythm disturbances.

The most commonly performed type of anesthesia during curettage is general anesthesia. Considering the short duration of the procedure, as well as the absence of the risk of gastric contents entering the lungs, general anesthesia during curettage is carried out while maintaining the patient’s spontaneous breathing. In this case, the patient breathes himself through an oxygen mask - this is the so-called intravenous anesthesia (anesthesia). Intravenous anesthesia during curettage causes deep sleep and absence of pain. In our country, when carrying out anesthesia during curettage, the following anesthesia agents are most often used: ketamine (Calypsol), sodium thiopental, propofol. Ketamine is not the best drug of choice, as it can cause threatening hallucinations during anesthesia, and also make recovery from anesthesia very unpleasant. The best drug for anesthesia during curettage is propofol, which ensures a soft fall asleep, light sleep, as well as quick and comfortable awakening from anesthesia.

The scraping procedure takes about 10-20 minutes.

Anesthesia for abortion

In some clinics, abortions continue to be performed without any anesthesia, but this vicious practice is increasingly becoming a thing of history and various types of anesthesia are beginning to be used more and more widely during abortions. Anesthesia during abortion can generally be three varieties: local anesthesia, sedation and general anesthesia.

Some obstetricians and gynecologists prefer to perform an abortion under local anesthesia, in which a local anesthetic solution is injected through the vaginal vault into the area near the cervix. With local anesthesia, the woman is conscious, and there may be some discomfort (if a vacuum is performed) or pain (if curettage is performed). Not all gynecologists like to perform an abortion under local anesthesia, since sometimes during this procedure it is possible that the local anesthetic may accidentally enter a blood vessel, which can cause loss of consciousness and convulsions.

More often abortion is performed under anesthesia(general anesthesia) or sedation. Anesthesia is deep medicated sleep, in which the patient does not feel anything. Sedation is a superficial sleep in which some discomfort or pain may be felt, however, as a rule, after the procedure these memories no longer remain in the memory. The line between deep sedation and anesthesia is thin, it is expressed only in the degree of falling asleep, so for a simpler understanding, these two types of anesthesia can be considered as one technique.

For sedation and anesthesia during abortion, non-inhalational anesthetics (propofol, thiopental, midazolam) and opioids (fentanyl) are most often used. Many clinics still continue to use the far from best anesthetic ketamine, which is associated with the development of hallucinations during anesthesia, and possibly memory impairment after anesthesia.

For the patient, abortion under anesthesia is a more comfortable anesthesia option than abortion under sedation. However, given the high risk of breathing problems characteristic of general anesthesia, anesthesia during abortion requires the presence of an anesthesia-respiratory apparatus.

This technique is not always available in the procedure rooms and operating rooms where gynecologists perform abortions, so performing an abortion under sedation is the smartest choice from a safety standpoint.

Indications for abortion

anesthesia gynecology anesthesia abortion

Before 12 weeks, abortion is performed at the woman’s voluntary request; at a later date, only for medical or social reasons. Medical indications include life-threatening situations for a woman: serious disease heart, lung, liver, kidney, blood, infection, tumor and psychiatric disorders.

Features of abortion

There are two types of abortion: mine-abortion (vacuum, vacuum aspiration) and curettage of the uterine cavity (curettage). During a mini-abortion, a special probe is inserted into the uterine cavity, through which aspiration is performed under negative pressure. ovum occupying the uterine cavity.

When curettage of the uterine cavity using a set of special dilators, the cervix is dilated, after which the contents of the uterine cavity are scraped out with a sharp curette.

A mini-abortion (vacuum) is performed in 5-7 minutes, curettage of the uterine cavity in 10-30 minutes (depending on the stage of pregnancy).

Anesthesia for hysterectomy

A hysterectomy is a gynecological operation in which the uterus is removed. Depending on the volume of anatomical structures removed (uterus, cervix, appendages, The lymph nodes etc.) there are several types of hysterectomy operations.

Removal of the uterus is performed under general anesthesia (anesthesia) or regional anesthesia (spinal or epidural anesthesia).

View anesthesia for hysterectomy depends on the patient’s health condition, urgency, as well as the volume and duration of the upcoming operation. So, if the planned operation to remove the uterus is large in duration (more than 2-3 hours) or volume (radical hysterectomy), or the operation is performed according to emergency indications(for example, bleeding), then the uterus is removed under anesthesia (general anesthesia). In other cases, the uterus is removed under regional anesthesia: spinal or epidural anesthesia. In addition, anesthesia for hysterectomy is used more often when abdominal access is used, and regional anesthesia when the operation is performed through vaginal access.

Anesthesia during hysterectomy surgery guarantees deep sleep and absence of pain. Regional anesthesia ensures that there is no sensation of pain, although the patient is conscious and awake.

Regional anesthesia for hysterectomy can be performed in the form of spinal or epidural anesthesia. The advantages of removing the uterus under spinal anesthesia include greater convenience for surgeons: anesthesia occurs quickly, in addition, this type of anesthesia provides good relaxation of the abdominal muscles, which makes the work of surgeons easier. The advantages of removing the uterus under epidural anesthesia are determined by the ability not only to anesthetize the operation, but also to treat pain that occurs in the postoperative period. Both regional anesthesia and anesthesia during hysterectomy are carried out in accordance with the classical canons of anesthesiology. You can read more about these types of anesthesia in the relevant sections of the site.

The operation to remove the uterus lasts about 1-3 hours.

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Inhalation anesthesia

From the use of chloroform modern medicine I gave up long ago, using much safer compounds: ether, cyclopropane or nitrous oxide. There are several main types of inhalational anesthesia.

Scope of application: minor and minimally invasive gynecological operations and procedures: removal of condylomas, polyps, traumatic types of diagnostics.

Potentiated and combined anesthesia

It is based on the work of Pierre Huguenard and Henri Laborie, who in the 1950s proposed the idea of so-called pharmacological artificial hibernation, a condition similar to hibernation in some animals. The combination of several substances used in this case has advantages over mono-anesthesia. In this case, one drug either enhances the effect of others, or in combination each of them gives greater effect than separately.

Scope of application: extensive and long-term abdominal operations, when it is necessary to achieve a stable and permanent effect.

Possible components of such anesthesia:

Neuroplegic substances. The most famous representative is aminazine, although the popular antihistamines have somewhat similar properties: ethizine, reserpine, diprazine and diphenhydramine. Its other components are diprazine (antihistamine), promedol (analgesic) and glucose, sometimes replaced by novocaine.
Relaxers. By themselves, they do not have an analgesic effect, but they help relax the muscles of the peritoneum, block the neuromuscular synaptic mechanism and allow simple operations to be performed under shallow anesthesia.

Non-inhalational anesthesia

Scope of application: any large-scale surgical interventions: hysterectomy, adnexectomy, cystectomy, conservative myomectomy.

Hexenal anesthesia. Used as a solution of 1 g active substance and 10 ml of water injected into a vein immediately before surgery. Due to the high risk of respiratory arrest, intravenous injection can be replaced with intramuscular or even rectal. The duration of sleep after surgery is about 2–3 hours.
Thiopental sodium anesthesia. The solution is administered using a double drip apparatus, and the patient’s condition is constantly monitored. Due to the use of narcotic drugs, this type of anesthesia requires high qualifications from medical personnel and is not free from the risk of side effects.

Spinal anesthesia

Scope of application: cupping pain syndrome during childbirth, gynecological operations of minor and moderate severity, any surgical interventions that do not require a long period of implementation.

Types of local anesthesia

Scope of application: minor gynecological operations, interventions with a high risk of side effects from traditional anesthesia, assistance to patients with a complicated medical history, urgent surgery when there is no time for clarifying examinations and preparation of the patient. It is also often used for vaginal and abdominal surgeries.

Local anesthesia. The main developer of the method is considered to be A.V. Vishnevsky, and the scheme he proposed is considered one of the most effective today. It involves the introduction of large volumes of novocaine solution for its direct contact with the nerve. The technique greatly facilitates the implementation abdominal operations thanks to hydraulic tissue separation, but requires mandatory preliminary preparation of the patient. In addition to the classical scheme of use, novocaine can also be dissolved in Ringer’s solution, and to enhance the effect of the composition, a combination of novocaine and sovcaine in equal parts is sometimes used. Unconditional contraindications include mental illness, a general excited state and large blood loss.
Local anesthesia used for transections. Usually they start with a subcutaneous injection of novocaine, and after exposing the aponeurosis, a solution of novocaine is injected into the thickness of the rectus vaginal muscles to complete blockade nerve branches. The width of the infiltration area is approximately 4–5 cm, and the length should be greater than the intended incision area.
Anesthesia according to L.S. Persianinov. First, anesthesia is performed abdominal wall, then the round ligaments are infiltrated or, if they are not detected, injections of novocaine solution are started into the vesicouterine fold of the peritoneum. After this, the round ligaments are treated along the entire length of the inguinal canal.

Local anesthesia depending on the type of intervention

Anterior plastic surgery (anterior colporrhaphy). Anesthesia is carried out by introducing a solution of novocaine in the direction of the midline through the vagina.
Cervix. Active substance(traditional novocaine solution) is injected into the base of the uterosacral ligaments.
Crotch. Due to the extremely high sensitivity, pain relief is carried out in two stages. First, a small amount of solution is injected into the edge of the scaphoid fossa with a very thin needle, then the volume of liquid is increased and the labia, deep layers of the perineum and the posterior wall of the vagina are injected.
Abortion and diagnostic curettage. First, the vaginal vault and cervix are exposed with special instruments, then they are disinfected, and after that a mixture of novocaine and adrenaline is injected. Final stage– 2–3 deep injections of 10–15 ml each. The total consumption of novocaine solution is 70–80 ml