From Big Medical Encyclopedia

ANESTHESIA LOCAL (anesthesia localis; synonym local anesthesia) — the reversible loss of sensitivity of fabrics (first of all painful) on limited body parts caused by action of various volumetric, physical or mechanical factors on formations of a peripheral nervous system.


Attempts to achieve in various ways of decrease in painful sensitivity of area of an operational wound have centuries-old history. However in the majority all of them were ineffective, and only achievement And. m by means of a prelum of nervous trunks [the so-called ligatura fortis offered by Ambrois Paré] and local cooling of fabrics due to the lack of other ways of anesthesia up to opening of an anesthesia (see) were applied in surgical practice, and A. M. cooling kept a certain value and in a crust, time.

Creation of effective methods A. In m it was prepared by introduction to medical practice of the syringe [A. Wood, G. Pravaz, 1853], a hollow needle [F. Rynd, 1845] and first of all discovery of local anesthetic effect of cocaine (see) which was in detail studied by the Russian scientist V. K. Anrep (1879). Anrep entered cocaine by means of subcutaneous injections and the first applied it to anesthesia. Koller (To. Roller), abroad attribute to Krom a priority of opening And. the m, reported about use of cocaine at eye operations only in 1884 Thus, the founder A. the m is the Russian scientist V. K. Anrep.

In the eighties 19 century cocaine for And. the m was widely adopted enough almost in all fields of medicine. In 1884 W. S. Halsted used cocaine for blockade of nervous trunks at extraction of tooth and at operations on a brachial plexus. In 1886 A. I. Lukashevich developed an original method of use of cocaine for anesthesia of fingers. Abroad similar way A. the m offered Will gather (M. Oberst) two years later. These researches laid the foundation conduction And. m. Infiltration And. by m it began to be developed since 1885.

In Russia large abdominal organs operations under And. m began to be carried out by cocaine in clinic professional. I. D. Monastyrsky. His employee A. V. Orlov managed to achieve reduction of side effects of cocaine. In 1887. Orlov reported about successful performance of a number of band operations under And. m during the use of weaker, than then it was accepted, solutions of cocaine (1:60). First stage of development infiltration And. the m was completed by works to P. Reclus in 1890 and Shleykh (S. L. Schleich) in 1891.

Emergence of the novocaine (see) synthesized in 1905 by A. Einhorn — drug much less toxic, than cocaine, promoted more bystry development And. to m and development of various options of infiltration and regional anesthesia. In 1923 — 1928 A. V. Vishnevsky's works and his schools created an original method infiltration And. m which gained the most wide spread occurance in the USSR. In 40 — the 50th years And. became m according to Vishnevsky a main type of anesthesia in the USSR, having practically forced out other methods A. m, also narrowed indications to an anesthesia. And. m allowed to carry out the most difficult interventions in the absence of the narcotic equipment and other difficult equipment and to considerably lower a lethality at some surgeries (e.g., impassability of intestines).

On fronts of the Great Patriotic War more than at 80% of wounded roughing-out of wounds of extremities, chest cavity and skull took place under And. m. It was applied then in all fields of surgery. In a crust. time And. the m according to Vishnevsky remains the prevailing look And. m in our country. Opportunities it even more increased thanks to synthesis of new anesthetics (see) and to its use in combination with nek-ry methods of the general anesthesia.

Physiological mechanisms

And. the m arises owing to the termination of carrying out impulses on sensitive nerve fibrils or blockade of receptors. The anesthetizing substances, without changing significantly the rest potential of nerve fibrils, processes of generation and distribution of action potential oppress. The irritation ceases to cause increase in permeability for ions of Na + and K+, and there is some kind of stabilization of a membrane. This effect is connected with ability of local anesthetics to get into lipidic layers of a cellular membrane. Sensitivity of nerve fibrils to effect of local anesthetics of subjects is higher, than less their diameter. Apparently, it is explained by relative increase in a surface of fiber at reduction of its diameter. As information from receptors of different types of sensitivity is transferred to c. the N of page on fibers of various structure and diameter, under the influence of local anesthetics occurs at first loss of painful, then temperature, tactile, proprioceptive sensitivity, and only after that there comes motive paralysis.

Types of local anesthesia

Exist three main types A. m: terminal (superficial), infiltration and regional. They differ in the place of the reached blockade of nervous conductors and methods of its creation.

Terminal anesthesia

Terminal anesthesia is preferential anesthesia of nerve terminations, arises at direct contact of the agent (the cold anesthetizing substances) causing anesthesia with fabric and can be reached in several ways. The cryanesthesia is carried out by spraying of a stream of quickly evaporating substance (ether or is more often than Aether chloratus) on skin. It is applied during the opening of superficially located abscesses. Besides, And. the m is applied by Aether chloratus as one of methods of blockade. Well diffusing anesthetics are necessary for terminal anesthesia of mucous membranes (cocaine, Dicainum, a xycain, etc.). The contact with mucous membranes is provided with greasing, an instillation, spraying, use of the tampons moistened with anesthetic, etc. Anesthesia is applied by greasing most often in otorhinolaryngological, ophthalmologic and urological practice. Solutions of cocaine or 1 — 2% solutions of Dicainum apply 3 — 5% to anesthesia of a mucous membrane of a nasal cavity, adnexal bosoms, a mouth, a throat, a throat, a gullet, a trachea and bronchial tubes, a middle ear.

In certain cases it is possible to use spraying or drop injection of the anesthetizing solutions stated above. At And. the m of a trachea and bronchial tubes use a so-called aspiration method at which 1% dig in solution of Dicainum in a nose during the forced breath. Anesthesia proceeds 20 — 30 min. J. Bonica recommends transtracheal administration of the anesthetizing solution in a gleam of a trachea after a puncture of membrana cricothyreoidea a fine needle. Cough causes spraying of solution and full anesthesia of a trachea. Some anesthetizing substances are produced in the form of aerosols that considerably facilitates performance terminal And. m. For anesthesia of an eyeglobe in a conjunctival sac dig in 2 — 4 drops of 2% of solution of cocaine or 0,5 — 1% of solution of Dicainum. For prevention of toxic reactions, possible at terminal anesthesia owing to bystry absorption of cocaine or Dicainum, add vasoconstrictive substances to their solutions: 0,1% solution of adrenaline or 5% solution of ephedrine (one drop on 1 — 2 ml of the anesthetizing solution).

An infiltration anesthesia

At infiltration And. m are blocked preferential nerve terminations and small nerve fibrils. It is reached And. m treatment (infiltration) of fabrics the anesthetizing solution. As well as at terminal And. the m, at an infiltration anesthesia disturbance of sensitivity of fabrics is limited to a zone of operation.

Infiltration anesthesia across Shleykh — to Rekl consisted in layer-by-layer treatment of fabrics the anesthetizing solution. At the same time Shleykh used weak solutions of cocaine (0,01 — 0,2%) in hypotonic salt solutions of various salts, considering that swelling of fabrics increases the anesthetizing effect of cocaine. Later solutions Reklya and Shleykh replaced 0,5% with solution of novocaine. Infiltration is carried out layer-by-layer, outside inside.

Fig. 1. An infiltration anesthesia from two points of a prick (scheme): 1 and 2 — points of pricks; 3 — skin; 4 — a fascia; 5 — a bone
Fig. 2. The scheme of an arrangement of the anesthetizing solution (black color) surrounding a thyroid gland (a horizontal cut of a neck at the level of a thyroid gland)
Fig. 3. A skin tumor («a lemon crust») at injection of the anesthetizing solution under skin
Fig. 4. Injection of the anesthetizing solution in a vagina of a direct muscle of a stomach
Fig. 5. Injection of the anesthetizing solution under a parietal peritoneum
Fig. 6. Creeping mesocolon infiltrate: 1 — injection sites of the anesthetizing solution; 2 — distribution of the anesthetizing solution (black color) entered into the right part of mesocolon (a sagittal section a little to the right from the centerline); 3 — distribution of the solution entered into the left part of mesocolon (a cross cut at the level of a spleen); 4 — distribution of the solution entered throughout a root of a mesentery colon transversum, and lig infiltrate. hepatogastricum (a cross cut at the level of a spleen); 5 — distribution of the solution entered in the middle of mesocolon (a sagittal section).
by Fig. 7. Formation of infiltrate in leaves of mesocolon at colon transversum which is cast away from top to bottom. Injections are made to places of raying of infiltrate and in ligamentum hepatogastricum

For anesthesia of skin in the area of a section the anesthetizing solution is entered vnutrikozhno therefore the tumor, or «a lemon crust» (fig. 3) is formed. Hypodermic cellulose and more deeply located fabrics become impregnated from two opposite points of a surgery field on all their depth (fig. 1).

At extensive operations of fabric of an infiltrirovala on a circle of a surgery field. And. m across Shleykh — to Rekl it was eurysynusic though gave only good anesthesia of skin and partly hypodermic cellulose. A basic lack of a method of Shleykh — to Rekl was the fact that the contact of the anesthetizing solution with nerve terminations and trunks was provided with diffusion. This method could not provide reliable anesthesia at operations on bodies of chest and belly cavities. At manipulations on deep fabrics it was necessary to wait for 3 — 5 min. before it was possible to continue operation. All these shortcomings led to the fact that by 20th years the method of an infiltration anesthesia across Shleykh — to Rekl, by words A. V. Vishnevsky, «was absolutely discredited as a method of ample opportunities».

An infiltration anesthesia according to Vishnevsky

the Main and basic advantage developed And. V. Vishnevsky of a method A. the m is direct contact of the anesthetizing solution with nerve fibrils in a surgery field and surrounding fabrics. Such contact is provided with forcing weak (0,25%) solution of novocaine under pressure («hard infiltration») in fabric.

Vishnevsky's method is based on the anatomic features of a human body caused by «the futlyarny principle» its structures (N. I. Pirogov) and considers a possibility of use for anesthesia of a peritoneum, a pleura, aponeuroses, fascial spaces, unions, commissures etc.

At And. the m according to Vishnevsky the solution forced under pressure extends on «cases» and fascial spaces of a body (so-called «creeping infiltrate»). Thus, to replace «treatment» of fabrics on all their thickness, almost impracticable by Shleykh's technique — to Rekl, A. V. Vishnevsky entered the principle anatomically of reasonable infiltration of fabrics. From there is a name given by Vishnevsky to the method: And. m on a way of «creeping infiltrate», or futlyarny anesthesia. Hard infiltration by weak solution of novocaine reaches also so-called hydraulic preparation of fabrics, edges considerably facilitates manipulations of the surgeon, reduces blood loss at operations.

Equipment A. the m according to Vishnevsky in the most habit view looks as follows. Vnutrikozhno enter solution of novocaine with formation of «a lemon crust» in the area of a section (similar to Shleykh's technique — to Rekl). Enter novocaine into hypodermic cellulose. Further the section of superficially located fabrics follows. Then the anesthetizing solution infiltrirut fascial receptacles of the subject fabrics: novocaine is entered under platysma at a thyroid gland operations, into a muscle-razgibatel of a backbone — at a laminectomy, into a vagina of a straight line or under an aponeurosis an outside braid of muscles — at laparotomies, infiltrirut mezhreberye at a thoracotomy etc. After that opening of the corresponding layer of fabrics possible to bare the body which is subject to operation. For ensuring painlessness of manipulations on bodies of a thorax novocaine is entered under a pleura with formation of massive «creeping infiltrate» between its parietal layer and fascia endothoracica.

At a thyroid gland operations the anesthetizing solution entered under short muscles of a neck impregnates pozadimyshechny space; the solution of novocaine forced under pressure spreads in friable connecting fabric and washes a thyroid gland (fig. 2).

At extremity operations prior to the beginning of a section soft tissues up to a bone become impregnated with solution of novocaine which fills fascial spaces. At amputations for the prevention of distribution of infiltrate in the proximal direction it is recommended to impose a plait (prior to anesthesia). This method reminds the «anesthesia of cross-section» applied earlier.

At abdominal organs operations Vishnevsky's method provides formation of massive central infiltrate in a root of a mesentery of a cross colon and its advance under pressure in the relevant department of a peritoneum. At operations on bodies of a small pelvis create two infiltrates: one from a crotch, another from a cavity of a stomach at the level of promontormm behind a peritoneum; both infiltrates merge on a front surface of a sacrum. And. to m at stomach operations it is shown in fig. 3 — 7.

Fig. 8. An injection of the anesthetizing solution (black color) between leaves of a renal fascia

At kidney operations novocaine is entered between leaves of a renal fascia (partially through a layer of muscles after a section of skin and hypodermic cellulose) to extent of hard infiltration (after opening of a muscular layer). As a result the kidney is completely surrounded with novocainic infiltrate, «floats» in the anesthetizing solution (fig. 8).

Thus, And. the m according to Vishnevsky goes with constant change of the syringe and a scalpel. An important component of anesthesia is conduction anesthesia, edge is also reached at distribution of «creeping infiltrate» (infiltration of an alate pole at skull operations, vagosympathetic blockade at intrathoracic operations, blockade of textures of a seed cord by the infiltrate directed under m. creniaster, etc.).

Undoubted advantage And. m are its technical simplicity and safety.

For performance of operations under And. the m according to Vishnevsky is not required the difficult equipment, participation of specially trained personnel; it is possible to avoid use of other pharmacological means necessary at an anesthesia and in some cases contraindicated for the patient. Infiltration And. the m does not oppress protective reflexes and therefore some deviations from the normal course of operation, unexpected accidents or technical errors do not gain so quickly character of life-threatening complications as it happens at an anesthesia.

The postoperative period after interventions under And. the m proceeds, as a rule, quite favorably even after big and difficult operations. Thus, thanks to simplicity, efficiency and safety And. the m according to Vishnevsky has the widest indications to use. It certainly is shown at rather small on volume and the short interventions which are not demanding an ideal relaxation of muscles.

At the old men weakened patients at organic lesions of cardiovascular and respiratory systems, at the expressed abnormal liver functions and kidneys, dekompensirovanny diabetes, a septic state And. the m according to Vishnevsky should prefer to an anesthesia even at more traumatic operations in spite of the fact that the modern combined anesthesia could provide to the surgeon the best conditions for manipulations (an exception only intrathoracic interventions make, at which And. the m cannot guarantee maintenance of adequate gas exchange). And. to m it is absolutely contraindicated at individual intolerance of novocaine, and also at persons with vulnerable mentality in which «presence on own operation» can cause excitement or the phenomena of shock. As a relative contraindication serves the children's age (see below Anesthesia local at children). Indispensable condition of success And. the m according to Vishnevsky is technical perfection in its performance; if the surgeon owns a technique of a local anesthesia at this operation insufficiently, it is better to carry out it under anesthetic. Local and general anesthesia should not be considered as the competing ways of anesthesia. And. the m is quite often used as one of components of the modern combined anesthesia (e.g., in the form of blockade of reflexogenic zones). In turn such methods of the general anesthesia as a neyroleptanalgeziya, an analgesia nitrous oxide, trichloroethylene, metoksiflurany, etc., and also carefully picked up premedication (see. Anesthesia ) considerably improve a current And. m also expand possibilities of its use.

Regional anesthesia

Regional anesthesia is reached by the directed administration of the anesthetizing solution which blocks nervous trunks, textures or roots of a spinal cord. At regional anesthesia switching off of painful sensitivity happens in a certain topographical area, edges can be far from borders of distribution of the anesthetizing solution and corresponds to a zone of an innervation of the blocked conductor. Depending on technology of creation of the regional nervous block and the place of blockade of nervous impulse allocate three main types regional And. m: conduction, spinal (subarachnoidal block) and peridural (extradural block). Treats regional anesthesia as well intravascular anesthesia.

There are numerous methods of conduction anesthesia considerably differing from each other on technology of performance, but combined by the fact that blockade is reached by effect of mestnoanesteziruyushchy solution on various sites on the course of a nerve after its escaping of an intervertebral opening — in a ganglion, a texture or in a trunk of a peripheral nerve.

Fig. 9. Paravertebralky anesthesia: 1 — in position of the patient lying; 2 — in position of the patient sitting
Fig. 10. Parasacral anesthesia. The scheme of advance of a needle on the way from the fifth (1) to the first (2) sacral root

The anesthesia coming after administration of the anesthetizing solution in close proximity to an intervertebral opening received the name juxtaspinal (fig. 9), It was offered by Zellgeym (N. to Sellheim, 1906) and Leuven (A. Läwen, 1911). Equipment of anesthesia: the needle is entered in the point located on 3 cm lateralny lines of acanthas perpendicular to skin on depth of 2,5 — 5 cm, to a cross shoot of a vertebra. Then it is slightly taken and directed over the upper edge of a cross shoot to 0,5 — 1 cm. Other way: the needle is carried out from the point located on 5 cm lateralny lines of acanthas at an angle 45 ° to the sagittal plane to a body of a vertebra. Through a needle enter 10 — 15 ml of 0,5% of solution of novocaine. A version juxtaspinal is pre-(or couple-) sacral And. m (fig. 10).

with Fig. 11. Presakralny anesthesia according to A. V. Vishnevsky. Distribution of novocainic infiltration on a front surface of a sacrum: 1 — the provision of a needle at the beginning of introduction; 2 — infiltrate spread on a pelvic surface of a sacrum (is shaded)

Two of its methods are offered. Brown's method (N. Braun): to the patient laid in litotomichesky situation from two points located on both sides from a tailbone on 2 cm lateralny the centerline, enter a long needle, to-ruyu will see in the sagittal direction parallel to a sacrum, to a bone about the second sacral opening (on depth of 6 — 7 cm). Here inject 20 — 30 ml of 0,5% of solution of novocaine then, slowly taking a needle, enter 20 — 30 more ml of the anesthetizing solution. The II—V pair of sacral nerves is as a result blocked. For blockade of the I sacral nerve it is necessary to carry out a needle on depth of 12 — 15 cm. Similarly block sacral nerves from the opposite side. A. V. Vishnevsky's method: to the patient lying on one side enter a long needle into the novocainic tumor formed in the middle between the end of a tailbone and an anus and, constantly injecting the anesthetizing solution, carry out it to a front surface of a sacrum (fig. 11). «Creeping infiltrate», extending on a surface of a sacrum, blocks nerves. For anesthesia enter 0,25% of solution of novocaine to 200 ml. This way is more reliable and more effective, than Brown's method. At it there is no danger of wound of bodies of a small pelvis.

Intercostal anesthesia consists in administration of the anesthetizing solution at corners of edges, on the back or average axillary line where intercostal nerves are located superficially.

Fig. 12. Anesthesia of a brachial plexus (in the drawing the injection site of a needle is shown)

Anesthesia of a brachial plexus. The method which is originally developed by G. Hirschel in 1911 (administration of the anesthetizing solution from an axillary pole on the course of a humeral artery), in a crust, time is left. In practice apply various ways based on the supraclavicular approach to a brachial plexus offered by D. Kulenkampff in 1912. Equipment of anesthesia (fig. 12): the patient is in a semi-sitting position, the head is turned in the healthy party. The needle is entered a little lateralny by points of a pulsation of a subclavial artery or on 1 — 1,5 cm over the middle of a clavicle and direct it down, medially and back — to acanthas of the II—IV chest vertebrae. At emergence of paresthesia enter 15 — 20 ml of 2% of solution of novocaine. V. Ya. Shla-pobersky and M. Ya. Glezer's modification: the patient lies with the roller under shoulders, the head is turned into the healthy party. The needle is entered 3 cm above by clavicles at the outer edge grudino - a clavicular and mastoidal muscle on Depth of 2 cm. At emergence of paresthesia the needle is tightened on 0,3 — 0,5 cm and, slightly changing its situation, enter 15 — 30 ml of 1% of solution of novocaine on both sides of a brachial plexus on the course it. There are some more options A. m of a brachial plexus [Mali, Patrick, Ball, Dolyotti (Mulley, Patrick, Ball, A. M. Dogliotti), etc.]. It oditsa from the most effective methods conduction And. m.

Anesthesia of fingers across Lukashevich — to Oberet. Novocaine is entered into fabrics at the basis of a finger on both sides of an extensor tendon. The applying a tourniquet is not obligatory (especially if adrenaline is added to solution of novocaine). In a crust, time apply modification of a method when 3 ml of 1% of solution of novocaine enter into interdigital intervals,

Anesthesia celiac gangliyev. Two ways are recommended: front — through an abdominal cavity, according to Brown, and back — through a back, across Kappis (M. Kappis). Brown's way. It is carried out after a laparotomy. The left hepatic lobe is taken away up, the stomach is displaced from top to bottom. The surgeon an index finger of the left hand presses an omentulum to a front surface of the XII chest vertebra. Enter a needle to a front surface of a vertebra into the interval which is formed between an aorta and a vena cava, then take away it a little back and inject 30 — 40 ml of 0,5% of solution of novocaine. Way Kapisa. The patient sits slightly having bent. The needle is entered by lower than XII edges in the point remote on 6 — 7 cm to the right from the line of acanthas, at an angle 45 ° to the sagittal plane and direct it slightly up. On reaching a body of the I lumbar vertebra the needle is slightly taken and directed on a side surface of this vertebra to 1 — 1,5 cm in depth. General depth of introduction of a needle of 6 — 7 cm. Here enter 30 — 40 ml of 0,5% of solution of novocaine.

Other methods of conduction anesthesia at abdominal organs operations are of only historical interest, napr, blockade of nerves at the basis of a mesentery of a gut on Finsterera (N. of Finsterer) or modification of this method by Drünner. Attractive line of conduction anesthesia is a basic opportunity one injection to achieve full anesthesia of an extensive zone of operation. In practice this method A. with m it is happy it is difficult. Its use demands thorough knowledge of anatomy of nervous trunks and an innervation of a surgery field. Basic shortcoming conduction And. the m is the fact that the injection is made blindly; various reference points (bone ledges, places of a pulsation of arteries, feelings of the patient) not always guarantee the correct provision of a needle. At anesthesia of a cervical plexus, e.g., the insignificant deviation of a needle from the right direction can lead to a puncture of a carotid artery, an internal jugular vein, vertebral vessels, a firm meninx. At anesthesia of a brachial plexus quite often there is pheumothorax and paralysis of a phrenic nerve. Therefore at conduction And. the m needs to check the provision of a needle constantly. Sometimes natural effects conduction And. m gain character of complications (hypotension because of blockade of sympathetic trunks at And. m across Kappis, etc.). And. the m can be complicated by long or even persistent paralyzes. Some methods conduction And. m demand multiple pricks. At last, at perineural administration of the anesthetizing substance (endoneural as injuring a nerve, it is applied only at amputations, resections of a nerve etc.) anesthesia comes not at once or at all it is not possible. In general conduction And. the m does not create so ample opportunities as infiltratsio other according to Vishnevsky, however in some cases she deserves broader research. Some methods conduction And. m are quite widely applied to postoperative anesthesia, at herpes zoster, and also with the medical purpose (vagosympathetic blockade, blockade of a star-shaped node, etc.).

Fig. 13. Venny anesthesia across Ryvlin

Intravascular anesthesia it is made by an injection of the anesthetizing substance in arterial or venous vascular network. Getting through walls of capillaries, anesthetic blocks at first the terminations, and then and the main trunks of nerves. This look And. the m is applied at extremity operations (to the level of border between an upper and average third of a shoulder or hip). Necessary condition of success intravascular And. the m and its safety is desalination of an extremity and isolation of its vascular network from the general circulation that is reached by use of plaits, the inflated cuffs, hard bandaging of an extremity in the raised situation. Anesthesia comes in 1 — 2 min. at intra arterial and in 20 — 30 min. at intravenous anesthesia and stops after resuming of blood circulation. At the correct technique of the toxic phenomena usually does not happen. The method developed in 1908 by A. Bier intravenous And. the m in a crust, time is not applied. Anesthesia according to Ya. B. Ryvlin (1947) who suggested to enter intravenously (fig. 13) of 100 — 250 ml of 0,5% of solution of novocaine gained distribution in the USSR then to wash out a vein twice the smaller volume of normal saline solution. Foreign authors recommend lidocaine (xycain) (40, 100 ml of 0,5% of solution for And. m top and bottom extremities respectively). Kind of this method A. the m is intra bone anesthesia: the anesthetizing substance is entered into an epiphysis of spongy bones (an anklebone, a head of the I plusnevy bone, condyles of a hip etc.). Depending on the level of operation enter 25 — 120 ml of 0,25 — 0,5% of solution of novocaine.

Intra arterial anesthesia it is offered by Goyanes in 1912. Enter 50 — 100 ml of 0,5% of solution of novocaine or 10 — 20 ml of 0,5% of solution of lidocaine into an artery. Intravascular anesthesia is contraindicated at long operations and at defeats of vascular system of extremities. It has no broad use.

Tools and solutions for anesthesia local

For infiltranionny and regional And. m are necessary syringes with a capacity from 1 — 2 to 10 ml, a set of needles of various length and diameter. For infiltr atsionny And. m of skin and conduction And. m of fingers are necessary short and fine needles. For And. the m of a pleura and a peritoneum serve special needles from the end bent at an angle 120 °. At intra bone And. m apply short thick needles with mandrin. Novocaine should be prepared for ex tempore. Powder it is poured into the boiling Vishnevsky's solution (NaCl — 5,0; KCl — 0,075; CaCl2 — 0,125; Aq. destillatae — to 1000,0) or normal saline solution. It is better to use the warmed-up anesthetizing solution. Vasoconstrictive substances — adrenaline (2 — 5 drops of 0,1% of solution for 100 ml of solution of novocaine — for an infiltration, 1 drop on 1 ml of solution of novocaine or Dicainum — for terminal And. m) or ephedrine (1 drop of 5% of solution for 1 ml of the anesthetizing solution — for terminal And. m) — it is necessary to add before the operation.

Complications of local anesthesia usually are a consequence of individual intolerance of the anesthetizing substance or increase in its concentration in blood owing to bystry absorption (especially at terminal And. m of a mucous membrane of respiratory tracts), exceeding of a dose, accidental introduction to a vessel etc. Toxic effect of novocaine is shown by excitement, concern, dizziness, a tremor, spasms, for to-rymi deep oppression of c can follow. N of page. At bystry intake of the anesthetizing substance in blood signs of oppression of cardiovascular system can prevail: pallor, perspiration, bradycardia, hypotension up to a collapse (see) and cardiac standstills. Respiratory depression can lead to an apnoea.

Treatment of complications. In mild cases there is enough inhalation of oxygen and stopping of spasms (barbituric anesthesia). At heavier complications — transfusion of blood substitutes, introduction vasoconstrictive and cardiacs, an artificial respiration (see), a cardiac massage (see) and other resuscitation measures (see. Resuscitation ). For prevention it is necessary to check before administration of solution the provision of a needle back motion of the piston, to use solution, vasoconstrictive substances are added to Krom, not to exceed the most tolerable doses.

Spinal anesthesia (synonym: lumbar, spinal, subarachnoidal anesthesia) — a version regional And. the m, is reached by introduction to a subarachnoid space of the spinal channel of the anesthetizing solution which blocks nerve conduction in roots of a spinal cord. At this method A. m are necessary for achievement of anesthesia the minimum quantities of anesthetic and its toxic influence on parenchymatous bodies is insignificant. For the first time spinal anesthesia was applied by Vir (A. K. of G. Bier, 1899) in 1897. Korning are considered as his predecessors (J. L. Corning, 1885), in experiences to-rogo spinal anesthesia arose after an injection of cocaine to the area of intervertebral intervals, and Quincke (N. of I. Quincke) who offered a lumbar puncture in 1891. In our country spinal anesthesia found broad application in the first half of 20 century, especially after issue of the monograph of S. S. Yudin (1925). With introduction to broad practice of modern methods of an anesthesia interest in spinal anesthesia considerably weakened. Nevertheless it remains on arms of service of anesthesia also now.

Spinal anesthesia is shown at all operations below a diaphragm (including and emergency), and also in cases when carrying out an anesthesia is undesirable (hron. diseases of lungs, oral cavities, drinks, throats, tracheas, in the presence of the reasons complicating an intubation of a trachea).

Contraindications should be considered acute blood loss, shock, obesity, obesity, a brain injury and its effects (epilepsy, encephalopathy), diseases of c. N of page (syphilis of c. N of page, meningitis, etc.), sepsis, pustulous diseases of skin of a back, deformation of a backbone in lumbar area, an idiopathic hypertensia of the II—III stage, hypotonia.

Preparation for spinal anesthesia. In 3 — 4 days prior to carrying out anesthesia purpose of bromides, phenobarbital, tranquilizers, for an hour before operation — opiates with atropine or Scopolaminum is recommended. The last is given preference. Before an immediate surgery it is necessary to empty a stomach the thick probe. In 10 min. prior to carrying out anesthesia when the patient already is on the operating table, for prevention of hypotension under skin enter 1 ml of 5% of solution of ephedrine. Are necessary for anesthesia 1 — the 2-gram syringe (the insulin syringe with accurately designated divisions is most convenient) and special needles is not higher than No. 20. Preference is given to the most fine needle from available. The anesthetizing solution shall be freshly cooked or ampoules irovanny.

Fig. 14. A spinal puncture in position of the patient sitting
Fig. 15. A spinal puncture in position of the patient lying
Fig. 16. The emergence of drops testimonial of the fact that the end of a needle is in a subarachnoid space

Equipment of spinal anesthesia. Spinal anesthesia is produced in position of the patient sitting or lying on one side (fig. 14 and 15). In both cases before a puncture the chin of the patient shall be sharply given to a breast and the back is most curved for achievement of optimum distance between acanthas of vertebrae. Hands are bent in elbows and given to a stomach crosswisely. Knees of the patient in a prone position also shall be given to a stomach. After processing of a surgery field alcohol and iodine the area of a puncture is repeatedly processed alcohol before disappearance of traces of iodine. Make a usual spinal puncture (see) in one of intervertebral intervals from ThXII to LIV. After emergence of freely falling drops of cerebrospinal liquid [the certificate that the end of a needle is in a subarachnoid space (fig. 16)] the anesthetizing solution is quickly entered into a subarachnoid space (0,4 — 0,8 ml of 1% of solution of a sovkain, to 2 ml of 1% of solution of Dicainum, to 3 ml of 5% of solution of novocaine). For increase in level of anesthesia use mixing of cerebrospinal liquid with the anesthetizing solution (bubbling). The needle is quickly taken and on skin in the place of a puncture impose a gauze sticker. The patient is stacked on a back at an angle 30 ° in the provision of Trendelenburga for 8 — 10 min. After administration of novocaine the provision of Trendelenburga is inexpedient. At the same time start intravenous drop injection of liquid.

The described equipment is proved by the following. At sitting sick the entered solution with specific weight big, than the specific weight of cerebrospinal liquid (the last is equal to 1,004 — 1,007), so-called heavy solution (e.g., novocaine), falls down and causes development of low spinal anesthesia. At the patient, to-rogo put on a back at once after an injection, thanks to a bend of spinal channel «tyazhely» solution gets into chest department. In the provision of Trendelenburga anesthetic falls even below, in the cranial direction. Solution with smaller specific weight («light» solution — Dicainum, sovkain) rises up and therefore anesthesia spreads to an upper half of a trunk. At the patient lying on spin, «light» solution remains in lumbar area. If to lay the patient on a stomach, then «light» solution gets into chest department of the spinal channel whereas «heavy» remains in lumbar area.

Thus, a possibility of use of solutions with various specific weight and creation of the relevant provision of a body of the patient allow to control the level of blockade of spinal roots. Due to position of the patient one more detail has important value. In situation on spin «heavy» solution falls to back, sensitive roots and causes full anesthesia with an incomplete muscular relaxation. During the use of «light» solution which in this situation spreads up to motor roots, there can come motive paralysis without full anesthesia. For this reason if anesthesia «light» solution shall be rather high, the patient for 8 — 10 min. is turned on a stomach. Same treats edgewise position: at administration of «light» solution of the patient shall lie on a healthy side, at administration of «heavy» solution — on a sick side within 8 — 10 min. During this time anesthetic is fixed, and subsequent change of situation has no sick significant effect on prevalence of anesthesia (F. Shvets, 1963). Therefore, position of the patient depending on the specific weight of the anesthetizing solution and curvature of a backbone shall be chosen in advance.

Duration of anesthesia depends on a type of anesthetic and a way of its introduction. Novocainic anesthesia lasts about an hour whereas anesthesia sovkainy till 2 — 3 o'clock. At long spinal anesthesia the anesthetizing solution is entered repeatedly by means of the catheter which is carried out through a gleam of a needle to a subarachnoid space. Anesthesia is supported within several hours and even days.

Current of anesthesia. At spinal anesthesia painful, temperature and tactile sensitivity consistently disappears. In the last turn there comes blockade of motive ventral roots. It gives full anesthesia and a sufficient relaxation of cross-striped muscles. Owing to blockade of adrenergic vasoconstrictive rami communicantes albi fibers there is an expansion of arterioles that leads to a lowering of arterial pressure. Decrease adrenergic and a prevalence of a cholinergic (parasympathetic) tone causes a nek-swarm delay of cordial activity and strengthening of a vermicular movement of intestines. At low spinal anesthesia lowering of arterial pressure is shown slightly.

Complications of spinal anesthesia and their prevention. The most dangerous complication during the carrying out spinal anesthesia is acute insufficiency of breath and blood circulation (see the Collapse). These heavy disturbances of the vital functions of an organism can result from the widespread blockade (more than 10 — 12 segments) of sensitive and motive roots of a spinal cord which is followed by paralysis of a large number of the sympathetic fibers and motive fibers innervating respiratory muscles. She is possible at overdose of anesthetic or at the wrong maintaining anesthesia. Danger of this sort of complications increases at high spinal anesthesia (higher than the level of a diaphragm). The symptomatology of these frustration (so-called bulbar thunder-storm) was explained with paralysis of the bulbar centers because of penetration of solution of anesthetic into a cavity of the IV ventricle earlier. Respiratory depression leads to a hypoxia (see), respiratory, and then and to a metabolic acidosis (see) that even more aggravates disturbances of blood circulation. Therefore at spinal anesthesia the condition of the patient shall be controlled also carefully, as well as during an anesthesia. Immediately after the patient is laid on the operating table, it is necessary to adjust drop intravenous injection of warm normal saline solution, Polyglucinum or blood and to regulate the speed of injection according to a condition of cardiovascular system, immediately filling blood loss if it arises on the course of operation. In the operating room there has to be an equipment for an anesthesia and artificial ventilation of the lungs. At initial signs of respiratory depression (increase or breath holding with yawning, emergence of feeling of constraint in breasts, a Crocq's disease) it is necessary to begin inhalation of oxygen through a mask of the narcotic device; at increase of the phenomena of a decompensation the assisted and artificial respiration can be required (see).

At a lowering of arterial pressure increase in volume of the circulating liquid (jet injection of the liquids stated above or blood), use of cardiacs, glucocorticoids, vazopressor is reasonable, etc. up to resuscitation measures (see Resuscitation).

Upon termination of operation of the patient shall be in horizontal position in order to avoid an orthostatic collapse. Complications which can develop in the postoperative period after spinal anesthesia come down to insignificant rise in temperature, sometimes to an ischuria, nausea, vomiting» the Most frequent complication (7% and more) — a headache. The main reason it the effluence of cerebrospinal liquid from an opening after a puncture of a firm meninx is considered; therefore it is recommended to use only fine needles. One of measures of prevention of this complication is preservation of horizontal position after operation: at least during 12 hours to the patient do not allow to raise the head. At headaches appoint analginum, pyramidon, carry out dehydrational therapy by hypertonic salt solutions of glucose, hexamethylenetetramine (urotropin). Purulent meningitis is a consequence of insufficient observance of rules of an asepsis. Late complications like paralyzes, paresthesia are, etc. quite rare. Strict observance of the technology of performance of anesthesia and preparation and use of the anesthetizing solutions reduces possibility of such complications to minimum. Careful control of a condition of the patient before operation, during it and in the postoperative period and timely correction of the arising complications is done spinal And. m in hands of the experienced surgeon by no more dangerous method of anesthesia, than a modern anesthesia. In process of accumulation of individual experience it can become anesthesia of the choice at many operations on bodies of the lower half of a body.

Peridural anesthesia (synonym: extradural, epidural) is one of versions regional And. m. It is offered by the French doctors A. Sicard and F. Cathelin in 1901, however practical distribution was gained after works the Page (F. Pagés, 1921) also by Doljotti (A. M. of Dogliotti, 1931 — 1933).

Peridural anesthesia is based on blockade of spinal nerves and their roots by solution of the local anesthetic entered into peridural space. It is characterized by vegetative (sympathetic) blockade, segmented anesthesia and relaxation of muscles.

Indications. Peridural anesthesia can be used at various intra belly, gynecologic, urological and proctologic interventions, at operations on an abdominal wall and the lower extremities and also as a component of anesthesia in thoracic surgery. It is shown at patients with «high risk», at associated diseases of cardiovascular and respiratory systems, endocrine disturbances, at advanced and senile age, in the emergency anesthesiology. It is applied to postoperative anesthesia, treatment of dynamic impassability of intestines, acute pancreatitis, peripheral vascular and neurologic frustration, to a labor pain relief.

Tools: needles with mandrin and a short cut 8 — 10 cm long, 1 mm thick, needles with a side arrangement of a cut [like Tuohy (E. V. Tuohy)] 1,5 — 2 mm thick, the syringes «Record» with a capacity of 5 and 10 ml, catheters to dia. 0,9 — 1,2 mm, 60 — 80 cm long.

Anesthetics. Solutions of a xycain (xylocainum), 1 — 2% solutions of Trimecainum and 0,3% solution of Dicainum use 1 — 2%. At the peridural anesthesia reached by single administration of anesthetic before introduction to solution add adrenaline, and for lengthening of effect of anesthesia — blood of the patient (1:5). In recent years abroad new anesthetics — mepivakain, bupivacaine found application.

Fig. 17. The provision of a needle at paramedian and median ways of peridural anesthesia: 1 — lig. flavum; 2 — peridural space; 3 — a firm meninx
Fig. 18. A puncture of peridural space in chest department

Equipment of peridural anesthesia. To the patient who is in situation for spinal anesthesia process leather, anesthetize it and the subject fabrics. The puncture can be made median and paramedian by ways (fig. 17). After a puncture of skin the needle passes hypodermic cellulose, lig in the first case. supraspinale, lig. interspinale, lig. flavum, in the second — hypodermic cellulose and lig. flavum. The direction of carrying out a needle in lumbar department horizontal, in chest — inclined, according to the provision of acanthas of vertebrae (fig. 18). Hit of a needle in peridural space is determined by disappearance of resistance to administration of liquid and but to retraction of a drop in a gleam of a needle. The equipment of the prolonged peridural anesthesia provides the subsequent introduction of a catheter through a needle.

Doses of the anesthetizing solution for patients of middle age make 20 — 30 ml. Persons have 60 years and are more senior at the expressed atherosclerosis they shall be reduced on 1/2 — 1/3. At first 5 ml (test dose), and then in 5 min. enter other amount of anesthetic. Anesthesia comes in 15 — 20 min. and lasts from 1,5 to 8 hours and more (depending on the used drug).

At the prolonged peridural anesthesia the anesthetizing solution is entered through a catheter which is kept in peridural space up to several days.

The choice of level of a peridural puncture depends on area of surgical intervention: at thoracic operations — ThV - VII, verkhneabdominalny — ThV - XI, nizhneabdominalny — ThXII — LII, at operations on bodies of a small pelvis, crotch and the lower extremities — the LII-V. A version peridural is with akraljny anesthesia, at a cut solution of anesthetic is entered into the sacral canal through hiatus sacralis.

Complications. The expressed hypotonia meets in 2 — 5% of cases. Heavy disorders of breath and blood circulations (frequency of 0,1 — 0,3%) can be: a) at not recognizable puncture of a firm meninx and subdural introduction of all dose of anesthetic; b) at widespread peridural blockade owing to relative or absolute overdose of the anesthetizing solution. The prevention of these complications is connected with obligatory use of a test dose and constant control behind a condition of the patient. Treatment: artificial ventilation of the lungs, introduction of vazopressor, correction of a hypovolemia. Toxic reactions and neurologic complications are noted seldom.

Contraindications. Absolute: an inflammation in the field of an estimated puncture; relative: deformation of a backbone, disease of the central or peripheral nervous system, hypotonia, hypovolemia, disturbances of coagulant system of blood.

Anesthesia of maxillofacial area it is reached in three ways: 1) cooling of fabrics with a stream of ether or Aether chloratus (it is applied extremely seldom); 2) application of anesthetic on a mucous membrane of an oral cavity (it is used at removal of a dental calculus, opening of superficially located abscess, etc.); 3) introduction of the anesthetizing .veshchestvo to fabrics (infiltration anesthesia) or to the area where there passes the nervous trunk or its peripheral branches (conduction anesthesia).

For removal of psychoemotional tension at the patient in 45 — 60 min. prior to surgical intervention carry out premedication: appoint small tranquilizers — Trioxazinum of 0,3 g, Meprotanum of 0,2 — 0,4 g with addition of analgetics.

Solutions of novocaine usually apply 0,5 — 1 — 2% to a local anesthesia on a face and jaws. Trimecainum and a xycain which apply in 0,25 — 0,5 — 1%, sometimes 2% solutions possess more expressed anesthetizing action. For deepening and extension of anesthesia add vasoconstrictors to solution of anesthetic: 0,1% solution of a hydrochloride of adrenaline (on 1 drop on 2 — 5 ml) or 1% solution of a phenylephine hydrochloride on 0,3 ml on each 10 ml of anesthetic.

by Fig. 19. The provision of a needle at an infiltration anesthesia of an alveolar shoot of an upper jaw: 1 — correct — the bevel of a needle is directed to a bone tissue; 2 — wrong — the bevel of a needle is directed against a bone tissue, the needle was thrust in a bone and bent (dotted line)

Infiltration anesthesia apply at operations on soft tissues of the person (0,5% solution of novocaine) and operations on an alveolar shoot of an upper jaw — 1 — 2% solution (an odontectomy, operation for a cyst of a jaw, surgical treatment of wounds of soft tissues at damages, etc.). At this way the solution of anesthetic entered into soft tissues of an alveolar shoot (from outer and its internal side), diffuses in a bone tissue through openings in a cortical plate of a jaw (indirect infiltration anesthesia) and interrupts conductivity of the branches of a tooth texture innervating the teeth, a bone tissue of an alveolar shoot and soft tissues covering its outer surface. It is necessary that the bevel of a needle was directed to a bone tissue, and at advance of a needle it is necessary to enter gradually the anesthetizing solution in order to avoid wound of vessels (fig. 19). On a mandible because of the considerable thickness of a cortical plate and trace amount in it natural foramens infiltration anesthesia is usually ineffective.

Conduction anesthesia is most often applied at surgical interventions on teeth, an alveolar shoot and jaws, and also at surgical treatment of the combined injuries of a facial skeleton and the covering soft tissues. Solutions of novocaine, a xycain, Trimecainum use 1 — 2%. Under a conduction anesthesia in combination with premedication it is possible to carry out extensive and traumatic operative measures (a resection of a jaw, a bone gnathoplasty, etc.).

Tuberalny anesthesia is carried out for switching off of back upper alveolar branches at a hillock of an upper jaw. At the same time the bone tissue of an alveolar shoot in the field of upper painters, a mucous membrane of its outer surface, the site of an upper jaw in the field of a hillock is anesthetized. At an intra oral way of anesthesia (the mouth of the patient is half-open) a needle stick in a transitional fold of an upper jaw behind a skulo-alveolar crest (at the level of the second big molar, fig. 20,1). The needle is advanced up, inside and kzad on a bone tissue of an upper jaw on depth to 1,5 — 2 cm, continuously entering the anesthetizing solution (1,5 — 2 ml). At an extraoral way a needle skin on depth apprx. 2,5 cm, against the stop needles stick in a hillock of an upper jaw through skin under a malar at the level of the outer edge of an eye-socket normally to the surface.

Infraorbital anesthesia — switching off of upper front alveolar branches in an infraorbital foramen. At the same time there comes anesthesia of soft tissues of infraorbital area, a wing of a nose, a half of an upper lip, bone tissue of an alveolar shoot in the field of cutters and a canine of the relevant party, sometimes small molars, a sidewall of an upper jaw and a mucous membrane of an outer surface of an alveolar shoot, also the average upper alveolar branch is often switched off.

At an intra oral way of anesthesia grope an eminence at bottom edge of an eye-socket and under it on site arrangements of an infraorbital foramen an index finger press the soft tissues covering it to a bone; a thumb delay up an upper lip. To Eagle also knaruzh to the surface of a bone in the field of a klykovy pole stick in a mucous membrane over a lateral cutter up and advance it to the site of a jaw under an index finger (fig. 20,2) where find a tip of a needle an entrance to an infraorbital foramen. The needle is entered into the canal on depth apprx. 7 mm and inject 0,5 — 0,75 ml of the anesthetizing solution.

At an extraoral way an index finger fix skin in the field of an infraorbital foramen, a needle stick through skin of a knutra and below a finger on 1 cm, and arrive as well as at an intra-oral way further.

Palatine anesthesia — switching off of a big palatal nerve in a big palatal opening; soft tissues of a half of a hard palate and an inner surface of an alveolar shoot to the level of canines are anesthetized. The needle is entered (the mouth of the patient is widely opened) at the basis of an alveolar shoot at the level of the rear edge of the second painter; the direction of a needle — up, knaruzh and kzad (fig. 20,3). Find the end of a needle an opening, in a cut enter 0,5 — 0,75 ml of anesthetic.

Incisal anesthesia — switching off of a nasopalatine nerve in an incisive foramen; the site of soft tissues of front department of a hard palate and an alveolar shoot at the level of the central and lateral cutters is anesthetized. At an intra oral way a needle stick vertically in the area of an incisal nipple behind the central cutters, find the end of a needle an opening and enter it into the canal on depth of 5 — 7 mm then inject 0,5 — 0,75 ml of solution of anesthetic. At an intranasal way of anesthesia solution of anesthetic is injected under a mucous membrane of a lower part of a partition of a nose on both sides or enter tampons, the impregnated 2 — 5% solution of Dicainum with adrenaline.

Mandibular anesthesia — switching off of the lower alveolar nerve at a mandibular opening and a lingual nerve; the soft tissues covering an alveolar shoot of a mandible, a mucous membrane of a half of a mouth floor, front two thirds of language, teeth and a bone tissue of an alveolar shoot are anesthetized. At an intra-oral way of anesthesia the syringe have across a mouth, stick a needle outside from an alate and mandibular fold 1 cm higher than a chewing surface of the lower painters before contact with an inner surface of a branch of a mandible (fig. 20,5). At a depth apprx. 0,75 — 1 cm inject 0,5 ml of solution of the anesthetizing substance for switching off of a lingual nerve. After that at a depth apprx. 2 — 2,5 cm enter 1,5 more ml of anesthetic. Anesthesia comes in 15 — 20 min. For switching off of the buccal nerve branching in a mucous membrane it is necessary to enter in addition anesthetizing solution into a transitional fold at the level of the second lower premolar tooth and the first painter or at a first line of an upper part of a branch of a mandible. At an extraoral way of anesthesia a needle stick (the head of the patient is cast away) in skin under bottom edge of a mandible on 1,5 — 2 cm of a kpereda from its corner and advance in close proximity to a bone on depth apprx. 4 cm parallel to the rear edge of a branch of a mandible.

Torusalny anesthesia — switching off lower alveolar, lingual and buccal nerves on «a mandibular eminence». For performing anesthesia a needle stick 0,5 cm below than chewing surfaces of upper painters of a kpereda from an alate and mandibular fold (fig. 20, 6). At a depth from 0,5 to 2 cm when the needle rests against a bone («a mandibular eminence»), inject 1,5 — 2 ml of the anesthetizing solution.

Mental anesthesia — switching off of sensitivity in the field of the lower canine and the lower premolar tooths, and also soft tissues of an outer surface of an alveolar shoot of a mandible and a half of an under lip. At an intra oral way a needle stick at the level of the first painter in a transitional fold of a mucous membrane of an entrance of the mouth, direct down, forward, knutr and enter into the mouth of the channel below roots of premolar tooths (fig. 20, 7). At an extraoral way a needle stick through skin of a body of the mandible 2 cm higher than edge, a kzada from a corner of a mouth (fig. 20, 8), giving it the same direction, as at an intra oral way. Inject into a mental foramen 0,5—0,75 of ml of the anesthetizing solution. It is in addition necessary to make an infiltration anesthesia from the lingual party in the corresponding teeth for switching off of branchings of a lingual nerve.

Bershe a way of anesthesia — switching off of motive branches of a mandibular nerve; make at an inflammatory contracture of a mandible or for redressment at cicatricial contractures of jaws. To Eagle stick through skin under a zygoma of a kpereda from a trestle of an ear on 2 cm, carry out it through cutting of a mandible on depth of 2 — 2,5 cm and inject 2 — 3 ml of the anesthetizing solution. In 10 — 15 min. there occurs relaxation of the muscles lifting a mandible.

Trunk anesthesia — switching off of maxillary and mandibular nerves (the second and third branches of a trifacial). Switching off of a maxillary nerve in a pterygopalatine pole is made in the extraoral ways: 1) the needle is entered under a malar (as well as at an extraoral way of tuberalny anesthesia), out up and inside on depth of 4 — 5 cm where enter 2 — 4 ml of solution of anesthetic; 2) orbital way: a needle stick through skin in the area of a middle part of bottom edge of an eye-socket and, carrying out it up to a bone of a bottom of an eye-socket on depth of 3 — 3,5 cm, get to a pterygopalatine pole and enter the anesthetizing solution. At an intra oral way a needle stick the same as at palatine anesthesia, carry out via the alate channel on depth of 2,5 — 3 cm where enter solution of anesthetic. Podskulo-krylovidny way of switching off of a maxillary nerve (S. N. Vaysblat): the needle is entered under a zygoma on the middle of distance between a trestle of an ear and the outer edge of an eye-socket (the middle of the trago-orbital line) it is perpendicular to integuments (fig. 20, 4) and will see to contact with a side plate of an alate shoot of a wedge-shaped bone, then delay knaruzh a little and move kpered on 1 — 1,5 cm, entering it on the same depth, i.e. enter into a pterygopalatine pole then inject the anesthetizing solution. For switching off of a mandibular nerve from the same place in Coca the needle, after its partial extraction, is directed to the same depth, but on 1 — 1,5 cm of a kzada and inject 4 — 5 ml of the anesthetizing solution.

For prevention of complications (a hematoma, postoperative pains, a change of a needle) it is necessary to enter the anesthetizing solution continuously that it moved apart soft tissues and vessels in process of advance of a needle deep into, to use needles of sufficient length, not to enter the anesthetizing solution directly into a nerve. It is not necessary to enter a large amount of anesthetic in order to avoid a necrosis of soft tissues of a hard palate into a big palatal opening.

Anesthesia local in field conditions — one of the most important elements of medical aid by the wounded at all stages of evacuation. During the Great Patriotic War in field army from 85 to 90% of all operations it was made under And. m (M. N. Akhutin, S. I. Banaytis, V. I. Popov). Despite snowballing of modern anesthesiology and improvement of various methods of an anesthesia, And. the m in field conditions keeps a dominant position, especially at the advanced stages of medical evacuation. It is explained by simplicity of a method, a possibility of bystry mastering it doctors of any qualification, safety and high performance.

At stages of medical evacuation And. the m is applied with various purposes. In PMP it is carried out in the form of conduction and futlyarny novocainic blockade according to Vishnevsky or by administration of solution of novocaine in a hematoma in the field of a fracture of a bone for the purpose of prevention and therapy of traumatic shock. In time the Great Patriotic War broad application was found by vagosympathetic blockade at wounds of a breast and futlyarny blockade at fire before ohms of extremities. For blockade 0,25% solution of novocaine which prepares in MEDSB and is given in PMP in bottles on 100 ml are used.

Primary and repeated novocainic blockade (see) in complex prevention of therapy of traumatic shock are applied in MEDSB (OMO) and at the subsequent stages of evacuation directly in antishock departments or dressing rooms. However at these stages of evacuation And. the m is more widely applied at surgical treatment of wounds. And. the m should be applied at operative measures concerning not getting wounds of a skull without change and with a fracture of the bones of the arch which are getting and not getting wounds of a breast if there are no indications to a thoracotomy, not getting wounds of a stomach and pelvic area, fire fractures of bones of a forearm, a brush, foot, fire fractures of a shoulder and shin without extensive destruction of bones and soft tissues, wounds of soft tissues of any localization; burns, at which uncomprehensive necretomies and free change limited are shown (to 300 cm2), sites of skin.

At surgical treatment of wounds of a skull and trunk the method of «creeping infiltrate» is used on And. To V. Vishnevsky, and during the processing of wounds of extremities it is more reasonable to combine this method with anesthesia as «cross-section» or intra bone anesthesia. In about all cases 0,25% solution of novocaine are applied.

At wounded with multiple heavy damages, with the getting wounds of a breast and stomach, with damage of pelvic bodies, fire fractures of a hip and extensive destructions of a shoulder or shin if there is no opportunity to apply an anesthesia (see), And. novocainic blockade (vagosympathetic — shall precede m at wounds of a breast, perinephric — at wounds of a stomach and a basin, conduction or futlyarny — at wounds of extremities).

During the mass surgical work for And. the m is recommended to use syringes automatic machines or continuous-action syringes (see Syringes). It allows to save time spent for anesthesia.

Anesthesia local at children's, advanced and senile age

Anesthesia local at children is applied considerably less than at adults. It is connected with features of mentality, intolerance of pain, difficulties of contact and motive excitement of children. Due to implementation in clinical practice of perfect and safe methods of an anesthesia (see) range of the operative measures which were carried out at children under And. the m, was even more reduced. However some operations and diagnostic testings at children in out-patient clinic and in a hospital are carried out under And. m. At the same time it is necessary to remember that during operation under And. m as well as under anesthetic, maintenance and correction of the main vital functions is necessary: breath and gas exchange, cardiovascular activity, etc.

Under infiltration And. m newborn such operations as a pylorotomy, a gastrostomy can be performed. At children of all age groups under And. the m can delete small superficial angiomas, cysts, to make a thoracocentesis, drainage of a pleural cavity. Also conduction anesthesia, e.g. anesthesia of fingers across Lukashevich — to Oberst, juxtaspinal anesthesia is applied at children at fractures of edges. Usually for this purpose solutions of novocaine use 1 — 2%. Indications to use of various blockade — vagosympathetic, presakralny, perinephric — at children are the same, as at adults (see. Novocainic blockade).

The wide spread occurance in prevention and treatment of subcopular hypostasis was received at children by intranasal blockade. For this purpose 0,25 — 0,5% enter solution of novocaine under a mucous membrane of the closing nasal stroke (on 0,5 — 2 ml on both sides).

And. the m is often applied at children of advanced age to anesthesia of the place of a change. Apply 2% solution of novocaine (1 ml for 1 year of life) which is entered directly into a hematoma in the field of a change. Recently finds the increasing distribution in children's surgery peridural anesthesia Trimecainum. Under peridural anesthesia newborns and babies can purely perform operations on bodies of a small pelvis. Peridural anesthesia can be applied and as a component of a balanced anesthesia in combination with the general anesthetics, relaxants. However peridural anesthesia is more shown for a continuous anesthesia after operational: interventions on bodies of a thorax and abdominal cavity at children.

At patients of advanced and senile age with development of the general anesthesia specific weight And. the m considerably decreased. However at the weakened patients suffering from a pneumosclerosis, emphysema of lungs, cardiovascular frustration in which even small concentration of the general anesthetics can cause disturbances of breath and blood circulation, such operations as appendectomy, herniotomies and other interventions on a body surface can be executed under And. m. It is necessary to consider also that in similar cases at patients with a full stomach at And. the m is less danger of vomiting and regurgitation, than at the general anesthesia. At patients with labile mentality at small operations A. the m can be applied in combination with inhalation of nitrous oxide and oxygen.

At the elderly patients suffering from a pneumosclerosis, emphysema of lungs, hron. bronchitis, at operations on bodies of a small pelvis it can be applied peridural And. m. Long peridural anesthesia for prevention of pains is very reasonable at patients of advanced and senile age after big and traumatic operations.

Technique And. the m at patients of advanced and senile age does not differ from usual. See also Anesthesia .

The bibliography

Anrep V. K. Kokain as the means which is locally anesthetizing, the Doctor, No. 46, page 773, 1884; Vishnevsky A. A. Local anesthesia on a way of creeping infiltrate in chest surgery, Surgery, No. 5, page 21, 1949; Vishnevsky A. V. A local anesthesia by a method of creeping infiltrate, M., 1956; Girshel G. The guide to local anesthesia, the lane with it., L., 1929; Gottlieb M. A local anesthesia on Schleich'y, Surgery, t. 2, No. 11, page 368, 1897, bibliogr.; Dudkevich G. A. Local anesthesia and novocainic blockade, Yaroslavl, 1966, bibliogr.; Zykov A. A. Sketches of development of a local anesthesia in the USSR, L., 1954, bibliogr.; Kazan V. I. and Rasstrigin N. N. Local anesthesia and its role in modern anesthesiology, Surgery, No. 8, page 89, 1965, bibliogr.; Lukashevich A. I. About hypodermic injections of cocaine, Medical obozr., t. 25, No. 10, page 950, 1886; Persianinov L. S. Local anesthesia according to A. V. Vishnevsky at obstetric and gynecologic operations, M., 1955, bibliogr.; Ryvlin Ya. B. Direct local intravenous anesthesia on extremities, Surgery, No. 6, page 10, 1947; Red A. N. A local anesthesia and the doctrine about a nervous trophicity according to A. V. Vishnevsky, in the same place, No. 5, page 9, 1949; Shaak B. And. and Andreyev L. A. A local anesthesia in surgery, M. — L., 1928, bibliogr.; Shlapobersky V. Ya. and Glezer M. Yu. Anesthesia of a brachial plexus, Surgery, No. 7, page 32, 1943; Adriani J. Nerve blocks, manual of regional anesthesia for practitioners, Oxford, 1954; it. Labat's regional anesthesia, Philadelphia, 1967; Anrep W. K. Über die physiologische Wirkung des Cocain, Pflügers Arch. ges. Physiol., Bd 21, S. 41, 1879; Bonica J. I. Transtracheal anesthesia for endotracheal intubation, Anesthesiology, v. 10, p. 736, 1949; Braun H. Die örtliche Betäubung, Lpz., 1925, Bibliogr.; Braun H. u. Läwen A. Die örtliche Betaubung, Lpz., 1951, Bibliogr.; Farr R. E. Practical local anesthesia and its surgical technic, Philadelphia — N. Y., 1923, bibliogr.; Finsterer H. Die Methoden der Lokälanasthesie in der Bauchchirurgie und ihre Erfolge, V., 1923; Jong P. H. a. Wagman I. H. Physiology of regional anesthesia. Int. Anesth. Clin., v. 1, p, 535, 1963, bibliogr.; Kappis M. Der derzeitige Stand der örtlichen Betäubung, Ergebn. ges. Med., Bd 11, S. 51, 1928; Macintosh R. R. a. Bryce-Smith R. Local analgesia abdominal surgery, Baltimore, 1962; Macintosh R. R. u. Mushin W. W. Örtliche Betaubung, Plexus brachialis, B. — N. Y., 1967; Macintosh R. R. and. Ostlere M. Local analgesia, head and neck, Edinburgh, 1955; Molesworth H. W. L. Regional analgesia, L., 1941; Monod O. e. a. L'anesthésie en chirurgie thoracigue d'apres 7000 cas operes de 1934 à 1954, P., 1955; Moore D. C. Complications of regional anesthesie, etiology, signs and symptoms, treatment, Springfield, 1955; Pitkin G. P. Conduction anesthesia, Philadelphia — L., 1946; Reclus P. L'anesthésie localisée par la cocaine, P., 1903; Schleich C. L. Schmerzlose Operationen, V., 1899, Bibliogr.; de Takáts G. Local anesthesia, Philadelphia, 1928.

Spinal anesthesia

Petrov B. A. Spinal anesthesia, M., 1948, bibliogr.; Shvets F. A pharmacodynamics of drugs, the lane with slovats., t. 1, page 682, Bratislava, 1971; Yudin S. S. Spinal anesthesia, Serpukhov, 1925, bibliogr.

Peridural anesthesia

Pryanishnikova N. T. and Spheres N. A. Trimekain, pharmacology and clinical use, L., 1967, bibliogr.; Shchelkunov V. S. Long peridural anesthesia, Vestie, hir., t. 98, No. 5, page 87, 1967, bibliogr.; Bromage P. R. Physiology and pharmacology of epidural analgesia, Anesthesiology, v. 28, p. 592, 1967; Lund P. C. Peridural analgesia and anesthesia, Springfield, 1966; Moore D. C. Regional block, p. 407, Springfield, 1965; Morisot P. L'anesthésie et l'analgésie péridurales, P., 1968; Regional anesthesia, ed. by J. J. Bonica, Philadelphia, 1971; Steenberge A. L. L'anesthésie peridurale, P., 1969.

Anesthesia of maxillofacial area

Bernadsky Yu. I. Fundamentals of surgical stomatology, page 39, Kiev, 1970; Vaysblat S. N. A local anesthesia at face operations, - jaws and teeth. Kiev, 1962, bibliogr.; M. D oaks. A local anesthesia in dental practice, L., 1969, bibliogr.

And. m in field conditions

Vishnevsky A. A. and Schreiber M. I. Field surgery, M., 1968; Illustrated handbook in local anesthesia, ed. byE. Eriksson, Chicago, 1969.

Local anesthesia at children's age

Isakov Yu. F. Intravenous and intra bone anesthesia at extremity operations at children, M., 1960, bibliogr.; Isakov Yu. F., Geraskin V. I. and Kozhevnikov V. A. Long peridural anesthesia after operation on bodies of a thorax at children, Grudn. hir., No. 1, page 104, 1971; Manevich A. Z. Pediatric anesthesiology with elements of resuscitation and an intensive care, page 261, M., 1970.

A. A. Vishnevsky; I. I. Deryabin (soldier.), V. I. Zausayev (ostomies.), V. A. Mi-helson, V. I. Geraskin (And. at children's, advanced and senile age); K. S. Si-monyan (spinal And.), Yu. N. Shanin (peridural And.).