NOVOCAINIC BLOCKADE — the method of nonspecific pathogenetic therapy based on ability of the solution of novocaine entered into fabrics to remove the strong irritation arising in a zone of the pathological center at the same time working as a weak irritant.
The doctrine about N. arose in connection with development of a local anesthesia (see. Anesthesia local ). The works of A. V. Vishnevsky and his pupils which allowed to formulate the concept which is theoretically proving N.'s action are devoted to deep studying of this question. Generalizing the long-term observations and data of experiments from positions of the ideas of a nervosism of H, E. Vvedensky, A. A. Ukhtomsky, I. P. Pavlov, A. V. Vishnevsky came to a conclusion that in a complete organism with its multilateral bonds novocaine, switching off an innervation even of a small reflexogenic zone and working as a weak irritant of a nervous sistekhma, leads to reflex reorganizations and by that exerts positive impact on all organism. This influence, in addition to switching off of a peripheral innervation and the related anesthesia, consists also in normalization of a nervous trophicity that is most brightly shown at diseases of inflammatory character and frustration of a muscle tone.
Types of novocainic blockade
School A. V. Vishnevsky a number of standard techniques of N. is developed. — cervical (vagosympathetic), lumbar (perinephric), presakralny, futlyarny and short. These techniques found broad application, in particular, in days of the Great Patriotic War.
Along with blockade according to Vishnevsky many surgeons offered the techniques thanks to what the range of use of N. considerably extended. Such blockade as intranasal, retrosternal, cardioaortical reflexogenic zones, paraperitone-alny, a seed cord, vnu-tritazovy concern to them.
Began to apply mixes of solution of novocaine with solutions of other anesthetics to extension of analgesic effect (the Ainu and, lidocaine, Trimecainum) and with prolongator (8% solution of gelatin, solutions of krupnomolekulyarny blood substitutes, etc. is wild). Besides, began to add to them various to lay down. drugs (antibiotics, Vikasolum, vitamins, etc.). The intra bone prolonged blockade developed by V. A. Polyakov are an example of such blockade.
At last, apply alcohol - new kainovye the blockade offered by M. O. Friedland.
Indications and contraindications to use of novocainic blockade, technology of performance
N. it has to be regarded only as one of to lay down. the factors applied in a complex with others.
The main indications to N.'s use. inflammatory processes, disturbance of a tone of muscles of bodies, the pathology which is followed by pain are (injuries, wounds, an obliterating endarteritis, hepatic and renal colic, etc.). By data A. V. Vishnevsky, under the influence of N. inflammatory process in a stage of serous treatment of fabrics can be suspended, in a stage of abscessing — is quicker delimited and allowed, in an infiltrative stage, and also at subacute and nek-ry hron, forms positive trophic shifts are observed, destructive processes quite often break and replaced by recovery. At disturbance of a tone of bodies (a gut, a uterus) N.'s use. promotes permission of spasms, on the one hand, and to increase of a tone at an atony — with another.
Originality of action of N. allows to use it not only in medical, but also in the diagnostic purposes (e.g., at differentiation of mechanical and dynamic impassability of intestines, inflammatory and noninflammatory process), for prevention (e.g., shock and other complications of reflex character at heavy damages and diseases).
Contraindications to N. practically not, except for cases of intolerance patients of novocaine and other means able it to replace.
N. it has to be carried out in aseptic conditions as any surgery.
General requirements to technology of carrying out any N. are as follows. Position of the patient — lying on the operating table. The surgery field is processed an antiseptic agent. By means of a fine needle infiltrirut solution of novocaine skin in an injection site of the blocking solution, at the same time the skin tumor is formed. Through a tumor stick and advance a long needle on the necessary depth, in process of advance entering through it solution of novocaine. The syringe is periodically removed from a needle, controlling a possibility of emergence of blood. Having reached necessary depth, enter all blocking solution, take a needle, press the place of a puncture for 5 min. a finger and close a sticker. At non-performance of all conditions of the technology of blockade can take place of a complication — a hematoma, aneurism, etc.
Novocainic blockade according to Vishnevsky. Cervical (vagosympathetic) blockade is applied to prevention and treatment of plevropulmonalny shock and a collapse at wounds, the closed damages and surgeries on bodies of a chest cavity, at the heavy burns of an upper half of a body, before evacuation wounded in a breast and a stomach for treatment of inflammatory infiltrates of a mediastinum, lungs, a thorax and their differentiation with new growths.
Position of the patient on spin with the roller under shovels, the head is taken to the party, opposite to the place of blockade, the hand on the party of blockade is given to a trunk and delayed from top to bottom. Strongly pressing an index finger in the point which is at the rear edge of a grudinoklyuchichno-mastoidal muscle places of decussation are higher than it with an outside jugular vein, bodies of a neck displace knutr. To Eagle stick at a top of a finger (fig. 1) and carry out deep into in the direction of a knutra and a little up, being guided by a front surface of a backbone. Enter from 40 to 50 ml of 0,25% of solution of novocaine. For the purpose of prevention and treatment of plevropulmonalny shock A. V. Vishnevsky recommended to make at the same time bilateral blockade that is sometimes unsafe (switching off of both vagus nerves).
Lumbar (paranefralyty) blockade is applied to prevention and treatment of shock at wound and the closed injury of a stomach, a basin, extremities, a burn disease, in the course of treatment of inflammatory diseases of abdominal organs (acute cholecystitis and pancreatitis, a perimitritis, a salpingitis), a peptic ulcer of a stomach and a duodenum, dynamic impassability of intestines, a nephrolithiasis, an acute renal failure, etc.
Position of the patient on one side with the roller under a waist. In the field of a corner between the XII edge and the muscle straightening a backbone enter a needle (fig. 2), to-ruyu advance deep into in situation, strictly normal to the surface skin. Having passed through a layer of muscles and a back leaf of a renal fascia, the end of a needle gets to space between front and back leaves of a renal fascia what intake of solution of novocaine and lack of a reversed current of liquid from a needle at removal of the syringe testifies free to (without essential pressure). After that enter 60 — 120 ml of 0,25% of solution of novocaine. At emergence of blood in a needle the last is slightly extended. Faultlessly carried out lumbar N. shall answer the rule: from a needle — at all liquids and at all blood. Sick after lumbar N. shall observe a bed rest within 1 — 2 days.
Presakralny blockade is applied at treatment of wounds and the closed damages of a sacrum and bodies of a basin, inflammatory diseases of a rectum and perirectal cellulose, at uterus operations and its appendages.
Position of the patient on one side with the knees tightened to a stomach or on spin with the hips which are strongly given to a stomach. The needle is entered between a tailbone and an anus under control of the finger entered into a rectum and advanced towards a top of a tailbone. As soon as there is a feeling that the needle passed the most dense fabric, begin to enter solution, advancing a needle more deeply and being guided at the same time by a front surface of a sacrum.
Enter from 100 to 120 ml of 0,25% of solution of novocaine.
Futlyarny blockade (fig. 3) is applied on extremities to prevention and treatment of traumatic shock at wounds and the closed injuries of extremities, to treatment of inflammatory diseases (the felon, a tendovaginitis, limfangiit, etc.), at stings of snakes.
Position of the patient on spin with the extended extremity (the upper extremity is stacked on a special support or an additional little table). To Eagle stick to a bone or only from front side of a hip (shoulder), or both from a lobby and from the back side. At a unilateral injection enter into a hip 120 — 200 ml of 0,25% of solution of novocaine, and into a shoulder — 100 — 120 ml, at bilateral — into a hip on 80 — 100 ml, into a shoulder — on 50 — 80 ml from each party. After futlyarny blockade the extremity is immobilized.
Short novocainic blockade is made at limited inflammatory diseases of face skin, trunk and extremities (a furuncle, an anthrax, a hydroadenitis), at a felon, a purulent complication of wounds, etc. At the same time quite often novocaine is entered in combination with antibiotics. Otstupya on 1 cm from the center of an inflammation (fig. 4), in healthy fabrics by a fine needle do a tumor and through it a long needle make infiltration of fabrics of 15 — 20 ml of solution of novocaine in a circle of the center, and then — 10 — 15 ml of solution of novocaine in its basis. It is necessary to avoid administration of solution in inflammatory infiltrate. Than more stoutly such chemical denervation of area of the inflammatory center, subjects a favorable effect is made.
Example of short N. the retromammary blockade (fig. 5) applied at a milk fever in a stage of serous infiltration is. At this blockade of 0,25% solution of novocaine (70 — 100 ml and more) sometimes with addition of antibiotics and proteolytic enzymes is entered into retromammary space through a puncture of skin in a fold of a mammary gland on the front axillary line.
Intranasal novocainic blockade is a nonspecific pathogenetic method of treatment of many diseases because the mucous membrane of a nasal cavity represents a powerful reflexogenic zone; in its thickness fibers branch and the terminations trigeminal, olfactory and autonomic nerves are located. Besides, the pterygopalatine nerve knot — the major collector intra-, ekstraretseptivny impulses — is located with back department of a nasal cavity in close proximity.
For the first time this type of N. G. L. Komendantov in 1937 applied at treatment of acute inflammatory diseases of okolonosovy bosoms. In the subsequent the method was widely adopted rather and at some other diseases. Intranasal N. with success apply at treatment of phlegmon of an oral cavity and a root of language, postoperative and traumatic hypostasis of area of the person, glaucoma, especially in initial stages, inflammatory diseases of a nasal cavity, a throat and throat (nonspecific quinsy, pharyngitis, laryngitis); apply it also at vasculomotor rhinitis, Menyer's disease, ear noise, headaches, an epileptiform neuralgia.
Intranasal N. it is possible to make both in stationary, and in out-patient conditions; in the latter case the patient within 30 min. — 1 hour shall be under observation of the doctor because of possible development of the phenomena of intoxication. N. carry out under control of sight by means of a lobby rinoskopiya (see). Before administration of solution of novocaine it is desirable to anesthetize a mucous membrane of a nose, having greased 1% with solution of Dicainum or 1 — 2% solution of Pyromecainum. The place of an injection — a sidewall of a nasal cavity, a kpereda from the front end of an average sink, either front or back department of the lower nasal sink (fig. 6). In the latter case it is better to use long curved needles.
Solution of novocaine is entered under a mucous membrane or into its thickness. A mucous membrane, the cut is entered into thickness solution of novocaine, around a needle becomes whitish and edematous. Intra-mucous introduction has advantages since at the same time solution comes to direct contact with the nerve terminations which are in a mucous membrane. Solution should be entered slowly, considering resistance of fabrics.
Concentration of solution of novocaine can vary from 0,25 to 2%, the quantity it depends hl. obr. from the applied technique: at submucosal introduction it can fluctuate from 1 to 5 ml, at intra mucous — from 0,2 to 1 ml. Usually begin with small doses, and further increase a dosage if the patient well transfers blockade.
Depending on character patol. process intranasal N. make from one or two parties, once or repeatedly. At acute diseases blockade is usually more effective, sometimes it is enough to make of it once; at chronic — do to its thicket repeatedly (daily, every other day or two times a week). The course of treatment can consist from 2 — 3 and even 10 — 15 and more procedures.
Retrosternal blockade on Kazan it is applied at treatment of stenocardia, idiopathic hypertensia, bronchial asthma.
Position of the patient on spin with the roller under shovels, the head is thrown back back. The curved needle (a needle for anesthesia of a root of a lung) is entered into the area of a nadgrudinny pole strictly in the sagittal plane. Sliding a needle but a back surface of a breast, pass in a front mediastinum to the level of an aortic arch * edges at the same time it is felt as the elastic pulsing education. Enter 100 ml of 0,5% of solution of the novocaine which is warmed up to 30 °, blocking front and superficial cordial neuroplexes. For blockade of a back nervous cardiac plexus the needle is entered perpendicularly to skin in a nadgrudinny pole before contact with a trachea. Then, sliding a curved part of a needle on the surface of a trachea, get to cellulose of a postmediastinum between a trachea and an aorta. Here enter 50 ml of 0,5% of solution of novocaine.
Novocainic blockade across Dudkevich. Blockade of cardioaortical reflexogenic zones is applied at the same diseases, as retrosternal blockade.
The long needle is entered strictly on the centerline 3 cm lower than a xiphoidal shoot, puncture an aponeurosis and enter 20 ml of 0,25 — 0,5% of solution of novocaine into preperitoneal cellulose. Then the needle is turned an edge up almost parallel to a breast and, slowly advancing, puncture a diaphragm (fig. 7). Enter 60 ml of 0,25 — 0,5% of solution of novocaine into a mediastinum.
Paraperitoneal blockade (fig. 8) is applied at treatment of acute cholecystitis and pancreatitis, attacks of cholelithiasis, a peptic ulcer of a stomach and duodenum in a stage of an aggravation.
After a puncture of skin on the centerline, is 3 — 5 cm lower than a xiphoidal shoot, infiltrirut hypodermic cellulose. Then puncture an aponeurosis and slowly enter 120 ml of 0,25 — 0,5% of solution of novocaine into preperitoneal cellulose. If after blockade of pain do not abate, it is necessary to think of existence of destructive process.
Blockade of a seed cord according to Lauryn-Epstein it is offered for stopping of renal colic and treatment of acute nonspecific diseases of epididymes.
Position of the patient on spin. On the party patol, process at a superficial abdominal ring into the area of a seed cord enter 50 — 100 ml of 0,5% of solution of novocaine.
Intra pelvic blockade across Shkolnikov it is shown at changes of pelvic bones, thrombophlebitis in the field of a basin and the lower extremities, a posttromboflebitichesky syndrome, hron, an inflammation of appendages of a uterus, a parametritis.
Position of the patient on spin. To Eagle stick otstupya on 1 cm of a knutra from an upper front ileal awn and advance on depth of 12 — 14 cm on an ileal bone. Enter into an ileal pole at unilateral blockade 400 — 450 ml of 0,25% of solution of novocaine, at bilateral — on 250 — 300 ml from each party. The solution following after extraction of a needle can have pink coloring from impurity of blood from the hematoma which is often formed here.
The intra bone prolonged blockade according to Polyakov are carried out for the purpose of receiving long anesthetic and to lay down. effect of introduction of mestnoanesteziruyushchy means in combination with others to lay down. drugs.
Before blockade to the patient enter intramusculary 2 ml of 2% of solution of Promedolum, 1 ml of 0,1% of solution of atropine and 2 ml of 2% of solution of Dimedrol. In the chosen place (fig. 9) produce anesthesia of soft tissues up to a bone introduction of 10 — 15 ml of 0,25% of solution of novocaine. The intraosteal anesthesia needle is entered into a bone on depth of 1 — 1,5 cm before emergence of a droplet of marrow from it then pour in the corresponding mix of drugs. On extremities blockade is carried out at the imposed plait, to-ry remove in 5 — 10 min.
Depending on the nature of pathology V. A. Polyakov recommends five types intra bone prolonged to lay down. blockade.
The simple intra bone prolonged blockade is recommended for anesthesia at operative measures on extremities, reposition of fragments and reposition of dislocations; in the postoperative period it joins in a package of measures, the early movements aimed at providing for the purpose of prevention of contractures, rigidity and trophic disturbances. Vnutrikostno enter the mix consisting of 10 ml of 5% of solution of novocaine and 90 ml of 8% of solution of gelatin (the last can be replaced with the same amount of any krupnomolekulyarny solution of a blood substitute). The come anesthesia continues within many hours.
The intra bone prolonged haemo static blockade is shown for a continuous anesthesia and a stop of bleeding from the damaged vessels of bones. Structure of the blocking means: 10 ml of 5% of solution of novocaine, 90 ml of 8% of solution of gelatin and 5 ml of 1% of solution of Vikasolum.
The intra bone prolonged antiinflammatory blockade is recommended at treatment inf. complications of wounds, burns, freezing injuries and other suppurative processes. At the same time vnutrikostno enter to lay down. the mix including 10 ml of 5% of solution of novocaine, 90 ml of 8% of solution of gelatin (or other prolongator in the same dose), 2 000 000 — 6 000 000 OOO ED of penicillin, 10 ml of 20% of solution Etazolum sodium (antibacterial means change depending on sensitivity of microbic flora).
The intra bone prolonged trophic blockade is recommended for prevention and treatment of trophic and vegetative disturbances (the slowed-down consolidation of fragments at a change, a nearthrosis), disturbances of blood circulation of extremities, etc. In a complex to lay down. drugs 10 ml of 5% of solution of novocaine, 90 ml of 8% of solution of gelatin, 1 ml of ODES of solution of atropine, 1 — 2 ml of 2% of solution of Dimedrol enter, 2 ml of 5% of solution of B^ vitamin
the Intra bone prolonged anti-coagulative blockade are used by hl. obr. at burns and freezing injuries for prevention of thrombosis of capillaries in the struck fabrics. In structure to lay down. mixes enter 10 ml of 5% of solution of novocaine, 90 ml Amincrovinum or albumine, 20 000 — 30 000 PIECES of heparin.
Alcohol-novocainic blockade it is offered M. O. Fried-landom in 1935. It is shown at treatment of changes, contractures, the deforming osteoarthroses, radiculitises, an obliterating endarteritis, anal fissures. The main solution for blockade includes 80 ml of alcohol (95%), 20 ml of a distilled water, 2 g of novocaine. This solution can be stored during many days. According to indications concentration it is reduced, adding a distilled water.
At fractures of edges of 3 — 4 ml of the main solution alcohol-novocaine is entered under bottom edge of an edge on 1 — 2 cross a finger of a kzada from the place of a change. At changes of cross shoots of vertebrae into the area of a change enter 5 ml of the main solution. At fractures of bones of a hip, shin, shoulder and forearm between fragments inject 8 — 15 ml of the main solution into a hematoma. Blockade is made once, right after an injury.
At the deforming osteoarthrosis of coxofemoral and knee joints intraartikulyarno enter 10 — 20 ml of the mix containing alcohol of 40 — 50% and 1% of solution of novocaine of 50 — 60%. At indications introduction in a week is repeated.
At reflex and spastic flat-footedness of 8 — 10 ml of the main solution enter into the general fibular nerve (peri-, paranevralno) on the rear edge of a head of a fibular bone.
At secondary radiculitises enter 5 — 6 ml half of divorced main solution to the place of an exit of back roots from intervertebral foramens. At the same time block no more than three roots from each party.
At an obliterating endarteritis produce peri-, paraarterial-ny blockade of a femoral artery introduction of 5 — 8 ml of the basic alcohol - novocainic solution.
At anal fissures produce alcohol - novocainic blockade across Aminev. Near the outside end of a crack through a fine needle enter 5 ml of 1% of solution of novocaine. 2 — 3 min. later through the same needle under the basis of a crack on depth of 1 cm from its bottom enter 1 ml of 70% of alcohol.
Complications. At technically incorrectly carried out blockade damage by a needle of the next bodies, hit of solution in blood vessels, bleeding can be observed. In these cases observation of the doctor is necessary, to the patient the high bed rest is appointed. Besides, the complications connected with hypersensitivity of the patient to are possible to novocaine (see).
Novocainic blockade at children
For N.'s performance. at children most often use 0,25% solution of novocaine.
The equipment and indications to N.'s carrying out. at children of essential features have no, however at newborns and babies most often would apply lumbar N. across Surin. Position of the child on a stomach. Anesthesia of skin is carried out a fine needle at the level of I lumbar vertebra at the outer edge of the muscle straightening a backbone. The same needle anesthetize deeper layers. Send to Eagle to the median plane of a body at an angle 60 — 70 ° to the surface of skin. After a puncture of a muscular layer (at the same time usually there is a feeling of a failure in emptiness) the needle gets to juxtaspinal space between a kidney and a backbone. Depth of advance of a needle on average shall not exceed 1 — 2 cm. Then, having convinced that the needle is not in a gleam of a vessel, enter 0,25% solution of novocaine in the following quantities: premature — 5 — 6 ml, the full-term newborn — 10 ml, to babies up to 6 months — 12 — 15 ml, to children from 6 months to 1 year — 15 — 20^. After extraction of a needle the place of a puncture is processed alcohol and stuck kleoly.
The similar number of 0,25% of solution of novocaine use also during the carrying out other types of N. at children.
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M of H. Lizanets, A. V. Nizova, Yu. G. Shaposhnikov; S. M. Krivorak (it is put. hir.), A. V. Fotin (ENT specialist.).