I. What is “anesthetic art”?
Foreign anesthesia colleagues often refer to “anesthetic art” in their daily work and communication, where “art” directly translates to technology, technique or skill. In fact, the term “anesthetic art” emphasizes that anesthesiologists should master anesthetic technique to the extent that it can be further sublimated to “anesthetic art”. We know that an artist can give people the enjoyment of sight, sound, smell, and even taste. The “art of anesthesia” should be: to eliminate or reduce the patient’s psychological and physical trauma to the maximum extent possible during the perioperative period when the patient is facing the fear and pain of surgery, so that he or she can recover safely and smoothly.
II. How does the “art of anesthesia” manifest?
1. Patient comfort and safety, appropriate preoperative (psychological and physical) preparation and reasonable preoperative medication for different patients, so that the patient enters the operating room in a better physical condition. Master the basic skills and techniques of anesthesia operation, and make all invasive operations under good local anesthesia, basic anesthesia or general anesthesia. After general anesthesia, suctioning and tracheal extubation operations (under the premise of ensuring patient safety) are performed before the patient is fully awake if possible. Good postoperative analgesia (PCA or PCEA) after anesthesia.
2. The anesthesiologist is well equipped. After strict clinical skills training, as long as the anesthesiologist fulfills the anesthesia routine carefully, and makes the formal anesthesia operation and rigorous thinking method form their own habits and styles, they can keep steady and confident when facing any complicated and difficult cases.
The basic duty of the anesthesiologist is to ensure that the patient is safe and painless during the operation, and to meet the surgeon’s needs to the greatest extent, so that the surgeon can focus completely on the operation.
4. The viewers are pleasant to the eyes, including the relevant staff in the operating room, visitors, trainees, interns and senior doctors. It makes the viewer feel that the whole anesthesia process is smooth, the patient’s vital signs are stable, there is no waste of time and movement, all anesthesia items and equipment are in order, and the tension is relaxed.
III. Content of “the art of anesthesia
1. operation skills skilled anesthesia operation, a high success rate, good anesthesia effect; anesthesia operation during the patient’s discomfort or pain is reduced to a minimum, the vital signs are stable; the surgeon is satisfied.
(1) Local anesthesia, using the “one-stitch technique”, select the appropriate local anesthetic; after local anesthesia, local pressure for 3 to 5 minutes before invasive operation or surgical skin cutting.
(2) Intradural anesthesia, regardless of the position (lateral, sitting or prone) for epidural or subarachnoid puncture, the patient should be positioned correctly, with the spine as far as possible forward flexed and relaxed; for intradural puncture, the arch space should be found according to the direction of the projection of the spinal canal on the body surface; the most important indications for successful epidural puncture are the feel (penetration of the ligamentum flavum) and the gas injection test (from resistance to no resistance). Epidural “negative pressure” is not a reliable indicator of successful epidural puncture, but may be the main cause of “mis-penetration of the dura”. The main factors determining the effectiveness and extent of intradural anesthesia are the dose and concentration of the local anesthetic. Before the injection of intralesional anesthesia, it is necessary to open a smooth intravenous infusion and drug delivery route, preoxygenation for patients with poor cardiopulmonary function or anemia, and the availability of anesthesia machines and rescue drugs to ensure that the patient enters the anesthesia state smoothly and safely.
(3) general anesthesia, appropriate preoperative medication, adequate oxygen “de-nitrogenation”, the upper limb intravenous injection of general anesthesia induction drug in stages to reduce its cardiovascular depression, and make the patient calmly sleep into general anesthesia; in the induction of general anesthesia drug blood or effect chamber concentration reaches its peak when the tracheal intubation, to reduce intubation reaction. Pay close attention to the progress of surgery during general anesthesia, and actively adjust the depth of anesthesia according to the needs of surgery. Shallow general anesthesia and deep muscle relaxation are not lost as the ideal state of general anesthesia, which makes general anesthesia safer to meet the needs of surgery. After the postoperative myorelaxant subsides or antagonism, then reduce shallow anesthesia, ventilation and protective reflexes are restored, oropharyngeal aspiration (no special reasons for endotracheal aspiration), and the tracheal tube is removed after adequate oxygenation. It is recommended to wake up naturally after general anesthesia, which will make the patient more comfortable, and the application of “wake-up call” is often counterproductive and one of the reasons for agitation after general anesthesia.
(4) Combined anesthesia, combined anesthesia is a popular anesthesia method in recent years, combined in many ways, such as: epidural – lumbar anesthesia (CSE), epidural – general anesthesia, lumbar anesthesia – general anesthesia, cervical plexus – general anesthesia, general anesthesia – local anesthesia (neurosurgery or orthopedic surgery).
①CSE The invention of CSE needle makes this method simpler and easier to operate. The main advantage of lumbar anesthesia combined with epidural is to use the characteristics of rapid onset of lumbar anesthesia, complete block and good muscle relaxation, to supplement the shortcomings of the limited operation time of lumbar anesthesia with continuous epidural block, and to continue to postoperative PCEA analgesia. the defects of CSE method are more complicated operation technique and easy to occur hypotension after lumbar anesthesia. A large number of clinical practices at Peking University First Hospital have shown that CSE can be used not only for healthy patients but also safely for maternal and elderly patients as long as the correct operation techniques are mastered. I have experienced that the incidence of hypotension due to light specific gravity lumbar anesthetics (0.15%-0.25% bupivacaine) is significantly lower than that of heavy specific gravity fluids. In addition, patients with poorly compensated cardiovascular function can be first administered with low-level lumbar anesthesia (application of 1/2 to 2/3 dose of lumbar anesthetics), and the lack of anesthetic coverage is gradually made up by epidural anesthesia. Of course, pre-infusion before CSE, appropriate volume expansion, preparation of atropine and ephedrine, and ensuring oxygenation are the basis for ensuring hemodynamic stability of CSE.
Epidural compound general anesthesia, epidural has good analgesic and inotropic effects, general anesthesia of unconsciousness eliminates the patient’s tension and discomfort, inotropic drugs make surgical operations easier, tracheal intubation, mechanical ventilation makes the patient’s cardiopulmonary function more controllable; the compound of the two methods makes the amount of epidural local anesthetics required significantly reduced, while shallow general anesthesia can meet the requirements of surgery, making the safety of anesthesia greatly improved, so it is by far the most respected anesthesia method in our hospital. This method is especially suitable for the anesthesia of elderly, critically ill and major surgery patients. This anesthesia needs to be noted: general anesthesia induction based on epidural block can lead to severe hypotension or/and bradycardia, in this case, attention should be paid to stagger the peak of epidural and general anesthesia induction drugs. In anesthesia, epidural or general anesthesia is the mainstay according to the surgical needs, such as: epidural anesthesia is the mainstay in general, epidural should be stopped in case of surgical blood loss or patient hypotension and general anesthesia should be the mainstay.
(5) Anesthesia monitoring and management During any anesthesia, the patient’s vital signs and the trend of changes in the internal environment should be closely monitored, and fluctuate as close to the physiological range as possible by adjusting the depth of anesthesia, infusion and application of drugs.
(6) Preoperative visits and postoperative follow-up are very important for the selection of preoperative anesthesia methods and the summation of postoperative anesthesia experience.
The thinking style of anesthesiologists is between that of medical doctors and surgeons, such as: internal medicine doctors focus on the pathogenesis of diseases, symptoms and signs, and are good at diagnosis and differential diagnosis of diseases; surgeons focus on the localization of diseases and surgical indications; while anesthesiologists, as “internal medicine doctors in the operating room”, focus more on surgical indications and surgical steps, and pay attention to patients. The anesthesiologist, as an “internal medicine doctor in the operating room”, focuses more on surgical indications and surgical steps, the patient’s general condition, the functional status of important organs, and the ability to compensate.
In the following, we propose the concept of “anesthetic balance” based on our own thinking habits.
(1) Psychological balance Preoperative visit to understand the requirements of the patient and family and explain the anesthesia process to gain their trust and cooperation. Meet the requirements of different surgeons. Anesthesiologists should improve their own cultivation, treat each case of anesthesia seriously, be good at summarizing experience, and enhance the ability to link theory with practice and innovation. That is, to anesthetize patients and meet the needs of surgeons with a calm psychological state.
(2) Balance of surgery and anesthesia Anesthesia work itself is to meet the needs of surgery, to be familiar with the steps of surgery, to choose the method of anesthesia and adjust the depth of anesthesia according to the needs of surgery and the surgeon. Careful preoperative preparation is the guarantee of anesthesia safety, therefore, “meeting the needs of surgery without losing the principle of anesthesia”.
(3) The compensatory capacity of important organs and the balance of anesthetic effects except for organic lesions of heart, lung, brain, kidney and liver, and understanding their functional status and medication. Avoid the influence of anesthetic drugs and methods on important organs during the operation, so that they always maintain a good functional state.
(4) Balance of the internal environment fluid balance, electrolyte and acid-base balance, balance of body heat loss and insulation (heat production), balance of energy supply and consumption, balance of oxygen supply and demand, coagulation and anticoagulation, blood loss and transfusion, infection and anti-infection, sympathetic and parasympathetic balance, and endocrine balance, etc.
(5) Stability of vital signs The balance of the internal environment and autonomic nervous system is the basis for the stability of vital signs. The relationship between blood pressure and heart rate, urine output, respiration, body temperature, eye signs and reflexes.
(6) Balance between depth of anesthesia and adverse stimuli: Understand the characteristics of each procedure and surgeon, pay close attention to the surgical steps, and actively adjust the depth of anesthesia according to the intensity of surgical stimuli.
(7) Balance of anesthetic drugs (interaction) Balance anesthesia, balance of different anesthetic drugs and methods in combined anesthesia, balance between emergency (rescue) drugs, and balance with anesthetic drugs. Pay attention to the factors affecting the use of drugs: age, body temperature, pregnancy, cardiac (circulation time), pulmonary (inhalation anesthetics), liver and kidney (drug elimination) functional status, etc.
(8) Autonomic nervous system (ANS) balance i.e. balance of sympathetic and parasympathetic nervous system. ANS consists of sympathetic and parasympathetic nervous system with tension activity, which is regulated by central and reflex mechanisms to increase or decrease ANS tension output, thus regulating organ blood flow and functional response to various stimuli (pharmacological, physiological and environmental). Drugs applied during anesthesia, painful stimuli and concomitant diseases (diabetes, advanced age, hypertension, coronary artery disease) can affect the reflex activity of the ANS, with significant blood pressure fluctuations during surgical stress or blood loss. The functional status of the patient’s ANS should be fully estimated preoperatively to ensure its functional stability intraoperatively. Clinically, the balance of the ANS can be maintained by decreasing sympathetic tension. Methods to affect sympathetic tension include:
Thoracic epidural block, b-blockers, and a2 agonists, whereby sympathetic tension can be reduced, plasma catecholamine concentrations can be lowered, and MAP and HR can be lowered to reduce perioperative tachycardia and hypertension.