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STUDIU PE CAZ
PATOLOGIA TIROIDIANĂ

ANESTEZII

AFECTIUNI CARDIOVASCULARE (nu tratamente lungi)

-premedicatie sedativ trankilizanta->med.prescrise de cardiolog:NITRODERIVATI,BLOCANTE ALE CANALELOR DE Ca,BETA-BLOCANTE,TONICARDIACE. NU VASOCORECTIVE ADRENERGICE,ANESTEZICE LOC.CONTRAINDICA- TE si NOVOCAINA

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

-boli cardiace congenitale ->necianogene / cianogene = cei cu valve->ANTIBIOTERAPIA ENDOCARDITEI SEPTICE

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

-hipertensiune-> MEDICAMENTE HIPOTENSOARE (tratamente lungi) => afectiuni bucale

Hipertensiunea afect cordul=>hipertrof ventric stg,marirea ariei card,scleroza vasc => coronaropatie iskemica, suferinta vasculara renala si cerebrala => sedare + monitorizare oblig

NORADRENALINA ca VASOCONSTRICTOR la cei in trat cu HIPOSERPIL,NEOCRISTEPIN

Pt beta-blocante sau blocante ale can de Ca,acestea leaga AGP=>leaga anestezicul=>supradoz =>

Anestezice tre dozate cu mare prudenta

***********************************************************************************************************

CARDIOPATIA ISKEMICA

Nedureroasa-modific EKG,fara simpt => risc aparitie la 65+,hipertens art.veke,diabet,obezi,fumatori

Angina pect -Angor stabil cu trat la zi=>tolereaza anestezia si vasocorectivul daca se administreaza in preanestezie

CORONODILATATOARE

Oxigenare,sedare,combat cresteri de tens,monitorizare oblig

NU NOVOCAINA

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

Angor stabil cu trat cu antiagregante => intrerupt 5 zile inainte (favoriz sangerarea->infectii)

VASOCONSTRICTOARE in dilutii mari doar daca e necesar

FELIPRESINE si ADRENALINA (concentr.1/200000) au prioritate

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

Angor instabil = infarct recent => combatere durere pe cale loc sau gen

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

Infarct in antecedente => infarct miocardic mai veki de 6 luni = angor stabil

Infarct miocardic mai recent de 6 luni = risc de recidiva => sedare oblig =>

Anestezia : XILINA ,oxigenare + monitor.

____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ____________________ 828g618i ___________

Coronaropatii operate => interventie stomatologica normala , dar nu mai mult de 1h

***********************************************************************************************************

CARDIOPATII VALVULARE

Vasocorective : FELIPRESINE,NORADRENALINA-eventual

Pt cardiopatii valvulare cu risc de decompensare,stenoza aortica sau mitrala cu tulb de ritm => temporizare interv

***********************************************************************************************************

TULBURARI DE RITM

Aritmiile => insuficienta cardiaca ,trombembolii,fibrilatie atriala

Pace maker => nu instrum cu camp mag sau electromag

In urgente stom => sedare + monitor / se folosesc HOSTACAINA,ADRENALINA (manifestari de supradoz-posibile)

************************************************************************************************************

ANTIBIOPROFILAXIA ENDOCARDITEI SEPTICE

In cav buc exista o serie de germ f periculosi (stafilococ,streptococ viridans)=>pot contamina leziuni cardiace in extractii,implantologie,trat endodontice,proceduri periodont,anestezii prin injectie,detartraje => favorizeaza solutii de continuitate => RISC DE INFECTIE il au cei cu valvulopatiicongenitale,prolaps de valva mitrala,transplant de cord RISC SEVER pt cei cu protezevalvulare,antecedente de endocardita,malformatii cardiace cianogene,sunturi create kirurgical

ANTIBIOPROFILAXIA se face pe CALE ORALA sau prin INJECTARE cu 1h inaintea trat stom cu

AMOXICILINA (oral/i.m): 2g/kg adult - 50mg/kg copil

CLINDAMICINA (oral/i.v): 600mg adul - 20mg copil

DERIVATI DE ERITROMICINA: 500mg adult - 15 mg copil

CEFALOSPORINE: 2g adult - 50mg copil

AFECTIUNILE AP RESPIRATOR

BRONSITA CRONICA - In forme asmatiforme => NU NOVOCAINA,HOSTACAINA

VASOPRESINE,ADRENALINA PRUDENT ca vasocorective

ROMERGAN,HIDROXIZINA,DIAZEPAM = premedicatie

******************************************************************************************************************

ASTMUL BRONSIC - poate asocia cord pulmonar cronic => tratament cu ORCIPRENALINA,TERBUTALINA,SALBUTAMOL, FENOTEROL,CROMOGLIGAT,MIOFILIN,CORTIZON

Anestezia necesita sedativ-trankilizant,pozitia sezanda,tartamentul antiasmatic permanent

NU ADRENALINA daca asociaza cu cord pulm cron

VASOPRESINE + OXIGENARE EFICIENTA

*****************************************************************************************************************

DIABETUL ZAHARAT - asociaza afectiuni cardiovasculare (cardiop.diabet,miocardiop dismetabolica) , tulburari metabolice severe (obezitate,acidoza,poliurie) ,neuropatie ,risc de infectie

SEDARE si premedicatie cu DROPERIDOL,BENZODIAZEPINE

******************************************************************************************************************

DIABETUL ZAHARAT JUVENIL - trat stom NU TREBUIE sa modifice regim mese si insulina

SEDARE + OXIGENARE

DIABETUL NONINSULINO DEPENDENT - trat stom se face cand diabetul e ekilibrat / dimineata ca pacientuul sa nu descarce catecolamine de emotie

NU NOVOCAINA ci NORADRENALINA

******************************************************************************************************************

INSUFICIENTA HEPATICA tre cercetat gradul de insuf prin analize.Ficatul fabrica esteraze care metabolizeaza anestezicele cu struct esterica=>pacientii care nu au enzime=>risc de spradoz

CIROZA -> trombocitopenie => risc sangerare

NU VASOCORECTIVE ADRENERGIE pt ca exista RISC DE HIPOXIE HEPATICA

Preoperator : SUBST COAGULANTE:VIT K, ETANXILAT,FITOMENADIONA,VIT C,

POLIVITAMINE

Posoperator : NU ATIINFLAMATOARE NESTEROIDIENE

ANTIBIOTICE cu prudenta daca apare infectia

******************************************************************************************************************

INSUFICIENTA RENALA

In forme medii -> creste uree => risc sangerare , creste potasiul => accid prin vagotonie , scade Ca => convulsii tetaniforme

Premedicatia cu prudentza / pozitia clinostatica

Vasocorective : VASOPRESINELE

ANESTEZICE AMIDICE in doze mici

NU ANTIINFLAMATOARE NESTEROIDIENE postoperator

Pacienti cu hemodializa => tratament dupa dializa,cel putin dupa 6h,cel mai bine in ziua fara dializa => de obicei spitalizare

******************************************************************************************************************

BOLILE ENDOCRINE

BOALA ADDISON - Nu tre oprit trat , ci kiar tre dublata doza cu o zi inainte,in ziua,o zi dupa trat

Premedicatie : BENZODIAZEPINE

ANESTEZICE AMIDICE CU sau FARA VASOCORECTOR

******************************************************************************************************************

FEOCROMOSITOM - posibil neces perfuziile

Premedicatie : BENZODIAZEPINE

Anestezia : NOVOCAINA ,XILINA simpla

******************************************************************************************************************

INSUFICIENTA TIROIDIANA MIXEDEM : tolereaza greu sedativele => accid grave la ANALGETICE CENTRALE (MIALGIN)

NU SEDATIVE

Bolnavii tolereaza prost hemoragia,pt ca au hipotens si anemie

Postoperator : ANTIBIOTICE

ANESTZICE AMIDICE FARA VASOCORECTIVE ADRENERGICE (coronaropat iskem)

Inductia anestezica lunga din cauza metabolismului lent

Vasocorective : FENILEFRINA,NORADRENALINA PRUDENT

Postoperator : HEMOSTATICE,ANTIBIOTICE

******************************************************************************************************************

HIPERFUNCTIA TIROIDIAN A (TIREOTOXICOZA)

Metabolism crescut => tulb de ritm cardiac => trat cu DIGIALICE,BETA-BLOCANTE => NU ADRENALINA

Criza hipertiroidiana = f grava , cu hipertermie,tahicardie => insuficienta circ acuta

Trat anestezic dimineata / SEDAREA f buna

ANESTEZICE AMIDICE : HOSTACAINA

NU CORBEFRINA ca vasocorectiv

TULBURARI DE COAGULARE

HEMOFILIA - de obicei spitaliz pt trat cu perfuz => trat realizat la o 1/2h,1h dupa trat de special

Nu sunt prob cu subst ANESTEZICE

Evitate manevre sangerande

Depistare la anamneza

COAGULOPATII - SE IMPUNE TEMPORARIZAREA TRAT PANA LA CONSULTUL CU HEMATOLG.

Teste coagulare => timp protromb = 11-13s / INR = 0.9-1.15 / ATTP = 20-30s /

Fibrinogen 200-400 mg/dl

Interventia la scurt timp dupa norm

Hemostaza prin sutura kirurgic,daca e necesar

Plaga urmarita postextractional 2h

NU ATIINFLAMATOARE NESTEROIDIENE postoperator

PACIENTII IN TRAT CU ANTICOAGULANTE => se temporariz interv sangeranda astfel

5 zile la trata cu TROMBOSTON sau medicamente ANTIAGREGANTE (ASPIRINA,DIPIRIDAMOL)

2 zile la trat cu CUMARICE

6-12h la trat cu HEPARINA

ANESTEZIA LA ALCOOLICI

Pacienti pluritarati : suferinte hepatice , modificari cardiovasculare (miocardopatie nutritionala) ,tulb neurologice centr si periferice

Alcoolul inductor enzimatic=>risc de spradoz => anestezie nu de calitate

Tulburari de absistenta la 8-10h sau 5 zile de la intrerup cons de alchol.

Necesita sedare preoperatorie eficienta : FENOTIAZINE , CLORPROMAZINA , PETIDINA , BENZODIAZEPINE

PACIENTII CU CANCER

Pot sa aiba boala de iradiere sau citostatica care scad colinesteraza hepatica
NU ANESTEZICE cu struct tip ESTERIC => riscul superdoz
Pacientii au mai multe sindroame :
Hematologic : leucopenie , trombocitopenie
Hemoragipar => trat cu ACID TRANEXAMIC per os/i.v .Trat general cu HEMOSTATICE si ANTICOAGULANTE
Sau local cu bureti de TROMBINA
Cardiotoxic , hepatotoxic , nefrotoxic
Pacienti casectici,anemici,hipoproteinimici => tolereaza prost sedativele si trankilizantele =>doze reduse de anestezic
Vasocorectivele adrenergice cu prudenta mare
MEPIVACAINA (nu necesita vasocorectiv) => cele mai bune VASOPRESINELE
Plaga postextractionala urmarita 1-2h => infectia apare frecvent postoperator
ACCIDENTE
CAUZE
1 PARTICULARITATI DE VASCULARIZATIE SI INERV A REG OMF
-ggl de pe traseul trigem.( cu rol secretor) au predominanta vegetativa parasimpatolitica => frecventa lipotimiilor
-vase de calibru mic si mij care se contracta mai puternic decat cele mari in prezenta vascorectivelor adrenergice => efect pe
vase mici => aa nu sunt influentate
2 PARTICULARITATI DE TEREN ALE PACIENTULUI
-varste extreme : batrani - tensiunea arter,monitorizarea,preoxigenarea, premedicatia ce combate hipoxia,hipertensiunea

sedarea

tineri - accid vegetative

- obezi : hipoxia

-RISC MARE la pacientii cu insuf cardiaca cu decompensari repetate,cardiopatii congenitale,infarct miocardic preexistent,hipertensiune arteriala veke visceralizata , suferinte valvulare cu tulb de ritm , diabet zaharat (crize de

hipoglicemie

3        ACCIDENTE TERAPEUTICE DETERMINATE DE IDIOSINCRAZIE la un anumit medicament , reactii adverse ,

Alergia si anafilaxia datorate unor defecte enzimatice care deprima brusc sistemul nerv vegetativ

Unele medic luate de pacient - TRE INTRERUPTE:

-cele cu efect de inhibare a mono amino oxidazei

-tonicardiacele digitalice (cu o sapt inainte) sau anestezie loc cu

FELIPRESINE

-unele anticoagulante

-                                                                                                                    NU SE INTRERUP:

-CORTIZON (in insuf cortico supra renala in trat cronic)

-INSULINA

-TRAT HORMONALE (insuf tiroidiana,oper pe tiroida,hipertiroidieni)

-BARBITURICE,BENZODIAZEPINE,ANTICONVULSIVANTE

-ANTIHIPERTENSIVE,TONICARDIACE,CORONARODILATAT.

Trebuie luate in vedere INTERFERENTELE dintre aceste medic si anestezice

NOVOCAINA accentueaza efectul bradicardic la cei ce iau beta blocante

Interfera cu bloc can de Ca , antibioticele , blocantele,alcoolul

XILINA interfera cu sulfamidele,hidantoidele (epileptici=>accid de convulsie) , alcoolul , induct enzim,beta-blocante

Da reactii adverse de tip alergic

ADRENALINA interfera cu tonicardiace , alfa blocante , beta blocante , antidepresive , tiroxina , anti colinergice

ACCIDENTELE IATROGENE

-                                                                                                                    Indicatie gresita a unei tehn sau subst anestezice

-                                                                                                                    Supra sau subdozaj

-                                                                                                                    Omiterea masurilor de profilaxie

-                                                                                                                    Intarzierea in depist accid din lipsa de monitorizare

-                                                                                                                    Dificit de irigare si oxigen cerebrala => pierderea cunostintei

TRATAMENTUL ACCIDENTELOR GENERALE

-                                                                                                                    patogenic = intreruperea trat stom

-                                                                                                                    pacientul asezat orizont (contraindicat la obezi,suferinzi pulmonari,boli cardiace)

-                                                                                                                    imbogatirea cu oxigen a aerului insp

-                                                                                                                    favoriz ventilatiei pulm prin controlul libertatii cailor aer.sup

-                                                                                                                    trat medicamentos: medic de stimulare a respiratie dupa eliberarea cailor resp.

ACCIDENTE LIPOTIMICE

- teg palide , uscate , calde

- respiratia bradipneica si superficiala => se mas tens si pulsul

-                                                                                                                    trat de stimul.a resp si circ cu : EFEDRINA i.v lent 1-2 fiole

CLORURA de Ca lent i.v

CORTIZON HHC 100-150mg sau FLEBOCORTID100mg

VAZOXIL 10-20 mg lent

Teg palide , cianotice , transpirate

Tensiune mare cu tahicardie , tulb de ritm , anxietate

Accid apare la simpla examinare sau la administr de vasocorective adrenergice

Jena precordiala ,cefalee

ATUNCI

Se face trat unui accid adrenergic cu SEDATIVE , SIMPATOLITICE , CORONARODILATATOARE : BENZODIAZEPINE , NITRODERIVATI, BLOC ALE CAN DE Ca

Sincopa cardiorespiratorie : pacientul nu mai are puls,resp slaba sau absenta => trat cu OXIGENOTERAPIE,Ca CLORAT i.v HHC i.v ,VASOXIL ,FENILEFRINA

CONVULSIILE

Cauze - trat incorect al starilor lipotimice

-                                                                                                                    supradozaj anestezic

-                                                                                                                    supradozare relativa datorata - scaderii AGP (pacienti in trat cu beta bloc,

verapamil,bloc ale recep H2,varst,hepat,copii mici)

-administr de NOVOCAINA cand lips coliesteraza

- introd I.v directa a anestezicului

-                                                                                                                    boli neurologice : epilepsii , sindrom de compresiune cerebrala

-                                                                                                                    stari neuro psihice particulare

SEMN PRECOCE DE CONVULSIE = PARESTEZIA PERIFERICA

TRATAMENTUL : ANTICONVULSIVANTE

TRANKILIZANTE = BENZODIAZEPINE lent i.v,TIOPENTAL 2.5% 5mg/kg , BROMURA DE Ca)

MEDICATIE ANTIEDEM CEREBRAL = CORTIZON , MANITOL in perfuzie ,FUROSEMID

ACCIDENTE ALERGICE

-forme usoare : eruptie cutanata,prurit , edem

-formele medii : formele usoare + hipotensiune,edem de mucoase

-forme grave : soc anafilactic (hipotensiune arter brutala , colaps ,edem imp al mucoaselor , insuf respirat grava , pierderea

cunostintei , convulsii

-tratament : etiopatogenetic general

medicamentos : ADRENALINA in soc 0.2 mg subcutanat sau in perfuzie

BENADRIL im /iv 20-40 mg

PROMETAZINA iv

CLORURA DE Ca strict iv

ANGINA PECTORALA

-tratament : pozitie clinostatica , oxigenoterapie , administrarea de coronodilatatoare , combaterea hipotensiunii

cu NORADRENALINA , CORTIZON , combaterea durerii cu PIAFEN , PETIDINA

CRIZA DE HIPOGLICEMIE => URGENTA

-Cauze : supradozare de insulina sau nemancat

-Carcaterizare : confuzie mentala , teg reci si transpirate, agitatie , foame , fasciculatii musc

-Tratamentul : GLUCOZA iv

CRIZA HIPERGLICEMIE => NU ESTE URGENTA

-Cauze:neprog la prima ora , durerea daca anestezia a fost insuficienta , interferarea prog masa insulina

-Caracterizare : teg uscate , confuzie mentala , pierderea cunostintei

HIPERTEMIA MALIGNA

Apare ca o CRIZA TIREOTOXICA , implicata f rar XILINA

Tratament : HHC , OXIGENOTERAPIE , DANTROLEN

ACCIDENTE ALE ANESTEZIEI GENERALE

SINDROMUL HIPERTERMIE - PALOARE - CONVULSII (OMBEDRAN) -> copii mici

SINDROMUL MENDELSON (BRONHO ALVEOLITA DE RESPIRATIE)

ACCIDENTE ESTETICE in timpul intubatiei oro traheale => AVULSII DENTARE sau TRAUMATIZARI LABIALE













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