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Samenvatting "Anesthesie" - Anesthesie & pijn
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  • Course
  • Anesthesie en pijn
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  • Universiteit Antwerpen (UA)

Samenvatting van "Anesthesie" als onderdeel van het vak 'Anesthesie & Pijn' gegeven door prof. Saldien V. in de 2e Bachelor Geneeskunde aan de UA. Samenvatting van slides én lesnotities.

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Document information

  • August 31, 2024
  • 103
  • 2023/2024
  • Summary

Subjects

  • hypnotica
  • barbituraten
  • benzodiazepines
  • sedativa
  • lachgas
  • xenon
  • spierverslappers
  • neostigmine
  • sugammadex
  • intubatie
  • ventilatie
  • monitoring

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  • Universiteit Antwerpen (UA)
  • Geneeskunde
  • Anesthesie en pijn
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Inhoudsopgave
1. Inleiding anesthesie...................................................................................................................................6
Algemene anesthesie...........................................................................................................................6
Premedicatie.............................................................................................................................6
Van sedatie tot slaap............................................................................................................................ 7
Inductie van slaap.....................................................................................................................7
Inhalatie anesthesie..................................................................................................................8
Intraveneuze anesthesie.......................................................................................................... 8
Analgesie (pijnstilling)...............................................................................................................9
Spierverslappers.....................................................................................................................10
Antagonisatie..........................................................................................................................10
Interacties...........................................................................................................................................10
2. Farmacologie: intraveneuze anesthetica............................................................................................... 11
Werking van hypnotica....................................................................................................................... 11
Inhibitoire GABA..................................................................................................................... 11
Inhibitoire glycine.................................................................................................................... 11
Excitatoire NMDA (N-methyl-D-aspartaat)............................................................................. 12
Hypnotica........................................................................................................................................... 12
Barbituraten............................................................................................................................ 12
Non-barbituraten.....................................................................................................................13
Benzodiazepines (sedativa)................................................................................................... 15
2. Farmacologie: inhalatie anesthetica...................................................................................................... 17
Inhalatie anesthetica.......................................................................................................................... 17
Werkingsmechanisme............................................................................................................ 17
Gasvormige anesthetica.....................................................................................................................19
Fysiologische effecten............................................................................................................ 19
Neveneffecten........................................................................................................................ 20
Lachgas.................................................................................................................................. 20
Xenon..................................................................................................................................... 20
Andere.................................................................................................................................... 21
Keuze van het juiste volatiel................................................................................................... 21
2. Farmacologie: spierverslappers.............................................................................................................22
Spierverslappers................................................................................................................................ 22
Fysiologie............................................................................................................................... 22
Indeling van spierverslappers.............................................................................................................24
Depolariserende NMB............................................................................................................ 24
Niet-depolariserende NMB..................................................................................................... 25
Depolariserend vs. niet-depolariserend NMB.........................................................................25
Interactie met medicatie......................................................................................................... 26
Monitoring van diepte neuromusculaire blok.......................................................................... 26
Antagonisme van NMB.......................................................................................................................27
Cholinesterase remmers........................................................................................................ 27
Sugammadex......................................................................................................................... 28
Neostigmine vs. Sugammadex...............................................................................................28
Crush inductie / rapid sequence induction (RSI)................................................................................ 28
3. Luchtweg, oxygenatie en ventilatie........................................................................................................29
1

, Moeilijke luchtweg.............................................................................................................................. 30
Preoperatieve evaluatie van luchtwegen............................................................................................30
Anamnese en klinisch onderzoek...........................................................................................30
Luchtwegtesten...................................................................................................................... 31
Controle van de luchtwegen...............................................................................................................32
Positionering...........................................................................................................................32
Maskerventilatie......................................................................................................................33
Supra-glotic airway devices (SAD)......................................................................................... 33
Endotracheale tube................................................................................................................ 34
Cricothyroidotomie..................................................................................................................35
Intubatie..............................................................................................................................................35
Algoritme................................................................................................................................ 35
Bevestiging............................................................................................................................. 36
Complicaties........................................................................................................................... 36
Ventilatie.............................................................................................................................................36
Ventilator.................................................................................................................................37
Complicaties van mechanische ventilatie...............................................................................38
4. Vasculair access...................................................................................................................................... 39
Inleiding.............................................................................................................................................. 39
Beslisboom.........................................................................................................................................39
Stap 1: eigenschappen van toegediende vocht/medicatie..................................................... 39
Soorten IV katheters...........................................................................................................................40
Tip in perifeer bloedvat........................................................................................................... 40
Tip centraal (SVC).................................................................................................................. 41
Complicaties.......................................................................................................................................43
Veneuze trombose..................................................................................................................43
Malfunctie............................................................................................................................... 43
Casussen........................................................................................................................................... 44
5. Monitoring.................................................................................................................................................45
Monitoring...........................................................................................................................................45
Klinische monitoring........................................................................................................................... 45
Monitoring circulatie........................................................................................................................... 45
ECG........................................................................................................................................45
Niet-invasieve bloeddrukmeting............................................................................................. 46
Invasieve bloeddrukmeting.....................................................................................................46
Centraal veneuze drukmeting (CVD)......................................................................................47
Transoesophageale echo (TEE).............................................................................................48
Monitoring ademhaling....................................................................................................................... 48
Pulsoximetrie.......................................................................................................................... 48
Capnometrie / capnografie..................................................................................................... 49
Gasmonitoring........................................................................................................................ 49
Zuurstofmeting........................................................................................................................50
Monitoring anesthesiediepte.............................................................................................................. 50
Neurologische monitoring...................................................................................................................50
Neuromusculaire monitoring.............................................................................................................. 50
Stimulatiepatronen..................................................................................................................51
Monitoring lichaamstemperatuur........................................................................................................ 52
Monitoring urinedebiet........................................................................................................................52
2

, Conclusie............................................................................................................................................52
6. Preoperatieve oppuntstelling..................................................................................................................54
Preoperatieve consultatie...................................................................................................................54
Anamnese.......................................................................................................................................... 54
Allergie....................................................................................................................................54
Abusus....................................................................................................................................54
Klinisch onderzoek................................................................................................................. 55
ASA-score.............................................................................................................................. 55
Thuismedicatie....................................................................................................................... 55
Evaluatie.................................................................................................................................56
Stollingsanamense................................................................................................................. 56
Preoperatieve onderzoeken................................................................................................... 57
Anesthesie techniek/plan........................................................................................................57
Nuchterheidsprincipes............................................................................................................ 57
Informed consent....................................................................................................................58
6. Preoperatieve cardiovasculaire evaluatie..............................................................................................59
Operatief cardiovasculair risico.......................................................................................................... 59
Risicostratificatie................................................................................................................................ 59
Heelkundige risicostratificatie................................................................................................. 59
Cardiovasculaire risicostratificatie.......................................................................................... 59
Functionele status.................................................................................................................. 61
Beleidsstroomdiagram............................................................................................................61
Aanvullende testen.............................................................................................................................61
Detectie ischemie................................................................................................................... 61
Cardioprotectieve maatregelen.......................................................................................................... 62
Specifieke maatregelen......................................................................................................................62
Endocarditis profylaxie........................................................................................................... 62
Aanpassing antistollingstherapie............................................................................................ 63
Aanpassing anti-aggregerende therapie................................................................................ 64
Pacemaker patiënten..............................................................................................................65
7. Perioperatieve homeostase.................................................................................................................... 66
Vochtbeleid.........................................................................................................................................66
Dynamisch evenwicht intake - output..................................................................................... 66
Vochttoediening...................................................................................................................... 66
Elektrolyten.........................................................................................................................................67
Na2+....................................................................................................................................... 68
K+........................................................................................................................................... 68
Ca2+....................................................................................................................................... 68
Mg+.........................................................................................................................................69
Bloed en stolling................................................................................................................................. 69
RBC........................................................................................................................................ 69
Plasma....................................................................................................................................70
Trombocyten...........................................................................................................................70
Complicaties........................................................................................................................... 70
Lichaamstemperatuur.........................................................................................................................70
Hypothermie........................................................................................................................... 71
Maligne hyperthermie............................................................................................................. 72
Zuur-base evenwicht.......................................................................................................................... 72
3

, Buffersystemen.......................................................................................................................72
Pulmonale compensatie......................................................................................................... 72
Renale compensatie...............................................................................................................73
Zuur-base stoornissen............................................................................................................73
Glycemie............................................................................................................................................ 73
8. Locoregionale anesthesie....................................................................................................................... 74
Locoregionale anesthetica................................................................................................................. 74
Werkingsmechanisme............................................................................................................ 74
Soorten zenuwvezels............................................................................................................. 75
Farmacologische begrippen............................................................................................................... 75
pKa......................................................................................................................................... 76
Liposolubiliteit......................................................................................................................... 76
Eiwit-binding........................................................................................................................... 76
Praktijk: lidocaïne vs. bupivacaine..........................................................................................76
Andere beïnvloedende factoren op werkingsduur.................................................................. 76
Neveneffecten.................................................................................................................................... 77
Praktijk................................................................................................................................................77
8. Locoregionale technieken.......................................................................................................................78
Locoregionale technieken.................................................................................................................. 78
Neuraxiale technieken / centrale blocks (ruggenprik)........................................................................ 78
Werkingsmechanisme............................................................................................................ 79
Spinale anesthesie................................................................................................................. 79
Epidurale anesthesie.............................................................................................................. 81
Spinale vs. epidurale anesthesie............................................................................................81
CSE = combined spinal epidural............................................................................................ 81
Contra-indicaties neuraxiale technieken.................................................................................82
Plexusanesthesie / perifere blocks.....................................................................................................82
Brachiale plexus blok..............................................................................................................82
Lumbosacrale plexus blok...................................................................................................... 84
Plane blocks....................................................................................................................................... 85
9. Complicaties van regionale anesthesie................................................................................................. 86
Complicaties vs. neveneffecten..........................................................................................................86
Complicaties bij alle locoregionale technieken...................................................................................86
Allergische reactie.................................................................................................................. 86
Lokale anesthetica systemische toxiciteit (LAST).................................................................. 86
CASUS 1................................................................................................................................ 87
Postdurale punctie hoofdpijn (PDPH).....................................................................................87
Complicaties bij neuraxiale technieken.............................................................................................. 88
Epiduraal hematoom.............................................................................................................. 88
CASUS 2................................................................................................................................ 89
Complicaties bij perifere zenuwblok................................................................................................... 89
Neurologische dysfunctie....................................................................................................... 89
9. Peri-operatieve complicaties.................................................................................................................. 90
Peri-operatieve complicaties.............................................................................................................. 90
Respiratoire complicaties (intubatie/larynxmasker)............................................................................90
Bovenste luchtwegobstructie..................................................................................................90
Pulmonale complicaties..........................................................................................................91
Cardiovasculaire dysfunctie............................................................................................................... 92
4

, Anaphylaxie........................................................................................................................................92
Bloeding............................................................................................................................................. 92
Maligne hyperthermie.........................................................................................................................93
Neurologische dysfunctie................................................................................................................... 93
Patiënt wordt niet wakker....................................................................................................... 93
Postoperatieve cognitieve dysfunctie (POCD) / delirium........................................................94
Postoperatieve nausea & vomiting (PONV)....................................................................................... 94
Multifactorieel......................................................................................................................... 95
Anti-emetica............................................................................................................................95
Preventie................................................................................................................................ 96
Pijnstilling........................................................................................................................................... 97
Ionen- / glycemiestoornissen..............................................................................................................97
Positionering.......................................................................................................................................97
Brand..................................................................................................................................................97
Menselijke fouten............................................................................................................................... 97
10. Pijnstilling bij de partus.........................................................................................................................98
Fysiologische veranderingen tijdens zwangerschap.......................................................................... 98
Hartfunctie en circulatie.......................................................................................................... 98
Luchtwegen en longfunctie.....................................................................................................98
Samenstelling van bloed........................................................................................................ 99
Gastro-intestinaal stelsel........................................................................................................ 99
Centraal zenuwstelsel............................................................................................................ 99
Pijnstilling bij partus............................................................................................................................99
Effect op moeder én foetus.................................................................................................... 99
Pijnbestrijding bij vaginale partus..................................................................................................... 100
Niet-medicamenteuze pijnstilling.......................................................................................... 100
Neuraxiale pijnstilling............................................................................................................100
Complicaties......................................................................................................................... 102
Contra-indicaties...................................................................................................................103
Anesthesie bij sectio.........................................................................................................................103
Algemene anesthesie........................................................................................................... 103
Pijnstilling tijdens sectio........................................................................................................104
Pijnstilling na sectio.............................................................................................................. 104
Borstvoeding.................................................................................................................................... 105
Borstvoeding en medicatie................................................................................................... 105




5

,1. Algemene anesthesie
types anesthesie
● algemene anesthesie: inhalatie, intraveneus, spierrelaxantia
● (lokale) en regionale anesthesie: lokale infiltratie, zenuwblocks, spinale en epidurale anesthesie
● combinatie


Algemene anesthesie
= medicamenteus geïnduceerde omkeerbare onderdrukking van het centraal zenuwstelsel, met
veranderingen in gedrag en/of perceptie op schadelijke stimuli

elementen
● bewusteloosheid en/of sedatie → ALTIJD amnesie (= de onmogelijkheid om zich iets te herinneren)
● pijnstilling (analgesie door opioïden)
● spierverslapping
○ enkel ‘slaap’ zal het lichaam niet verhinderen om activatie van OS te initiëren
● protectie tegen autonome reflexen
○ vagale reactie, bradycardie OCR, salivatie, stress respons
● peroperatieve stabilisatie
○ hemodynamisch, vochtbeleid, stolling
○ respiratoir: oxygenatie, ventilatie
○ glycemiecontrole
■ risico op hyperglycemie door stress
○ zuur-base
● antagonisatie: anesthesie omdraaien op het einde van ingreep


Premedicatie
doel
● anxiolyse
● pijnbestrijding
● voorkomen van complicaties

minder toegepast dan vroeger
● identificatie en markage: patiënt moet zich kunnen identificeren tot op de operatietafel
● ouders bij inductie van kind

indicatie: zware ingrepen (bv. cardio, thoraco-abdominale)

medicatie
● sedativum of anxiolyticum: bij kinderen en extreem angstige volwassenen
● parasympaticolyticum: ter preventie bradycardie, slijmproductie en salivatie (vnl bij kinderen)
● farmaca als voorbereiding
○ chronische medicatie
○ post-operatieve nausea & vomiting (PONV) profylaxe
○ anti-trombotische profylaxe
○ anti-aspiratie (bij zwangeren)
○ anti-allergie



6

, Van sedatie tot slaap
Observer’ Assessments of Alertness scale (OAA) & Wilson scale




⇒ bij volatiele anesthetica zijn de stadia preciezer op te volgen dan bij IV-inductie, omdat de stadia zo snel
worden doorlopen dat step-by-step analyse niet mogelijk is


Inductie van slaap
methodes
● IV inductie en onderhoud
● IV inductie en inhalatie onderhoud
● inhalatie inductie en onderhoud (vnl bij kinderen)
● inhalatie inductie en IV onderhoud
○ bij moeilijk IV-access: inhalatie van de medicatie geeft geïnduceerde vasodilatatie →
makkelijker aan te prikken
● inhalatie inductie en onderhoud met ander volatiel

4 stadia van Guedel: stadia van algemene anesthesie (coma)
1. amnesie/analgesie: begin tot optreden van bewustzijnsverlies
2. excitatie: toename in hersenactiviteit in bepaalde zone’s op EEG → bewegingen, hoesten,
onregelmatige ademhaling
3. chirurgisch stadium
3.1. verlies ooglidreflex en slikreflex, oogbolbewegingen stoppen
3.2. verlies laryngeale en cornea reflex
3.3. paralyse intercostaalspieren
3.4. paralyse diafragma
4. toxisch stadium: respiratoir arrest en cardiovasculaire collaps met pupildilatatie

⇒ tijdens een heelkundige ingreep wordt stadium III (2,3,4) nagestreefd




7

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