INHOUDSOPGAVE
1. examen ............................................................................................................................................................ 6
2. inleiding ........................................................................................................................................................... 6
3. De geschiedenis van de anesthesie .................................................................................................................. 7
Inleiding........................................................................................................................................................................ 7
Pre 1846: fundamenten v anesthesie ........................................................................................................................... 7
Industriële en wetenschappelijke revolutie ............................................................................................................ 7
Geschiedenis v inhalatie anesthesie ........................................................................................................................ 8
lachgas ................................................................................................................................................................. 8
Ether .................................................................................................................................................................... 8
1846-1900: verankering anesthesie ............................................................................................................................. 8
Chloroform............................................................................................................................................................... 8
Geschiedenis v lokale en regionale anesthesie ....................................................................................................... 9
20ste eeuw: consolidatie en groei ................................................................................................................................. 9
21STE EEUW: DE TOEKOMST ......................................................................................................................................... 9
2. De peri-operatieve stress respons .......................................................................................................................10
Heelkundige stress en anesthesie .............................................................................................................................. 10
De stress respons........................................................................................................................................................ 10
De peri-operatieve stress respons .............................................................................................................................. 11
De endocriene stress respons (examen) ............................................................................................................... 11
................................................................................................................................................................................12
De stress respons en metabolisme ............................................................................................................................. 13
De immunologische stress respons ............................................................................................................................ 13
De hematologische stress respons ............................................................................................................................. 14
De peri-operatieve stress respons .............................................................................................................................. 14
Veranderingen bij stress respons ............................................................................................................................... 14
3. De pre-operatieve oppuntstelling en risico stratificatie .......................................................................................15
De pre-operatieve evaluatie ....................................................................................................................................... 15
De anamnese.............................................................................................................................................................. 16
voorgeschiedenis ................................................................................................................................................... 16
systeemanamnese ................................................................................................................................................. 17
metabole equivalenten ..................................................................................................................................... 17
medicatie ............................................................................................................................................................... 18
Het klinisch onderzoek ............................................................................................................................................... 18
Technische onderzoeken (niet altijd) .......................................................................................................................... 19
Risico – stratificatie en classificatie (EXAMEN) .......................................................................................................... 21
1
, Risico scores ........................................................................................................................................................... 21
American Society of Anesthesiology score........................................................................................................ 21
NHYA ................................................................................................................................................................. 22
Lee’s Revised Cardiac Risk Index ....................................................................................................................... 22
GOLD klasse ....................................................................................................................................................... 23
Cardiale risicobepaling en oppuntstelling .................................................................................................................. 23
Pre-operatieve evaluatie en risicobepaling ........................................................................................................... 23
Patiënt gerelateerd risico .................................................................................................................................. 24
Heelkundig risico ............................................................................................................................................... 24
Pre-operatieve oppuntstelling en optimalisatie .................................................................................................... 25
Medicamenteuze voorbereiding ................................................................................................................................ 27
Sedativa – Hypnotica – tranquilizers ..................................................................................................................... 27
Reductie van maaginhoud en stijging van de zure maag pH ................................................................................. 27
Verlies tonus bovenste gastro-oesophagale sfincter ........................................................................................ 27
Risicopopulatie voor aspiratie (>25 ml – pH <2.5) ............................................................................................ 27
Richtlijnen preoperatief nuchter zijn ................................................................................................................ 28
Chronische thuismedicatie DOORGEVEN .............................................................................................................. 28
Corticosteroiden: Perioperatieve substitutie ........................................................................................................ 29
Mogelijke strategie ............................................................................................................................................ 29
Anti-diabetica ........................................................................................................................................................ 29
Klinische casus (zoals op examen) .............................................................................................................................. 30
4. Het doel van anesthesie: hypnose, analgesie, spierverslapping en stabilisatie ................................................31
Inleiding...................................................................................................................................................................... 31
5 Doelen van anesthesie ............................................................................................................................................ 32
Slaap/bewustzijnsverlies ....................................................................................................................................... 32
Stadia van Guedel.............................................................................................................................................. 33
Inhalatie - anesthetica ....................................................................................................................................... 34
Intraveneuze hypnotica ..................................................................................................................................... 34
Analgesie .................................................................................................................................................................... 34
Spierverslapper........................................................................................................................................................... 34
Fysiologische stabilisatie ............................................................................................................................................ 35
Monitoring ................................................................................................................................................................. 35
De kunstmatige luchtweg .......................................................................................................................................... 37
manuele maskerventilatie ..................................................................................................................................... 38
larynxmasker: supraglottic airway device ............................................................................................................. 38
laryngoscoop.......................................................................................................................................................... 39
Endotracheale tube ........................................................................................................................................... 39
Cormack en Lehane classificatie bij directe laryngoscopie ............................................................................... 39
Videolaryngoscopie ........................................................................................................................................... 40
Fiberoptische intubatie .......................................................................................................................................... 40
tracheostomie........................................................................................................................................................ 40
5. Farmacologie van hypnotica, analgetica en spierrelaxantia ............................................................................41
Inleidende begrippen.................................................................................................................................................. 41
Farmacodynamiek ................................................................................................................................................. 41
Farmacokinetiek .................................................................................................................................................... 43
Triade v alegemene anesthesie ............................................................................................................................. 44
2
,Farmacologie van intraveneuze hypnotica ................................................................................................................ 45
Inleiding en werkingsmechanisme ........................................................................................................................ 45
GABAA receptor ................................................................................................................................................. 45
NMDA receptor ................................................................................................................................................. 46
overzichtstabel .................................................................................................................................................. 46
Hypnotica - propofol .............................................................................................................................................. 47
Klinisch gebruik ................................................................................................................................................. 47
Farmacokinetiek ................................................................................................................................................ 47
Nevenwerkingen ............................................................................................................................................... 48
Hypnotica - etomidaat ........................................................................................................................................... 49
Klinisch gebruik ................................................................................................................................................. 49
farmacokinetiek................................................................................................................................................. 49
Nevenwerkingen ............................................................................................................................................... 50
Hypnotica ketamine ............................................................................................................................................... 51
Klinisch gebruik ................................................................................................................................................. 51
farmacokinetiek................................................................................................................................................. 52
Nevenwerkingen ............................................................................................................................................... 52
Benzodiazepines .................................................................................................................................................... 53
Hypnotica - midazolam...................................................................................................................................... 54
Farmacologie van inhalatie of volatiele anesthetica!!! ............................................................................................. 55
Farmacokinetiek en algemene effecten ................................................................................................................ 56
Farmacokinetiek ................................................................................................................................................ 56
Hemodynamica ................................................................................................................................................. 58
Effecten ............................................................................................................................................................. 59
Klinisch gebruik lachgas ......................................................................................................................................... 59
Klinisch gebruik Isoflurane ..................................................................................................................................... 60
Klinisch gebruik Sevoflurane .................................................................................................................................. 60
Klinisch gebruik Desflurane ................................................................................................................................... 60
Klinisch gebruik edelgassen ................................................................................................................................... 60
Farmacologie van opiaten.......................................................................................................................................... 61
analgetica-algemeen.............................................................................................................................................. 61
Klinisch gebruik ................................................................................................................................................. 61
Werkingsmechanisme ....................................................................................................................................... 61
Opioidreceptoren .............................................................................................................................................. 61
Analgetica – Toedieningswijze ............................................................................................................................... 63
Analgetica – farmacokinetiek ................................................................................................................................ 63
Analgetica – Andere orgaansystemen ................................................................................................................... 64
Analgetica .............................................................................................................................................................. 65
Opiaat – antagonist: µ-receptor ............................................................................................................................ 65
Farmacologie van niet-opioide analgetica ................................................................................................................. 66
Farmacologie van spierverslappers (neuromusculaire blokkers) ............................................................................... 66
Spierrelaxantia – Werkingsmechanisme ............................................................................................................... 66
Spierrelaxantia – Indeling ...................................................................................................................................... 66
Succinylcholine .................................................................................................................................................. 68
Niet depolariserende spierverslappers ............................................................................................................. 68
Spierrelaxantia – Neveneffecten ........................................................................................................................... 69
Succinylcholine .................................................................................................................................................. 69
Niet depolariserende ......................................................................................................................................... 69
Spierrelaxantia – Metabolisme .............................................................................................................................. 69
Spierrelaxantia – Antagonisten.............................................................................................................................. 70
3
, Cholinesterase – inhibitoren ............................................................................................................................. 70
Suggamadex (Bridion ®) .................................................................................................................................... 70
6. Locoregionale anesthesie ....................................................................................................................................71
Inleiding...................................................................................................................................................................... 71
Anatomie van een zenuwcel .................................................................................................................................. 71
Histologie van een zenuw ...................................................................................................................................... 72
Fysiologie v zenuwimpulsgeleiding ............................................................................................................................ 72
Farmacologie van lokale anesthetica ......................................................................................................................... 73
Concentratie .......................................................................................................................................................... 75
Additieven aan LA mengsels .................................................................................................................................. 76
Overzicht ................................................................................................................................................................ 76
Vormen locoregionale anesthesie: spinaal, epiduraal en perifere zenuwblocks ........................................................ 78
Centraal neuraxiale blocks ..................................................................................................................................... 78
Spinale anesthesie ............................................................................................................................................. 78
Epidurale anesthesie ......................................................................................................................................... 79
Combined spinal epidural anesthesie (CSE) ...................................................................................................... 79
Perifere zenuwblocks ............................................................................................................................................. 80
Het “Biers”block..................................................................................................................................................... 86
Complicaties ............................................................................................................................................................... 87
7. De postoperatieve periode ..................................................................................................................................90
Postoperatieve monitoring......................................................................................................................................... 90
Postoperatieve analgesie ........................................................................................................................................... 91
Recovery en ontstlag uit PAZA/ziekenhuis ................................................................................................................. 94
Postoperatief vochtbeleid .......................................................................................................................................... 96
8. Complicaties van anesthesie ..............................................................................................................................102
PONV ........................................................................................................................................................................ 103
Hypothermie ............................................................................................................................................................ 104
POCD ........................................................................................................................................................................ 105
Awareness ................................................................................................................................................................ 106
Maligne hyperthermie.............................................................................................................................................. 108
Restcurarisatie ......................................................................................................................................................... 108
Aspiratie ................................................................................................................................................................... 109
9. Lange termijn effecten van anesthesie ..............................................................................................................110
Metastasering en herval van kanker ........................................................................................................................ 110
Neuronale ontwikkeling bij herhaalde anesthesie ......................................................... Error! Bookmark not defined.
Transitie van acute naar chronische pijn.................................................................................................................. 110
4
1. examen ............................................................................................................................................................ 6
2. inleiding ........................................................................................................................................................... 6
3. De geschiedenis van de anesthesie .................................................................................................................. 7
Inleiding........................................................................................................................................................................ 7
Pre 1846: fundamenten v anesthesie ........................................................................................................................... 7
Industriële en wetenschappelijke revolutie ............................................................................................................ 7
Geschiedenis v inhalatie anesthesie ........................................................................................................................ 8
lachgas ................................................................................................................................................................. 8
Ether .................................................................................................................................................................... 8
1846-1900: verankering anesthesie ............................................................................................................................. 8
Chloroform............................................................................................................................................................... 8
Geschiedenis v lokale en regionale anesthesie ....................................................................................................... 9
20ste eeuw: consolidatie en groei ................................................................................................................................. 9
21STE EEUW: DE TOEKOMST ......................................................................................................................................... 9
2. De peri-operatieve stress respons .......................................................................................................................10
Heelkundige stress en anesthesie .............................................................................................................................. 10
De stress respons........................................................................................................................................................ 10
De peri-operatieve stress respons .............................................................................................................................. 11
De endocriene stress respons (examen) ............................................................................................................... 11
................................................................................................................................................................................12
De stress respons en metabolisme ............................................................................................................................. 13
De immunologische stress respons ............................................................................................................................ 13
De hematologische stress respons ............................................................................................................................. 14
De peri-operatieve stress respons .............................................................................................................................. 14
Veranderingen bij stress respons ............................................................................................................................... 14
3. De pre-operatieve oppuntstelling en risico stratificatie .......................................................................................15
De pre-operatieve evaluatie ....................................................................................................................................... 15
De anamnese.............................................................................................................................................................. 16
voorgeschiedenis ................................................................................................................................................... 16
systeemanamnese ................................................................................................................................................. 17
metabole equivalenten ..................................................................................................................................... 17
medicatie ............................................................................................................................................................... 18
Het klinisch onderzoek ............................................................................................................................................... 18
Technische onderzoeken (niet altijd) .......................................................................................................................... 19
Risico – stratificatie en classificatie (EXAMEN) .......................................................................................................... 21
1
, Risico scores ........................................................................................................................................................... 21
American Society of Anesthesiology score........................................................................................................ 21
NHYA ................................................................................................................................................................. 22
Lee’s Revised Cardiac Risk Index ....................................................................................................................... 22
GOLD klasse ....................................................................................................................................................... 23
Cardiale risicobepaling en oppuntstelling .................................................................................................................. 23
Pre-operatieve evaluatie en risicobepaling ........................................................................................................... 23
Patiënt gerelateerd risico .................................................................................................................................. 24
Heelkundig risico ............................................................................................................................................... 24
Pre-operatieve oppuntstelling en optimalisatie .................................................................................................... 25
Medicamenteuze voorbereiding ................................................................................................................................ 27
Sedativa – Hypnotica – tranquilizers ..................................................................................................................... 27
Reductie van maaginhoud en stijging van de zure maag pH ................................................................................. 27
Verlies tonus bovenste gastro-oesophagale sfincter ........................................................................................ 27
Risicopopulatie voor aspiratie (>25 ml – pH <2.5) ............................................................................................ 27
Richtlijnen preoperatief nuchter zijn ................................................................................................................ 28
Chronische thuismedicatie DOORGEVEN .............................................................................................................. 28
Corticosteroiden: Perioperatieve substitutie ........................................................................................................ 29
Mogelijke strategie ............................................................................................................................................ 29
Anti-diabetica ........................................................................................................................................................ 29
Klinische casus (zoals op examen) .............................................................................................................................. 30
4. Het doel van anesthesie: hypnose, analgesie, spierverslapping en stabilisatie ................................................31
Inleiding...................................................................................................................................................................... 31
5 Doelen van anesthesie ............................................................................................................................................ 32
Slaap/bewustzijnsverlies ....................................................................................................................................... 32
Stadia van Guedel.............................................................................................................................................. 33
Inhalatie - anesthetica ....................................................................................................................................... 34
Intraveneuze hypnotica ..................................................................................................................................... 34
Analgesie .................................................................................................................................................................... 34
Spierverslapper........................................................................................................................................................... 34
Fysiologische stabilisatie ............................................................................................................................................ 35
Monitoring ................................................................................................................................................................. 35
De kunstmatige luchtweg .......................................................................................................................................... 37
manuele maskerventilatie ..................................................................................................................................... 38
larynxmasker: supraglottic airway device ............................................................................................................. 38
laryngoscoop.......................................................................................................................................................... 39
Endotracheale tube ........................................................................................................................................... 39
Cormack en Lehane classificatie bij directe laryngoscopie ............................................................................... 39
Videolaryngoscopie ........................................................................................................................................... 40
Fiberoptische intubatie .......................................................................................................................................... 40
tracheostomie........................................................................................................................................................ 40
5. Farmacologie van hypnotica, analgetica en spierrelaxantia ............................................................................41
Inleidende begrippen.................................................................................................................................................. 41
Farmacodynamiek ................................................................................................................................................. 41
Farmacokinetiek .................................................................................................................................................... 43
Triade v alegemene anesthesie ............................................................................................................................. 44
2
,Farmacologie van intraveneuze hypnotica ................................................................................................................ 45
Inleiding en werkingsmechanisme ........................................................................................................................ 45
GABAA receptor ................................................................................................................................................. 45
NMDA receptor ................................................................................................................................................. 46
overzichtstabel .................................................................................................................................................. 46
Hypnotica - propofol .............................................................................................................................................. 47
Klinisch gebruik ................................................................................................................................................. 47
Farmacokinetiek ................................................................................................................................................ 47
Nevenwerkingen ............................................................................................................................................... 48
Hypnotica - etomidaat ........................................................................................................................................... 49
Klinisch gebruik ................................................................................................................................................. 49
farmacokinetiek................................................................................................................................................. 49
Nevenwerkingen ............................................................................................................................................... 50
Hypnotica ketamine ............................................................................................................................................... 51
Klinisch gebruik ................................................................................................................................................. 51
farmacokinetiek................................................................................................................................................. 52
Nevenwerkingen ............................................................................................................................................... 52
Benzodiazepines .................................................................................................................................................... 53
Hypnotica - midazolam...................................................................................................................................... 54
Farmacologie van inhalatie of volatiele anesthetica!!! ............................................................................................. 55
Farmacokinetiek en algemene effecten ................................................................................................................ 56
Farmacokinetiek ................................................................................................................................................ 56
Hemodynamica ................................................................................................................................................. 58
Effecten ............................................................................................................................................................. 59
Klinisch gebruik lachgas ......................................................................................................................................... 59
Klinisch gebruik Isoflurane ..................................................................................................................................... 60
Klinisch gebruik Sevoflurane .................................................................................................................................. 60
Klinisch gebruik Desflurane ................................................................................................................................... 60
Klinisch gebruik edelgassen ................................................................................................................................... 60
Farmacologie van opiaten.......................................................................................................................................... 61
analgetica-algemeen.............................................................................................................................................. 61
Klinisch gebruik ................................................................................................................................................. 61
Werkingsmechanisme ....................................................................................................................................... 61
Opioidreceptoren .............................................................................................................................................. 61
Analgetica – Toedieningswijze ............................................................................................................................... 63
Analgetica – farmacokinetiek ................................................................................................................................ 63
Analgetica – Andere orgaansystemen ................................................................................................................... 64
Analgetica .............................................................................................................................................................. 65
Opiaat – antagonist: µ-receptor ............................................................................................................................ 65
Farmacologie van niet-opioide analgetica ................................................................................................................. 66
Farmacologie van spierverslappers (neuromusculaire blokkers) ............................................................................... 66
Spierrelaxantia – Werkingsmechanisme ............................................................................................................... 66
Spierrelaxantia – Indeling ...................................................................................................................................... 66
Succinylcholine .................................................................................................................................................. 68
Niet depolariserende spierverslappers ............................................................................................................. 68
Spierrelaxantia – Neveneffecten ........................................................................................................................... 69
Succinylcholine .................................................................................................................................................. 69
Niet depolariserende ......................................................................................................................................... 69
Spierrelaxantia – Metabolisme .............................................................................................................................. 69
Spierrelaxantia – Antagonisten.............................................................................................................................. 70
3
, Cholinesterase – inhibitoren ............................................................................................................................. 70
Suggamadex (Bridion ®) .................................................................................................................................... 70
6. Locoregionale anesthesie ....................................................................................................................................71
Inleiding...................................................................................................................................................................... 71
Anatomie van een zenuwcel .................................................................................................................................. 71
Histologie van een zenuw ...................................................................................................................................... 72
Fysiologie v zenuwimpulsgeleiding ............................................................................................................................ 72
Farmacologie van lokale anesthetica ......................................................................................................................... 73
Concentratie .......................................................................................................................................................... 75
Additieven aan LA mengsels .................................................................................................................................. 76
Overzicht ................................................................................................................................................................ 76
Vormen locoregionale anesthesie: spinaal, epiduraal en perifere zenuwblocks ........................................................ 78
Centraal neuraxiale blocks ..................................................................................................................................... 78
Spinale anesthesie ............................................................................................................................................. 78
Epidurale anesthesie ......................................................................................................................................... 79
Combined spinal epidural anesthesie (CSE) ...................................................................................................... 79
Perifere zenuwblocks ............................................................................................................................................. 80
Het “Biers”block..................................................................................................................................................... 86
Complicaties ............................................................................................................................................................... 87
7. De postoperatieve periode ..................................................................................................................................90
Postoperatieve monitoring......................................................................................................................................... 90
Postoperatieve analgesie ........................................................................................................................................... 91
Recovery en ontstlag uit PAZA/ziekenhuis ................................................................................................................. 94
Postoperatief vochtbeleid .......................................................................................................................................... 96
8. Complicaties van anesthesie ..............................................................................................................................102
PONV ........................................................................................................................................................................ 103
Hypothermie ............................................................................................................................................................ 104
POCD ........................................................................................................................................................................ 105
Awareness ................................................................................................................................................................ 106
Maligne hyperthermie.............................................................................................................................................. 108
Restcurarisatie ......................................................................................................................................................... 108
Aspiratie ................................................................................................................................................................... 109
9. Lange termijn effecten van anesthesie ..............................................................................................................110
Metastasering en herval van kanker ........................................................................................................................ 110
Neuronale ontwikkeling bij herhaalde anesthesie ......................................................... Error! Bookmark not defined.
Transitie van acute naar chronische pijn.................................................................................................................. 110
4
