Anesthesie en pijn
Introductie anesthesie........................................................................................................... 14
Definitie algemene anesthesie ........................................................................................... 14
Elementen algemene anesthesie........................................................................................ 14
Premedicatie ..................................................................................................................... 14
Type “anesthesie”.............................................................................................................. 15
Algemene anesthesie......................................................................................................... 15
Inductie van “slaap” ................................................................................................... 15
Inhalatie anesthesie ................................................................................................... 16
Inhalatie: en dan? ....................................................................................................... 16
Inhalatie-inductie ....................................................................................................... 17
Intraveneuze anesthesie ............................................................................................. 17
Awareness ................................................................................................................. 17
Oorzaken ................................................................................................................ 17
Analgesie ................................................................................................................... 18
Spierverslappers......................................................................................................... 18
Waarom spierverslappers? ...................................................................................... 18
Antagonisatie ............................................................................................................. 19
Farmacologie van intraveneuze anesthetica: hypnotica .......................................................... 20
Hypnotica: werkingsmechanisme ...................................................................................... 20
Protein site theorie...................................................................................................... 20
Hypnotica.......................................................................................................................... 21
Barbituraten ............................................................................................................... 21
Thiopental .................................................................................................................. 21
Non-barbituraten ........................................................................................................ 22
Propofol (1-2%) ....................................................................................................... 22
Fysiologische neveneffecten ................................................................................ 22
Target controlled infusion (TCI)............................................................................. 22
Ketamine ................................................................................................................ 23
Eigenschappen .................................................................................................... 23
Voordelen............................................................................................................ 23
1
, Etomidaat .................................................................................................................. 24
Dexmedetomidine ...................................................................................................... 24
Benzodiazepines ........................................................................................................ 24
Fysiologische effecten ............................................................................................. 24
Midazolam vs Diazepam ............................................................................................. 25
Flumazenil .............................................................................................................. 25
Farmacologie – inhalatie anesthetica ..................................................................................... 26
Inhalatie/volatiele anesthetica ........................................................................................... 26
Gassen en volatielen.......................................................................................................... 26
Werkingsmechanisme inhalatieanesthetica ....................................................................... 26
Dampvormige anesthetica: algemene kenmerken............................................................... 26
Inhalatie anesthetica ......................................................................................................... 27
Opname in de longen .................................................................................................. 27
Opname in het bloed .................................................................................................. 27
Opname in de weefsels ............................................................................................... 27
Oplosbaarheidscoëfficiënt ................................................................................................. 28
Vetoplosbaarheid .............................................................................................................. 28
Besluit: snelheid inductie ................................................................................................... 28
Inhalatie anesthetica ......................................................................................................... 29
Lachgas...................................................................................................................... 29
Farmacokinetiek ..................................................................................................... 29
Neveneffecten ........................................................................................................ 29
Xenon......................................................................................................................... 30
Dampvormige anesthetica ................................................................................................. 30
Cardiovasculair effect ................................................................................................. 30
Pulmonaal effect ........................................................................................................ 30
Cerebraal effect.......................................................................................................... 30
Algemeen ................................................................................................................... 31
Welk volatiel te kiezen? ...................................................................................................... 31
Inductie ............................................................................................................................. 31
Farmacologie van de spierverslappers ................................................................................... 32
Waarom spierverslappers? ................................................................................................ 32
Fysiologie van de neuromusculaire junctie ......................................................................... 32
2
, Acetylcholine..................................................................................................................... 33
Presynaptische acetylcholine receptoren .................................................................... 33
Acetylcholine receptor ................................................................................................ 33
Indeling spierverslappers ................................................................................................... 33
Depolariserend NMB .......................................................................................................... 34
Werkingsmechanisme ................................................................................................ 34
Effect ......................................................................................................................... 34
Neveneffect ................................................................................................................ 34
Niet-depolariserende NMB ................................................................................................. 34
Werkingsmechanisme ................................................................................................ 34
Interactie met medicatie .................................................................................................... 35
Indeling neuromusculaire blokkers werkingsduur ............................................................... 35
Monitoring diepte neuromusculair blok .............................................................................. 35
Niet-depolariserend blok: klinisch verloop .......................................................................... 36
Effect type anesthesie........................................................................................................ 36
Antagonisatie NMB ............................................................................................................ 36
Beperkingen cholinesterase remmers ......................................................................... 37
Verschil werkingsmechanisme: Sugammadex ............................................................. 37
Verschillende dieptes van spierblok ................................................................................... 37
Onmiddellijke antagonisatie van een intens block ............................................................... 38
Indicatie Sugammadex....................................................................................................... 38
Crush inductie/ rapid sequence induction .......................................................................... 38
Samenvatting .................................................................................................................... 38
Monitoring............................................................................................................................. 39
Doel: monitoring ................................................................................................................ 39
Klinische monitoring .......................................................................................................... 39
Monitoring circulatie .......................................................................................................... 39
ECG ........................................................................................................................... 39
Niet-invasieve bloeddrukmeting .................................................................................. 39
Invasieve bloeddrukmeting ......................................................................................... 40
Indicaties ................................................................................................................ 40
Werkwijze ............................................................................................................... 40
Centraal veneuze drukmeting (CVD) ............................................................................ 41
3
, Indicatie ................................................................................................................. 41
Swan-Ganz katheter ................................................................................................... 41
Transoesophageale echo (TEE) .................................................................................... 42
Monitoring ademhaling ...................................................................................................... 43
Pulsoximetrie ............................................................................................................. 43
Capnometrie – capnografie ......................................................................................... 43
Gasmonitoring ............................................................................................................ 44
Zuurstofmeting ........................................................................................................... 45
Monitoring anesthesiediepte .............................................................................................. 45
Neurologische monitor ...................................................................................................... 45
Neuromusculaire monitoring ............................................................................................. 45
Monitoring lichaamstemperatuur ....................................................................................... 47
Monitoring urinedebiet ....................................................................................................... 48
Monitoring conclusies ........................................................................................................ 48
Preoperatieve oppuntstelling ................................................................................................. 49
Preoperatieve consultatie .................................................................................................. 49
Allergieën ................................................................................................................... 49
Abusus ....................................................................................................................... 50
Klinisch onderzoek...................................................................................................... 50
MET ........................................................................................................................ 50
ASA score ................................................................................................................... 51
Thuismedicatie ........................................................................................................... 51
Luchtwegevaluatie...................................................................................................... 51
Andere ....................................................................................................................... 52
OSAS.......................................................................................................................... 52
Stollingsanamnese ..................................................................................................... 52
Extra onderzoeken ...................................................................................................... 52
Anesthesietechniek/plan ............................................................................................ 53
Nuchterheidsprincipes ............................................................................................... 53
Informed consent ....................................................................................................... 54
Locoregionale technieken...................................................................................................... 55
Neuraxiaal ......................................................................................................................... 55
Spinale anesthesie ..................................................................................................... 58
4
, Wat spuiten we in .................................................................................................... 58
Epidurale anesthesie .................................................................................................. 59
Verschil spinaal-epiduraal .......................................................................................... 59
CSE = Combined Spinal Epidural ................................................................................. 60
Contra-indicaties neuraxiale technieken ..................................................................... 60
Specifieke zenuwen/plexus ................................................................................................ 60
Veel gebruikte zenuwblokken ...................................................................................... 60
Brachiale plexus ......................................................................................................... 60
Lumbale plexus .......................................................................................................... 62
Sacrale plexus ............................................................................................................ 62
In vlak waar zenuwen doorlopen ......................................................................................... 63
Voorbeelden ............................................................................................................... 63
Complicaties locoregionale technieken .............................................................................. 65
Oorzaken ‘niet-werkende’ epidurale ................................................................................... 65
Alle locoregionale technieken ............................................................................................ 65
Post durale punctie hoofdpijn = PDPH ................................................................................ 66
Klinische presentatie en diagnose ............................................................................... 67
Behandeling ............................................................................................................... 67
Casus: spinaal-epiduraal hematoom.................................................................................. 67
Neurologische dysfunctie bij perifere zenuwblokken ........................................................... 69
Luchtweg, oxygenatie en ventilatie ......................................................................................... 70
Moeilijke luchtweg ............................................................................................................. 70
Bovenste luchtweg/onderste luchtweg ............................................................................... 70
Preoperatieve evaluatie luchtweg ....................................................................................... 70
Anamnese en klinisch onderzoek ................................................................................ 70
Moeilijke maskerventilatie? ..................................................................................... 71
Specifieke luchtwegtesten .......................................................................................... 71
LEMON ....................................................................................................................... 72
Controle van de luchtweg................................................................................................... 72
Positionering .............................................................................................................. 72
Methoden ................................................................................................................... 73
Masker.................................................................................................................... 73
Supraglottic devices: larynxmasker .......................................................................... 73
5
, Voordelen tov intubatie ........................................................................................ 74
Contra-indicaties................................................................................................. 74
Second generation ............................................................................................... 74
Endotracheale tube ................................................................................................. 75
Intubatie: hulpmiddelen ....................................................................................... 75
Intubatie: algoritme ............................................................................................. 76
Intubatie: bevestiging ........................................................................................... 76
Invloed anesthesie op ademhaling ..................................................................................... 76
Beademingscircuits ........................................................................................................... 77
Ventilator .......................................................................................................................... 77
Functies ..................................................................................................................... 77
Test ............................................................................................................................ 77
Instellingen................................................................................................................. 78
Adequate ventilatie? ................................................................................................... 78
Monitoring ventilatie .......................................................................................................... 78
Pulsoxymeter ............................................................................................................. 79
Mechanische ventilatie: complicaties................................................................................. 79
Pre-operatieve cardiovasculaire evaluatie .............................................................................. 80
Operatief cardiovasculair risico .......................................................................................... 80
Probleemstelling ............................................................................................................... 80
Risicostratificatie............................................................................................................... 80
Heelkundige ingreep ................................................................................................... 80
Cardiovasculaire risicostratificatie .............................................................................. 81
Functionele status ...................................................................................................... 82
Beleidsstroomdiagram....................................................................................................... 82
Aanvullende testen ............................................................................................................ 82
Echocardiografie ........................................................................................................ 82
Detectie ischemie ....................................................................................................... 83
Prognostische waarden van stress testen .................................................................... 83
Andere aanvullende testen.......................................................................................... 83
Cardioprotectieve maatregelen .......................................................................................... 83
Profylactische revascularisatie .......................................................................................... 84
Endocarditis ...................................................................................................................... 84
6
, Endocarditis profylaxie ............................................................................................... 84
Aanpassing ontstollende therapie ...................................................................................... 84
Aanpassing anti-aggregerende therapie .............................................................................. 85
Pacemaker patiënt............................................................................................................. 86
Pijnstilling bij de partus .......................................................................................................... 87
Fysiologische veranderingen tijdens zwangerschap ............................................................ 87
Hartfunctie en circulatie ............................................................................................. 87
Spinale anesthesie .................................................................................................. 87
Luchtwegen en longfunctie ......................................................................................... 87
Samenstelling bloed ................................................................................................... 88
Gastro-intestinaal stelsel ............................................................................................ 88
Centraal zenuwstelsel ................................................................................................ 88
Pijnstilling bij de partus ...................................................................................................... 89
Analgesie bij vaginale partus .............................................................................................. 89
Fysiologische veranderingen bij partus ............................................................................... 89
Pijnstilling.......................................................................................................................... 90
Pijnstilling bij vaginale bevalling.......................................................................................... 90
Epiduraal/spinaal/CSE ................................................................................................ 90
Anatomie ................................................................................................................ 90
Epidurale techniek .................................................................................................. 91
Epiduraal: bevalling ................................................................................................. 91
Epidurale pijnstilling ................................................................................................ 91
CSE bij bevalling...................................................................................................... 91
Complicaties ..................................................................................................................... 92
Postdurale punctie hoofdpijn (PDPH) .......................................................................... 92
Andere complicaties ................................................................................................... 92
Contraindicaties ................................................................................................................ 93
Absolute contraindicaties ........................................................................................... 93
Relatieve contraindicaties ........................................................................................... 93
Sectio ................................................................................................................................ 93
Algemene anesthesie.................................................................................................. 94
Pijnstilling na sectio .................................................................................................... 94
Perifere blocks na section AA ...................................................................................... 94
7
, Borstvoeding ..................................................................................................................... 95
Borstvoeding en medicatie .......................................................................................... 95
Peri-operatieve anesthesiologische complicaties ................................................................... 96
1. Respiratoire complicaties............................................................................................... 96
Bovenste luchtweg obstructie ..................................................................................... 96
Pharynx................................................................................................................... 96
Larynx ..................................................................................................................... 96
Pulmonale complicaties ............................................................................................. 97
Algemene anesthesie .............................................................................................. 97
Pulmonaal oedeem ................................................................................................. 97
Andere .................................................................................................................... 97
2. Cardiovasculaire dysfunctie ........................................................................................... 97
3. Anaphylaxie ................................................................................................................... 98
4. Bloeding ........................................................................................................................ 98
5. Maligne hyperthermie ................................................................................................. 98
6. Neurologische dysfunctie ............................................................................................... 99
Patiënt wordt niet wakker‼ .......................................................................................... 99
Delirium ................................................................................................................... 100
Postoperatieve dysfunctie (POCD) ............................................................................ 100
7. Restcurarisatie (patiënt wordt niet wakker) ................................................................... 100
8. Postoperatieve Nausea en Vomiting (PONV).................................................................. 101
Risicoprofiel ............................................................................................................. 102
Anti-emetica............................................................................................................. 102
Anticholinergica – antihistaminica ......................................................................... 102
Dopaminerge antagonisten ................................................................................... 103
Serotonine receptor antagonisten .......................................................................... 103
Corticoïden ........................................................................................................... 103
Alternatieve therapie ............................................................................................. 103
Praktisch: profylaxis – behandeling ............................................................................ 104
PONV preventie ........................................................................................................ 104
9. Pijnstilling .................................................................................................................... 104
10. Temperatuursveranderingen ....................................................................................... 104
11. Ionen/ glycemie stoornissen ....................................................................................... 104
8
, 12. Positionering .............................................................................................................. 105
13. Brand ......................................................................................................................... 105
14. Menselijke fouten ....................................................................................................... 105
Veneuze access .................................................................................................................. 106
Inleiding .......................................................................................................................... 106
Grondig katheterassessment is belangrijk ........................................................................ 106
De ideale veneuze toegang ............................................................................................... 106
Keuze van het type katheter.............................................................................................. 107
Eigenschappen van toe te dienen medicatie .............................................................. 107
Perifere katheters ............................................................................................................ 108
Punctieplaats .................................................................................................................. 108
Midline katheters ............................................................................................................. 109
Indicaties ................................................................................................................. 109
PICC (Peripheral Inserted Central Catheter) ..................................................................... 109
‘Acute’ centraal veneuze catheter .................................................................................... 109
Indicaties ................................................................................................................. 110
Nadelen ................................................................................................................... 110
Vena subclavia ................................................................................................................ 110
Vena jugularis interna ...................................................................................................... 110
Vena femoralis ................................................................................................................ 110
Speciale soorten centrale katheters ................................................................................. 111
Meest voorkomende complicaties .................................................................................... 111
Veneuze trombose ........................................................................................................... 111
Malfunctie ....................................................................................................................... 112
Casussen ........................................................................................................................ 112
Perioperatieve homeostase ................................................................................................. 113
Vochtbeleid ..................................................................................................................... 113
Elektrolyten ..................................................................................................................... 114
Natrium .................................................................................................................... 114
Kalium...................................................................................................................... 115
Calcium ................................................................................................................... 115
Magnesium............................................................................................................... 115
Bloed en stolling .............................................................................................................. 115
9
, Lichaamstemperatuur ..................................................................................................... 117
Zuur-base evenwicht ....................................................................................................... 118
Glycemie ......................................................................................................................... 119
Besluit ............................................................................................................................. 119
Pathofysiologie van acute & chronische pijn ......................................................................... 120
Leerdoelstellingen ........................................................................................................... 120
“Normale pijn fysiologie” ................................................................................................. 120
Stimulus .......................................................................................................................... 120
Nociceptoren .................................................................................................................. 121
Dubbel afferent systeem ........................................................................................... 121
Subtypes van nociceptoren ....................................................................................... 122
Modulatie – korte termijn.................................................................................................. 122
Sensitisatie...................................................................................................................... 122
Pathologische mechanismen (chronische pijn) ................................................................. 124
Acute en chronische pijn ..................................................................................................... 127
Leerdoelstellingen ........................................................................................................... 127
Acute vs. chronische pijn ................................................................................................. 127
Het verloop van pijn: van acute naar chronische pijncondities ........................................... 128
Van chronische pijnklacht naar chronisch pijnsyndroom ................................................... 128
Vergelijking tussen chronische pijn (CP) en chronische pijnsyndromen (CPS) ............. 128
Chronische pijnsyndroom: symptomen ............................................................................ 129
“Chronische pijn-patiënt” ................................................................................................ 129
Hoe chronische pijnsyndromen zich ontwikkelen: chronische pijncyclus ........................... 129
Risicofactoren op chronificatie......................................................................................... 130
Algemene doelstellingen behandeling .............................................................................. 130
Enkele essentiële vragen! ................................................................................................. 130
RODE VLAGGEN .............................................................................................................. 130
Algemene behandelingsprincipes ..................................................................................... 131
Farmacotherapie van pijn .................................................................................................... 132
Leerdoelstellingen ........................................................................................................... 132
Perifeer zenuwstelsel ....................................................................................................... 132
Treatment ‘step by step’................................................................................................... 133
Adjuvantia ....................................................................................................................... 133
10
Introductie anesthesie........................................................................................................... 14
Definitie algemene anesthesie ........................................................................................... 14
Elementen algemene anesthesie........................................................................................ 14
Premedicatie ..................................................................................................................... 14
Type “anesthesie”.............................................................................................................. 15
Algemene anesthesie......................................................................................................... 15
Inductie van “slaap” ................................................................................................... 15
Inhalatie anesthesie ................................................................................................... 16
Inhalatie: en dan? ....................................................................................................... 16
Inhalatie-inductie ....................................................................................................... 17
Intraveneuze anesthesie ............................................................................................. 17
Awareness ................................................................................................................. 17
Oorzaken ................................................................................................................ 17
Analgesie ................................................................................................................... 18
Spierverslappers......................................................................................................... 18
Waarom spierverslappers? ...................................................................................... 18
Antagonisatie ............................................................................................................. 19
Farmacologie van intraveneuze anesthetica: hypnotica .......................................................... 20
Hypnotica: werkingsmechanisme ...................................................................................... 20
Protein site theorie...................................................................................................... 20
Hypnotica.......................................................................................................................... 21
Barbituraten ............................................................................................................... 21
Thiopental .................................................................................................................. 21
Non-barbituraten ........................................................................................................ 22
Propofol (1-2%) ....................................................................................................... 22
Fysiologische neveneffecten ................................................................................ 22
Target controlled infusion (TCI)............................................................................. 22
Ketamine ................................................................................................................ 23
Eigenschappen .................................................................................................... 23
Voordelen............................................................................................................ 23
1
, Etomidaat .................................................................................................................. 24
Dexmedetomidine ...................................................................................................... 24
Benzodiazepines ........................................................................................................ 24
Fysiologische effecten ............................................................................................. 24
Midazolam vs Diazepam ............................................................................................. 25
Flumazenil .............................................................................................................. 25
Farmacologie – inhalatie anesthetica ..................................................................................... 26
Inhalatie/volatiele anesthetica ........................................................................................... 26
Gassen en volatielen.......................................................................................................... 26
Werkingsmechanisme inhalatieanesthetica ....................................................................... 26
Dampvormige anesthetica: algemene kenmerken............................................................... 26
Inhalatie anesthetica ......................................................................................................... 27
Opname in de longen .................................................................................................. 27
Opname in het bloed .................................................................................................. 27
Opname in de weefsels ............................................................................................... 27
Oplosbaarheidscoëfficiënt ................................................................................................. 28
Vetoplosbaarheid .............................................................................................................. 28
Besluit: snelheid inductie ................................................................................................... 28
Inhalatie anesthetica ......................................................................................................... 29
Lachgas...................................................................................................................... 29
Farmacokinetiek ..................................................................................................... 29
Neveneffecten ........................................................................................................ 29
Xenon......................................................................................................................... 30
Dampvormige anesthetica ................................................................................................. 30
Cardiovasculair effect ................................................................................................. 30
Pulmonaal effect ........................................................................................................ 30
Cerebraal effect.......................................................................................................... 30
Algemeen ................................................................................................................... 31
Welk volatiel te kiezen? ...................................................................................................... 31
Inductie ............................................................................................................................. 31
Farmacologie van de spierverslappers ................................................................................... 32
Waarom spierverslappers? ................................................................................................ 32
Fysiologie van de neuromusculaire junctie ......................................................................... 32
2
, Acetylcholine..................................................................................................................... 33
Presynaptische acetylcholine receptoren .................................................................... 33
Acetylcholine receptor ................................................................................................ 33
Indeling spierverslappers ................................................................................................... 33
Depolariserend NMB .......................................................................................................... 34
Werkingsmechanisme ................................................................................................ 34
Effect ......................................................................................................................... 34
Neveneffect ................................................................................................................ 34
Niet-depolariserende NMB ................................................................................................. 34
Werkingsmechanisme ................................................................................................ 34
Interactie met medicatie .................................................................................................... 35
Indeling neuromusculaire blokkers werkingsduur ............................................................... 35
Monitoring diepte neuromusculair blok .............................................................................. 35
Niet-depolariserend blok: klinisch verloop .......................................................................... 36
Effect type anesthesie........................................................................................................ 36
Antagonisatie NMB ............................................................................................................ 36
Beperkingen cholinesterase remmers ......................................................................... 37
Verschil werkingsmechanisme: Sugammadex ............................................................. 37
Verschillende dieptes van spierblok ................................................................................... 37
Onmiddellijke antagonisatie van een intens block ............................................................... 38
Indicatie Sugammadex....................................................................................................... 38
Crush inductie/ rapid sequence induction .......................................................................... 38
Samenvatting .................................................................................................................... 38
Monitoring............................................................................................................................. 39
Doel: monitoring ................................................................................................................ 39
Klinische monitoring .......................................................................................................... 39
Monitoring circulatie .......................................................................................................... 39
ECG ........................................................................................................................... 39
Niet-invasieve bloeddrukmeting .................................................................................. 39
Invasieve bloeddrukmeting ......................................................................................... 40
Indicaties ................................................................................................................ 40
Werkwijze ............................................................................................................... 40
Centraal veneuze drukmeting (CVD) ............................................................................ 41
3
, Indicatie ................................................................................................................. 41
Swan-Ganz katheter ................................................................................................... 41
Transoesophageale echo (TEE) .................................................................................... 42
Monitoring ademhaling ...................................................................................................... 43
Pulsoximetrie ............................................................................................................. 43
Capnometrie – capnografie ......................................................................................... 43
Gasmonitoring ............................................................................................................ 44
Zuurstofmeting ........................................................................................................... 45
Monitoring anesthesiediepte .............................................................................................. 45
Neurologische monitor ...................................................................................................... 45
Neuromusculaire monitoring ............................................................................................. 45
Monitoring lichaamstemperatuur ....................................................................................... 47
Monitoring urinedebiet ....................................................................................................... 48
Monitoring conclusies ........................................................................................................ 48
Preoperatieve oppuntstelling ................................................................................................. 49
Preoperatieve consultatie .................................................................................................. 49
Allergieën ................................................................................................................... 49
Abusus ....................................................................................................................... 50
Klinisch onderzoek...................................................................................................... 50
MET ........................................................................................................................ 50
ASA score ................................................................................................................... 51
Thuismedicatie ........................................................................................................... 51
Luchtwegevaluatie...................................................................................................... 51
Andere ....................................................................................................................... 52
OSAS.......................................................................................................................... 52
Stollingsanamnese ..................................................................................................... 52
Extra onderzoeken ...................................................................................................... 52
Anesthesietechniek/plan ............................................................................................ 53
Nuchterheidsprincipes ............................................................................................... 53
Informed consent ....................................................................................................... 54
Locoregionale technieken...................................................................................................... 55
Neuraxiaal ......................................................................................................................... 55
Spinale anesthesie ..................................................................................................... 58
4
, Wat spuiten we in .................................................................................................... 58
Epidurale anesthesie .................................................................................................. 59
Verschil spinaal-epiduraal .......................................................................................... 59
CSE = Combined Spinal Epidural ................................................................................. 60
Contra-indicaties neuraxiale technieken ..................................................................... 60
Specifieke zenuwen/plexus ................................................................................................ 60
Veel gebruikte zenuwblokken ...................................................................................... 60
Brachiale plexus ......................................................................................................... 60
Lumbale plexus .......................................................................................................... 62
Sacrale plexus ............................................................................................................ 62
In vlak waar zenuwen doorlopen ......................................................................................... 63
Voorbeelden ............................................................................................................... 63
Complicaties locoregionale technieken .............................................................................. 65
Oorzaken ‘niet-werkende’ epidurale ................................................................................... 65
Alle locoregionale technieken ............................................................................................ 65
Post durale punctie hoofdpijn = PDPH ................................................................................ 66
Klinische presentatie en diagnose ............................................................................... 67
Behandeling ............................................................................................................... 67
Casus: spinaal-epiduraal hematoom.................................................................................. 67
Neurologische dysfunctie bij perifere zenuwblokken ........................................................... 69
Luchtweg, oxygenatie en ventilatie ......................................................................................... 70
Moeilijke luchtweg ............................................................................................................. 70
Bovenste luchtweg/onderste luchtweg ............................................................................... 70
Preoperatieve evaluatie luchtweg ....................................................................................... 70
Anamnese en klinisch onderzoek ................................................................................ 70
Moeilijke maskerventilatie? ..................................................................................... 71
Specifieke luchtwegtesten .......................................................................................... 71
LEMON ....................................................................................................................... 72
Controle van de luchtweg................................................................................................... 72
Positionering .............................................................................................................. 72
Methoden ................................................................................................................... 73
Masker.................................................................................................................... 73
Supraglottic devices: larynxmasker .......................................................................... 73
5
, Voordelen tov intubatie ........................................................................................ 74
Contra-indicaties................................................................................................. 74
Second generation ............................................................................................... 74
Endotracheale tube ................................................................................................. 75
Intubatie: hulpmiddelen ....................................................................................... 75
Intubatie: algoritme ............................................................................................. 76
Intubatie: bevestiging ........................................................................................... 76
Invloed anesthesie op ademhaling ..................................................................................... 76
Beademingscircuits ........................................................................................................... 77
Ventilator .......................................................................................................................... 77
Functies ..................................................................................................................... 77
Test ............................................................................................................................ 77
Instellingen................................................................................................................. 78
Adequate ventilatie? ................................................................................................... 78
Monitoring ventilatie .......................................................................................................... 78
Pulsoxymeter ............................................................................................................. 79
Mechanische ventilatie: complicaties................................................................................. 79
Pre-operatieve cardiovasculaire evaluatie .............................................................................. 80
Operatief cardiovasculair risico .......................................................................................... 80
Probleemstelling ............................................................................................................... 80
Risicostratificatie............................................................................................................... 80
Heelkundige ingreep ................................................................................................... 80
Cardiovasculaire risicostratificatie .............................................................................. 81
Functionele status ...................................................................................................... 82
Beleidsstroomdiagram....................................................................................................... 82
Aanvullende testen ............................................................................................................ 82
Echocardiografie ........................................................................................................ 82
Detectie ischemie ....................................................................................................... 83
Prognostische waarden van stress testen .................................................................... 83
Andere aanvullende testen.......................................................................................... 83
Cardioprotectieve maatregelen .......................................................................................... 83
Profylactische revascularisatie .......................................................................................... 84
Endocarditis ...................................................................................................................... 84
6
, Endocarditis profylaxie ............................................................................................... 84
Aanpassing ontstollende therapie ...................................................................................... 84
Aanpassing anti-aggregerende therapie .............................................................................. 85
Pacemaker patiënt............................................................................................................. 86
Pijnstilling bij de partus .......................................................................................................... 87
Fysiologische veranderingen tijdens zwangerschap ............................................................ 87
Hartfunctie en circulatie ............................................................................................. 87
Spinale anesthesie .................................................................................................. 87
Luchtwegen en longfunctie ......................................................................................... 87
Samenstelling bloed ................................................................................................... 88
Gastro-intestinaal stelsel ............................................................................................ 88
Centraal zenuwstelsel ................................................................................................ 88
Pijnstilling bij de partus ...................................................................................................... 89
Analgesie bij vaginale partus .............................................................................................. 89
Fysiologische veranderingen bij partus ............................................................................... 89
Pijnstilling.......................................................................................................................... 90
Pijnstilling bij vaginale bevalling.......................................................................................... 90
Epiduraal/spinaal/CSE ................................................................................................ 90
Anatomie ................................................................................................................ 90
Epidurale techniek .................................................................................................. 91
Epiduraal: bevalling ................................................................................................. 91
Epidurale pijnstilling ................................................................................................ 91
CSE bij bevalling...................................................................................................... 91
Complicaties ..................................................................................................................... 92
Postdurale punctie hoofdpijn (PDPH) .......................................................................... 92
Andere complicaties ................................................................................................... 92
Contraindicaties ................................................................................................................ 93
Absolute contraindicaties ........................................................................................... 93
Relatieve contraindicaties ........................................................................................... 93
Sectio ................................................................................................................................ 93
Algemene anesthesie.................................................................................................. 94
Pijnstilling na sectio .................................................................................................... 94
Perifere blocks na section AA ...................................................................................... 94
7
, Borstvoeding ..................................................................................................................... 95
Borstvoeding en medicatie .......................................................................................... 95
Peri-operatieve anesthesiologische complicaties ................................................................... 96
1. Respiratoire complicaties............................................................................................... 96
Bovenste luchtweg obstructie ..................................................................................... 96
Pharynx................................................................................................................... 96
Larynx ..................................................................................................................... 96
Pulmonale complicaties ............................................................................................. 97
Algemene anesthesie .............................................................................................. 97
Pulmonaal oedeem ................................................................................................. 97
Andere .................................................................................................................... 97
2. Cardiovasculaire dysfunctie ........................................................................................... 97
3. Anaphylaxie ................................................................................................................... 98
4. Bloeding ........................................................................................................................ 98
5. Maligne hyperthermie ................................................................................................. 98
6. Neurologische dysfunctie ............................................................................................... 99
Patiënt wordt niet wakker‼ .......................................................................................... 99
Delirium ................................................................................................................... 100
Postoperatieve dysfunctie (POCD) ............................................................................ 100
7. Restcurarisatie (patiënt wordt niet wakker) ................................................................... 100
8. Postoperatieve Nausea en Vomiting (PONV).................................................................. 101
Risicoprofiel ............................................................................................................. 102
Anti-emetica............................................................................................................. 102
Anticholinergica – antihistaminica ......................................................................... 102
Dopaminerge antagonisten ................................................................................... 103
Serotonine receptor antagonisten .......................................................................... 103
Corticoïden ........................................................................................................... 103
Alternatieve therapie ............................................................................................. 103
Praktisch: profylaxis – behandeling ............................................................................ 104
PONV preventie ........................................................................................................ 104
9. Pijnstilling .................................................................................................................... 104
10. Temperatuursveranderingen ....................................................................................... 104
11. Ionen/ glycemie stoornissen ....................................................................................... 104
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, 12. Positionering .............................................................................................................. 105
13. Brand ......................................................................................................................... 105
14. Menselijke fouten ....................................................................................................... 105
Veneuze access .................................................................................................................. 106
Inleiding .......................................................................................................................... 106
Grondig katheterassessment is belangrijk ........................................................................ 106
De ideale veneuze toegang ............................................................................................... 106
Keuze van het type katheter.............................................................................................. 107
Eigenschappen van toe te dienen medicatie .............................................................. 107
Perifere katheters ............................................................................................................ 108
Punctieplaats .................................................................................................................. 108
Midline katheters ............................................................................................................. 109
Indicaties ................................................................................................................. 109
PICC (Peripheral Inserted Central Catheter) ..................................................................... 109
‘Acute’ centraal veneuze catheter .................................................................................... 109
Indicaties ................................................................................................................. 110
Nadelen ................................................................................................................... 110
Vena subclavia ................................................................................................................ 110
Vena jugularis interna ...................................................................................................... 110
Vena femoralis ................................................................................................................ 110
Speciale soorten centrale katheters ................................................................................. 111
Meest voorkomende complicaties .................................................................................... 111
Veneuze trombose ........................................................................................................... 111
Malfunctie ....................................................................................................................... 112
Casussen ........................................................................................................................ 112
Perioperatieve homeostase ................................................................................................. 113
Vochtbeleid ..................................................................................................................... 113
Elektrolyten ..................................................................................................................... 114
Natrium .................................................................................................................... 114
Kalium...................................................................................................................... 115
Calcium ................................................................................................................... 115
Magnesium............................................................................................................... 115
Bloed en stolling .............................................................................................................. 115
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, Lichaamstemperatuur ..................................................................................................... 117
Zuur-base evenwicht ....................................................................................................... 118
Glycemie ......................................................................................................................... 119
Besluit ............................................................................................................................. 119
Pathofysiologie van acute & chronische pijn ......................................................................... 120
Leerdoelstellingen ........................................................................................................... 120
“Normale pijn fysiologie” ................................................................................................. 120
Stimulus .......................................................................................................................... 120
Nociceptoren .................................................................................................................. 121
Dubbel afferent systeem ........................................................................................... 121
Subtypes van nociceptoren ....................................................................................... 122
Modulatie – korte termijn.................................................................................................. 122
Sensitisatie...................................................................................................................... 122
Pathologische mechanismen (chronische pijn) ................................................................. 124
Acute en chronische pijn ..................................................................................................... 127
Leerdoelstellingen ........................................................................................................... 127
Acute vs. chronische pijn ................................................................................................. 127
Het verloop van pijn: van acute naar chronische pijncondities ........................................... 128
Van chronische pijnklacht naar chronisch pijnsyndroom ................................................... 128
Vergelijking tussen chronische pijn (CP) en chronische pijnsyndromen (CPS) ............. 128
Chronische pijnsyndroom: symptomen ............................................................................ 129
“Chronische pijn-patiënt” ................................................................................................ 129
Hoe chronische pijnsyndromen zich ontwikkelen: chronische pijncyclus ........................... 129
Risicofactoren op chronificatie......................................................................................... 130
Algemene doelstellingen behandeling .............................................................................. 130
Enkele essentiële vragen! ................................................................................................. 130
RODE VLAGGEN .............................................................................................................. 130
Algemene behandelingsprincipes ..................................................................................... 131
Farmacotherapie van pijn .................................................................................................... 132
Leerdoelstellingen ........................................................................................................... 132
Perifeer zenuwstelsel ....................................................................................................... 132
Treatment ‘step by step’................................................................................................... 133
Adjuvantia ....................................................................................................................... 133
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