HEELKUNDIG ZORGTRAJECT:
OLA2: INLEIDING TOT DE ANESTHESIE
MARC VANDEVELDE
,Inhoudsopgave
H1: GESCHIEDENIS VAN DE ANESTHESIE..........................................................4
GESCHIEDENIS VAN INHALATIE ANESTHESIE................................................................................4
LOKALE EN GESCHIEDENIS VAN LOKALE EN REGIONALE ANESTHESIE................................................4
GESCHIEDENIS VAN IV-ANESTHESIE.......................................................................................... 4
ANESTHESIE IN BELGIË........................................................................................................... 4
H2: PERI-OPERATIEVE STRESS RESPONS..........................................................5
H3: PRE-OPERATIEVE OPPUNTSTELLING EN RISICO-CLASSIFCIATIE....................8
PRE-OPERATIEVE EVALUATIE.................................................................................................... 8
ANAMNESE.......................................................................................................................... 8
KO.................................................................................................................................. 10
TO.................................................................................................................................. 10
RISICO STRATIFICATIE EN CLASSIFICATIE...................................................................................12
CARDIALE RISICOBEPALING EN OPPUNTSTELLING........................................................................14
pre-operatieve evaluatie en risicobepaling................................................................14
Pre-operatieve oppuntstelling en optimalisatie..........................................................15
MEDICAMENTEUZE VOORBEREIDING........................................................................................16
sedativa, hypnotica, tranquilizers...............................................................................17
reductie maaginhoud en stijging van zure maag ph...................................................17
H4: DOEL VAN ANESTHESIE: HYPNOSE, ANALGESIE, SPIERVERSLAPPING EN
STABILISATIE............................................................................................... 20
SLAAP/BEWUSTZIJNSVERLIES................................................................................................. 20
ANALGESIE........................................................................................................................ 23
SPIERVERSLAPPER............................................................................................................... 24
KUNSTMATIGE LUCHTWEG.................................................................................................... 24
MONITORING..................................................................................................................... 26
monitoring circulatie.................................................................................................. 26
Monitoring ademhaling............................................................................................... 26
Monitoring van anesthesiediepte...............................................................................27
Neuromusculairemonitoring.......................................................................................27
Monitoring lichaamstemperatuur...............................................................................27
Monitoring urineproductie..........................................................................................28
FYSIOLOGISCHE STABILISATIE................................................................................................ 28
H5: FARMACOLOGIE VAN HYPNOTICA, ANALGETICA EN SPIERRELAXANTIA.......29
INLEIDENDE BEGRIPPEN........................................................................................................ 29
FARMACOLOGIE VAN INTRAVENEUZE HYPNOTICA........................................................................31
Werkingsmechanisme................................................................................................31
Propofol...................................................................................................................... 31
Etomidaat................................................................................................................... 33
Ketamine.................................................................................................................... 34
Benzodiazepines........................................................................................................ 35
FARMACOLOGIE VAN VOLATIELE ANESTHETICA..........................................................................36
Farmacokinetiek en algemene effecten.....................................................................36
FARMACOLOGIE VAN OPIATEN................................................................................................ 37
Opiaatreceptoren....................................................................................................... 38
Algemene eigenschappen opioïden............................................................................38
Farmacokinetiek......................................................................................................... 39
Klinisch gebruikte opiaten.......................................................................................... 40
FARMACOLOGIE VAN SPIERVERSLAPPERS..................................................................................41
Fysiologie NMJ............................................................................................................ 41
Werking spierverslappers........................................................................................... 42
antagonisatie............................................................................................................. 43
H6: LOCOREGIONALE ANESTHESIE.................................................................44
, FYSIOLOGIE VAN DE ZENUWIMPULSGELEIDING...........................................................................44
FARMACOLOGIE VAN LOKALE ANESTHETICA..............................................................................44
VORMEN VAN LOCOREGIONALE ANESTHESIE.............................................................................46
Spinale anesthesie..................................................................................................... 46
Epidurale anesthesie.................................................................................................. 46
Combined spinal epidural anetshesie (CSE)...............................................................47
Perifere zenuwblocks.................................................................................................. 48
Het “Biers” block........................................................................................................ 49
COMPLICATIES REGIONALE ANESHTESIE...................................................................................49
Algemene complicaties..............................................................................................49
Centraal neuraxiale anesthesie..................................................................................50
Perifere zenuwblocks.................................................................................................. 52
H7: POST-OPERATIEVE PERIODE....................................................................53
POST-OPERATIEVE MONITORING............................................................................................. 53
POST-OPERATIEVE ANALGESIE............................................................................................... 53
Pathofysiologie van pijn.............................................................................................53
Nevenwerkingen post-operatieve pijn........................................................................54
Post-operatieve pijnstilling.........................................................................................55
RECOVERY EN ONTSLAG UIT PAZA........................................................................................57
POST-OPERATIEF VOCHTBELEID.............................................................................................. 58
Lichamelijke vochtcompartimenten............................................................................59
Controlemechanismen............................................................................................... 59
Infuusvloeistoffen....................................................................................................... 60
per-operatief vochtbeleid........................................................................................... 62
H8: COMPLICATIES VAN ANESTHESIE.............................................................65
POST-OPERATIEVE MISSELIJKHEID EN BRAKEN...........................................................................65
HYPOTHERMIE.................................................................................................................... 65
POST-OPERATIEVE COGNITIEVE DYSFUNCTIE.............................................................................66
AWARENESS...................................................................................................................... 66
MALIGNE HYPERTHERMIE...................................................................................................... 67
RESTCURARISATIE............................................................................................................... 67
ASPIRATIE......................................................................................................................... 67
H9: LANGE-TERMIJN EFFECTEN VAN ANESTHESIE............................................69
METASTASERING EN HERVAL VAN KANKER...............................................................................69
NEURONALE ONTWIKKELING BIJ HERHAALDE ANESTHESIE.............................................................69
TRANSITIE VAN ACUTE NAAR CHRONISCHE PIJN.........................................................................69
, H1: GESCHIEDENIS VAN DE ANESTHESIE
NIET KENNEN
GESCHIEDENIS VAN INHALATIE ANESTHESIE
Ether
o Via glazen reservoir waarin spons doordrenkt met ether werd gelegd
Lachgas
Chloroform
o Krachtiger dan ether
o Toxisch voor hart en lever
Gevaar: achteroverzakken tong met belemmering van luchtweg
o Dus: tracheale intubatie
LOKALE EN GESCHIEDENIS VAN LOKALE EN REGIONALE ANESTHESIE
Cocaïne in cocabladeren
o Roesdrug voor hersenen
o Krachtig lokaal anestheticum
Spinale anesthesie
o Lumbale epidurale anesthesie
GESCHIEDENIS VAN IV-ANESTHESIE
Spuit en naald uitvinden
Barbituraatzuur
Benzodiazepines
Ketamine
o = eerste intraveneuze anestheticum met minimale cardiale en respiratoire onderdrukking
Etomidaat
o Maar: onderdrukking bijnierfunctie
Propofol
o Korte werkingsduur
o Eerstelijns/standaard IV anestheticum
Morfine uit opium
Spierverslappers of curares
ANESTHESIE IN BELGIË
Eerste heelkundige ingreep: 1847
APSA = Association Professionnelle des Spécialistes en Anesthésiologie
o Officieel orgaan om belangen van anesthesisten te verdedigen
RIZIV
o Eerst geen terugbetaling anesthesisten
o Daarna wel
Verantwoordelijkheid anesthesie geëvolueerd
o Van zuiver intra-operatieve verantwoordelijkheid
o Naar pre-operatieve opvang voorbereiding, intra-operatief beleid, post-op zorgen en quality of
life op lange termijn
OLA2: INLEIDING TOT DE ANESTHESIE
MARC VANDEVELDE
,Inhoudsopgave
H1: GESCHIEDENIS VAN DE ANESTHESIE..........................................................4
GESCHIEDENIS VAN INHALATIE ANESTHESIE................................................................................4
LOKALE EN GESCHIEDENIS VAN LOKALE EN REGIONALE ANESTHESIE................................................4
GESCHIEDENIS VAN IV-ANESTHESIE.......................................................................................... 4
ANESTHESIE IN BELGIË........................................................................................................... 4
H2: PERI-OPERATIEVE STRESS RESPONS..........................................................5
H3: PRE-OPERATIEVE OPPUNTSTELLING EN RISICO-CLASSIFCIATIE....................8
PRE-OPERATIEVE EVALUATIE.................................................................................................... 8
ANAMNESE.......................................................................................................................... 8
KO.................................................................................................................................. 10
TO.................................................................................................................................. 10
RISICO STRATIFICATIE EN CLASSIFICATIE...................................................................................12
CARDIALE RISICOBEPALING EN OPPUNTSTELLING........................................................................14
pre-operatieve evaluatie en risicobepaling................................................................14
Pre-operatieve oppuntstelling en optimalisatie..........................................................15
MEDICAMENTEUZE VOORBEREIDING........................................................................................16
sedativa, hypnotica, tranquilizers...............................................................................17
reductie maaginhoud en stijging van zure maag ph...................................................17
H4: DOEL VAN ANESTHESIE: HYPNOSE, ANALGESIE, SPIERVERSLAPPING EN
STABILISATIE............................................................................................... 20
SLAAP/BEWUSTZIJNSVERLIES................................................................................................. 20
ANALGESIE........................................................................................................................ 23
SPIERVERSLAPPER............................................................................................................... 24
KUNSTMATIGE LUCHTWEG.................................................................................................... 24
MONITORING..................................................................................................................... 26
monitoring circulatie.................................................................................................. 26
Monitoring ademhaling............................................................................................... 26
Monitoring van anesthesiediepte...............................................................................27
Neuromusculairemonitoring.......................................................................................27
Monitoring lichaamstemperatuur...............................................................................27
Monitoring urineproductie..........................................................................................28
FYSIOLOGISCHE STABILISATIE................................................................................................ 28
H5: FARMACOLOGIE VAN HYPNOTICA, ANALGETICA EN SPIERRELAXANTIA.......29
INLEIDENDE BEGRIPPEN........................................................................................................ 29
FARMACOLOGIE VAN INTRAVENEUZE HYPNOTICA........................................................................31
Werkingsmechanisme................................................................................................31
Propofol...................................................................................................................... 31
Etomidaat................................................................................................................... 33
Ketamine.................................................................................................................... 34
Benzodiazepines........................................................................................................ 35
FARMACOLOGIE VAN VOLATIELE ANESTHETICA..........................................................................36
Farmacokinetiek en algemene effecten.....................................................................36
FARMACOLOGIE VAN OPIATEN................................................................................................ 37
Opiaatreceptoren....................................................................................................... 38
Algemene eigenschappen opioïden............................................................................38
Farmacokinetiek......................................................................................................... 39
Klinisch gebruikte opiaten.......................................................................................... 40
FARMACOLOGIE VAN SPIERVERSLAPPERS..................................................................................41
Fysiologie NMJ............................................................................................................ 41
Werking spierverslappers........................................................................................... 42
antagonisatie............................................................................................................. 43
H6: LOCOREGIONALE ANESTHESIE.................................................................44
, FYSIOLOGIE VAN DE ZENUWIMPULSGELEIDING...........................................................................44
FARMACOLOGIE VAN LOKALE ANESTHETICA..............................................................................44
VORMEN VAN LOCOREGIONALE ANESTHESIE.............................................................................46
Spinale anesthesie..................................................................................................... 46
Epidurale anesthesie.................................................................................................. 46
Combined spinal epidural anetshesie (CSE)...............................................................47
Perifere zenuwblocks.................................................................................................. 48
Het “Biers” block........................................................................................................ 49
COMPLICATIES REGIONALE ANESHTESIE...................................................................................49
Algemene complicaties..............................................................................................49
Centraal neuraxiale anesthesie..................................................................................50
Perifere zenuwblocks.................................................................................................. 52
H7: POST-OPERATIEVE PERIODE....................................................................53
POST-OPERATIEVE MONITORING............................................................................................. 53
POST-OPERATIEVE ANALGESIE............................................................................................... 53
Pathofysiologie van pijn.............................................................................................53
Nevenwerkingen post-operatieve pijn........................................................................54
Post-operatieve pijnstilling.........................................................................................55
RECOVERY EN ONTSLAG UIT PAZA........................................................................................57
POST-OPERATIEF VOCHTBELEID.............................................................................................. 58
Lichamelijke vochtcompartimenten............................................................................59
Controlemechanismen............................................................................................... 59
Infuusvloeistoffen....................................................................................................... 60
per-operatief vochtbeleid........................................................................................... 62
H8: COMPLICATIES VAN ANESTHESIE.............................................................65
POST-OPERATIEVE MISSELIJKHEID EN BRAKEN...........................................................................65
HYPOTHERMIE.................................................................................................................... 65
POST-OPERATIEVE COGNITIEVE DYSFUNCTIE.............................................................................66
AWARENESS...................................................................................................................... 66
MALIGNE HYPERTHERMIE...................................................................................................... 67
RESTCURARISATIE............................................................................................................... 67
ASPIRATIE......................................................................................................................... 67
H9: LANGE-TERMIJN EFFECTEN VAN ANESTHESIE............................................69
METASTASERING EN HERVAL VAN KANKER...............................................................................69
NEURONALE ONTWIKKELING BIJ HERHAALDE ANESTHESIE.............................................................69
TRANSITIE VAN ACUTE NAAR CHRONISCHE PIJN.........................................................................69
, H1: GESCHIEDENIS VAN DE ANESTHESIE
NIET KENNEN
GESCHIEDENIS VAN INHALATIE ANESTHESIE
Ether
o Via glazen reservoir waarin spons doordrenkt met ether werd gelegd
Lachgas
Chloroform
o Krachtiger dan ether
o Toxisch voor hart en lever
Gevaar: achteroverzakken tong met belemmering van luchtweg
o Dus: tracheale intubatie
LOKALE EN GESCHIEDENIS VAN LOKALE EN REGIONALE ANESTHESIE
Cocaïne in cocabladeren
o Roesdrug voor hersenen
o Krachtig lokaal anestheticum
Spinale anesthesie
o Lumbale epidurale anesthesie
GESCHIEDENIS VAN IV-ANESTHESIE
Spuit en naald uitvinden
Barbituraatzuur
Benzodiazepines
Ketamine
o = eerste intraveneuze anestheticum met minimale cardiale en respiratoire onderdrukking
Etomidaat
o Maar: onderdrukking bijnierfunctie
Propofol
o Korte werkingsduur
o Eerstelijns/standaard IV anestheticum
Morfine uit opium
Spierverslappers of curares
ANESTHESIE IN BELGIË
Eerste heelkundige ingreep: 1847
APSA = Association Professionnelle des Spécialistes en Anesthésiologie
o Officieel orgaan om belangen van anesthesisten te verdedigen
RIZIV
o Eerst geen terugbetaling anesthesisten
o Daarna wel
Verantwoordelijkheid anesthesie geëvolueerd
o Van zuiver intra-operatieve verantwoordelijkheid
o Naar pre-operatieve opvang voorbereiding, intra-operatief beleid, post-op zorgen en quality of
life op lange termijn
