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MONITORING DEPTH OF GENERAL ANESTHESIA


V.L. Vinogradov
The first and main task of the anesthesiologist is to ensure an effective and adequate level of anesthesia at all stages of the surgical procedure. The concept of the adequacy of anesthesia includes as necessary components:
effective pain relief - we must guarantee the patient the absence of any pain associated with anesthesia and surgery;
amnesia - the patient should not be “present at his own operation”, i.e. should not remember anything related to surgery;
neo-vegetative inhibition - the effectiveness of which, as a first approximation, is usually judged by indirect signs: the absence of a reaction of blood pressure, heart rate, etc.
Myoplegia, hemodynamic management and other components of general anesthesia determine the quality of anesthesia, but do not affect its depth.
At the initial stages of the development of anesthesiology, all components of general anesthesia were achieved by the use of a single narcotic agent. However, this required the use of significant doses of a general anesthetic and a rather profound suppression of the vital structures of the body. Such anesthesia, of course, was associated with a great risk to the patient.
In modern conditions, when the more advanced method of anesthesia is used - general combined anesthesia, in which sleep, analgesia, muscle relaxation, neurovegetative blockade, etc. are selectively provided by the use of various drugs - the problem of controlling the depth of anesthesia becomes even more necessary. Although it should be recognized that at present the question of an overdose of anesthetics and, as a consequence, the unjustifiably dangerous depth of anesthesia is not as acute as in the era of mononarcosis. The problem of unjustifiably superficial anesthesia becomes more urgent. An anesthesiologist is sometimes deprived of the opportunity to solve the question of the sufficiency of anesthesia in order to prevent the patient from having consciousness and pain, since in conditions of combined anesthesia none of the existing methods for controlling the depth of anesthesia is completely reliable.
Messages about cases of inadequate depth of anesthesia began to appear simultaneously with publications about the first experiments of operations under anesthesia.
In 1959, Cheek DB suggested that the patient, even with deep anesthesia, is able to hear what is happening around on a subconscious level, but usually patients cannot remember what happened during the operation.
However, the intraoperative period can be reproduced in a state of hypnosis. This possibility was demonstrated in 1965 by Levinson BW. He managed to get patients who did not have obvious signs of consciousness during the operation to recall the operation under hypnosis.
At present, it is recognized that consciousness is preserved in the presence or absence of subsequent memory for events, even against the background of, as we believe, anesthesia quite adequate.
According to literature data, the frequency of cases of preservation of consciousness during operations ranges from 0 to 4% and occurs even with "well-conducted anesthesia." However, using the hypnosis technique, it is possible to restore auditory memories of the progress of the operation in 20-30% of patients. The following prerequisites may contribute to this:
- light inhalation anesthesia;
- total intravenous anesthesia;
- hardware problems;
- obesity;
- chronic alcoholism or drug dependence;
- hypoventilation;
- high oxygen concentration;
- errors of medical personnel.
They also increase the risk of intraoperative awakening and certain clinical situations. It is believed that more often the preservation of consciousness is observed during operations in cardiology, obstetrics, emergency traumatology and in children.
The problem of awakening during surgery remains not only a great ethical and theoretical problem. The presence of consciousness and pain during surgery can have far-reaching consequences for the physiological state of the patient, since inadequate anesthesia at best causes discomfort for the patient, and in the worst case leads to the development of shock of one degree or another and the breakdown of the entire harmonious system of adaptive mechanisms, which ultimately leads to organ and systemic disorders and, of course, negatively affects the course of the postoperative period and the results of surgical treatment in general. Conscious recollection of the traumatic moments of the operation can be suppressed, but the emotions accompanying them are not inhibited and contribute to the manifestation of anxiety and depression in the future. “Invisible scars of an operation” - this is what Cheek DB calls them. And a rebuke to anesthetists is the study done by Moermann N. et al. (1992), which showed that a quarter of 678 people who underwent surgery under general anesthesia, for one reason or another, are not satisfied with the quality of the anesthesia performed.
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MONITORING DEPTH OF GENERAL ANESTHESIA

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    Despite the apparent simplicity, it is actually very difficult to answer the question of how to identify and observe the lip of anesthesia, since lack of consciousness, analgesia, relaxation are all or nothing values. Observing the patient, the anesthesiologist must solve a number of problems for himself, such as: if the patient has a motor reaction in response to surgical manipulation, then how can this be
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