The most common cause of hypotension when injected into anesthesia is latent hypovolemia, which can be eliminated even before the operation begins with a quick intravenous infusion of crystalloid solutions (5% glucose solutions) followed by the injection of polyglucin and plasma in a total volume of 1.0 ml. Such an infusion load reduces the concentration of humoral factors of pathological information, improves the rheological properties of the blood, ensures the creation of a reserve of extracellular fluid, and prevents dangerous circulatory disorders during induction anesthesia and tracheal intubation. Therefore, this type of prophylactic isovolemic hemodilution is performed for all patients.

The next prerequisite for patient safety during induction anesthesia and tracheal intubation is pre-oxygenation of the patient through the mask for 7-10 minutes with spontaneous breathing along the half-open contour and oxygen flow rate of 8 — l / min. Pre-oxygenation not only eliminates the stress oxygen debt and triples the supply of oxygen in the

body, but also raises the threshold of reflex reactions, prevents the development of side effects of injected drugs, the effect of which in conditions of hypoxia and acidosis can vary significantly.

Introductory anesthesia-analgesia and myorelaxation are achieved by injecting 2 mg / kg ketamine, 4 μg / kg fentanyl and 4 mg arduana in a single syringe. The combination of these drugs is in our opinion the most favorable, since it corresponds to the natural defense mechanisms: the use of fentanyl, which has a powerful and relatively short analgesic effect, allows the opioid channel of the antinociceptive system to be controlled in a controlled manner and potentiates the analgesic effect of ketamine. Ketamine, in turn, does not generally suppress the centers of regulation, but changes the intracentral ratios, selectively increasing the activity of those brain structures that provide an increase in cardiac productivity and oxygen transport. Fentanyl-induced respiratory muscle rigidity is prevented by Arduan,and a decrease in total peripheral vascular resistance is compensated by the sympathomimetic action of ketamine. Use of droperidol or seduksena enhances the myoplegia caused by Arduan or other anti-depolarizing muscle relaxants of the new generation (Tracrium, Pancuronium, etc.), which allows the vast majority of patients to avoid the use of depolarizing muscle relaxants and, accordingly, eliminate their hyperkalemic and other side effects.

Subsequently, the hypnotic effect is maintained by intravenous administration every 30 to min with 50 mg of ketamine, and strong central analgesia is maintained with injections of 0.1 mg of fentanyl at the most traumatic stages of surgery, but no less than 20 minutes later. 30 minutes before the end of the operation, the administration of drugs is stopped. Since the duration of the action of fentanyl is subject to significant individual fluctuations, in a number of weakened patients, respiratory depression lasts several hours after surgery. Therefore, it is advisable to use fentanyl only until the end of the main stage of the operation, and later to introduce opiate antagonist agonists — 50– mg / hour, Bupranal — 0.3—, 6 mg / hour — selectively enhancing analgesia without suppressing the respiratory center. Such a sequence provides faster recovery of consciousness,effective independent breathing and, accordingly, early activation of the patient after surgery.

As our studies have shown, the chosen method of administering and maintaining anesthesia does not cause significant changes in the pulse rate and mean arterial pressure. The state of blood circulation is characterized by moderate hyperdynamic, caused primarily by an increase in stroke volume against the background of some decrease in the tone of peripheral vessels. This mode of the heart is the most effective, while maintaining compliance with the transport of oxygen to the growing needs of tissues.

However, none of the modern types of general anesthesia, regardless of the dose and combination of drugs, can provide adequate protection for the regulation centers. Skin incision, dissection parietal pleura, the selection of elements of the lung root, displacement, stretching or deformation of tissues, ligaments, internal organs cause such a powerful afferentation that at these stages central analgesia is always insufficient and must be strengthened by conduction and local anesthesia. For conduction analgesia, epidural, spinal, or subpleural blockades are used, and the anesthetic is administered before the operation begins. An important difference between subpleural blockade is the simplicity of its implementation and the absence of dangerous complications. Its essence lies in achieving a common blockade of intercostal and sympathetic nerves from intercostal access.

The most convenient venue for the blockade is a point in the 4– intercostal space along the line that mentally connects the corners of the ribs (5 cm from the spinous processes of the thoracic vertebrae). At the selected point, anesthesia of the skin, subcutaneous tissue is performed, gradually moving the needle forward until it touches the rib. Next, the end of the needle is directed to the upper edge of the rib, preliminarily introducing the anesthetic, and then 2– mm behind it until a feeling of slight failure. In those cases when it is not possible to feel the upper edge of the rib, one should use the test of loss of resistance, which is generally accepted for the epidural box. A catheter with a diameter of 0.8 mm is inserted through the lumen of the needle, which is advanced to a depth of 2 cm towards the spine. The needle is removed, and the catheter is fixed with a plaster and injected through it with 20 ml of lidocaine or trimecain during and after the operation every 3 to an hour.

However, the possibility of conductive blockades can not be exaggerated. Nociceptive impulses from the area of ​​operation can reach the CNS in various ways. Sympathetic fibers from the parietal pleura pass as part of the intercostal and phrenic nerves, from the visceral pleura — along the pulmonary branches of the thoracic sympathetic trunk. But there is still a third way — from the root of the lung and the bronchi — through the fibers of the vagus nerve. And this pathway is unable to interrupt the epidural, subpleural or spinal blockade. The consequences of inadequate protection of this zone may be different. These should be attributed very often observed when epidural or spinal anesthesia, bradycardia, which by no means always reflects an adequate defense of the body against operational stress, most often being a result of an imbalance of regulatory mechanisms in conditions of effective sympathetic blockade and simultaneous stimulation of the vagus nerve. As a result, changes in regulation hinder the preservation of the optimal blood circulation regime and, therefore, complicate the solution of the overall task of the entire intensive care system. No less dangerous are the numerous pathological axon and viscero-visceral reflexes that occur in response to stretching, displacement or deformation of all tissues and internal organs. The basis of such reactions is also a sudden increase in parasympathetic activity, combined with inhibition of the sympathetic part of the autonomic nervous system.Within a few seconds, the overall intensity of blood flow in the body can be reduced by half, which we have repeatedly observed with extended and combined resections of the lung, fixing the decrease in oxygen tension in the tissues sharp to a critical level. At the same time, the changes of other indicators monitored during the operation are so insignificant and fleeting that they rarely attract the attention of the anesthesiologist, even the values ​​of pulse oximetry remain almost unchanged, only the signal becomes weaker. There can be many such episodes at the main stage of the operation, and their consequences for treatment outcomes are very significant. Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.that we have repeatedly observed with extended and combined resections of the lung, fixing the decrease in oxygen tension in the tissues sharp to a critical level. At the same time, the changes of other indicators monitored during the operation are so insignificant and fleeting that they rarely attract the attention of the anesthesiologist, even the values ​​of pulse oximetry remain almost unchanged, only the signal becomes weaker. There can be many such episodes at the main stage of the operation, and their consequences for treatment outcomes are very significant. Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.that we have repeatedly observed with extended and combined resections of the lung, fixing the decrease in oxygen tension in the tissues sharp to a critical level. At the same time, the changes of other indicators monitored during the operation are so insignificant and fleeting that they rarely attract the attention of the anesthesiologist, even the values ​​of pulse oximetry remain almost unchanged, only the signal becomes weaker. There can be many such episodes at the main stage of the operation, and their consequences for treatment outcomes are very significant. Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.At the same time, the changes of other indicators monitored during the operation are so insignificant and fleeting that they rarely attract the attention of the anesthesiologist, even the values ​​of pulse oximetry remain almost unchanged, only the signal becomes weaker. There can be many such episodes at the main stage of the operation, and their consequences for treatment outcomes are very significant. Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.At the same time, the changes of other indicators monitored during the operation are so insignificant and fleeting that they rarely attract the attention of the anesthesiologist, even the values ​​of pulse oximetry remain almost unchanged, only the signal becomes weaker. There can be many such episodes at the main stage of the operation, and their consequences for treatment outcomes are very significant. Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.Additional local anesthesia, warning of these violations, has reduced the incidence of postoperative complications by 18%.