Anesthesias bases in maxilla-facial surgery. Indications, contraindications and general anesthesias characteristics in stomatology.

For a lot of time the pain and anesthesia problem is taking people's attention. Last years, considerably risen the interest about the application of anesthesia in the most mass form of medical service - teeth treatment. In connection with the appearance of pain syndrome and psychoemotional discomfort, during the stomatologic procedures, patients refuse seasonable stomatologic aid, which transforms this medical problem into social disaster. It is well known that almost all patients associate their's visit to stomatologist with the feeling of fear and pain. Pain Pain - the occurrence, which touches different aspects of human's activity and the whole society. It is the symptom of many acute and chronic human diseases. In modern society it creates a number of medical, social and economical problems. Millennial experience of its' studying showed us, that in spite of imagined simplicity of this occurrence, it is a phenomenon which is expressed in different physiological, biochemical and psychological body's reactions, which are closely connected to medical and other spheres of human society's activity.

Anesthetic protection From the practical point of view patient's anesthetic protection is reasonably to consider like analgesia, supposing the selective reflexes' blockade (guides, centers of pain's integration and vegetative pain's components). The second factor of anesthetic protection should be the inhibition of somatic and vegetative reflexes, including the suppressive action on consciousness, emotions' motivation, and sensations. This kind of separation is reasonable also from the viewpoint of pain's selective pharmacological control and correction of pain's reaction psychoemotional components. Modern general anesthesia is characterized by important pharmaceutical discoveries, deeper cognitions about physiologic and physiopathological pain's bases, important technical changes, and fundamental changes in anesthesia, which change anesthesias position from practice to scientific class - ANAESTHESIA. It began in 1923 at the same time with the appearance of intravenous introduction of barbiturates and continues to perfect itself till our days, by discovering new aesthetic products. Now besides the classical methods appeared a big number of different combined methods, which permit to realize a qualified aesthesia. Anesthesia is a surgical method, in consequence of it temporary and reversible are oppressed painful sensations, by introducing some chemical preparations. In modern understanding, anesthesia is a complex of surgical manipulations, which are firstly used in the majority surgical interventions. Its' object is to offer optimal conditions for a normal surgical manipulations for patients and surgeon.

OBJECTS Seasonable pain killing and protecting from pain stress assume the maintenance of homeostasis' regulation mechanisms, the absence of negative influence on blood circulation and breathing, the 1

maintenance of moderate stimulation of symphaticoadrenal system. It could be obtained by e few methods: - By interrupting the pain's impulsion with the help of central narcotic analgesics, which connect to opiate receptors and blockade the rising pain's information; - using of non narcotic analgesics, which's action is the influence of antiprostaglandine substances with selective analgesic action (M.D. Mashkovski 1980); - introducing the anaesthetics, which blockade the periferic impulsion; - analgesia, by using the reflexotherapy methods (acupuncture, electro-analgesia, stimulation of nerve trunks throw skin with the point to produce endogenous opiate peptides and to "close the gate" of pain) (R.A. Durinean 1983; V.N. Tsibuleac 1983); - with the help of suggestive therapy (hypnosis) a method of analgesia; - neuro-surgical methods (chemic and laser hypophysectomia, sympathectomia) Now local anaesthesia keeps the most large indications in stomatology and oral cavity surgery, general anaesthesia is indispensable at the big number of patients in consideration of having different kinds of psychological, allergic, infectious, oncological components. In modern anaesthesia is used combined technic of analgesia. After mixing a big quantity of preparations, some theirs qualities considerably rise.

CLASSIFICATION OF ANAESTHETIC METHODS USED IN STOMATOLOGY, MAXILLO-FACIAL SURGERY GENERAL ANAESTHESIA LOKO-REGIONAL BLOCK ANAESTHESIA LOCAL BLOCK BY COOLIN G CONTAC T INJECTI ONS Infiltration of dental branches Local infiltration Infiltration at a distance Papillary and ligamentous STEM PERIPHE RIC INTERMEDIATE METHODS

GENERAL ANAESTHE SIA WITH SHORT ACTION GENERAL ANAESTHE SIA WITH LONG ACTION

NEUROLEP TANALGESI A NEUROLEP SY

In hospitals perform mean and big operations, and also the medical procedures for patients with associated diseases, who need anaesthesia and anaesthetist's presence. In ambulatory conditions perform little surgical procedures, sometimes over short-term general anaesthesia. 2

Choosing the anaesthetic methods and preparations for its' performance we have to take account of psychologic state, patient's general condition, age, operation's durability, local pathological changes, place of surgery's performance (ambulatory or hospital), technic equipment, medical staff's competence. Local anaesthesia is indicated for majority ordinary interventions in stomatologic room, where are performed therapeutical, orthodontic, orthopaedic treatment, and also little surgical interventions. General anaesthesia is the most suitable method for children, persons with disabilities, persons with excessive sensation of fear, alcoholics, epileptics, allergics to local anaesthetics, for interventions on traumatized nerves and vessels in MFS. In cases of inflamed processes in maxillo-facial area, tumors in region of anaesthesia insertion - is preferably to use general narcosis. According to author CATHELIN (1992) in stomatology is preferably, as much as it is possible, to use local anaesthesia, the only one indication for general anaesthesia is contraindication for local. General narcosis in maxillo-facial surgery - is the reversible organism's condition, which has the object to protect from noxious agents, especially pain sensations, it is also the method of temporary pain's oppression, by reversible and controlled paralysis of CNS.

Peculiarities of general anesthesia in maxillo-facial surgery General anesthesia is performed by introducing in organism chemical preparations throw inhalations, intravenous or mixed which, using the hematogenic way, penetrate into CNS level. There take place a selective influence over different segments of CNS, after that over cortical, subcortical centers, cerebellum, spinal cord, medulla oblongata. Thanks to this selective action, anesthesia invoke next effects by turns: - The loss of pain sensibility (analgesia) - The loss of consciousness (anesthetic sleep) - neurovegetative protection (reflexes' slow-down) - Muscular relaxation. It doesn't have an influence over breathing and blood circulation, but big (toxic) doses can affect the medulla oblongata, which can paralyze the breath and cardiovascular centers. Peculiarities and difficulties of anesthesia in MFS are connected with specific structure in this sphere. Firstly - anesthetic access pass throw surgical area, the fact which complicates the work of anesthetists and maxillo-facial surgeon.

Some diseases (inflammations, tumors, fractures) are closely reported to upper airways, deform area's anatomy, bring down tissues' mobility, and in oral cavity could be different eliminations and blood. Mouth opening disorders in consequence of inflammatory or traumatic trismus - incapacity or limitation of mouth opening. - Limitation from keeping clean the respiratory tracts in consequence of profuse discharge, 3

foreign objects. - Anesthetist can't impede the surgeon and so he has to follow next steps: he has to observe the clinical anesthesias indications at the distance, limit himself by monitoring the pulse, blood pressure and the color of members' cutaneous coverings. - MFS contains a lot of reflexogenic zones. - In majority cases, MFS surgeries suppose profuse bleeding, which have to be permanently controlled to avoid considerable hemorrhage. - Quick recovery after narcosis is also an obligatory demand for general anaesthesia in MFS. COMPLICATIONS' RISK IN GENERAL ANAESTHESIA is meeting more often in MFS than in general surgery. Risk elements connected to surgical specific character - patient's position, possibility of foreign objects appearance. Risk elements appointed by pathology's specification - anatomic changes of respiratory tracts, difficulties during the intubation, abundant local eliminations, profuse bleedings. Risk elements connected to patient - frequent chronic diseases.

GENERAL NARCOSIS'S CLINIC: 4 stages 1 stage - analgesia, 2 stage - excitations, 1 and 2 stages are inductions periods 3 stage MFS surgeries don't need evident muscular relaxation, because MFS doesn't have pronounced muscular masses, like in general surgery. 4 stage - the determination of 4-th stage is very important because it involves medulla oblongata which can provoke asfixia, 4-th stage is not a narcosis, it is a difficult anesthetic complication with fatal consequences. METHODS OF GENERAL ANALGESIA IN MFS are classified by: sedation with analgesia, short-time general narcosis, Long-time general narcosis. Sedation with analgesia is a group of border-line methodology between local and general analgesia. INDICATIONS FOR GENERAL NARCOSIS: patients with evident sensation of fear, mentally ills, epileptics, 4

patients with evident vomiting reflex.

CONTRAINDICATIONS FOR GENERAL NARCOSIS (relative): flu, pulmonary emphysema, adenoids' hypertrophy acute respiratory failure SEDATION METHODS WITH ANALGESIA Relative analgesia - general anesthesia throw inhalation, using N2O+O2. Inhalation of this mixture leads to physical sedation, psychological relaxation, sometimes it evokes feeling of euphoria. It is indicated for little and short-time surgical interventions. If surgical intervention is long-timed it has to be combined with local anaesthesia. General autoanalgesia. Intravenous sedation with analgesia. N.B. Jorgensen put in practise a mixture of barbiturates and analgesic. Today are used Phenobarbital + Fentanyl +Atropine. This method is used only for long-term interventions, obligatory in combination with general anesthesia in hospital conditions, because absolute reflexes' recovery happens during 3-4, sometimes 6 hours. With the object of analgesia and sedation is also used the mixture of Diazepam and Midazolam, intravenous introduced. In conclusion we have to mention that preparations used for general narcosis, have to assure a good sedation, fear relieving, partial anesthesia during the intervention, and also theirs quick evacuation from organism and the absence of side effects. NEUROLEPTANALGESIA (NLA) - is the same, only that Fentanyl is used like analgetic and Droperidol as a neuroleptic, which considerably rise the effectivity of Fentanyl's analgesic properties. Diazanalgesia - here are used benzodiazepines, Fentanyl + Diazepam. No one of these methods is indicated in ambulatory conditions and for short-time surgical interventions. GENERAL SHORT-TIME ANAESTHESIA - is indicated for 20-30 minutes interventions. It is a monoanaesthesia (it is used only one preparation). We also have INHALATIONAL (NARCOTHANE) and INTRAVENOUS (PENTOTAL, KETALAR) ANAESTHESIA, it is used only in hospital conditions under qualified staff's care. LONG-TIME NARCOSIS - is used only in hospitals for serios interventions, with the utilization of combined substances, the oxygenation is done by artificial pulmonary ventilation (APV), with intubation.