High blood pressure after general anesthesia. Anesthesia for hypertension

24.07.2007, 11:08

At the dentist's appointment, anesthesia was performed, the pressure rose sharply 180/110. I am seen by a cardiologist. I drink egilok, preductal and tritace. I need to go to the dentist soon. What to tell the doctor, what kind of anesthesia can I do? Can I take samples for intolerance? My cardiologist says that I can’t do it with adrenaline.

24.07.2007, 18:44

Blood pressure during local anesthesia does not always increase due to the adrenaline contained in the anesthetic. The excitement of a patient suffering from essential hypertension can affect. Some of the patients, for some incomprehensible reasons, decide not to take antihypertensive drugs that they drink daily before taking a dentist - this is another reason for the rise in blood pressure. And much less common is such a complication as the introduction of the drug into the vascular bed - when the doctor accidentally enters the vessel with the tip of the needle. Sometimes - if a non-carpool (ready-made) anesthetic is used - the solution may be incorrectly prepared, with a higher concentration of adrenaline.
A vasoconstrictor (adrenaline) greatly increases the effectiveness of a local anesthetic and significantly increases its duration of action. Insufficient pain relief can lead to a rise in blood pressure rather than adrenaline itself.
The overwhelming majority of anesthetic substances used in practice have the ability to dilate blood vessels. This leads to their rapid absorption into the bloodstream and destruction - and, accordingly, to a shorter duration and effectiveness of anesthesia. Mepivacaine does not dilate blood vessels. There are also carpool anesthetics with a lower adrenaline content (ultracain-DS, for example).

Tests are carried out to identify allergies to any substance, therefore, in the case of adrenaline, this is meaningless, and an increase in blood pressure for adrenaline is not even a side effect, but a direct effect due to its properties.

A couple of many bukoffs turned out ...

25.07.2007, 10:56

The excitement of a patient suffering from essential hypertension can affect. Some of the patients, for some incomprehensible reasons, decide not to take antihypertensive drugs that they drink daily before taking a dentist - this is another reason for the rise in blood pressure.

Thanks.
There was no excitement, because I went to the dentist for six months already, once a week. as to my home. came that time, they pricked, they say let's go have some tea, and you Tanya, if you want - read the magazine. I read, I feel - one eye is taken away and does not see, then the brain seems to have become cotton and then the other eye. and then the nurse accidentally dropped in, and I was completely sick. Before taking any means I did not take from pressure, (and a month before that I started taking Eutirox), since before that I did not suspect that I had high blood pressure. It turns out then that it was increased for me. Although this did not happen before with anesthesia. Endocrinologists tell me that an increase in blood pressure cannot be associated with the intake of thyroxine, but somehow everything started synchronously with the intake of eutirox.
In short, I've already got all the doctors here ...

25.07.2007, 14:44

25.07.2007, 15:32

You mentioned the eye. I conclude that you have had one of your maxillary molars treated. When these teeth are numbed, an anesthetic is injected into the dense venous plexus. The risk of anesthetic entering the bloodstream is quite high. Probably in this case there was a vascular reaction to a vasoconstrictor.

Nope, lower jaw, penultimate tooth (in terms of location, not in general)))))

25.07.2007, 15:35

Before that, an injection of anesthesia was given in the same place, then my eye also became numb and did not close, that is, it was like a dead person, the eyelid did not obey ... I covered the eyelid with my fingers so that the eye would not dry out. What a horror. It lasted 6 hours later.

25.07.2007, 16:06

hmm ... interesting

25.07.2007, 21:43

26.07.2007, 09:19

Tatyana, this sometimes happens when not only the sensitive, but also the motor branches of the nerves are involved in the zone of action of the anesthetic. Not comfortable, but goes away with the action of anesthesia
With the anesthesia that you did, it is also possible to get the needle into the vessel. For example, in my practice, this was. Didn't you have a feeling that a hot wave ran down your face?

I don't remember about the hot wave, to be honest ..
It turns out that if they get into the vessel again, the same situation can happen? Are all teeth done at once under general anesthesia? I woke up, and all my teeth were cured))))

26.07.2007, 10:20

26.07.2007, 11:22

Tatiana, tell me, how long did you have that lower tooth treated when it took anesthesia?

When the pressure jumped, the tooth had not even begun to be treated yet, when I came in, they had an injection right away.
And the one when the eye could not leave for a long time - about an hour, in my dentistry any appointment lasts an hour. I hope I understood your question correctly.

26.07.2007, 11:39

26.07.2007, 11:48

Yes, right. Do you think each tooth will be treated for an hour under anesthesia?

Then I will have to lie there for a day.

According to the uniform international criteria (adopted in 1999), arterial hypertension (AH) is a condition in which the systolic blood pressure is 140 mm Hg. Art. or higher, and / or diastolic blood pressure 90 mm Hg. Art. or higher in people who are not currently receiving antihypertensive treatment.

Depending on the level of blood pressure, they emit degree of arterial hypertension, which are listed in the table below.

Perioperative arterial hypertension

Preoperative period

Arterial hypertension is found very often, especially among elderly patients - more than 40%. Hypertension of the first or second degree slightly increases the risk of cardiovascular complications during anesthesia. Higher pressure values ​​are accompanied by an indication that there may be more complications and they are more serious.

In elective patients with grade 3 hypertension (systolic blood pressure> 180 mmHg and / or DBP> 110 mmHg), postponement should be considered to optimize hypertension therapy.

Medicines used to treat hypertension and anesthetics, when interacting, can lead to the development of resistant hypotension and other intraoperative complications. The criterion for correctly selected antihypertensive drug therapy for elective surgery is the patient's normal age-related blood pressure level with a deviation of ± 20%.

The time during which blood pressure returned to normal is also considered an important condition for the safe conduct of anesthesia. The patient's body needs a lot of time to adapt to the lowered blood pressure. For example, in a patient with third-degree arterial hypertension, using intravenous vasodilators, it is possible to "normalize" blood pressure in a few tens of minutes. And if such a patient begins to carry out, for example, epidural anesthesia, then the likelihood of developing a stroke, uncontrolled hypotension, and heart attack will increase rapidly.

Physicians should pay attention to the fact that it is unacceptable to carry out forced correction of arterial hypertension of the 2-3rd degree before a planned operation in one or two days. And even more so - in 3-4 hours. It takes at least two to three weeks to find the optimal antihypertensive therapy. We also note that the standards for the treatment of arterial hypertension are set aside for these purposes for at least a month (30 days).

The question is posed, whether it is necessary to interrupt taking antihypertensive drugs before the operation? There is no consensus among experienced specialists whether or not to interrupt medication on the eve of the intervention. For example, some experts believe that patients should continue taking antihypertensive drugs as usual until an hour of surgical treatment. And basically, there are no special problems during the conduct of anesthesia in connection with such tactics of patient management.

But for today large quantity specialists highlight another approach that provides, in their opinion, better hemodynamic stability of the patient during anesthesia:

  • ACE inhibitors or angiotensin II antagonists do not need to be canceled if patients are receiving this drug due to heart failure or left ventricular dysfunction;
  • ACE inhibitors or angiotensin II antagonists prescribed for hypertension should be temporarily canceled exactly one day before the start of the operation;
  • Diuretics are not prescribed on the day of surgery. Patients should continue taking beta-blockers as usual.

Perioperative period in patients with arterial hypertension

The main challenge is to maintain optimal blood pressure levels during surgery. If there are no special indications, then the doctors are guided by the "working" level of the patient's pressure ± 20%. In patients over 80 years of age, it is advisable not to lower the SBP to less than 150 mm Hg. Art.

Blood pressure during hypertension can fluctuate significantly. It is capable of not only rising sharply, but also sharply decreasing. For prevention, there are such techniques:

If controlled ventilation is planned, then 2-3 minutes before intubation, it is recommended to inject an increased dose of an analgesic (fentanyl works well at a dose of 3-5 μg / kg) and induction with a drug that does not increase blood pressure (propofol, sodium thiopental, diazepam, etc. etc.). An increase in blood pressure during intubation is a separate anesthetic problem.

When carrying out intravenous anesthesia, sodium thiopental should be chosen as the anesthetic, because these are drugs that do not increase blood pressure in humans. There is no need to reduce the medication pressure before epidural and spinal anesthesia. Enough to enhance sedation (midazolam, propofol, diazepam).

In case of blockade of peripheral nerves, it is recommended to add to the anesthetic (as an adjuvant), which improves the quality of anesthesia and, at the same time, somewhat reduces the patient's pressure. But, in the overwhelming majority of cases, it is enough to add ataractics to the premedication (diazepam and midazolam give a good effect in this regard).

Intraoperative hypotension in patients with arterial hypertension

A sharp decrease in blood pressure in a patient can threaten various complications that are associated with insufficient blood supply to various organs - myocardial ischemia, stroke, renal failure, etc.

Physicians should remember that against the background of antihypertensive therapy, the vasopressors traditionally used to correct hypotension - ephedrine and phenylephrine - may not have the desired effect. In this case, hypotension is treated with (norepinephrine), epinephrine (adrenaline), or vasopressin.

Intraoperative arterial hypertension

It is considered to be perioperative arterial hypertension in a person when systolic blood pressure during surgery, and in the post-anesthetic awakening ward, corresponds to one of the following conditions:

  • is higher than 200 mm Hg. st;
  • exceeds the preoperative level by 50 mm Hg. st;
  • requires intravenous administration of antihypertensive drugs.

The most common cause of perioperative hypertension is activation of the sympathetic nervous system, combined with insufficient depth of blockade of nociceptive stimulation during anesthesia and surgery. Therefore, the traditional method for the relief of intraoperative hypertension is called the deepening of anesthesia with the help of narcotic analgesics, inhalation anesthetics and benzodiazepines.

It is recommended to take for these purposes (a bolus of 25-50 mg until the effect is obtained, after which, if necessary, you can switch to continuous administration). The drug acts quickly, has a short half-life, and combines well with almost all drugs that are used for anesthesia.

In many cases, it is possible to prescribe magnesium sulfate to a patient with a dose of 2-5 g per injection, it is not administered immediately, but in 10-15 minutes. This drug not only gently lowers blood pressure, but significantly reduces the need for analgesics during surgery, and in the early postoperative period, improves the quality of anesthesia. In cases resistant to this therapy, as well as when the pressure must be reduced in a short time, doctors use antihypertensive drugs with a short half-life.

Postoperative hypertension

Doctors need to take into account that if the patient has been taking beta-blockers or alpha-adrenergic receptor agonists for a long time, for example, clonidine (clonidine), then taking these medicines it is necessary to continue after the operation, otherwise withdrawal syndrome may develop with a sharp increase in blood pressure.

Primarily, attending physicians pay attention to maintaining adequate analgesia. As soon as possible, you need to resume taking those antihypertensive drugs that were effective in this person before the operation. In choosing a drug, experts sometimes use a special table. But doctors do not advise the routine administration of calcium antagonists, since this is associated with an increased risk of postoperative vascular complications.

Choice of antihypertensive therapy

Low doses of antihypertensive drugs should be used at the initial stage of treatment, starting with the minimum dosage of the drug (the goal is to reduce adverse side effects). If there is a good response to a low dose of this drug, but blood pressure control is still insufficient, it is recommended to increase the dosage of this drug, provided it is well tolerated.

An effective combination of small doses of antihypertensive drugs should be used to minimize blood pressure with minimal side effects. This means that if one drug is ineffective, it is preferable to add a small dose of the second drug, rather than increasing the dosage of the first one used.

It is necessary to completely replace one class of drugs with another class of drugs: with a low effect or poor tolerance without increasing the dosage or adding another drug.

1. Antagonists of angiotensin II receptors + diuretic;

2. Angiotensin II receptor antagonists + calcium antagonist;

3. Angiotensin-converting enzyme inhibitors + diuretic;

4. Angiotensin-converting enzyme inhibitors + calcium antagonist;

5. Calcium antagonist + diuretic.

Emergency conditions for arterial hypertension

All situations in which a rapid decrease in blood pressure is required in that, are divided into 2 large groups:

  • The first is a group of diseases and conditions in which an urgent (within 1-2 hours) decrease in blood pressure is required.

The same group includes a complicated (with damage to target organs) hypertensive crisis - a sudden (several hours) and significant increase in blood pressure in relation to the level usual for a person. An increase in blood pressure leads to the appearance or worsening of symptoms from the target organs:

  • unstable angina;
  • about dissecting aortic aneurysm;
  • system of left ventricular failure;
  • hemorrhagic stroke;
  • eclampsia;
  • in case of injury or damage to another genesis of the central nervous system;
  • swelling of the nipple of the optic nerve;
  • in patients during the operation and in the postoperative period with the threat of bleeding and in some other cases.

For emergency lowering of blood pressure such parenteral drugs are used as:

  • nitroglycerin (it is preferred for myocardial ischemia in a patient);
  • sodium nitropruside (suitable for most cases of resistant hypertension);
  • magnesium sulfate (preferred for eclampsia);
  • (it is chosen mainly for lesions of the central nervous system);
  • enalapril (preference is given to him in the presence of heart failure in the patient);
  • furosemide (preferred for hypervolemia, acute LV failure);
  • phentolamine (if pheochromocytoma is suspected).

Recommendations. To avoid ischemia of the central nervous system, kidneys and myocardium, it is not necessary to lower blood pressure too quickly. The systolic pressure should be reduced by 25% from the initial level in the first two hours, and to 160/100 mm Hg. Art. - over the next 2-6 hours. In the first 2 hours after the start of antihypertensive treatment, you need to monitor blood pressure every 15-30 minutes. Doctors select the dosage of the drug individually. Preference is given to drugs (in the absence of contraindications in each case) with a short half-life.

  • The second group, where experts include all other cases of increased blood pressure, when it should be normalized in a few hours.

In itself, a sharp increase in blood pressure, without the manifestation of symptoms from other organs, requires mandatory, but not so urgent intervention. It can be controlled by oral administration of relatively fast-acting drugs (calcium antagonists (nifedipine), beta-blockers, short-acting ACE inhibitors, clonidine, loop diuretics).

It should be noted that the parenteral route of taking antihypertensive drugs should be the exception rather than the rule. That is, in most cases it is not used.

Oral drugs for the urgent reduction of blood pressure

Examples of appointment in such cases:

  • moxonidine (Physiotens) 0.4 mg should be given to the patient for oral administration. It is effective when increasing blood pressure in patients with high sympathetic activity;
  • captopril 25-50 mg dabt to the patient by mouth. Indications: moderate increase in blood pressure in patients without high sympathetic activity;
  • 10-20 mg sublingually (give the patient to chew), if there is no effect, repeat the reception after half an hour. It is indicated for a moderate increase in pressure in patients without high sympathetic activity;
  • propranolol 40 mg is taken sublingually (or by mouth, with a glass of warm water). It is used when arterial hypertension is combined with tachycardia.

A. Bogdanov, FRCA

Hypertension is a very common disease. For example, in the United States, according to some estimates, up to 15% of the adult population suffers from hypertension. This is neither more nor less - 35 million people! Naturally, the anesthesiologist encounters such patients almost every day.

The severity of the disease increases with age. However, recent studies have shown that a significant proportion of children, at least in the US where the study was conducted, have a tendency to high blood pressure. According to many experts on hypertension, this condition develops into hypertension at a more mature age, although blood pressure in such patients remains normal until the age of 3o years.

Physiological changes in patients at the initial stage of hypertension are minimal. Sometimes they show increased cardiac output, but peripheral vascular resistance remains normal. Sometimes there is an increase in diastolic pressure up to 95 - 100 mm Hg. In this phase of the disease, no disturbances from the side of the internal organs are detected, the damage of which manifests itself at a later stage (brain, heart, kidneys). The average duration of this phase is 5-10 years, until the phase of permanent diastolic hypertension occurs with diastolic pressure constantly exceeding 100 mm Hg. In this case, the previously increased cardiac output decreases to normal. There is also an increase in peripheral vascular resistance. Clinical symptoms in this phase of the disease vary widely and most often include headache, dizziness, and nocturia. This phase lasts long enough - up to 10 years. The use of drug therapy in this phase leads to a pronounced decrease in mortality. This means that the anesthetist will meet with patients receiving sufficiently strong antihypertensive drugs in the relative absence of severe clinical symptoms.

After a while, an increase in peripheral vascular resistance and a decrease in organ blood flow cause disturbances in the internal organs, most often manifested as:

  1. Left ventricular hypertrophy with an increase in its blood supply; at the same time, conditions are created for the development of ischemic heart disease and heart failure.
  2. Renal failure due to progressive atherosclerosis of the renal arteries.
  3. Dysfunction of the brain as a result of both transient ischemic episodes and minor strokes.

If untreated in this phase of the disease, life expectancy is predicted to be 2 to 5 years. The whole process described can take a much shorter time - several years, sometimes months, when the disease is especially malignant.

The stages of hypertension are summarized in the table.

Table 1 . Stages of hypertension.

Comments and clinical manifestations

Anesthetic risk

Labile diastolic hypertension (diastolic blood pressure< 95)

Increased CO, normal PSS, no dysfunctions of internal organs. There are practically no symptoms. Diastolic blood pressure is sometimes elevated, more often normal.

< 110 и нет нарушений со стороны внутренних органов

Persistent diastolic hypertension

SV decreases, increases PSS. At first there are no symptoms, but later - dizziness, headache, nocturia. ECG - LV hypertrophy

No more than healthy person provided that diastolic blood pressure< 110 и нет нарушений со стороны внутренних органов

Internal organ disorders

Heart - LV hypertrophy, heart failure, myocardial infarction. CNS - strokes, cerebrovascular accident. Kidney failure.

High if not thoroughly examined and treated.

Organ failure

Serious failure of the above organs

Very tall

Until recently, systolic hypertension with normal diastolic pressure was considered a natural consequence of aging. However, at present, a number of authors express their doubts about this; nevertheless, it is generally agreed that this form of hypertension is a risk factor.

The search for the biochemical causes of hypertension has not yet been crowned with success. There is no evidence that the sympathetic nervous system is overactive in these patients; moreover, one gets the impression that its activity is suppressed. In addition, evidence is accumulating that, contrary to popular belief, sodium retention and accumulation in the body does not occur, with the exception of certain conditions accompanied by activation of the renin-angiotensin system. Clinical studies confirm the fact that hypertensive patients excrete excess sodium in the same way as healthy people. Although dietary sodium restriction can improve the patient's condition, there is no evidence of pathological sodium retention in these patients.

There was an actual decrease in the BCC in hypertensive patients not receiving treatment. This fact may explain the increased sensitivity of such patients to the hypotensive effect of volatile anesthetics.

According to modern views, hypertension is a quantitative rather than a qualitative deviation from the norm. Degree of defeat of cardio-vascular system depends on the degree of increase in blood pressure and the duration of this condition. Therefore, from a therapeutic point of view, a drug-induced decrease in blood pressure is accompanied by an increase in the life expectancy of these patients.

Preoperative assessment of the condition of patients with essential hypertension

From a practical point of view, one of the most difficult problems for an anesthesiologist facing a patient with hypertension is the differential diagnosis between primary hypertension (essential hypertension) and secondary. If there is enough evidence in favor of hypertension, then the question comes down to an adequate assessment of the patient's condition and the determination of the degree of operational risk.

The cardiovascular system

The leading cause of mortality in an untreated hypertensive patient is heart failure (see table).

Table 2. Causes of mortality in hypertensive patients (in descending order)

Untreated hypertension

  • * Heart failure
  • * Stroke
  • * Renal failure

Treated hypertension

  • * Myocardial infarction
  • * Renal failure
  • * other reasons

The simplified mechanism of events in this case is approximately the following: increased peripheral vascular resistance leads to hypertrophy of the left ventricle and an increase in its mass. This hypertrophy is not accompanied by an adequate increase in coronary blood flow, which leads to the development of relative myocardial ischemia. Ischemia in combination with increased peripheral vascular resistance creates conditions for the development of left ventricular failure. The diagnosis of left ventricular failure can be established on the basis of such signs as the presence of moist rales in the basal parts of the lungs, left ventricular hypertrophy and opacification in the lungs on the radiograph, signs of left ventricular hypertrophy and ischemia on the ECG. However, it should be noted that in such patients, left ventricular hypertrophy is diagnosed by echocardiography; ECG and X-ray chest often do not change. In these cases, the patient should be carefully interviewed for coronary heart disease. If a major surgical intervention is ahead, it is quite possible that a more detailed assessment of the coronary circulation system is needed. Naturally, the presence of even a small degree of left ventricular failure seriously increases the degree of operational risk; it is necessary to correct it before the operation.

Patient complaints provide additional information. Decreased exercise tolerance serves as a useful indicator of the patient's response to forthcoming surgical stress. Episodes of dyspnea at night and a history of nocturia should make the anesthesiologist think about the state of the reserves of the patient's cardiovascular and urinary systems.

Assessment of the degree of fundus changes provides an excellent opportunity to establish the severity and duration of hypertension. This is especially important in patients with previously undiagnosed hypertension. The most commonly used classification is Keith-Wagner, which includes 4 groups:

Although arteriosclerosis and hypertension are different diseases, there is no doubt that atherosclerotic changes develop faster in hypertensive patients. In this case, coronary, renal, cerebral vessels are affected, reducing the perfusion of the corresponding organs.

Urinary system

A characteristic manifestation of hypertension is renal artery sclerosis; this leads to a decrease in renal perfusion and an initial decrease in the glomerular filtration rate. With the progression of the disease and further deterioration of renal function, creatinine clearance decreases. Therefore, the determination of this indicator serves as an important marker of renal dysfunction in hypertension. In addition to this, proteinuria is diagnosed with a general urinalysis. Untreated hypertension leads to renal failure with azotemia and hyperkalemia. It should also be borne in mind that with prolonged use of diuretics for the treatment of hypertension in such patients (especially the elderly) hypokalemia develops. Therefore, the determination of the plasma potassium level should be included in the routine preoperative examination of hypertensive patients.

Late stages of renal failure lead to fluid retention as a result of the combination increased secretion renin and heart failure.

Central nervous system

The second most common cause of death in patients with untreated hypertension is stroke. In the later stages of the disease, arteriolitis and microangiopathy develop in the vessels of the brain. Small aneurysms appearing at the level of arterioles are prone to rupture with an increase in diastolic pressure, causing a hemorrhagic stroke. In addition to this, high systolic pressure leads to increased cerebral vascular resistance, which can be the cause of ischemic stroke. In severe cases, acute hypertension leads to the development of hypertensive encephalopathy, which requires an urgent reduction in blood pressure.

Drug therapy for hypertension

In addition to knowledge of the pathophysiology of hypertension and a clear definition of the physiological status of the patient, the anesthesiologist needs knowledge of the pharmacology of antihypertensive drugs, in particular their possible interaction with drugs used during anesthesia. These drugs, as a rule, have a sufficiently long-lasting effect, that is, they continue to exert their influence during anesthesia, and often after its termination. Many antihypertensive drugs affect the sympathetic nervous system, so it makes sense to briefly recall the pharmacology and physiology of the autonomic nervous system.

The sympathetic nervous system is the first of two constituents of the autonomic nervous system. The second part is represented by the parasympathetic nervous system. The postganglionic fibers of the sympathetic nervous system are called adrenergic and have a number of functions. The neurotransmitter in these fibers is norepinephrine, which is stored in vesicles located along the entire length of the adrenergic nerve. Sympathetic nerve fibers do not have neuromuscular synapse-like structures; the nerve endings form a kind of network that envelops the innervated structure. When the nerve endings are stimulated, vesicles with norepinephrine by means of reverse pinocytosis are ejected from the nerve fiber into the interstitial fluid. Receptors located close enough to the place of release of norepinephrine are stimulated under its influence and cause a corresponding reaction from the effector cells.

Adrenergic receptors are classified into α1 α2, α3, β1 and β2 receptors.

1-receptor is a classic postsynaptic receptor, which is a receptor-activated calcium channel, the activation of which is accompanied by an increase in the intracellular synthesis of phosphoinositol. This, in turn, leads to the release of calcium from the sarcoplasmic reticulum with the development of a cellular response. The β 1 receptor mainly causes vasoconstriction. Norepinephrine and adrenaline are nonselective agonists of β-receptors, that is, they stimulate both β1 and β-receptors. 2-subgroups. Antagonists of α 1 receptors include prazosin, which is used as an oral antihypertensive drug. Phentolamine also causes mainly? I-blockade, although to a lesser extent it blocks and? 2-receptor.

a2 receptors are presynaptic receptors whose stimulation decreases the rate of adenylate cyclase activation. Under the influence of a2-receptors, the further release of norepinephrine from the endings of adrenergic nerves is inhibited according to the principle of negative feedback.

Clonidine belongs to non-selective a-receptor agonists (the ratio of a2-effect: a1 -effect = 200: 1); Dexmedotimedine, which is much more selective, belongs to the same group.

1-receptors are mainly defined as cardiac receptors. Although their stimulation occurs under the influence of adrenaline and norepinephrine, isoproterenol is considered the classic agonist of these receptors, and metoprolol is the classic antagonist. ? З I-receptor is the enzyme adenylcyclase. When the receptor is stimulated, the intracellular concentration of cyclic AMP increases, which in turn activates the cell.

The 3 and 2 receptors are considered mainly peripheral, although their presence has recently been found in the heart muscle. Most of them are presented in the bronchi and smooth muscles of peripheral vessels. The classic agonist of these receptors is terbutaline, the antagonist is atenolol.

Drugs for the treatment of hypertension

1-agonists: prazosin is the only member of this group used during long-term therapy of hypertension. This drug lowers peripheral vascular resistance without significantly affecting cardiac output. Its advantage is the absence of serious side effects from the central nervous system. The total number of side effects is small, and no interaction with the drugs used on the day of anesthesia has been described.

Phenoxybenzamine and phentolamine (regitin) are α 1-blockers that are most often used to correct hypertension in pheochromocytoma. They are rarely used in the routine therapy of hypertension. However, phentolamine can be used for emergency correction of blood pressure in hypertensive crisis.

a2-agonists: a few years ago, a representative of this group of drugs, kponidine, was widely used to treat hypertension, but its popularity has noticeably decreased due to pronounced side effects. Clonidine stimulates the a2 receptors of the central nervous system, which ultimately decreases the activity of the sympathetic neuronal system. A well-known problem with clonidine is withdrawal syndrome, which clinically manifests itself in the development of severe hypertension 16 to 24 hours after stopping the drug. Clonidine therapy is a rather serious problem for the anesthesiologist in connection with the withdrawal syndrome. If the patient has a relatively minor operation, then the usual dose of clonidine is taken several hours before the induction of anesthesia. After recovering from anesthesia, it is recommended to start oral administration of the drug in normal doses as soon as possible. However, if the patient is to undergo an operation, as a result of which he will not be able to take oral medications for quite a long time, it is recommended to switch the patient to another antihypertensive drug before the planned operation, which can be done gradually within a week using oral medications, or somewhat faster with them. parenteral administration. In the case of urgent surgery, when there is no time for such manipulations, in the postoperative period it is necessary to observe such patients in the intensive care unit with careful monitoring of blood pressure.

ß-blockers: the table below shows the drugs in this group, the most commonly used for the treatment of hypertension.

B1 -receptor drug

Main path

selectivity

elimination half-life (hour)

excretion

Propranolol

Metoprolol

Atenolol

Propranolol: The first β-blocker used in the clinic. It is a racemic mixture, while the L-form has a greater β-blocking activity, and the D-form has a membrane stabilizing effect. A significant amount of propranolol when taken orally is immediately eliminated by the liver. The main metabolite is 4-hydroxy propranolol, an active β-blocker. The half-life of the drug is relatively short - 4 - 6 hours, but the duration of receptor blockade is longer. The duration of action of propranolol does not change with impaired renal function, but can be shortened under the influence of enzyme inducers (phenobarbital). The spectrum of antihypertensive action of propranolol is characteristic of all β-blockers. It includes a decrease in cardiac output, renin secretion, sympathetic influence of the central nervous system, as well as blockade of reflex stimulation of the heart. The side effects of propranolol are quite numerous. Its negative inotropic effect can be enhanced by a similar effect of volatile anesthetics. Its use (like most other β-blockers) is contraindicated in bronchial asthma and chronic obstructive pulmonary diseases, since airway resistance increases under the influence of β-blockade. It should also be borne in mind that propranolol potentiates the hypoglycemic effect of insulin in diabetics. A similar effect is inherent in all β-blockers, but the most pronounced in propranolol.

Nadolol (corgard), like propranolol, is a non-selective β1 and β2 receptor blocker. Its benefits include a much longer half-life, which allows you to take the drug once a day. Nadolol does not have a quinidine-like effect, and therefore its negative inotropic effect is less pronounced. In terms of lung disease, nadolol is similar to propranolol.

Metoprolol (lopressor) predominantly blocks β1 -receptors, and therefore is the drug of choice for lung diseases. It has been clinically noted that its effect on airway resistance is minimal compared to propranolol. The half-life of metoprolol is relatively short. There are isolated reports of a pronounced synergism of the negative inotropic effect of metoprolol and volatile anesthetics. Although these cases are viewed as casuistry rather than regularity, anesthesia in patients using this drug should be approached with extreme caution.

Labetalol is a relatively new drug with aI, βI, β2-blocking activity. It is often used in anesthesiology, not only for hypertensive crises, but also to create controlled hypotension. The half-life of labetalol is about 5 hours, it is actively metabolized by the liver. The ratio of β u α blocking activity is approximately 60: 40. This combination allows you to reduce blood pressure without the occurrence of reflex tachycardia.

Timolol (blockadren) is a non-selective β-blocker with a half-life of 4-5 hours. Its activity is about 5 to 10 times more pronounced than that of propranolol. The drug is used mainly locally in the treatment of glaucoma, however, due to the pronounced effect, systemic β-blockade is often observed, which should be taken into account when anesthesia of patients with glaucoma.

For the treatment of hypertension, drugs from other groups are also used. Probably one of the most long-term used drugs is aldomet (a-methyldopa), which has been used in the clinic for more than 20 years. It was assumed that this drug realizes its action as a false neurotransmitter. More recent studies have found that methyldopa is converted in the body to α-methylnoradrenaline, which is a potent α2-agonist. Thus, in its mechanism of action, it resembles clonidine. Under the influence of prenarat, a decrease in peripheral vascular resistance is observed without a noticeable change in cardiac output, heart rate, or renal cow flow. However, aldomet has a number of side effects that are important for the anesthesiologist. First of all, there is a potentiation of the action of volatile anesthetics with a decrease in their MAC. This is understandable given the similarity of action between clonidine and aldomet. another problem is the fact that continuous therapy with aldomet in 10 - 20% of patients causes a positive Coombs test. In rare cases, hemolysis has been described. Difficulties have been noted in determining compatibility in blood transfusion. In 4 - 5% of patients under the influence of aldomet, an abnormal increase in liver enzymes is noted, which should be taken into account when using halogen-containing volatile anesthetics (hepatotoxicity). It should be emphasized that no relationship has been reported between the hepatotoxicity of volatile anesthetics and aldomet. In this case, we are talking more about issues of differential diagnosis.

Diuretics: Thiazide diuretics are the most commonly used drugs in this group. Their side effects are well known and must be taken into account by the anesthesiologist. The main problem in this case is hypokalemia. Although hypokalemia as such can cause ventricular arrhythmias up to their fibrillation, it is now believed that chronic hypokalemia resulting from prolonged use of diuretics is not as dangerous as previously thought.

A decrease in the volume of circulating blood under the influence of diuretics has also been described, especially in the early stages of therapy. The use of various anesthetics in this situation can be accompanied by the development of a rather sharp hypotension.

Angitensin-converting enzyme inhibitors: these include captopril, lisinopril, enalapril. These drugs block the conversion of inactive angiotensin 1 to active angiotensin 11. Therefore, these drugs are most effective in renal and malignant hypertension. Side effects include a slight increase in potassium levels. No serious interactions have been reported between captopril and anesthetic drugs. However, some cardiac surgery centers avoid using these drugs in the preoperative period, as severe and difficult to correct hypotension has been described. It should also be taken into account that drugs in this group are capable of causing a massive release of catecholamines in pheochromocytoma.

Calcium channel blockers: The most popular member of this group is nifedipine, which not only causes vasodilatation but also blocks renin secretion. Sometimes this drug can cause quite significant tachycardia. In theory, drugs in this group can interact with volatile anesthetics, causing hypotension; however, this concept has not found clinical confirmation. However, the combination of calcium channel blockers and β-blockers should be kept in mind in the context of volatile anesthetics. This combination can seriously reduce myocardial contractility.

Anesthetic approach to a patient with essential hypertension

Times change. 20 years ago, the general rule was to stop taking all antihypertensive drugs at least 2 weeks before elective surgery. Now the opposite is true. It is axiomatic that the maximum prepared for the operation is the hypertensive person whose blood pressure is controlled by means of drug therapy until the moment of the operation. Moreover, there is some evidence that the operational risk is increased in untreated hypertensive patients.

A number of large enidemiological studies have shown that when the level of diastolic pressure is below 110 mm Hg. and in the absence of serious subjective complaints, elective surgery does not represent an increased risk for such patients. Naturally, this does not apply to cases when there are organ disorders as a result of hypertension. From a practical point of view, this means that an asymptomatic patient with labile hypertension, or with persistently high blood pressure, but with a diastolic pressure below 110 mm Hg. in the case of a planned operation has no greater operational risk than a patient with normal blood pressure. However, the anesthesiologist should keep in mind that such patients have very labile blood pressure. During surgery, they often develop hypotension, and in the postoperative period, hypertension in response to the release of catecholamines. Naturally, it is desirable to avoid both extremes.

Currently, hypertension is not a contraindication for any type of anesthesia (excluding the use of ketamine). It is important to note that a sufficiently deep level of anesthesia must be achieved prior to stimulation to activate the sympathetic nervous system, such as tracheal intubation. The use of opiates, local anesthetics for irrigation of the trachea, also, according to some authors, can reduce sympathetic stimulation.

What is the optimal level of blood pressure during surgery in a patient with essential hypertension? It is difficult, if not impossible, to answer this question definitely. Of course, if the patient has a moderately high diastolic pressure, then a slight decrease in it is likely to improve myocardial oxygenation. A decrease in the increased tone of peripheral vessels (afterload) ultimately leads to the same result. Therefore, a moderate decrease in blood pressure, especially if it is initially elevated, is quite reasonable. Fluctuations in blood pressure have the most dramatic effect on changes in renal blood flow. Naturally, it is difficult to assess glomerular filtration during surgery. The best practical monitor in this case is the assessment of hour diuresis.

It is known that autoreulation of cerebral blood flow in hypertensive disease does not disappear, but the autorelation curve shifts to the right towards higher numbers. Most patients with essential hypertension tolerate a drop in blood pressure of 20 - 25% from the initial without any disturbances in cerebral blood flow. In such situations, the anesthesiologist is faced with a dilemma: lowering blood pressure, on the one hand, reduces mortality from heart failure, and, on the other hand, increases the number of problems associated with a decrease in cerebral perfusion. Either way, a moderate decrease in blood pressure is physiologically better than an increase in blood pressure. The anesthesiologist should remember that the use of β-blockers in hypertensive patients during anesthesia enhances the negative inotropic effect of volatile anesthetics, and therefore should be used with great caution. Bradycardia with the use of 3-blockers is corrected by intravenous administration of atropine or glycopyrrolate. If this is not enough, intravenous administration of calcium chloride can be used: adrenergic agonists are last line defense.

As mentioned above, discontinuation of antihypertensive therapy before surgery is rare in modern practice. It has been convincingly proven. that the continuation of taking almost all antihypertensive drugs not only reduces the hypertensive response to tracheal intubation, but also increases the stability of blood pressure in the postoperative period.

Patients with severe hypertension, which is defined as diastolic blood pressure greater than 110 mm Hg. and / or signs of multiple organ failure present a slightly more complex problem. If hypertension in such patients is diagnosed for the first time and they have not received any treatment, then elective surgery should be postponed and drug treatment prescribed (or revised) until the blood pressure drops to acceptable levels. In surgical patients, severe hypertension is accompanied by an increase in surgical mortality. From this point of view, the relative contraindications for the planned operation are:

  1. Diastolic pressure above 110 mm Hg.
  2. Severe retinopathy with exudate, hemorrhage and papilledema.
  3. Renal dysfunction (proteinuria, decreased creatinine kpirence).

Postoperative period

In the operating room, the anesthesiologist is in an ideal position when constant monitoring allows you to quickly diagnose certain disorders and take measures to correct them. Naturally, pain impulses that cause sympathetic stimulation are much easier to suppress in the operating room than elsewhere. After cessation of anesthesia, pain impulses and all other stimuli can cause a significant increase in blood pressure. Therefore, blood pressure monitoring in the immediate field-operative period is of great importance. Patients with very labile blood pressure may need invasive monitoring.

One of the advantages of the recovery room is that the patient is already out of anesthesia and can be contacted. The very fact of establishing contact serves as a diagnostic technique, indicating the adequacy of cerebral perfusion. In this case, blood pressure can be reduced to the required level and at the same time be able to assess the adequacy of cerebral blood flow.

It should also be noted that, according to a number of authors, a decrease in blood pressure in hypertensive patients is contraindicated if there is a history of stroke or cerebrovascular accident. In this case, the autoregulation of the cerebral cow flow disappears and the decrease in blood pressure becomes risky. This issue is still being debated and there is no consensus on this issue.

Monitoring the CT segment and renal function (urine output) is still important.

It should also be borne in mind that in addition to hypertension, there are a number of other reasons for an increase in blood pressure. For example, hypercapnia, a full bladder, are only two factors that can lead to severe hypertension. It is hardly advisable to use antihypertensive therapy without first eliminating the cause of hypertension.

Literature

    B. R. Brown "Anesthesia for the patient with essential hypertension" Seminars in Anesthesia, vol 6, no 2, June 1987, pp 79-92

    E.D. Miller Jr "Anesthesia and Hypertension" Seminars in Anesthesia, vol 9, no 4, December 1990, pp 253 - 257

    Tokarcik-I; Tokarcikova-A Vnitr-Lek. 1990 Feb; 36 (2): 186-93

    Howell-SJ; Hemming-AE; Allman-KG; Glover-L; Sear-JW; Foex-P "Predictors of postoperative myocardial ischaemia. The role of intercurrent arterial hypertension and other cardiovascular risk factors". Anesthesia. 1997 Feb; 52 (2): 107-11

    Howell-SJ; Sear-YM; Yeates-D; Goldacre-M; Sear-JW; Foex-P "Hypertension, admission blood pressure and perioperative cardiovascular risk." Anesthesia. 1996 Nov; 51 (11): 1000-4

    Larsen-JK; Nielsen-MB; Jespersen-TW Ugeskr-Laeger. 1996 Oct 21; 158 (43): 6081-4

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In a healthy person, after anesthesia, a decrease in blood pressure and short-term bradycardia are observed. This is due to the peculiarity of the effect of drugs for anesthesia on the body. Increased pressure after anesthesia can be observed in hypertensive patients due to a decrease in the elasticity of blood vessels. In most cases, this is a short-term phenomenon, but with a significant increase in blood pressure, appropriate measures must be taken.

Normally, the pressure after general anesthesia is always low. This is due to the principle of action of drugs used for pain relief. They inhibit the activity of the nervous system, as a result, all processes in the body slow down. Since the nervous system needs time to recover, on the first day after general anesthesia, a breakdown and dizziness are possible due to a decrease in pressure by 15-20 mm Hg. in comparison with normal indicators for a person.

High blood pressure after anesthesia is a problem for hypertensive patients. This is due to the following mechanisms in the body.

The long course of hypertension leads to a violation of the elasticity of blood vessels. They lose flexibility and can no longer quickly respond to changes in internal and external conditions. Due to the loss of elasticity, the change in vascular tone occurs slowly and usually it is always increased, which is explained by the peculiarities of the cardiovascular system.

In hypertensive patients, the elasticity of blood vessels is insufficient for an adequate response.

At the time of the introduction of anesthesia, all processes in the body slow down. The absence of pain syndrome is explained by the effect on the nervous system, which inhibits the work of certain receptors. At this time, every person, including hypertensive patients, slows down all processes in the body, including pressure, heart rate and respiration.

After the anesthesia ceases to work, the vascular tone rises rapidly, that is, it returns to a normal state characteristic of hypertension. Due to a prolonged decrease in vascular tone at the time of the action of anesthesia, too rigid walls experience an even greater load, so the pressure rises. For example, if a hypertensive patient always had a pressure of 150 mm Hg before the operation, after the cessation of the effect of anesthesia, it can jump to 170. This state persists for some time, and then the pressure returns to normal.

Why is it dangerous to increase blood pressure during surgery?

In rare cases, with hypertension, the pressure remains high even despite the effect of anesthesia. This phenomenon is dangerous and requires monitoring of the patient's condition during the operation.

Increased pressure during local anesthesia or general anesthesia can cause large blood loss due to high vascular tone.

There are a number of risks associated with the administration of strong anesthesia to hypertensive patients. These include:

  • hemorrhage in the brain during the operation;
  • violation of the heart rhythm in response to the action of anesthesia;
  • heart failure;
  • hypertensive crisis after the cessation of anesthesia.

Adequate therapy of hypertension before surgery helps to prevent dangerous complications. Usually, the operating doctor, knowing about the high blood pressure in the patient, makes a number of recommendations some time before the operation. This minimizes the negative effects of anesthesia.


High blood pressure during surgery can cause bleeding

Hypotension and anesthesia

If with hypertension the danger lies in the fact that the pressure remains high both during the action of anesthesia and after the operation, then with hypotension the risks are due to a sudden drop in blood pressure.

After anesthesia, the low pressure drops even lower, especially with the introduction of general anesthesia. During the operation, the vital signs of the patients are carefully monitored, as there is a risk of pressure drop to critical values.

During the operation, negative reactions of the body to the action of anesthesia are possible. For hypotensive patients, this is dangerous with acute cerebral hypoxia and sudden cardiac arrest.

Help for hypertensive patients after anesthesia

Having figured out that the pressure can really increase after anesthesia, you should first consult with the anesthesiologist and the operating doctor about the methods of reducing the pressure after the cessation of the anesthesia.

Usually, hypertensive patients are given an injection of magnesia for reduction in the hospital. The clinic staff carefully monitors the fluctuations in the patient's blood pressure both at the time of the operation and after the cessation of the anesthesia.

If magnesia is ineffective, more potent drugs can be used. In addition to drugs, a patient prone to high blood pressure is shown bed rest, regardless of the type of operation, and rest. To speed up recovery from anesthesia, you need a balanced diet.

Before the operation, a hypertensive person must inform the doctor about all allergic reactions to drugs. It is imperative to inform the doctor about the antihypertensive drugs that the patient is taking constantly.

Despite the discomfort during the pressure surge, the patient has nothing to worry about, since the normalization of blood pressure after the operation is carried out by qualified specialists.

Hypertension is one of the most common comorbidities in people requiring surgical treatment. Without going into consideration of the pathogenesis of this condition, let us briefly discuss the dangerous consequences to which hypertension can lead during anesthesia and surgery. There are several of them: 1) increased bleeding, which increases surgical blood loss, 2) high sensitivity of the cardiovascular system to various, including pharmacological, influences, 3) the possibility of cerebral hemorrhage before, during and after surgery, 4) tendency to develop acute or progressive heart weakness, especially if hypertension is accompanied by coronary insufficiency.

High blood pressure sets two requirements for the anesthesiologist: a) not to use substances and influences that increase hypertension; b) protect the cardiovascular system from reflex influences that increase blood pressure. It is the high activity of vascular reflexes that explains the ease with which severe hypertensive crises arise. A sharp rise in pressure that began during anesthesia and surgery can cause a stroke, acute weakness of the heart. Patients with so-called hypertensive encephalopathy and brain disorders in the past are especially prone to strokes.

Of the special therapeutic effects for the expansion of cerebral vessels, aminophylline (synthophyllin) is used, the effectiveness of which, however, is disputed. Lassen (Lassen, 1959) cites data that aminophylline causes a distinct decrease in cerebral blood flow in humans by about 25%. Therefore, the main way to prevent spasm of cerebral vessels and stroke, obviously, should be a decrease in vascular tone in general, and the exclusion of hypertensive crises.

Finally, hypertensive crises are dangerous in another respect. A sharp, usually sudden increase in vascular resistance can cause cardiac overload and acute left ventricular failure. Thus, the fight against high blood pressure in general, and the increase in hypertension during surgery in particular, is at the center of the efforts of the anesthesiologist. In the preoperative period, with the participation of a therapist, measures are taken to lower blood pressure and eliminate crises. For the same purpose, during anesthesia and surgery, gangliolytics are used, which allow for the possibility of controlling the level of blood pressure. The dosage of these substances is strictly individual and, in any case, obviously less than that which is considered optimal for patients with normal blood pressure. So, the initial dose of hexonium is usually 20-25 mg, pentamine 30-50 mg. Arfonad is injected drip in the form of a 0.1% solution at a rate of 60-100 drops at the beginning and 10-15 drops subsequently, depending on the selected level of blood pressure. Sometimes the initial doses of hexonium and pentamine are insufficient and they have to be increased, guided by the level of blood pressure.

So far, this path seems to be the most realistic and effective of all available. But let's not forget about the shadow sides of this direction. In hypertension, cell metabolism is adapted to high blood pressure and any significant decrease in it quickly leads to symptoms of oxygen starvation. However, ganglion block is beneficial in protecting the cardiovascular system from excessive reflex influences. Only he can completely and with the least risk prevent hypertensive crises. Hence the following logical conclusion suggests itself: the decrease in blood pressure should be moderate (no more than 30-40 mm from the initial high level), and the interruption of transmission in the ganglia, if possible, complete. If you ponder over the above motives, the idea of ​​the expediency of ganglionic block without hypotension (more precisely, with moderate hypotension) during interventions in these patients cannot but come to mind.

Purely anesthetic issues... As in the previous chapters, we will now try to clarify General requirements to anesthesia for patients with pathology of the cardiovascular system.

1. The chosen method of anesthesia should ensure an increased supply of oxygen to the blood and adequate removal of carbon dioxide at all stages of the intervention. Good anesthesia control is imperative.

2. For premedication and anesthesia, only those agents can be used that do not cause sharp fluctuations in blood pressure, do not depress the myocardium and do not increase its irritability.

3. All factors that create an increased load on the circulatory system (mental stress before surgery, excitement during the induction period, excessive intravenous infusions, etc.) are extremely dangerous and should be excluded.

4. By his measures, the anesthesiologist must maintain a stable composition and volume of blood (timely and complete compensation for blood loss, accounting and compensation for shifts in pH and blood electrolyte composition), provide nutrition to the myocardium and protect it from the harmful effects of a reflex order.

From the point of view of the choice of drugs, premedication and additional pharmacological effects, the possibilities of the anesthesiologist are limited, while the tasks facing him are very diverse. Of the large arsenal of funds, only those are suitable that do not depress the myocardium, do not cause hypotension and do not delay the patient's awakening. For this reason, it is necessary to significantly reduce the dose of thiopental and abandon the technique of anesthesia, which involves the repeated administration of this substance. At the same time, thiopental remains the drug of choice for induction of anesthesia. It is not the drug itself that is dangerous, but its inept use. Slow administration of it in a minimum dose (0.2-0.25 g in 2% solution) against the background of excessive oxygen supply through a mask or catheter avoids hypotension, respiratory depression and hypoxia. Three agents - nitrous oxide, ether and cyclopropane - are most suitable as a means of maintaining anesthesia. Shallow intubation ether anesthesia (I level III stage) or inhalation of nitrous oxide after light premedication, carried out against the background of complete muscle relaxation, ganglionic block without hypotension with controlled breathing are the most accessible and completely safe in the examined category of patients. Despite the continuing ubiquitous domination of ether, against which there are no compelling objections in this group of patients, one should remember about hyperglycemia, acidotic shifts and possible liver dysfunction. For these reasons, as well as in view of the prolonged post-anesthetic depression, nitrous oxide is preferred. Of course, nitrous oxide anesthesia should not be hypoxic. In the latter case, the unstable compensation of the functions of the cardiovascular system turns into explicit, and explicit into threatening.

The optimal ratio of nitrous oxide and oxygen in a narcotic mixture for anesthesia of patients with cardiac pathology should be considered 1: 1. Such a proportion of gases can be easily maintained if, after intubation, for 3-5 minutes, the lungs are hyperventilated with high concentrations of ether, and after the restoration of spontaneous breathing (when the effect of ditilin is over), we switch to a half-open circuit supplying the patient with I L of oxygen and 1 L of laughing gas B In the conditions of ganglion block during quiet stages of the operation, we manage to maintain anesthesia by inhalation of 1.5 liters of oxygen and 1 liter of nitrous oxide without curarization. A good addition to nitrous oxide is intravenous local anesthetics or viadril, as we have discussed before. With extensive gastrointestinal tract infections and thoracotomies, our sympathies are always on the side of nitrous oxide, especially when it comes to risky operations in the elderly and patients who, in addition to concomitant heart diseases, have insufficient liver and kidney function. Emergency interventions under gas anesthesia proceed favorably. acute abdomen»In patients with symptoms of peritonitis and intoxication due to intestinal obstruction, which will be discussed further.

With the introduction of anesthesia, cyclopropane practically does not limit the supply of oxygen (75-80 vol,% O 2). However, its ability to increase blood pressure and myocardial excitability does not allow recommending this drug for patients with cardiovascular pathology. However, there are other opinions on this score. Cyclopropane in combination with nitrous oxide and oxygen is used (according to the Shein-Ashman method) with good results.

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