RU2104053C1 - Method of general anesthesia at urgent operative interferences in patients with traumatic shock - Google Patents

Abstract

FIELD: medicine, anesthesiology, revivification. SUBSTANCE: preliminarily at the stage of preoperative preparation anesthetization is conducted by intravenous bolus injection of nubaine at the dose of 0.60-0.80 mg/kg/h per 40-60 mg every hour, at premedication period nubaine is injected intravenously at the dose of 40-50 mg, in 7-10 min after premedication and the onset of diprivane infusion at 1.0 mg/kg/h induction is performed at anesthetization by ketamine, anesthetization maintenance is conducted by diprivane infusion at the dose of 1.0-3.0 mg/kg/h in connection with intravenous bolus nubaine injection at 20-40 mg before cutting, 40-60 mg every hour, at traumatic moments of operation 60-80 mg nubaine is additionally introduced, its last injection is carried out 5-10 min before the end of operation. EFFECT: decreased risk of operational and postoperative complications. 1 tbl

Description

 The invention relates to medicine, namely to anesthesiology and intensive care, and can be used for anesthetic management of emergency surgery in patients with traumatic shock.

 Among the most important problems of emergency anesthesiology, intraoperative anesthetic protection of patients with traumatic shock takes a leading place, since up to 2.5% of all injuries are accompanied by shock and about 70% of these patients require surgical treatment, 80% of them are operated on in the next hours after the injury, t .e. against the background of shock (Gvozdev M.P., Seleznev S.A., Ershova I.N. // In the book: Traumatic shock. Act. treatment issues. Issue 6. Rep. collection of scientific works.-L. , 1979, p. 10, Ryabov G.A., Semenov V.N., Terentyeva L.M. Emergency anesthesiology.-M., Med., 1983, p. 274).

 Mortality from severe trauma, accompanied by shock, even in specialized medical institutions is from 15 to 30% (D.J. Kreis // Bull. N.Y. Akad.med., 1988, 64, 7).

 None of the existing methods of anesthetic management guarantees complete protection of the patient from multifactorial stress, such as surgery, especially performed in conditions of ongoing shock.

A known method of general anesthesia for emergency surgery in patients with traumatic shock is endotracheal anesthesia with ketamine in combination with narcotic analgesics-agonists (fentanyl, morphine) (Anesthesiology Manual / Ed. By A. A. Bunyatyan. -M., Honey. ., 1994, S. 540-541. 596-597; H. W. Inkler, P. Hochstein, A. Wentzensen // Akt. Traumatol., 1989, 19, 246-254), which allows the patients to maintain hemodynamics at a satisfactory level during the operation. Nevertheless, this method is not without drawbacks.
the hemodynamic effect of ketamine is in the nature of a sympatotonic cardiovascular crisis (Guide to Anesthesiology / Edited by A.A. Bunyatyan. -M. Med., 1994. p. 214) due to the activation of central adrenergic mechanisms. With an initially reduced myocardial reserve in this category of patients, additional catecholamine stimulation of the cardiovascular system can lead to the disruption of a very thin facet of compensation, which clinically, when repeated standard doses of ketamine are administered, worsens central hemodynamics (cardiac output, peripheral vasoconstriction) ;
aggravation of metabolic disorders in tissues, manifested in an increase in tissue acidosis, increased activity of lipid peroxidation processes.

 The closest way to the proposed one is the method of total intravenous anesthesia based on diprivan (propofol) infusion in combination with benzodiazepine series drugs and fentanyl with preliminary intravenous administration of ketamine in a subhypnotic dose [1].

Applying a subhypnotic dose of ketamine before induction into diprivan infusion, the authors neutralized the hypotensive effect of the latter during planned endoscopic surgical interventions in patients with tracheobronchial tree pathology. With all the positive qualities of this technique, it is impossible to apply it in patients with traumatic shock during emergency surgical interventions for the following reasons:
the use of diprivan for induction into anesthesia with initial hypovolemia and reduced myocardial reserve in patients with traumatic shock will lead to a critical uncontrolled drop in cardiac output;
intravenous administration of ketamine in a subhypnotic dose (0.5 mg / kg) before induction into anesthesia in patients with traumatic shock does not provide leveling of the negative hemodynamic effects of diprivan and stabilization of blood circulation at the stages of anesthesiology;
the use of fentanyl as an analgesic component of the anesthetic aid entails undesirable effects characteristic of this drug, such as the ability to cause bradycardia, decreased myocardial contractility and cardiac output, which is especially dangerous in patients with traumatic shock.

 The objective of the invention is a new method of general anesthesia for emergency surgical interventions, which reduces the risk of surgical and postoperative complications in patients with traumatic shock.

 The task is achieved by the fact that, at the preoperative preparation stage, anesthesia is carried out by intravenous bolus administration of nubain in a dose of 0.60-0.80 mg / kg / hour of 40-60 mg every hour, nubain in a dose of 40-50 mg is administered intravenously, 7–10 min after premedication and the start of infusion of diprivan at a dose of 1.0 mg / kg / h, induction of ketamine anesthesia is performed, and maintenance of anesthesia is carried out by infusion of diprivan at a dose of 1.0-3.0 mg / kg / h in combination with intravenous bolus administration of nubain in an amount of 20-40 mg before an incision, 40-60 mg each Al and traumatic surgery moments additionally administered 60-80 mg Nubain and last introduction it is produced in 5 - 10 minutes before the operation is completed.

 The proposed method used the positive qualities of diprivan as an intravenous anesthetic, the rapid onset of a sedative effect, minimal hepato-and nephrotoxicity, no effect on the endocrine status of the body, no nausea and vomiting in the postoperative period, quick exit from anesthesia. The use of diprivan infusion in the proposed dosages (1.0 mg / kg / h before induction into ketamine anesthesia and 1.0-3.0 mg / kg / h to maintain anesthesia) provides sufficient sedation for the patient and does not adversely affect ketamine induction on hemodynamics in conditions of hypovolemia, helps to prevent an increase in the activity of lipid peroxidation processes and an increase in the degree of tissue acidosis during surgical interventions in conditions of traumatic shock.

 The use of nubaine as an analgesic component during preoperative preparation, anesthesia and the immediate postoperative period is due to the high analgesic effect of nubain in combination with ketamine and diprivan in the scheme of total intravenous anesthesia and the absence of complications at various stages of treatment of a patient with traumatic shock.

 Any traditional methods of general anesthesia based on narcotic analgesic agonist drugs (even in supermassive doses) are not effective enough to suppress stress reactions associated with surgical trauma (Osipova N.A. // Anest. And resuscitation., 1994, N: 4, p. . 18).

 Nubain (nalbuphine hydrochloride), unlike traditional opiate agonists and semisynthetic analgesics, antagonist agonists mediates its effect through κ opioid receptors is a safe and effective analgesic. An adequate effect of nubaine analgesia is accompanied by a decrease in the activity of one of the important mechanisms for the implementation of the stress response, the pituitary-adrenal gland, which serves as additional confirmation of the effectiveness of the drug (V.V. Nikoda, V.A. Sandrikov, R.N. Lebedeva and others // Anest. and resuscitation., 1994, N: 2, p. 42), does not significantly affect respiration, hemodynamics, gas composition of arterial blood (ibid.), is not addictive. Nubain is deprived of such side effects inherent in narcotic analgesics as dizziness, nausea, vomiting, urinary retention.

 The use of nubain during preoperative preparation at a dose of 0.6-0.8 mg / kg / h and anesthetic allowance at higher dosages than those indicated by the manufacturer (DU PONT GMBH, Germany) as equivalent to morphine is due to the peculiarities of the agonist analgesia mechanism antagonists and the need to suppress stress impulses in conditions of traumatic shock.

 Dosages of nubain 0.60-0.80 mg / kg / h during preoperative preparation, 40-50 mg premedication, 20-40 mg before incision, 40-60 mg every hour and at traumatic moments of the operation 60-80 mg tested in clinical trials and are optimal for surgical intervention in patients with traumatic shock.

 The method is as follows.

 When a patient with a traumatic shock enters the admission department, two central or central and peripheral veins are catheterized if it has not been performed at the prehospital stage, preoperative preparation, the volume, composition and duration of which depends on the severity of the patient’s condition and the urgency of the operation, the patient is served on operating table.

 Anesthesia during preoperative preparation from the moment the patient enters the admission department is carried out with nubain at a dose of 0.60-0.80 mg / kg / h (40-60 mg intravenously bolus every hour).

 Premedication is carried out on the operating table, intravenously slowly: a solution of atropine 0.1% -1 ml (0,01 mg / kg), diphenhydramine 1% -1ml, nubain 40-50 mg.

 At the same time as premedication into a separate central or peripheral vein, an intravenous infusion of diprivan at a dose of 1.0 mg / kg / h begins by means of an infusion pump until a sedation occurs.

 Diprivan solution is prepared immediately before use by diluting 400 mg of diprivan in 400 ml of 5% - or 10% glucose or dextrose solution under aseptic conditions.

 In 7-10 min after premedication and the start of diprivan infusion, ketamine anesthesia is administered at a dose of 1.5-2.0 mg / kg, the solution is injected intravenously slowly for 30-40 seconds into the same venous line where the diprivan infusion is carried out.

 During induction in anesthesia, the diprivan infusion rate is reduced by half - 0.5 mg / kg / h.

 After the onset of clinical signs of anesthesia against the background of the introduction of a 0.25% dithilin solution at a dose of 2-4 mg / kg, tracheal intubation is performed using Selik.

 Artificial ventilation of the lungs during anesthesia is carried out using anesthesia-respiratory equipment with the supply of oxygen-air mixture in moderate hyperventilation.

 Anesthesia is maintained by continuous infusion of diprivan at a rate of 1.0-3.0 mg / kg / h in combination with an intravenous bolus of nubain according to the following scheme: 20-40 mg before an incision, 40-60 mg every hour and at traumatic moments of the operation 60-80 mg of nubain is additionally introduced.

 Muscular relaxation during anesthesia is ensured by the use of arduan (tracrium) in conventional dosages.

 The composition, quality and pace of infusion therapy during anesthesiology can be determined by clinical tasks according to generally accepted schemes.

 Diprivan infusion is stopped 3-5 minutes before the end of the surgery, the last injection of nubain is made 5-10 minutes before the end of the operation.

 Anesthesia in the postoperative period is carried out by nubain in a dose of 0.4-0.6 mg / kg / h (20-40 mg bolus) during the first 12 hours after surgery.

 According to the proposed method, anesthetics were carried out in case of emergency surgical interventions in 47 patients with a traumatic shock of the II-IV degree. The average age of patients was 31 years old, males were 59%. The parameters of central hemodynamics during the anesthesiology manual were studied by the method of tetrapolar rheography according to Kubitschek in the Pushkar modification with processing at the time of the study on IBM PC-286, the determination of lipid peroxidation (LPO) products in heptane-isopropanol blood extracts was carried out on an SF spectrophotometer -26 according to the standard method.

 The control was a randomized group of patients (31 people) with a traumatic shock of the II-IV degree, operated on emergency indications under endotracheal anesthesia using ketamine in combination with a narcotic analgesic fentanyl. The tactics of infusion therapy in both groups was the same. Statistical processing of the obtained results was carried out using simple statistics, pairwise comparisons using Student t-test on IBM PC-386 using the ADAN application software package developed at the Department of Informatics Novokuznetsk GIDUVA.

 Baseline hemodynamics, lactic acid content and lipid peroxidation products (diene conjugates) did not statistically differ in both groups (see table).

 In the group of patients where the anesthesiological aid was carried out according to the proposed technique, stable hemodynamic parameters were noted at the stages of the anesthetic administration - a significant increase in stroke volume of the heart and cardiac index by the end of the operation compared with the initial values (p <0.001), a decrease in heart rate compared with control group (p <0.05). The content of lactic acid and diene conjugates decreased by the end of the operation (p <0.001 and p <0.01, respectively), which indicates a decrease in the degree of tissue acidosis during the operation and the adequacy of the anesthetic benefit.

 In the control group, there was a decrease in stroke volume of the heart and cardiac index by the end of the operation (p <0.01), an increase in the total peripheral vascular resistance (p <0.05), which was significantly accompanied by an increase in the concentration of lactic acid (p <0.05) and the accumulation of lipid peroxidation products (diene conjugates) (p <0.05).

 In the experimental group, after an operative intervention, independent adequate respiration and consciousness were restored earlier (data are unreliable), and in the immediate postoperative period, there was a tendency to an earlier restoration of hourly urine output.

 Example. Patient P., 29 years old, weight 80 kg, height 176 cm, case history N: 654, delivered to the emergency department of the 1st City Clinical Hospital of Novokuznetsk by passing vehicles from the scene of a road accident 30 minutes after the injury. Diagnosis at admission: Combined road traffic injury. Dull abdominal trauma, intra-abdominal bleeding. Closed pelvic fracture. An open fracture of the bones of the left tibia in the middle third. Traumatic shock of the III degree.

 The condition at admission is extremely serious, due to traumatic, hemorrhagic shock. Consciousness is preserved, the skin is pale, moist. Independent breathing, carried out in all departments, frequency 26 per minute. Oxygen saturation 92%. Unstable hemodynamics, blood pressure 60/30 mm Hg, heart rate 122 beats / min.

 The abdomen is tense, painful on palpation, the symptoms of peritoneal irritation are positive.

 An anesthesiologist performed percutaneous catheterization of the right subclavian vein from the supraclavicular access and the left femoral vein according to the Seldinger technique in the admission department, and 60 mg of nubain was administered intravenously.

 For 35 minutes, simultaneously with the clinical and radiological examination, preoperative preparation was carried out in two veins in a volume of 1600 ml of colloidal crystalloid solutions, prednisone was administered in a total dose of 120 mg. Hemodynamics stabilized at blood pressure 85/40 mm Hg, heart rate-120 beats / min, CVP remained negative. The patient was served on the operating table.

 Operation; Laparotomy Splenectomy. PHO of an open fracture of the left lower leg bones, intraosseous lavage with antibiotics according to Syzganov-Tkachenko, transosseous distraction-compression osteosynthesis according to Ilizarov.

 On the operating table, premedication was made - intravenously atropine 0.1% 0.8 ml, diphenhydramine 1% 1.0 ml, nubain 50 mg. Diprivan infusion was started into the femoral vein using an infusion pump at a rate of 1.0 mg / kg / h (1.47 ml / min infusion solution), and blood substitutes were continued into the subclavian vein.

 After 7 minutes, the patient began to sedate, and ketamine was induced to anesthetize at a dose of 1.5 mg / kg (120 mg), and the solution was administered intravenously for 40 s. Diprivan infusion rate during induction of anesthesia was reduced by half-0.5 mg / kg / h (0.74 ml / min infusion solution).

 After the administration of 160 mg of dithylin without auxiliary ventilation, after 10 s the trachea was intubated through the mouth under the control of direct laryngoscopy with an 11 mm diameter endotracheal tube, and the RO-6 ventilator was started with the Polynarcon-2P anesthetic attachment with an oxygen-air mixture with a gas flow of 5 l / min mode of moderate hyperventilation (DO 600 ml, MOD 12 l / min). Through the nose, after tracheal intubation, the stomach was intubated with a probe to prevent regurgitation of the gastric contents during anesthesia.

 Before the incision, nubain in a dose of 40 mg was intravenously administered. Continuous infusion was made into the subclavian vein: polyglucin 400 ml at a rate of 60 drops / min at the initial stage of anesthesia, lactasol 400 ml at a rate of 50 drops / min, polydez 400 ml at a rate of 50 drops / min, gelatin 400 ml at a rate of 60 drops / min .

 The diprivan infusion rate after induction in anesthesia and tracheal intubation was 2 mg / kg / h (2.90 ml / min infusion solution) with a gradual increase to 3 mg / kg / h (4.40 ml / min infusion solution) to the traumatic time surgery (revision of the abdominal cavity) and was maintained as such until the end of anesthesia.

 When revising the abdominal organs before applying a clamp to the vascular pedicle of the spleen, an open reposition of a fracture of the bones of the left lower leg was administered intravenously, respectively, 60 mg of nubain. Additional intravenous administration of nubain was made three more times-40 mg in the first hour of operation, 60 mg in the second, 40 mg in the third. The duration of the operation is 3 hours 25 minutes.

 Muscle relaxation during anesthesia was provided by intravenous fractional administration of arduan in a total dose of 7 mg.

 During anesthetic management, which lasted 3 hours 40 minutes, hemodynamics was stable. HELL after sedation 90/40 mm RT. Art., after induction in anesthesia 100/70 mm RT. Art., after intubation of 100/70 mm Hg, at traumatic moments of surgery 90/60 -100/70 -95/60 mm Hg. Art., by the end of the operation 100/70 mm RT. Art. Oxygen saturation during anesthesiology benefits 99-100%.

 Intravenous infusion was 3900 ml, incl. polyglucin 400 ml, lactosol 400 ml, polydeza 400 ml, gelatin 400 ml, 5% glucose 1200 ml, fresh donated blood 800 ml, 4% sodium bicarbonate 300 ml. Diuresis was 420 ml (114.5 ml / h).

 Diprivan infusion was stopped 7 minutes before the end of the operation, the last injection of nubain was performed 8 minutes before the end of the operation.

 14 minutes after the end of the operation, spontaneous respiration was restored, oxygen saturation during respiration by atmospheric air was 96%, hemodynamic parameters: blood pressure 110/70 mm Hg. Art., heart rate 92 beats / min, CVP 70 mm water. Art.

 The total amount of nubain during the anesthetic was 410 mg, diprivan 730 mg (800 ml of diprivan in 5% glucose).

 At the end of the operation, given the severity of the condition, the volume and morbidity of the surgical intervention, the patient on the endotracheal tube was transported to the general intensive care unit for the planned extended mechanical ventilation.

 In the intensive care unit, during the first 12 hours after the operation, 60 mg of nubain was administered intravenously every hour, infusion-transfusion, detoxification, and antibacterial therapy were carried out according to generally accepted schemes.

 The patient spent 5 days in the intensive care unit, then was transferred to the general ward of the trauma unit. Discharged for outpatient treatment after 3 weeks.

Claims (1)

The method of general anesthesia for emergency surgical interventions in patients with traumatic shock, which consists in the use of total intravenous anesthesia using diprivan and ketamine, characterized in that, at the preoperative preparation stage, anesthesia is carried out by intravenous bolus administration of nubain at a dose of 0.60 0.80 mg / (kg • h ^-1) at 40 mg every 60 hours, in Nubain premedication is administered at a dose of 40 to 50 mg, 7 10 min after start of infusion and premedication Diprivan 1 mg / (kg • h ^-1) is performed in anesthesia induction ketamine anesthesia and maintenance carried Diprivan infusion at a dose of 1 - 3 mg / (kg • hr ^-1) in combination with intravenous bolus Nubain in an amount of 20 to 40 mg slit 40 mg every 60 hours and traumatic surgery moments additionally added 60 80 mg of nubain, and the last injection is carried out 5 to 10 minutes before the end of the operation.

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