RU2192859C2 - Method for anesthetics in postoperative period - Google Patents

Abstract

FIELD: medicine, anesthesiology, resuscitation. SUBSTANCE: one should epidurally inject clophelin at 0.5-1 mcg/kg patient's body weight according to the scheme: the 1st d after operation - 3-4 times in 6-8 h, the 2nd d, 2-3 times in 8-12 h, and the 3rd d, 1-2 times in case of pain syndrome availability. The method provides stable anesthetics along with prophylaxis and the decrease of bronchopulmonary complications in postoperative period in elderly and old patients. EFFECT: higher efficiency of anesthetics. 1 ex, 1 tbl

Description

 The invention relates to medicine, namely anesthesiology, resuscitation, surgery, and can be used for postoperative pain management of elderly and senile patients operated on with abdominal organs.

 The problem of postoperative analgesia in gerontological patients operated on in the abdominal cavity remains unresolved and requires further clinical studies.

A known method of pain relief in the postoperative period, including intramuscular administration of opioids (morphine 0.05-0.2 mg / kg, promedol 0.5-1 mg / kg), G. Edward Morgan, Jr. , MD, Maged S. Mikhail, MD, "Clinical Anesthesiology", 1998. However, these methods of analgesia have a number of significant drawbacks:
soreness of injection;
instability of absorption and unpredictability of the concentration of the drug in the blood;
alternation of sedation, analgesia and inadequate pain relief;
a decrease in the sensitivity of the respiratory center to carbon dioxide and an increase in the threshold of the stimulating effect of carbon dioxide on the respiratory center;
suppression of cough reflex;
respiratory depression;
excitation of the emetic center;
constipation;
opiate tolerance;
opiate addiction.

 Closest to the proposed method of analgesia is the epidural administration of morphine 2-5 mg (V.V.Suslov, V.F. Kovelsky, "Intensive care for surgical patients of the elderly and senile", 1987). However, in elderly and senile patients (Intensive Therapy of Surgical elderly and senile patients, 1987), epidural administration of even 3 mg of morphine can lead to impaired pulmonary ventilation and gas exchange. The most serious complication of epidural opioid administration is dose-dependent delayed respiratory depression. This is due to the diffusion of opioids into the cerebrospinal fluid and migration in the rostral direction and penetration into the respiratory center of the medulla oblongata. Early depression (1-2 hours) after epidural administration is due to the drug entering the systemic circulation through the vessels of the spinal cord. Elderly patients are at risk for respiratory depression. Epidural administration of opioids is accompanied by the same side effects as parenteral administration. Clinical Anesthesiology, 1998, G. Edward Morgan, Jr., MD, Maged S. Mikhail, MD.

 The aim of the invention is the prevention and reduction of bronchopulmonary complications in the postoperative period in elderly patients operated on on the abdominal organs.

This goal is achieved by the fact that the patient is epidurally injected with the drug. As a medicine, clonidine is used. Enter it at the rate of 0.5-1 μg / kg body weight according to the scheme:
first day: after 6-8 hours, daily dose of 200-300 mcg;
second day: after 8-12 hours, daily dose of 100-150 mcg;
third day: after 12 hours, if necessary.

 Comparative analysis with the prototype showed that the proposed method differs from the known one in that clonidine is used as a medicine, which is administered at a rate of 0.5-1 μg / kg body weight, while clonidine is administered 3-4 times a day on the first day after surgery after 6-8 hours, on the second day 2-3 times a day after 8-12 hours and on the third day 1-2 times a day, if necessary, while maintaining the pain syndrome.

 Thus, the proposed technical solution meets the criteria of the invention of "novelty."

 The analysis of patent and specialized literature showed that the proposed method differs not only from the prototype, but also other technical solutions in this and related fields. So the authors did not find a way of pain relief, which would include the epidural administration of clonidine. And the drug we are offering and the schedule for its administration can reduce bronchopulmonary complications in gerontological patients operated on in the abdominal organs.

 This method of analgesia can be used in the intensive care unit and resuscitation. Therefore, the proposed solution meets the criteria of "inventive step" and "industrial applicability".

The method is as follows:
Patients in the preoperative period or after surgery perform a puncture and catheterization of the epidural space according to the generally accepted method. The level of puncture and catheterization depended on the area of surgical intervention (T ₈ -T ₁₂ ). In the postoperative period, under the conditions of the intensive care and resuscitation chamber, after recovery of consciousness and depending on the severity and intensity of the pain syndrome, clonidine is epidurally administered at a rate of 0.5-1 μg / kg body weight, diluted in 6-8 ml of physiological saline. The maximum dose of clonidine with a single injection is 100 mcg. An analgesic effect occurred within 15-20 minutes from the time of administration. The onset of the analgesic effect was determined by a decrease in tactile sensitivity, taking into account the segmentality of the epidural block and a decrease in pain intensity. The duration of the analgesic effect is 6-8 hours. Repeated administration of clonidine was performed in the same dosage:
first day: after 6-8 hours, daily dose of 200-300 mcg;
second day: after 8-12 hours, daily dose of 100-150 mcg;
third day: after 12 hours, if necessary.

 Example 1

 Patient I., 68 years old, was admitted to the surgical department with a diagnosis of Acute adhesive intestinal obstruction. For the purpose of preoperative preparation and for carrying out additional methods for studying the state of homeostasis, the patient was transferred to PITR.

 Upon admission, the patient’s condition is serious, due to endogenous intoxication on the background of enterohergy, disturbances in the hydro-ion balance, concomitant pathology (IHD, hypertension I st, NK 0-I). The skin is dry, normal color. Skin turgor is not changed.

Spontaneous breathing, NPV = 22 per min. SpО2 = 92%. Auscultation in the posterior basal regions on both sides of the breath is weakened, dry, rales of various sizes are heard. Vital lung capacity (VC) = 2600 ml, maximum inspiratory force (PmaxIn) = 48 cm. Н ₂ О, maximum expiratory effort (РmахЕх) = 71 cm. Н ₂ О.

Heart sounds are muffled, rhythmic. Hemodynamic parameters: HELL = 140/90 mm Hg, PS = 108 per min. CVP = 2 cm. N ₂ About Art.

 The tongue is dry, coated with a brown coating. The stomach is limitedly involved in the act of breathing. Palpation painful in all departments. Peristalsis by single waves.

 Diuresis in the urinary catheter - 200 ml. Urine is dark, concentrated.

 A patient under PITR conditions underwent a survey R-graph of the chest. Conclusion: pneumosclerosis, congestive, right-sided, lower lobar pneumonia.

 ECG examination: sinus rhythm, heart rate = 106-108 per min, incomplete blockade of the left bundle branch, electrolyte disturbances in myocardial function.

For the purpose of postoperative analgesia under the conditions of PITiR, puncture and catheterization of the epidural space in the interval Th ₁₁ -Th _{12 were} performed.

 After preoperative preparation, the patient was transferred to the operating room for surgical intervention. Operation: laparotomy, enterolysis, drainage of the abdominal cavity.

In the postoperative period, clofelin epidural analgesia was used in the complex of treatment and prophylactic measures. The first day, clonidine was administered at the rate of 1 μg / kg weight with an interval of 8 hours. The total dose of the drug on the first day was 250 mcg. On the second day, clonidine was administered at a rate of 0.7 μg / kg with an interval of 8 hours. The total daily dose was 180 mcg. On the third day of the postoperative period, clonidine was injected once 0.7 μg / kg and after restoration of the passage through the intestine, the epidural catheter was removed. Indicators of the function of external respiration: respiratory rate (NPV) = 20 per min, VC = 2300 ml, PmaxIn = 42 cm. N ₂ O, PmaxEx = 61 cm. N ₂ O. Hemodynamic disturbances in the postoperative period were not observed: minute volume of blood circulation ( IOC) = 4.2 l / min, cardiac index (SI) = 2.6 l / (min • m ² ), shock index (UI) = 38 ml / m ² , total peripheral vascular resistance index (IOPS) = 2300 [dyn • s / (cm ⁵ • m ² ). The patient was transferred to the surgical department. The length of stay in the hospital was 21 days. The patient was discharged with recovery.

 Example 2

 Patient K., 64 years old, was admitted to the surgical department with a diagnosis of Chronic calculous cholecystitis, obstructive jaundice. After carrying out additional laboratory and instrumental methods of research, the patient was offered surgical intervention in a planned manner. When preparing the patient for surgery, the following concomitant pathology was revealed: coronary heart disease, GB II art, NK 0-I. Obesity II degree.

An ECG study: sinus rhythm, heart rate = 76-78 per min, violation of repolarization processes, incomplete blockade of the left bundle branch. JELL = 2450 ml. PmaxIn = 58 cm. H ₂ O, PmaxEx = 76 cm. H ₂ O.

Operation: Cholecystectomy, choledocholithotomy. The operation was performed under ETN. After the operation, under the conditions of the intensive care and resuscitation chamber (PITiR), for the purpose of postoperative analgesia and prevention of bronchopulmonary complications, puncture and catheterization of the epidural space were performed in the interval T ₈ -T ₉ . In the postoperative period, epidural analgesia with clonidine was performed for two days. The first day, clonidine was administered at a rate of 0.5 μg / kg weight with an interval of 6 hours. The total daily dose was 200 mcg. On the second day of the postoperative period, the dose of clonidine was 150 mcg, with an administration interval of 12 hours. The course of the postoperative period is normal. Bronchopulmonary complications and hemodynamic disturbances were not noted. VC = 2200 ml, PmaxIn = 41 cm. H ₂ O, PmaxEx = 64 cm. H ₂ O; IOC = 4.8 l / min, SI = 3.1 l / (min • m ² ), UI = 42 ml / m ² , IOPSS = 22600 [dyn • s / (cm ⁵ • m ² ).

 On the third day of the postoperative period, the epidural catheter was removed and the patient was transferred to the surgical department. After 19 days, the patient was discharged with recovery.

This method of pain relief was used in 76 patients. The average age is 68 years. Women 49, men 27. Patients underwent the following operations:
gastrectomy - 9,
cholecystectomy - 31,
bowel resection - 11,
laparotomy - 17,
herniolaparotomy - 8.

 Due to the use of this method of analgesia in the complex of treatment and prophylactic measures of the postoperative period, the frequency of bronchopulmonary complications was reduced from 38 (analogue method) to 12%, mortality in the main group of patients was not noted (see table).

 The efficacy of clofelin epidural analgesia in the postoperative period was confirmed by research results. In the main group of patients, the analgesic effect was significantly higher than in patients of the analogue. These differences are noted as when using a 5-point scale of postoperative analgesia, "Anesthesiology and intensive care," 1993, 3, p. 40-42, as well as the analgesia assessment system proposed by the authors, which takes into account several factors: decrease in VC in% of the initial value, coughing efficiency and activity of movements: 3 points ≤ 30%, 2 points - 30-40%, 1 point ≥ fifty%; 3 points - productive cough, pain does not prevent coughing, 2 points - pain limiting productive coughing, 1 point - inability to perform coughing; 3 points - active movements in bed, 2 points - the absence of pain at rest and the appearance of active movements, 1 point - severe pain at rest.

 When using prolonged EDF by clonidine, the effectiveness on the first day was 4.1 ± 0.15 and 7.4 ± 0.2, respectively, according to the 5-point and the authors proposed systems for assessing the effectiveness of pain relief. According to the analogue method, these indicators were 3.7 ± 0.1 and 6.1 ± 0.2 points. On the third day of the postoperative period, the values were (4.7 ± 0.1; 8.2 ± 0.1) in the main group and (4.2 ± 0.15; 6.9 ± 0.15) by the analogue method.

 The effectiveness of epidural anesthesia with clonidine is confirmed by VC. In the main group of patients, the VC values at all stages of the studies significantly differed from the parameters of the analogue method.

 Differences are noted both in absolute values and in% relation to the initial values. On the first day of the postoperative period, when using clofelin epidural analgesia, VC M ± m = 2.25 ± 0.1 (l), by the analogue method, this indicator was M ± m = 1.75 ± 0.1 (l).

 The maximum difference of the indicator was noted on the second day of the postoperative period, which amounted to M ± m = 2.6 ± 0.1 and M ± m = 2.0 ± 0.1 (l) in the main group according to the analogue method. By the third day of the postoperative period, the values of lung capacity in the main group of patients were M ± m = 2.9 ± 0.1 (l), which is 90.6% of the initial value and 16% higher than in patients of the analogue method.

 Analyzing the dynamics of VC indicators at all stages of research, we can talk about the beneficial effect of epidural analgesia by clonidine on the function of external respiration. Indicators of tidal volume (DO) in the comparison groups did not have significant differences. Given the relative constancy of DO, the change in VC is due to an increase in the reserve volume (RO) of inspiration and RO of expiration, which prevents lung atelectasis in the early postoperative period. This, in turn, prevents blood bypass surgery and reduces the likelihood of inflammatory processes.

 In the study of bronchial patency, significant differences were obtained in the comparison groups, which in the main group were M ± m = 66.5 ± 4 (%) and M ± m = 53.5 ± 4 (%) by the analogue method. The flow-volume curve at the level of large bronchi did not have significant differences. Improving bronchial patency prevents violations of the ventilation-perfusion ratio, reduces blood shunting and the degree of hypoxemia.

When studying the functional state of the respiratory muscles, it was found that in the main group of patients, the indicators of maximum exhalation effort (Pmax Ex) and inspiration (PmaxIn) were significantly higher than by the analogue method: M ± m = 58 ± 6 and M ± m = 41 ± 6 (see H ₂ O); M ± m = 42 ± 5 and M ± m = 27 ± 5 (see H ₂ O), respectively.

In the study of the circulatory system in the postoperative period, high efficacy and positive effect of prolonged EDA by clonidine on the blood circulation indices in gerontological patients in the postoperative period was revealed. The results obtained in patients of the main group significantly differed from the values of the analogue group at the whole stage of the study. So indicators (IOC, SI, UI) characterizing central hemodynamics in the main group were: 3.85 ± 0.1 l / min, 2.3 ± 0.1 l / (min • m ² ) and 31 ± 3 ml / m ² , which is 0.8 ± 0.1 l / min, 0.4 ± 0.1 l / (min • m ² ) and 8 ± 3 ml / m ² higher than by the analogue method.

The beneficial effect of prolonged EDA by clonidine on the microcirculation system was also revealed, as evidenced by the indicators of the index of total peripheral vascular resistance (IOPS): 2389 ± 150 in the main and 2809 ± 150 [dyn • s / (cm ⁵ • m ² ) by the analogue method.

 Clinical studies have revealed that prolonged epidural analgesia with clonidine is an effective and preferred method of pain relief in elderly and senile patients with a high risk of postoperative pulmonary complications.

 It was established that epidural analgesia with clonidine favorably affects the function of external respiration and the cardiovascular system. The effectiveness of the use of prolonged EDA by clonidine made it possible to activate patients in the early stages, to reduce the period of observation of patients in PITiR from 5.1 to 2.3 and stay in hospital from 21.3 to 17.1 days.

 This method of prolonged analgesia is recommended for use in clinical practice.

Claims (1)

 A method of analgesia in the postoperative period, including epidural administration of a drug, characterized in that clonidine is used as a drug, which is administered at a rate of 0.5-1 μg / kg body weight, while 3-4 days later, clonidine is administered 3-4 once a day after 6-8 hours, on the second day 2-3 times a day after 8-12 hours and on the third day 1-2 times a day while maintaining pain.

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