RU2195278C2 - Method for anesthisilogical supply of vertebrological operations in children and youth - Google Patents

Abstract

FIELD: medicine, anesthesiology. SUBSTANCE: method deals with highly traumatic operations accompanied with massive blood losses in patients with initial disorders of essential body functions. Preoperative preparation is carried out by the following scheme: 72 and 48 h before operation pyrogenal is injected at the dosage of 0.5 mcg/kg intramuscularly, 24 h before operation pyrogenal is injected at the dosage of 1 mcg/kg intramuscularly in combination with vitamin E at the dosage of 10 mg/kg. Premedication is conducted including only relanium at the dosage of 0.2 mg/kg and dimedrol at the dosage of 0.4 mg/kg intramuscularly. Introductory narcosis includes phenthanyl at the dosage of 0.002 mg/kg, sodium thiopental 2.5-1%-solution at the dosage of 10 mg/kg, listenon at the dosage of 2.5 mg/kg with subsequent tracheal intubation. After this clophelin is injected as a 0.01%-solution at the dosage of 0.4 mcg/kg intravenously by boluses. The major narcosis includes a central analgetic, for example, phenthanyl at the dosage of 0.002 mg/kg/h intravenously by boluses, a hypnoanesthetic preparation calipsol at the dosage of 2.5 mg/kg/h intravenously constantly through a dosator, clophelin 0.4 mcg/kg/h intravenously constantly through a dosator at total myoplegia with arduan at the dosage of 0.03 mg/kg/h intravenously by boluses at artificial pulmonary ventilation with an apparatus working by a flow at the mode from plateau at inspiration with FiO2 40%. The method efficiently provides body protection in the course of such operations. EFFECT: higher efficiency. 2 cl

Description

 The invention relates to medicine, namely anesthesiology, and can be used for highly traumatic operations accompanied by massive blood loss in patients with initial disorders of vital functions of the body, in particular respiratory and cardiovascular.

 Known methods of preoperative preparation using pyrogenal and anesthetic management of operations with the inclusion of the clonidine stress-protective drug in the anesthesia program (in neurosurgical patients of children - EI Vereshchagin "Modulation of the body's reactivity to surgical aggression (trauma, ischemia, endotoxemia)" // Abstract of the dissertation of the doctor of medical sciences - Novosibirsk., 1998. - 28 p .; Osipova N.A. et al. "Clonidine as a component of general anesthesia and a means of postoperative analgesia in oncological surgery" // Anesthesiology and resuscitation. - 1988. - 6. - pp. 14-18 .; Samoilov K. A., Zhuchkov SL "Actual problems of drug anesthesia." - L., 1989. - p. 78-81 .; Nazarov I.P. et al. "The Use of Clonidine in Premedication" // Anesthesiology and Intensive Care. - 1990. - 5. - p. 76-78).

 These methods of anesthetic management provide quite effective anti-stress and antinociceptive protection, prevent unwanted hyperdynamic hemodynamic reactions in the adult patient population. However, these methods are unacceptable in children and adolescents due to the risk of developing persistent arterial hypotension at the stage of sedation, induction into anesthesia and the beginning of surgery. A breakthrough of anesthetic protection during interventions of more than 3 hours with undesirable blood circulation reactions, especially with massive blood loss, is not ruled out.

 The method of preoperative preparation in pediatric neurosurgical patients increases the body's resistance to surgical trauma, massive blood loss. This method of preoperative preparation avoids a systemic inflammatory reaction in the body, affecting only the phagocyte and macrophage system.

 However, the method does not include another necessary component, namely, prophylactic antioxidant protection of the body at the stages of the operation and in the postoperative period.

 Closest to the claimed method relates to anesthetic management Kralina AB and others. "Anesthetic management of operations in patients with scoliosis with simultaneous intervention on the ventral and dorsal spine" // Bulletin of Traumatology and Orthopedics. Priorov. - 1999. - 3. - p. 45-49).

 The method is as follows.

Induction into anesthesia is carried out using relanium at a dose of 0: 2 mg / kg, morphine at a dose of 0.2 mg / kg, sodium thiopental at a dose of 4.1-7.3 mg / kg, short-acting relaxants followed by tracheal intubation. Before the skin incision, morphine 0.25 mg / kg or fentanyl 0.0025 mg / kg is administered in combination with droperidol at a dose of 0.125 mg / kg. In order to create an "infusion backwater" hemodilution is carried out in a volume of 30-45% of BCC by introducing FFP and saline 1: 3 (35 ml / kg). Maintenance of anesthesia is carried out on the basis of N ₂ O and O ₂ (1: 2), sodium thiopental at a dose of 0.24 mg / kg / h, fentanyl 0.002 mg / kg / h with mechanical ventilation in moderate hyperventilation.

 This method of anesthetic management determines an adequate level of antistress protection for the patient, provides effective analgesia, reduces the need for opioid analgesics.

 However, a combination of the drugs used, each of which has a hypotensive effect, the administration of a large dose of clonidine is fraught with negative hemodynamic reactions with the threat of developing persistent arterial hypotension with unwanted ischemic damage to vital organs. A single injection of clonidine does not provide the proper vegetonormalizing effect during operations lasting more than 3 hours. This method does not guarantee in cases of massive blood loss to adequately protect the patient from possible severe circulatory disorders. Using the recommended hemodilution regimen for operations over 6 hours does not exclude a critical increase in intrapulmonary bypass grafting, which can lead to inadequate gas exchange with the development of hypoxemia.

 The objective of the invention is to effectively and safely protect the patient from surgical injury at the stages of the operation and in the postoperative period.

 In solving this problem, there is a positive therapeutic effect, which consists in increasing the body's resistance to surgical trauma and blood loss through special preoperative preparation, which consists in the use of pyrogenal in combination with vitamin E according to the scheme. In addition, the proposed method allows to realize the optimal level of antistress and antinociceptive protection and prevent possible severe circulatory disorders in case of massive blood loss, both through preoperative preparation and by using the TBA method (total intravenous anesthesia) based on a combination of fentanyl, calypsol and stress clonidine protector with maintaining a constant concentration by continuous infusion through a dispenser.

 The method allows to reduce the amount of intraoperative blood loss due to the creation of stable hemodynamic parameters with an optimal level of blood pressure by using the vegetonormalizing effect of clonidine. The method allows to avoid post-narcotic respiratory depression by reducing the total dose of narcotic analgesics used and, therefore, is the prevention of the development of postoperative pulmonary complications. The method allows to prevent severe complications of the postoperative period, primarily infectious, due to the creation of induced phagocyte tolerance to endotoxin and thus avoids a systemic inflammatory reaction in the body in response to surgical aggression.

 When using the method, there is an economic effect, consisting in reducing the consumption of drugs and blood products, reducing the length of stay of the patient in the intensive care unit, reducing the number of complications, the presence of which requires additional costs.

The problem is solved due to the fact that preoperative preparation is carried out according to the scheme: 72 and 48 hours before surgery, pyrogenal is administered at a dose of 0.5 μg / kg intramuscularly, 24 hours before surgery, pyrogenal is administered at a dose of 0.5 μg / kg intramuscularly vitamin E at a dose of 10 mg / kg; conduct premedication, including only relanium at a dose of 0.2 mg / kg and diphenhydramine at a dose of 0.4 mg / kg intramuscularly; induction of anesthesia includes fentanyl at a dose of 0.002 mg / kg, thiopental sodium (2.5-1% solution) at a dose of 10 mg / kg, listenone at a dose of 2.5 mg / kg, followed by tracheal intubation, clonidine is administered after tracheal intubation 0.01% solution at a dose of 0.4 mcg / kg intravenously bolus; main anesthesia includes a central analgesic, for example, fentanyl at a dose of 0.002 mg / kg / h intravenously bolus, a hypnesthetic calypsol at a dose of 2.5 mg / kg / h intravenously continuously through a dispenser, clonidine 0.4 μg / kg / h intravenously continuously through a dispenser at total myoplegia with arduan at a dose of 0.03 mg / kg / h by intravenous bolus with artificial lung ventilation with the EVITA-2-DURA apparatus, working in the flow mode with a plateau on inspiration with FiО ₂ 40%.

 The method is as follows.

The patient undergoes a special preoperative preparation, carried out by three times the introduction of the domestic polysaccharide preparation of pyrogenal according to the scheme. Dosage and administration: 72 and 48 hours before surgery, pyrogenal is administered at a dose of 0.5 μg / kg intramuscularly, 24 hours before surgery, pyrogenal is administered at a dose of 1 μg / kg intramuscularly. In addition, an antioxidant - vitamin E at a dose of 10 mg / kg intramuscularly is administered 24 hours before the operation. Premedication is carried out 30 minutes before surgery using relanium at a dose of 0.2 mg / kg, and diphenhydramine at a dose of 0.4 mg / kg intramuscularly. Induction in anesthesia (induction of anesthesia) is carried out by the administration of fentanyl at a dose of 0.002 mg / kg, sodium thiopental (2.5-1% solution) at a dose of 10 mg / kg, after the introduction of listenone at a dose of 2.5 mg / kg trachea. Immediately after induction, clonidine 0.01% solution at a dose of 0.4 μg / kg is injected intravenously into anesthesia. The main anesthesia is carried out against the background of the administration of fentanyl 0.002 mg / kg / h (bolus administration with an interval of 30 min), calypsol 2.5 mg / kg / h (continuous administration through the dispenser), clonidine 0.4 μg / kg / h (continuous administration through a dispenser) for total myoplegia with arduan 0.03 mg / kg (bolus injections) with artificial lung ventilation with the EVITA-2-DURA apparatus, working in the flow mode with a plateau on inspiration with FiО ₂ 40%.

 An example of the clinical use of the method.

 Patient P., born in 1987 (12 years old), she was admitted to the clinic of the Novosibirsk Research Institute of Traumatology and Orthopedics on November 29, 1999. In the clinic, according to the accepted methodology, a complete clinical, laboratory and X-ray examination was performed. Clinical diagnosis: Idiopathic uncomplicated progressive right-sided thoracic subcompensated scoliosis of the IV degree. Examination of the function of external respiration revealed an extremely sharp decrease in the ventilation capacity of the lungs with VC 49%, FVC 35% and FEV 34% of the required parameters. An X-ray examination of the chest revealed a deformation of the chest and a dislocation of internal organs. General blood tests, urine tests, biochemical tests are within normal limits. After clinical analysis, it was decided to perform simultaneous two-stage surgical treatment of the underlying disease. Considering the initial somatic status and the volume of the upcoming operation, a special preoperative preparation was carried out, including triple intramuscular administration of pyrogenal according to the scheme: 72 and 48 hours before surgery at a dose of 0.5 μg / kg, 24 hours before surgery at a dose of 1 μg / kg .

 The preoperative preparation regimen also includes a single administration of vitamin E at a dose of 10 mg / kg intramuscularly 24 hours before surgery. The operation multilevel mobilizing discectomy (D5-6 - D10-11) and posterior spinal fusion using Harrington's instruments (according to Drummond) was performed on December 9, 1999 under conditions of TVA with mechanical ventilation. Premedication was carried out 30 minutes before surgery using diphenhydramine at a dose of 0.4 mg / kg and relanium at a dose of 0.2 mg / kg. Induction anesthesia: atropine 0.006 mg / kg, fentanyl 0.002 mg / kg, sodium thiopental 1% solution at a dose of 10 mg / kg, listenone 2.5 mg / kg, followed by tracheal intubation.

Immediately after intubation, clonidine 0.01% solution was administered at a dose of 0.4 μg / kg bolus. Basic anesthesia was supported by the administration of fentanyl at a dose of 0.002 mg / kg / h (bolus administrations with an interval of 30 min), calypsol at a dose of 2.5 mg / kg / h (continuous administration through a dispenser), and clonidine at a dose of 0.4 μg / kg / h (continuous administration through the dispenser) in case of total myoplegia with arduan at a dose of 0.04 mg / kg / h with an EVITA 2-DURA ventilator operating in a flow mode with a plateau on inspiration with FiО ₂ 40%. The duration of anesthesia was 5 hours 40 minutes. Anesthesia at all stages of the operating period proceeded with stable hemodynamic parameters with minimal fluctuations in the level of blood pressure and hours. from. (Systolic blood pressure 95-90 mm Hg, diastolic blood pressure 55-45 mm Hg, h.s. 100-80). Indicators SaO ₂ 99-100. Blood loss in stage I (discectomy) was 80 ml (1.7 ml / kg), blood loss in stage II (posterior fusion) was 470 ml (10 ml / kg). The total intraoperative blood loss is 650 ml (17.3% of the BCC).

 Infusion therapy was carried out using crystalloid solutions of 7.6 ml / kg / h, FFP 11.5 ml / kg, erythrocyte mass 5.7 ml / kg. In order to control homeostasis at the main stages of the operating period, the level of cortisol: albumin: lactate: glucose and indicators of er, Нb, Ht were monitored. There were no significant deviations of the controlled indicators from the level of stress norm.

 After the operation, the patient with restored adequate independent breathing and stable hemodynamics was transferred to the intensive care unit. Transferred to the specialized department on the 1st day after the operation, during the postoperative period without complications.

Claims (3)

1. The method of anesthetic management of vertebrological operations in children and adolescents by creating anti-stress and antinociceptive protection of the patient’s body, characterized in that they carry out preoperative preparation according to the scheme: pyrogenal is administered at a dose of 0.5 μg / kg intramuscularly 72 and 48 hours before surgery 24 hours before surgery, pyrogenal is administered at a dose of 1 μg / kg intramuscularly in combination with vitamin E at a dose of 10 mg / kg; conduct premedication, including only relanium at a dose of 0.2 mg / kg and diphenhydramine at a dose of 0.4 mg / kg intramuscularly; induction of anesthesia includes fentanyl at a dose of 0.002 mg / kg, sodium thiopental 2.5-1% solution at a dose of 10 mg / kg, listenone at a dose of 2.5 mg / kg, followed by tracheal intubation, clonidine 0 is administered after tracheal intubation 01% solution at a dose of 0.4 mcg / kg bolus intravenously; the main anesthesia includes a central analgesic intravenously, a hypnesthetic calypsol at a dose of 2.5 mg / kg / h intravenously continuously through a dispenser, clonidine 0.4 μg / kg / h intravenously continuously through a dispenser with total myoplegia with arduan at a dose of 0.03 mg / kg / h intravenously with artificial ventilation of the lungs by a device operating in a flow mode with a plateau on inspiration with a FiO _{2 of} 40%.  2. The method according to p. 1, characterized in that fentanyl is used as a central analgesic at a dose of 0.002 mg / kg / h by bolus intravenously.  3. The method according to p. 1, characterized in that the apparatus EVITA - 2 DURA is used for artificial ventilation of the lungs.