RU2200590C1 - Method for combined spinal-epidural anesthesia - Google Patents

Abstract

FIELD: medicine, anesthesiology. SUBSTANCE: anesthetic is injected due to two punctures into subarachnoidal and epidural spaces, moreover, into epidural space it should be introduced by catheterization through sacral channel. The innovation simplifies the method of anesthesia due to improved catheterization of epidural space at lower traumaticity. It, also, excludes the possibility for dura mater and spinal cord lesions. EFFECT: higher efficiency of anesthesia. 4 cl

Description

 The invention relates to medicine, namely to anesthesiology, and can be used for anesthesia during operations on the lumbosacral spine in neurosurgery, pelvic and perineal organs in surgery, obstetrics, gynecology, urology, proctology, lower limbs in vascular surgery, traumatology , orthopedics and for postoperative pain management.

 Known methods of epidural anesthesia (patent RU 2173181; PCT patent WO 00/307/5, 02.06.2000) and methods of combined spinal-epidural anesthesia (E.U. Gallinger. Combined spinal-epidural anesthesia. Anest. And resuscitation. - 1995. - N 2.- P. 60; E. Yu. Gallinger, M. N. Seleznev, G. V. Babalyan, N. Yu. Zolicheva, S. P. Kryukov. Combined spinal-epidural and epidural anesthesia during vascular operations lower limbs Anest. and resuscitation. - 1999. - N 5.- P. 44-48; V.A. Koryachkin, V.I. Strashnov. Spinal and epidural anesthesia. - St. Petersburg: Publishing House OO About Saint-Petersburg Medical Publishing House, 2000, 95 p .; A.M. Ovechkin, A.V. Gnezdilov, M.L. Kukushkin, E.Yu. Khmelkova. Regional anesthesia and prevention of postoperative pain syndrome in orthopedics - traumatology. Pain and Modern Aspects of Regional Analgesia. - Thesis Doc. Scientific and Practical Conf. Voronezh, 1999. P. 28-29; V. A. Svetlov, S. P. Kozlov, T. V. Vashchinskaya, N. G. Sarkisova Subarachnoid anesthesia: limits of possibilities. Anest. and resuscitation. - 1999. - N 5. - S. 38-44; A.M. Stabnitsky. Regional anesthesia - return to the future (Collection of materials of scientific-practical conference on current problems of regional anesthesia). - M. 2001. - P.35-41), combining the two main variants of central regional blockades - spinal and epidural. By type of access to the nerve structures of the spinal cord, combined spinal-epidural anesthesia is divided into single-segment (single-segment) (I. A. Vitenbek. Combined spinal-epidural anesthesia as a variant of conduction anesthesia during surgery. Vestn. Khir. - 1981. -T. 126. - S. 123-128; V.A. Koryachkin, V.I. Strashnov. Spinal and epidural anesthesia. - St. Petersburg: Publishing House LLC St. Petersburg Medical Publishing House, 2000, 95 pp.) And two-segment (two-segment ) (E. Yu. Gallinger. Combined Spinal but-epidural anesthesia. Anest. and resuscitation. - 1995. - N 2.- P. 60; V.A. Koryachkin, V.I. Strashnov. Spinal and epidural anesthesia. - St. Petersburg: Publishing House LLC St. Petersburg medical publishing house, 2000, 95 pp.). The first is characterized by the introduction of anesthetic into the subarachnoid and epidural spaces through a single puncture using an epidural needle as a conductor for the spinal. For the second - the introduction of anesthetic into these spaces through two punctures in adjacent segments of the spine, separately for spinal and epidural needles.

 For both variants of combined spinal-epidural anesthesia, a catheter must be inserted into the epidural space through an epidural needle to catheterize this space.

 The disadvantages of the single-segment (single-segment) method of anesthesia are its complexity, the high cost of the tool kit, the difficulty of monitoring the position of the epidural catheter due to the inability to assess the effect of the test dose of the anesthetic against the background of already developed spinal anesthesia (E.Yu. Gallinger, M.N. Seleznev, GV Babalyan, N.Yu. Zolicheva, SP Kryukov. Combined spinal-epidural and epidural anesthesia for operations on the vessels of the lower extremities. Anest. And resuscitation. - 1999.- N 5.- P. 44-48 ; V. A. Koryachkin, V. I. Strashnov. Spinal cord I and epidural anesthesia. - St. Petersburg.: Publishing House LLC St. Petersburg Medical Publishing House, 2000, 95 pp.).

 The disadvantages of the two-segment (two-segment) method of anesthesia are an increase in trauma, the risk of possible complications (epidural hematoma, puncture of the epidural vein, back pain, infection) by almost 50% with two punctures (E. Yu. Gallinger. Combined spinal-epidural anesthesia. Anest. and resuscitation. - 1995. - N 2. - C.60).

 Closest to the claimed is a method of combined spinal-epidural anesthesia in two-segment (two-segment) performance. (V. A. Koryachkin, V. I. Strashnov. Spinal and epidural anesthesia. - St. Petersburg: Publishing House LLC St. Petersburg Medical Publishing House, 2000, 95 pp.). It is as follows. Spinal and epidural anesthesia are performed in different interspinous spaces. First, puncture and catheterization of the epidural space is performed, the effect of the test dose is evaluated, then spinal anesthesia is performed at an appropriate level below. Indications for combined spinal-epidural anesthesia.

 Anesthesia for operations on the lumbosacral spine, pelvic organs, perineum, lower extremities and anesthesia in the postoperative period.

Contraindications to combined spinal-epidural anesthesia
Absolute:
1. Refusal of the patient from regional anesthesia.

 2. Infection at the puncture site.

 3. Coagulopathy or taking anticoagulants.

 4. A true allergy to local anesthetics.

 5. Uncorrected hypovolemia.

 6. Congenital malformations of the spine.

 7. Lack of adequate contact with the patient (alcohol intoxication, psychosis).

Relative:
1. Severe obesity.

 2. Insufficient experience of the anesthetist.

 The patient is prepared as follows. Refusal of food on the day of surgery. Blockade is preceded by peripheral vein catheterization. The procedure is performed with strict adherence to asepsis rules. To perform anesthesia, as a rule, use two syringes with a capacity of 5 and 10 ml with needles, an epidural needle of the Tuoha type, an epidural catheter compatible with the needle, and a spinal needle. Manipulation is usually carried out immediately before surgery. Premedication is provided with sedatives and antihistamines. There are 2 basic positions of the patient: sitting and lying on his side. Most punctured in a sitting position.

After processing the surgical field under local infiltration anesthesia, 4-5 ml of anesthetic with an epidural needle in the selected interspinous gap (usually L ₂ -L ₃ ) puncture the epidural space. Damage to epidural veins is ruled out by existing samples, for example, magnesia - see the work of N. A. Lopatkin, D. M. Rubinova. Epidural-sacral anesthesia in urology. - Tashkent -1969. If after 15-30 seconds after the injection of 2 ml of 25% magnesia sulfate through the needle, the patient feels heat, burning in the mouth and throat, which indicates a puncture of the veins, the test is considered positive. In these cases, combined spinal-epidural anesthesia is replaced by spinal. In case of a negative test, combined anesthesia is performed in full. When the cerebrospinal fluid expires, the needle is removed and the epidural space is repeatedly punctured in adjacent interspinous spaces or operated on under other anesthesia. Before introducing the catheter into the epidural space, 5-6 ml of 0.9% sodium chloride with an air bubble are injected through the needle for the "resistance loss" test. The bubble should not be deformed, and the surface tissues around the needle should not be infiltrated with the solution. After identifying the position of the needle according to the test "loss of resistance" catheterize the space in the cranial direction and remove the needle, and the catheter is fixed to the skin with adhesive tape. During catheterization, the catheter must bend at right angles to advance cranially, which is quite difficult, especially in the elderly due to age-related anatomical changes in the spine (N.A. Lopatkin, D.M. Rubinov. Epidural-sacral anesthesia in urology. - Tashkent - 1969 - 110s .; IM Matyashin, L.G. Zaverny. Guide to Geriatrics. - M. - 1982. - P. 382-399; BC Schelkunov. Peridural anesthesia. L., Medicine, 1976, S. 6 , 79.). A test dose (5 ml) of anesthetic is administered through the catheter. After evaluating the effect of the test dose with a spinal needle in the interval L ₃ -L ₄ perform subarachnoid puncture. The position of the needle is identified by the appearance of cerebrospinal fluid in the lumen of the needle. A pre-selected dose of anesthetic is injected into the subarachnoid space through the needle and the needle is removed.

 To ensure the spinal component of spinal-epidural anesthesia, a 2% aqueous lidocaine solution, 1% hyperbaric lidocaine solution, 0.5% bupivacaine solution, a combination of lidocaine solutions with fentanyl and / or clonidine are used.

 The spinal component of combined spinal-epidural anesthesia provides a rapidly advancing blockade in the desired area.

 If necessary, local anesthetic solutions, for example, 5-8 ml of 2% lidocaine, are administered epidurally through a catheter in fractional doses.

 The catheter placement is designed to expand the blockade zone, extend it and conduct postoperative anesthesia.

 The disadvantage of the closest analogue is the complexity, and often the inability to catheterize the epidural space in the lumbar spine in the right direction due to the epidural veins and adipose tissue located in it. The complexity of puncture and catheterization of the epidural space, especially in the elderly, requires a highly qualified anesthesiologist and careful observance of the execution technique.

 The objective of the invention is to simplify the method of anesthesia by facilitating catheterization of the epidural space while reducing trauma and eliminating the likelihood of damage to the dura mater and spinal cord.

 The essence of the invention lies in the fact that in the method of combined spinal-epidural anesthesia of the lumbosacral spine, including the introduction of anesthetic through two punctures into the subarachnoid and epidural spaces, and, more recently, through catheterization, the anesthetic is introduced into the epidural space through the sacral canal.

 In addition, a modification of the proposed method is the introduction of an anesthetic through the sacral channel through a trocar needle inserted through a conductor needle.

 Another difference of the proposed method is a combination of optimal signs regarding the use of equipment: the use of a needle 10-12 cm long, 0.9 mm in diameter, as a conductor needle, 4 cm long needle, 3 mm in diameter, with a blunt end, as a needle a trocar compatible with a trocar delivering an anesthetic device such as a venous catheter, preferably from fluoroplastic, and a dispenser.

 Another difference of the proposed method is the use of weakly concentrated solutions of anesthetic for introduction into the subarachnoid and epidural spaces.

The inventive method is as follows. When performing it, the anatomy of the caudal canal, which is the distal part of the epidural system, accessible through the sacral canal, is taken into account. The sacral canal is located in the lower third of the posterior wall of the sacrum and is formed due to non-fusion of the arches S ₄ -S ₅ (sacral opening). The volume of the sacral canal in adults varies. The sacral channel contains epidural fiber, the terminal part of the dura mater at the level of S ₁ -S ₃ , five sacral nerves and the coccygeal nerves forming cauda eguina, fulum terminale - the terminal part of the spinal cord that does not contain nerves and exits through the sacral channel.

 The preparation of the patient and the surgical field is carried out according to the rules described in the section relating to the method of anesthesia closest to the claimed method. Use weakly concentrated solutions of local anesthetics, it is possible to use 1% lidocaine. To perform puncture and catheterization of the caudal canal, as a rule, use two syringes with a capacity of 5 and 10 ml, one needle with a length of 10-12 cm and a diameter of 0.9 mm (needle-conductor), a second needle with a blunt end 4 cm long and a diameter of 3 mm (trocar needle), epidural venous catheter compatible with a trocar needle, preferably from fluoroplastic.

 There are 3 basic positions of the patient: on the abdomen, on the side and an intermediate between them. Often punctured in the position of the patient lying on his stomach with a roller under the bosom, legs shoulder-width apart with toes inward for free access to the caudal canal.

 Find the sacral opening, passing along the sacral ridge down. In a patient with severe subcutaneous fat, they go from the coccyx up to the sacrococcygeal joint. In a manner similar to crushing fiber with a finger, the horns of the sacrum and the depression between them, corresponding to the sacred opening, are fixed. A thin skin needle conducts local infiltration anesthesia of the area of the proposed puncture of 1-3 ml of anesthetic, depending on the patient’s body weight.

In the projection of the sacral opening, a conductor needle is inserted with a trocar needle attached to it perpendicular to the sacrum. After a puncture of the skin, the needle pavilion is lowered by 45 ^o and is advanced until it feels the resistance of the sacrococcygeal ligament, breaking which the needle passes into the sacral canal. The required location of the needle-conductor is determined by the tight fit of the needle in the tissue during traction of its end. A trocar needle is inserted through the conductor needle into the sacral canal to a depth of no more than 3 cm (to avoid damage to the dura mater) and the conductor needle is removed.

 Exclude damage to the epidural veins and dura mater by the techniques described in the section relating to the closest to the claimed method of anesthesia.

 After identifying the position of the needle according to the test "loss of resistance" catheterize the sacred channel.

A catheter is inserted without difficulty, possible obstacles are easily overcome by its rotation. For catheterization, a more rigid fluoroplastic catheter is preferred. In this case, as a rule, damage to epidural veins is not observed. The end of the catheter should be located in the middle of the blocked dermatomes. For operations on the pelvis, perineum and lower extremities, this is L ₅ , at a higher level - L ₃ . The insertion depth is measured with a ruler from the sacral opening to the desired level.

Through a catheter, like a conductor, a trocar needle is removed from the sacral canal and the catheter is fixed with a band-aid. A syringe with an anesthetic is attached and a test dose (5 ml) is administered. After 5 minutes, in the absence of signs of a subarachnoid block and toxicity of the anesthetic (vomiting, convulsions, disorientation, psychomotor agitation), spinal puncture is performed in the interval L ₃ -L ₄ . After clarifying the position of the needle, a pre-selected dose of anesthetic is injected into the subarachnoid space and the needle is removed. The patient is laid on his back. After 5 minutes, a calculated dose of anesthetic is administered through the caudal epidural catheter.

 Having a small concentration gradient with respect to the nerve tissue, an epidurally weakly concentrated solution provides a clinically effective intraneural concentration under conditions of background subarachnoid inhibition of radicular conduction (I. A. Wittenbek. Combined spinal-epidural anesthesia as an option for conduction anesthesia during surgery. Vestn. chir. - 1981. - T. 126. - S. 123-128).

 In addition, in addition to the mutual potentiating effect of the surface depth of spinal and epidural anesthesia, the use of weakly concentrated solutions of the anesthetic in the claimed method virtually eliminates the development of systemic general toxic reactions and makes possible its epidural administration of significant volumes to expand the blockade zone.

 In contrast to the proposed method, the commonly used long-term epidural anesthesia and analgesia provide fractional administration of anesthetic with a variation in the depth of anesthesia from maximum after administration to minimum by the end of its action, which leads to discomfort of the patient. In addition, frequent disconnection and attachment of the syringe is fraught with infection of the catheter.

 However, continuous drip administration of anesthetic is practically not used epidurally due to the inability to calculate the rate of infusion and the threat of overdose.

 When performing the proposed method, continuous automatic caudal epidural anesthesia is used using a dispenser. The latter is connected after the administration of a test dose of anesthetic. In the absence of signs of a subarachnoid block, the anesthetic feed rate is set at 90 ml / h for the first 15 minutes, 12-15 ml / h throughout the operation, and 2-5 ml / h in the postoperative period.

 This method of combined spinal-epidural anesthesia was tested on 72 patients (60 men and 12 women) aged 40-85 years, operated on for various pathologies of the lumbosacral spine, pelvic organs, perineum and lower extremities. The method of analgesia proved to be effective and safe in 67 (93.2%) patients.

Example 1. Patient A., 64 years old, and. 1813, was operated under the claimed method of anesthesia in the neurosurgical department for a hernia of the intervertebral disc L ₅ -S ₁ , a diskectomy was performed.

 Example 2. Patient S., 77 years old, ib. 786, was operated under the same method of anesthesia in the urology department for benign prostatic hyperplasia of the second stage, performed simultaneous transvesical hemiprostatectomy.

 Example 3. Patient M., 43 years old, and.b. 1247, was operated under this method of anesthesia in the trauma unit for a closed comminuted fracture of the right femur with displacement of fragments, an intramedullary osteosynthesis was performed.

 Anesthesia with the claimed method with full sensory and motor blockade from the tips of the toes to the costal arch develops after 14-16 minutes. The duration of analgesia is about 3 hours. Position discomfort is eliminated by intravenous infusion of 1-1.5 mg / kg / h of ketamine and 1.5 μg / kg / h of fentanyl.

Conclusions:
All surgical interventions are performed while maintaining adequate (SpO ₂ 94-100%) respiration. Prevention of hemodynamic and coagulation disorders is provided by intravenous infusion of 0.4 l of reopoliglukin, 0.8-1.2 l of 0.9% sodium chloride. Blood transfusion is carried out with an operating blood loss of more than 0.5 liters. Throughout the operation, verbal contact with the patient is maintained. Most of the operated patients note a pleasant feeling of being in space, in the virtual world. Pain is absent during the operation and within 72 hours after it.

 Patients feel comfortable, active, do not need narcotic analgesics. Intestinal motility is restored in the first day. Hemodynamic and cardiorespiratory disorders do not exist. The injection site of the caudal epidural catheter is checked daily with a change of labels. Typically, the catheter is removed no later than 72 hours.

 The medical and social aspect of the proposed method of anesthesia is that it has a minimal effect on the function of the vital systems of the body during surgery and in the immediate postoperative period. Combined spinal-epidural anesthesia in the proposed embodiment provides reliable, safe and long-term protection of patients from surgical aggression throughout the perioperative period during operations on the lumbosacral spine, pelvic organs, perineum, lower extremities, allowing to maintain independent effective breathing and stable hemodynamics . Unlike commonly used methods of combined spinal-epidural anesthesia, the claimed method creates more favorable conditions for limiting the manipulations associated with puncture of the spinal canal below the level of the end of the spinal cord. The use of weakly concentrated solutions of local anesthetics when refusing narcotic analgesics provides adequate analgesia and muscle relaxation in the necessary zone, eliminates the development of systemic general toxic reactions and increases the economic attractiveness of the method. The rapid restoration of motor activity and the preservation of the psychophysiological status of patients greatly facilitates the work of medical personnel.

Claims (5)

 1. A method of combined spinal-epidural anesthesia of the lumbosacral spine, comprising administering anesthetic through two punctures into the subarachnoid and epidural spaces, the latter through catheterization, characterized in that the anesthetic is introduced into the epidural space through the sacral canal.  2. The method according to p. 1, characterized in that the introduction of the catheter into the sacral channel is carried out through a trocar needle inserted through a conductor needle.  3. The method according to p. 2, characterized in that as a needle-conductor use a needle 10-12 cm long, 0.9 mm in diameter, and as a trocar needle - a 4 cm long needle, 3 mm in diameter, with a blunt end .  4. The method according to PP. 1 or 2 and 3, characterized in that the delivery of the anesthetic to the epidural space is carried out metered and portionwise by means of a delivery device such as a venous catheter, preferably from fluoroplastic, and a dispenser.  5. The method according to PP. 1 or 2, 3 and 4, characterized in that they use weakly concentrated solutions of anesthetic to guide into the subarachnoid and epidural spaces.