RU2219918C2 - Anesthesia method in surgical treatment of patients with damages and diseases of lower extremities - Google Patents

Abstract

FIELD: anesthesiology, surgery, and traumatology. SUBSTANCE: mixture of preparations consisting of 2% solution of lidocaine in dose 3 mg/kg and clonidine in dose 3 mg/kg is portionwise injected into epidural cavity. When prolonged anesthesia is needed, the same mixture of preparations is readministered 2 h later in amount 1/2 the initial dose. EFFECT: enhanced anesthesia efficiency and ensured adequate antinociceptive protection of patients. 2 cl, 2 ex

Description

 The present invention relates to medicine, namely to anesthesiology, surgery, traumatology and orthopedics, and can be used for pain relief during surgical treatment of injuries and diseases of the lower extremities.

 Known methods of analgesia in the surgical treatment of injuries and diseases of the lower extremities, including the combined introduction of non-inhalation anesthetics in combination with narcotic analgesics in calculated dosages. Of non-inhalation anesthetics, thiopental Na, hydroxybutyrate Na, and ketamine are used. Central analgesia is achieved by the intravenous administration of narcotic analgesics (fentanyl, promedol). With the combined use of anesthetics, it is possible to achieve a decrease in the total dosages of the drugs and neutralize the negative effect of each of them. But, given that of the listed anesthetics, only ketamine, along with hypnotic, has an analgesic effect, fentanyl or promedol are used to achieve adequate analgesia [1].

 Closest to the proposed is a method of epidural anesthesia using local anesthetics, for example lidocaine, trimecaine in combination with narcotic analgesics (morphine, fentanyl) [2].

 The essence of the known method is that in the preoperative period perform puncture and catheterization of the epidural space in the gap corresponding to the area of surgical intervention according to standard methods. After a test injection of 2 ml of a 2% solution of lidocaine and in the absence of signs of a spinal block, a 2% solution of lidocaine or trimecaine is administered through a catheter at the rate of 1.5-2 ml per spinal segment. To prolong the action of local anesthetics and deepen epidural analgesia, morphine (0.1 mg / kg) or fentanyl (1.4 μg / kg) is added to the solution. The operation begins 15-20 minutes after the completion of the epidural administration of painkillers. To achieve a sedative effect, seduxen (0.07-0.15 mg / kg) is administered intravenously. According to the authors, this method of anesthesia allows surgical intervention on the organs of the small pelvis, lower limbs and hip joint lasting 2.5-3 hours, repeated doses of the anesthetic mixture are administered in the amount of 1/3 of the initial dose.

However, the known methods of pain relief in the surgical treatment of injuries and diseases of the lower extremities are not without significant drawbacks, namely:
The use of narcotic analgesics with intravenous multicomponent balanced anesthesia, even at calculated dosages, does not always allow reaching the required level of analgesia.

 The use of opioids, especially fentanyl, is often complicated by respiratory depression and requires assisted ventilation. Conducting an auxiliary mechanical ventilation using a mask does not exclude the partial ingress of air into the stomach, which increases the risk of latent regurgitation.

 The cumulative effect when using several anesthetics and narcotic analgesics, despite the calculation of the dose of drugs, leads to the prolongation of post-narcotic drug sleep.

 In turn, the known method of epidural anesthesia using local anesthetics and opioids does not take into account the latent period of the action of narcotic analgesics, and the time factor (15-20 minutes) is also not an absolute criterion for achieving effective anesthesia.

 The use of narcotic analgesics with epidural anesthesia, especially morphine in a dose (0.1 mg / kg), is fraught with delayed respiratory depression and the development of hypoventilation. Given the age factor of patients, for example, with pathology of the hip joints and the presence of the initial multiple organ failure, this argument must be taken into account first.

 Based on the current level of anesthesia technologies in the surgical treatment of injuries and diseases of the lower extremities, as well as eliminating the disadvantages of known technologies, the task was to increase the effectiveness of anesthesia and provide adequate antinociceptive protection for patients.

 The problem was solved by the preliminary introduction of sleeping pills and sedatives, followed by sedation by intramuscular injection of narcotic and antihistamines and by performing puncture and catheterization of the epidural space at a level corresponding to the lesion area and by injection of painkillers. A new solution to the problem is that a mixture of drugs consisting of a 2% solution of lidocaine at a dose of 4 mg / kg of the patient’s weight and clonidine at the rate of 3 μg / kg of the patient’s weight is injected epidurally fractionally, if necessary, additionally introduce this mixture of drugs in the amount of 1/2 of the initial dose.

 We explain the significance of the distinctive features of the proposed method.

 Epidural and fractional administration of a mixture of preparations consisting of a 2% solution of lidocaine at a dose of 4 mg / kg of the patient’s weight and clonidine at a dose of 3 μg / kg of the patient’s weight provides effective antinociceptive protection, prevents the hyperdynamic circulation reaction, eliminates the functional tension of the hypothalamic-pituitary adrenal and sympatho-adrenal systems. Additional administration, if necessary, after 2 hours, a mixture of solutions of lidocaine and clonidine in the amount of 1/2 of the initial dose allows prolonged analgesia.

 The essence of the proposed method of pain relief for injuries and diseases of the lower extremities is as follows.

 On the eve of the operation (at night and in the morning), patients are prescribed individual doses of sleeping pills and sedatives. 30-40 minutes before surgery, diphenhydramine (0.15-0.2 mg / kg), atropine (0.008-0.016 mg / kg), promedol (0.2-0.3 mg / kg) are intramuscularly administered.

In the operating room, in a sitting or lying position, the epidural space is punctured according to the standard technique in the interval L ₄ -L ₃ or L ₃ -L ₂ . The level of puncture depends on the severity of interspinous spaces. The catheter is carried out in the cranial direction by 3-4 cm, taking into account the level of puncture and marks on the catheter. To exclude damage to the dura mater and the development of the spinal block, an aspiration test is performed before the introduction of the anesthetic.

The test dose of lidocaine is 40 mg. In case of a negative aspiration test and no signs of spinal anesthesia (motor block), subsequent doses of lidocaine and clonidine are administered according to the dose-effect technique, which makes it possible to neutralize the undesirable hypotensive effect of epidural anesthesia and reduce the speed and volume of infusion therapy necessary to restore the ratio of bcc and vascular volume riverbed. The dose of a 2% lidocaine solution is 4 mg / kg of patient weight. Clonidine is administered in the same syringe with lidocaine at a dose of 3 μg / kg of patient weight. The total volume of the injected mixture is 5-7 ml, which provides a blockade of 4-5 spinal segments to a level of T ₁₂ -T ₁₁ . The development of sensory anesthesia is assessed using the pin prick test (loss of skin pain sensitivity in response to needle irritation). The motor block is considered satisfactory if the patient is unable to perform leg flexion in the hip and knee joints. After the development of the sensory and motor blocks, relanium (0.15-0.20 mg / kg) + GHB (50-60 mg / kg) is administered intravenously to exclude the effect of presence on the operating table and sedation. Effective anesthesia lasts for 1.5-2 hours. If it is necessary to prolong the anesthesia after 2 hours, this mixture of drugs is additionally administered in the amount of 1/2 of the initial dose.

 The effectiveness of analgesia during surgery is assessed by cortisol and glycemia, which are 421 nmol / L and 5.8 mmol / L, respectively. Pulse oximetry during surgery did not reveal significant changes in hemoglobin saturation, and hemodynamic parameters were stable at all stages of the operation.

 The essence of the proposed method is illustrated by clinical examples.

Example 1
Patient N., 54 years old, weight 80 kg, height 162 cm.

The main diagnosis: Dysplastic coxarthrosis of the III degree, pain,
Concomitant diagnosis: Coronary heart disease. Angina pectoris, II functional class, circulatory failure I degree. Hypertension II stage, slowly progressing course. Type II diabetes mellitus, insulin-dependent, diabetic angiopathy. Obesity 2 degrees.

 On the eve of the operation (at night), the patient was administered intramuscularly with Relanium 10 mg (2.0) for sedation. In the morning, 30 minutes before surgery, premedication is prescribed in the intensive care and resuscitation chamber: promedol 2% 1.0 ml; atropine 0.1% 0.8 ml; diphenhydramine 1% 1.0 ml.

 Before the operation, for the purpose of intraoperative analgesia, puncture and catheterization of the epidural space was performed according to the standard method. After performing an aspiration test and a trial (test dose) of lidocaine administration, a mixture of drugs was epidurally introduced: a lidocaine solution of 2% 2.5 mg / kg patient weight and clonidine 2 μg / kg patient weight. After 15 minutes from the moment of introduction of the mixture of solutions, a good analgesic effect with signs of motor blockade was noted. Additionally, to achieve effective anesthesia, epidurally introduced: 2% solution of lidocaine 120 mg and clonidine 100 μg. After 10 minutes from the moment of additional administration of the mixture of anesthetics, the development of anesthesia with loss of pain and motor sensitivity was noted. In order to level the effect of presence on the operating table and relieve psychoemotional stress, the following drugs were injected intravenously: GHB 4 grams and Relanium 10 mg (2.0 ml).

 Operation: Total arthroplasty of the left hip joint.

 Duration of operation: 1 hour 40 minutes.

 After the operation, the patient is conscious, adequately answers the questions. There are no pains in the field of surgical intervention. The patient was transferred to the intensive care unit for further observation and treatment.

Example 2
Patient K., 63 years old, weight 86 kg, height 171 cm.

 The main diagnosis: Closed comminuted oblique fracture of the middle third of the diaphysis of the right femur with displacement.

 Concomitant diagnosis: Coronary heart disease. Angina pectoris, II functional class, circulatory failure I. Postinfarction cardiosclerosis. Hypertension II stage, slowly progressing course. Chronic bronchitis in remission. Obesity of 1 degree.

 On the eve of the operation (at night), the patient was administered intramuscularly with Relanium 10 mg (2.0) for sedation. In the morning, 30 minutes before surgery, premedication is prescribed in the intensive care and resuscitation chamber: promedol 2% 1.0 ml; atropine 0.1% 0.9 ml; diphenhydramine 1% 1.0 ml.

 Before the operation, for the purpose of intraoperative analgesia, puncture and catheterization of the epidural space was performed according to the standard method. After performing an aspiration test and a trial (test dose) of lidocaine administration, a mixture of drugs was epidurally introduced: a lidocaine solution of 2% 2 mg / kg of the patient’s weight and clonidine 1.5 μg / kg of the patient’s weight. After 20 minutes from the moment of introduction of the mixture of solutions, a good analgesic effect with signs of motor blockade was noted. Additionally, to achieve effective anesthesia epidurally introduced: 2% solution of lidocaine 2 mg / kg of patient weight and clonidine 1.5 μg / kg of patient weight. After 15 minutes from the moment of additional administration of the mixture of anesthetics, the development of anesthesia with loss of pain and motor sensitivity was noted. To level the effect of the presence on the operating table and relieve psychoemotional stress, the following drugs were injected intravenously: GHB 5 grams and Relanium 10 mg (2.0 ml). After 1 hour 45 minutes, given the duration of the operation, an additional mixture of drugs was epidurally introduced: a 2% solution of lidocaine 160 mg 2 mg / kg of patient weight and clonidine 150 μg 1.5 μg / kg of patient weight. In order to prolong sedation, intravenously administered: GHB 2 grams and Relanium 5 mg (1.0 ml).

 Operation: Combined transosseous osteosynthesis of the right femur. Duration of surgery: 2 hours 30 minutes.

 After the operation, the patient is conscious, oriented, adequately answers questions. Pain in the field of surgical intervention is not noted. Transferred to the intensive care unit for further observation and treatment.

 Thus, the proposed "Method of anesthesia in the surgical treatment of injuries and diseases of the lower extremities" allows, in comparison with other known methods of anesthesia, to increase the effectiveness of analgesia, to provide adequate antinociceptive protection for patients, as well as to prevent the hyperdynamic reaction of blood circulation and level the neuroendocrine reactions of the body.

Sources of information
1. Bunyatyan A.A. Guide to anesthesiology. M .: Medicine, 1997 .-- 656 p.

 2. Tsibulyak V.N., Tsibulyak G.N. Trauma, pain, anesthesia. M .: Medicine, 1994 .-- 224 p.

Claims (2)

1. The method of analgesia in the surgical treatment of injuries and diseases of the lower extremities, including the preliminary administration of sleeping pills and sedatives, subsequent sedation by intramuscular injection of antihistamines and narcotic drugs and performing puncture and catheterization of the epidural space at a level corresponding to the lesion zone and infusion of painkillers, characterized in that epidurally fractionally injected a mixture of drugs consisting of a 2% solution of lidocaine at a dose of 4 mg / kg of patient weight and clonidine at a dose of 3 mg / kg of patient weight. 2. The method according to claim 1, characterized in that, if necessary, prolonged pain relief after two hours, this mixture of drugs is additionally administered in an amount of 1/2 of the initial dose.