RU2228148C1 - Method for giving postsurgical anesthesia to patients pancreatonecrosis after performing omentobursostomy with multiple programmed sanation relaparotomies - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying epidural analgesia, nonsteroid anti-inflammatory means, opiates, Dalargin, spasmolytics, adjuvant therapy with analgesia process being divided into four stages with the order and number of sanation relaparotomies taken into account. Analgesia of current stage is carried out with previous stage prescriptions as well as analgesia synergism and prolongation, pain syndrome intensity at surgical treatment stages taken into consideration. EFFECT: enhanced effectiveness in arresting pain syndrome with functional activity of patients being retained.

Description

The present invention relates to anesthesiology and resuscitation, and in particular to methods for postoperative analgesia of patients with pancreatic necrosis after omentobursostomy with multiple programmed sanative relaparotomies, including epidural analgesia, non-steroidal anti-inflammatory drugs, opiates, dalargin, antispasmodic.

1. It is known that:

- postoperative analgesia in surgical patients who have undergone extensive surgery, is an essential component of intensive care of the postoperative period. A modern understanding of the mechanisms of pain leads a leading role in the modulation of pain to biologically active substances - mediators (serotonin, cytokines, substances P, leukotrienes, prostaglandins), which are released at the site of tissue damage and stimulate polymodal nociceptors.

In a number of surgical pathologies, the most problematic are surgical patients operated on for destructive pancreatitis. Among the methods of surgical interventions for pancreatic necrosis, the most severe are omentobursostomy with subsequent planned debridement relaparotomy.

The duration of stage surgical interventions reaches from 21 to 43 days.

The main symptom of acute pancreatitis is pain. The pains are intense, without light gaps. Sometimes patients even lose consciousness. In some situations, a sharp pain syndrome can lead to collapse and shock phenomena: profuse sweat, lowering blood pressure, tachycardia with weakening heart rate.

The pain syndrome is supported by four sources of pain impulse - cutaneous, deep somatic, visceral and humoral, and they, in turn, cause a reflex vascular spasm, forming a vicious circle, leading ultimately to general and organ hypodynamia and the development of various kinds of complications: muscle weakness , indigestion, intestinal paresis, impaired bronchial conduction, hypoventilation, tachycardia, cardiac arrhythmias, hypovolemia, red blood cell sequestration, thrombosis and embolism, oliguria, floor sphincter spasm x organs, atelectasis and pneumonia.

Relief of pain at the stages of treatment of destructive pancreatitis is carried out taking into account the main factors of pain mediation, the severity of the systemic inflammatory response to a specific period of treatment of patients. It should be low toxic, not have a pronounced deprimative effect on vital organs and systems of the body.

It is believed that narcotic analgesics are the main treatment for severe pain syndromes [1].

After extensive intracavitary surgical interventions, the use of opioids in doses that cause pronounced sedation, respiratory depression, nausea, vomiting, gastrointestinal paresis, biliary and urinary tract dysfunction is often required to achieve adequate analgesia. This negatively affects the condition of the operated patients, complicates their activation, contributes to the development of respiratory, thromboembolic and other complications. Given that the surgical treatment of destructive pancreatitis requires frequent debridement relaparotomies, the issue of tolerance and dependence on narcotic analgesics becomes relevant. In this regard, in addition to opiates, it is required to use drugs of other pharmacological groups that can potentiate the analgesic effect of narcotic analgesics. The most pathogenetically substantiated is the use of analgesics with anti-inflammatory action [2].

See: [1]. The order and timing of the appointment of narcotic analgesics. Guidelines №2001 / 129. MZRF MNII them. P.A. Herzen. Author: professor N.A. Osipova. Institution-developer: Moscow Cancer Research Institute P.A. Herzen. / Printing house of “LACUS” LLC. 107140, Moscow, Lesnoryadsky per., D.18, p.1. / Moscow, 2001, p. 3-4; 10-12.

[2]. Clinical anesthesiology / Equipment and monitoring. Regional anesthesia. Pain treatment. J. Edward Morgan - Jr., Magid S. Michael. / Translation from English under the editorship of Academician RAMS A.A. Bunyatyan, Cand. Honey. sciences A.M. Zeitlin./ Department of Anesthesiology University of Southern California School of Medicine Los Angeles /. Binom Publishing House, Moscow, 2001, pp. 170-172.

II. It is also known that:

- the main properties of non-steroidal anti-inflammatory drugs are anti-inflammatory, antipyretic, analgesic. In addition, non-steroidal anti-inflammatory drugs of the latest generation (ketorol, diclofenac, xifocam and others) are distinguished by an opioid-saving effect. At the same time, the ulcerogenic nature of non-steroidal anti-inflammatory drugs does not allow their prolonged use in the postoperative period in surgical patients at the stages of pancreatic necrosis treatment for more than 5-7 days. An intermittent course of prescribing non-steroidal anti-inflammatory drugs is necessary, depending on the severity of the systemic inflammatory reaction.

Ketorolac tromethamine is markedly distinguished in this group of non-steroidal anti-inflammatory drugs by its analgesic activity. The basis of the mechanism of analgesic and anti-inflammatory action is inhibition of prostaglandin synthesis in traumatic tissues. Ketorolac, inhibiting cyclooxygenase, prevents the formation of pain mediators, such as bradykinin, histamine, substance P, etc. It does not bind to opioid receptors. Ketorolac is prescribed in a daily dose of 90-120 mg in combination with an opioid analgesic prescribed “according to the indications”.

See: Pharmacotherapy for acute pain. R.N. Lebedeva, V.V. Nikoda. RSCH RAMS / M., Air Art Publishing House, 1998, pp. 44-47; 66.

III. It is also known that:

- Epidural analgesia by its mechanism of action is able to prevent the influence of three components of pain impulse: cutaneous, deep somatic and visceral.

The sympatholytic effects of epidural analgesia contribute to the removal of reflex vasospasm, increased intestinal motility, increased perfusion of organs and tissues, which is most important in surgical patients with pancreatic necrosis [1].

Epidural anesthesia with local anesthetics favorably affected the suppression of endocrine and metabolic changes caused by surgery [2].

The use of prolonged epidural anesthesia in the treatment of acute pancreatitis not only effectively inhibits the triggering mechanism of the pathophysiological process, but, acting on many links of pathogenesis, it can significantly reduce the number of pharmacological agents, reduce their dosage, and reduce the negative effects of polyprograms without decreasing the effectiveness of treatment [3].

In patients with pancreatitis, epidural analgesia completely relieves pain, relieves visceral vasospasm, spasm of the sphincter of Oddi, pancreatic and bile ducts, due to which pancreatic perfusion increases, and normalization of blood and urine amylase is accelerated.

Puncture and catheterization of the epidural space is performed at the level of Th 7-8. The dose of anesthetic administered is determined by the need for blockade of 7-8 segments of the spinal cord (Th 5-12) at a rate of 1.2-2.0 ml / seg. Usually use 6-10 ml of a 2% solution of lidocaine or anecaine 25 mg × 4 times / day [1].

See: [1]. Spinal and epidural anesthesia. V.A. Koryachkin, V.I. Strashnov / Department of Anesthesiology, Intensive Care and Intensive Care, St. Petersburg State Medical University Acad. I.P. Pavlova / St. Petersburg: Publishing House LLC St. Petersburg Medical Publishing House, 2000, pp. 73-75; 70.

[2]. Postoperative pain. Edited by F. Michael Ferrante, M.D., Timothy R. WadeBoncor, M.D., Translated from English by prof. M.A. Karachunsky, Ph.D. U.V. Melnikova. / Department of Anesthesia Harvard Medical School, Pain Management Center Department of Anesthesia Brigham and Women′s Hospital Boston, Massachusetts./ Moscow, Medicine, 1998, pp. 94-95; 557.

[3]. Regional anesthesia - return to the future. (Collection of materials of the scientific-practical conference on the problems of regional anesthesia). Moscow, 2001, article: “Prolonged epidural anesthesia in the treatment of acute pancreatitis” Imported KP, Mishustin IV, Obraztsova EN GKB “Electronics”, Department of Anesthesiology and Intensive Care, Voronezh (Head of the Department S.L. Avtomonov), pp. 69-70.

IV. It is also known that:

- the humoral component of pain impulse in pancreatic necrosis can be stopped by a number of other inhibitors of biologically active substances.

For this purpose, the peptide drug dalargin is used, which inhibits the intracellular processes of pancreatic enzyme synthesis, reduces basal and stimulated pancreatic secretion, inhibits kinin synthesis, eliminates disorders of intraorgan microhemolymphocirculation, delimits necrosis foci [1].

Using the radioimmune method, it was found that the T 1/2 period of dalargin in vivo is 2 minutes. Additional studies using the method of nuclear magnetic resonance clarified the pharmacokinetics of dalargin: a period of T 1/2 in blood plasma is 14 minutes. With the breakdown of dalargin, substances are formed in the body that can bind to opioid receptors. Radioreceptor studies have shown that dalargin is an opiate receptor agonist. It has a high affinity for delta receptors, less for mu receptors and does not bind to kappa and sigma receptors [2].

According to reports, dalargin is administered at a dose of 75 μg per 1 kg of body weight per 20 ml of saline for 4-6 days, 2-3 times intravenously [1].

Sandostatin is a long-acting synthetic octapeptide that has a number of advantages over natural somatostatin: it suppresses gastric secretion and the formation of pancreatic enzymes. It was shown that somatostatin and its synthetic analogue, octreotide acetate (sandostatin) are the strongest inhibitors of basal and stimulated secretion of the pancreas, stomach and small intestine, regulators of the immune system and cytokinogenesis, splanchnic blood flow, which, along with the cytoprotective effect of the drugs, determines their pathogenetic use patients with pancreatic necrosis. Sandostatin is used in a daily dose of 300-600 mcg / day with triple subcutaneous or intravenous administration. Somatostatin therapy is a reasonable method for the prevention and pathogenetic treatment of destructive pancreatitis in patients with a high risk of extra-abdominal (cardiopulmonary, renal, stress bleeding) systemic complications in the early stages of the disease [4].

Inhibition of enzymes is achieved by intravenous or intracranial administration: contracal, trasilol, gordoks. Protease inhibitors inhibit the activity of proteolytic enzymes, forming stable complexes with them. These drugs inhibit the formation of kinins and autolysis by inactivating trypsin, kalecrein, chymotrypsin and plasmin, inhibit fibrinolysis, inhibit the activity of kalecrein in the gland tissue, inhibit the overall metabolic activity of the gland parenchyma, actively affect microcirculation and oxygen saturation of the tissues, inhibit enzymes directly in the pancreas [ thirteen]. To eliminate enzymatic toxinemia, protease inhibitors are used: countercal up to 150 thousand KIE / day; gordoks up to 500-700 thousand KIE / day, etc. Thus, the positive clinical effect of inhibitors is due only to the inactivation of enzymes circulating in the blood and lymph of a patient with pancreatitis. However, their widespread use is constrained by the high cost of drugs [3].

See: [1] “Topical issues of clinical medicine”. Collection of scientific papers dedicated to the 20th anniversary of the Moscow Clinical Hospital No. 15 of Moscow. Ed. prof. EAT. Evsikova, article: “Pancreatic necrosis. The choice of treatment depending on the cause and stage of the disease. ” Nesterenko Yu.A., Laptev V.V., Mikhaylusov S.V., Shapovalnts S.G., Burova V.A., Gridchik I.E., Zakharenko N.V., Tronin R.Yu., Imanaliev M .R. / Publishing House Institute of Youth, 111395, Moscow, ul. Youth, 5/1 /, Moscow, 2001, pp. 250-252.

[2] “Regulatory peptides in the treatment of surgical diseases of the abdominal organs." V.A. Penin. Moscow Order of the Red Banner of Labor Dental Medical Institute. ON THE. Semashko. / Printing house of Military Publishing. / Moscow, 1992, p. 5-9; 18, 20-23.

[3] "Pancreatic necrosis” (clinic, diagnosis, treatment). Yu.A. Nesterenko, SG Shapovalnts, VV Laptev. City Clinical Hospital No. 15 of the city of Moscow. / Orekhovo-Zuevskaya Printing House, Orekhovo- Zuevo, Moscow Region, Dzerzhinsky St., 1 /, Moscow, 1994, pp. 127-129; 152-155.

[4] “Acute pancreatitis. A manual for doctors.” Edited by Academician V. S. Saveliev, M. M. Filimonov, B. R. Gelfand, S. S. Burnevich, B. B. Orlov, E. Ts. Tsydenzhapov, Russian State Medical University, Department of Faculty Surgery with a course of anesthesiology-resuscitation and a course of cardiovascular surgery FUV / Publishing House of the Central Scientific and Practical Center named after AN Bakulev RAMS / Moscow, 2000, p. 33.

The aim of the invention is to anesthetize while maintaining the functional activity of patients, the use of a minimal arsenal of mutually potent analgesic drugs of various types of action, and the reduction in the need for opiates up to their exclusion.

This goal is achieved by the fact that anesthesia is divided into stages, taking into account the order and number of rehabilitation relaparotomies, with anesthesia at each stage taking into account the prescriptions in the previous stages, synergism and prolongation of the analgesic effect, the degree of intensity of the pain syndrome at the stages of surgical treatment: at the first stage - from omentobursostomy to the 1st sanation relaparotomy, a continuous infusion of dalargin is carried out at a dose of 0.6-0.8 mg / kg / day in combination with non-steroidal anti-inflammatory drugs, ing protease inhibitors, antispasmodics, opiates if necessary; at the second stage - from the first rehabilitation relaparotomy to the II-III-th rehabilitation sanitation relaparotomy - epidural analgesia is added with local anesthetics, excluding non-steroidal anti-inflammatory drugs; at the III-m stage - from the second-third to the fourth-sixth rehabilitation sanitation relaparotomy - they give up narcotic analgesics and protease inhibitors; at the IV stage, after the sixth debridement relaparotomy and subsequent debridement relaparotomies, pain relief is provided exclusively by intramuscular administration of dalargin at a dose of 0.25-0.3 mg / kg / day and non-steroidal anti-inflammatory drugs.

The essence of the present invention is illustrated by the following specific examples:

Example 1

Patient S., 86 years old, was admitted to 6 chir. branch of 4 mountains. b-ts 8.11.01. with a clinical diagnosis: “hemorrhagic pancreatic necrosis”.

Anamnesis of the disease: acutely ill on 11/11/01, when abdominal pain appeared, gradually intensifying.

Etiology: chronic calculous cholecystitis. Violation of the diet.

The patient was examined in a hospital: 1) 9.11.01. Ultrasound of the abdominal cavity: diffuse changes in the liver, chronic calculous cholecystitis. Acute pancreatitis. Moderate amount of fluid in the abdominal cavity.

2) 11.11.01, Laparoscopic abdominal drainage. Diagnosis: mixed pancreatic necrosis.

After treatment and diagnostic laparoscopy, the patient was transferred to the ICU on November 9, 2001 for preoperative preparation.

Upon admission to ICU, the patient retained severe pain, which was evaluated by YOUR at 5.0 points; the analgesia score was 3.5 points. The type of hemodynamics is hypokinetic. In the analysis of KShchS revealed shifts towards compensated metabolic acidosis. The patient showed a predominance of activity of the sympathoadrenal system: Kerdo index = +18, the severity of the condition was assessed using integrated scales: ARACNE II 11 points (15% predicted mortality), Ranson - 2 points (<1% predicted mortality).

The patient was prescribed a scheme of complex postoperative analgesia developed in our clinic (SKPA): dalargin at a dose of 0.6 mg / kg / day + ketorol 30 mg / 2 times / day + octreotide 0.1 mg / day + contracal 30 mg × 2 times / day + baralgin 5 ml × 4 times / day. After 12 hours from the start of the use of SCAP, the patient had a positive therapeutic effect of analgesia, characterized by a decrease in the intensity of the pain syndrome and an improvement in the functional methods for assessing nociception. On the 2nd day from the moment of admission to the ICU, the phenomena of pancreatogenic toxemia were eliminated. In a deferred order, the patient performed omentobursostomy: 11/12/01. Intraoperatively: steatonecrosis, in the region of the lesser omentum, the root of the mesocolon. Gross necrosis in the area of the head and tail of black color.

After surgery, in the intensive care unit, the patient continued infusion-correcting therapy, with the appointment of a complete parenteral nutrition and the continuation of the stage SCA. Changes in the patient’s condition, the level of analgesia, the response of the cardiovascular system and homeostasis as a whole are presented in the table “Map of postoperative pain management in the ICU” (Appendix No. 1).

It should be noted that at this stage a satisfactory level of analgesia: YOUR = 2.5-3.0 points; analgesia score = 4-4.5 points, good sensometry: TP = 1.25-2.5 mA; BP = 5-10 mA and higher was provided due to the second stage of SCAP: epidural analgesia: anecaine 25 mg × 4 times / day + dalargin 0.6 mg / kg / day + octreotide 0.1 mg / day + contrical 30 mg × 2 times / day The introduction of narcotic analgesics was not required.

During the observation in the ICU, the patient underwent several programmed debridement relaparotomies. 11/16/01 - reorganization relaparotomy I. / Intraoperatively: there are necrosis of the pancreas head, with a transition to the lesser omentum, no fresh necrosis in the tail /; 11.21.01 - reorganization relaparotomy II.

At the third stage - from the first rehabilitation relaparotomy to the second rehabilitation relaparotomy (November 16, 2001 - November 21, 2001), the complex postoperative analgesia (SCA) scheme developed by our clinic is a satisfactory level of analgesia: YOUR: 2.5-3.0 points; analgesia score: 4 points; stable sensors: TP = 1.5-2 mA, BP = 10 mA and higher were achieved due to: epidural analgesia - anecaine 25 mg × 4 times / day + dalargin 0.6 mg / kg / day + baralgin 5 ml × 4 times / day 11/21/2001 year epid. the catheter is removed.

At the fourth stage, after the second rehabilitation relaparotomy and subsequent rehabilitation sanitation relaparotomies: from November 22, 2001, anesthesia was provided by the intramuscular injection of dalargin at a dose of 5 mg × 4 times / day and ketorol 30 mg × 2 times / day.

Clinical and laboratory dynamics of the effectiveness of postoperative analgesia at the stages of programmed relaparotomy in a patient L. Stepanova presented in the table “Map of postoperative analgesia in the ICU”, see Appendix No. 1.

11/22/01, after a 13-day stay in the ICU, the patient was transferred to 6 surgeons. Dep. in satisfactory condition. Discharged home on 12.28.01, the condition at discharge is quite satisfactory.

Example 2

Patient P., 58 years old, was admitted to 6 hir. branch of 4 mountains. BC 25.01.02 with a diagnosis of “infected pancreatic necrosis”.

Anamnesis of the disease: within 2 weeks of pain in the right hypochondrium. The intensification of pain during the last 3 days (01/22/02 - 01/25/02), a rise in temperature to 38.5 ° C; chills, nausea, vomiting.

Etiology: chronic calculous cholecystitis. Violation of the diet.

Objectively: infiltrate is palpated in the right hypochondrium.

The patient was admitted to the ICU after omentobursostomy performed on a deferred order on January 28, 02. Upon admission to ICU, the patient retained severe pain, which was evaluated by YOUR 4.5 points; the analgesia score was 4 points. The type of hemodynamics is normokinetic. When analyzing the acid-base syndrome, no shifts towards compensated metabolic acidosis or alkalosis were detected. The patient noted a predominance of activity of the sympathoadrenal system: Kerdo index = +26, the severity of the condition was assessed by the integrated scales: ARACNE II - 13 points (10% predicted mortality); Ranson - 2 points (<1% of the predicted mortality), after 48 hours - 3 points (15% of the predicted mortality).

Postoperative pain relief at the stages of programmed relaparotomy in a patient Z. Pyshkina presented in the table “Map of postoperative pain management in the ICU”, see Appendix No. 2.

The patient was prescribed a scheme of complex postoperative analgesia developed in our clinic (SKPA): dalargin at a dose of 0.6 mg / kg / day + ketorol 30 mg / 2 times / day + octreotide 0.1 mg / day + contracal 30 mg × 2 times / day + baralgin 5 ml × 4 times / day. After 12 hours from the start of the use of SCAP, the patient had a positive therapeutic effect of analgesia, characterized by a decrease in the intensity of the pain syndrome and an improvement in the functional methods for assessing nociception. On the 2nd day from the moment of admission to the ICU, the phenomena of pancreatogenic toxemia were eliminated.

It should be noted that at this stage, a satisfactory level of analgesia: YOUR = 4.0-4.5 points; analgesia score = 4-4.5 points, good sensometry: TP = 1.75-2.5 mA; BP = 3.5-5 mA was provided due to the first stage of the control panel.

During the observation in the ICU, the patient underwent several programmed debridement relaparotomies: 1.02.02 - debridement relaparotomy I; 5.02.02 - reorganization relaparotomy II; 02/08/02 - reorganization relaparotomy III.

After surgery, in the intensive care unit, the patient continued infusion-correcting therapy, with the appointment of a complete parenteral nutrition and the continuation of the stage SCA.

At the second stage, from the first rehabilitation relaparotomy to the second rehabilitation relaparotomy (1.02.02 - 5.02.02), the scheme of complex postoperative analgesia developed in our clinic is a satisfactory level of analgesia: YOUR: 3.0-3.5 points; analgesia score: 4-5 points; stable indicators of sensometry: T.P. = 2-2.5 mA; BP = 4-5 mA was ensured by epidural analgesia: anecaine 25 mg × 4 times / day (catheterization of the epidural space 1.02.02) + dalargin 0.6 mg / kg / day + octreotide 0.1 mg / day + contriculum 30 mg × 2 times / day.

Changes in the patient’s condition, the level of analgesia, the response of the cardiovascular system and homeostasis as a whole are presented in the table “Map of postoperative pain management in the ICU” (Appendix No. 2).

At the third stage: from the second rehabilitation relaparotomy to the third rehabilitation relaparotomy (February 5, 02 - February 8, 02), the scheme of complex postoperative analgesia developed in our clinic is a satisfactory level of analgesia: YOUR: 3.0-3.5 points; analgesia score: 4-5 points; stable sensometry: TP = 1-2.5 mA; BP = 5 mA was provided due to epidural analgesia: anecaine - 25 mg × 4 times / day + dalargin 0.6 mg / kg / day, 02/09/02 - epid. the catheter is removed.

At the fourth stage, after the third rehabilitation relaparotomy and subsequent rehabilitation sanitation relaparotomies (from February 9, 02), anesthesia was provided by intramuscular administration of dalargin at a dose of 5 mg × 4 times / day + ketorol 30 mg × 2 times / day.

Clinical and laboratory dynamics of the effectiveness of postoperative analgesia at the stages of programmed relaparotomy in a patient Z. Pyshkina presented in the table “Map of postoperative analgesia in the ICU”, see Appendix No. 2.

On the 14th day it was transferred to 6 chir. the department is in satisfactory condition. 02/14/02 discharged home.

Example 3

Patient S., 21 years old, was admitted at 6 h./about. 4 GKB 10/14/01 with a diagnosis of "edematous form of pancreatitis."

Anamnesis of the disease: epigastric pain from 12.10.01 after alcohol abuse, nausea, repeated vomiting.

Etiology: alcohol abuse.

Examinations and terms of staged relaparotomy: 1) 10/14/01. Laparoscopic drainage - Diagnosis: edematous form of pancreatitis.

2) 10.16.01 - Ultrasound of the abdominal cavity: diffuse changes in the liver, ascites, pancreas are not visualized.

3) 10.17.01 - repeated ultrasound of br. cavities: signs of acute pancreatitis, ascites.

4) 10.19.01. Omentobursostomy. Intraoperative: subtotal pancreatic necrosis. Phlegmon retroperitoneal space.

5) 10.19.01. Chest X-ray: Left-sided reactive pleurisy.

6) 10.22.01. Remediation Relaparotomy I.

7) 25.1.01. Remediation Relaparotomy II. X-ray of the chest - residual pleurisy.

8) 10.30.01. Remediation Relaparotomy III.

9) 2.11.01. Sanitary relaparotomy IV - residual necrosis in the tail of pancreas, pus in the stuffing bag no.

10) 9.11.01. Sanitation relaparotomy V - suturing of a laparotomy wound.

11) 11/30/01 - discharged home.

After repeated ultrasound of the abdominal cavity on 10/18/01, the patient was transferred to the ICU for preoperative preparation.

Upon admission to ICU, the patient retained severe pain, which was evaluated by YOUR at 5.0 points; the analgesia score was 3.5 points. The type of hemodynamics is normokinetic. Marked depletion of the sympathoadrenal system with a negative value of the Kerdo index: -3.4 was noted. When analyzing the acid-base syndrome, no shifts towards compensated metabolic acidosis or alkalosis were detected. The severity of the condition was assessed by the integrated scales: ARACNE II - 8 points (10% of the predicted mortality); Ranson - 1 point (less than 1% of the predicted mortality), after 48 hours - 2 points (less than 1% of the predicted mortality).

The patient was prescribed the scheme of complex postoperative analgesia developed in our clinic (SCA): dalargin at a dose of 0.6 mg / kg / day + ketorol 30 mg × 2 times / day + octreotide 0.1 mg / day + contracal 30 mg × 2 times / day + baralgin 5 ml × 4 times / day. After 12 hours from the beginning of the use of SKPA, the patient noted a positive therapeutic effect of analgesia, characterized by a decrease in the intensity of the pain syndrome and improved functional methods for assessing nociception. On the 2nd day from the moment of admission to the ICU, the phenomena of pancreatogenic toxemia were eliminated. In a deferred order, the patient underwent an omentobursostomy on 10/19/01. Intraoperative: subtotal pancreatic necrosis. Phlegmon retroperitoneal space.

After surgery, in the intensive care unit, the patient continued with infusion-corrective therapy, with the appointment of full parenteral nutrition and the continuation of the stage SCA. Changes in the patient’s condition, the level of analgesia, the response of the cardiovascular system and homeostasis as a whole are presented in the table “Map of postoperative pain management in the ICU” (Appendix No. 3).

It should be noted that at this stage a satisfactory level of analgesia: YOUR = 4 points; analgesia score = 3.5-4 points; good sensometry: TP = 1.75-2.5 mA; BP = 4.5-5 mA was provided due to the second stage of SKPA: epidural analgesia: anecaine 25 mg × 4 times / day + dalargin 0.6 mg / kg / day + octreotide 0.1 mg / day + contracal 30 mg × 2 times / day

During the observation in the ICU, the patient underwent several programmed debridement relaparotomies. 10.22.01 - debridement relaparotomy I / intraoperatively: there are necrosis of the head and tail of pancreas, with a transition to the lesser omentum /. 10/25/01 - reorganization relaparotomy II; 10.30.01 - reorganization relaparotomy III; 2.11.01 - debridement relaparotomy IV: / intraoperatively: residual necrosis in the tail of pancreas, pus in the stuffing bag no /.

At the third stage - from the first rehabilitation relaparotomy to the second rehabilitation relaparotomy (10/22/2001 - 10/25/2001) developed in our clinic complex postoperative analgesia (SCA) scheme, a satisfactory level of analgesia: YOUR: 3.5-5 points; analgesia score: 3.5-4 points; stable sensometry TP = 1.75-2.25 mA; BP = 5 mA was provided due to epidural analgesia: anecaine 25 mg × 4 times / day + dalargin 0.6 mg / kg / day + baralgin 5 ml × 4 times / day. 10/26/2001, epid. the catheter is removed. At this stage, the administration of narcotic analgesics was twice required: 10.24.01 - for the purpose of sedation before the planned stage relaparotomy and in the immediate postoperative period, after relaparotomy II.

At the fourth stage, after the second rehabilitation relaparotomy and subsequent rehabilitation sanitation relaparotomies from 11.22.2001, anesthesia was provided by the administration of IM dalargin at a dose of 5 mg × 4 times / day and ketorol 30 mg × 2 times / day.

Clinical and laboratory dynamics of the effectiveness of postoperative analgesia at the stages of programmed relaparotomy in a patient Smirnova VV; 21 years old, is presented in the table “Map of postoperative analgesia in the ICU”, see Appendix No. 3.

Application Notes:

- Criteria for analgesia:

- YOUR - Visual analogue scale.

- Sensometry (in mA).

- BP - Pain threshold.

- TP - Tactile threshold.

- Hemodynamic indicators:

- CVP - Central venous pressure.

- GARDEN - Mean arterial pressure.

- SI - Heart index.

- UI - shock index.

- OPSS - General peripheral vascular resistance.

- DNLL - Diastolic filling of the left ventricle.

- LVH - The work of the left ventricle.

- IMRA - Index of mechanical work of the left ventricle.

- Indicators of activity of the autonomic nervous system:

- DP - Double product (HELL _sit x heart rate).

- Systems for assessing the severity of patients.

- ARASN II

- ranson

The claimed method is not obvious to specialists working in this field:

1. For the first time in clinical practice, a staged approach to postoperative analgesia in surgical patients with destructive forms of pancreatic necrosis has been applied, due to modern surgical tactics, including: programmable order, number and extent of debridement relaparotomy with the above pathology. The method was analyzed in detail in 35 severe patients.

2. For the first time, the step-by-step method of postoperative analgesia is aimed not so much at blocking somatic and visceral nociception, but primarily at creating anti-stress protection, taking into account modern views of the formation of pain and stress.

3. It turned out quite unexpectedly that the developed method of postoperative analgesia almost completely coincides with the phases of metabolic stress studied by Moore in 1968. The combined method of postoperative analgesia has a fairly powerful anti-stress protection, which is characterized by the suppression of humoral and systemic reactions of the body in the 1st (adrenocorticoid) phase of operational stress: there is a normalization of indicators of acid-base state, a decrease in proteolytic enzymes, normalization blood glucose and reducing stress harmonics: cortisol.

4. The proposed approach to postoperative analgesia revealed a previously unfeasible opportunity to significantly reduce the need for opiates, up to their complete elimination, to make them reserve analgesics, to reduce their general toxicity to vital organs and systems.

5. The method allows to maintain the functional activity of patients, taking into account the length of stay in the clinic, which, as a rule, is at least 30-60 hospital days, the most difficult stage from omentobursostomy to 3-4 relaparotomy is in the intensive care unit.

6. Quite unexpectedly, it turned out that the developed method of postoperative analgesia in patients with pancreatic necrosis improves the digestibility of nutritional support, normalizes the parameters of nitrogen balance in the near future postoperative period and prevents the catabolic phase of stress, improves reparative processes.

7. The method allows to achieve etiopathogenetic treatment of pain by conducting anti-stress protection of the body and eliminating metabolic disturbances at all stages of rehabilitation relaparotomy.

8. Long-term studies in the clinic for treating the disease have reduced mortality to 10%, which seemed previously unattainable.

Claims (1)

A method of postoperative analgesia for patients with pacreonecrosis after omentobursostomy with multiple programmed debridement relaparotomies, including epidural analgesia, non-steroidal anti-inflammatory drugs, opiates, dalargin, antispasmodics, adjuvant therapy, characterized in that the anesthesia is divided up each stage is made taking into account the appointments in the previous stages, synergism and prolongation of pain medication about the action, the degree of intensity of the pain syndrome at the stages of surgical treatment: at the first stage - from omentobursostomy to the first rehabilitation relaparotomy - a continuous infusion of dalargin at a dose of 0.6-0.8 mg / kg / day is carried out in combination with non-steroidal anti-inflammatory drugs, protease inhibitors antispasmodics, if necessary, opiates; at the second stage - from the first rehabilitation relaparotomy to the second or third rehabilitation sanitation relaparotomy - add epidural analgesia with local anesthetics, excluding non-steroidal anti-inflammatory drugs; at the third stage - from the second-third to the fourth-sixth sanation relaparotomy, - narcotic analgesics and protease inhibitors are excluded; in the fourth stage, after the sixth rehabilitation debridement and subsequent subsequent rehabilitation relaparotomy, analgesia is provided exclusively by intramuscular administration of dalargin at a dose of 0.25-0.3 mg / kg / day and non-steroidal anti-inflammatory drugs.